HPB Flashcards
What is Liver Cirrhosis?
Scarring of the the liver tissue due to long-term damage.
It occurs as a result of necrosis of liver cells
Most common cause of Liver Cirrhosis worldwide?
Viral Hepatitis
Most common cause of Liver Cirrhosis in the developed world?
Alcohol
Signs of Decompensated Liver disease?
- Jaundice
- Ascites
- Variceal bleeding
- Hepatic Encephalopathy
What is Wernickes syndrome?
Triad of confusion, encephalopathy and Ophthalmoplegia
Risk factors for non-alcoholic fatty liver disease?
- Obesity
- Dyslipidaemia
- Insulin resistance
- Hypertension
- Genetic factors
What is the most common form of hepatitis?
Hepatitis A is the most common and commonly appears in endemics
How is Hepatitis A and E spread?
Faeco-oral route, usually from infected food
What drugs should be avoided in Cirrhosis?
- NSAIDs: can reduce renal blood flow to precipitate hepatorenal failure.
- ACEi: can redult renal blood flow to precipitate hepatorenal renal failure
- Codeine: leads to hepatic encephalopathy
- Narcotics: leads to hepatic encephalopathy
- Anxiolytics: leads to hepatic encephalopathy
Risk factors for acalculous cholecystitis?
- Starvation
- TPN
- Narcotic analgesics
- Immobility
- Viral and bacterial infections
What is Charcot’s triad and what does it indicate?
- Right upper quadrant pain
- Fluctuating jaundice
- Swinging fevers, usually with rigors
Indicates ascending cholangitis
Causes of pancreatitis?
Idiopathic
Gallstones/Genetics (CF)
Ethanol
Trauma
Steroids
Mumps/Malignancy
Autoimmune pancreatitis
Scorpion sting
Hyperlipidaemia/Hypercalcaemia/Hyperparathyroidism
ERCP
Drugs
What drugs can cause pancreatits?
Azathioprine
Thiazide diuretics
Furosemide
Sulfonamides
Tetracyclines
Oestrogen
Valproic acid
What is the Ranson score used for?
Ranson Score
A mortality estimation scoring system for acute pancreatits with 11 criteria. A point is scored for each of the following during admission:
WBC > 16,000
Age > 55
Glucose >10 mmol/L
AST >250
LDH > 350
A point is scored for each of the following at 48 hours after admission:
Hct drop of > 10% from admission
Blood Urea Nitrogen increase by > 1.79 mmol/L from admission,
Ca2+ < 2 mmol/L
PaO₂ < 7.9 kPa
Base deficit >4 mg/dL
Fluid needs >6 L within 48 hours
What are intrahepatic causes of portal hypertension?
- Cirrhosis
- Schisosomiasis: common cause in developing countries
- Primary biliary cirrhosis
- Drug induced: Methotrexate
- Metastatic malignant disease
- Sarcoidosis
What are pre-hepatic causes of portal hypertension?
- Portal vein thrombosis e.g. sepsis, procoagulopathy
- Abdominal trauma
What are some post-hepatic causes of portal hypertension?
- Budd-Chiara syndrome
- Right heart failure
- Constrictive pericarditis
Clinical features of portal hypertension?
- Splenomegaly
- Haematemesis and/or malaena from bleeding oesophageal varices. -Characterised by painless, massive bleeding
- Rectal varices, which are often mistaken for haemorrhoids
- Ascites
- Fetor hepaticus (faecal breath) due to portosystemic shunting, allowing thiols to enter the lungs
- Renal failure
What is the tumour marker for cholangiocarcinoma?
Ca19-9
What is the main medical treatment for primary biliary cholangitis?
Ursodeoxycholic acid
What are the features indicative of DEcompensated liver disease?
- Ascites
- Hepatic encephalopathy
- Bleeding oesophageal varices
- Jaundice
What is the pathophysiology behind how certain genotypes of alpha-1 antitrypsin deficiency affect the liver?
The liver produces an abnormal mutant version of the alpha-1 antitrypsin protein, which builds up in the liver cells and has a toxic effect, causing inflammation
What disease is associated with anti-smooth muscle antibodies (anti-SMA)?
Type 1 autoimmune hepatitis
What hormone may contribute to the development of focal nodular hyperplasia in the liver?
Oestrogen
What proportion of newly infected patients with hepatitis C will develop chronic hepatitis C?
3 in 4 (75%)
What blood results would you expect in iron deficiency anaemia secondary to chronic microscopic gastrointestinal bleeding?
- Low Hb
- Low MCV
- Low Ferritin
Patients with which condition are screened every six months for liver cancer?
What does screening involve?
- Liver Cirrhosis
- Liver Ultrasound
- Alpha-fetoprotein
What enzymes produced in the liver will give the greatest rise in hepatocellular injury and hepatitis?
- Alanine aminotransferase (ALT)
- Aspartate aminotransferase (AST)
What are the top genetic diseases that cause liver cirrhosis?
- Haemochromastosis
- Wilson’s Disease
- Alpha-1 antitrypsin deficiency
When would a patient with ascites be given prophylactic antibiotics against spontaneous bacterial peritonitis?
When there is less than 15g/Litre of protein in the ascitic fluid
What type of hiatus hernia involves the stomach sliding through the diaphragm, with the gastro-oesophageal junction passing up into the thorax?
Sliding hiatus hernia
What non-invasive investigation confirms the diagnosis of haemochromatosis?
Genetic testing for mutations in the HFE gene
What common and harmless genetic condition is associated with episodes of jaundice?
Gilbert’s syndrome
What are the top autoimmune causes of liver cirrhosis?
- Autoimmune hepatitis
- Primary biliary cholangitis
- Primary sclerosing cholangitis
What scoring systems are available to estimate the degree of liver fibrosis in patients with non-alcoholic fatty liver disease?
NAFLD Fibrosis Score (NFS)
Fibrosis 4 (FIB-4) score
What regular monitoring for complications is carried out in patients with liver cirrhosis?
- MELD score every 6 months
- Ultrasound and AFP every 6 months for HCC
- Endoscopy every 3 years for oesophageal varices
What treatment for liver cancer involves injecting chemotherapy directly into the hepatic artery that feeds the tumour?
Transarterial Chemoembolisation (TACE)
What are the two most common causes of acute liver failure requiring an immediate liver transplant?
- Acute Viral Hepatitis
- Paracetamol overdose
What general dietary recommendations are given to patients with liver cirrhosis?
- Eat regular meals
- High protein and calorie intake
- Low sodium intake
What marker on a blood test is often the first indication of non-alcoholic fatty liver disease?
Raised alanine aminotransferase
What sign may be seen in the eyes in Wilson’s disease?
What does this sign represent?
- Kayser-Fleischer rings in the cornea
- Deposition of copper in Descemet’s membrane
What term describes telangiectasia with a central arteriole with small vessels radiating away found on the skin of patients with liver cirrhosis?
Spider Naevi
What is the usual medical treatment for managing the effects of alcohol withdrawal?
Chlordiazepoxide
What antibodies are most specific to primary biliary cholangitis and form part of the diagnostic criteria?
Anti-mitochondrial antibodies (AMA)
What two skin signs may be seen on examination of a patient with primary biliary cholangitis, and what is the underlying cause of these changes?
- Xanthelasma (cholesterol deposits in the skin) caused by high serum cholesterol
- Jaundice (yellow skin) caused by high serum bilirubin
What is the diagnostic imaging investigation for primary sclerosing cholangitis?
Magnetic resonance cholangiopancreatography (MRCP)
What enzyme produced in the liver and biliary system will give the greatest rise in obstructive pathology of the biliary system?
Where else is the enzyme produced?
Alkaline phosphatase (ALP)
Bone and placenta
What non-invasive investigation is used to confirm the diagnosis of hepatic steatosis (fatty liver)?
Liver ultrasound
What liver enzyme is particularly raised in primary sclerosing cholangitis?
Alkaline phosphatase
What blood test is the first-line investigation for assessing fibrosis in non-alcoholic fatty liver disease?
Enhanced liver fibrosis (ELF)
Which hepatitis B marker indicates active viral replication and high infectivity?
E antigen (HBeAg)
What scoring system is used to assess the severity of liver cirrhosis and the prognosis?
Child-Pugh score
What treatment is used for Wilson’s disease?
Which specific drug options are available?
Copper chelation
Penicillamine and Trientin
Which type of viral hepatitis is only found in patients that also have hepatitis B?
Hepatitis D
What large vessels drain into the portal vein before it enters the liver?
- Superior mesenteric vein
- Splenic vein
What medications are used to manage hepatic encephalopathy?
- Lactulose (aiming for 2-3 soft stools daily)
- Antibiotics, usually rifaximin
What are the key causes of acute right upper quadrant pain?
- Biliary Colic
- Acute cholecystitis
- Acute cholangitis
What 2 serological markers are used initially in hepatitis B screening?
Hepatitis B surface antigen and hepatitis B core antibod
Which marker gives a direct count of the viral load in Hepatitis B?
Hepatitis B virus DNA
What is injected in the Hepatitis Vaccine?
Hepatitis B surface antigen
Which hepatitis B serological marker indicates immunity post vaccination?
Hepatitis B Surface antibody
What findings might you see in necrotising haemorrhagic pancreatits?
Cullen’s sign (Peri-umbilical blue discoloration)
Grey-Turner’s sign (Bilateral flank blue discolouration)
Fox’s sign
Erythematous skin changes
Erythema in the flanks
Haemoperiotoneum
What is the most sensitive blood test for diagnosis of acute pancreatitis?
Lipase
What is the pathophysiology behind Mirizzi syndrome?
- Common hepatic duct obstruction
- Caused by extrinsic compression from an impacted stome
- In the cystic duct or infundibulumn of the gallbladder
What is Budd-Chiari syndrome?
Rare disorder characterized by obstruction of hepatic venous outflow. Often where a clot narrows or blocks the hepatic veins which carry blood out of the liver
What are the causes of Budd-Chiari syndrome?
Usually, the cause is a disorder that makes blood more likely to clot, such as the following:
Chronic myeloproliferative disorders
Pregnancy or use of oral contraceptive pills
Excess red blood cells (polycythemia)
Sickle cell disease
Inflammatory bowel disease
Connective tissue disorders
Injury
