Hepatopancreatic Flashcards by Kay Bryson

LFTs

Bilirubin (3-17 umol/L)
AST (5-35 IU/L)
ALT (5-35 IU/L)
ALP (30-300 IU/L)
GGT (11-51 IU/L)
albumin (35-50 g/L)
INR (1 )

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Alcoholic liver disease

Alcohol related fatty liver —> Alcoholic hepatitis—> cirrhosis
CAGE:Cut down, Annoyed, Guilty, Eye opener
AUDIT: 10 Q’s, >8 = harmful use
Signs: Jaundice, Hepatomegaly, Spider Naevi, Palmar erythema, Gynaecomastia, Asterixis, Caput Medusae, bruising
Bloods: ^MCV, ^ALT and AST, ^^GGT, ^ALP later in disease, low albumin, ^ Bilirubin in cirrhosis
Tests: Endoscopy, fibroscan, Ultrasound, CT, MRI, Biopsy
Management; thiamine and high protein diet

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Alcohol withdrawal

Can cause delirium tremens
6-12 h : tremor , sweating, headache, anxiety
12-24 h : hallucinations
24-48 h : Seizures 
24-72 h : Delirium tremens

Alcohol stimulates GABA (parasympathetic )= relax
Also inhibits glutamate receptors (NMDA , sympathetic )
Withdraw = excessive adrenergic activity
Management: Chlordiazepoxide , diazepam less commonly used
5-7 days
IV high dose B vitamins (pabrinex)+ low dose oral thiamine (prevent wernicke korsakoff )

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Wernicke- Korsakoff syndrome

Thiamine deficiency
Wernicke encephalopathy —-> Korsakoffs
WE: confusion, oculi motor disturbances, ataxia
KS: memory impairment, behavioural changes

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Causes of liver cirrhosis

Alcoholic liver disease
Hep B C
Non alcoholic fatty liver disease

Rarer cause:
Autoimmune hepatitis
Primary biliary cirrhosis
Heamochromatosis 
Wilson’s disease 
Alpha 1 antitrypsin def.
CF
Drugs (amiodarone, methotrexate, Sodium valproate )

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Marker for hepatic cancer

Alpha fetoprotein - checked ever 6months as screening in cirrhosis patients with ultrasound

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Enhanced Liver Fibrosis blood test

First line recommendation in non alcoholic fatty LD

HA, PIIINP, TIMP-1 markers

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Cirrhosis findings

Ultrasound: Nodularity to surface, corkscrew hepatic arteries with increase flow as they compensate for reduced portal flow, enlarge portal vein, as cities, splenomegaly.

Screening every 6months (cancer)
Endoscopy: oesophageal varices

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Child- Pugh Score for cirrhosis

5-15

Bilirubin, albumin, INR, ascities, encephalopathy

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Hepatic blood supply

Portal vein from Sup. Mesenteric Vein and splenic vein

Hepatic artery

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Tx of stable varices

Propranolol - non selective , reduce P hypertension
elastic band ligation
Inject sclerosant
TIPS: Transjugular intra-hepatic portosystemic shunt : hepatic and Portal vein

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Tx Bleeding Oesophageal varices

Resus:
Vasopressin analogue- terlipressin (vasoconstriction )
Correct coagulation with Vit K and FFPs
Prophylactic ABs
consider intubation

Urgent endoscopy - injection of sclerosant / band ligation
Sengstaken blakemore tube - tamponade bleeding

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Cirrhosis ascites

Low protein count - transudate
^ renin- ^ aldosterone - ^ reabsorption = fluid and sodium overload

Management: Low Na diet, Anti-aldosterone diuretics (spironalactone), Paracentesis (tap/drain), ABs (ciproflxacin), consider TIPS, transplant

Bacterial peritonitis: E. Coli, Klebsiella, Gram + cocci (staph)
Cefotaxime - cephalosporin

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Hepatorenal syndrome

In liver cirrhosis when portal hypertension leads to stretching of the portal veins. Leads to loss of blood volume in other areas, then activation of renin angiotensin system leading to renal vasoconstriction = starvation of kidneys - rapid deterioration.

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Hepatic encephalopathy

Portosystemic encephalopathy
Build up of toxins - AMMONIA - produced by gut bacteria
Tx: laxatives and ABs

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None alcoholic fatty liver disease

NAFLD —> NA steatoheptitis (NASH)—> fibrosis —> cirrhosis
Same RF as CVS disease
Autoantibodies : Antinuclear AB (ANA)
Smooth muscle AB (SMA)
Anti mitochondrial AB (AMA)
AB to liver kidney microsome type 1 (LKM-1)

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Wilson’s disease

Copper accumulation
Normally excreted in bile
Sx: Jaundice, Kayser- fleisher rings, uncontrolled movement, speech and swallow problems

Test: Caeruloplasmin blood test, biopsy

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Hepatitis A

Most common viral hep worldwide , quite rare in UK
faecel oral 
Contaminated water / food
Nausea vomiting anorexia jaundice 
Can cause cholestasis - slowing of bile flow 
Dark urine and place stoles 
Resolves without Tx in 1-3 months 
Notifiable to public health

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Hep B

DNA virus
Blood or body fluid transmission, vertical transmission
10-15% chronic infection carrier
HBV surface antigen protein test

Hep C

RNA 
Blood
No vaccine available 
Curable with Direct acting antivirals - taken for 8-12 weeks
Without tx 3/4 become chronic

Hep D

RNA

Only survive in patients who have Hep B

Hep E

RNA
Faecal oral route
Very rare in UK
Only mild illness , virus cleared in a month

Autoimmune hepatitis

Rare cause of chronic hepatitis 
T cell mediated response 
Type 1: adults, Type 2: children 
^ALT + AST and IgG and lots of antibodies (ANA)
Tx: prednisolone, azathioprine

Raised ALT

Liver trouble

Liver damage

Raised ALP

Bile Duct and bone disease | ALP alone - bone tomor, vid D def, fracture

Raised AST

Liver or muScle damage

Raised GGT

Drugs and alcohol or bile obstruction/ damage

Raised albumin

Infection, burns, surgery, MI, stress

Low albumin

Malnutrition, liver disease, kidney disease, HF, inflammation

Raised bilirubin

Anaemia, cirrhosis, viral hep, Gilbert’s syndrome, viral hep Jaundice- isolated = pre-hepatic

ALT>AST

Chronic liver disease

ALT< AST

Cirrhosis, acute alcoholic hepatitis

ALT> ALP

Hepatocellular injury

ALP

Cholestatic injury

Gallstone types | Cholelithiasis

Sx: sudden intense pain in right upper abdo radiates to back between shoulder blades Nausea and vomiting Cholesterol stones - 75-90% - precipitated YELLOW - can’t be seen on X-ray - radiolucent If they have CaCO3 they might be seen Bilirubin stones - pigmented - BLACK From too much unconjugated bilirubin Radioopac as have CaCO3 RF: extravascular hemolysis - sickle cell, B thalasemia, spherocytosis Brown stones - calcium and UCB and phospholipids Sign of infection (eg E. coli) More in Asian populations ``` RF: 4 F’s Female fertility fat forty All gallstones more common in women- oestrogen and oral contraceptives Pregnancy Obesity - ^ cholesterol so also stone s Rapid weight loss ```

``` Pain in right upper quad which radiates to right scapula and shoulder Fever and Nausea and vomiting Pos Murphy’s sign High ALP High CRP and WCC ```

Acute cholecystitis Ultrasound shows inflammation Tx : cholecystectomy Can lead to peritonitis is perforated from ischemia - rebound tenderness - sepsis - 72h Emergency 10% cases can be without stones ACALCULOUS - usually hospitalised patients. - from GB stasis and ischemia - RF: sepsis, immunosuppression, DM, ventilation, trauma, burns, CMV infection

Fever Right upper quad pain Jaundice

``` Charcots triad Ascending cholangitis - ACUTE Gallstone in common bile duct Can lead to septic shock Urgency cholecystectomy ? ERCP ```

Commonest place for pancreatic cancer

``` Adenocarcinoma 60% head 15% body 5% tail 20% entire gland ``` Hard, stellate, Greg white, poorly defined

Intermittent pain in right upper quadrant | Worsened by fatty food

Biliary colic | Can progress to acute cholecystitis and ascending cholangitis

Oesophageal varices management

Resus Correction of clotting abnormalities IV terlipressin and band ligation to stop bleeding If not stopped, sengstaken blakemore to be used - balloon tamponade

History of vomiting and retching After acute alcohol intoxication Bleeding in vomit

Mallory Weiss tear

Causes of acute pancreatitis | - serum lipase (preferred) or amylase

``` GET SMASHED Gallstones Ethanol Trauma Steroids Mumps and malignancy Autoimmune Scorpion and spider venom Hyperlipidemia / calcemia ERCP Drugs ```

Painless jaundice for 4. Months Raised ALP UColitis

Primary sclerosing cholangitis Autoimmune mediated Diagnosis: MRCP

Episodes of mild jaundice Otherwise asymptomatic Bloods show - elevated unconjugated bilirubin

Gilbert’s syndrome Decreased uridine diphosphoglurconate UDPGT activity leads to decreased conjugation of unconjugated bilirubin No treatment nessesary

5 Fs of gallstones

``` Fat Female Fertile Forty Fair ```

Causes of acute pancreatitis | I GET SMASHED

``` Idiopathic Gallstones Ethanol Trauma Steroids Mumps Autoimmune Hypercalcemia/ hypertriglyceridemia Scorpion sting ERCP Drugs ```