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Phase 2a > Liver > Flashcards

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
Q

What are the causes of coma in patients with chronic liver disease?

A
  1. Hepatic encephalopathy
  2. Hyponatraemia/hypoglycaemia
  3. Intracranial event
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26
Q

How are the consequences of liver disease treated?

A
  • Malnutrition - nasogastric feeding
  • Variceal bleeding - endoscopic banding
  • Encephalopathy - lactulose
  • Infections - antibiotics
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27
Q

What is viral hepatitis?

A

Inflammation of the liver caused by infection of Hep A-E.

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28
Q

How are the different types of Hepatitis spread?

A

A - faecal-oral
B - IV
C - IV
D - IV
E - faecal-oral

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29
Q

What signs and symptoms are associated with the prodromal phase of viral hepatitis?

A
  • Flu-like symptoms (malaise, nausea)
  • Distaste for cigarettes (Hep A)
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30
Q

What signs and symptoms are associated with the icteric phase of viral hepatitis?

A
  • Acute jaundice (A-C)
  • Abdo pain
  • Hepatomegaly
  • Cholestasis
  • Extrahepatic features
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31
Q

What signs and symptoms are associated with the chronic phase of viral hepatitis?

A

Cirrhosis (C>B)

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32
Q

What investigations are ordered for patients with suspected viral hepatitis?

A
  • FBC
  • LFTs
  • Clotting
  • Hep ABC serology
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33
Q

What is the supportive management of viral hepatitis?

A
  • No alcohol
  • Avoid hepatotoxic drugs (eg. aspirin)
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34
Q

What is the anti-viral treatment of viral hepatitis?

A
  • Indicated chronic disease
  • PEGinterferon (HBV)
  • PEGinterferon + ribavarin (HCV)
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35
Q

What are the complications associated with viral hepatitis?

A
  • Cirrhosis
  • Liver failure
  • Hepatocellular carcinoma
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36
Q

What is autoimmune hepatitis?

A

Chronic inflammatory disease of unknown origin.

Characterised by antibodies directed against hepatocyte surface antigens.

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37
Q

How is autoimmune hepatitis classified?

A

Depending on the autoantibodies present.

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38
Q

What are the causes of autoimmune hepatitis?

A
  • Genetic predisposition
  • Environmental triggering agents
  • Auto-antigens
  • Dysfunction of immunoregulatory system

Exact cause unknown, may be a combination.

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39
Q

What are the risk factors for autoimmune hepatitis?

A
  • Young women (<40)
  • History of viral infections
  • Family history
  • Autoimmune disease comorbidity
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40
Q

How do patients with autoimmune hepatitis present?

A
  • Constitutional symptoms
  • Cushingoid symptoms
  • Hepatitis
  • Hepatosplenomegaly
  • Fever
  • Other less common symptoms
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41
Q

What investigations are ordered in suspected autoimmune hepatitis?

A
  • LFTs
  • IgG
  • Auto-antibodies
  • Low WCC and platelets
  • Liver biopsy
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42
Q

What is the management of autoimmune hepatitis?

A
  • Immunosuppression (prednisolone)
  • Liver transplant
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43
Q

What are the complications associated with autoimmune hepatitis?

A
  • Cirrhosis
  • Hyperviscosity syndrome
  • Hepatocellular carcinoma
  • Complications of treatment
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44
Q

What is biliary colic?

A

Gallstones obstructing the cystic duct or passing into the common bile duct.

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45
Q

What is the pathophysiology of biliary colic?

A

Gallbladder spasm against a stone, impacts the neck of the gallbladder.

Stone may be in the common bile duct (less common).

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46
Q

What are the risk factors for biliary colic?

A

Same as gallstones (5 F’s)
- Family history
- Female
- Forty
- Fat
- Fertile

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47
Q

How does a patient with biliary colic present?

A
  • RUQ pain radiating to back
  • Associated with sweating pallor, nausea, vomiting
  • Tenderness in right hyperchondrium
  • Possible jaundice
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48
Q

What urine tests should be done for suspected biliary colic?

A
  • Bilirubin
  • Urobilinogen
  • Haemoglobin
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49
Q

What blood tests should be done for suspected biliary colic?

A
  • FBC
  • U&Es
  • Amylase
  • LFTs
  • Clotting
  • CRP
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50
Q

What imaging should be done for suspected biliary colic?

A
  • AXR
  • CXR
  • Ultrasound
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51
Q

What are the differential diagnoses for biliary colic?

A
  • Cholecystitis or other gallstone disease
  • Pancreatitis
  • Bowel perforation
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52
Q

What is the conservative management of biliary colic?

A
  • Rehydrate
  • Nil by mouth
  • Opioid analgesia
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53
Q

Why is surgery preferred in the management of biliary colic?

A

It has a high recurrence rate.

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54
Q

What is the surgical management of biliary colic?

A

Laparoscopic cholecystectomy.

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55
Q

What are the complications associated with biliary colic?

A
  • Mirizzi syndrome
  • Gallbladder empyema
  • Chronic cholecystitis
  • Gallstone ileus
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56
Q

What is acute cholecystitis?

A

Inflammation of the gallbladder that develops over hours.

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57
Q

What is the pathophysiology of acute cholecystitis?

A

Stone impaction in Hartmann’s pouch, leading to chemical/bacterial inflammation.

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58
Q

What are the causes of acute cholecystitis?

A
  • Gallstones
  • Tumour
  • Bile duct blockage
  • Infection
  • Blood vessel problems
59
Q

How do patients with acute cholecystitis present?

A
  • Severe RUQ pain (radiates to scapula and epigastrium)
  • Fever
  • Vomiting
60
Q

What is Murphy’s sign?

A

2 fingers over the gallbladder, ask the patient to breathe in.

Pain and breath catch = inflammation

(Must be negative on LHS)

61
Q

What is Boa’s sign?

A

Hyperaesthesia below right scapula.

62
Q

What urine tests should be done for suspected acute cholecystitis?

A
  • Bilirubin
  • Urobilinogen
63
Q

What blood tests should be done for suspected acute cholecystitis?

A
  • FBC (raised WCC)
  • U&Es
  • Amylase
  • LFTs
  • Clotting
  • CRP
64
Q

What imaging tests should be done for suspected acute cholecystitis?

A
  • AXR
  • Erect CXR
  • Ultrasound
65
Q

What are the signs of acute cholecystitis?

A
  • Local peritonism in RUQ
  • Tachycardia with shallow breathing
  • Positive Murphy’s sign
  • Potential jaundice
66
Q

What are the differential diagnoses for acute cholecystitis?

A
  • Peptic ulcer disease
  • Liver disease
  • Pancreatitis
  • Cardiac disease
67
Q

What is the conservative management of acute cholecystitis?

A
  • Nil by mouth
  • Fluid resuscitation
  • Analgesia
  • Antibiotics
68
Q

What analgesia is given for acute cholecystitis?

A
  • Paracetamol
  • Diclofenac
  • Codeine
69
Q

What is the surgical management for acute cholecystitis?

A

Cholecystectomy.

70
Q

What are the complications of acute cholecystitis?

A
  • Gangrene
  • Perforation (rare)
  • Chronic cholecystitis
71
Q

What are the symptoms of chronic cholecystitis?

A
  • ‘flatulent dyspepsia’
  • Vague upper abdominal discomfort
  • Nausea
  • Distension, bloating
  • Flatulence
72
Q

What exacerbates symptoms of chronic cholecystitis?

A

Fatty foods - CCK release stimulates the gallbladder

73
Q

What investigations are ordered for chronic cholecystitis?

A
  • AXR
  • US
  • Magnetic resonance cholangiopancreatography
74
Q

What is found on an AXR in chronic cholecystitis?

A

Porcelain gallbladder.

75
Q

What is found on an ultrasound in chronic cholecystitis?

A
  • Stones
  • Fibrosis
  • Shrunken gallbladder
76
Q

What are the differential diagnoses of chronic cholecystitis?

A
  • Peptic ulcer disease
  • IBS
  • Hiatus hernia
  • Chronic pancreatitis
77
Q

What is the medical management of chronic cholecystitis?

A

Bile salts (not very effective)

78
Q

What is the surgical management of chronic cholecystitis?

A

Elective cholecystectomy or ERCP.

(Endoscopic retrograde cholangiopancreatography)

79
Q

What is ascending cholangitis?

A

Inflammation of the bile duct.

80
Q

What is the pathophysiology of ascending cholangitis?

A

Bacterial seeding of the biliary tree due to common bile duct obstruction.

Sludge formation creates a growth medium for bacteria.

81
Q

What causes ascending cholangitis?

A
  • Gallstones
  • Iatrogenic (ERCP)
  • Cholangiocarcinoma
  • Ascending infection from duodenum junction
82
Q

What are the risk factors for ascending cholangitis?

A
  • History of gallstones
  • Sclerosing cholangitis
  • HIV
  • Narrowing of common bile duct
83
Q

What are the symptoms of ascending cholangitis?

A
  • Charcot’s triad
  • Reynold’s pentad
84
Q

What is Charcot’s triad?

A
  • Fever
  • RUQ pain
  • Jaundice
85
Q

What is Reynold’s pentad?

A
  • Charcot’s triad
  • Shock
  • Confusion
86
Q

What blood tests should be done for suspected ascending cholangitis and what results would be expected?

A
  • FBC (elevated WCC)
  • CRP (elevated)
  • LFTs (hyperbilirubinaemia)
87
Q

What imaging tests should be ordered for suspected ascending cholangitis?

A

Transabdominal ultrasound.

88
Q

What are the common differential diagnoses for ascending cholangitis?

A
  • Acute cholecystitis
  • Peptic ulcer disease
  • Acute pancreatitis
  • Hepatic abscess
  • Acute appendicitis
89
Q

What is the management of ascending cholangitis?

A
  • Antibiotics
  • ERCP
  • Open or laparoscopic stone removal with T tube drain
90
Q

What are the possible complications of ascending cholangitis?

A
  • Acute pancreatitis
  • Hepatic abscess
91
Q

What is acute pancreatitis?

A

Acute inflammation of the pancreas.

92
Q

What is the pathophysiology of acute pancreatitis?

A
  • Pancreatic enzymes released and deactivated
  • Hypovolaemic shock
  • Enzymes cause autodigestion leading to retroperitoneal haemorrhage
  • Necrosis
93
Q

What are the causes of acute pancreatitis?

A

I GET SMASHED
- Idiopathic
- Gallstones
- Ethanol (alcohol)
- Trauma
- Steroids
- Mumps (and other infections)
- Autoimmune
- Scorpion
- Hyper (lipidaemia, calcaemia, thermia)
- ERCP
- Drugs (thiazides)

94
Q

What are the risk factors for acute pancreatitis?

A
  • Alcoholism
  • Smoking
  • Obesity
  • Family history
95
Q

What are the symptoms associated with acute pancreatitis?

A

Severe epigastric pain and vomiting.

96
Q

What blood tests are done for suspected acute pancreatitis?

A
  • FBC
  • Amylase and lipase
  • U&Es
  • LFTs
  • Glucose
  • CRP
97
Q

What urine tests are done for suspected acute pancreatitis?

A
  • Glucose
  • Conjugated bilirubin (high)
  • Urobilinogen (low)
98
Q

What imaging tests are done for suspected acute pancreatitis?

A
  • CXR
  • AXR
  • Ultrasound
  • Contrast CT
99
Q

What is the first-line test for suspected acute pancreatitis?

A

Serum amylase.

100
Q

What signs are associated with acute pancreatitis?

A
  • High HR and RR
  • Fever
  • Hypovolaemia
  • Epigastric tenderness
  • Jaundice
  • Ileus
101
Q

What are the differential diagnoses for acute pancreatitis?

A
  • Perforated duodenal ulcer
  • Mesenteric infarction
  • Myocardial infarction
102
Q

What is the Glasgow criteria for assessing the severity of acute pancreatitis?

A

PANCREAS:
- PaO2
- Age
- Neutrophils
- Ca2+
- Renal function
- Enzymes
- Albumin
- Sugar

103
Q

What is the conservative management of acute pancreatitis?

A
  • Fluid resuscitation
  • Pancreatic rest (nil by mouth)
  • Analgesia
  • Antibiotics
104
Q

What is the surgical management of acute pancreatitis?

A

Laparotomy.

105
Q

What are the indications for surgical management of acute pancreatitis?

A
  • Infected pancreatic necrosis
  • Pseudocyst/abscess
  • Unsure diagnosis
106
Q

What is the interventional management of acute pancreatitis?

A

ERCP

107
Q

What are the possible early complications of acute pancreatitis?

A
  • ARDS
  • Pleural effusion
  • Hypovolaemic shock
  • Sepsis
  • Renal failure
  • Metabolic acidosis
108
Q

What are the possible late complications of acute pancreatitis?

A
  • Pancreatic necrosis
  • Pancreatic infection
  • Pancreatic abscess
  • Thrombosis
  • Bleeding
109
Q

What is chronic pancreatitis?

A

Progressive inflammation of the pancreas marked by frequent acute attacks and risk of permanent organ damage.

110
Q

What are the causes of chronic pancreatitis?

A

AGITS:
- Alcohol
- Genetic (CF, haemochromatosis)
- Immune
- Triglycerides
- Structural (obstruction by tumour)

111
Q

What are the risk factors for chronic pancreatitis?

A
  • Male sex
  • Alcohol misuse
  • Smoking
  • Obesity
  • Recurrent acute pancreatitis
  • CKD
  • Gallstones
112
Q

How might a patient with chronic pancreatitis present?

A
  • Epigastric pain
  • Steatorrhoea
  • Weight loss
  • Diabetes mellitus
  • Epigastric mass
113
Q

What investigations are ordered in suspected chronic pancreatitis?

A
  • Ultrasound
  • AXR
  • CT
114
Q

What are the signs of chronic pancreatitis?

A
  • Hyperglycaemia
  • low faecal elastase
  • Pseudocyst
  • Speckled pancreatic calcification
115
Q

What are the differential diagnoses for chronic pancreattis?

A
  • Peptic ulcer disease
  • Reflux disease
  • Abdominal aortic aneurysm
  • Biliary colic
  • Chronic mesenteric ischaemia
116
Q

What is the lifestyle management of chronic pancreatitis?

A
  • No alcohol
  • Low fat, high carb diet
117
Q

What is the medical management of chronic pancreatitis?

A
  • Analgesia
  • Enzyme supplements
  • ADEK vitamins
  • Management of diabetes mellitus
118
Q

What is the surgical management of chronic pancreatitis?

A
  • Distal pancreatectomy (Whipple’s)
  • Pancreaticojejunostomy
  • Endoscopic stenting
119
Q

What are the complications of pancreatitis?

A
  • Pseudocyst
  • Diabetes mellitus
  • Pancreatic calcification
  • Pancreatic swelling
  • Splenic vein thrombosis
120
Q

Where can venous collaterals occur in portal hypertension?

A
  • Gastro-oesophageal junction
  • Anterior abdominal wall
  • Anorectal junction
  • Veins from the retroperitoneal viscera
121
Q

What are the consequences of portal hypertension?

A

SAVE:
- Splenomegaly
- Ascites
- Varices
- Encephalopathy

122
Q

What are the pre-hepatic causes of portal hypertension?

A

Portal vein thrombosis

123
Q

What are the hepatic causes of portal hypertension?

A
  • Cirrhosis
  • Schistosomiasis
  • Sarcoidosis
124
Q

What are the post-hepatic causes of portal hypertension?

A
  • Budd-Chiari syndrome
  • Right heart failure
  • Constrictive pericarditis
  • Tricuspid regurgitation
125
Q

What are the risk factors for portal hypertension?

A
  • Cirrhosis
  • Congestive heart failure
  • Arteriovenous malformations
  • Hypercoagulable states
126
Q

What are the signs and symptoms of portal hypertension?

A
  • Ascites
  • Hepatic encephalopathy
  • Variceal bleeding
  • Splenomegaly
127
Q

When will a patient exhibit symptoms of portal hypertension?

A

Pressure reaches high levels and causes complications.

128
Q

What investigations are ordered for patients with suspected portal hypertension?

A
  • Abdominal ultrasound (dilated portal vein)
  • Doppler ultrasound (slow velocity)
  • Endoscopy (presence of oesophageal varices)
129
Q

What are the common differential diagnoses of portal hypertension?

A
  • Budd-Chiari syndrome
  • Cirrhosis
  • Constrictive pericarditis
  • Myeloproliferative disease
  • Polycystic kidney disease
  • Other less common
130
Q

What is the management of portal hypertension?

A
  • Treat the underlying cause
  • Salt reduction and diuretics
  • Beta-blockers and nitrates to reduce blood pressure
131
Q

WHat are the potential complications of portal hypertension?

A
  • Bleeding from gastric or oesophageal varices
  • Ascites
  • Pulmonary hypertension
  • Hepatopulmonary syndrome
  • Liver failure
  • Hepatic encephalopathy
132
Q

What are ascites?

A

An accumulation of free fluid in the peritoneal cavity.

133
Q

What is the pathophysiology?

A
  • Local inflammation
  • Low protein
  • Low flow
134
Q

What are the risk factors for ascites?

A
  • High sodium diet
  • Hepatocellular carcinoma
  • Splanchnic vein thrombosis resulting in portal hypertension
135
Q

What are the signs and symptoms of ascites?

A
  • Abdominal swelling
  • Distended abdomen
  • Fullness in flanks
  • Mild abdo pain and discomfort
  • Respiratory distress
136
Q

How is ascites diagnosed?

A
  • Shifting dullness
  • Diagnostic aspiration of ascitic fluid
137
Q

How is ascites treated?

A
  • Treat the underlying issue
  • Reduce sodium
  • Increase renal sodium excretion
  • Diuretic
  • Drain fluid
  • Shunts
138
Q

What is peritonitis?

A

Inflammation of the peritoneum.

Can be primary (eg. bacterial infection/ascites) or secondary (eg. bile).

139
Q

How is peritonitis classified?

A
  1. Onset
    - Acute
    - Chronic
  2. Source of origin
    - Primary
    - Secondary
140
Q

What causes peritonitis?

A

Most often bacterial infection.

Can be chemical (due to blockage), traumatic or ischaemic.

141
Q

What are the clinical presentations of peritonitis?

A
  • Pain
  • Nausea
  • Fever
  • Tachycardia
  • Rebound tenderness
  • Localised guarding
  • Subphrenic pain
142
Q

What investigations are done for peritonitis?

A
  • Urine dipstick for UTI
  • ECG
  • U&Es
  • FBC
  • Serum amylase
  • Group and save
143
Q

How is peritonitis managed?

A
  • Treat underlying cause
  • NG tube
  • IV fluids
  • IV antibiotics
  • Surgery

Phase 2a (11 decks)

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