Jaundice Flashcards
What is iron stored bound to?
Ferritin
What is the role of albumin?
Transports lipophilic substances (FFAs, bilirubin, thyroid hormones)
What is copper bound to for transport?
Caeruloplasmin
What are the normal ranges for LFTs?
ALT: 5-35 U/L AST: 5-35 U/L ALP: 30-150 U/L GGT: 11-51 U/L (Men) and 7-33 U/L (Women) Bilirubin: 3-17 micromol/L Albumin: 35-50 g/L PT: 10-14 secs
What defines acute liver disease?
Any insult causing damage In a previously normal liver Less than 6 months duration Causing: - Encephalopathy - Prolonged coagulation
Clinical features of acute liver disease?
Jaundice Lethargy Nausea Anorexia RUQ pain Itch Arthralgia
What are the causes of acute viral liver disease?
Hepatitis viruses: - A (travellers and shellfish) - B + C (blood borne) - D - E (sausage and travellers) CMV EBV Toxoplasmosis
What are the other causes of acute liver disease?
Drugs Hypoperfusion Cholangitis Alcohol Malignancy Chronic LD
What is Budd-Chiari?
Hepatic vein clot Results in venous infarct: - Liver pain - Ascites - Jaundice
When is Budd-Chiari common?
In young women on the oral contraceptive pill
What are the two causes of acute liver disease in pregnancy?
Acute Fatty Liver in Pregnancy (AFLP)
Cholestasis of pregnancy
What immunological conditions can predispose to liver disease?
Autoimmune hepatitis
Primary biliary cirrhosis
What are some genetic conditions that can predispose to liver disease?
Wilson’s disease
Haemochromatosis
What investigations are carried out into jaundice/acute LD?
LFTs
PT
USS
Virology
What drugs can cause hepatic drug reactions?
Co-amoxiclav
Flucloxacillin
NSAIDs
What are the common causes of fulminant hepatic failure?
Paracetamol
Hep B
Drugs
What are the common causes of liver cirrhosis?
Alcohol NAFLD Hep C Primary biliary cirrhosis Autoimmune hep Hep B
What is the clinical context of NAFLD?
Obesity Type 2 Diabetes High triglycerides Low HDL Hypertension NASH
What mediated primary biliary cirrhosis?
CD4+ cells
How does primary biliary cirrhosis present?
Middle aged woman Symptoms - Itch (no rash) - Fatigue - Xanthelasma - Xanthoma
How do we diagnose PBC?
Positive AMA
Cholestatic LFTs
Liver biopsy
What are the extra hepatic manifestations of autoimmune hepatitis?
Thyroiditis Graves' disease Chronic UC Pernicious anaemia Systemic sclerosis ITP SLE
How is autoimmune hepatitis diagnosed?
Increased AST and ALT
Increased IgG
Presence of ASMA
Is primary sclerosing cholangitis more common in men or women?
Men
How do we diagnose primary sclerosing cholangitis?
Biliary tree imaging (ERCP)
What can cause portal hypertension?
Pre-hepatic - HPV thrombosis Intra-hepatic - Schistosomiasis - Cirrhosis
Signs of cirrhosis
Compensated: - Spider naevi - Palmar erythema - Clubbing - Gynaecomastia - Hepatomegaly - Splenomegaly - ?None Decompensated: - Jaundice - Ascites - Encephalopathy - Bruising
What is the primary diuretic for ascites?
Spironolactone
What is TIPS?
Trans-jugular Intrahepatic Porto-systemic Shunt
How do we treat mild spontaneous bacterial peritonitis?
PO Co-trimoxazole
How do we treat severe spontaneous bacterial peritonitis?
Piperacillin/Tazobactam IV
Step down to PO Co-trimoxazole
Terlipressin for vascular instability
What is required for Hep D to propagate?
A Hep B co-infection
What does the presence of HBsAg indicate?
Current infection
- ?Acute
- ?Chronic
What does the presence of Anti-HBs IgG indicate?
The patient has immunity to Hep B
- ?Vaccine
- ?Past infection
What is the presence of HbeAg an indicator for?
Replication and infectivity
When is Anti-HBe present?
When infectivity declines in a patient with Hep B
When can HBcAg be detected?
Never.
What does the presence of Anti-HBc IgM indicate?
The patient is suffering from an acute infection
What does the presence of Anti-HBc IgG indicate?
The patient is immune via a natural infection
What is HBV DNA used for?
To quantify viral load
How long must the patient be HBsAg positive for to be classed as a carrier?
Greater than six months
Roughly how long does it take for a chronic hepatitis infection to result in
- Cirrhosis
- Hepatocellular carcinoma?
- Greater than 20 years
2. Greater than 30 years
What are the treatment options for chronic HBV infection?
Option 1:
- PegINF only
- Sustained cure
- More side effects
Option 2:
- Entecavir and Tenofovir
- Safer
- Not a cure
- Resistance develops
In what structures do arterial and venous blood mix within the liver?
Sinusoids
How is each lobule arranged?
Hexagonal
Central vein
Portal triad at each corner
What direction do blood and bile flow in a lobule and what carries each?
Blood - Inwardly - Via sinusoids Bile - Outwardly - Via canaliculi
Where are hepatocytes positioned?
Between sinusoids
What is the structure of the hepatocyte plates?
Basolateral membrane
- Faces pericellular space
Apical membrane
- Grooved by canaliculi
What cells are present in the sinusoidal spaces?
Endothelial cells (fenestrated for free solute movement) Kuppfer cells (resident macrophages) Stellate (Ito) cells (store vitamin A)
Why are cholangiocyte secretions alkaline?
Micelle formation
Chyme neutralisation
Enzymes
Mucosal protection
What is hepatic bile composed of?
Primary bile acids Water and electrolytes Lipids Cholesterol IgA Bilirubin
What analgesia is used for biliary colic?
Morphine (also constricts sphincter of Oddi)
Buprenorphine
Pethidine
What are the three histological zones in a hepatic lobule?
Periportal
Midacinar
Pericentral
What is the limiting plate?
Interface between portal tract and the parenchyma
What is the histological appearance of liver cirrhosis?
Bands of fibrosis separate hepatocytes
Macronodular or micronodular (alcoholic)
How does paracetamol toxicity appear histologically?
Confluent necrosis in zone 3
Why do patients with cirrhosis suffer from ascites?
Hypoalbuminaemia
Secondary hyperaldosteronism
Portal hypertension
Why do cirrhosis patients suffer from purpura, bleeding and bruising?
Decreased clotting factors
What does decreased Kuppfer cell function result in?
Infections
What are the features of alcoholic hepatitis (histology)?
Hepatocyte necrosis Neutrophils Mallory bodies - Inclusions - Highly eosinophilic Pericellular fibrosis
What autoantibodies are present in autoimmune hepatitis?
Smooth muscle
Nuclear
LKM
What are Kayser-Fleischer rings a sign of?
Wilson’s disease
What are the histological types of hepatocellular carcinoma?
Hepatocytic
Cholangio
What is the clinical setting of a patient with cholesterol gallstones?
Female
Obese
Diabetes
Genetic
What can gallstones result in?
Cholecystitis Mucocoele Empyema Carcinoma Ascending cholangitis Obstructive jaundice Gallstone ileus Pancreatitis
What are Rokitansky-Aschoff sinuses a feature of?
Chronic cholecystitis
What is cholangiocarcinoma associated with?
UC
Primary sclerosing cholangitis
Increased serum amylase, sudden onset abdo pain and severe shock.
Acute pancreatitis
What are the complications of acute pancreatitis?
Death Shock Pseudocyst formation Abscess formation Hypocalcaemia Hyperglycaemia
What is the aetiology of chronic pancreatitis?
Alcohol Cholelithiasis CF Hyperparathyroidism Familial
What is pancreatic carcinoma associated with?
Smoking
Diabetes
Familial pancreatitis
What cardiovascular complications can result of GI surgery?
Haemorrhage
MI
DVT
How does postoperative haemorrhage present?
Overt
Tachycardia
Hypotension
Oliguria
What increases the risk of postoperative DVT?
Age over 40 Previous DVT Major surgery Obesity Malignancy
How does DVT present as a complication?
Low grade Fever High grade fever Calf/thigh tenderness Increased leg diameter Shiny skin
What are the respiratory complications of GI surgery?
Atelectasis
Pneumonia
PE
How do atelectasis and pneumonia result postoperatively?
Lung tissue collapse
Anaesthesia causes hypersecretion and inhibits cilia
Postop pain prevents coughing
Stomach contents are aspirated
What is ileus?
Paralysis of intestinal motility
What can cause ileus?
Bowel handling Peritonitis Retroperitoneal injury Immobilisation Hypokalaemia Drugs
What symptoms does ileus have?
Vomiting
Abdominal distension
Dehydration
Silent abdomen
What is anastomotic dehiscence and where can it occur?
Intestinal
Vascular
Urological
How do the three kinds of anastomotic dehiscence present?
Intestinal - Peritonitis - Abscess - Ileus - Fistula Vascular - Bleeding - Haematoma Urological - Urine leak - Urinoma
What can cause adhesions?
Inflammation and ischaemia
How can adhesions be prevented?
No powder on gloves
Avoid infection
Laparoscopy
Sodium hyaluronidate
A solid hepatic lesion in elderly patients is likely to be what?
Secondary tumour
A solid hepatic lesion in patients with chronic liver disease is likely to be what?
Primary malignancy
In young, non-cirrhotic patients what is a hepatic lesion likely to be?
Haemangioma
What types of benign liver lesions are common?
Haemangioma
Focal modular hyperplasia
Adenoma
Liver cysts
What is the most common benign liver lesion?
Haemangioma
What is the clinical presentation of focal modular hyperplasia?
Young women
Not sex hormone related
Often asymptomatic
How does focal modular hyperplasia appear?
Central scar with unusually large artery
Radiating branches
What are the clinical features of a hepatic adenoma?
More common in females
Associated with contraceptive hormones
RUQ pain
What are the types of cystic lesions?
Simple Hyatid Atypical Polycystic Pyogenic/Amoebic abscess
What is a simple cyst?
Liquid collection surrounded by epithelium
Does a simple cyst communicate with the biliary tree?
No
What is an echinoccocus granulosus?
Hyatid cyst
How does a hyatid cyst present?
Disseminated
Erosion into adjacent structures/vasculature
Marsupialization and albendazole are used to treat what kind of cyst?
Hyatid
What do embryonic ducal plate malformations of the Intrahepatic biliary tree cause?
Polycystic liver disease
What are Von Meyenburg Complexes?
Microhamartomas in the liver
Bile duct malformations
Remnants develop into small hepatic cysts
What further problems can arise from gallstones?
Colic Cholecystitis Jaundice Pancreatitis Bowel obstruction
Where does biliary colic pain radiate to?
Back
Shoulder
What is biliary colic associated with?
Indigestion
Nausea
What are the differential diagnoses of severe epigastric pain apart from biliary colic?
Peptic ulcer
Oesophageal spasm
MI
Acute pancreatitis
Treatment of acute cholecystitis?
IV antibiotics and fluids
Nil by mouth
Ultrasound
How do we diagnose CBD pathology?
Symptoms - Itch - Nausea - Anorexia - Jaundice Abnormal LFTs
What is the treatment of gallstone ileus?
Urgent laparotomy
Small bowel enterotomy
How does a cholangiocarcinoma present?
Late Jaundice Weight loss Anorexia Lethargy
What viral infections can increase the risk of pancreatic cancer?
Mumps
Coxsackie B
Hepatitis
What metabolic factors increase the risk of pancreatic cancer?
Hyperparathyroidism
Hyperlipoproteinaemia (Types 1 and 4)
What examination signs are suggestive of pancreatic cancer?
Tenderness Peritonism Distension Bowel sound change Skin marks
What features on a conventional x Ray may suggest pancreatic cancer?
Pleural effusion
Sentinel loop
What complications of pancreatic cancer may be picked up on a CT scan?
Fluid Necrosis Ascites Bleeding Abscess
What is the Glasgow Prognostic Score?
PaO2 < 8kPa Age > 55 Neutrophils > 15x10^9/L Calcium < 2mmol/L Renal Function (Urea > 16mmol/L) Enzymes (AST/ALT > 200iU/L or LDG > 600iU/L) Albumin < 32g/L Sugar (Glucose > 10mmol/L)
Any three means acute severe pancreatitis
What are the symptoms of pseudo cysts?
Pain Nausea Vomiting Jaundice Weight loss
What is the Beger procedure?
Duodenum preserving pancreatic head resection and reconstruction
What can cause biliary obstructions?
Oedema
Calcification
Fibrosis
Pancreatic head tumour
What is an exocrine pancreatic tumour and where is it located?
Adenocarcinoma
Head
Body
Tail
What are the three kinds of endocrine pancreatic tumours?
Gastrinoma
Insulinoma
Glucagonoma
The Whipple procedure?
A pancreaticoduodenectomy
What are ANCA and what condition are they seen in?
Anti neutrophilic cytoplasmic antibodies
Primary sclerosing cholangitis
