liver Flashcards
1
Q
What is the most common cause of acute liver disease?
A
paracetamol overdose
2
Q
What are the key presentations of acute liver disease?
A
jaundice
hepatic encephalopathy
coagulopathy
renal failure
3
Q
What are the 1st line and gold standard investigations for acute liver disease?
A
LFTs - hyperbilirubinaemia + raised liver enzymes
INR >1.5
4
Q
What is the 1st line care for all patients with acute liver disease?
A
ICU monitoring + liver transplant assessment
5
Q
What is the treatment for paracetamol overdose?
A
acetyl cysteine
6
Q
what is the treatment for herpes simplex hepatitis?
A
aciclovir
7
Q
What is the treatment for hep b?
A
oral nucleoside (adefovir/telbivudine)
8
Q
What is the treatment for autoimmune hepatitis?
A
methylprednisolone
9
Q
What are the two ways in which alcohol is broken down by the liver?
A
alcohol dehydrogenase (leads to NADH production which increases fatty acid oxidation)
cytochrome P450 ( generates free radicals through oxidation of NADPH)
10
Q
What are the key presentations of alcoholic liver disease?
A
abdo pain
hepatomegaly
11
Q
What are the first line investigations for alcoholic liver disease?
A
aspartate aminotransferase (AST)
alanine aminotransferase (ALT)
AST:ALT
FBC
12
Q
What is the gold standard investigation for alcoholic liver disease?
A
liver biopsy
13
Q
What is the 1st line treatment for alcoholic liver disease?
A
alcohol abstinence
liverstyle factors
ADJUNCT - corticosteroids + sodium restriction (diuretics)
14
Q
What is the key mechanism for hepatic steatosis?
A
insulin resistance - triglyceride accumulation in the liver
15
Q
What are the key presentations of non alcoholic fatty liver disease?
A
absence of alcohol misuse
fatigue + malaise
hepatosplenomegaly
truncal obesity
jaundice
16
Q
What is fetor hepaticus?
A
The characteristic breath of patients with liver disease - garlic/rotten eggs
17
Q
What are the first line investigations for hepatic steatosis?
A
aspartate aminotransferase AST, alanine aminotransferase ALT, AST:ALT
FBC
18
Q
What is the gold standard test for hepatic steatosis?
A
diagnosed by exclusion + histology (biopsy)
19
Q
What is the 1st line management for hepatic steatosis?
A
lifestyle modification + insulin sensitiser (thiazolidinediones) in DM
20
Q
What is the 2nd line treatment for hepatic steatosis?
A
transjugular intrahepatic portosystemic shunt (TIPS)
21
Q
What are the key presentations of hepatitis?
A
abdo pain (RUQ)
fatigue
pruritis
jaundice
nausea/vomiting
anorexia
fever
22
Q
How is hep a transmitted?
A
faecal-oral route - contaminated water/food
23
Q
What are the 1st line investigations for hepatitis?
A
serum transaminases (AST/ALT) (high)
INR
bilirubin (high)
24
Q
What is the treatment for a patient with recent exposure to hep A?
A
hep a vaccination and/or immunoglobulin
25
What is the treatment for confirmed hep A infection?
supportive care, often goes away on its own
w/ worsening jaundice and encephalopathy-> liver transplant
26
How is hep b transmitted?
blood products, sexually
vertical transmission (mother to baby)
27
What proportion of people infected with hep b become carriers? (HBV DNA integrates with patients)
10%
28
What is the gold standard investigation for hep b?
serum HBV DNA
29
What is the 1st line treatment for an acute hep b infection?
supportive care
ADJUNCT - antiviral therapy + assess for liver transplant
30
What is the 1st line treatment for a chronic hep b infection?
antiviral therapy - tenofovir
31
What antiviral treatments are used for hep b?
tenofovir, pegylated interferon alpha
32
What is the 1st line and gold standard investigation for hep c?
hepatitis C virus (HCV) - RNA PCR
33
What are the complications of hep C?
cirrhosis
hepatocellular carcinoma
34
What is the treatment for hep C?
direct acting antiviral (DAAs) - ribavirin
+ protease inhibitors - ritonavir
35
What must patients be infected with to have Hep D?
HBV infection
36
What is the gold standard investigation for Hep D?
PCR of hep D RNA
37
What are the treatments for hep D?
same as hep B
antiviral therapy pegylated interferon alfa, tenofovir)
(liver transplant in liver failure)
38
How is hep E transmitted?
faecal-oral route
39
What is the gold standard investigation for Hep E?
PCR of hep E RNA
40
What is autoimmune hepatitis?
T cells of the immune system attack the liver - cause necrosis and fibrosis
41
What is the gold standard test for autoimmune hepatitis?
liver biopsy
42
What is the first line treatment for immune hepatitis?
high dose prednisolone + immunosuppressants (azathioprine)
(liver transplant with advanced liver disease)
43
Give an example of a drug that can cause liver cirrhosis
amiodarone/methotrexate/methyldopa
44
What are the four most common causes of cirrhosis
alcoholic liver disease
NAFLD
hep B and C
45
What are the key presentations of liver cirrhosis?
abdominal distension - ascites
jaundice and pruritus
haematemesis and malena
hand and nail features
46
What will blood tests show in cirrhosis?
can often be normal
in decompensated cirrhosis:
Liver enzymes and bilirubin raised
47
What are the best serum indicators of liver function?
prothrombin time and albumin
48
What scan tests liver elasticity and can diagnose cirrhosis?
Fibroscan
49
What score is used to assess the severity of cirrhosis?
Child-Pugh score
50
What is the gold standard investigation for liver cirrhosis?
liver biopsy
51
What is the first line treatment for liver cirrhosis?
Treat underlying condition, prevent further hepatic damage
ADJUNCT
sodium restriction
52
What is the 2nd line treatment for liver cirrhosis?
liver transplantation OR transjugular portosytemic shunt (TIPSS)
53
What is a transudative ascites?
low protein content ascites
54
What is exudative ascites?
high protein content ascites
55
How would you treat ascites?
diuretics - spironolactone + restrict sodium
56
How would you treat cerebral oedema?
mannitol - decreases ICP
57
How would you treat bleeding in liver cirrhosis?
vitamin K or fresh frozen plasma (FFP)
58
How does cirrhosis cause encephalopathy?
ammonia is not detoxified or bypasses the liver
59
How would you treat encephalopathy?
laxatives - lactulose (decreases ammonia), abx (rifamaxin) and enemas
60
What would you give for hypoglycaemia in liver cirrhosis?
dextrose
61
What are varices?
a result of portal hypertension that results in swelling of the anastomoses between the portal system and systemic venous system
62
what medication can be used to help stable varices?
propanolol
63
What surgical technique can relieve pressure on varices?
TIPS (transjugular intra-hepatic portosystemic shunt)
64
How would you treat bleeding oesophageal varices?
vasopressin analogues - terlipressin
Vit K or fresh frozen plasma
prophylactic borad spectrum antibiotics
65
What complication can occur in patients with ascites secondary to liver cirrhosis?
spontaneous bacterial peritonitis
66
How is spontaneous bacterial peritonitis treated?
IV cephalosporin - cefotaxime
67
What are the most common organisms to to cause spontaneous bacterial peritonitis?
e. coli
gram postive cocci (staphylococci/enterococcus)
68
What is a pre-hepatic cause of portal hypertension?
thrombosis (portal or splenic vein)
69
What is an intrahepatic cause of portal hypertension?
cirrhosis mainly
schistosomiasis (common worldwide)
70
What is hepatorenal syndrome?
loss of blood supply to the kidney because of pooling in the portal vessels
71
What is a post-hepatic cause of portal hypertension?
Budd-chiari syndrome, right heart failure, veno-occlusive disease
72
What are the signs of portal hypertension?
depends on underlying cause
ascites
splenomegaly
signs of hepatic encephalopathy
jaundice
73
What are the gold standard investigations for portal hypertension?
wedged hepatic venous pressure (reflects sinusoidal pressure)
free hepatic venous pressure (reflects systemic venous pressure
pressure gradient
74
What are some of the treatments for portal hypertension?
treat underlying cause
surgical decompressive shunts
beta blockers
liver transplant
75
What is the most common cause of ascites?
cirrhosis
76
What are the key presentations of ascites?
abdominal distension
flank bulging
signs of underlying cause
77
What are the gold standard tests for ascites?
abdominal ultrasound
SAAG (serum-ascites albumin gradient) >11g/L (indicates portal hypertension)
78
What drug can be given to control ascites?
spironolactone (aldosterone antagonist)
furosemide if response is poor
79
What else can be done to treat ascites?
fluid restriction + low salt diet
80
explain a pre-hepatic cause of jaundice
excessive RBC breakdown - overwhelms the livers ability to conjugate bilirubin
unconjugated hyperbilirubinaemia
81
explain an intra-hepatic cause of jaundice
dysfunction of hepatic cells - stops livers ability to transport conjugated bilirubin into the biliary system
conjugated hyperbilirubinaemia
82
explain a post-hepatic cause of jaundice
obstruction of the biliary drainage
conjugated hyperbilirubinaemia
83
What would LFTs show in cholestatic jaundice?
raised ALP/GGT
84
What would LFTs shoe in hepatocellular jaundice?
raised ALT/AST
85
What are the risk factors for biliary colic?
5fs
Fat
Female
Fertile
Forty
fair
86
What causes the formation of gallstones?
an increase in cholesterol and decrease in bile salts and biliary stasis
87
What are the key presentations of biliary colic?
RUQ pain - intermittent and crampy
worse after fatty foods
nausea and vomiting
88
What are the first line investigations for biliary colic?
LFTS
CRP
ESR
will all be normal
89
What is the gold standard test for biliary colic?
abdominal ultrasound
90
What invasive procedure is used to treat gallstones?
laparoscopic cholecystectomy
91
What is an alternative to surgery with gallstones?
manage with diet - this is tricky so most will have surgery
92
What is acalculous cholecystitis?
multiple pathopysiologies - gallbladder stasis, hyperperfusion, infection
93
What is acute cholecystitis?
fixed obstruction in cystic duct
irritation due to build up of bile
prostaglandin secretion mediates inflammatory respone
94
What test can differentiate cholecystitis from biliary colic?
FBCs (WBCs)
CRP
ESR
all will be raised, sign of inflammation
95
What is the first line treatment for cholecystitis?
analgesia, early cholecystectomy
Consider - fluid resus + abx therapy
96
What is primary biliary cirrhosis?
immune system attack the bile ducts and causes cholestasis
97
What physical manifestation can raised cholesterol cause?
xanthelasma and xanthomas (cholesterol deposits in skin
98
What antibodies are tested for an are tested for in primary biliary cirrhosis?
anti-mitochondrial antibodies (most specific)
anti-nuclear antibodies
99
what medication is used to reduce intestinal absorption of cholesterol to treat PBC?
ursodeoxycholic acid
100
What medication prevents absorption of bile in the gut to help pruritus in PBC?
colestyramine
101
What are the 3 defects that cause cholelithiasis?
bile supersaturated with cholesterol
accelerated nucleation
gallbladder hypermobility
102
What is accelerated nucleation in regards to the gallbladder?
its the precipitation of cholesterol microcrystals in the gallbladder by the presence of nucleating agents (e.g. mucin)
103
What is gallbladder hypermobility?
retention fo abnormal bile-
microcrystals agglomerate in a mucin scaffold and grow into gallstones
104
What is the main treatment for all gallbladder symptoms?
laparoscopic cholecystectomy
105
What is ascending cholangitis?
infection of the biliary tree due to obstruction of the common bile duct and bacteria seeding in the biliary tree - growth of bacteria can cause extravasation of bacteria into the blood
106
What is charcots triad (the key presentations for cholangitis)?
fever
jaundice
RUQ pain
107
What is the gold standard investigation for ascending cholangitis?
ERCP - endoscopic retrograde cholangiopancreatography
108
What is the first line treatment for ascending cholangitis?
IV abx, intensive medical management, biliary decompression
109
What antibiotics are normally used for ascending cholitis?
penicillins and aminoglycosides
110
What is the second line treatment for ascending cholangitis?
biliary decompression - surgery + IV abx
consider lithotripsy opioid analgesic+ paracetamol
111
What is primary sclerosing cholangitis?
intra/extrahepatic ducts become strictured and fibrotic causing cholestasis
112
What is the gold standard diagnostic tool for primary sclerosing cholangitis?
Magnetic resonance cholangiopancreatography (MRCP)
113
What medication can be used to treat primary sclerosing cholangitis?
colestyramine
114
What intervention can be used to treat primary sclerosing cholangitis?
ERCP
115
What is primary biliary cholangitis?
a chronic disease of the small intrahepatic bile ducts by progressive damage and eventual loss
116
describe the pathophysiology of primary biliary cholangitis
portal inflammation -> bile duct damage -> loss of bile duct area -> cholestasis -> bile duct damage -> secondary liver damage
117
What are the key presentations of primary biliary cholangitis?
pruritus
fatigue
female sex + 45-60yrs
118
What are the gold standard tests for primary biliary cholangitis?
LFTs - ALP raised
anit-mitochondrial antibodies (AMA)
liver biopsy
119
What is the treatment for early stage primary biliary cholangitis?
bile acid analogue + immunomodulatory therapy + antipruritic + lifestyle modification
120
What are the key presentations of primary sclerosing cholangitis
male sex and history of IBD
121
What is the gold standard investigation for primary sclerosing cholangitis?
ERCP - endoscopic retrograde cholangiopancreatography
122
What are some of the treatments for early stage primary sclerosing cholangitis?
1st line - lifestyle changes
calcium and vit D supplementation
bisphosphonate +/- HRT
pruritus relief
no effective medication available (liver transplant in end stage liver disease)
123
What are the most common causes of acute pancreatitis?
gallstones and excessive alcohol consumption
124
What are the key presentations of acute pancreatitis?
sudden onset of mid epigastric/LUQ abdo pain that radiates to the back
nausea and vomiting
signs fo hypokalaemia - hypotension/oliguria
anorexia
125
What is the 1st line blood test for acute pancreatitis?
serum lipase (more sensitive and specific) or amylase
126
What is the first line care for acute pancreatitis?
fluid resus + analgesia + nutritional support
127
What imaging can be done to assess for complication in pancreatitis?
ultrasound (gallstones)
CT abdomen
128
What score is used to assess the severity of pancreatitis?
Glasgow score
129
What mnemonic can be used to remember the criteria for the Glasgow score?
PANCREAS
PaO2 <8
Age >55
Neutrophils (WBC >15)
Calcium >2
uRea >16
Enzymes (LDH, ALT/AST)
Albumin <32
Sugar glucose >10
130
if acute pancreatitis fails to improve, what treatments should be used?
1st line - CECT (contrast enhanced computed tomography) + supportive care and nutritional support
131
What is the most common cause of chronic pancreatitis?
chronic alcohol ingestion
132
What are the key presentations of chronic pancreatitis?
abdominal pain
steatorrhea (excessive fat in faeces)
jaundice
(similar to acute but less severe and longer lasting)
133
What is the first line investigation for chronic pancreatitis?
CT/MRI of abdomen (gold standard)
134
What is the first line treatment for chronic pancreatitis?
lifetsyle mods - alcohol + smoking cessation
135
What can be given to replace pancreatic enzyme?
pancrelipase
136
What invasive procedure can help pancreatitis?
ERCP with stenting
137
What is the most common cause of peritonitis?
bacterial infection (E.coli, strep, staph aureus etc)
138
Describe and intestinal cause of peritonitis
bacterial translocation from intestinal flora into mesenteric lymph nodes, into the bloodstream -> leads to colonisation of ascitic fluid
139
Give and example of a non-intestinal cause of peritonitis
resp infection/UTI/invasive procedure
140
What are the key presentations of peritonitis?
abdo pain
fever
nausea
signs of ascites
diarrhoea
141
What are the gold standard investigations for peritonitis?
ascitic fluid absolute neutrophil count (ANC)
periscreen - rules out spontaneous bacterial peritonitis
142
What is the 1st line treatment for spontaneous bacterial peritonitis (SBP)?
empirical IV antibiotics (initital abx regimen)
143
What is the 1st line treatment for non SBP?
surgery
144
What is hepatic encephalopathy?
a brain dysfunction caused by liver dysfunction and/or portosystemic shunt
145
What is the pathophysiology of hepatic encephalopathy?
ammonia is not detoxed by the liver and travels to the brain where it alters the amino acid conc, effects neurotransmitter synthesis
146
What are the key presentations of hepatic encephalopathy?
mood/sleep/motor disturbances
neurological defecits
147
What is the gold standard investigation for hepatic encephalopathy?
PHES - psychometric hepatic encephalopathy score
148
What is the first line care of hepatic encephalopathy?
supportive care+reversal of precipitating factors + lactulose
149
What other drugs can be given in hepatic encephalopathy?
2nd line - rifamixin +/- lactulose
3rd line L-ornithine-L-aspartate or branched amino acids
150
What is wernickes encephalopathy?
a neurological emergency resulting from thiamine deficiency
151
What is thiamine used for?
its a water soluble vitamin used to make pyruvate dehydrogenase + alpha ketoglutarate in the krebs cycle
152
What are the key presentations of wernickes encephalopathy?
mental slowing
oculomotor dysfunction
mental status changes
gait dysfunction
153
What is the 1st line and gold standard test for wernickes encephalopathy?
therapeutic trial of parenteral thiamine
154
What is the first line management of wernickes encephalopathy?
stabilisation + thiamine + magnesium + multivitamins
155
What is haemochromatosis?
an autosomal recessive disorder of iron absorption and metabolism resulting in iron accumulation
156
What does hepcidin do?
its an iron regulation hormone - decreases duodenal absorption, decreases macrophage iron release
157
What are the key presentations of haemochromatosis?
fatigue, weakness, arthralgias, impotence in males, skin pigmentation (bronze/slate grey skin)
158
What is the 1st line investigation for haemochromatosis?
serum ferritin
serum transferrin
159
Why is transferrin checked as well as ferritin in haemochromatosis?
ferritin can increase with inflammation, a high transferrin will show the increase is due to iron overload
160
What is the gold standard investigation for haemochormatosis?
liver biopsy
161
What is the 1st line treatment for haemochromatosis (stage 1 and 0)
observation - yearly follow up, lifestyle modification, hep A and B vaccine
162
What is the treatment for stages 2,3, and 4 haemochromatosis?
phlebotomy or iron chelation therapy
163
How can haemochromatosis effect the heart?
Can cause cardiomyopathy due to iron build up
164
How can haemochromatosis effect the thyroid?
can cause hypothyroidism by depositing iron in the thyroid
165
What other complications can haemochromatosis cause?
hepatocellular carcinoma
chrondocalcinosis/pseudogout (calcium build up in joints)
166
What is Wilsons disease?
an autosomal recessive disease of copper accumulation and toxicity
167
What parts of the body does excessive copper damage?
liver (copper is stored in the liver)
basal ganglia (most sensitive)
168
What are the neurological symptoms of Wilsons disease?
dysarthria
dystonia
169
What does deposition of copper in the basal ganglia lead to?
parkinsonism - tremor, bradykinesia and rigidity
170
What is a feature of motor symptoms in Wilsons disease?
they are often asymmetrical
171
What may be visible in the corneas of patients with Wilsons disease?
Kayser-fleischer rings
172
What is the first line investigation for Wilsons disease?
serum caeruloplasmin - elevated (suggestive but not specific of Wilsons disease)
173
What is the treatment for acute copper toxicity (in Wilsons disease)?
trientine + zinc + dietary restriction
if nazer score is >9 - liver transplant
174
What supplementation reduces copper accumulation?
zinc
175
What drug is used as an alternative to trientine?
penicillamine
176
What does alpha-1-antitripsin do?
protects the body - especially the lungs - from harmful enzymes
177
What is elastase secreted by?
neutrophils
178
What does elastase do?
is breaks down connective tissue
179
What does alpha-1-antitripsin do?
inhibits the action of elastase
180
What two main organs are effected by alpah-1-antitripsin deficiency?
the lungs and liver
181
How does A1AT deficiency effect the liver?
causes cirrhosis
182
How does A1AT deficiency effect the lungs?
causes bronchiectasis and emphysema
183
What are the key presentations of alpha-1-antitripsin?
productive cough
SOB
hepatomegaly
ascites
confusion
(hepatic syms due to accumulation in liver)
184
What is the first line and gold standard investigation for A1ATD?
serum A1AT level - low
185
What would a liver biopsy show in A1ATD?
cirrhosis and acid-schiff-positive staining globules
186
What is the first line treatment for A1ATD?
smoking cessation, polluting avoidance, hep A vacc (NICE recommend AGAINST A1AT replacement)
187
What may de done for end stage lung or liver disease as a result of A1ATD?
liver/lung transplant
188
hat are the two main types of liver cancer?
hepatocellular carcinoma, cholangiocarcinoma
189
What mutation can cause hepatocellular carcinoma?
a mutation resulting in ineffective AAT
190
What are the main risk factors for hepatocellular carinoma?
liver cirrhosis due to:
viral hep B and C
alcohol
NAFLD
chronic liver disease
191
How does liver cancer typically present?
weight loss
abdo pain
anorexia
nausea/vomiting
jaundice
pruritus
192
What is the main tumour marker for hepatocellular carcinoma?
alpha-fetoprotein
193
What is the main tumour marker for cholangiocarcinoma?
CA19-9
194
What is the gold standard investigation for liver cancer?
liver biopsy (not done frequently)
195
What treatments are there for hepatocellular carcinoma?
resection, liver transplant
kinase inhibitors
196
How do kinase inhibitors treat HCC?
they prevent proliferation of cancer cells
197
Give an example of a kinase inhibitor
sorafenib, regorafenib, lenvatinib
198
What are the treatment options for cholangiocarcinoma?
surgical resection
endoscopic retrograde cholangiopancreatography (ERCP) with stenting
199
Which area of the pancreas is more likely to be affected by cancer?
the head (65% of pancreatic cancers)
200
Name a precursor lesion to pancreatic cancer
pancreatic intraepithelial neoplasia
intraductal papillary mucinous neoplasm
mucinous cystic neoplasm
201
What are the key presentations of pancreatic cancer?
painless obstructive jaundice
weight loss
jaundice
upper abdo pain
pale stools
dark urine
pruritus
202
What genetic mutation is associated with pancreatic cancer?
KRAS
203
What does a new diagnosis of diabetes or poor glycaemic control with diabetes sometimes indicate?
pancreatic cancer
204
What is Courvoisiers law?
a palpable gallbladder with jaundice is unlikely gallstones - its more likely cholangiocarcinoma or pancreatic cancer
205
What is trousseau's sign of malignancy?
migrating thrombophlebitis - inflammtion and blood clotting occuring in different locations over time
206
What are the gold standard investigations for pancreatic cancer?
biopsy and CT thorax, abdo, pelvis
207
What blood marker may be raised in cholangiocarcinoma and pancreatic caner?
CA19-9
208
What are some of the treatments for pancreatic cancer?
surgical recision
enzyme replacement
radio/chemotherapy
biliary stenting
209
What surgical options are there for pancreatic cancer?
total pancreatectomy
distal pancreatectomy
(modified) Whipple procedure
210
What is removed in a Whipple procedure?
head of the pancreas
pylorus of stomach
duodenum
gall bladder
bile duct
relevant lymph nodes
211
What is an inguinal hernia?
a protrusion of abdominal contents through a dilated internal inguinal ring or attenuated inguinal floor into the inguinal canal
212
What is an indirect cause of an inguinal hernia?
congenital - processus vaginalis fails to undergo regression
213
What is a direct cause of an inguinal hernia?
weakness in abdominal wall at Hesselbach's triangle
214
What is the 1st line treatment for a large/symptomatic hernia?
open mesh or laparoscopic repair
prophylactic abx
215
What is the treatment for an incarcerated or strangulated hernia?
surgical repair
prophylactic abx
216
What is a femoral hernia?
a protrusion of abdominal contents through a dilated femoral ring into the femoral canal
217
What are the key presentations of a femoral hernia?
small lump in groin
218
What is the treatment for femoral hernia?
herniotomy - ligation and excision of sac
herniorrhaphy - hernia pushed back and tissue repaired
219
What is the treatment for small/symptomatic umbilical hernias?
observation - most umbilical hernias will close by 4-5 yrs of age
(option for elective surgical repair)
220
What is the treatment for incarcerated umbilical hernia?
surgical repair following attempted reduction
221
What are the 4 surgical options for treatment of incision hernia?
laparoscopic mesh repair
abdo wall reconstruciton
open mesh repair
suture repair
222
What is an epigastric hernia?
a protrusion through the linea alba above the umbilicus
223
What is the gold standard investigation for epigastric hernias?
upper Gi series
224
surgical treatment of epigastric hernias is the same as incision hernias, what are the treatment options?
laparoscopic mesh repair
abdo wall reconstruction
open mesh repair
suture repair
225
What is hiatal hernia?
a hernia through an enlarged oesophageal hiatus of the diaphragm
226
What does hiatal hernia dispose patients to and why?
GORD due to decrease in lower oesophageal sphincter pressure
227
What are the key presentations of hiatal hernia?
can be asymptomatic
heartburn
regurgitation
bowel sound in chest
228
What is the gold standard investigation for hiatal hernia?
upper GI series
229
What is the first line treatment for hiatal hernia?
surgical repair w/ anti-reflux procedure (PPI- lanzoprazole (-zole))
230
What two steps does the liver use to metabolise paracetamol?
glucuronidation
sulfonation
231
What is the name of paracetamols toxic intermiediate?
NAPQI (N-acetyl-p-benzoquinone imine)
232
What detoxifies NAPQI?
glutathione
233
What are the key presentations of paracetamol overdose?
GI symptoms
nausea and vomiting
234
What is the gold standard test for paracetamol overdose?
serum paracetamol concentration
235
What drug, when used at least 8 hours after overdose, is used for a paracetamol OD?
acetylcysteine
236
What is Gilbert syndrome?
an inherited disorder - decreased levels of UDPGT=impaired conjugation of bilirubin
results in unconjugated hyperbilirubinaemia
237
What are the key presentations of Gilberts syndrome?
sometimes asymptomatic
jaundice
absence of hepatosplenomegaly
no chronic liver disease
238
What are the gold standard investigations for gilberts syndrome?
elevated unconjugated bilirubin
normal LFTs and FBCs
239
What is the 1st line treatment for gilberts syndrome?
patient education + avoidance/reversal of inciting factors
240
How is hep E transmitted?
faecal-oral route
241
What scan tests liver elasticity and can diagnose cirrhosis?
Fibroscan
242
How would you treat encephalopathy?
lactulose (decreases ammonia), abx and enemas
243
What are the main risk factors for hepatocellular carinoma?
liver cirrhosis due to:
viral hep B and C
alcohol
NAFLD
chronic liver disease
244
What is primary schelerosing cholangitis?
intra/extrahepatic ducts become strictured and fibrotic causing cholestasis
