Liver Flashcards
Alcoholic liver disease overview
Damage to liver from alcohol
ALD Patho
Caused by alcohol abuse
Fatty liver
Alcohol metabolism -> fat production, cells swell with fat (steatosis)
Alcoholic hepatitis
Fatty change, inflammation
infiltration by leukocytes
hepatocyte necrosis, mallory bodies, giant mito
Alcoholic cirrhosis
Fibrosis
conversion from normal structure to abnormal nodules
irreversible
ALD Px
Fatty liver
asymptomatic
Vague abdo symptoms - N+V, diarrhoea
hepatomegaly
Alcoholic hepatitis
Jaundice
Signs of chronic liver disease (ascites, bruising, clubbing, Dupuytren’s)
Abdo pain, fever
Alcoholic cirrhosis
Signs of chronic liver disease
Features of alcohol dependency
ALD Ix
LFTs - GGT and ALP raised, AST and ALT mildly raised
FBC - thrombocytopenia, hypoglycaemia, elevated bilirubin and PTT, increased WCC, elevated MCV
Abdo USS
CT/MRI
Liver biopsy
ALD Mx
Stop drinking alcohol
Withdrawal symptoms - diazepam
IV thiamine - prevent Wernicke-Korsakoff encephalopathy (confusion, ataxia, nystagmus)
Good diet, infection prophylaxis
Liver transplant
ALD Cx
cirrhosis, liver failure, encephalopathy
Ascites overview
Free fluid in peritoneal cavity
Ascites causes
Local inflammation
Peritonitis, infection, abdo cancer, surgery
Low protein
Low albumin, loss of oncotic pressure
Hypoalbuminaemia, nephrotic syndrome, malnutrition
Low flow
Fluid cannot move through vessels, pressure raises, fluid leaks out
Cirrhosis (portal HTN), cardiac failure, constrictive pericarditis
Ascites Px
Signs Abdo swelling Fullness in flanks Shifting dullness Peripheral oedema Wt gain from water retention
Symptoms
Abdo pain (if severe, think bacterial peritonitis)
Maybe respiratory distress, difficulty eating
Ascites Ix
Abdo exam
USS/CT/MRI
Ascitic tap (WCC, culture, transudate/exudate)
Ascites Mx
Tx underlying cause
Oral spironolactone - K-sparing duiretic
Paracentesis - drain fluid
Transjugular intrahepatic portosystemic shunt (TIPS)
Biliary colic overview
Pain from gallstone in CD or CBD
Gallstones Patho
Cholesterol gallstone
Large, often solitary stone
Causes - female, age, obesity
Cholesterol crystallisation - either bile salt deficiency or relative excess cholesterol
Bile pigment stones
Small Ca stones, irregular
Black - from haemolysis (sickle cell, thalassaemia) and cirrhosis
Brown - stasis and infection (Ecoli/klebsiella)
Gallstones Risk Factors
Fair, fat, fertile, female, forty
Biliary colic Px
Sudden onset pain
Severe, constant, crescendo-like (not colicky)
Mid-evening onset, last to early morn
Epigastric/RUQ
Radiation - right shoulder, right subscapular
N+V
Biliary colic Ix
Abdo USS
Biliary colic Mx
Laparoscopic cholecystectomy
Gallstone Cx
In gallbladder/CD - biliary colic, cholecystitis, empyema (GB fills with pus), carcinoma, Mirizzi’s syndrome (stone in GB presses on BD, causes jaundice)
In BDs - obstructive jaundice, cholangitis, pancreatitis
Cholecystitis overview
Gallbladder inflammation
Cholecystitis patho
Stone obstructs GB emptying, increase of GB glandular secretion, distention, GB vascular supply may be compromised
Inflammatory response secondary to bile retained in liver (maybe infection secondary to vascular and inflammatory events)
Repeated acute attacks -> chronic
Cholecystitis Px
Epigastric pain -> localised RUQ (as inflammation progresses)
Tenderness, guarding, rigidity
Inflammation - vomiting, fever, local peritonism, raised WCC
Murphy’s sign - pain on deep breath in with two fingers on RUQ (and no pain for LUQ)
Jaundice if stone moves to CBD (but not normally)
Cholecystitis Ix
Bloods - raised WCC, CRP, bilirubin, ALP, ALT/AST
Abdo USS - thick walled, shrunken bladder, stones, fluid nearby
Cholecystitis Mx
Lap chol
IV fluids, analgesia, cefuroxime/ceftriaxone
Stone dissolution - oral ursodeoxycholic acid
Shock-wave therapy
Cholangitis overview
Inflammation of bile duct system
Cholangitis patho
Causes
- Secondary to CBD obstruction from gallstones
- strictures (following surgery)
- cancer of pancreas head -> BD obstruction
- biliary parasites
- ERCP
Infection ‘ascends’ up CBD from duodenum after biliary stasis
Common orgs in UK (KEES) - Klebsiella, Ecoli, enterococcus, streptococcus
Cholangitis Px
Biliary colic
Fever, rigors, jaundice, RUQ pain
Jaundice is cholestatic - dark urine, pale stools, itchy skin
(maybe lethargy/confusion, shock)
Biliary tract disease DDx
Biliary colic - RUQ
Cholecystitis - RUQ pain and fever/increased WCC
Cholangitis - RUQ pain, fever and jaundice
Cholangitis Ix
Bloods - increased WCC, ESR/CRP, bilirubin, ALP, ALT, AST
Abdo USS/CT
Magnetic resonance cholangiography
Cholangitis Mx
ABs - cefotaxime, metronidazole
Biliary drainage with endoscopic retrograde cholangio-pancreatography (ERCP) and sphincterectomy (cut biliary sphincter)
Remove stones
Cholangitis Cx
Sepsis, AKI, system dysfunction
Liver cirrhosis overview
Irreversible liver damage
Loss of normal structure, fibrosis
Liver cirrhosis causes
Common
- chronic alcohol abuse
- non-alcoholic fatty liver disease
- Hepatitis
Others
- primary biliary cirrhosis
- autoimmune hepatitis
- hereditary haemochromatosis
- Wilson’s disease
Liver cirrhosis Px
signs Leukonychia - white nails (from hypoalbuminaemia) clubbing palmar erythema Dupuytren's Spider naevi xanthelasma - yellow fat deposits under skin, usually around eyelids body hair loss jaundice hepatomegaly bruising ankle swelling, oedema ascites
symptoms
Abdo pain from ascites
Liver cirrhosis Ix
Child-Pugh classification
Liver biopsy
LFTs - low albumin, long PTT, high bilirubin
low Na - severe disease
Raised serum creatinine
Alpha-fetoprotein - hepatocellular carcinoma
USS/CT/MRI/Endo
Liver cirrhosis Mx
Treat underlying causes No alcohol Treat ascites Hep A/B vaccination Avoid NSAIDs, aspirin, salt Liver transplant
Liver cirrhosis Cx
Coagulopathy - fall in clotting factors 2,7,9,10
Encephalopathy - liver flap, confusion/coma
Hypoalbuminaemia - oedema
Portal HTN - ascites, oesophageal varices, caput medusa
Hepatocellular carcinoma
Portal HTN overview
Abnormally high pressure in hepatic portal vein
Portal HTN patho
Causes ascites, splenomegaly, portosystemic shunt (inc oesophageal varices), caput medusae (enlarged superficial periumbilical veins)
causes
Pre-hepatic - portal vein thrombosis
Intra-hepatic - cirrhosis, schistosomiasis, sarcoidosis
Post-hepatic - right heart failure, constrictive pericarditis, IVC obstruction, Budd Chiari syndrome (occlusion of hepatic vein)
Portal HTN Px
signs
splenomegaly
caput medusae
ascites
Evidence of causes of liver disease - eg jaundice, alcohol consumption, FHx (Wilson’s/haemochromatosis)
Cx of portal HTN may be present
- bleeding varices (haematemesis/melaena)
- encephalopathy - lethargy, irritability
Abdo pain/fever - SBP
Signs of chronic liver disease
Portal HTN Ix
Bloods
Abdo USS, doppler USS
CT/MRI
Liver biopsy - find underlying cause
Vascular imaging
Portal HTN Mx
Treat cause
Liver transplant
Reduce pressure - BBs, nitrates, shunt (transjugular intrahepatic portosystemic shunt (TIPS))
Salt restriction, diuretics
Portal HTN Cx
Oesophageal varices
Ascites and its Cx
Portopulmonary HTN
Liver failure, hepatic encephalopathy
Variceal haemorrhage Px
signs pallor shock - hypotension, tachycardia reduced urine output reduced GCS signs of chronic liver disease
symptoms haematemesis, malaena abdo pain dysphagia (uncommon) confusion - encephalopathy
Variceal haemorrhage Ix
Endoscopy
Bloods - FBC, LFT, clotting
CXR
ascitic tap if bacterial peritonitis suspected
Variceal haemorrhage Mx
Prevention - BBs, variceal banding, liver transplant
Resuscitate Blood if anaemic vit K, platelets - correct clotting abnormalities IV terlipressin (vasopressin) - causes vasoconstriction IV somatostatin if terlipressin CI (IHD) Balloon tamponade Variceal banding TIPS
Coeliac disease overview
Immune-mediated, inflammatory systemic disorder provoked by gluten (found in wheat, rye, barley)
CD Patho
T-cell responses -> villous atrophy and malabsorption
Associated with dermatitis herpetiformis
CD Px
Stinky stools/steatorrhoea Diarrhoea Abdo pain Bloating N+V Wt loss Fatigue, weakness Osteomalacia Mouth ulcers May mimic IBS
CD Ix
Anti-transglutaminase test (IgA) - check for alpha gliadin auto-ABs
Endoscopy and biopsy
CD Mx
Gluten free diet
CD Cx
Malabsorption, dermatitis herpetiformis, anaemia, osteoporosis, anxiety/depression
Diarrhoea overview
Increased stool freq and volume, decreased consistency
Acute <4wks, chronic >4wks
Diarrhoea causes
Viral most common
Children - rotavirus
Adults - norovirus
Bacterial
Campylobacter, E coli, salmonella, shigella
AB associated
ABs beginning with C can lead to C difficile
Clindamycin, ciprofloxacin, co-amoxiclav, cephalosporins
Parasitic
Giardia lamblia, entamoeba histolytica, cryptosporidium
Traveller’s diarrhoea, IBD, IBS, colorectal cancer, gastroenteritis
Diarrhoea Px
Diarrhoea (blood usually = bacterial infection)
Vomiting
Abdo cramping
Viral causes - fever, fatigue, headache, muscle pain
red flags
blood, recent hospital tx or ABs, persistent vomiting, weight loss, painless watery diarrhoea (dehydration risk), symptoms disturb sleep
Diarrhoea Ix
Thorough history
Look for dehydration (higher CRT, shock, dry mucous membranes), fever, goitre
Bloods - FBC
Stools - MC&S
Lower GI endoscopy
Diarrhoea Mx
Treat cause (ABs)
Oral rehydration
Anti-emetic for vomiting (metoclopramide)
Anti-motility - loperamide, codeine
Diarrhoea Cx
Dehydration, electrolyte imbalance, reactive Cx (reactive arthritis), infection spread, IBS, lactose intolerance
Acute hepatitis
Inflammation of liver
<6months = acute
Causes
Viral - Hep A,E,C,B/D, EBV, CMV, VZV
Non-viral - eg TB, toxoplasmosis
Non-infective - alcohol, drugs, toxins, metabolic, autoimmune, pregnancy
Px
signs
- cholestatic jaundice (pale stools, dark urine)
- hepatomegaly
- signs of fulminant hepatitis (acute liver failure) - bleeding, ascites, encephalopathy
symptoms
- malaise
- myalgia
- GI upset
- RUQ abdo pain
Ix
raised AST, ALP, +/-bilirubin
Chronic hepatitis
> 6months = chronic
Can maintain compensated liver function sometimes
Px can be asymptomatic signs when compensated - clubbing - palmar erythema - Dupuytren - spider naevi
signs when decompensated
- jaundice
- ascites
- low albumin
- coagulopathy - increased PTT, INR
- encephalopathy
Ix
LFT can be normal
Cx
hepatocellular carcinoma, portal HTN, varices
Autoimmune hepatitis
Inflammatory liver disease, characterised by continuing inflammation, necrosis, cirrhosis
Type 1 - anti-SM ABs (ASMA), ANAs, increased IgG
Type 2 - anti-liver/kidney microsomal type 1 (KLM1) ABs
Px
hepatitis, HSM, ascites, encephalopathy
fever, malaise, urticarial rash, polyarthritis, pleurisy, pulmonary infiltration, glomerulonephritis
jaundice, signs of chronic liver disease
Ix Raised bilirubin, AST, ALT, ALP, IgG auto-ABs liver biopsy MRCP
Mx
Prednisolone, azathioprine
Liver transplant
Hep A
RNA, causes acute hepatitis only
Faeco-oral transmission, 2-6wk incubation, usually self-limiting, 100% immunity after
IgM (acute), IgG (long-term)
Px
Viraemia - nausea, fever, malaise, anorexia, arthralgia
Jaundice (dark urine, pale stools)
HSM
Ix
LFTs - AST/ALT, bilirubin
Bloods - leukopenia
HAV ABs
Mx
Supportive (fluids, antiemetics, rest)
Monitor liver function
Vaccine for prevention
Hep E
RNA, hepatitis similar to HAV, usually only acute, usually self-limiting, high mortality in pregnancy
Faeco-oral transmission (also water/food bourne). 2-9wk incubation
Px
Mostly asymptomatic, or same as HAV, neurological manifestations
Ix
HEV IgM, IgG detection
Check RNA for if chronic
Mx
Supportive
Ribavirin (antiviral) maybe
Vaccine to prevent
Hep B
DNA
Blood-bourne transmission, bodily fluids, also vertical
1-6month incubation
5% develop chronic - cirrhosis, decompensation, hepatocellular carcinoma
IgM acute, IgG chronic, but anti-HB surface antibody in resolution
Px subclinical in many signs - rashes (urticaria) - jaundice, dark urine, pale stools - HSM
symptoms
- viraemia - nausea, fever, malaise
Ix
LFTs
Hep B surface antigen
ABs against HBV
Mx
Supportive
Chronic - s/c pegylated interferon-alpha 2A, nucleoside analogues
Vaccination to prevent
Hep D
Incomplete RNA virus, needs HBV to manifest - co-infection/superinfection
Blood-bourne, bodily fluid transmission
Px
similar to HBV
Ix
Similar to HBV
Hep D AB, HDV RNA
Mx
Supportive
s/c pegylated interferon-alpha 2a
liver transplant maybe
Hep C
RNA, transmission of blood products, sexual (but is rare)
is acute/chronic - chronic -> HCC, cirrhosis, liver failure
Px
Most asymptomatic
Mild flu-like symptoms, jaundice
Ix LFTs POCTs HCV AB HCV RNA
Mx
s/c pegylated interferon alpha-2a, oral ribavirin, directly-acting antivirals
No vaccine, and previous infection =/= immunity
Hernia
protrusion of organ through defect in the walls of its containing cavity into an abnormal position
Reducible - can be pushed back
Irreducible - obstructed / incarcerated (stuck by adhesions)
Strangulated - blood supply cut, ischaemia, gangrene, perforation of hernial contents - toxic
Inguinal hernia overview
Protrusion of abdo contents through inguinal canal
Inguinal hernia patho
Both hernias present above and medial to pubic tubercle
Direct (20%) - medial to inferior epigastric artery, hernia enters through posterior wall of canal
Indirect (80%) - lateral to inferior epigastric artery, hernia enters canal through deep inguinal ring
Inguinal hernia Px
signs
swelling in groin
indirect more prone to cause scrotum pain (dragging sensation)
Impulse (increase in swelling) - maybe on coughing
lump reducible
symptoms
maybe painful
Inguinal hernia Ix
Look for lump
USS/CT/MRI if in doubt
Inguinal hernia Mx
Reassurance
Truss
Surgery - if very symptomatic - mesh
Femoral hernia overview
bowel comes through femoral canal, below inguinal ligament
Femoral hernia Px
Mass in upper middle thigh - inferior and lateral to pubic tubercle
Cough impulse maybe
lower abdo pain maybe
Femoral hernia Ix
Clinical dx
USS/CT/MRI
Femoral hernia Mx
Surgical repair
Incisional hernia overview
tissue protrudes through surgical scar that is weak (is failure of wound to heal)
Incisional hernia Px
depends on location
Incisional hernia Mx
Surgical repair - mesh
Epigastric hernia
in linea alba, above umbilicus - organs push through weakened section of muscle
Epigastric hernia Px
asymptomatic
epigastric pain
bloating, N+V
bulging on strain
Epigastric hernia Ix
USS/CT to confirm dx
Epigastric hernia Mx
Surgical repair
Umbilical hernia
hernia through umbilicus
may present with pain on coughing/straining, ache, dragging sensation
USS
Surgical repair
Hiatus hernia
herniation of stomach through oesophageal aperture of diaphragm
hiatus hernia patho
Sliding (80%)
part of stomach and gastro-oesophageal junction slide up, reflux (LOS less competent)
Rolling (20%)
part of fundus prolapses through (GOJ remains), LOS intact, reflux uncommon
Associated with - reflux, Barrett’s oesophagus, adenocarcinoma
Hiatus hernia risk factors
obesity, female, pregnancy, ascites, older age, trauma
Hiatus hernia Px
GORD, heartburn
Hiatus hernia Ix
CXR
Barium swallow
Upper GI endo
Hiatus hernia Mx
lose weight
treat reflux - PPI
Surgery - if resp Cx or therapeutic regimes not working
Hepatocellular carcinoma
Primary liver tumour (the most common type)
HCC Px
symptoms of advancing cirrhosis/liver failure
- spider naevi, flapping tremor, peripheral oedema, pruritus
signs
jaundice
ascites
hepatomegaly (may be irregular)
symptoms wt loss anorexia fever, fatigue ache in right hypochondrium
HCC Ix
Alpha-fetoprotein (AFP) may be raised
USS, CT
Liver biopsy
HCC Mx
Surgical resection of isolated region
liver transplant
ablative therapy
chemo (cancer resistant to it tho)
Cholangiocarcinoma
Cancer of biliary tree
Cholangiocarcinoma Px
signs
jaundice
hepatomegaly
pruritus
symptoms fever RUQ abdo pain (+/- ascites) malaise weight loss anorexia pale stools, dark urine
Cholangiocarcinoma Ix
Raised bilirubin, ALP
CT/MRI
Biopsy/fine needle aspiration
Cholangiocarcinoma Mx
Surgical resection
Stent to relieve symptoms
Primary biliary cholangitis
autoimmune granulomatous inflammation of intrahepatic ducts, may lead to fibrosis, cirrhosis, portal HTN
F>M
Px
lethargy, pruritus
jaundice, skin pigmentation, xanthelasma, HSM, RUQ pain, maybe present with Cx (cirrhosis, osteoporsis, HCC, ADEK malabsorption -> coagulopathy, osteomalacia)
Ix
ALP, GGT raised, bilirubin raised, albumin decreased, PTT increased
Antimitochondrial ABs (AMA), IgM raised
Biopsy, USS
Mx Colestyramine Bisphosphonates Ursodeoxycholic acid ADEK vitamins Liver transplant
Primary sclerosing cholangitis
fibrosis of intrahepatic and extrahepatic ducts -> inflammation and strictures
associated with UC
M>F
Px
Pruritus, fatigue, RUQ pain, jaundice, hepatomegaly
Ix
ALP, bilirubin raised
MRCP, ERCP
Liver biopsy
Mx
Liver transplant
Ursodeoxycholic acid
Colesytramine
Secondary liver tumour
Is the most common liver tumour
Particularly from GI tract, breast, bronchus (lung)
Secondary liver tumour Px
signs
hepatomegaly +/- jaundice
ascites
symptoms weight loss malaise RUQ abdo pain anorexia
Secondary liver tumour Ix
USS, CT/MRI
ALP raised
Secondary liver tumour Mx
Remove primary tumour, hepatic resection
Chemo
Pancreatic adenocarcinoma
adenocarcinoma of pancreas
99% of pancreas cancer occurs in exocrine component (ductal)
60% in head, 25% in body, 15% in tail
Pancreatic adenocarcinoma risk factors
Smoking, alcohol, coffee, diabetes, chronic pancreatitis, genetics, FHx, diet
Pancreatic adenocarcinoma Px
signs
acute pancreatitis
jaundice, palpable gallbladder
HSM, lymphadenopathy
symptoms
anorexia
weight loss
Head of pancreas - painless obstructive jaundice (pale stools, dark urine)
Body and tail - epigastric pain, radiates to back, relieved by sitting forward
Pancreatic adenocarcinoma Ix
Bloods - FBC, LFT (cholestatic jaundice), serum glucose (hyper)
USS, CT
Biopsy
Pancreatic adenocarcinoma Mx
Surgery
Pancreatico-duodectomy (whipples)
chemo
stenting
opiates for pain
Liver failure overview
Hepatic failure occurs when liver loses ability to regenerate/repair - decompensation
Acute or acute-on-chronic
Liver failure patho
Marked by:
Hepatic encephalopathy
abnormal bleeding
ascites
jaundice
There is necrosis of hepatocytes
Liver failure causes
Virus - hep, CMV, EBV, herpes
Drugs - paracetamol, alcohol, antidepressants, NSAIDs, ABs
HCC
Genetics
Liver failure Px
signs
- jaundice
- small liver
- encephalopathy (confusion, coma, liver flap (asterixis), drowsiness)
- fetor hepaticus (smells like pear drops)
- fever, vomiting, HTN
- spasticity and hyperreflexia
signs of chronic liver disease suggest acute-on-chronic
- bruising
- clubbing
- Dupuytren’s
- ascites (rare)
Liver failure Ix
Bloods - high bilirubin, ALT, AST, low coagulation factors, PTT increase, ammonia high
Imaging - EEG to grade encephalopathy, USS, CXR, doppler USS
Microbio - blood culture, urine culture, ascitic tap
Liver failure Mx
Treat cause
IV glucose if necessary
Raised ICP - IV mannitol
Mineral supplements
Coagulopathy - vit K, platelets, blood, FFP
Infection prophylaxis
Liver transplant
Liver failure Cx
Infection, cerebral oedema, intracranial HTN, death
Haemorrhage, varices, sepsis, AKI, resp failure
Hereditary haemochromatosis (HHC) overview
ncreased intestinal iron absorption
HHC patho
Iron deposition in joints, liver, heart, pancreas, pituitary, adrenals, skin
Eventually, fibrosis, organ failure
Hereditary condition (HFE gene, chromosome 6)
HHC Px
Tiredness, arthralgia
Hypogonadism
Slate-grey skin, signs of chronic liver disease (ascites, oedema, bruising), hepatomegaly, osteoporosis
Heart - failure, arrhythmias
Gross iron overload - bronze skin, DM
HHC Ix
Bloods - raised serum iron, ferritin, transferrin
LFTs, liver biopsy
Genetic testing
MRI
HHC Mx
Venesection
If venesection not tolerated - chelation therapy (desferrioxamine)
Low dietary iron
Liver transplant if decompensation
Wilson’s disease overview
Too much copper in liver and CNS (basal ganglia)
Wilson’s patho
Autosomal recessive hereditary condition
Normally, copper absorbed from GI tract, processed in liver, remaining excreted in bile/faeces
Wilson’s - error of copper metabolism -> copper deposition in organs (precise mechanism unknown)
Wilson’s Px
Liver problems - hepatitis, cirrhosis, fulminant liver failure
CNS problems - tremor, dysarthria (slurred/slow speech), involuntary movts, dysphagia, diskinesia (impaired voluntary movt), reduced memory
Kayser-Fleischer ring - green/brown pigment at outer edge of cornea
Wilson’s Ix
Serum copper and ceruloplasmin (copper-containing enzyme)
24hr urinary copper excretion high
Liver biopsy
MRI - basal ganglia, cerebellar degeneration
Wilson’s Mx
Avoid high copper foods (liver, chocolate, nuts, mushrooms, shellfish)
Chelating agent - penicillamine
Liver transplant if severe
Alpha 1-antitrypsin deficiency
Genetic disorder - liver/lung disease
A1AT deficiency patho
Autosomal recessive
Deficiency of A1AT (inhibits proteolytic enzyme neutrophil elastase)
Affects lung (emphysema) and liver (cirrhosis, HCC)
A1AT deficiency Px
Lung disease (tends to be adults)
- resp problems
- SOB
- emphysema
Liver disease (tends to be children)
- cirrhosis
- hepatitis
- cholestatic jaundice
A1AT deficiency Ix
serum A1AT levels low
CXR, lung function tests
LFTs, liver biopsy
A1AT deficiency Mx
treat cx of liver disease
stop smoking, manage emphysema
Liver transplant maybe if decompensation
Acute pancreatitis
Inflammation of pancreas
Acute pancreatitis patho
Inflammation -> release of exocrine enzymes -> autodigestion of organ (leaky vessels, destruction…)
Acute pancreatitis causes
I GET SMASHED
idiopathic gallstones (majority) ethanol trauma steroids mumps autoimmune scorpion venom hyperlipidaemia ERCP drugs (azathioprine, diuretics, NSAIDs, ACEi)
also pregnancy, neoplasia
Acute pancreatitis Px
signs hyperlipidaemia tachycardia dehydration jaundice fever hypotension, hypoxaemia Cullen's - periumbilical bruising Grey Turner's - left flank bruising oedema tetany
symptoms
LUQ abdo pain, penetrates to back, relieved by sitting forward
anorexia
N+V
Acute pancreatitis DDx
Other causes of raised amylase - acute cholecystitis, renal failure, DKA
Other causes of similar pain - upper GI perforation, MI, dissecting AA
Acute pancreatitis Ix
Bloods - raised serum, urinary amylase, serum lipase
CXR, AXR, abdo USS, contrast enhanced CT/MRI
Pancreatic scoring system
Glasgow and Ranson scoring
APACHE II score
Acute pancreatitis Mx
Nil by mouth IVI crystalloid Analgesia - pethidine/morphine Prophylactic ABs - cefuroxime, metronidazole Insulin (correct blood sugar levels) ERCP and gallstone removal Surgery, fluid drainage
Acute pancreatitis Cx
Hyper/hypoglycaemia renal failure shock ARDS DIC SIRS pseudocyst - fluid in lesser sac necrosis, fluid collections
Chronic pancreatitis
chronic inflammation, irreversible damage
fibrosis
Various causes - genetic, autoimmune, alcohol, CF
Chronic pancreatitis Px
Abdo pain - epigastric (radiating to back)
N+V
decreased appetitie
exocrine dysfunction - malabsorption, wt loss, diarrhoea, steatorrhoea
endocrine dysfunction - DM
Chronic pancreatitis Ix
Bloods
Secretin stimulation test (insert secretin into duodenum through tube, see if pancreas responds)
Imaging - CT/MRI/endo USS
Chronic pancreatitis Mx
Modify RFs - smoking, alcohol
Analgesia for pain - paracetamol, NSAIDs
Treat malabsorption - replace pancreatic enzymes
Surgery possibly (resection)
Peritonitis
Inflammation of peritoneum
Peritonitis patho
rimary/secondary
Localised/generalised
Acute/chronic
Bacterial/chemical
causes
Bacterial - E coli, klebsiella, S.aureus (could be SBP - perforation)
Chemical - bile, old clotted blood
Peritonitis Px
Perforation = sudden onset
Pain poorly localised (irritate visceral peritoneum) then localised (irritates parietal peritoneum)
signs rigid abdo patient lies very still pain relieved by resting hands on abdo pyrexia, tachycardia confusion (encephalopathy) Guarding, silent abdo is ominous sign
symptoms
abdo pain
systemic - nausea, chills, rigor, dizziness, weakness
Peritonitis Ix
Bloods - raised WCC, CRP
Erect CXR - see free air under diaphragm
AXR
CT abdo
Peritonitis Mx
ABCDE Tx underlying cause IV fluids IV ABs - broad spec - cefuroxime, metronidazole Peritoneal lavage Surgery - eg repair perforated organ
Peritonitis Cx
Septicaemia, local abscess formation, kidney failure, paralytic ileus
Variceal haemorrhage
Bleeding from dilated veins/varices - tend to be distal oesophagus/proximal stomach
