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Phase2a > Liver > Flashcards

Liver Flashcards

1
Q

Give four functions of the liver.

A
  • Glucose and fat metabolism
  • Detoxification and excretion
  • Protein synthesis
  • Defence against infection (R-E system)
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2
Q

Give three things that the liver detoxifies/excretes.

A
  • Bilirubin
  • Ammonia
  • Drugs/hormones/pollutants
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3
Q

Give two proteins that are produced by the liver.

A
  • Albumin

- Clotting factors

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4
Q

Describe the hepatocyte zones within the liver lobule.

A

Zones 1-3 going towards the central vein.

Going from 1-3, the hepatocytes get progressively less blood and become increasingly susceptible to toxins.

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5
Q

Give two methods of hepatocyte cell death.

A
  • Apoptosis

- Necrosis

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6
Q

Give six reasons why patients with chronic liver disease may become acutely ill.

A
  • Constipation
  • Drugs
  • GI bleed
  • Infection
  • Metabolite disturbances (Hypo… Na/K/glycaemia)
  • Alcohol withdrawal
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7
Q

Give four reasons why liver patients are vulnerable to infection.

A
  • Impaired reticulo-endothelial function
  • Reduced opsonic activity
  • Leukocyte function
  • Permeable gut wall
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8
Q

Give five sites of infection that liver patients are vulnerable to.

A
  • Spontaneous bacterial peritonitis
  • Septicaemia
  • Pneumonia
  • Skin
  • Urinary tract
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9
Q

What is the most common serious infection which occurs in liver cirrhosis?

A

Spontaneous bacterial peritonitis

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10
Q

Give six drugs which should not be prescribed to liver patients without careful consideration.

A
  • Sedatives
  • Analgesics
  • NSAIDs
  • Diuretics
  • ACE inhibitors
  • Aminoglycosides
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11
Q

Give three reasons why patients with liver disease might go into a coma.

A
  • Hepatic encephalopathy
  • Hyponatraemia/hypoglycaemia
  • Intracranial event
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12
Q

Describe hepatic encephalopathy.

A

A decline in brain function that occurs due to the liver not being able to metabolise ammonia, causing it to build up in the brain.

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13
Q

Give three reasons why coagulopathy occurs in liver disease.

A
  • Impaired coagulation factor synthesis
  • Vitamin K deficiency (cholestasis)
  • Thrombocytopenia
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14
Q

Give three endocrine changes which occur in liver disease.

A
  • Gynaecomastia
  • Impotence
  • Amenorrhoea
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15
Q

How is malnutrition in liver disease treated?

A

Naso-gastric feeding

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16
Q

How is variceal bleeding in liver disease treated?

A
  • Endoscoping banding
  • Propranolol
  • Terlipressin
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17
Q

How is encephalopathy in liver disease treated?

A
  • Lactulose

- Rifaximin (antibiotic)

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18
Q

How are infections in liver disease treated?

A

Antibiotics

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19
Q

Which analgesics can and can’t be prescribed in liver disease?

A
  • Sensitive to opiates
  • NSAIDs cause renal failure
  • Paracetamol safest
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20
Q

Which sedations can be used in patients with liver disease?

A

Short-acting benzodiazepines

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21
Q

Which antihypertensives must be avoided in liver disease?

A

ACE inhibitors

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22
Q

Describe the onset of drug-induced liver injury.

A

Usually occurs within 1-2 weeks of starting the drug, and may occur several weeks after stopping.

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23
Q

Give seven types of drugs which can cause drug induced liver injury.

A
  • Antibiotics
  • CNS drugs
  • Immunosuppressants
  • Analgesics/musculoskeletal
  • Gastrointestinal drugs
  • Dietary supplements
  • Alternative herbal therapies
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24
Q

What percentage of acute liver failure is drug induced liver injury responsible for?

A

> 65%

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25
Q

What percentage of acute hepatitis is drug induced liver injury responsible for?

A

30%

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26
Q

What three serum measurements would you take in suspected liver disease?

A
  • Bilirubin
  • Albumin
  • Prothrombin time
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27
Q

Which two cholestatic liver enzymes can give an indication about liver/bile health?

A
  • Alkaline phosphatase

- gamma-GT

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28
Q

Which two hepatocellular enzymes are raised in liver injury?

A
  • Aspartate aminotransferase (AST)

- Alanine aminotransferase (ALT)

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29
Q

What are the two main outcomes of acute liver injury?

A
  • Liver failure

- Recovery

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30
Q

What are the three possible outcomes of chronic liver injury?

A
  • Recovery
  • Liver failure
  • Cirrhosis (which leads to liver failure)
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31
Q

Give six causes of acute liver injury.

A
  • Viral (A, B, EBV)
  • Drugs
  • Alcohol
  • Vascular
  • Obstruction
  • Congestion (HF)
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32
Q

Give four causes of chronic liver injury.

A
  • Alcohol
  • Viral (B, C)
  • Autoimmune
  • Metabolic (iron, copper)
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33
Q

Give four common presenting features of acute liver injury.

A
  • Malaise
  • Nausea
  • Anorexia
  • Jaundice
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34
Q

Give four rarer presentations of acute liver injury.

A
  • Confusion
  • Bleeding
  • Liver pain
  • Hypoglycaemia
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35
Q

What are the common presentations in chronic liver injury?

A
  • Ascites
  • Oedema
  • Haematemesis (varices)
  • Malaise
  • Anorexia
  • Wasting
  • Easy bruising
  • Itching
  • Hepatomegaly
  • Abnormal LFTs
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36
Q

Give two rarer presentations of chronic liver injury.

A
  • Jaundice

- Confusion

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37
Q

Describe the current trend in pancreatic carcinoma in the UK.

A

Incidence is rising

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38
Q

Which gender is pancreatic carcinoma more common in?

A

Males

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39
Q

What age is pancreatic carcinoma more common in?

A

> 60 years

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40
Q

What is the genetic element of pancreatic carcinoma?

A

95% have mutations in KRAS2 gene

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41
Q

Give seven risk factors for pancreatic carcinoma.

A
  • Smoking
  • Alcohol
  • Carcinogens
  • Diabetes mellitus
  • Chronic pancreatitis
  • Increased waist circumference
  • Possibly high fat and red/processed meat diet
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42
Q

What type of cancer are most pancreatic carcinomas?

A

Ductal adenocarcinomas

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43
Q

What percentage of pancreatic carcinoma occurs in the head?

A

60%

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44
Q

What percentage of pancreatic carcinoma occurs in the body?

A

25%

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45
Q

What percentage of pancreatic carcinoma occurs in the tail?

A

15%

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46
Q

In which areas of the pancreas does carcinoma give a better prognosis?

A
  • Ampulla of Vater

- Pancreatic islet cells

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47
Q

When does pancreatic carcinoma metastasize?

A

Early

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48
Q

When does pancreatic carcinoma present?

A

Late

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49
Q

What is the usual presenting feature of pancreatic carcinoma of the head?

A

Painless obstructive jaundice

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50
Q

What is the usual presenting feature of pancreatic carcinoma of the body/tail?

A

Epigastric pain which radiates to the back and is relieved on sitting forward.

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51
Q

Give four general presentations of pancreatic carcinoma.

A
  • Anorexia
  • Weight loss
  • Diabetes
  • Acute pancreatitis
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52
Q

Give five rare features of pancreatic carcinoma.

A
  • Thrombophlebitis migrans (arm vein becomes swollen and red, then a leg vein)
  • Raised calcium
  • Marantic endocarditis (nonbacterial)
  • Portal hypertension
  • Nephrosis
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53
Q

Give seven signs of pancreatic carcinoma.

A
  • Jaundice
  • Palpable gall bladder
  • Epigastric mass
  • Hepatomegaly
  • Splenomegaly
  • Lymphadenopathy
  • Ascites
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54
Q

What would blood tests show in pancreatic carcinoma?

A

Cholestatic jaundice

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55
Q

Give three potential features of an USS/CT in pancreatic carcinoma.

A
  • Pancreatic mass
  • Dilated biliary tree
  • Hepatic metastases
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56
Q

What surgery may be carried out in pancreatic carcinoma?

A

Pancreatoduodenectomy (Whipple’s procedure)

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57
Q

Why is surgery rarely used in pancreatic cancer?

A

It is only effective if there are no metastases, and most present with metastatic disease.

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58
Q

When is a laparoscopic excision easiest to perform in pancreatic cancer?

A

When the carcinoma is in the tail.

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59
Q

When would chemotherapy be used in pancreatic cancer?

A

Post-op

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60
Q

What may be done for palliation of jaundice/anorexia in pancreatic carcinoma?

A

Endoscopic or percutaneous stent

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61
Q

What can be given to control pain in pancreatic carcinoma?

A
  • Opiates

- Radiotherapy

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62
Q

What is the mean survival in pancreatic carcinoma?

A

<6months

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63
Q

What is the 5 year survival rate in pancreatic carcinoma?

A

3%

64
Q

What is acute pancreatitis?

A

Self-perpetuating pancreatic inflammation by enzyme-mediated autodigestion.

65
Q

Give 12 causes of acute pancreatitis.

A

GETSMASHED

  • Gallstones
  • Ethanol
  • Trauma
  • Steroids
  • Mumps
  • Autoimmune
  • Scorpion venom
  • Hyperlipidaemia, hypothermia, hypercalcaemia
  • ERCP and emboli
  • Drugs

Also pregnancy and neoplasia

66
Q

What happens to the blood volume in acute pancreatitis?

A

There is hypovolaemia.

67
Q

Briefly describe the pathophysiology behind acute pancreatitis and hypovolaemia.

A
  • There is oedema and fluid shifting, and extracellular fluid gets trapped in the gut, peritoneum, and retroperitoneum.
68
Q

Describe the progression of acute pancreatitis.

A

Progression may be rapid from mild oedema to necrotising pancreatitis.

69
Q

What percentage of pancreatitis patients progress to necrotising pancreatitis?

A

20%

70
Q

Describe the symptoms of acute pancreatitis.

A
  • Gradual or sudden severe epigastric/central abdominal pain
  • Pain radiates to back
  • Sitting forward may relieve pain
  • Prominent vomiting
71
Q

Give the signs of acute pancreatitis.

A
  • Tachycardia
  • Fever
  • Jaundice
  • Shock
  • Ileus
  • Rigid abdomen +/- local or general tenderness
  • Periumbilical bruising (Cullen’s sign)
  • Flank bruising (Grey Turner’s sign)
72
Q

Why does bruising occur in acute pancreatitis?

A

Due to blood vessel autodigestion and retroperitoneal haemorrhage.

73
Q

How is the degree of elevation of serum amylase relate to acute pancreatitis?

A

It is not related to disease severity

74
Q

Give three conditions which may cause a lesser rise in serum amylase in acute pancreatitis.

A
  • Cholecystitis
  • Mesenteric infarction
  • GI perforation
75
Q

Give a condition which may increase levels of serum amylase in acute pancreatitis.

A

Renal failure

76
Q

How is serum lipase used to investigate chronic pancreatitis?

A

It is more sensitive than amylase and is specific for pancreatitis.

77
Q

Why is an ABG carried out in acute pancreatitis?

A

To monitor oxygenation and acid-base.

78
Q

What X rays should be carried out in acute pancreatitis?

A
  • AXR

- Erect CXR

79
Q

What may the AXR show in acute pancreatitis?

A

No psoas shadow

80
Q

Why is a CT scan used in acute pancreatitis?

A

To assess severity and complications

81
Q

When would an USS be used in acute pancreatitis?

A

If there is gallstones

82
Q

When would an ERCP be used in acute pancreatitis?

A

If LFTs decline

83
Q

What does CRP suggest about acute pancreatitis if it is high for a long time?

A

It is a predictor of severe disease

84
Q

Give the 8 Glasgow criteria for predicting severe disease in acute pancreatitis.

A

PANCREAS

  • PaCO2 <8KPa
  • Age >55yrs
  • Neutrophilia >15x10^9/L
  • Calcium <2mmol/L
  • Renal function (urea >16mmol/L)
  • Enzymes (high liver enzymes)
  • Albumin <32g/L
  • Sugar >10mmol/L
85
Q

Give the principles of management of acute pancreatitis.

A
  • Nil by mouth (may need NG tube)
  • IV fluids
  • Analgesia (pethidine, morphine)
  • Monitoring
  • ERCP and gallstone removal if progressive
86
Q

Give seven early complications of acute pancreatitis.

A
  • Shock
  • ARDS
  • Renal failure
  • DIC
  • Sepsis
  • Hypocalcaemia
  • Hyperglycaemia
87
Q

Give seven late complications of acute pancreatitis.

A
  • Pancreatic necrosis
  • Pseudocyst
  • Abscesses
  • Bleeding
  • Thrombosis
  • Fistulae
  • Recurrent oedematous pancreatitis
88
Q

What is chronic pancreatitis?

A

A chronic inflammatory process of the pancreas, leading to irreversible loss of pancreatic function.

89
Q

Describe the pathogenesis of chronic pancreatitis.

A
  • Chronic inflammation in the pancreas leads to replacement of functional pancreatic tissue by fibrous scar tissue
  • There are dilated ducts and areas of calcification
90
Q

Describe the progression of chronic pancreatitis, in terms of endocrine and exocrine function.

A

Loss of exocrine tissue predominates early, whereas endocrine tissue is typically spared until late disease.

91
Q

What is the main cause of chronic pancreatitis?

A

Alcohol

92
Q

Give six rare causes of chronic pancreatitis.

A
  • Familial
  • Cystic fibrosis
  • Haemochromatosis
  • Pancreatic duct obstruction (stones/tumour)
  • Increased parathyroid hormone
  • Congenital
93
Q

Describe the clinical presentation (signs/symptoms) of chronic pancreatitis.

A
  • Epigastric pain which ‘bores’ through to the back
  • Pain relieved by sitting forward or hot water bottle on epigastrum or back
  • Bloating
  • Steatorrhoea
  • Weight loss
  • Brittle diabetes
  • Symptoms relapse and worsen
94
Q

What investigations should be carried out in chronic pancreatitis?

A
  • Ultrasound +/- CT
  • MRCP + ERCP
  • AXR
  • Blood glucose
  • Breath tests
95
Q

What feature on an ultrasound/CT is diagnostic of chronic pancreatitis?

A

Pancreatic calcifications

96
Q

What may be seen on an AXR in chronic pancreatitis?

A

Speckled calcification

97
Q

What may the blood glucose tests show in chronic pancreatitis?

A

Hyperglycaemia

98
Q

How is chronic pancreatitis treated?

A
  • Analgesia (coeliac-plexus block)
  • Lipase
  • Potentially insulin
  • Dietary changes
  • Pancreatectomy/pancreaticojejunostomy
99
Q

What dietary changes should be made in chronic pancreatitis?

A
  • No alcohol
  • Low fat
  • Medium-chain triglycerides may be tried
100
Q

Give three reasons why surgery may be carried out in chronic pancreatitis.

A
  • Unremitting pain
  • Narcotic abuse
  • Weight loss
101
Q

Give seven complications of chronic pancreatitis.

A
  • Pseudocyst
  • Diabetes
  • Biliary obstruction
  • Local arterial aneurysm
  • Splenic vein thrombosis
  • Gastric varices
  • Pancreatic carcinoma
102
Q

What is a hernia?

A

The protrusion of a viscus or part of a viscus through a defect of the walls of its containing cavity into an abnormal position.

103
Q

What does ‘irreducible’ mean, in relation to hernias?

A

Cannot be pushed back into proper place.

104
Q

What does ‘incarceration’ mean, in relation to hernias?

A

Contents of the hernial sac are stuck inside by adhesions.

105
Q

What does ‘obstructed’ mean, in relation to hernias?

A

Bowel contents cannot pass through.

106
Q

When is a hernia described as ‘strangulated’?

A

If ischaemia occurs

107
Q

What is a herniotomy?

A

Ligation and excision of the hernia.

108
Q

What is a herniorrhaphy?

A

Repair of the defect

109
Q

Give seven risk factors for inguinal hernias.

A
  • Male
  • Chronic cough
  • Constipation
  • Urinary obstruction
  • Heavy lifting
  • Ascites
  • Past abdominal surgery
110
Q

Describe an indirect inguinal hernia.

A

The hernia passes through the deep inguinal ring and out of the superficial inguinal ring.

111
Q

Where is an indirect inguinal hernia in relation to the epigastric vessels?

A

Hernial is lateral to the vessels.

112
Q

What percentage of inguinal hernias are direct and indirect?

A
  • Direct = 20%

- Indirect = 80%

113
Q

Out of direct and indirect inguinal hernias, which are more likely to strangulate?

A

Indirect

114
Q

Do direct or indirect inguinal hernias reduce more easily?

A

Direct

115
Q

What is a direct inguinal hernia?

A

The hernia pushes out directly through the posterior wall of the inguinal canal.

116
Q

Where is a direct hernia in relation to the epigastric vessels?

A

The hernia is medial to the vessels.

117
Q

What pre-op advice is given to patients with hernias?

A
  • Lose weight (if overweight)

- Stop smoking

118
Q

Give two surgical techniques that can be used to repair inguinal hernias.

A
  • Mesh technique (polypropylene mesh reinforces posterior wall)
  • Laparoscopic repair
119
Q

Describe a femoral hernia.

A

Bowel enters the femoral canal.

120
Q

How does a femoral hernia present?

A

Mass in the upper medial thigh or above the inguinal ligament.

121
Q

Which gender are femoral hernias more common in?

A

Women

122
Q

Which age are femoral hernias more common in?

A

Middle age/elderly

123
Q

What method of treatment is recommended for femoral hernias?

A

Surgical

124
Q

What is the likelihood of a femoral hernia being irreducible or strangulating?

A

High for both

125
Q

Where does a paraumbilical hernia occur?

A

Just above or below umbilicus.

126
Q

Give two risk factors for paraumbilical hernias.

A
  • Obesity

- Ascites

127
Q

What does surgery for paraumbilical hernias involve?

A

Repair of rectus sheath

128
Q

What can herniate through the defect in paraumbilical hernias?

A

Omentum or bowel

129
Q

What is an epigastric hernia?

A

Hernia which passes through the linea alba above the umbilicus.

130
Q

What causes incisional hernias?

A

Breakdown of muscle closure after surgery.

131
Q

What age are hiatus hernias more common in?

A

Over 50yrs

132
Q

Give the typical patient demographic for hiatus hernias.

A

Obese women

133
Q

How can hiatus hernias present?

A

Symptomatic GORD (50%)

134
Q

What is the best diagnostic test for hiatus hernias?

A

Barium swallow

135
Q

Give three treatment options for hiatus hernias.

A
  • Weight loss
  • Treat reflux
  • Surgery
136
Q

Why is an upper GI endoscopy sometimes used in a hiatus hernia?

A

To visualise the mucosa

137
Q

Give two indications for surgery in hiatus hernia.

A
  • Intractable symptoms

- Complications

138
Q

Why should rolling hiatus hernias always be prepared?

A

They should be prepared prophylactically as they may strangulate, which requires emergency surgery.

139
Q

What are the relative incidences of hiatus hernias?

A 
Sliding = 80%
Rolling = 20%
140
Q

Describe a sliding hiatus hernia.

A

Gasto-oesophageal junction slides up into chest.

141
Q

Describe a rolling hiatus hernia.

A

Gasto-oesophageal junction remains in abdomen but a bulge of stomach herniates into the chest alongside the oesophagus.

142
Q

In which type of hiatus hernia is GORS more likely to occur?

A

Sliding

143
Q

Why does GORD occur in sliding hiatus hernia?

A

Lower oesophageal sphincter becomes less competent.

144
Q

Give a side effect of N-acetylcysteine.

A

Rash

145
Q

Describe the acid-base balance of the blood in liver disease.

A

Likely to have metabolic acidosis

146
Q

What autoantibody may be associated with, but not specific to, primary sclerosing cholangitis?

A

ANCA

147
Q

How is oestrogen linked to bile secretion?

A

Oestrogen inhibits bile secretion, leading to cholestasis.

148
Q

Describe hepatorenal syndrome.

A

In late stage liver failure the RAAS system is activated due to splanchnic vasodilation.
This causes vasoconstriction of the renal vasculature, so blood is diverted away from the renal cortex.
Therefore glomerular filtration rate is reduced, leading to ‘functional’ renal failure.

149
Q

Describe hepatic pulmonary syndrome.

A

Hypoxaemia in end stage liver failure due to intrapulmonary vascular dilation.

150
Q

How is a gallstone ileus treated?

A

Laparotomy (don’t need to remove gallbladder)

151
Q

Why should the gallbladder always be removed in gallstones?

A

50-60% will recur

152
Q

Why does dehydration occur in jaundice?

A

Osmotic effects of bile salts

153
Q

Give three mechanisms of acinar cell injury which lead to acute pancreatitis.

A
  • Duct obstruction (impaired blood flow and necrosis)
  • Direct injury
  • Defective intracellular transport (intracellular activation of enzymes)
154
Q

Give three conditions that cause rigors.

A
  • Lobar pneumonia
  • Cholangiitis
  • Pyelonephritis
155
Q

What is the cut off for serum amylase and lipase levels to diagnose pancreatitis?

A

> 3x upper limit of normal

Phase2a (12 decks)

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