Hepatology Lectures Flashcards
Describe the changes in blood pressure in the hepatic portal system. (3)
1) normal - 5-8mmHg
2) gastro-oesophageal varices - >10mmHg
3) major haemorrhage - >12mmHg
List 5 things measured in a liver function test (LFT) blood test
1) PTT
2) AST
3) ALT
4) albumin
5) bilirubin
List 2 reasons why hepatocytes are susceptible to injury and infection.
1) receive low oxygenated blood
2) process infective agents
What is the main type of bilirubin that in pre-hepatic jaundice?
Unconjugated bilirubin.
What is the main type of bilirubin that in cholestatic (hepatic or post-hepatic) jaundice?
Conjugated bilirubin.
List the 2 types of cholestatic jaundice.
1) intrahepatic
2) posthepatic
What differentiates intrahepatic jaundice from posthepatic jaundice?
High unconjugated bilirubin in intrahepatic jaundice, normal unconjugated bilirubin in posthepatic jaundice.
What is the most common cause of acute viral hepatitis?
Hepatitis A.
Where is hepatitis A endemic? (2)
1) Africa
2) South America
What is fulminant hepatitis?
Rapid liver inflammation that can cause acute liver failure.
What is the icteric stage of hepatitis?
Once jaundice has presented.
Where is hepatitis E common?
Indochina.
Where is hepatitis B endemic? (3)
1) Far East
2) Africa
3) Mediterranean
What does hepatitis D require for assembly?
Hepatitis B.
Where is hepatitis D common? (2)
1) Eastern Europe
2) Northern Africa
Describe hepatitis D co-infection. (3)
1) infected with HBV and HDV simultaneously
2) clinically indistinguishable from acute icteric HBV infection
3) confirmed by anti-HDV IgM and anti-HBV IgM
Describe hepatitis D superinfection. (3)
1) chronic HBV infected with HDV
2) increased risk of fulminant hepatitis
3) only indicated by high AST and high ALT
Where is hepatitis C very incident and why?
Egypt. Failed public health initiative.
What type of food is associated with hepatitis A?
Shellfish.
Describe the pathophysiology of hepatic encephalopathy. (8)
1) liver failure
2) build up of nitrogenous waste (e.g. ammonia)
3) ammonia crosses blood brain barrier
4) ammonia is neurotoxic (halts Krebs cycle —> irreparable cell damage)
5) astrocytes attempt to clear ammonia (conversion of glutamate to glutamine)
6) excess glutamine causes an osmotic imbalance
7) influx of fluid into cells
8) cerebral oedema
List 3 grade I hepatic encephalopathy symptoms.
1) altered mood/behaviour
2) sleep disturbances
3) dyspraxia
List 3 grade II hepatic encephalopathy symptoms.
1) increasing drowsiness
2) confusion
3) slurred speech
List 3 grade III hepatic encephalopathy symptoms.
1) incoherent
2) restless
3) stupor
What is the grade IV hepatic encephalopathy symptoms.
Coma.
What is biggest cause of liver failure in the UK?
Paracetamol overdose (>50%).
What percentage of acute hepatitis B progress to chronic hepatitis?
10%.
What percentage of acute hepatitis C progress to chronic hepatitis?
90%.
Describe biliary colic pain. (6)
1) sudden onset
2) dull
3) constant
4) crescendo
5) right upper quadrant
6) radiated to epigastrium, right shoulder and right subscapular
List 2 factors that affect the onset of biliary colic.
1) excessive fatty food
2) time (mid-evening —> early hours)
What differentiates biliary colic from acute cholecystitis?
Inflammation.
What is Mirizzi’s syndrome? (3)
1) gallstone becomes impacted in gallbladder or cystic duct
2) compression of common hepatic duct or common bile duct
3) jaundice
What percentage of acute pancreatitis are severe and what is the mortality?
10% of cases (40-80% mortality).
What is systemic inflammatory response syndrome (SIRS)? (4)
Pro-inflammatory state. Any two from: 1) tachycardia (>90bpm) 2) tachypnoea (>20bpm) 3) pyrexia (>38C) 4) high white cell count
Where does autoimmune chronic pancreatitis have a high prevalence?
Japan.
List 3 factors that indicate cholestatic jaundice?
1) dark urine
2) pale stool
3) itching
What is Wernicke-Korsakoff encephalopathy? (3)
1) alcohol withdrawal
2) ataxia, confusion, nystagmus
3) lasts up to a week
List 5 organs that accumulate iron during haemochromatosis and the associated pathology.
1) liver* - cirrhosis
2) pancreas - diabetes mellitus
3) pituitary gland - hypogonadism
4) heart - dilated cardiomyopathy, arrhythmias…
5) joints - arthralgia
What is the most common single gene disorder in Caucasians?
Hereditary haemochromatosis.
Why is hereditary haemochromatosis less common in females than males?
Menstrual blood loss is protective.
Describe the change in total body iron content in symptomatic haemochromatosis patients. (2)
1) 20-40g symptomatic patients
2) 3-4g normal people
What age do haemochromatosis patients generally present?
50s.
When is deferoxamine used to treat haemochromatosis?
When patient is intolerant to venesection due to cardiac pathology.
How does deferoxamine treat haemochromatosis?
Cheating agent that binds to iron preventing its absorption.
Describe how venesection treats haemochromatosis. (4)
1) regular removal of blood
2) decreases RBCs
3) excess iron used to make new RBCs
4) decreases iron concentration
List 4 foods that should be avoided with haemochromatosis.
1) tea
2) coffee
3) fruit
4) red meat
List 2 organs where copper accumulates in Wilson’s disease.
1) liver
2) basal ganglia
What practice is associated with Wilson’s disease?
Consanguinity.
What do children with Wilson’s disease generally present with?
Liver disease.
What do young adults with Wilson’s disease generally present with?
Neuropsychiatric symptoms.
List 4 side effects of penicillamine (Wilson’s disease).
1) skin rashes
2) low white cell count
3) renal damage
4) haematuria
What do children with alpha-1-anti-trypsin deficiency generally present with?
Liver disease.
What do adults with alpha-1-anti-trypsin deficiency generally present with?
Respiratory problems (emphysema).
What percentage of alpha-1-anti-trypsin deficient patients develop respiratory problems?
75%.
What is the commonest cause of liver tumours?
Metastases (90%).
What is the 5 year survival rate of hepatocellular carcinoma?
<5%.
Where is hepatocellular carcinoma common?
China.
List 2 causes of primary liver cancers.
1) hepatocellular carcinoma (90%)
2) cholangiocarcinoma (10%)
What is the most common benign liver tumour?
Haemangioma.
List 3 common tumour locations that metastasise to the liver.
1) gastrointestinal tract (via hepatic portal vein)
2) breast
3) bronchus (lung)
What is the prognosis of cholangiocarcinoma?
5 months.
What percentage of cholangiocarcinomas are inoperable?
70%
What percentage of operated cholangiocarcinomas recur?
76%.
What is the 5 year survival of pancreatic adenocarcinoma?
3%.
List 3 sites of pancreatic adenocarcinoma and their prevalence.
1) head of pancreas - 60%
2) body of pancreas - 25%
3) tail of pancreas - 15%
Why is the prognosis of pancreatic adenocarcinoma poor?
Usually presents late stage.
List the 3 main causes of ascites.
1) cirrhosis (80%)
2) cancer (10%)
3) congestive cardiac failure (3%)
List 3 features of parietal peritoneum.
1) covers abdominal wall
2) somatic innervation
3) well localised sensation
List 3 features of visceral peritoneum.
1) covers organs
2) autonomic innervation
3) poorly localised sensation
When does peritonitis present?
Sudden onset when peritoneum perforates.
What is the mortality of peritonitis?
15%.
List 6 reasons people with peritonitis die.
1) sepsis
2) multi-organ failure
3) cardiovascular event (MI, stroke)
4) respiratory complications (pneumonia, pulmonary embolus)
5) surgical complications
6) frailty
List the 4 types of hernia.
1) reducible
2) irreducible - obstructed
3) irreducible - incarcerated
4) irreducible - strangulated
Define Dupuytren’s contracture.
Permanently flexed finger/s.
Define fetor hepaticus.
Extreme bad breath, a sign of end stage liver failure.
Define asterixis.
Liver flap, hand tremor when wrist is extended.
Define cholelithiasis.
Presence of gallstones in gallbladder.
Define Murphy’s sign.
Pain on taking a deep breath when examiner places two finger on right upper quadrant.
Define choledocholithiasis.
Presence of gallstones in common bile duct.
Define Grey Turner’s sign.
Flank bruising.
Define Cullen’s sign.
Periumbilical bruising.
Define steatorrhea.
Fatty stool.
Define hepatic steatosis.
Fatty liver.
Define spider angioma.
Enlarged blood vessels near the skin surface that contain a red spot with radiating reddish extensions.
Define congestive splenomegaly.
Spleen enlargement due to portal hypertension.
Define fulminant hepatitis.
Acute liver failure.
Define Kayser-Fleischer rings.
Dark rings that surround the iris due to copper deposition.
List Charcot’s triad. (3)
1) right upper quadrant pain
2) fever
3) jaundice
List Reynolds’ pentad. (5)
1) right upper quadrant pain
2) fever
3) jaundice
4) hypotension
5) altered mental status
Define endoscopic banding.
Rubber bands used to treat haemorrhaging varices without surgery.
Define transjugular intrahepatic portosystemic shunt.
Artificial passage created from hepatic portal vein to portal vein to treat portal hypertension.
Define venesection.
Removal of blood, used to treat haemochromatosis.
Define haemobilia.
Bleeding of/into biliary tree.
Define gallstone ileus.
Gallstone blocking bowel (esp. terminal ileum).
Describe gallstone ileus formation. (3)
1) gallstone erodes gallstone wall
2) cholecystoenteric fistula forms
3) gallstone blocks bowel (esp. terminal ileum)
Define choledocholithiasis.
Gallstone temporarily blocking common bile duct.
List 4 hernias that rare in children.
1) direct inguinal hernia
2) femoral hernia
3) sliding hiatus hernia
4) rolling hiatus hernia
