Jaundice, HSM, Ascites, Autoimmune Hepatology Flashcards
What are causes of hepatomegaly
3 C’s and 3 I’s
C - cirrhosis (early)
C - cancer (craggy)
C - congestion (portal hypertension 2 to RHF or cirrhosis)
I - infection (HBV HCV / CMV / EBV / malaria)
I - immune - (hepatitis / PSC / PBC)
I - infiltration with amyloid / sarcoid / haem malignancy / haemochromatosis
What should you do if abnormal LFT and what is 1st line imaging / other imaging [4]
Liver screen
USS = 1st line to show duct dilatation / mets
MRCP - MRI
ERCP if removing i.e. cholangitis / pancreatitis
What is in a liver screen [8]
Hep B,C,E EBV, CMV, HIV Auto-immune / Ab / Ig Serum copper - for Wilson disease Ferritin and transferrin - Haemochromatosis A1-anti-trypsin Glucose Lipids
How do you investigate hepatomegaly [6]
LFT’s
If abnormal = liver screen
FBC - liver disease cause BM suppression / MCV alcohol
U+E - hepatorenal syndrome / malnourishment
CLotting / albumin
CRP
Imaging
What is 1st line imaging
USS to show mets / stone / cirrhosis
What is hepatorenal syndrome
Liver disease affects kidney
High mortality
What are causes of splenomegaly [7]
Infection - Lyme’s, meningitis, sepsis, Glandular fever, TB
DIC
Malignancy - lyphhoma / leukaemia / myeloma
Sjogren / SLE / RA / vasculitis/ Sarcoid
Portal hypertension
IE, Rheumatic fever
Amyloid
What are causes of massive splenomegaly [4]
Malaria
CML
Myelofibrosis
Leishmaniasis
What is important in history of splenomegaly [7]
Fever - infection / TB / malignancy / sarcoid
Lymphadenopathy - glandular / malignancy
Ascites - portal / malignancy
Arthritis / vasculitis/ RA / sjogre / SLE / lyme
Weight loss - malignancy / TB
Purpura - meningitis / DIC /sepsis
Murmur - IE / rheumatic
What can cause abdominal distension 5 F’s
Flatus Fat Fluid Faeces Fetus
What are differential of ascites? [6]
Malignancy Infection - TB Decreased albumin CCF Pancreatitis / cancer Portal hypertension - cirrhosis / IVC / portal vein thrombosis
How do you investigate differentials for ascites [7]
FBC + film U+E, LFT, CRP Ca tumour marker - Ca19-19 (pancreas) TB USS CT, MRI
What are RF for jaundice [7]
BBV - Blood transfusion, IVDA, Piercing / tattoo, STI, Foreign travel
Alcohol
FH
Drugs
What causes mass in RIF [8]
Appendicitis Caecal cancer Crohn's disease Intussception TB Kidney malformation / transplant Undescended testis
What can obstructive jaundice be further classified into [2]
Calcular
Malignant
Calcular causes of obstructive jaundice features [4]
F>M
Biliary colic
No weight loss
Fluctuates
Malignant causes of obstructive jaundice features [4]
M>F
Painless
Weight loss
Progressive
Ascitic fluid investigations, biochemistry [7]
Tap: MC&S and AFB, cytology, albumin, LDH, glucose, protein
Ascitic fluid investigations: SAAG
What does it mean if SAAG >1.1g/dL and what does it mean if <1.1 [4]
Serum ascites albumin gradient (SAAG): serum albumin – ascites albumin
o SAAG >1.1g/dL: portal HTN (transudates)
o SAAG <1.1g/dL: other causes (peritoneal or visceral neoplasia, inflammation (pancreatitis), nephrotic syndrome, TB peritonitis) (exudates)
Management of ascites [4]
daily weights (aim for <0.5kg/d) & restrict Na intake fluid restriction (<1.5L/d) therapeutic paracentesis (with 100mL 20% albumin per L drained to reduce post paracentesis circulatory dysfunction) TIPSS transjugular intrahepatic portosystemic shunt
Spontaneous bacterial peritonitis
Ax [4]
Symptoms [3]
Ix [2]
Ax: ascites becomes infected with E. coli, Klebsiella or strep
Sy/Si: ascites, abdo pain, fever
Ix: paracentesis (neutrophil count >250 cells/uL and MC&S tends to show E. coli)
Spontaneous bacterial peritonitis
Mx
Cx
Prevention
Mx: IV CEFOTAXIME
Cx: hepatorenal syndrome 30%
Pre: prophylactic CIPROFLOXACIN if ascites and protein <15g/L
What is PBC
Chronic autoimmune granulomatous attack on bile duct INSIDE liver
Leads to cholestasis
Cirrhosis / portal hypertension
What causes PBC
Autoimmune
Genetic
Environment
M rule
- Middle age
- IgM
- Anti mitochondrial Ab
What are the symptoms of PBC
None Incidental raised ALP Fatigue *Tiredness & Pruritus = classic Jaundice RUQ pain Bone and joint pain Dry eyes and mouth Hyperpigmentation HSM Clubbing Xanthesomata
Who is at risk of PBC
Women Smoking Autoimmune Pregnancy UTI Nail polish FH
What is associated with PBC
Sjogren
Systemic sclerosis
RA
Thyroid
How do you Dx PBC
MRCP
Blood - raised ALP, GGT
AMA + IGM = Dx
Increased bilirubin, INR, decreased platelet
Increased TSH?
USS to exclude extra-hepatic
Liver biopsy / cholangiogram not usually needed
How do you treat PBC
No definite UDCA - flush out salts Fat soluble vitamin Treat dry eyes Treat pruritus - cholestryalmine Liver transplant if severe
How do you monitor PBC
Regular LFT
USS and AFP 6 monthly
What are the complications of PBC
Cirrhosis Decompensated liver Vitamin deficiency due to fat malabsorption - ADEK -Osteomalacia -OSteoporosis -Coagulopathy HCC
What is PSC
Chronic autoimmune inflammation and scarring of intra and extra hepatic ducts
Cholestasis
What causes PSC
Unknown
80% = UC
Who is at risk of PSC
Male Young adult pANCA ANA +ve AMA -ve Autoimmue hepatitis Chron's HIV
What are the symptoms of PSC
Fatigue CHolestasis = jaundice / pruritus Abdo pain RUQ Fever Ascending cholangitis if advanced Cirrhosis Hepatic failure
How do you Dx PSC
Bloods - LFT / ANCA / IgG
USS - look for other cause e.g. gall stone
MRCP = diagnostic, beaded appearance
ERCP if going to do invasive Rx
Liver biopsyy / cholangiogram not usually needed
How do you treat PSC
URODEOXYCHOLIC ACID Treat itch - rifampicin Liver transplant = main stay Endoscopic treatment of bile duct / stent Ax if infection
When do you transplant
Chronic and poor QOL
Carcinoma
Genetic
MELD score
What do you give before transplant
Anti-rejection
Immunosuppresion
Steroid
Ax
What are the complications of PSC
Cirrhosis
Intrahepatic obstruction
Cholangiocarcinoma
What is advised in patients with PSC
Annual colonoscopy especially if UC
What is cholangiocarcinoma
Cancer of the bile ducts
90% adenocarcinoma
Extrahepatic 80%
What are the symptoms of cholangiocarcinoma
Obstructive jaundice - gradual onset Persistent colic Fever Abdominal pain Weight loss Anoreixa Mass in RUQ LN (peri-umbilical) + Virchow AScites Pruritus Non-specific - malaise Hypercalcaemia Hypophosphate
What tumour markers are elevated
Ca-125 - ovarian
Ca19-19 - pancreas
CEA - bowel
What are the RF for cholangiocarcinoma
PSC / UC Age Liver fluke Biliary cysts Chronic liver Carcinogens
How do you Dx cholangiocarcinoma
Raised bilirubin and ALP Coag and INR may be affected USS = 1st line may show dilatation EUS Staging = CT / MRI / MRCP
How do you treat cholangiocarcinoma
Surgery = only option but only 30% operable
Adjuvant chemo / RT
What is palliative Rx for cholangiocarcinoma
Surgical bypass
ECRP / PTC to stent
Chemo or RT
What are post-op complications
Liver failure
Bile leek
Bleeding
What is Ddx
Stone
Cholecystitis
Benign stricture
What is ampulla cancer
Cancer of ampulla
Adenocarcinoma
Rx = endoscopic excision or pancreaticoduodectomy
What do you do for FAP
Remove as will cause cancer
What is gallbladder cancer
Very rare but very aggressive
