Liver Flashcards
1
Q
What are the main functions of the liver?
A
Oestrogen regulation
Detoxification
Carb metabolism
Albumin production
Clotting factor production
Bilirubin regulation
Immunity-Kupffer cells in reticuloendothelial system
Storage of vitamins/iron/copper/fat
2
Q
What are the consequences of the liver being unable to regulate estrogen?
A
Gynecomastia
Spider naevi
Palmar erythema
3
Q
What are the consequences of the liver being unable to detoxify substances?
A
Hepatic encephalopathy
4
Q
Describe the pathophysiology of hepatic encephalopathy
A
Accumulation of NH3: normally detoxified and excreted via urea cycle
Crosses BBB and accumulates in CNS-causes confusion
5
Q
What are the consequences of the liver being unable to metabolise carbohydrates?
A
Hypoglycaemia
6
Q
Name a few conditions that affect the liver’s storage of things
A
Wilson’s: copper
Haemochromatosis: iron
A1AT deficiency:
7
Q
What are the consequences of the liver being unable to produce albumin?
A
Oedema
Ascites
Leukonychia
8
Q
What are the consequences of the liver being unable to produce clotting factors?
A
Easy bruising and bleeding
9
Q
What are the consequences of impaired liver immunity function?
A
Increased susceptibility to infections
10
Q
What are the consequences of the liver being unable to metabolise bilirubin?
A
Jaundice
Pruritus
11
Q
Which blood tests directly relate to liver damage?
A
Bilirubin (mostly unconjugated)
Albumin
Prothrombin time
12
Q
Would you expect bilirubin to be high or low in someone with liver damage?
A
High
13
Q
Would you expect albumin to be high or low in liver damage?
A
Low
14
Q
Would you expect PT/INR to be high or low in liver damage?
A
High
15
Q
How are liver enzymes indicative of liver damage?
A
High levels suggest they have spilled out into the blood so likely liver damage
16
Q
Where can you find AST and ALT?
A
Liver
Heart
Kidneys
Muscles
17
Q
What is the normal ratio of AST:ALT?
A
1
18
Q
When would you find high ALP levels?
A
Biliary tree specific damage and bone pathology
19
Q
How is GGT helpful when looking at liver function?
A
High in acute liver damage
Also helps differentiate high ALP as a hepatic or bony cause
20
Q
Define liver failure
A
Liver loses regeneration/repair ability and is irreversibly damaged. Decompensated
21
Q
What is acute liver failure?
A
Live injury accompanied with hepatic encephalopathy, ascites, jaundice, and coagulopathy (>1.5 INR) in a patient with a previously healthy liver
22
Q
What happens in fulminant liver failure?
A
Massive hepatocyte necrosis
23
Q
What would you see histologically in someone with fulminant liver failure?
A
Multiacinar necrosis
24
Q
What are the 3 categories of fulminant liver failure?
A
Hyperacute: HE within 7 days of jaundice
Acute: HE within 8-28 days of jaundice
Subacute: HE within 5-26 weeks of jaundice
25
What is the most common cause of chronic liver failure?
Paracetamol overdose
26
What is acute on chronic liver failure?
Abrupt decline in a patient with chronic liver symptoms
27
What is chronic liver failure?
Progressive liver disease >6 months due to repeated liver insults
28
Describe the progression of chronic liver failure
Hepatitis->fibrosis->compensated cirrhosis->decompensated cirrhosis
29
Name some causes of acute liver failure
Viral: Hep A, B, E, CMV, EBV
Autoimmune hepatitis
Drugs: paracetemol, alcohol, ecstasy
HCC
Metabolic: Wilson's, haemochromatosis, A1ATD
Obstruction: Budd chiari, gallstones
Congestion: e.g. heart failure
30
Describe the signs and symptoms of acute liver failure
Jaundice, coagulopathy, HE
More seen in chronic:
Spider naevi
Fetor hepaticus(rotten egg+ garlic breath)
Caput medusae (distended abdominal blood vessels)
Dupuytren's contracture(fingers bent towards hand)
31
What is the name of the criteria used to classify HE?
West Haven
32
Describe the West Haven criteria grades 1-4
1. Altered mood, sleep issues
2. Lethargy, mild confusion, asterixis
3. marked confusion, quiet
4. comatose
33
What is asterixis?
Liver flap-flap hands like a bird
34
What investigations could you use to diagnose acute liver failure?
Bloods: high AST/ALT, high NH3, low glucose, high bilirubin, low albumin, high PT/INR
Imaging: EEG to grade HE, abdominal US to check Budd chiari
Microbiology to rule out infections
Serology for Hep/high paracetamol levels
35
Describe the treatment for acute liver failure
Acutely: ABCDE, fluids, analgesia
Treat underlying cause and complications
36
What is the treatment for a paracetamol overdose?
Activated charcoal then N acetyl cysteine
37
How would you treat raised ICP?
IV mannitol
38
How would you treat HE?
Lactulose (increase NH3 excretion)
39
How would you treat ascites?
Diuretics, mostly spironolactone
40
How would you treat haemorrhage from acute kidney failure?
Vitamin K
41
What is the most common cause of chronic liver failure?
Alcoholic liver disease
42
Name some causes of chronic liver failure
Alcoholic liver disease
Non-alcoholic fatty liver disease
Viral: Hep B/C
Metabolic: Iron, copper
Budd Chiari
Autoimmune
43
What is Budd Chiari syndrome?
Obstruction of hepatic venous outflow
44
Name some risk factors for developing chronic liver disease
Alcohol
Obesity
T2DM
Drugs
Inherited metabolic disease
Existing AI diseases
45
Is fibrosis damage reversible or irreversible?
Reversible
46
Is cirrhosis damage reversible or irreversible?
Irreversible
47
What can cirrhosis lead to?
Compensated or decompensated(ed stage) liver failure
48
What is meant by compensated liver failure?
Some liver function is left
49
Name some signs of decompensated liver failure
Jaundice, HE, coagulopathy, ascites, portal HTN->oesophageal varices
50
What is a huge risk factor for developing HCC?
End-stage liver failure-decompensated cirrhosis
51
What is the Child pugh score used for?
Assessing prognosis and extent of chronic liver failure
Mostly for decompensated cirrhosis
52
What factors does the Child-Pugh score take into account?
Bilirubin
Presence of ascites
Serum albumin
PT/INR
HE presence
53
Describe the staging of the Child-Pugh score
A: 100% 1-year survival
B: 80% 1 year survival
C: 45% 1 year survival
54
What is the Meld score used for?
Model for end-stage liver disease-stratifies severity of ESLD for transplant planning
55
Name some symptoms of chronic liver failure
Jaundice
ascites
HE
portal HTN and oesophageal varices
Caput medusae
Spider naevi
Palmar erhythema
Gynecomastia
Clubbing
Fetor hepaticus (breath)
56
What is the gold standard investigation for diagnosing chronic liver failure?
Liver biopsy
57
Why is a liver biopsy needed?
To determine extent of chronic liver disease: fibrosis vs cirrhosis
58
What investigations are used to diagnose chronic liver failure?
Biopsy-GS
LFT's
Ultrasound
Ascitic tap culture
59
Describe the treatment of chronic liver disease
Prevent progression: lifestyle modifications
Consider liver transplant (if decompensated liver failure)
Manage complications
60
Name some complications and treatments for chronic liver disease
HE-lactulose
ascites-diuretics
Oesophageal varices ruptures
SBP (spontaneous bacterial peritonitis
HCC
61
What is the equation to calculate units of alcohol?
(Strength (ABV) x vol/mL ) / 1000
62
What is the maximum number of recommended units of alcohol a week
14 units
63
How many grams and mL are in 1 unit of alcohol?
8g
10mL
64
What are the risk factors for developing alcoholic liver disease?
Chronic alcohol use
obesity
smoking
65
Describe the progression of alcoholic liver disease
Steatosis (fatty undamaged liver)->alcoholic hepatitis (with mallory bodies)->alcoholic cirrhosis (micronodular)
66
Describe the early-stage symptoms of alcoholic liver disease
Might have none!
67
Describe the late stage symptoms of alcoholic liver disease
Jaundice, hepatomegaly, palmar erythema, ascites, HE, spider naevi, easy bruising etc
Also alcohol dependency!
68
What are the 2 main alcohol dependency questionnaires?
CAGE
AUDIT
69
Describe the CAGE questionnare
Should you Cut down?
Are people Annoyed by your drinking?
Do you feel Guilty about drinking?
Do you drink in the morning (Eye opener)
>2=dependent
70
Describe the AUDIT questionnare
10 questions, alcohol use disorder ID test
71
What investigations would you carry out to diagnose alcoholic liver disease?
Bloods
Biopsy
72
What would you expect to find in the liver function blood test results of a patient with alcoholic liver disease?
LFT's: hgih bilirubin, low albumin
High PT
High GGT
AST: ALT>2
73
What would you expect to find in the FBC of a patient with alcoholic liver disease?
Macrocytic non-megaloblastic anaemia
Potentially low folate
74
Why is a biopsy needed and what would it show in a patient with alcoholic liver disease?
Needed to confirm extent of cirrhosis or if it's just hepatitis
Inflammation, necrosis, mallory cytoplasmic inclusion bodies
75
What are the 3 approaches to treating alcoholic liver disease?
Conservative
Pharmacological
Surgical
76
Describe the conservative treatment for alcoholic liver disease
Stop alcohol intake, healthy diet, BMI
77
What is a potential serious complication of alcohol withdrawal?
Delirium tremens
78
How would you manage delirium tremens?
Give chlordiazepoxide or diazepam
79
Name some alcohol withdrawal symptoms
Tremors
Agitation
Ataxia
Disorientation
80
Describe the pharmacological treatment of alcoholic liver disease
Consider short term steroids
B1 and folate supplements
81
What discriminant value should you use when deciding wether to prescribe short term steroids to someone with alcoholic liver disease
Maddrey's discriminant value >32
Assesses alcoholic liver disease severity and need for treatment
82
Describe the surgical management of alcoholic liver disease
Liver transplant for ESLF patients
Must abstain from alcohol for >3 months before consideration
83
Name some complications of alcoholic liver disease and how you would treat them
Pancreatitis (IgE and smashed)
HE (lactulose)
Ascites (diuretics)
HCC (chemo, surgery)
Mallory Weiss tear
Wernicke Korsakoff syndrome
84
What is a Mallory Weis tear?
Tearing of tissue in lower oesophagus
85
What is Wernicke's encephalopathy?
Encephalopathy caused by lack of B1 due to alcohol abuse
86
What is Korsakoff syndrome?
Memory affected by lack of B1
87
What is Wernicke Korsakoff syndrome?
Combined B1 deficiency and alcohol withdrawal symptoms
88
Name some symptoms of Wernicke Korsakoff syndrome.
Ataxia
Nystagmus
Encephalopathy
'Confabulational' make up stories to fill up memory gaps-disproportionate memory loss compared to other symptoms
89
When else might you see 'confabulation'?
Fronto-temporal lobe amnesia
90
What is non-alcoholic fatty liver disease?
Chronic liver disease not due to alcoholism
91
Name some risk factors for developing non-alcoholic fatty liver disease
Obesity, htn, hyperlipidaemia, T2DM
family hx, endocrine disroders, drugs
92
Which drugs are risk factors for developing non-alcoholic fatty liver disease
NSAID'S
Amiodarone
93
When should non-alcoholic fatty liver disease be suspected?
Anyone obese/with T2DM and deranged LFT's
94
Describe the progression of non-alcoholic fatty liver disease
Hepatosteatosis(NAFLD)->non alcoholic steatohepatitis(NASH)->fibrosis->cirrhosis
95
Describe the symptoms of non-alcoholic fatty liver disease
Usually asymptomatic and incidental findings
If very severe: signs of liver failure
96
What investigations should be done to diagnose non-alcoholic fatty liver disease?
Bloods: deranges LFT's (high PT/INR, low albumin, high bilirubin)
FBC: thrombocytopenia, hyperglycaemia
Imaging: US abdomen
Screen for other causes: metabolic, HbA1c, lipid profile, hep serology
97
Would you do a biopsy to look for NAFLD?
Not unless absolutely necessary-US has 94% specificity for moderate-severe steatosis
98
Give an example of a non invasive scoring system used to assess the risk of fibrosis
Fibrosis 4 score
>2.67-advanced-refer to hepatology
99
Describe the treatment for NAFLD
Control risk factors:
Weight loss
Lipids: statins
Diabetes: metformin
Htn: ACE-i
Vitamin E: recommended by NICE-improves histological steatotic/fibrotic liver appearance)
100
Name some complications of NAFLD
HCC!
HE
Ascites
Portal htn and oesophageal varices
101
What is liver cirrhosis?
Diffuse pathological process characterised by fibrosis and presence of regenerative nodules.
Final stage of any chronic liver disease
Generally irreversible
102
Name some causes of liver cirrhosis
AFLD-most common in developed countries
Hep B/C
Fatty liver disease
HH
WD
103
How would you diagnose liver cirrhosis?
Deranged liver bloods: PT/IR high, albumin low, platelets low, thrombocytopenia etc
Liver biopsy gold standard
104
What is the definitive treatment for liver cirrhosis?
Liver transplant
105
What is the conservative treatment for liver cirrhosis?
Fluids, analgesia, alcohol abstinence, good nutrition
106
What is the medical treatment for liver cirrhosis?
Treat complications
107
Name some complications of liver cirrhosis
Ascites
Portal HTN
Varices
Also:
Jaundice
Coagulopathy
Hypoalbuminaemia(causing oedema)
Portosystemic encephalopathy
Hepatorenal and hepatopulmonary syndrome
108
What is viral hepatitis?
Inflammation of the liver as a result of viral replication within hepatocytes
109
Which form of hepatitis is a notifiable disease to public health England?
Hep A
110
What type of virus is Hep A?
RNA
111
How is Hep A transmitted?
Faecal-oral, contaminated food, fly vectors
112
Describe the infection associated with Hep a
Acute-usually cleared by host immune system
100% immunity after infection
113
Describe the epidemiology of Hep A
Associated with travel history
High prevalence in Africa
Also Asia, south America, middle east
114
What are the risk factors for contracting Hep A?
Overcrowding
Poor sanitation
Shellfish
Travel
115
Describe the incubation and replication of Hep A
Incubation for 2 weeks
Replicates in liver, excreted in bile
Self limiting within 6 weeks
116
Describe the presentation of Hep A patients
Prodromal phase (1-2weeks): nausea, vomiting, malaise, fever, weight loss
After 1-2 weeks: liver symptoms: Jaundice, dark urine and pale stools, hepatosplenomegaly
117
What investigations can be done to diagnose Hep A?
Bloods: High ESR and leukopenia
LFT'S: raised ALT, raised bilirubin
HAV serology: HAV IgM if acutely infected
118
Describe the management of Hep A
Often not required, mostly supportive
Travellers vaccine available
119
Name a complication of Hep A
Fulminant liver failure
120
What kind of virus is Hep B?
DNA
121
Describe the infection caused by Hep B
Acute: infects hepatocytes, usually cleared
Chronic: If HBsAg>6 months, depends on age/immunocompetence. Inflammation can last 10 yrs->cirrhosis
122
Describe the transmission of Hep B
Blood products-needle sticks, IVDU, tattoos
Sexual
Vertical (mother to child)
123
In what bodily substances is Hep B found?
Semen
Saliva
124
Name some risk factors for contracting HBV
IVDU
MSM
Dialysis patients
Healthcare workers
125
Where in the world is HBV found?
Worldwide!
Especially Africa, Middle and far east
126
Describe HBV symptoms
1-2 weeks prodrome:
Then: deepening jaundice, dark urine, pale stools, hepatosplenomegaly urticaria, arthralgia
127
How long is the incubation period in HBV
1-6 months
128
How would you diagnose HBV?
HBVsAg: 1-6 months of infection
HBsAB: present after 6 months of infection
HbcAg: exposed to HBV at some point
HBcIgG: chronic infection/carrier
HBeAg: Marker of infectiousness(acutely infected)
HBeAB: All chronically infected patients or if they have cleared infection
129
What percentage of adult HBV cases progress to chronic liver failure and what does this increase the risk of?
5-10%
Increased HCC risk
HCC with HBV associated decompensation has worst prognosis
130
What percentage of HBV cases in children become chronic decompensation liver failure and how is this treated?
90%
Liver transplant
131
Describe the management of HBV
Vaccine available
Antivirals: Tenofovir, pegylated interferon alpha 2a
132
What are the main complications of HBV?
Increased risk of liver cirrhosis
HCC
133
What kind of virus is Hep C?
RNA
134
What kind of infections does Hep C cause?
Acute and chronic( causes slowly progressive fibrosis over years)
135
How is Hep C transmitted?
Blood borne
Especially IVDU
Also sexually but IVDU more
136
Describe the presentation of Hep C patients
Acute: often asymptomatic, occasionally flu-like symptoms
Present later with chronic liver signs and hepatosplenomagaly
137
How is Hep C diagnosed?
LFT'S
Serology:
HCVRNA: current infection/acte infection
HCVAb: within 4-6 weeks of infection
138
Describe the treatment for Hep C
Direct acting antivirals-ribavirin
139
What are the main complications of Hep C?
30% progress to chronic liver failure
cirrhosis and HCC risk
140
What kind of virus is Hep D?
RNA
141
How is Hep D transmitted?
Blood borne-sexually, IVDU
142
Describe the pathophysiology of Hep D
Unable to replicate on its own, requires concurrent HBV infection
Makes HBV more likely to progress to cirrhosis
143
How does Hep D manifest?
Same as co-infection
IgM HDV + IgM HBV
144
What kind of virus is Hep E?
RNA
145
Describe the transmission of Hep E
Faeco-oral-undercooked meat
146
Describe the epidemiology of Hep E
Common in the UK
147
Describe the presentation of Hep E
Mostly asymptomatic as virus is self-limiting
148
How is Hep E diagnosed?
Serology: HEV IgM-acute infection, HEV RNA
149
Describe the treatment for Hep E
Supportive
Vaccine only in China
150
Describe immunity after Hep E infection
100% immunity after infection
151
Describe the complications of Hep E
Chronic disease in immunosuppressed
Can cause fulminant liver failure: normal mortality 1-2%, pregnancy 10-20%)
152
How does hepatitis appear histologically?
Interface necrosis
153
What is autoimmune hepatitis?
Adaptive immunity mounts autoimmune response against hepatocytes
154
What is another name for AI hepatitis?
Lupoid hepatitis
Causes lupus-like rash
155
Name some risk factors for developing AI hep
Female
Other AI diseases
Viral hepatitis
HLA DR3 or DR4
156
What are the 2 types of AI hep?
Type 1: Adult females (80%): ANA, ASMA
Type 2: Young females: ALC1(anti liver cytosol)
ALKM1(anit liver kidney microsome)
157
Describe the presentation of AI hep
25% asymptomatic
Many: jaundice, fever, hepatosplenomegaly
158
Describe the diagnosis of AI hep
Serology
ANA
ASMA
ALC-1
ALKM1
159
Describe the treatment for AI hep
Corticosteroids (prednisolone)
Azathioprine (immunosuppressant)
Hep A +B vaccination
Last resort: liver transplant
160
Describe the process of RBC metabolism
In the spleen:
Hb->Haem and globin
Haem->Fe2+ and biliverdin
Biliverdin->unconjugated bilirubin, transported in blood bound to albumin
In the liver: Unconjugated bilirubin+glucuronic acid->conjugated bilirubin, travels in bile to duodenum
Conjugated bilirubin->urobilinogen
90%-stercobilin-faeces
5%-urobilin-urine
5%-enterohepatic recycling
161
What is jaundice?
AKA icterus
Yellowing of the skin/eyes due to accumulation of conjugated/unconjugated bilirubin
Sign of liver dysfunction
162
Describe the pathophysiology of pre-hepatic jaundice
Increased haemolysis (RBC breakdown) leads to increased unconjugated bilirubin as liver can't conjugate it fast enough
163
Name some causes of pre-hepatic jaundice
Haemolytic anaemias:
Sickle cell
G6PDH deficiency
AI haemolytic anaemia
Thalassaemia
Malaria
164
Describe the pathophysiology of intra-hepatic jaundice
Liver damage leads to conjugated/unconjugated bilirubin in blood
165
Name some causes of intra-hepatic jaundice
HCC
ALD/NAFLD
Hepatitis
Hepatotoxic drugs
Gilbert syndrome
166
Describe the pathophysiology of post hepatic jaundice
Blockage of bile ducts leads to backflow of conjugated bilirubin into the blood
167
Name some causes of post hepatic jaundice
Biliary tree pathology:
-Choledocholiathis(stone stuck in CBD)
-Pancreatic cancer
-Cholangiocarcinoma
-Mrizzi syndrome
-Drug induced cholestasis
Autoimmune: PBC + PSC
168
What is Mirizzi syndrome?
Gallstones stuck in gallbladder neck and externally compress CBD and cause obstruction
169
Give some examples of drugs that can cause drug-induced cholestasis
Ampicillin
COCP
170
What is Gilbert's syndrome?
Mutation of uGT1A1 gene->underactive uGT enzyme->low conjugated bilirubin
171
Which kind of jaundice causes pale stool and dark urine?
Obstructive/post hepatic jaundice
172
Explain the pathophysiology of pale stool and dark urine in obstructive jaundice?
Increased levels of conjugated bilirubin in blood and low levels in intestine
Less stercobilin->pale poo
Les urobilin->dark urine
173
What is the inheritance pattern of Gilbert's syndrome?
Autosomal recessive
174
Describe the presentation of Gilbert's syndrome
Typically young males
Painless jaundice, sudden onset
175
What is Courvoisier sign?
Painless jaundice and palpable gallbladder
176
What is Courvoisier's sign indicative of?
Most likely pancreatic cancer or cholangiocarcinoma
177
What is Charcot's triad and what is it used to assess?
Fever, RUQ pain, jaundice
Biliary colic: RUQ pain
Cholecystitis: fever + RUQ pain
Ascendign cholangitis: all 3
178
What is Reynold pentad and what is it indicative of?
Seen in ascending cholangitis
Fever, RUQ pain, jaundice, confusion, hypotension
179
What is the Murphy sign and what is it indicative of?
RUQ tenderness, ask patient to breathe in while pressing RUQ. Patient will wince/stop inspiring normally
Cholecystitis
180
What tests would you use to diagnose jaundice?
Bloods + LFT's: bilirubin, albumin, PT/INR, AST, ALT, GGT, ALP
Urine bilirubin: Positive in dark urine, post and intra hepatic causes
Urobilinogen: Normally positive, high in haemolysis, low in intra/post hepatic causes
US 1st line
181
Describe urine bilirubin and urobilinogen levels in a normal patient
Negative urine bilirubin
Positive urine urobilinogen
182
Describe urine bilirubin and urobilinogen levels in a patient with a biliary obstruction
Positive urine bilirubin
Low urine urobilinogen
183
Describe urine bilirubin and urobilinogen levels in a patient with hepatic disease
Positive urine bilirubin
Low urine urobilinogen
184
Describe urine bilirubin and urobilinogen levels in a patient with haemolysis
Low urine bilirubin
High urine urobilinogen
185
What is pancreatic cancer?
Adenocarcinoma of the exocrine pancreas(99% of cases) of cutal origin, typically affecting head
186
Name some risk factors for developing pancreatic cancer
Smoking
Alcohol
diabetes
fhx
chronic pancreatitis
genetic predisposition
males, >60yrs
187
Describe the common distribution of pancreatic cancer
Head: 60%
Body: 25%
Tail: 15%
188
Describe the signs and symptoms of pancreatic cancer
Head: Courvoisier sign(painless jaundice +palpable gallbladder) with pale stool and dark urine
Body + tail: epigastric pain radiating to back, relieved when sitting forward
Maybe: trousseau sign of malignancy
189
What is Trousseau's sign of malignancy?
Non specific episodes of vessel inflammation and clots in different parts of the body: migratory thrombophlebitis
190
Mutation in what gene makes you susceptible to pancreatic cancer?
PRSS-1 mutation
191
How would you diagnose pancreatic cancer?
1st line: abdominal US(less sensitive)
Pancreatic CT protocol then bile duct drainage
192
What can be used to monitor pancreatic cancer progression?
Ca19-9 tumour marker
193
What is the treatment for pancreatic cancer?
Poor prognosis: 5yr survival -3%
Surgery and post-op chemo if no mets
Palliative care if mets
194
Describe the different types of liver cancers
Primary (less common): hepatocellular carcinoma, cholangiocarcinoma
Secondary: GI tract, breast, bronchial
195
Where does HCC arise from?
Arise from liver parenchyma
196
What percentage of primary liver cancers doe HCC make up?
90%
197
Is HCC seen mostly in males or females
Males
198
Name some risk factors for HCC
Chronic hep C/B virus
Cirrhosis from ALD/NAFLD/haemochromatosis
199
Where does HCC metastasize to?
Lymph nodes
bones
lungs
Via hematogenous spread(hepatic/portal veins)
200
Describe the symptoms of HCC
Signs of decompensated liver failure(jaundice, ascites HE etc)
Cancer signs: weight loss, night sweats etc
Might have irregular hepatomegaly
201
How can HCC be diagnosed?
Might show high serum AFP
Imaging: US 1st line
CT confirmation
202
Name 2 conditions that might show high AFP
HCC
Testicular cancer
203
Why aren't biopsies done to diagnose pancreatic cancer?
Prevents seeding of tumour elsewhere
204
Describe the management of HCC
Surgical resection of tumor
Only real cure->liver transplant
Prevention: HBV vaccine
205
Where does cholangiocarcinoma arise from?
Arises from biliary tree
206
What kind of carcinoma is cholangiocarcinoma?
Typically adenocarcinomas
207
Name some risk factors for cholangiocarcinoma
Parasitic flukeworms, biliary cysts, IBD, PSC
208
Describe the symptoms of cholangiocarcinoma
Abdominal pain
jaundice
weight loss
pruritus
fevers
Also courvoiier's sign-but more seen in pancreatic cancer
209
How would you diagnose cholangiocarcinoma?
High CEA and high CA19-9
LFT: high bilirubin, high ALP
1st line imaging: abdominal US and CT
GS: ERCP(imaging of biliary tree)
Biopsy
210
Name 2 advantages and one disadvantage of using ERCP to diagnose cholangiocarcinoma
Advantages: Can stent structures present in tree and can obtain sample for biopsy
Disadvantage: Invasive
211
Describe the treatment for cholangiocarcinoma
Most cases are inoperable as patients present very late
212
Name 2 benign liver primary tumours
Haemangioma: seen in infants as strawberry mark in skin within first weeks of life
Hepatic adenoma
213
Are primary or secondary liver tumors more common?
Secondary tumours are more common
214
Where do secondary liver tumours typically come from?
GI tract
lungs
breast
215
How would you diagnose secondary liver tumours?
High serum ALP
Imaging: US, CT/MRI for staging
216
Describe the treatment of secondary liver tumours
Surgical resection if possible of primary cancer and hepatic cancer
Chemo
217
What are the 3 main biliary tract diseases?
Biliary colic(gallstones)
Cholecystitis
Ascending cholangitis
218
What are gallstones made of?
Cholesterol-80%
Pigment
Mixed
219
What are the risk factors for developing biliary tract diseases?
4F's
Fat
Female
Forty +
Fertile (pregnancy/many children)
Also: FHx, T2DM, NAFLD, haemolytic conditions
220
How is biliary colic different from typical colic?
Biliary colic: constant severe episodes of pain
Typical colic like renal colic: often comes and goes
221
Describe the symptoms of gallstones
RUQ biliary colic (constant severe episodes of pain >30 minutes
Worse after eating a fatty meal
Referred shoulder pain
Nausea and vomiting
222
Describe the symptoms of cholecystitis
RUQ pain: might be referred to shoulder by phrenic nerve
Fever
Tender gallbladder: Positive Murphy's sign
223
Describe the symptoms of ascending cholangitis
Charcot's triad:
RUQ pain
Fever
Jaundice (obstructive-dark urine and pale stools)
Reynold's pentad: Charcot's triad + confusion + septic shock
224
Describe the pathophysiology behind biliary colic
Temporary blockage of the cystic duct by gallstones
225
Describe the pathophysiology of cholecystitis
Blockage of the cystic duct leads to the buildup of bile causing transmural inflammation of the gallbladder
226
What is ascending cholangitis
Medical emergency characterized by bacteria(especially E.Coli) ascending through and colonising the biliary tree from the intestines leading to septicemia
227
What does MRCP stand for?
Magnetic resonance cholangiopancreatography
228
What does ERCP stand for?
Endoscopic retrograde cholangiopancreatography
229
What investigations are done to diagnose a patient with biliary colic?
FBC, CRP, LFT'S
Abdominal US 1st line to ID gallstones
230
Describe the treatment for gallstones
Analgesia: NSAID's if mild, IM diclofenac if severe
Elective laparoscopic cholecystectomy if symptomatic
Lifestyle changes like low fat diets
231
What investigations are done to diagnose cholecystitis?
FBC: leukocytosis+neutrophilia
CRP
LFT's-should be normal
Abdominal US: >3mm thickened gallbladder wall
232
Describe the treatment for cholecystitis
Early lap cholecystectomy(within 1 week) or have to wait 6 weeks
Supportive measures prior to surgery-fluids, analgesia, usually no antibiotics
233
What investigations are done to diagnose ascending cholangitis?
FBC: leukocytosis + neutrophilia
LFT's: high conjugated bilirubin
Amylase/lipase
CRP
US abdomen: CBD dilation and gallstones
MRCP: diagnostic and best pre-intervention management
234
Describe the treatment of ascending cholangitis
eli sucks
Aggressive fluid resuscitation
IV abx: penicillins and aminoglycosides
ERCP for bile duct clearance first
Cholecystectomy once stable to prevent recurrence
235
What is a major risk that must be considered when treat ascending cholangitis
Sepsis
236
What is the difference between primary biliary cholangitis and primary biliary cirrhosis?
The is no difference!
237
Describe the biliary tree
Common hepatic duct->Common bile duct
Cystic duct comes off common hepatic duct to gallbladder. Common bile duct->Ampula of Vater and pancreatic duct
238
What is primary biliary cholangitis?
Progressive autoimmune destruction of the liver and biliary tree(intralobular bile ducts) leading to fibrosis and eventually cirrhosis
239
What causes pruritus in PBC?
Excess conjugated bilirubin leaking out
240
What are the risk factors for developing PBC?
Female
40-50yrs
Other AI diseases
Smoking
241
Which is more common: PBC or PSC?
PBC more common
242
Describe the pathophysiology of PBC
Autoantibodies cause intralobular bile duct damage->chronic AI granulomatous inflammation
Results in cholestasis->fibrosis, cirrhosis, portal htn and infections
243
Describe the symptoms of PBC
Often asymptomatic/not specific symptoms at first
Fatigue
Pruritus
Advanced: jaundice, hepatomegaly, xanthelesma
244
What complications can arise from PBC?
Cirrhosis
Malabsorption of fats and vitamins A,D,E,K->steatorrhoea
Osteomalacia
Coagulopathy
245
What investigations are carried out to diagnose PBC?
LFT's: high ALP and GGT, high conj. bilirubin, low albumin
Rule out acute hep: HeapBsAg, HCVAb
Serology: 95% have AMA antibodies
US: exclude extrahepatic cholestasis
Liver biopsy
246
What would you see on a liver biopsy of a patient with PBC?
Portal tract infiltrate(lymphocyte and plasma cells)
40% granulomatous
Portal tract fibrosis
247
Describe the treatment for PBC
Ursodeoxycholic acid: lifelong
For pruritus: colestyramine
Vitamin A,D,E,K supplements
Consider osteomalacia treatments
May ultimately need liver transplant
248
What is ursodeoxycholic acid used for and how does it work?
PBC:
Bile acid analogue
Dampens immune response and reduces cholestasis
249
What is primary sclerosing cholangitis?
Progressive sclerosis of the biliary tree leading to cholestasis and ESLD
AI destruction of intra and extra-lobular hepatic duct
250
What are the risk factors foe developing PSC
Male
40-50
Strong link to IBD, especially UC
251
Which affects more ducts: PBC or PSC?
PSC
252
Describe the symptoms of PSC
Initially asymptomatic
Pruritus, fatigue, jaundice, Charcot's triad (if CBD involved)
Hepatosplenomegaly
IBD relates symptoms
253
What tests would you use to diagnose PSC?
LFT's
Serology:
HBVsAg/HCVAb negative
ANA negative
Coeliac screen negative
pANCA often positive
GS: MRCP imaging
254
What is acute pancreatitis?
Sudden inflammation of the pancreas leading to autodigestion of the gland-usually reversible
255
Name the causes of acute pancreatitis
I GET SMASHED
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion venom/spider bite
Hypercalcaemia/hyperlipidaemia
ERCP
Drugs(NSAID's, ACE-i's, azathioprine0
256
What is the most common cause of acute pancreatitis?
Gallstones
257
What is the most common cause of chronic pancreatitis?
Ethanol
258
Describe the pathophysiology of acute pancreatitis caused by gallstones
Gallstones obstruct pancreatic secretion, so digestive enzymes accumulate in the pancreas
Host defences soon overwhelmed
Autodigestion->inflammation and enzymes leak into blood
259
Describe the symptoms of acute pancreatitis
Sudden severe epigastric pain radiating to the back
Jaundice
Pyrexia
Steatorrhea
Grey Turner sign (flank bleeding)
Cullen sign(periumbilical bleeding)
260
How would you diagnose acute pancreatitis?
Bloods: High serum amylase/lipase, LFT's, CRP
Erect CXR to exclude gastroduodenal perforation(can also increase amylase/lipase)
US: diagnostic for gallstones
CT/MRI: look at extent of damage
261
Is serum amylase or lipase more specific for acute pancreatitis?
Lipase more specific but less routine
262
For a diagnosis of acute pancreatitis to be made what criteria have to be met?
At least 2 of:
1. Characteristic symptoms/signs
2. High amylase/lipase
3. Radiological evidence
263
What is a differential diagnosis for acute pancreatitis epigastric pain?
AAA
264
Describe the acute pancreatitis scoring systems
APACHE 2: severity within 24 hours
Glasgow and Ranson score: prediciton of severe attack after 48 hours
265
What is the treatment for acute pancreatitis?
Nil by mouth, TPN if required
Agressive fluid rescuscitation
Analgesia: usually morphine
Antibiotics if necrotising pancreatitis
Catheterise
266
What complications can arise from acute pancreatitis?
SIRS
Pancreatic pseudocyst
Insulant dependent DM
ARDS and pleural effusion
DIC
267
What is SIRS and how is it diagnosed?
Systemic inflammatory response syndrome-complication of acute pancreatitis
2 of:
Tachycardia
Tachypnoea
Pyrexia
High WCC
268
What is chronic pancreatitis?
> 3-month history of pancreatic deterioration-irreversible pancreatic inflammation and fibrosis
Can be persistent pain and malabsorption or acute on chronic episodes
269
Name some causes of chronic pancreatitis
Alcohol-most common
Cystic fibrosis
Cancer
AI
CKD
Traume
Recurrent acute pancreatitis
270
Describe the symptoms of chronic pancreatitis and give a differential diagnosis for these symptoms
Epigastric pain boring to back, exacerbated by alcohol
Steatorrhoea
Weight loss-malabsorption
Insulin-dependent DM
DDx: pancreatic cancer
271
How is chronic pancreatitis diagnosed?
Bloods: lipase and amylase: unlikely to be high in severe cases
Secretin stimulation test
Fecal elastase: typically high
US, CT-detects pancreatic calcification and dilated pancreatic duct
272
Why are amylase and lipase unlikely to be high in severe chronic pancreatitis cases?
Such a deficiency that there's none left to leak out
273
Describe the management of chronic pancreatitis
Alcohol cessation
NSAID.s/opiates for pain
Pancreatic supplements like insulin and creon
ERCP or surgery if required
274
What is portal hypertension?
Pathologically high BP in the portal vein
275
Name the causes of portal hypertension
Pre hepatic: portal vein thrombosis
Intrahepatic: cirrhosis, schistosomiasis
Posthpeatic: Budd Chiari, RHS failure, constrictive pericarditis
276
What is the normal and abnormal pressure in the portal vein?
5-8mmHg
>10: bad
>12: very bad
277
Explain the pathophysiology behind portal hypertension
Cirrhosis: increased resistance to blood flow->splanchnic dilation and compensatory increase in CO->fluid overload in the portal vein
278
How does portal hypertension lead to oesophageal varices?
Fluid overload in portal vein->collateral blood shunting to gastroesophageal veins(typically small)->oesophageal varices
279
Where are oesophageal varices most commonly found?
Cardia and lower oesophagus
280
Describe the symptoms of portal hypertension
Mostly asymptomatic
Ascites
Bleeding varices
281
When do patients with portal hypertension most commonly present?
When oesophageal varices rupture
282
What is a differential diagnosis for oesophageal varices and how can you differentiate between them?
Mallory Weiss tear: very acute history, high abdominal pressure(retching, alcoholic heaves)
Varices: History of alcoholism/liver cirrhosis
283
What is the main concern of ruptured oesophageal varices
Haemorrhage, patients with haematemesis
284
How do you diagnose oesophageal varices?
Oesophagogastroduodenoscopy
285
Describe the management of haemorrhaging oesophageal varcise
Acutey: resus until haemodynamically stable
Consider blood transfusion (Hb<70g/L)
Stop bleed:
1. IV Terlipressin
2. Variceal banding
3. TIPPS: transjugular;ar intrahepatic portasystemic shunt-decrease portal pressure by diverting blood to other larger veins
Prevent bleed:
Beta blocker-propanolol and nitrates
Repeat variceal banding
Last resort: liver transplant
286
What is ascites?
Free fluid in the peritoneal cavity
287
Name the causes of ascites
Local inflammation: peritonitis, TB, abdominal cancer
Low protein: hypoalbuminemia(liver failure), nephrotic syndrome
Flow stasis: build-up causes leakage: cirrhosis, Budd Chiari, congestive heart failure, constrictive pericarditis
288
What are the symptoms of ascites?
Abdominal distention
May have jaundice and pruritus
Shifting dullness and fullness in flanks
289
How do you diagnose ascites?
Shifting dullness on exam
Ascitic tap (periocentesis of 10-20ml fluid)
Cytology: WCC, albumin etc
Protein measurement
290
Explain transudate measurement and causes for ascites
<30g/L protein (low), <11gL SAAG
Clear fluid
Fluid due to high hydrostatic pressure
Portal hypertension, budd chiari, constrictive pericarditis, CJF, nephrotic syndrome
291
Explain exudate protein measurement and causes for ascites
>30g/L protein, SAAG >11g/L
Cloudy fluid
Fluid due to inflammation, mediated exudation or low oncotic pressure
Malignancy, peritonitis, pancreatitis
292
What is SAAG?
Serum albumin-ascitic gradient
Serum albumin-albumin in ascitic fluid
293
How do you treat ascites?
Treat underlying cause
Diuretic to increase Na+ excretion so more fluid is pushed out-spironolactone
Paracentesis
Liver transplant
294
What is peritonitis?
Inflammation of the peritoneal cavity
295
What are the different sensations in the abdomen related to peritonitis?
T5-9: epigastric: greater splanchnic, foregut(up to duodenum)
T10-11: umbilical: lesser splanchnic, midgut (2/3 transverse colon)
T12: hypogastric: least splanchnic, hindgut (up to rectum)
296
What is the difference between primary and secondary peritonitis?
Primary: ascites, SBP
Secondary: underlying cause e.g. bile, malignancy
297
What is the most common cause of peritonitis?
SBP (infection)
298
Describe the bacterial causes of peritonitis
Gram negative: E.Coli+Kliebsiella (colliform rods)
Gram positive: Staph aureus (cocci)
299
Name some chemical causes of peritonitis
Bile
Old clotted blood
Ruptured ectopic pregnancy
Intestinal perforation
Ultimately get infected
300
Describe the symptoms of peritonitis
Sudden onset severe abdominal pain, then collapse, fever, septic shock
Rigidity helps pain: guarding, hands on abdo to stop it moving and avoid speedbumps when driving
Poorly localised
Ascites
301
What is a differential diagnosis for rigidity helping pain from peritonitis
Renal colic
302
How is peritonitis diagnosed
Ascitic tap: neutrophilia
Cultures: causative organism
High ESR and CRP
Exclude pregnancy and bowel obstruction as cause
Erect CXR: under diaphragm-indicates perforated colon
303
How is peritonitis treated?
ABCDE
Treat underlying cause
IV fluids, antibiotics (cefotaxime, metronidazole)
Surgery: peritoneal lavage
304
Name some causes of peritonitis
Scepticaemia
Subphrenic/pelvic abscesses
Paralytic ileus
305
What are the 3 main metabolic liver diseases?
Haemochromatosis
Wilson's disease
Alpha 1 antitrypsin deficiency
306
What is hemochromatosis?
Autosomal recessive mutation of HFE gene that leads to dysregulated iron absorption and increased iron release from macrophages
307
Why is hemochromatosis unlikely in women?
Iron loss in menstruation
308
Name some risk factors for hemochromatosis
Male
50 years
FHx
309
Describe the pathophysiology of hemochromatosis
Excess Fe uptake by transferrin 1 and low hepcidin synthesis->accumulation of iron which accumulates and causes fibrosis o organs: liver, joints, pancreas, heart, skin, gonads
310
What does hepcidin do?
Protein that regulates iron homestasis
311
How much iron is usually in the body and how much is there in hemochromatosis?
Usually: 3-4g
hemochromatosis: 20-30g
312
Describe the symptoms of hemochromatosis
Fatigue
joint pain
hypogonadism
slate grey->bronze skin
liver cirrhosis symptoms
osteoporosis
heart failure
313
What is the gross Fe overlad triad?
Bronze statue skin
Hepatomegaly
T2DM
314
What can cause secondary iron overload?
Multiple transfusion
315
How is hemochromatosis diagnosed?
Fe studies: High serum Fe, high ferritin, high transferrin index, low TIBC
Genetic test
Liver biopsy-assess degree of liver stain with prussian blue stain
316
Describe the treatment of hemochromatosis
Venesection: regularly removing blood
Iron chelation 2nd line: desfernoxamine
Lifestyle changes, low iron, avoid fruits
Definitive: liver transplant
317
What is Wilson's disease?
Autosomal recessive mutation of ATP78 gene on chromosome 13-> excess body copper
318
Describe a typical patient with Wilson's disease
Young-20yrs
Family history
319
Describe the pathophysiology of Wilson's disease
Impaired copper biliary excretion and normal transport-> copper accumulation in liver , basal ganglia and cornea
320
Describe the symptoms of Wilson's disease
Hepatic: liver disease, jaundice etc
Neurological: Parkinsonian, depression, memory problems
Opthalmological: Kayser Fleischer rings(green-brown rings)
321
How is Wilson's disease diagnosed?
24 hr urine copper and blood caeruloplasmin(low)
Liver biopsy: definitive
MRI brain: cerebellar and BG degeneration
322
Describe the treatment for Wilson's disease
D-Penicillinamine (copper chelation-lifelong)
Diet changes-avoid high copper foods like mushrooms and shellfish
Last resort: liver transplant
323
What is A1AT deficiency?
Deficiency of alpha 1 antitrypsin enzyme due to autosomal recessive mutation of protease inhibitor gene('SERPINA-1 gene) on chromosome 14
324
Describe the pathophysiology of A1AT deficiency
A1AT normally inhibits neutrophil elastase(degrades elastic tissue)
Insufficient A1AT->high NE
Lungs: degrades elastic tissue causing alveolar duct collapse, air trapping and panacinar emphysema
liver: unprotected, soon become fibrotis-cirrhosis and HCC risk
325
How does liver fibrosis make A1AT synthetic function even worse?
A1AT made by liver
326
Describe the presentation of a patient with A1AT deficiency
Young/middle-aged male with no/little smoking history but symptoms of COPD
Dyspnoea, chronic cough, sputum production, barrel chest
Liver symptoms like jaundice
327
How is A1AT diagnosed?
Serum A1AT (low: <20mmol/L)
Barrel chest on exam, CXR: hyperinflated lungs
CT: panacinar emphysema
LFT: Spirometry shows obstruction (FEV:FVC<0.7)
Genetic test: positive PI mutation
328
Describe the management for A1AT deficiency
No curative treatment
Smoking cessation
Manage emphysema: inhalers, SABA's/LABA's
Consider hepatic decompensation patients for liver transplants
329
What does of paracetamol is classed as an overdose?
>75mg/kg
330
Describe teh sympotms of a paracetamol overdose
Acute severe RUQ pain, severe nausea and vomiting
331
Describe normal paracetemol metabolism
90%: glucuronidation/sulfation->excreted
10%: Phase 1 conjugation (CYP450)->NAPQ1->phase 2 glutathione->excreted
332
What happens to paracetamol metabolism in an overdose?
Glucuronidation and sulfation pathways saturated, more metabolised by P450->depleted glutathione->increases NAPQ1 production which is toxic and accumulates in the liver
333
What is the treatment for a paracetamol overdose?
Activated charcoal (within 1 hour of ingestion) and N-acetyl-cysteine
334
What does N acetyl cysteine do?
Increases availability of glutathione to get rid of excess NAPQ1
335
What is Gilbert's syndrome?
Most common cause of hereditary jaundice
Autosomal recessive
Liver unable to conjugate bilirubin
336
Name some risk factors for Gilbert's syndrome
Male
T1DM
fhX
337
Describe the pathophysiology of Gilbert's syndrome
Deficient or abnormal uGT-> increased unconjugated bilirubin
338
Describe the symptoms of Gilbert's syndrome
30% asymptomatic
May present with just painless jaundice at a young age
Criggler Najjor: more severe: jaundice with nausea and vomiting and lethargy
339
Describe the management of Gilbert's syndrome
Usually fine without treatment
340
What is Crigler Najjar syndrome and why is it dangerous?
More severe porgression
Can die from kernicterus (accumulation of bilirubin in basal ganglia->neurological deficits) in childhood
341
What is the treatment for Crigler Najjar syndrome?
Phototherapy: breaks down unconjugated bilirubin
342
What are hernias?
Protrusion of an organ through defect in containing cavity, typically bowerl
343
What is a hiatal hernia?
Stomach hernia through diaphragm aperture
344
What are the 2 types of hiatal hernia?
Rolling(20%): LES stays in abdomen, part of fundus rolls into thorax
Sliding (80%): LES slides into abdomen
345
Name some symptoms of hiatal hernia
GORD
Dysphagia
346
How are hiatal hernias diagnosed?
CXR
Barium swallow
OGD
347
Name some risk factors for developing a hiatal hernia
Obese
Female
>50
348
How can hernias be classed?
Reducible->pushed back into place
Irreducible:
Obstructed-intestinal obstruction
Strangulated-intestinal ischaemia->gangrene, infarction
Incarcerated-contents are fixed in sac due to size/adhesion
349
What is a femoral hernia?
Bowel through femoral canal
Very likely to strangulate due to rigid femoral canal borders
350
Name some risk factors for developing a femoral hernia
Female
Mid-old age
351
Name some symptoms of a femoral hernia
Swelling in upper thigh pointing down
352
How would you diagnose a femoral hernia?
US abdo/pelvis if unsure, but usually can be diagnosed clinically
353
What is an inguinal hernia?
Spermatic cord herniates through inguinal canal
Direct(20%): In Hesselbachs triangle, medial to inferior epigastrics
Indirect(80%): Lateral to inferior epigastric, not in triangle
354
Name some risk factors for developing an inguinal hernia
Male
Hx of heavy lifting/abdominal pressure
355
Name some symptoms s of an inguinal hernia
Painful swelling in groin
Points along groin margin
356
How are inguinal hernias diagnosed?
Usually clinical
If unsure: AUSS/CT/MRI
357
What is the curative treatment for hernias?
Surgery
358
What is an umbilical hernia?
Intestine pushes through umbilical ring
Common in children
May get worse when laughing/sneezing
359
What is an incisional hernia?
Protrusion of tissue at the site of a healing surgical scar
360
Where is an epigastric hernia found?
Between sternum and belly button
