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Gastro > Jaundice, HSM, Ascites, Autoimmune Hepatology > Flashcards

Jaundice, HSM, Ascites, Autoimmune Hepatology Flashcards

1
Q

What are causes of hepatomegaly

3 C’s and 3 I’s

A

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

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2
Q

What should you do if abnormal LFT and what is 1st line imaging / other imaging [4]

A

Liver screen
USS = 1st line to show duct dilatation / mets
MRCP - MRI
ERCP if removing i.e. cholangitis / pancreatitis

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3
Q

What is in a liver screen [8]

A 
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
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4
Q

How do you investigate hepatomegaly [6]

A

LFT’s
If abnormal = liver screen
FBC - liver disease cause BM suppression / MCV alcohol
U+E - hepatorenal syndrome / malnourishment
CLotting / albumin
CRP
Imaging

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5
Q

What is 1st line imaging

A

USS to show mets / stone / cirrhosis

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6
Q

What is hepatorenal syndrome

A

Liver disease affects kidney

High mortality

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7
Q

What are causes of splenomegaly [7]

A

Infection - Lyme’s, meningitis, sepsis, Glandular fever, TB
DIC
Malignancy - lyphhoma / leukaemia / myeloma
Sjogren / SLE / RA / vasculitis/ Sarcoid
Portal hypertension
IE, Rheumatic fever
Amyloid

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8
Q

What are causes of massive splenomegaly [4]

A

Malaria
CML
Myelofibrosis
Leishmaniasis

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9
Q

What is important in history of splenomegaly [7]

A

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

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10
Q

What can cause abdominal distension 5 F’s

A 
Flatus
Fat
Fluid
Faeces
Fetus
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11
Q

What are differential of ascites? [6]

A 
Malignancy
Infection - TB 
Decreased albumin
CCF
Pancreatitis / cancer
Portal hypertension - cirrhosis / IVC / portal vein thrombosis
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12
Q

How do you investigate differentials for ascites [7]

A 
FBC + film
U+E, LFT, CRP
Ca tumour marker - Ca19-19 (pancreas)
TB
USS
CT, MRI
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13
Q

What are RF for jaundice [7]

A

BBV - Blood transfusion, IVDA, Piercing / tattoo, STI, Foreign travel
Alcohol
FH
Drugs

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14
Q

What causes mass in RIF [8]

A 
Appendicitis
Caecal cancer
Crohn's disease
Intussception
TB
Kidney malformation / transplant
Undescended testis
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15
Q

What can obstructive jaundice be further classified into [2]

A

Calcular

Malignant

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16
Q

Calcular causes of obstructive jaundice features [4]

A

F>M
Biliary colic
No weight loss
Fluctuates

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17
Q

Malignant causes of obstructive jaundice features [4]

A

M>F
Painless
Weight loss
Progressive

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18
Q

Ascitic fluid investigations, biochemistry [7]

A

Tap: MC&S and AFB, cytology, albumin, LDH, glucose, protein

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19
Q

Ascitic fluid investigations: SAAG

What does it mean if SAAG >1.1g/dL and what does it mean if <1.1 [4]

A

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)

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20
Q

Management of ascites [4]

A 
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
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21
Q

Spontaneous bacterial peritonitis
Ax [4]
Symptoms [3]
Ix [2]

A

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)

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22
Q

Spontaneous bacterial peritonitis
Mx
Cx
Prevention

A

Mx: IV CEFOTAXIME
Cx: hepatorenal syndrome 30%
Pre: prophylactic CIPROFLOXACIN if ascites and protein <15g/L

23
Q

What is PBC

A

Chronic autoimmune granulomatous attack on bile duct INSIDE liver
Leads to cholestasis
Cirrhosis / portal hypertension

24
Q

What causes PBC

A

Autoimmune
Genetic
Environment

M rule

  • Middle age
  • IgM
  • Anti mitochondrial Ab
25
Q

What are the symptoms of PBC

A 
None
Incidental raised ALP
Fatigue
*Tiredness &amp; Pruritus = classic
Jaundice
RUQ pain
Bone and joint pain
Dry eyes and mouth
Hyperpigmentation
HSM
Clubbing
Xanthesomata
26
Q

Who is at risk of PBC

A 
Women
Smoking
Autoimmune
Pregnancy
UTI
Nail polish
FH
27
Q

What is associated with PBC

A

Sjogren
Systemic sclerosis
RA
Thyroid

28
Q

How do you Dx PBC

A

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

29
Q

How do you treat PBC

A 
No definite 
UDCA - flush out salts
Fat soluble vitamin
Treat dry eyes 
Treat pruritus - cholestryalmine
Liver transplant if severe
30
Q

How do you monitor PBC

A

Regular LFT

USS and AFP 6 monthly

31
Q

What are the complications of PBC

A 
Cirrhosis
Decompensated liver
Vitamin deficiency due to fat malabsorption - ADEK
-Osteomalacia 
-OSteoporosis 
-Coagulopathy 
HCC
32
Q

What is PSC

A

Chronic autoimmune inflammation and scarring of intra and extra hepatic ducts
Cholestasis

33
Q

What causes PSC

A

Unknown

80% = UC

34
Q

Who is at risk of PSC

A 
Male 
Young adult 
pANCA
ANA +ve
AMA -ve
Autoimmue hepatitis
Chron's
HIV
35
Q

What are the symptoms of PSC

A 
Fatigue
CHolestasis = jaundice / pruritus
Abdo pain RUQ
Fever
Ascending cholangitis if advanced
Cirrhosis
Hepatic failure
36
Q

How do you Dx PSC

A

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

37
Q

How do you treat PSC

A 
URODEOXYCHOLIC ACID
Treat itch - rifampicin
Liver transplant = main stay
Endoscopic treatment of bile duct / stent
Ax if infection
38
Q

When do you transplant

A

Chronic and poor QOL
Carcinoma
Genetic
MELD score

39
Q

What do you give before transplant

A

Anti-rejection
Immunosuppresion
Steroid
Ax

40
Q

What are the complications of PSC

A

Cirrhosis
Intrahepatic obstruction
Cholangiocarcinoma

41
Q

What is advised in patients with PSC

A

Annual colonoscopy especially if UC

42
Q

What is cholangiocarcinoma

A

Cancer of the bile ducts
90% adenocarcinoma
Extrahepatic 80%

43
Q

What are the symptoms of cholangiocarcinoma

A 
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
44
Q

What tumour markers are elevated

A

Ca-125 - ovarian
Ca19-19 - pancreas
CEA - bowel

45
Q

What are the RF for cholangiocarcinoma

A 
PSC / UC
Age
Liver fluke
Biliary cysts
Chronic liver 
Carcinogens
46
Q

How do you Dx cholangiocarcinoma

A 
Raised bilirubin and ALP
Coag and INR may be affected
USS = 1st line may show dilatation
EUS
Staging = CT / MRI / MRCP
47
Q

How do you treat cholangiocarcinoma

A

Surgery = only option but only 30% operable

Adjuvant chemo / RT

48
Q

What is palliative Rx for cholangiocarcinoma

A

Surgical bypass
ECRP / PTC to stent
Chemo or RT

49
Q

What are post-op complications

A

Liver failure
Bile leek
Bleeding

50
Q

What is Ddx

A

Stone
Cholecystitis
Benign stricture

51
Q

What is ampulla cancer

A

Cancer of ampulla
Adenocarcinoma
Rx = endoscopic excision or pancreaticoduodectomy

52
Q

What do you do for FAP

A

Remove as will cause cancer

53
Q

What is gallbladder cancer

A

Very rare but very aggressive

54
Q
A

Gastro (17 decks)

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