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Liver Flashcards

1
Q

What are the possible results of acute liver injury?

A
  • Recovery
  • Failure
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2
Q

What are the possible results of chronic liver injury?

A
  • Recovery
  • Cirrhosis
  • Liver failure
  • Varices
  • Hepatoma
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3
Q

What are the causes of acute liver injury?

A
  • Viral causes (eg. Hepatitis A and B, EBV)
  • Drugs
  • Alcohol
  • Vascular
  • Obstruction
  • Congestion
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4
Q

What are the causes of chronic liver injury?

A
  • Alcohol
  • Viral (eg. Hepatitis B and C)
  • Autoimmune
  • Metabolic
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5
Q

What are the presentations of acute liver injury?

A
  • Malaise
  • Nausea
  • Anorexia
  • Jaundice

(Rare symptoms: confusion, bleeding, pain)

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6
Q

What are the presentations of chronic liver injury?

A
  • Ascites
  • Oedema
  • Haematemesis
  • Malaise
  • Anorexia
  • Easy bruising
  • Hepatomegaly
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7
Q

What do LFTs tell us?

A
  • Serum bilirubin, albumin, and prothrombin time
  • Serum liver enzymes

Don’t actually give much index of liver function.

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8
Q

Define Jaundice.

A

Raised serum bilirubin.

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9
Q

What are the types of Jaundice?

A
  • Unconjugated - “pre-hepatic” (eg. Gilbert’s, haemolysis)
  • Conjugated - “cholestatic”
  • “Hepatic” (eg. liver disease)
  • Bile duct obstruction - “post-hepatic”
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10
Q

What are the different signs of Pre-hepatic vs Post-hepatic jaundice?

A
  1. Pre-hepatic
    - No changes to urine or stool
  2. Post-hepatic
    - Dark urine
    - Pale urine
    - Itching
    - Abnormal LFTs
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11
Q

What aspects of past medical history are relevant relating to Jaundice?

A
  • Biliary disease/intervention
  • Malignancy
  • Heart failure
  • Transfusion
  • Autoimmune disease
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12
Q

What other aspects of patient history are important relating to Jaundice?

A
  • Drug history
  • Alcohol use
  • Potential Hepatitis contact
  • Family history system review
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13
Q

What tests are used to diagnose Jaundice?

A
  • Liver enzymes (very high AST/ALT suggests liver disease)
  • Biliary obstruction
  • Further imaging (CT, MRCP, ERCP)
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14
Q

What is a MRCP?

A

Magnetic resonance cholangiogram.

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15
Q

What is an ERCP?

A

Endoscopic retrograde cholangiogram.

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16
Q

What is the makeup of gallstones and where are they found?

A

Mostly form in the gallbladder.

70% cholesterol, 30% pigment (and calcium)

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17
Q

What are the risk factors for gallstones?

A

The 5 Fs:
- Female
- Fat
- Forty
- Fair
- Fertile

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18
Q

How are gallstones treated?

A
  • Laparoscopic cholecystectomy (gallbladder stones)
  • ERCP with removal or stent placement (bile duct stones)
  • Surgery (large stones)
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19
Q

What are the types of Drug-Induced Liver Injury?

A
  • Hepatocellular
  • Cholestatic
  • Mixed
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20
Q

What are the most common drugs that cause DILI?

A
  • Antibiotics (32-45%)
  • CNS drugs
  • Immunosuppressants
  • Analgesics
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21
Q

How is paracetamol-induced hepatic failure treated?

A

N acetyl Cysteine (NAC)

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22
Q

What is Ascites?

A

An accumulation of free fluid in the peritoneal cavity.

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23
Q

How are ascites managed?

A
  • Fluid and salt restriction
  • Diuretics
  • Large-volume paracentesis
  • Trans-jugular intrahepatic portosystemic shunt (TIPS)
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24
Q

What are the complications of chronic liver disease?

A
  • Constipation
  • Drugs (sedatives, analgesics)
  • GI bleeding
  • Infection (ascites, skin, chest etc)
  • Hyponatraemia, hypokalaemia, hypoglycaemia
  • Alcohol withdrawal
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25
What are the causes of coma in patients with chronic liver disease?
1. Hepatic encephalopathy 2. Hyponatraemia/hypoglycaemia 3. Intracranial event
26
How are the consequences of liver disease treated?
- Malnutrition - nasogastric feeding - Variceal bleeding - endoscopic banding - Encephalopathy - lactulose - Infections - antibiotics
27
What is viral hepatitis?
Inflammation of the liver caused by infection of Hep A-E.
28
How are the different types of Hepatitis spread?
A - faecal-oral B - IV C - IV D - IV E - faecal-oral
29
What signs and symptoms are associated with the prodromal phase of viral hepatitis?
- Flu-like symptoms (malaise, nausea) - Distaste for cigarettes (Hep A)
30
What signs and symptoms are associated with the icteric phase of viral hepatitis?
- Acute jaundice (A-C) - Abdo pain - Hepatomegaly - Cholestasis - Extrahepatic features
31
What signs and symptoms are associated with the chronic phase of viral hepatitis?
Cirrhosis (C>B)
32
What investigations are ordered for patients with suspected viral hepatitis?
- FBC - LFTs - Clotting - Hep ABC serology
33
What is the supportive management of viral hepatitis?
- No alcohol - Avoid hepatotoxic drugs (eg. aspirin)
34
What is the anti-viral treatment of viral hepatitis?
- Indicated chronic disease - PEGinterferon (HBV) - PEGinterferon + ribavarin (HCV)
35
What are the complications associated with viral hepatitis?
- Cirrhosis - Liver failure - Hepatocellular carcinoma
36
What is autoimmune hepatitis?
Chronic inflammatory disease of unknown origin. Characterised by antibodies directed against hepatocyte surface antigens.
37
How is autoimmune hepatitis classified?
Depending on the autoantibodies present.
38
What are the causes of autoimmune hepatitis?
- Genetic predisposition - Environmental triggering agents - Auto-antigens - Dysfunction of immunoregulatory system Exact cause unknown, may be a combination.
39
What are the risk factors for autoimmune hepatitis?
- Young women (<40) - History of viral infections - Family history - Autoimmune disease comorbidity
40
How do patients with autoimmune hepatitis present?
- Constitutional symptoms - Cushingoid symptoms - Hepatitis - Hepatosplenomegaly - Fever - Other less common symptoms
41
What investigations are ordered in suspected autoimmune hepatitis?
- LFTs - IgG - Auto-antibodies - Low WCC and platelets - Liver biopsy
42
What is the management of autoimmune hepatitis?
- Immunosuppression (prednisolone) - Liver transplant
43
What are the complications associated with autoimmune hepatitis?
- Cirrhosis - Hyperviscosity syndrome - Hepatocellular carcinoma - Complications of treatment
44
What is biliary colic?
Gallstones obstructing the cystic duct or passing into the common bile duct.
45
What is the pathophysiology of biliary colic?
Gallbladder spasm against a stone, impacts the neck of the gallbladder. Stone may be in the common bile duct (less common).
46
What are the risk factors for biliary colic?
Same as gallstones (5 F's) - Family history - Female - Forty - Fat - Fertile
47
How does a patient with biliary colic present?
- RUQ pain radiating to back - Associated with sweating pallor, nausea, vomiting - Tenderness in right hyperchondrium - Possible jaundice
48
What urine tests should be done for suspected biliary colic?
- Bilirubin - Urobilinogen - Haemoglobin
49
What blood tests should be done for suspected biliary colic?
- FBC - U&Es - Amylase - LFTs - Clotting - CRP
50
What imaging should be done for suspected biliary colic?
- AXR - CXR - Ultrasound
51
What are the differential diagnoses for biliary colic?
- Cholecystitis or other gallstone disease - Pancreatitis - Bowel perforation
52
What is the conservative management of biliary colic?
- Rehydrate - Nil by mouth - Opioid analgesia
53
Why is surgery preferred in the management of biliary colic?
It has a high recurrence rate.
54
What is the surgical management of biliary colic?
Laparoscopic cholecystectomy.
55
What are the complications associated with biliary colic?
- Mirizzi syndrome - Gallbladder empyema - Chronic cholecystitis - Gallstone ileus
56
What is acute cholecystitis?
Inflammation of the gallbladder that develops over hours.
57
What is the pathophysiology of acute cholecystitis?
Stone impaction in Hartmann's pouch, leading to chemical/bacterial inflammation.
58
What are the causes of acute cholecystitis?
- Gallstones - Tumour - Bile duct blockage - Infection - Blood vessel problems
59
How do patients with acute cholecystitis present?
- Severe RUQ pain (radiates to scapula and epigastrium) - Fever - Vomiting
60
What is Murphy's sign?
2 fingers over the gallbladder, ask the patient to breathe in. Pain and breath catch = inflammation (Must be negative on LHS)
61
What is Boa's sign?
Hyperaesthesia below right scapula.
62
What urine tests should be done for suspected acute cholecystitis?
- Bilirubin - Urobilinogen
63
What blood tests should be done for suspected acute cholecystitis?
- FBC (raised WCC) - U&Es - Amylase - LFTs - Clotting - CRP
64
What imaging tests should be done for suspected acute cholecystitis?
- AXR - Erect CXR - Ultrasound
65
What are the signs of acute cholecystitis?
- Local peritonism in RUQ - Tachycardia with shallow breathing - Positive Murphy's sign - Potential jaundice
66
What are the differential diagnoses for acute cholecystitis?
- Peptic ulcer disease - Liver disease - Pancreatitis - Cardiac disease
67
What is the conservative management of acute cholecystitis?
- Nil by mouth - Fluid resuscitation - Analgesia - Antibiotics
68
What analgesia is given for acute cholecystitis?
- Paracetamol - Diclofenac - Codeine
69
What is the surgical management for acute cholecystitis?
Cholecystectomy.
70
What are the complications of acute cholecystitis?
- Gangrene - Perforation (rare) - Chronic cholecystitis
71
What are the symptoms of chronic cholecystitis?
- 'flatulent dyspepsia' - Vague upper abdominal discomfort - Nausea - Distension, bloating - Flatulence
72
What exacerbates symptoms of chronic cholecystitis?
Fatty foods - CCK release stimulates the gallbladder
73
What investigations are ordered for chronic cholecystitis?
- AXR - US - Magnetic resonance cholangiopancreatography
74
What is found on an AXR in chronic cholecystitis?
Porcelain gallbladder.
75
What is found on an ultrasound in chronic cholecystitis?
- Stones - Fibrosis - Shrunken gallbladder
76
What are the differential diagnoses of chronic cholecystitis?
- Peptic ulcer disease - IBS - Hiatus hernia - Chronic pancreatitis
77
What is the medical management of chronic cholecystitis?
Bile salts (not very effective)
78
What is the surgical management of chronic cholecystitis?
Elective cholecystectomy or ERCP. (Endoscopic retrograde cholangiopancreatography)
79
What is ascending cholangitis?
Inflammation of the bile duct.
80
What is the pathophysiology of ascending cholangitis?
Bacterial seeding of the biliary tree due to common bile duct obstruction. Sludge formation creates a growth medium for bacteria.
81
What causes ascending cholangitis?
- Gallstones - Iatrogenic (ERCP) - Cholangiocarcinoma - Ascending infection from duodenum junction
82
What are the risk factors for ascending cholangitis?
- History of gallstones - Sclerosing cholangitis - HIV - Narrowing of common bile duct
83
What are the symptoms of ascending cholangitis?
- Charcot's triad - Reynold's pentad
84
What is Charcot's triad?
- Fever - RUQ pain - Jaundice
85
What is Reynold's pentad?
- Charcot's triad - Shock - Confusion
86
What blood tests should be done for suspected ascending cholangitis and what results would be expected?
- FBC (elevated WCC) - CRP (elevated) - LFTs (hyperbilirubinaemia)
87
What imaging tests should be ordered for suspected ascending cholangitis?
Transabdominal ultrasound.
88
What are the common differential diagnoses for ascending cholangitis?
- Acute cholecystitis - Peptic ulcer disease - Acute pancreatitis - Hepatic abscess - Acute appendicitis
89
What is the management of ascending cholangitis?
- Antibiotics - ERCP - Open or laparoscopic stone removal with T tube drain
90
What are the possible complications of ascending cholangitis?
- Acute pancreatitis - Hepatic abscess
91
What is acute pancreatitis?
Acute inflammation of the pancreas.
92
What is the pathophysiology of acute pancreatitis?
- Pancreatic enzymes released and deactivated - Hypovolaemic shock - Enzymes cause autodigestion leading to retroperitoneal haemorrhage - Necrosis
93
What are the causes of acute pancreatitis?
I GET SMASHED - Idiopathic - Gallstones - Ethanol (alcohol) - Trauma - Steroids - Mumps (and other infections) - Autoimmune - Scorpion - Hyper (lipidaemia, calcaemia, thermia) - ERCP - Drugs (thiazides)
94
What are the risk factors for acute pancreatitis?
- Alcoholism - Smoking - Obesity - Family history
95
What are the symptoms associated with acute pancreatitis?
Severe epigastric pain and vomiting.
96
What blood tests are done for suspected acute pancreatitis?
- FBC - Amylase and lipase - U&Es - LFTs - Glucose - CRP
97
What urine tests are done for suspected acute pancreatitis?
- Glucose - Conjugated bilirubin (high) - Urobilinogen (low)
98
What imaging tests are done for suspected acute pancreatitis?
- CXR - AXR - Ultrasound - Contrast CT
99
What is the first-line test for suspected acute pancreatitis?
Serum amylase.
100
What signs are associated with acute pancreatitis?
- High HR and RR - Fever - Hypovolaemia - Epigastric tenderness - Jaundice - Ileus
101
What are the differential diagnoses for acute pancreatitis?
- Perforated duodenal ulcer - Mesenteric infarction - Myocardial infarction
102
What is the Glasgow criteria for assessing the severity of acute pancreatitis?
PANCREAS: - PaO2 - Age - Neutrophils - Ca2+ - Renal function - Enzymes - Albumin - Sugar
103
What is the conservative management of acute pancreatitis?
- Fluid resuscitation - Pancreatic rest (nil by mouth) - Analgesia - Antibiotics
104
What is the surgical management of acute pancreatitis?
Laparotomy.
105
What are the indications for surgical management of acute pancreatitis?
- Infected pancreatic necrosis - Pseudocyst/abscess - Unsure diagnosis
106
What is the interventional management of acute pancreatitis?
ERCP
107
What are the possible early complications of acute pancreatitis?
- ARDS - Pleural effusion - Hypovolaemic shock - Sepsis - Renal failure - Metabolic acidosis
108
What are the possible late complications of acute pancreatitis?
- Pancreatic necrosis - Pancreatic infection - Pancreatic abscess - Thrombosis - Bleeding
109
What is chronic pancreatitis?
Progressive inflammation of the pancreas marked by frequent acute attacks and risk of permanent organ damage.
110
What are the causes of chronic pancreatitis?
AGITS: - Alcohol - Genetic (CF, haemochromatosis) - Immune - Triglycerides - Structural (obstruction by tumour)
111
What are the risk factors for chronic pancreatitis?
- Male sex - Alcohol misuse - Smoking - Obesity - Recurrent acute pancreatitis - CKD - Gallstones
112
How might a patient with chronic pancreatitis present?
- Epigastric pain - Steatorrhoea - Weight loss - Diabetes mellitus - Epigastric mass
113
What investigations are ordered in suspected chronic pancreatitis?
- Ultrasound - AXR - CT
114
What are the signs of chronic pancreatitis?
- Hyperglycaemia - low faecal elastase - Pseudocyst - Speckled pancreatic calcification
115
What are the differential diagnoses for chronic pancreattis?
- Peptic ulcer disease - Reflux disease - Abdominal aortic aneurysm - Biliary colic - Chronic mesenteric ischaemia
116
What is the lifestyle management of chronic pancreatitis?
- No alcohol - Low fat, high carb diet
117
What is the medical management of chronic pancreatitis?
- Analgesia - Enzyme supplements - ADEK vitamins - Management of diabetes mellitus
118
What is the surgical management of chronic pancreatitis?
- Distal pancreatectomy (Whipple's) - Pancreaticojejunostomy - Endoscopic stenting
119
What are the complications of pancreatitis?
- Pseudocyst - Diabetes mellitus - Pancreatic calcification - Pancreatic swelling - Splenic vein thrombosis
120
Where can venous collaterals occur in portal hypertension?
- Gastro-oesophageal junction - Anterior abdominal wall - Anorectal junction - Veins from the retroperitoneal viscera
121
What are the consequences of portal hypertension?
SAVE: - Splenomegaly - Ascites - Varices - Encephalopathy
122
What are the pre-hepatic causes of portal hypertension?
Portal vein thrombosis
123
What are the hepatic causes of portal hypertension?
- Cirrhosis - Schistosomiasis - Sarcoidosis
124
What are the post-hepatic causes of portal hypertension?
- Budd-Chiari syndrome - Right heart failure - Constrictive pericarditis - Tricuspid regurgitation
125
What are the risk factors for portal hypertension?
- Cirrhosis - Congestive heart failure - Arteriovenous malformations - Hypercoagulable states
126
What are the signs and symptoms of portal hypertension?
- Ascites - Hepatic encephalopathy - Variceal bleeding - Splenomegaly
127
When will a patient exhibit symptoms of portal hypertension?
Pressure reaches high levels and causes complications.
128
What investigations are ordered for patients with suspected portal hypertension?
- Abdominal ultrasound (dilated portal vein) - Doppler ultrasound (slow velocity) - Endoscopy (presence of oesophageal varices)
129
What are the common differential diagnoses of portal hypertension?
- Budd-Chiari syndrome - Cirrhosis - Constrictive pericarditis - Myeloproliferative disease - Polycystic kidney disease - Other less common
130
What is the management of portal hypertension?
- Treat the underlying cause - Salt reduction and diuretics - Beta-blockers and nitrates to reduce blood pressure
131
WHat are the potential complications of portal hypertension?
- Bleeding from gastric or oesophageal varices - Ascites - Pulmonary hypertension - Hepatopulmonary syndrome - Liver failure - Hepatic encephalopathy
132
What are ascites?
An accumulation of free fluid in the peritoneal cavity.
133
What is the pathophysiology?
- Local inflammation - Low protein - Low flow
134
What are the risk factors for ascites?
- High sodium diet - Hepatocellular carcinoma - Splanchnic vein thrombosis resulting in portal hypertension
135
What are the signs and symptoms of ascites?
- Abdominal swelling - Distended abdomen - Fullness in flanks - Mild abdo pain and discomfort - Respiratory distress
136
How is ascites diagnosed?
- Shifting dullness - Diagnostic aspiration of ascitic fluid
137
How is ascites treated?
- Treat the underlying issue - Reduce sodium - Increase renal sodium excretion - Diuretic - Drain fluid - Shunts
138
What is peritonitis?
Inflammation of the peritoneum. Can be primary (eg. bacterial infection/ascites) or secondary (eg. bile).
139
How is peritonitis classified?
1. Onset - Acute - Chronic 2. Source of origin - Primary - Secondary
140
What causes peritonitis?
Most often bacterial infection. Can be chemical (due to blockage), traumatic or ischaemic.
141
What are the clinical presentations of peritonitis?
- Pain - Nausea - Fever - Tachycardia - Rebound tenderness - Localised guarding - Subphrenic pain
142
What investigations are done for peritonitis?
- Urine dipstick for UTI - ECG - U&Es - FBC - Serum amylase - Group and save
143
How is peritonitis managed?
- Treat underlying cause - NG tube - IV fluids - IV antibiotics - Surgery

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