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CP3 SURGERY > HPB - Liver Malignancy, Cirrhosis and the Portal system > Flashcards

HPB - Liver Malignancy, Cirrhosis and the Portal system Flashcards

1
Q

Malignant causes of liver enlargement (3)

A

Mets
Hepatoma
Cholangiocarcinoma

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2
Q

Metabolic storage diseases causing liver enlargement (3)

A

Glycogen
Fatty liver
Amyloid

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3
Q

Inflammatory causes of liver enlargement (4)

A

Hepatitis
Parasites
Abscesses
TB

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4
Q

Vascular causes of liver enlargement (3)

A

HF
Pericarditis
Tricuspid regurg

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5
Q

Haematological causes of liver enlargement (3)

A

Myelofibrosis
Lymphoma
Leukaemia

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6
Q

What are the 3 main routes bacteria infiltrate the liver?

A 
Ascending infection (cholangitis) 
Portal spread from focus of sepsis in abdomen 
Septic bloodstream (septicaemia)
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7
Q

Cause of pyogenic liver abscess

A

Ascending spread - appendicitis, perf

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8
Q

Most common causative organisms - pyogenic liver abscess

A

E.coli

Strep

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9
Q

PS pyogenic liver absccess

A

Long Hx malaise
Usually not acutely unwell
Can PS w/ abdo sepsis + tender hepatomegaly

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10
Q

Ix pyogenic liver abscess

A

USS/CT

CXR

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11
Q

CXR findings pyogenic liver abscess

A

Elevation R diaphragm

+/- pleural effusion

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12
Q

Mx pyogenic liver abscess (3)

A

Aspirate under USS
+ IV Abx
Tx underlying cause

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13
Q

When to suspect amoebic abscess

A

If Hx of travel

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14
Q

Causative agent amoebic abscess

A

Entamoeba histolytica

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15
Q

Acute PS etnamoeba histolytica

A

Asymp

Or profuse bloody diarrhoea

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16
Q

PS amoebic abscess

A

Swinging high fever
RUQ pain
Tenderness

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17
Q

Ix amoebic abscess

A

USS

CT

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18
Q

Mx amoebic abscess (2)

A

Metronidazole 5 days

USS drainage

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19
Q

Cause - hyatid abscess

A

dog tapeworm

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20
Q

Sx hyatid cyst

A

Asymp

Or dull ache RUQ

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21
Q

Ix hyatid cyst (5_

A 
\+ve hyatid complement fixation test
Eosinophilia 
AXR
USS
CT
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22
Q

AXR findings hyatid cyst

A

Calcification of wall

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23
Q

Mx hyatid cyst (3)

A

Albendazole
FNA under USS
Deworm doggo

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24
Q

Are the majority of liver cancers 1’ or 2’

A

2’

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25
Q

Where do liver mets tend to come from?

A 
Lung 
Stomach 
Colon 
Breast 
Uterus
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26
Q

What cancer makes up the vast majority of 1’ liver cancers

A

Hepatocellular carcinoma

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27
Q

Which areas of the world is hepatocellular carcinoma > common? (2)

A

China

Africa

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28
Q

Causes hepatocellular carcinoma (PRAT COST COC)

A 
Parasite schistomiasis 
Rare diseases e.g. tyrosinaemia, a-1-a deficiency 
Arsenic
Tobacco use
Cirrhosis 
Obesity 
Steroids 
T2DM 
Chronic hepatitis 
OCP
Chem exposure - alfrotoxins, vinyl chloride, thorium dioxide
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29
Q

Sx hepatocellular carcinoma (4)

A

Non-specific fever
Malaise
W loss
RUQ pain

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30
Q

Signs hepatocellular carcinoma (4)

A

Hepatomegaly
Signs chronic liver disease
Abdo mass/bruit
Jaundice (late)

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31
Q

Ix hepatocellular carcinoma (9)

A 
FBC
LFT
Clotting 
Hepatitis serology 
AFP 
USS/CT
MRI
ERCP/biopsy
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32
Q

Why screen for AFP if suspecting Hepatocellular carcinoma

A

= raised in 50%cases

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33
Q

Mx solitary <3cm HCC

A

Surgery

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34
Q

Prognosis HCC

A

<6m

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35
Q

What is cholangiocarcinoma?

A

Adenocarcinoma arising from biliary tree

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36
Q

PS cholangiocarcinoma?

A

Painless jaundice

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37
Q

What predisposes to cholangiocarcinoma

A

Any type of chronic inflamm e.g. 1’SC

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38
Q

Spread - cholangiocarcinoma

A

Direct invasion of liver

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39
Q

If caught early - what is mx cholangiocarcinoma

A

Extended liver resection

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40
Q

If caught late - what is Mx cholangiocarcinoma

A

Palliatoin w/ ERCP

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41
Q

E.g.s of benign liver tumours

A

Haemangiomas

Liver cell adenoma

42
Q

Which benign tumour of the liver is found in young F on COCP

A

Liver cell adenoma

43
Q

What are the 3 key characteristics of liver cirrhosis

A

Destruction of liver cells
Assoc chornic inflamm, stimulating fibrosis
Regen of hepatocytes –> nodules

44
Q

What does micronodular cirrhosis (nodular <3mm) due to

A

Alcoholic liver damage

Biliary tract disease

45
Q

Macronodular cirrhosis (nodules >3mm) occur due to

A

Previous hepatitis

46
Q

What is biliary cirrhosis

A

Fibrosis centred around intrahepatic bile ducts

47
Q

Common causes liver cirrhosis (4)

A

Alcohlic liver disease
Cryptogenic liver disease
NAFLD
Chronic viral hepatitis

48
Q

What is primary biliary cirrhosis

A

Autoimmune destruction of intra-hepatic bile canaliculi

49
Q

Who gets primary biliary cirrhosis

A

40-60y/o F

50
Q

Which condition is primary biliary cirrhosis related to?

51
Q

PS primary biliary cirrhosis (3)

A

jaundice
pruritis
skin xanthomas

52
Q

What Ix is diagnostic for primary biliary cirrhosis

53
Q

Av survival 1’ biliary cirrhosis

54
Q

Mx 1’BC

A

replace fat soluble vits

55
Q

What is primary sclerosing cholangitis

A

Autoimmune inflammation + fibrosis around bile ducts in liver

56
Q

What condition does 15% of 1’SC progress into

A

Cholangiocarcinoma

57
Q

Mx 1’SC

A

Transplant

58
Q

Classical PS chronic liver disease

A 
Fatigue 
W loss/anorexia 
Jaundice 
Leg swelling 
Bleeding/bruising 
Itching
59
Q

Nail signs in liver disease (3)

A

leukonychia
koilonychia
clubbing

60
Q

Hand signs chronic liver disease (3)

A

Palmar erythema
Dupuytren’s contracture
Liver flap

61
Q

What is palmar erythema a sign of

A

High Oestrogen levels

62
Q

what is Dupuytren’s contracture a sign of

A

Alcoholism

63
Q

What is leukonychia is a sign of

A

Low albumin

64
Q

Skin changes chronic liver disease (4)

A

pigmentation
Striae
Spider naevi
bruising

65
Q

Eye signs chronic liver disease (4)

A

Yellow sclera
Kayser Fleisher rings
Xanthalsma
Pale conjunctiva

66
Q

what is xanthalasma a sign of

A

Primary biliary sclerosis

67
Q

Signs of portal hypertension (4)

A

Caput medusae
HSmegaly
Ascites
Varices

68
Q

Signs decompensated liver disease (3)

A

Encephalopathy
Ascites
Jaundice

69
Q

Why do you get encephalopathy in decompensated liver disease

A

Liver = unable to clear toxins from the blood which originate in the gut

70
Q

why do you get ascites in decompensated liver disease

A

hyponatraemia b/c decr synthesis plasma protein in liver
2’ hyperaldosteronism after activation RAAS b/c reduced circ volume
–> portal HTN

71
Q

Precipitants of chronic liver disease ‘decompensating’

A

Alcohol binge
Variceal bleed
Hepatotoxic drugs
Portal/hepatic vv thrombosis

72
Q

Complications of chornic liver disease (4)

A

Hepatocellular failure
Portal HOTN
Malignant change
Renal failure

73
Q

Which steroids are importantly metabolised in the liver and accumulate in chronic liver disease?

A

Aldosterone

Oestrogen

74
Q

What is Wilson’s disease

A

Error of Cu metabolism –> depositon in organs

75
Q

Which organs does Wilsons disease classically effect (3)

A

Liver\
BG
Cornea

76
Q

Ix Wilsons disease (3)

A

Se caeruloplasmin reduced
Urinary Cu increased
Liver biopsy - incr Cu

77
Q

Mx Wilsons ddisease

A

Chelating agents e.g. D-penicillamine

78
Q

What is Haemochromatosis

A

inherited condition –> XS Fe deposition in organs –> fibrosis + organ failure

79
Q

Triad of Sx Haemochromatosis

A

Bronze skin
Hepatomegalyt
DM

80
Q

Ix haemochromatosis (4)

A

Se Fe/ferritin raised
TIBC decreased
Genetic testing
Liver biopsy

81
Q

Mx haemochromatosis

A

Weekly venesection

82
Q

What % of pt w/ cirrhosis will develop G-O varices over 10y

83
Q

Pathology G-O varices

A

Cirrhosis –> backlog of blood in portal vv –> splenic cc –> HSmegaly –> AV anatomoses in oesophagus

84
Q

mx ascites

A

Bed rest _ fl restrict
Low Na diet
Spironolactone
Furosemide added if response poor

85
Q

Grade I encephalopathy

A

Altered mood/behaviour, sleep disturbance

86
Q

Grade II encephalopathy

A

Increased drowsiness, confusion

87
Q

Grade III encephalopathy

A

Stupor, incoherence, restlessness

88
Q

Grade IV encephalopathy

89
Q

Mx encephalopathy

A

ICU + 20’ head tilt
PO lactulose
+ IV mannitol + hyperventilation if evidence cerebral oedema

90
Q

E.g.s of porto-systemic anastomoses locations (4)

A 
Cardia stomach (G-O varices)
Anus - rectal varices
Retroperitoneal organs - stomal varices
paraumbilical vv ant abdo wall - caput medusae
91
Q

Def portal HTN

A

P in portal vv >10mmHg

92
Q

Pre-hepatic causes portal HTN

A

Portal vv thrombosis

93
Q

Hepatic causes portal HTN (5)

A 
Cirrhosis 
Hepatitis 
Idiopathic non-cirrhotic portal HTN
Shisctosomiasis 
Congental hepatic fibrosis
94
Q

Post-hepatic causes portal HTN

A

Budd-Chairi syndrome

95
Q

What is Budd-Chairi syndrome

A

Obstruction of hepatic vv (due to thrombosis or ext mass)

96
Q

How can portal HTN PS (5)

A 
Variceal bleeding 
Haemorrhoids/caput medusae
Ascites
Splenomegaly 
Porto-systemic encephalopathy
97
Q

mx acute variceal bleed

A 
A-E
Vit K +FFP
IV terlipressin 
IV Abx prophylaxis 
Endoscopic banding + adrenaline under GA
98
Q

Alt Mx variceal bleed (to endoscopic stapiling)

A

Balloon tamponade devide

Or transjugular intrahepatic portosystemic shunting

99
Q

2’ prophylaxis variceal bleed

A

Endoscopy

Non-selective B blockers

100
Q

1; prophylaxis variceal bleeed

A

Banding + B vlocker if asymp varices are found

101
Q

Dx Mx - pruritis

A

Cholestyramine

CP3 SURGERY (19 decks)

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