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NMF: General Surgery > Liver > Flashcards

Liver Flashcards

1
Q

Which antibiotic commonly causes jaundice and deranged LFTs?

A

co-amoxiclav

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2
Q

What is the only sexually transmitted disease that has a safe and effective vaccine to protect against infection?

A

hep b

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3
Q

Give vascular causes of jaundice

A

budd chiari syndrome

haemolysis

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4
Q

What is budd-chiari?

A

causes hepatic vein obstruction leading to abdominal pain, ascites, and liver enlargement.

seen in patients on COCP, pregnancy or thrombophilia

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5
Q

Give infectious causes of jaundice

A

viral hepatitis
ascending cholangitis
weil’s disease

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6
Q

Give neoplastic causes of jaundice

A

hepatocellular carcinoma
pancreatic cancer
cholangiocarcinoma
liver mets

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7
Q

Give drugs that cause jaundice

A

co-amoxiclav
COCP
sodium valproate
paracetamol OD

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8
Q

Give autoimmune causes of jaundice

A

autoimmune hepatitis
primary sclerosing cholangitis
primary biliary cirrhosis

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9
Q

Give traumatic causes of jaundice

A

gallstones

previous surgery

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10
Q

Give endocrine causes of jaundice

A

haemochromatosis

willson’s disease

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11
Q

What is cholangiocarcinoma?

A

cancer of the bile duct

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12
Q

What questions are important when taking a jaundice history?

A 
pain? 
fever?
pruritus?
weight loss? fatigue? night sweats
symptoms of diabetes: polyuria? weight loss?
colour of urine and stools
travel hx
sexual hx
family hx of liver problems, diabetes, haemolysis...
alcohol and drug use
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13
Q

What should you look for in a jaundice exam?

A

jaundice
tanned bronze skin
needle marks
tattoos

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14
Q

What should you examine for in a jaundice exam?

A 
signs of chronic liver disease/ liver failure
RUQ tenderness
hepato-splenomegaly
masses suggestive of malignancy
ascites
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15
Q

Name some signs of chronic liver disease/ liver failure

A

bruising
palmar erythema
spider naevi
caput medusae

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16
Q

What initial investigations should be carried out in someone with jaundice? why?

A

FBC to exclude haemolysis
LFTs to work out if hepatitic or cholestatic
PT and albumin as markers of liver function
urinalysis

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17
Q

Why is urinalysis carried out in someone with jaundice?

A

bilirubin in urine suggests post-hepatic obstruction

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18
Q

What do raised ALT and AST in a jaundices patient suggest?

A

hepatic picture eg.viral hepatitis, autoimmune hepatitis

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19
Q

What do raised ALP and GGT in a jaundiced patient suggest?

A

cholestatic picture eg. gallstones

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20
Q

What other investigations should be considered in a jaundiced patient depending on their clinical picture?

A

ferritin and iron

viral screen

autoimmune screen

copper and ceruloplasmin

US of liver and abdomen

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21
Q

Why would ferritin and iron studies be carried out in a jaundiced patient?

A

to exclude haemochromatosis

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22
Q

What viruses would be screened for in a jaundiced patient?

A

Hepatitis A,B,C,D,E
Cytomegalovirus
Ebstein-Barr virus

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23
Q

What auto antibodies would be screened for in a jaundiced patient?

A

ANA
anti-smooth muscle
anti-mitochondrial

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24
Q

Why would copper and ceruloplasmin be screened for in a jaundiced patient?

A

to exclude wilson’s disease

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25
Q

Why would an US of liver and abdomen be carried out in a jaundiced patient?

A

look for malignancy

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26
Q

Which examination finding may be seen in acute viral hepatitis but not in chronic hepatitis?

A

Hepatomegaly

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27
Q

What would FBC show if haemolysis is the cause of jaundice?

A

Reduced haemoglobin

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28
Q

Which disease is often concurrent with haemachromatosis?

A

Diabetes

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29
Q

Do IgM or IgG antibodies indicate a chronic infection?

A

IgG

Old is gold

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30
Q

Do IgM or IgG antibodies indicate an acute infection?

A

IgM

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31
Q

In a person with an active hepatitis B infection, which serology findings would be positive?

A 
DNA
Surface antigen (HbsAg)
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32
Q

Which type of hepatitis have immunisations?

A

Hep A and B

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33
Q

How would an acute hepatitis B infection be treated?

A

Supportive management with fluids

Avoid hepatotoxic agents eg. Paracetamol & alcohol

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34
Q

What proportion of adults with acute hep B infection self resolve?

A

95%

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35
Q

What indicates a severe hepatitis B infection?

A

Coagulopathy
Prolonged jaundice (>4 weeks)
Acute liver failure

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36
Q

How can severe hepatitis B infection be managed?

A

Tenofovir

Liver transplant

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37
Q

Which class of drug is tenofovir?

A

Nucleotide reverse transcriptase inhibitors (NRTIs)

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38
Q

Which step out with patient treatment must be taken for a hep B infection?

A

Contact tracing of sexual partners

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39
Q

How do children respond to acute hep B infection?

A

Likely to progress to chronic infection if they are under 1

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40
Q

How do children get hep B?

A

Mother to child transmission

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41
Q

What proportion of chronic hep B patients develop complications?

A

20-30%

42
Q

What are the complications of chronic hep B?

A

Cirrhosis

Hepatocellular carcinoma

43
Q

When are the complications of chronic Hep B worse?

A

If concurrent hep D virus

44
Q

What serology would be positive for someone with a hep B immunisation?

A

Anti-Hbs IgG

45
Q

What serology differentiates between a past hep B infection and a hep B immunisation?

A

Anti-HBc IgG

Positive in past infection
Negative in serology

46
Q

What is anti Hbc?

A

The antibody to hep B core antigen

Means you have hep B or have had it some time in the past

47
Q

What is anti Hbs?

A

The antibody to hepatitis B surface antigen

Means you are immune to Hep B through immunisation or past infection

48
Q

Can someone with anti Hbs pass hep b to others?

A

No

49
Q

What is HbsAg?

A

Hep b surface antigen

Indicates current infection and that hep B is transmittable

50
Q

How are babies born to Hep B positive mothers protected?

A

Give hep B vaccine and immunoglobulin within 12 hours from birth

51
Q

What is pre-hepatic jaundice?

A

When excessive red cell destruction overwhelms the liver’s ability to conjugate bilirubin so there is increased unconjugated bilirubin in the blood

52
Q

Give an example of a cause of pre-hepatic jaundice

A

Haemolytic anaemia

53
Q

What is intrahepatic jaundice ?

A

Liver dysfunction disrupts bilirubin conjugation so there is increased unconjugated and conjugated bilirubin

54
Q

What is post hepatic jaundice?

A

When biliary drainage is obstructed leading to increased conjugated bilirubin

55
Q 
What is the urine colour of 
a) prehepatic
b) intrahepatic
c) posthepatic 
jaundice patient?
A

a) normal
b) dark
c) dark

56
Q 
What is the stool colour of 
a) prehepatic
b) intrahepatic
c) posthepatic 
jaundice patient?
A

a) normal
b) normal
c) pale

57
Q

What makes urine dark in jaundiced patient?

A

increased conjugated bilirubin

58
Q

What makes stool pale in jaundiced patient?

A

bile salts cause fat to be excreted in poo

59
Q

Which type of jaundice has the most to least bilirubin?

A

post hepatic
intrahepatic
prehepatic

60
Q

How is unconjugated bilirubin made?

A

macrophage breaks down red blood cell into globin and heme

heme becomes protoporphyrin and then unconjugated bilirubin

61
Q

is UCB water or lipid soluble?

A

lipid soluble

62
Q

How does UCB get to the liver?

A

carried by albumin

63
Q

Which molecule conjugates bilirubin?

A

uridine glucuronyl transferase (UGT)

64
Q

Where is conjugated bilirubin stored?

A

in the gall bladder as bile

65
Q

Where is conjugated bilirubin released to when eating?

A

along common bile duct to duodenum of small intestine

66
Q

What happens to conjugated bilirubin in the small intestine?

A

microbes convert it to urobilinogen

some urobilinogen oxidises to urobilin which is excreted in faeces, 20% urobilinogen is recycled

mostly to liver and 10% to kidneys where it is excreted in urine

67
Q

Give causes of increased unconjugated bilirubin

A

extravascular haemolytic anaemia
ineffective haemopoiesis
physiological jaundice of the newborn
gilbert’s syndrome

68
Q

Give causes of increased conjugated bilirubin

A

obstructive eg. gallstones, pancreatic cancer, cholangiocarcinoma, liver flukes
dubin-johnson syndrome

69
Q

Why does Gilbert’s syndrome cause jaundice?

A

low UGT activity so if there is increased haemolysis then unconjugated bilirubin can build up

70
Q

What is dubin-johnson syndrome?

A

low transporter protein for moving conjugated bilirubin to bile duct so it is instead moved into the blood

71
Q

How does obstructive jaundice present? why?

A

pruritus, cholesterolaemia and xanthomas

bile salts, bile acids and cholesterol are pushed into the blood due to increased pressure

72
Q

Does viral hepatitis cause an increase in conjugated or unconjugated bilirubin?

A

both

infected hepatocytes lose ability to conjugate and also let bile leak into blood

73
Q

How does PBC present?

A

severe itching and mild jaundice

female > male

74
Q

What autoantibodies are +ve in PBC?

A

anti-mitochondrial

high ALP

75
Q

How does PSC present?

A

cholestasis (jaundice and itch) and biliary colic

young men with IBD

76
Q

What autoantibodies are present in PSC?

A

pANCA

anti-nuclear antibodies

77
Q

What autoantibodies are present in autoimmune hepatitis?

A

ANA
anti-smooth muscle antibody
anti-mitochondrial antibody

normal ALP

78
Q

What is PSC?

A

biliary disease of unknown cause that is characterised by inflammatrion and fibrosis of the large bile ducts

79
Q

How is PSC treated?

A

urseodeoxycholic acid

80
Q

Where is ALP found?

A

liver
bile duct
bone

81
Q

Which marker indicates alcoholic liver damage?

A

GGT

82
Q

What are the 3 signs of ascending cholangitis?

A

Charcot’s triad

  • RUQ pain
  • fever
  • jaundice
83
Q

What is cholecystitis?

A

an inflamed gall bladder due to cholestasis

84
Q

Does cholecystitis cause jaundice?

A

no

85
Q

What is ascending cholangitis?

A

bacterial infection of the biliary tree often due to gallstones

86
Q

Does PBC or PSC have an increased risk of cholangiocarcinoma?

A

PSC

87
Q

What is a hepatitis superinfection?

A

Hep B and hep D

88
Q

which types of hepatitis can be sexually transmitted

A

B, C, D,

B is easily transmittable but the others are less so

89
Q

which types of hepatitis have faecal-oral spread?

A

A and E

90
Q

What type of virus is Hep D?

A

RNA virus

91
Q

What increases the transmission of Hep C?

A

concurrent HIV infection

92
Q

In developed countries, what is the most common way to get Hep C?

A

IVDU

93
Q

Is Hep A or C more likely to become chronic?

A

C

94
Q

What marker is raised in hepatocellular carcinoma?

A

AFP

95
Q

How is an acute variceal bleed managed?

A

ABCDE
correct clotting with FFP and vitamin K
terlipressin (vasoactive)

96
Q

How can hepatic encephalopathy be managed?

A

lactulose

rifaximin

97
Q

What blood test findings would someone with liver cirrhosis have?

A

low platelets
anaemia
>2.5 rise in AST to ALT

98
Q

What is the AST:ALT in alcoholic hepatitis?

A

2:1

99
Q

What blood findings suggest haemochromatosis?

A

raised ferritin and transferrin

100
Q

What is Gilbert’s syndrome?

A

hereditary unconjugated hyperbilirubin

101
Q

How does Gilbert’s syndrome?

A

asymptomatically jaundiced with normal LFTs in times of stress

NMF: General Surgery (8 decks)

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