Liver Flashcards
1
Q
what are the functions of the liver
A
where oestrogen level regulation
albumin production
clotting factors
sorage
metabolism of carbs
immunity (Kupfer)
detoxification
bilirubin metabolism
2
Q
what are markers of liver function
A
bilirubin - conjugated vs unconjugated
albumin
prothrombin time (PT/INR)
3
Q
what happens to levels of bilirubin in liver damage
A
increase
4
Q
what happens to levels of albumin in liver damage
A
decrease
5
Q
what happens to prothrombin time in liver disease
A
it increases
6
Q
Where are ALT and AST found
A
found in the liver, heart, kidney and muscles
7
Q
why do you test for ALT and AST
A
they will show an increase in liver damage (likely) as they spill out into the blood
8
Q
what is the ratio of AST:ALT seen in alcoholic liver disease (typically)
A
> 2:1 (especially with an increased GGT)
9
Q
what is the GGT test used for
A
it is the gamma-glutamyl transferase test - which measures the amount GGT in the blood, which increases when the liver is damaged
10
Q
when might you see an increase in ALP levels
A
in biliary tree specific damage
11
Q
what is acute liver damage
A
when there is liver injury which ic accompanied with HE, Jaundice and coagulopathy (>1.5INR) in a patient with a previously normal liver
12
Q
what is the main cause of acute liver failure (fulminant liver failure) in the UK
A
Paracetamol overdose
13
Q
what is fulminant liver failure
A
it is a rare syndrome of massive hepatocyte necrosis
14
Q
what is seen histologically in acute liver failure
A
multiacinar necrosis
15
Q
what is hyper acute fulminant liver failure
A
Hepatic encephalopathy within 7 days of jaundice
16
Q
what is acute fulminant liver failure
A
it is hepatic encephalopathy within 8-28 days of jaundice
17
Q
what is chronic liver failure
A
a patient which has a progressive history of liver disease
18
Q
what are causes of acute liver injury
A
viral - HepA, B, E, CMV, EBV
autoimmune hepatitis
drugs - paracetamol, alcohol, ecstasy
HCC
metabolic - wilsons, haemochromotosis, A1ATD
Budd chiari
19
Q
how does liver failure progress from hepatitis
A
hepatitis - fibrosis - compensated cirrhosis - decompensated cirrhosis
20
Q
what are symptoms of acute liver failure
A
jaundice, coagulopathy, hepatic encephalopathy
- spider naevi
- fetor hepaticus
- caput-medusae
- Dupuytren’s contracture
21
Q
what are the West haven criteria grades 1-4 for hepatic encephalopathy
A
- altered mood and sleep issues
- lethargy, mild confusion, asterixis
- marked confusion, somnolent
- comatose
22
Q
How do you diagnose acute liver injury
A
Bloods (LFTs)
imaging: ECG to grade the HE, USS to check budd chiari
microbiology to rule out infection
23
Q
what microbiological test will be performed in acute liver injury to rule out infection
A
blood culture
urine culture
ascitic tap
24
Q
what would be seen on bloods in an acute liver injury
A
increased bilirubin, decreased albumin, increased prothrombin time and INR. There will be an increased serum AST and ALT, increased NH3 and a decreased glucose
25
how do you acutely treat acute liver failure
ITU - ABCDE
fluids
analgesia
26
how do you treat acute liver failure
treat the underlying cause and complications
- increase ICP give IV mannitol
- HE give lactulose
- ascites give diuretics
- haemorrhage - give vitamin K
27
what are the two outcomes for acute liver injury
can lead to liver failure or recovery
28
what is the presentation of acute liver injury
malaise, nausea, anorexia, jaundice
rare
- confusion
- bleeding
- liver pain
- hypoglucaemia
29
what is the presentation of chronic liver injury
ascites
oedema
haematemesis (varices)
malaise
anorexia
wasting
easy bruising
hepatomegaly
abnormal LFTs
30
what are the two types of liver enzymes tested for
cholestatic: alkaline phosphate and gamma GT
hepatocellular: transaminases (AST, ALT)
31
what are the reasons someone may develop pre-hepatic jaundice
Gilbert syndrome
Haemolysis
32
What are causes for conjugated bilirubin jaundice
liver disease - hepatic
bile duct obstruction - post hepatic
33
what is chronic liver failure
it is progressive liver disease over 6 months due to repeated liver insults
34
what are risk factors of developing chronic liver failure
alcohol, obesity, T2DM, drugs, inherited metabolic disease, autoimmunity
35
what are causes of chronic liver failure
1. Alcohol related liver disease
2. Non-alcoholic fatty liver disease
3. Viral
36
what is the pathophysiology behind chronic liver failure development
Hepatitis/cholestasis - fibrosis (reversible) - cirrhosis (irreversible) - compensated or decompensated liver failure
37
what are the symptoms of decompensated liver failure
jaundice, hepatic encephalopathy, ascites, coagulopathy, low serum albumin
38
what is the Childpugh score
it assesses the prognosis and extent of the treatment required for chronic liver failure
- especially for decompensated cirrhosis
39
what are the classes scores of the Childpugh score
A = 100% 1y survival
B = 80% 1y survival
C = 45% 1y survival
40
what is a clear risk factor for developing hepatocellular carcinoma
end-stage liver failure with decompensated cirrhosis
41
what is the MELD score
it is the model for end-stage liver disease liver disease, which stratifies the severity of ESLD for transplant planning
42
what are symptoms of chronic liver injury
jaundice, ascites, hepatic encephalopathy, oesophageal varices, palmar erythema, gynecomastia, clubbing, setor hepaticus, Dupuytren's contracture
43
how do you diagnose chronic liver failure
Liver biopsy - see the extent of CLD
Lifer function tests
Imaging: USS
Ascetic tap culture
44
what is the treatment for chronic liver failure
prevent progression - lifestyle modifying
consider liver transplant (if decompensated)
manage the complications
45
what lifestyle changes can be made to prevent chronic liver failure progression
drink less alcohol
decreased BMI
46
what do you give to manage hepatic encephalopathy
lactulose
47
how do you manage ascites
diuretics
48
what is ascites
build up of fluid in the belly
49
what are risk factors for alcohol liver disease
chronic alcohol consumption
obesity
smoking
50
how does alcoholic liver disease progress
steatosis - fatty liver undamaged
alcoholic hepatitis - mallory bodies
alcoholic cirrhosis - micronodular
51
what are the symptoms of alcoholic liver disease
early stages may show very little symptoms
in the more severe stages patients will develop chronic liver failure symptoms and alcohol dependency
52
what symptoms are seen in late stage alcoholic liver disease
jaundice
hepatomegaly
Dupuytren contracture
ascites
hepatic encephalopathy
spider naeiri
easy bruising
53
what is the maximum units of alcohol recommended per week
14 units a week
54
how do you work out the units using alcohol ABV
Strength (ABV) X Vol/ml ÷ 1000
55
how much is one unit of alcohol in g and mL
1. 8g
2. 10mL
56
what are the two types of gall stone
1. Cholesterol stones (70%)
2. Pigment stones (30%)
57
how do you manage gall stones
- laparoscopic cholecystectomy
- bile acid dissolution therapy
if they are in the bile duct
- ERCP with sphincterotomy and removal
- surgery with large stones
58
what type of liver disease is itching associated with
cholestatic liver disease
59
what are the different types of drug-induced liver injury
hepatocellular
cholestatic
mixed
60
what are the common drugs which cause drug-induced liver disease
antibiotics - augmentin, flucloxacillin
CNS drugs
immunosuppressants
analgesics/MSK - diclofenac
Gastrointestinal drugs - PPIs
Dietary supplements
multiple drugs
61
what is the alcohol dependency questionnaire CAGE
1. should you Cut down
2. are people Annoyed by your drinking
3. do you feel Guilty about drinking
4. do you drink in the morning (Eye opening)
62
other than CAGE what other alcohol dependency questionnaires can be used
AUDIT - 10 questions: alcohol use disorder ID test
63
how do you diagnose alcohol liver disease
bloods - LFTs, FCB (macrocytic non megaloblastic anaemia)
Biopsy - to confirm extent of cirrhosis
64
what is the treatment for alcoholic liver disease
STOP ALCOHOL
give diazepam for tremors (withdrawal)
healthy diet and reduce BMI
steroids (short term)
B1 and folate supplements
liver transplant
65
what must someone with alcohol liver disease do if they need a liver transplant
must abstain for 3 plus months from alcohol before they are considered
66
what are complications of alcohol liver disease
pancreatitis
hepatic encephalopathy
ascites
hepatocellular carconoma
Mallory Weiss tear
Wernicke korsakoff syndrome
67
what is a mallory weiss tear
it is a tear of the tissue in the lower oesophagus which can be brought about by violent coughing or vomiting
68
what are the symptoms of a mallory weiss tear
blood in vomit
black or tar like stools
weakness
dizziness
faintness
shortness of breath
diarrhoea
pale
abdominal or chest pain
69
what are the infectious causes of liver failure
Viral hepatitis (B, C, CMV)
yellow fever
leptospirosis
EBV
70
what is Wernicke Korsakoff syndrome
it is B1 deficiency due to excess alcohol intake.
it is the combines presence of Wenicke encephalopathy and Korsakoff syndrome
71
What are the vascular causes of liver failure
Budd-Chiari syndrome
Veno-occlusive disease
72
what is Budd - Chiari syndrome
it is a condition where the hepatic veins are blocked or narrowed by a clot
73
what toxins cause liver failure
amanita phalloides mushroom
carbon tetrachloride
paracetamol overdose
halothane
isoniazid
alcohol
74
what are obstructive causes of liver failure
fatty liver of pregnancy
eclampsia
75
what are some other causes for liver failure
autoimmune disease
Wilsons disease
Cirrhosis
76
when will prothrombin time be high
in acute renal failure
77
what is asterixis
a tremor when the wrist is extended
78
what is fetor hepaticus
breath has a strong musty smell
79
what is constructional apraxia
you cant perform tasks which involve construction i.e drawing a star
80
how is liver failure monitored
fluids = Urinary and central venous cannulas
bloods = daily
glucose = 1-4 hr plus a dextrose IV
81
what are the complications of liver failure
hepatorenal syndrome
bleeding
sepsis
ascites
hypoglycaemia
seizures
cerebral oedema
82
what are the symptoms of Wernicke Korsakoff syndrome
ataxia
nystagmus = a rhythmical, repetitive and involuntary movement of the eyes
encephalopathy
83
what is non alcoholic fatty liver disease
chronic liver disease not due to alcoholism
84
what are risk factors of non alcoholic fatty liver disease
obesity, hypertension, hyperlipidemia, type 2 diabetes, endocrine disorders, drugs (NSAIDs, amiodarone)
85
what is the disease progression of non alcoholic fatty liver disease
hepatosteatosis (non alcoholic fatty liver) - non alcoholic steatohepatitis - fibrosis - cirrhosis
86
what are the patient symptoms of non alcoholic fatty liver disease
it is typically asymptomatic: any findings are incidental initially
- if it is very severe then they will present with liver failure signs
87
how do you diagnose non alcoholic fatty liver disease
bloods = rearranged LFTs (increased PT/INR, low albumin, high bilirubin). FBC (thrombocytopenia and hyperglycaemia)
imaging = 1st line for suspected NAFLD - USS abdomen
88
how do you assess the risk of fibrosis in NAFLD
the non invasive scoring system
89
what is the treatment for NAFLD
- lose weight (reduce BMI)
- control risk factors: statins, metformin, ACE-i
- VITAMIN E
90
what are complications for NAFLD
hepatic encephalopathy
ascites
hepatocellular carcinoma
portal hypertension
oesophageal varices
91
what is viral hepatitis
inflammation of liver as a result of viral replication within hepatocytes
92
what are the features of Hep A induced hepatitis
Acute
Mild
Faecal - oral spread
Shellfish
ssRNA virus
93
what are risk factors of catching HepA
overcrowding
poor saturation
shellfish
travel
94
how long is the incubation period for Hep A
incubation is 2 weeks - replicated in the liver and excreted in the bile
95
what are the symptoms of HepA
prodromal phase - 1-2 weeks
- malaise, nausea, vomiting, fever
Then jaundice, dark urine, pale stools, hepatosplenomegaly
96
how do you diagnose HepA
bloods - increased ESR and leukopenia
LFTs - bilirubin increase
HAV serology - HAV IgM indicated acute infection
97
what is the treatment for hepatitis A
supportive treatment
- travelers vaccine is available
98
what is a rare complication of hepatitis A
fulminant (rapid) liver failure
99
what are features of Hep C infection
acute and chronic infection
ssRNA virus
blood bone
large association with IVDU, limited vertical and sexual transmission
100
what are the symptoms of Hep C infection
often asymptomatic
few patients with influenza like symptoms
resent later with chronic liver failure signs and hepatosplenomegaly
101
how do you diagnose Hep C
serology
- HCV RNA = current infection
- HCV Ab = presents within 4-6 weeks of infection
102
what is the treatment for Hep C
direct acting antivirals
- oral rivavarin plus NSSA-I, NSSB-I
103
what percentage of Hep C cases progress onto chronic liver failure
30%
104
what are the features of HepE
acute infection
ssDNA infection
associated with undercooked pork
faecal - oral spread
common in india and china
105
how do you diagnose Hep E infection
Bloods
- HEV IgM = acute infection
- HEV RNA
106
what is the treatment for Hep E
supportive
self limiting disease so will get better (usually)
107
what are features of Hep D
acute and chronic infection
ssRNA
blood born
dependent on HBV
108
why does Hep D require HBV for infection
it is incomplete - required HBV genome for viral assembly
109
what are the features of Hep B
it is an acute and chronic virus
dsDNA
blood born
110
how is Hep B transmitted
needles
Sexual
vertical
horizontal (between children)
111
What body fluids is HBV found in
saliva and semen
112
what are the risk factors for HBV
IV drug user
MSM
dialysis patients
healthcare workers
113
what are the symptoms of Hep B
similar to hepatitis A
1-2 week prodrome with a then deepening jaundice, dark urine and pale stool. Hepatosplenomegaly, urticaria, arthralgia
114
what is the incubation period for HBV
1-6 months
115
how do you diagnose Hep B
serology
- HBVsAg = present for 1-6 months of infection
- HBsAg = present after 6 months of infection (denotes immunity)
- HBcAg = exposed to HBV at some point
- HBcIgM = acute infection
- HBcIgG = chronic infection
- HBeAg = marker of patient infectiousness
- HBeAb = implies reduced infectivity, present in all chronic infections
116
what is the treatment for HepB
peglyated interferon
alpha 2A
117
what percentage of HBV cases progress to chronic liver failure
5-10% of cases, but in 90% of cases in children they will become chronic decompensated and associated with a very poor prognosis - will require a liver transplant
118
what do all types of hepatitis show
interface necrosis on histology
119
what is autoimmune hepatitis
very rare - an adaptive immunity that mounts a response against hepatocytes
120
what are risk factors of autoimmune hepatitis
female
other autoimmune diseases (such as SLE)
viral hepatitis
HLA DR3/4
121
what are the two types of autoimmune hepatitis
T1 = adult females (80%)
T2 = young females
122
what are the two types of antibody found in type 1 autoimmune hepatitis
antinuclear antibody
anti smooth muscle antibody
123
what are the two types of antibody found in T2 autoimmune hepatitis
anti liver cytosol
anti liver - kidney microsome
124
what are the symptoms of autoimmune hepatitis
25% of cases asymptomatic
many present with jaundice, fever and hepatosplenomegaly
125
how do you diagnose autoimmune hepatitis
serology
- ANA, ASMA plus or minus ALC-1 or ALKM1
126
how do you treat autoimmune hepatitis
corticosteroids (prednisolone) and azathioprine
- also have Hep A and Hep B vaccination
transplantation considered as last resort
127
what is jaundice
the yellowing of the skin/eyes due to the accumulation of conjugated or unconjugated bilirubin
128
what is the normal method of bilirubin metabolism
1 Haemoglobin is broken down into haem and globin
2 haem is converted into biliverdin (+ Fe++)
3 biliverdin reductase converts biliverdin to unconjugated biliruben
4 unconjugated bilirubin travels to the liver where its bound to glucuronic acid making conjugated bilirubin
5 this goes into the duodenum and becomes urobilinogen
6 urobilinogen converted into stercobilin (90%)
6 5% of urobilinogen becomes urobilin and excreted in the wee
129
what is the cause for pre-hepatic jaundice
it is when there is high unconjugated bilirubin due to an increased red blood cell breakdown
- haemolytic anaemia
- sickle cell
- C6PDH deficiency
- autoimmune haemolytic anaemia
- thalassemia
- malaria
130
what are causes for intrahepatic jaundice
parenchymal disease
- HCC
- ALD/NAFLD
- hepatitis (viral, autoimmune)
- hepatotoxic drugs (rifampicin)
- Gilberts syndrome
- crigler Nijar syndrome
131
what is gilbers syndrome
a mutation of UGT1A1 gene; causes underreactive UGT enzyme and therefore there is reduced conjugated bilirubin
132
What is Crigler Najjar syndrome
absence of UGT
133
what are causes of post hepatic jaundice
conjugated hyperbilirubinemia due to obstruction
- biliary tree pathology
- choledocholithiasis
- pancreatic cancer
- cholangiocarcinoma
- Mirizzi syndrome
- drug induced cholestasis (ampicillin)
- Autoimmune
134
what is Mirizzi syndrome
rarely gallstones get stuck and can externally compress the common bile duct and cause obstruction
135
why is there pale stool and dark urine in obstructive jaundice
as conjugated bilirubin affects stool and urine, when there is a blockage there is more in the blood and less in the intestine.
136
is gilberts syndrome more common in men or women
young men
137
What is Courvoisier sign
painless jaundice with a palpable gall bladder
- most likely pancreatic cancer
138
where is the most common site of pancreatic cancer
60-70% occurs at the head of the pancreas
139
what is charcots triad
fever
jaundice
Right upper quadrant pain
140
what are symptoms of cholecystitis
fever and right upper quadrant pain
141
what are features of biliary cholic pain
right upper quadrant pain
142
what are features of ascending cholangitis
fever
right upper quadrant pain
jaundice
143
what is reynolds pentad
ascending cholangitis (obstructive)
- fever, right upper quadrant pain, jaundice, confusion, hypotension
144
what is murphys sign
right upper quadrant tenderness; ask patient to take a breath in while pressing the right upper quadrant + cholecystitis
145
how do you diagnose jaundice
bloods and LFTs - bilirubin, albumin, PT/INR, AST, ALT, GGT, ALP, Urine, Bilirubin and urobilinogen
- imaging: first line is ultrasound scan
146
what are 99% of pancreatic cancer cases
adenocarcinoma of the exocrine pancreas, of ductal origin typically affecting the head
147
where does pancreatic cancer typically affect
the head of the pancreas
148
what are risk factors for developing pancreatic cancer
smoking
alcohol
Diabetes mellitus
family history
chronic pancreatitis
genetic predisposition - PRSS-1 mutation
149
what are the presentations of a pancreatic cancer of the head of the pancreas
Courvoisier sign - painless jaundice and palpable gall bladder with pale stoll and dark urine.
150
what are the presentations of pancreatic cancer of the body or tail of the pancreas
epigastric pain radiating to the back which is relieved by sitting forward
151
how do you diagnose pancreatic cancer
pancreatic CT protocol and then a bile duct drainage
- will have ca19-9 tumour marker (not diagnostic but used to monitor the patients)
152
what is the treatment for pancreatic cancer
prognosis is very poor
- surgery and post-operative chemo if there are no Mets
- palliative care otherwise
153
what is the five year survival for pancreatic cancer
3% 5 yr survival
154
what are primary types of liver cancer
hepatocellular carcinoma
cholarigiocarcinoma
155
what are secondary causes of liver cancer
metastasis - GIT, Breast, bronchial
156
what does hepatocellular carcinoma arise from
liver parenchyma
157
what are risk factors of hepatocellular carcinoma
chronic hepatitis virus - C and B
cirrhosis from ALD/NAFLD/haemochromotosis
158
where does HCC often metastasise to
lymph nodes
bones
lungs
159
what are patient symptoms of HCC
signs of decompensated liver failure
- jaundice
- ascites
- hepatic encephalopathy
- irregular hepatomegaly
Signs of cancer
- weight loss
- tired all the time
160
what are the steps in diagnosing HCC
may show an increase in serum AFP
imaging - ultrasound, GS CT for confirmation
161
why is biopsy often avoided with HCC
to prevent seeding of the tumour everywhere
162
how do you treat HCC
surgical resection of the tumour
when decompensated cirrhosis - liver transplant
prevention - HBV vaccination
163
what does a cholangiocarcinoma arise from
it arises from the biliary tree - typically adenocarcinoma
164
what are risk factors of developing cholangiocarcinoma
parasitic flukeworms
biliary cysts
IBD
Primary sclerosing cholangitis
165
what are symptoms of cholangiocarcinoma
abdominal pain
jaundice
weight loss
fevers
puritis
Courvoisier sign
166
when do symptoms present in cholangiocarcinoma
present late as it is a slow growing tumour
167
how do you diagnose cholangiocarcinoma
may show increased CEA and CA19-9
LFT shows increased bilirubin and ALP
ERCP is used to image the biliary tree
biopsy
168
how do you treat cholangiocarcinoma
Operation
majority of cases are inoperable as the patients present very late
169
what are examples of benign primary liver tumours
Haemangioma
hepatic adenoma
170
what is seen on infants with haemangioma
seen as a strawberry mark on the skin within the first few weeks of life
171
how o you diagnose secondary liver tumours
increased serum ALP
Ultrasound
CT/MRI of the chest and abdomen for staging and identifying the primary tumour
172
how do you treat secondary cancer of the liver
surgical resection if possible (and of primary cancer)
chemotherapy
173
what are the different types of biliary tract disease
gall stones
cholecystitis
ascending cholangitis
174
what are risk factors for biliary tract disease
Overweight/high BMI
female
over 40
Fertile
175
what are the symptoms of Gallstones
right upper quadrant pain "biliary cholic"
constant severe episodes of pain
pain is worse after a fatty meal
176
wha are symptoms of cholecystitis
right upper quadrant pain
fever
tender gall bladder
may have referred pain to right shoulder
murphy sign positive
177
at are the symptoms of ascending cholangitis
right upper quadrant pain
fever
jaundice
dark urine
pale stool
Charcots triad
178
what is reynolds triad
charcots triad plus an altered mental state and hypotension
179
how do you diagnose gallstones
abdominal ultrasound
180
how do you treat gall stones
elective laparoscopic cholecystectomy if symptomatic
until then
- mild pain = NSAIDS
- severe pain = IM diclofenac
change lifestyle - reduce fatty diet
181
how do you diagnose cholecystitis
FBC - leukocytosis and neutrophilia
LFT (normal)
Abdominal ultrasound - thickened gall bladder wall
182
how do you diagnose ascending cholangitis
FBC - leukocytosis and neutrophilia
LFT - increased conjugated hyperbilirubinaemia
Abdominal ultrasound - CBD dilation and gallstones
MRCP - diagnostic and best pre-intervention management
183
how do you treat cholangitis
surgery done within 1 WEEK (MUST by NICE) - laproscopic cholecystectomy
till then put on IV fluid, analgesia and antibiotics if necessary
184
how do you treat ascending cholangitis
ERCP (bile duct clearance) and then a laparoscopic cholecystectomy one stable to prevent recurrence
- consider the risk of stenosis
185
what is a MRCP
magnetic resonance cholangic pancreatography - magnetic resonance imaging (MRI) exam that produces detailed images of the hepatobiliary system
186
what is ERCP
endoscopic retrograde cholangic- pancreatography
187
What is primary biliary cirrhosis
intrahepatic autoimmune jaundice, affecting the intralobular bile ducts
188
what are the risk factors of primary biliary cirrhosis
female
40-50 year olds
other autoimmune diseases
smoking
189
what is the pathophysiology of primary biliary cirrhosis
autoantibodies cause intralobular bile duct damage: chronic autoimmune granulomatous inflammation
this results in cholestasis leading to fibrosis, cirrhosis, portal hypertension and infection
190
what are the symptoms of primary biliary cirrhosis
it is initially often asymptomatic
the earliest symptoms are pruritis and fatigue
jaundice
hepatomegaly
xanthelasma - yellow growths on or near eyelids
191
what are the complications of primary biliary cirrhosis
cirrhosis
malabsorption of fats and vitamins A, D, E and K
osteomalacia
coagulopathy
192
how do you diagnose primary biliary cirrhosis
LFT - increase ALP, conjugated bilirubin and decreased albumin
rule out acute hepatitis in bloods
serology - 95% have AMA antibodies
ultrasound
liver biopsy - portal tract infiltrate and fibrosis
193
what is the treatment of primary biliary cirrhosis
1st line = Ursdeoxycholic acid - bile acid analogue (life long)
for pruritis = cholestyramine
vitamin ADE and K supplements
may need liver transplant
194
what is primary sclerossing cholangitis
chronic liver disease in which the bile ducts inside and outside the liver become inflamed and scarred, and eventually narrowed or blocked. When this happens, bile builds up in the liver and causes further liver damage.
195
what are the risk factors for primary sclerosing cholangitis
male
40-50
strong link to IBD especially UC
196
what are the symptoms of primary sclerosing cholangitis
initially asymptomatic
then pruritis and fatigue
charcot triad
hepatosplenomegaly
IBD
197
how do you diagnose primary sclerosing cholangitis
LFT
Serology - HBVsAg/HCVAb negative, ANA negative, pANCA positive in some cases
GS imaging - MRCP
198
how do you treat primary sclerosing cholangitis
conservative symptom management
- cholestyramine for puritis
- fat soluble A, D, E, K vitamin supplements
- consider liver transplant
199
what other autoimmune conditions is PBC associated with
sjorgens
SLE
200
what is acute pancreatitis
acute inflammation of the pancreatic gland
201
what are reasons for acute pancreatitis
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion venom or spider bite
hypercalcaemia or hyperlipidaemia
ERCP
drugs - azathioprine, NSAIDs, ACE -i
202
what is the most common reason for acute pancreatitis
gall stones
203
what is the most common reason for chronic pancreatitis
ethanol
204
what causes autoimmune pancreatitis
an increase in serum IgG4 - autoimmune destruction of pancreas
205
how do you treat autoimmune pancreatitis
oral prednisolone for 4-6 weeks
206
what is the pathology of acute pancreatitis
gallstones obstruct pancreatic secretions and therefore there are accumulated digestive enzymes in the pancreas. This causes host defences to be overwhelmed and leads to autodigestion (inflammation and enzymes leak into the blood)
207
what are the symptoms of acute pancreatitis
sudden severe epigastric pain radiating to the back
jaundice
pyrexia
steatorrhoea
grey turner sign - flank bleeding
cullen sign - periumbilical bleeding
208
how do you diagnose acute pancreatitis
bloods - increased serum amylase and lipase
exclude gastroduodenal perforation
ultrasound to diagnose gall gallstones
CT and MRI = extent of damage
209
for a diagnosis to be made of acute pancreatitis what must be present
1. characteristic symptoms and signs
2. increased amylase and lipase
3. radiological evidence
210
what are the two pancreatic scoring systems
1. APACHE 2 - assesses severity within 24hours
2. Glasgow and Rouson score - prediction of severe attack after 48 Hrs
211
how do you treat acute emergency pancreatitis
IV fluid
NU by mouth
Analgesia (morphine)
Catheterize
antibiotic prophylaxis
212
what are complications of acute emergency pancreatitis
systemic inflammatory response syndrome
- tachycardia
- tachypnoea
- pyrexia
- increased white cell count
213
what is chronic pancreatitis
three month history or pancreatic deterioration: irreversible pancreatic inflammation and fibrosis
214
what are the main causes of chronic pancreatitis
alcohol, chronic kidney disease, cystic fibrosis, trauma, recurrent acute pancreatitis
215
what are symptoms of chronic pancreatitis
epigastric pain radiating to the back which is exacerbated by alcohol
216
How do you diagnose chronic pancreatitis
bloods - lipase and amylase unlikely to be raised in severe cases
fecal elastase - typically increased
Abdominal ultrasound and CCT - detects calcification and dilated pancreatic duct
217
how do you treat chronic pancreatitis
mainly alcohol cessation
NSAIDs for abdominal pain
Pancreatic supplements - enzymes and insulin
218
what is portal hypertension
complications of cirrhosis
pathology increases pressure in the portal vein
219
what are the three types of portal hypertension
1. prehepatic
2. intrahepatic
3. post hepatic
220
what are reasons of pre hepatic portal hpertension
portal vein thrombosis
221
what causes intrahepatic portal hypertension
cirrhosis
Schistosomiasis - worms
222
what are causes of post hepatic portal hypertension
Budd chiari (hepatic vein obstruction)
RHS heart failure
constrictive pericarditis
223
what is the pathophysiology of portal hypertension
the normal pressure is between 5-8mmHg in the portal vein. Cirrhosis causes an increased resistance to flow and therefore splanchnic dilation and compensatory increase in cardiac output. this results in fluid overload in the portal vein
- leads to collateral blood shunting to gastroesophageal veins
224
what are the symptoms of portal hypertension
mostly asymptomatic
present when there is rupture of oesophageal varices
225
what are oesophageal varices
Oesophageal varices are extremely dilated sub-mucosal veins in the lower third of the esophagus. They are most often a consequence of portal hypertension, commonly due to cirrhosis.
226
how do you diagnose oesophageal varices
an oesophagogastroduodenoscopy
227
How do you treat oesophageal varices
Acutely - resus until haemodynamically stable and consider blood transfusion
Stop the bleed - IV terlupressin, variceal banding and TiPPS
Prevent bleeding - non selective beta blocker and nitrates
Last resort is a liver transplant
228
What is TiPPS
A transjugular intrahepatic partosystemic shunt - it decreases portal pressure by diverting blood to other larger veins
229
what are ascites
accumulated free fluid in the abdominal cavity
230
what is ascites a complication of
cirrhosis
231
what are causes of ascites
local inflammation - peritonitis, TB, abdominal cancer
low protein - nephrotic syndrome, hypoalbuminemia
flow stasis - cirrhosis, Budd chiari, congestive heart failure, constrictive pericarditis
232
what are symptoms of ascites
abdominal distension
shifting or dullness in flanks
may have jaundice and puritis
can have painful distension
233
how would you examine a patient with suspected ascites
1. tap on their central abdomen when supine (resonant)
Tap on their flanks and this will sound dull due to the fluid
2. ask the patient to lay on their side and tap the flank: resonant as the fluid will have moved to the other side
234
how do you diagnose ascites
shifting dullness on exam
Ascitic tap
1. cytology, look at white blood cell counts
2. protein measurement
235
what proteins are you measuring in ascites diagnosis
Transudate proteins - fluid found here due to increased hydrostatic pressure
Exudate proteins - fluid due to inflammation mediated exudation
236
what causes transudate fluid to accumulate
portal hypertension, Budd Chiari, Constrictive pericarditis, chronic heart failure, nephrotic syndrome
237
what causes exudate fluid to accumulate
malignancy, peritonitis, pancreatitis
238
how do you treat ascites
treat the underlying cause
diuretic to increase fluid excretion = spironolactone
Paracentesis
Liver transplant
239
what is peritonitis
an inflamed peritoneal cavity
240
Where does nerves T5-9 give sensation to in the gut
Epigastric - the greater splanchnic nerve
supplies foregut up to the second part of the duodenum
241
where does nerves T10-11 give sensation to in the gut
umbilical - lesser splanchnic nerve
supplies the midgut up to 2/3 of the transverse colon
242
what does nerve T12 give sensation to in the gut
hypogastric region - lesser splanchnic nerve
supplies the hindgut up to the rectum
243
what are primary causes for peritonitis
ascites
SBP (infection)
244
what are secondary reasons for peritonitis
underlying cause i.e bile or malignancy
245
what are bacterial causes for peritonitis
Gram negative = E.coli and klebsiella
Gram positive = Staphylococcus aureus
246
what are symptoms of pericarditis
sudden onset of severe abdominal pain
collapse and septic shock, fever
pain is poorly localised at first and then it becomes well localised as it becomes more inflamed
247
how can you help the pain in pericarditis
rigidity helps with the pain
- guarding, resting hands on the abdomen to stop it moving
248
how do you diagnose ascites
Ascitic tap shows neutrophillia and cultures will show causative organism
increased EST and CRP
exclude pregnancy as a cause
exclude bowel obstruction as a cause
erect CXR will show air under diaphragm
249
how do you treat ascites
ABCDE
treat the underlying cause: IV fluid and antibiotics
Surgery - peritoneal lavage - clearing out of peritoneum
250
what are complications of ascites
septicemia if not treated early
subphrenic or pelvic abscesses
paralytic ileus
251
what is haemochromotosis
it is a mutation of the HFE gene which results in excess body iron
252
what are risk factors for haemochromotosis
males
women after menopause
over 50
253
what is the pathophysiology of haemochromotosis
excess iron is taken up by transferrin-1 and there is reduced hepcidin synthesis (protein that regulated iron homeostasis) which causes iron accumulation. This normally accumulates in liver, pancreas, kidney, heart, skin and anterior pituitary and damages the organ
254
what are the symptoms of haemocromotisis
fatigue
joint pain
hypogonadism (due to anterior pituitary damage)
slate grey skin
liver cirrhosis
osteroperosis
heart failure
255
what is the gross Fe overload triad
bronze statue skin
hepatomegaly
type 2 diabetes
256
how do you diagnose haemochromotosis
Fe studies - increased serum iron and ferritin, increased transferrin saturation and decreased TIBC
Genetic tests - HFE
Liver biopsy - assess extent of liver damage
257
what is the treatment for haemochromotosis
Venesection - regularly removing blood
if contraindicated use desfernoxamine
change lifestyle and have a low iron diet
258
what is wilsons disease
an a recessive mutation of ATP78 gene which causes an excess of copper
259
what is the pathophysiology of Wilsons disease
impaired copper biliary secretion and normal transport bound to calculoplasmin which means there is an increased calcium accumulation in the liver and the CNS
260
what are the symptoms of Wilsons disease
Hepatic - liver disease
Neurological - parkinsonism, memory issues
opthalmological - Kayser fleischer rings (green brown ringed appearance in cornea)
261
how do you diagnose Wilsons disease
calcium tests = reduced serum calcium as more is deposited
liver biopsy = increased calcium and liver damage
MRI brain = cerebellar and basal ganglia degeneration
262
what is the treatment for Wilsons disease
1st line = D-Penicillinamine (lifelong)
change in the diet to avoid high copper foods such as shellfish
a severe and last resort is liver transplant
263
what is AIAT deficiency
an auto recessive mutation of the protease inhibitor gene (Serpina-1 gene) causing a deficiency of alpha 1 antitrypsin enzyme.
264
what is the pathophysiology of AIAT deficiency
AIAT normally inhibits neutrophil elastase (which degrades elastic tissue). With a deficiency in AIAT it means there is an increase in neutrophil elastase. This is devastating for the lungs and liver
265
what is neutrophil elastase
Neutrophil elastase is secreted by neutrophils during inflammation, and destroys bacteria and host tissue
266
what does AIAT deficiency do to the lungs
an increase in neutrophil elastase degrades elastic tissue causing alveolar duct collapse and air trapping - panacinar emphysema
267
what does AIAT deficiency do to the liver
the liver becomes fibrotic due to neutrophil elastase, leading to cirrhosis and hepatocellular carcinoma risk.
268
where is AIAT normally made
in the liver
269
what are the symptoms of AIAT deficiency
COPD like symptoms
dyspnoea
chronic cough
sputum production
barrel chest
jaundice
270
how do you diagnose AIAT deficiency
serum AIAT is severely decreased (<20mmol/L)
barrel chest on exam
CXR will show hyperinflated lungs
panacinar emphysema on CT
LTF shows signs of obstruction
Genetic tests
271
what is the treatment for AIAT deficiency
there is no curative treatment
stop smoking
manage emphysema - inhalers
consider hepatic decompensation patients for liver transplant
272
how much paracetamol needs to be taken for it to be overdose
over 75mg per KG
273
what are symptoms of liver failure
acute
severe right upper quadrant pain
severe nausea and vomiting
274
What happens in normal paracetamol metabolism
90% of paracetamol undergoes phase 2 conjugation (glucuronidation) and is excreted
10% of paracetamol undergoes phase 1 conjugation and forms NAPQ1 and then undergoes phase 2 conjugation and is excreted
275
what happens in paracetamol overdose to cause liver damage
the phase 2 pathway is saturated and therefore there is shunting down the phase 1 pathway. this means that there is accumulation of the toxic NAPQ1 in the liver
276
what is the treatment for a paracetamol overdose
give activated charcoal within 1 hours of the paracetamol ingestion
N-acetyl-cysteine - increases availability of the phase 2 pathway
277
What is Gliberts syndrome
An autosomal recessive mutation which causes hereditary jaundice
278
what is the pathophysiology of Gilberts syndrome
You have an abnormal or deficient UGT therefore you have an increase in unconjugated bilirubin leading to unconjugated hyperbilirubinemia
279
what are the symptoms of Gilberts syndrome
30% of cases are asymptomatic may present with a painless jaundice
280
What is Gilberts + cirgler najjar
More severe
Jaundice with nausea and vomiting, lethargy
281
How do you treat gilberts syndrome
Gilberts - most people are fine without treatment
Crigler Najjar - phototherapy as wit breaks down bilirubin
282
What can people with Grigler Najjar die of
Can die of Kernicterus in childhood
- this is where you get an accumulation of bilirubin in the basal ganglia causing neurological defects
283
what is hernia
it is the protrusion of an organ through a defect in its containing cavity
284
What is the most common type of hernia
bowel
285
what are the two types of hernias
Reducible
Irreducible
286
What is a reducible hernia
One that can be pushed back into place
287
What is a irreducible hernia
one that is
- obstructed
- strangled (ischema)
- incarcerated (contents are fixed)
288
What is a hiatal hernia
it is where the stomach herniates through the diaphragm aperture
289
What are the two types of hiatal hernia
Rolling and sliding
290
what is a rolling hiatal hernia
the LES stays in the abdomen and part of the fundus rolls into the abdomen
291
what is a sliding hiatal hernia
the LES slides into the abdomen
292
what are the symptoms of a Hiatal hernia
GORD
dysphagia
293
How do you diagnose a hiatal hernia
chest X ray
Barium swallow
OGD
294
what is a femoral hernia
it is when the bowel moves through the femoral canal
295
what is a femoral hernia likely to do
strangulate the bowel due to the rigid femoral canal boarders
296
What are the symptoms of a femoral hernia
swelling in the upper thigh pointing down
297
how do you diagnose a femoral hernia
you can ultrasound the abdominal/pelvis
298
what is an inguinal hernia
it is when the bowel herniates through the inguinal canal
299
What are the two types of inguinal hernia
Direct
Indirect
300
What is a direct inguinal hernia
is in Hesselbachs triangle
- Medial to inferior epigastrics
301
What is an indirect inguinal hernia
it is lateral to the inferior epigastrics
302
what are the risk factors of an inguinal hernia
male
history of heavy lifting or abdominal pressure
303
What are symptoms of a inguinal hernia
painful swelling in the groin, which points along the groin margin
304
how do you diagnose an inguinal hernia
if you are clinically unsure you can perform an abdominal ultrasound or CT
305
How do you treat hernia
SURGERY
306
What is an acute on chronic liver failure
when there is an abrupt decline in a patient with chronic liver symptoms
307
What are the blood investigations for liver failure
FBC - Infection, bleed, MCV
U&Es - low urea,high creatinine
LFTs - AST:ALT ratio, albumin, PT
Clotting
Glucose
ABG - acidosis
Ferritin
paracetamol levels
308
What AST:ALT ratio is seen in alcoholic liver disease
AST:ALT >2
309
What AST:ALT ratio is seen in viral liver disease
AST:ALT <1
310
What microbiology investigations for liver failure
Hepatitis, CMV, EBV and serology
Ascites MCS and SAAG
311
What are radiological investigations for liver failure
Chest X ray
Abdominal ultrasound
Portal vein duplex
312
What are complications of liver failure
Bleeding
Hepatorenal syndrome
Sepsis
Ascites
Hypoglycaemia
Encephalopathy
Seizures
Cerebral oedema
313
what is biliary colic
It is where you have sudden pain due to gallstone blockage - cystic obstruction or passing into the common bile duct
314
what is the pathophysiology of biliary colic
There is gallbladder spasm against a stone in the neck of the gallbladder
315
What are the risk factors of biliary colic
Family history
Female
Over forty
Overweight
Fertile
316
What are the symptoms of biliary colic
Right upper quadrant pain radiating to back
Sweating, pallor, nausea and vomiting
May be precipitated with fatty food
right tender hypochondrium
possible jaundice
317
What are the differential diagnoses of biliary colic
Cholecystitis or other gall stone disease
pancreatitis
bowel perforation
318
What is the management of biliary colic
Rehydrate by mouth
Opioid analgesia - morphine 5-10mg
Laparoscopic cholecystectomy
319
what are complications of biliary colic
Mirizzi syndrome
Gallbladder empyema
Chronic cholecystitis
Bouveret's syndrome
Gallstone ileus
320
What urine tests should be done with suspected biliary colic
Bilirubin
Urobilirubin
Haemoglobin
321
What blood tests should be done with suspected biliary colic
FBC
U&Es
Amylase
LFTs
Clotting
CRP
322
What imaging tests should be done with suspected biliary colic
AXR - 10% of gallstones are radio-opaque
Erect CXR
Ultrasound - stones, ducts and inflammation
323
What test should be ordered when diagnosis of biliary colic is uncertain after an ultrasound
HIDA cholescintigraphy - shows failure of gallbladder filling
324
If dilated ducts are seen on ultrasound of suspected biliary colic + can't see gallstones, what test should be ordered?
Magnetic resonance cholangiopancreatography (MRCP)
325
what is acute cholecystitis
Inflammation of the gall bladder which occurs over hours
326
what is the pathogenesis of acute cholecystitis
Sludge or stone in Hartmanns pouch leads to chemical or bacterial inflammation of the gall bladder
327
What can cause acute cholecystitis
Gallstones
tumour
Bile duct blockage
Infection
Blood vessel problems
328
What is muphys sign
2 fingers over the gall bladder, ask patient to breathe in
Pain and breath catch - inflammation
Must be negative on left hand side
329
What is Boa's sign
Hyperaesthesia below right scapula
330
what urine tests are done for acute cholecystitis
Bilirubin
Urobilinogen
331
what blood tests are done for acute cholecystitis
FBC
High white cell count
U&Es
Dehydration from vomiting
Amylase
LFTs
Group and save
Clotting
CRP
332
what are the imaging test for acute cholecystitis
AXR
Erect CXR
US
333
What test is ordered if diagnosis of acute cholecystitis is uncertain after ultrasound?
HIDA cholescintigraphy
334
What test is ordered if dilated bile ducts are found on ultrasound in suspected acute cholecystitis?
MRCP (magnetic resonance cholangiopancreatography)
335
What are the differential diagnoses for acute cholecystitis?
Peptic ulcer disease
Liver disease
Pancreatitis
Cardiac disease
336
What analgesia is given for acute cholecystitis?
Paracetamol
Diclofenac
Codeine
337
What are the complications of acute cholecystitis?
Gangrene
Rarely perforation
Chronic cholecystitis
Empyema
338
what are the symptoms of chronic cholecystitis
'flatulent dyspepsia'
Vague upper abdominal discomfort
Nausea
Distension, bloating
Flatulence/burping
339
what exacerbates the symptoms of chronic cholecystitis
fatty foods
340
what investigations are done for chronic cholecystitis
AXR
US
Magnetic resonance cholangiopancreatography
341
What are the differential diagnoses of chronic cholecystitis?
Peptic ulcer disease
IBS
Hiatus hernia
Chronic pancreatitis
342
What is the management of chronic cholecystitis?
Bile salts - not great Elective cholecystectomy
ERCP (Endoscopic retrograde cholangiopancreatography) if ultrasound shows distended ducts and stones
343
what is the general composition of gallstones
phospholipids
bile pigments
cholesterol
344
what are characteristics of pigment stones
Small, black, gritty, fragile
Calcium bilirubinate
Associated with haemolysis
345
what are characteristics of cholesterol stones
Often solitary
Large
346
What is Admirand's triangle
low bile salts
low lecithin
high cholesterol
347
what are causes of gallstones
Lithogenic bile
biliary sepsis
gall bladder hypomotility
pregnancy/oestrogen contraceptive pill
total parenteral nutrition or fasting
348
what can be done to confirm gallstones
Murphy's sign
ultrasound scan
349
Why might you order a cholangiography and CT for gallstones
1. To assess the condition of the gallbladder
2. Look for complications of gallstones
350
what is the differential diagnosis for gallstones
Mirizzi syndrome
Gallbladder empyema
Chronic cholecystitis
Bouveret’s Syndrome
Gallstone Ileus
351
what are the complications of gallstones in the gallbladder
Biliary colic
Acute cholecystitis +- empyema
Chronic cholecystitis
Mucocele
Carcinoma
Mirizzi's syndrome
352
what are the complications of gallstones in the common bile duct
Obstructive jaundice
Pancreatitis
Cholangitis
353
What are the complications of gallstones in the gut?
Gallstone ileus
354
what is the pathophysiology of ascending cholangitis
There is common bile duct obstruction which causes bacterial seeding of the biliary tree
- sludge formation creates a growth medium for bacteria
355
what causes ascending cholangitis
Gallstones
Iatrogenic - ERCP
Cholangiocarcinoma
Ascending infection from duodenum junction
356
what are risk factors for ascending cholangitis
Gallstones
Sclerosing cholangitis
HIV
Narrowing of common bile duct
357
What are the differential diagnosis for ascending cholangitis
Acute cholecystitis
Peptic ulcer disease
Acute pancreatitis
Hepatic absess
Acute pyelonephritis
Acute appendicitis
Right lower lobe pneumonia
HELLP syndrome of pre-eclampsia
358
what are the complications of ascending cholangitis
Acute pancreatitis
Hepatic abscess
359
What blood tests are performed in suspected acute pancreatitis?
FBC - High WCC
Amylase and lipase - high
U&Es - dehydration and renal failure
LFTs - cholestatic picture (high AST and LDH)
Low calcium
High glucose
CRP raised in severe
ABG - low O2 suggests ARDS
360
what urine tests are performed in suspected acute pancreatitis
glucose
high conjugated bilirubin
low urobilinogen
361
what are the signs associated with acute pancreatitis
High heart and respiratory rate
Fever
Hypovolaemia - shock
Epigastric tenderness
Jaundice
Ileus (absent bowel sounds)
Ecchymoses (discolouration of skin due to bleeding underneath it)
Grey Turners: flank
Cullens: periumbilical
362
what is the differential diagnosis for acute pancreatitis
Perforated duodenal ulcer
Mesenteric infarction
Myocardial infarction
363
what is the Glasgow criteria in assessing acute pancreatitis severity
PaO2
Age
Neutrophils
Ca2+
renal function
enzymes
Albumin
Sugar
364
what are the complications of acute pancreatitis
ARDS - O2
Hyperglycaemia - insulin
Alcohol withdrawal - chlordiazepoxide
365
What are the indications for surgical management of acute pancreatitis?
Infected pancreatic necrosis
Pseudocyst/abscess
Unsure diagnosis
366
what are the possible early complications of acute pancreatitis
Systemic:
-Resp
-ARDS
-Pleural effusion
Shock
-Hypovolaemic
-Septic
Renal failure
Disseminated intravascular coagulation
Metabolic
-Hypocalcaemia
-Hyperglycaemia
Metabolic acidosis
367
What are the possible late complications of acute pancreatitis?
Pancreatic necrosis
Pancreatic infection
Pancreatic abscess
Bleeding
Thrombosis
Fistula formation
Pancreatic pseudocyst
368
what is the pathophysiology of chronic pancreatitis
Progressive loss of lobular morphology and structure of pancreas due to necrosis/apoptosis, inflammation and/or duct obstruction
Deformation of the large ducts and severe changes in arrangement and composition of islets
Irreversible morphological and structure changes - impair exocrine and endocrine functions
369
What are the characteristics of pain in chronic pancreatitis?
Bores through the back
Relieved by sitting forward or hot water bottle (erythema ab igne - hot water bottle rash)
Exacerbated by fatty foods/alcohol
370
what are signs of chronic pancreatitis
Hyperglycaemia
Low faecal elastase (low exocrine function)
Pseudocyst in US
Speckled pancreatic calcification (AXR)
Pancreatic calcifications (CT)
371
what are the differential diagnosis for chronic pancreatitis
Peptic ulcer disease
Reflux disease
Abdominal aortic aneurysm
Biliary colic
Chronic mesenteric ischaemia
372
what is the indication for surgery in chronic pancreatitis
Unremitting pain
Weight loss
Duct blockage
373
what is the surgical management of chronic pancreatitis
Distal pancreatectomy (Whipple's)
Pancreaticojejunostomy (drainage)
Endoscopic stenting
374
what are the complications of chronic pancreatitis
Pseudocyst
Diabetes mellitus
Pancreatic calcification
Pancreatic swelling (?cause duct obstruction)
Splenic vein thrombosis - splenomegaly
375
what is fatty liver
build-up of fat within liver cells
376
what is the pathophysiology of cirrhosis
Stellate cells are activated - major source of extracellular matrix
Accumulation of collagen in hepatic parenchyma and space of Disse
Space of Disse collagen accumulation called capillarisation of sinusoids - fenestration lost affection exchange
Activated stellate cells more contractile, increased portal resistance
Progressive process
377
what are common causes of cirrhosis
Chronic alcohol
Chronic hepatitis C (and hepatitis B)
Non-alcoholic fatty liver disease/non alcoholic steatohepatitis
378
what are symptoms of cirrhosis
Fatigue
Nausea
Anorexia
Weight loss
Jaundice
Haematemesis
Puritis
Dark pee and tarry-looking poo
Bleeding or bruising easily
Oedema
Low libido
379
where can venous collaterals occur in portal hypertension
gastro-oesopageal junction
anterior abdominal wall
anorectal junction
veins from retroperitoneal viscera
380
What is the sequelae of portal hypertension?
SAVE:
Splenomegaly
Ascites
Varices
Encephalopathy
381
what are risk factors of portal hypertension
cirrhosis
congestive heart failure
arteriovenous malformations
hypercoagulable states
382
What are the signs and symptoms of portal hypertension?
Ascites
Hepatic encephalopathy
Variceal bleeding
Splenomegaly
Associated with cirrhosis means liver failure symptoms may also be observed
383
What investigations are ordered for patients with suspected portal hypertension?
Scans
Abdo US - dilated portal vein
Doppler US - slow velocity + dilated portal vein
Endoscopy - presence of oesophageal varices
384
What is the management of portal hypertension?
Treat underlying cause
Salt reduction and diuretics
Beta-blockers and nitrate to reduce blood pressure
385
what is the clinical presentation of oesophageal varices
Signs of chronic liver damage
Splenomegaly
Ascites
Hyponatraemia
386
What is the clinical presentation of oesophageal varices if ruptured?
Haematemesis
Abdo pain
Shock
Fresh rectal bleeding
Hypotension and tachycardia
Pallor
387
what are the differential diagnosis of oesophageal varices
Hiatal hernia
Gastric varices
Mallory-Weiss tear
PUD (peptic ulcer disease)
Gastric antral vascular ectasia
388
What is transjugular intrahepatic portoclaval shunt (TIPS)?
Shunt between systemic and portal systems
Reduces sinusoial and portal vein pressures
Only used when variceal bleeding cannot be controlled acutely, or rebleeds
389
what is the pathophysiology of alcoholic hepatitis
Liver main site of alcohol metabolism - main site of injury due to excessive drinking
Widespread hepatic lesions (steatosis, hepatitis, cirrhosis)
Malnutrition - protein-energy malnutrition (calories obtained from alcohol not food)
Alcohol induces hypermetabolic state in hepatocytes, leading to hypoxic damage
Direct damage from metabolites (free radicals and oxidative injury)
390
what are risk factors for alcoholic hepatitis
female
obesity
genetics
ethnicity
binge drinking
391
what is the management for alcoholic hepatitis
stop alcohol and treat withdrawal
high dose B vitamins
optimize nutrition
manage complications
392
what is the monitoring of alcoholic hepatitis
Daily
- weight
- LFTs
- U&Es
- INR
393
what hepatic signs are associated with the icteric phase of viral hepatitis
abdominal pain
hepatomegaly
cholestasis - dark urine/pale stools
394
what are extrahepatic features of the icteric phase of viral hepatitis
Urticaria or vasculitic rash
cryoglobulinemia
polyarteritis nodosa
glomerulonephritis
arthritis
395
what is type 3 autoimmune hepatitis
there is soluble liver antigen antibodies present, (antismooth muscle and antinuclear antibody negative)
396
what are associated conditions of autoimmune hepatitis
Pernicious anaemia
Ulcerative colitis
Glomerulonephritis
Autoimmune thryoiditis
Autoimmune haemolysis
Diabetes mellitus
Primary biliary cirrhosis
397
What investigations are ordered in suspected autoimmune hepatitis?
LFTs (raised)
IgG (raised)
Auto antibodies: SMA, LKM1, SLA, ANA
Low WCC and plateles (hypersplenisnm)
Liver biopsy
398
What is the pathophysiology of pseudomembranous colitis?
C. diff replaces normal gut flora, aided by the use of antibiotics
Release of C. diff toxins causes necrosis and formation of pseudomembranes
399
What are the viral causes of infective diarrhoea?
Rotovirus (children)
Norovirus (adults)
Adenovirus
Astrovirus
400
what are the bacterial causes of infective diarrhoea
Campylobacter jejuni (poultry)
E. coli (children)
Salmonella (children)
Shigella spp (children)
401
what are parasitic causes of infectious diarrhoea
Giardia lamblia
Entamoeba histolytia
Cryptosporidium
402
what are antibiotic associated causes of infectious diarrhoea
(start with C) - antibiotic induced C. diff
Clindamycin
Ciprofloxacin (quinolones)
Co-amoxiclav (penicillins)
Cephalosporins
403
what are risk factors for infective diarrhoea
Foreign travel
PPI or H2 antagonist use
Crowded area
Poor hygiene
404
What are the risk factors for pseudomembranous colitis?
Elderly
Antibiotics
Long hospital admission
Immunocompromised (i.e. HIV)
Acid suppression (PPIs H2 antags etc)
405
what are the clinical presentations of infective diarrhoea
diarrhoea - if bloody likely bacterial
vomiting
abdominal cramping
fever, fatigue, headache, myalgia
406
what are the investigations ordered in infective diarrhoea
Bloods - look at MCV, iron and WCC
Stool culture
Sigmoidoscopy with biopsy
407
What are the differential diagnosis for infective diarrhoea
Appendicitis
Volvulus
IBD
UTI
Diabetes mellitus
Pancreatic insufficiency
Short bowel syndrome
Coeliac disease
Laxative abuse
408
how is pseudomembranous colitis treated
Antibiotics
Stool transplant
Stop C antibiotic
409
what is the treatment for infective diarrhoea
Treat underlying causs
Oral rehydration and avoid sugary drinks
Anti-emetics (metoclopramide)
Antibiotics
Anti-motility agents (loperamide hydrochloride)
410
what are the side effects of penicillamine
Skin rashes
fall in white blood cell, Hb and platelets
Haematuria
renal damage
411
what are complications of a-1 antitrypsin deficiency
Emphysema
liver cirrhosis
hepatocellular carcinoma
412
what is the pathophysiology of ascites
local inflammation - fluid accumulation
low protein
low flow - fluid cant move and raises the pressure in vessels
413
what are the risk factors for ascites
high sodium diet
hepatocellular carcinoma
splanchnic vein thrombosis resulting in portal hypertension
414
what are chemical causes of peritonitis
bile
old clotted blood
ruptured ectopic pregnancy
intestinal perforation
415
what is an obstructed hernia
intestine obstructed due to pressure from edges of the hernia, but the blood flow is maintained
416
what is an incarcerated hernia
contents of the hernial sac are stuck inside by adhesions
417
what is a strangulated hernia
this is where the blood supply is cut off
Ischemia and gangrene/perforation of the hernial contents
418
what are risk factors of inguinal hernias
Male
Chronic cough
Constipation
Urinary obstruction
Heavy lifting
Ascites
Past abdominal surgery
419
what are risk factors for incisional hernias
Emergency surgery
Wound infection post op
Persistent coughing/heavy lifting
Poor nutrition
420
what makes repair of incisional hernias more difficult to repair
obesity
