Liver and Biliary Tree Flashcards
what is the underlying pathology to liver disease
insult to hepatocytes initially causing reversible inflammation but if persistent causes irreversible fibrosis
what time frame is acute and chronic liver disease
acute <6 months
chronic >6 months
what are some of the main causes of liver disease
alcohol NAFLD paracetamol poisoning hep C PBC autoimmune hepatitis
describe compensated and decompensated cirrhosis
compensated - may not present with symptoms as still some normal liver function
decompensated - will present with symptoms, running out of functioning liver
what is portal hypertension classed as
> 5-8mmHg
what causes portal hypertension
liver doesnt function correctly, causes increased resistance to flow and increased portal venous outflow. causes increased back pressure in the artery which has systemic effects
what are the main causes of cirrhosis
alcoholism NALFD chronic HCV HBV genetic and autoimmune disorders drugs eg methotrexate
what are some signs of cirrhosis
leukonychia, xanthelasma, ascites, palmar erythema, gynaecomastia, spider naevi, encephalopathy, caput medusae, heptaosplenomegaly
what causes encephalopathy
ammonia that is usually metabolised in the liver goes directly to systemic circulation because of liver not functioning correctly. causes neurotransmitter problems and liver flap
what causes ascites
increase in interstital fluid due to increased back pressure
what are the main complications of cirrhosis
portal hypertension
oesophageal varices
rectal varices
what is the overall treatment for cirrhosis
good nutrition - high calorie diet
avoid alcohol completely
spirnolactone for ascites
prophylactic lactulose for encephalopathy
what is TIPS and when is it used
creates a new connection between portal and hepatic vein, used in portal hypertension to relieve pressure
what is a complication of NAFLD
can develop onto NASH - non-alcoholic steatosis hepatitis leading to end stage liver failure requiring transplant
what are 3 autoimmune conditions affecting liver/gallbladder
primary biliary cholangitis
autoimmune hepatitis
primary sclerosing cholangitis
what causes PBC and who typically gets it
bile ducts are damaged by chronic autoimmune granulomatous - causes build up of bile and cirrhosis
typically middle aged women present
what are the symptoms of primary biliary cholangitis
fatigue painless jaundice itch without rash xanthelasma hepatosplenomegaly
what investigations are carried out to diagnose PBC
anti-mitochondrial antibodies
LFTs showing cholestatic picture
liver biopsy
what is the treatment for PBC and complications
treat itch with urseodeoxycholic acid
cirrhosis can develop which may require liver transplant
what causes autoimmune hepatitis
abnormal T cell function targets hepatocytes causing inflammation
who typically presents with autoimmune hepatitis and with what symptoms
young or middle ages women
fatigue and lethargy - general autoimmune symptoms
also hepatomegaly and possible jaundice
what investigations are carried out for autoimmune hepatitis
anti-smooth muscle antibodies
LFTs showing hepatocellular picture
(raised ALT/AST and PT)
liver biopsy
what is the treatment for autoimmune hepatitis (think reduce inflammation)
prednisolone or budesonide
immune suppression - azathioprine
urseodeoxycholic acid
what causes primary sclerosing cholangitis
progressive cholecystatis with bile duct inflammation affecting medium and large sized ducts
PSC is associated with which gender and which condition
male
Ulcerative Colitis
what are the symptoms of PSC
fatigue/lethargy
jaundice - late symptom
what investigations are carried out for PSC
LFTs showing cholestatic picture pANCA +ve test liver imaging (US and ERCP)
what is the treatment for PSC
liver transplant most effective
also prevention of cirrhosis
what is the main complication of PSC especially with UC
cancer of the liver, gallbladder, bile duct and colon
annual colonoscopy required
what is haemochromatosis
autosomal recessive condition causing iron overload in the joints and skin
(high iron levels can cause hepatic toxicity)
what are the signs and symptoms of haemochromatosis
slate grey appearance
‘bronzed diabetic’
typical signs of cirrhosis ascites, encephalopathy etc
what investigations are carried out for haemochromatosis
raised ferritin levels
LFTs
what is the treatment for haemochromatosis
regular venesection to remove excess iron
also good diet and no alcohol
what is Wilsons disease
autosomal recessive condition causing loss of ceruloplasmin causing excess copper in liver and ganglia
what are the symptoms of Wilsons disease
child presenting with liver disease
CNS problems
Kaiser Fleischer rings around eyes
what is the treatment of Wilsons disease
copper chelation drugs to help bind to copper
alpha 1 antitrypsin deficiency causes symptoms in what body systems
lungs - emphysema
liver - cirrhosis and cholestatic jaundice
what tests are carried out for alpha 1 antitrypsin deficiency and what do they show
low serum anti-trypsin
reduced FEV1
liver biopsy
what is Budd-Chiari and who typically develops it
thrombosis of hepatic veins causing tender hepatomegaly, jaundice and ascites
young women on oral contraceptive
what investigations and treatment are used for Budd-Chiari
ultrasound of hepatic veins
remove trigger, anti-coagulation, thrombolysis and TIPS
name the benign liver tumours
haemangioma
focal nodular hyperplasia
hepatic adenoma
cystic lesions
who typically develops haemangioma and what is the severity of it
more common in females
hypervascular tumour, incidental finding with no treatment required
describe hepatic adenoma and the treatment
benign neoplasm which has malignant potential
more common in females, oral contraceptive pill and steroid use
if present in males, requires resection and if >5cm in females requires resection due to risk of becoming malignant
what is the main treatment for cystic lesions
removal and drainage
if an abscess also requires antibiotics
what is the most common type of malignant liver tumour
hepatocellular carcinoma (hepatoma)
what are the risk factors for developing hepatocellular carcinoma
NAFLD, cirrhosis, chronic HCV HBV, haemochromatosis,
more common in men
primary liver tumours are more common than secondary ones true/false
false - 90% are metastases
what are common sites of cancer that metastasise to the liver
breast, lung, colon, stomach and pancreas
what are the signs and symptoms of liver cancer
jaundice, ascites, weight loss, fatigue, RUQ pain, hepatomegaly
what investigations are required for diagnosing liver cancer
US/CT
biopsy
alpha feto protein
what is the main treatment for liver cancer
liver transplant best chance
resection has high recurrence rate
what causes gallstones to occur
abnormal ratio of cholesterol and lipids in bile
what two types of gallstones can occur
cholesterol
pigment (dark)
or mixture of both
what are the causes of gallstones
abnormal bile composition
bile stasis
infection
excess cholesterol
what are the risk factors for gallstones
fat female fertile forty and fair
describe acute cholecystitis
blockage of the cystic duct causing inflammation of the gallbladder
gallbladder pain is typically referred to
the right shoulder
what are the symptoms of gallstones
biliary colic in RUQ radiating to shoulder typically after eating fatty meal
nausea, flatulence, jaundice, PALE STOOLS DARK URINE
what is murphys sign and when is it positive
pain when breathing in and palpating the RUQ
positive during acute cholecystitis
what investigations are required for gallstones
US of biliary tree
further investigations using CT and ERCP
what is the treatment for symptomatic gallstones
nil by mouth
antibiotics
urgent laparoscopic cholecystectomy
what are the main complications of gallstones
migration of the stone to another site - gallstone ileus, pancreatitis and acute cholecystitis
what is the second most common hepatobiliary cancer
cholangiocarcinoma - cancer of the bile duct
cholangiocarcinoma risk is increased with what conditions
UC and PSC
what are the symptoms of cholangiocarcinoma and investigations
vague abdominal pain
jaundice
weight loss, lethargy, anorexia
investigations - US, MRCP/ERCP
what is the treatment for cholangiocarcinoma
surgical resection of bile duct and liver - often too late
palliation through biliary stenting
which part of the colon is most likely to develop colorectal cancer
sigmoid colon
what are the risk factors for developing colorectal cancer
age, smoking, obesity/low fibre diet, polyps, genetic predisposition, PSC, UC
what is lynch syndrome
also known as hereditary non-polyposis colorectal cancer
increases risk of developing colorectal and endometrial cancer. genetic condition
what is FAP and what does it produce
familial adenomatous polyposis - causes mutation in APC causing carpet of polyps with malignant potential
the majority of colorectal cancers are left/right sided
left sided 75% - sigmoid colon
what are the symptoms of colorectal cancer (left and right sided)
left - rectal bleeding, tenesmus, constipation, altered bowel habit
right - weight loss, anorexia and anaemia, fatigue
what are the common sites colorectal cancer can spread to
lung, liver through blood
lymph nodes - IMA or superficial inguinal nodes
ovaries/prostate through direct invasion
what is the main treatment options for colorectal cancer
surgical resection of affected area eg hemicolectomy or proctectomy
neo-adjuvant radiotherapy
palliative radiotherapy
what are oesophageal varices and how do the occur
submucosal venous dilatation secondary to portal hypertension
what are the symptoms of oesophageal varices
haematemasis
ground coffee vomit
symptoms of liver disease eg jaundice, cirrhosis and encephalopathy
name some pre, hepatic and post causes of portal hypertension
pre - thrombolysis
hepatic - cirrhosis
post - budd-chiari or heart failure
what is the management for oesophageal varices
IV fluids
take bloods and insert catheter
urgent endoscopy and either oesophageal banding or sclerotherapy to close off the vein from the inside
name some causes of pancreatitis
gallstones, alcohol, iatrogenic, trauma, drugs, autoimmune
what are the symptoms of pancreatitis
epigastric pain radiating to the back
fever, nausea, vomiting - acute
relapsing remitting symptoms and steatorrhoea - chronic
what are grey turners sign and cullens sign
grey tuners - flank bruising
cullens - periumbilical bruising
both signs of pancreatitis
what are the investigations and treatment done for pancreatitis
inv - CT, US
treatment - analgesia, fluids and stop alcohol
what are the complications of pancreatitis that require surgery
pseudocysts
shock
abscess
necrosis/chronic pancreatitis
what are the risk factors for developing pancreatic carcinoma
smoking, alcohol, poor diet high in red meat, chronic pancreatitis, age and male gender
what are the symptoms of pancreatic cancer - think about parts of the pancreas
head - painless jaundice
body and tail - epigastric pain radiating to the back
both, weight loss and fatigue
which types of viral hepatitis can be treated with vaccination
Hep A and B
name some antivirals that can be used and when are they used in hepatitis
entecavir adefovir
only used in chronic infection
which strains of viral hepatitis can produce chronic infection
hep B, C, D
describe the spread of each type of viral hepatitis
A - faecal oral B - blood/sex C - blood/sex but less common D - only developed with hep B E - faecal oral and animal spread
what lab tests are carried out for hep A
Hep A IgM and serology for clotted blood
positive anti-HBe Ab indicates
low infectivity of hep B
chronic hep B infection is defined as a positive HbsAg for how long?
> 6 months
Hep B DNA positive indicates
highly infectious individual
Hep B IgM positive indicates
recently infected
what are the complications of developing chronic hepatitis
cirrhosis and increased risk of hepatocellular carcinoma
if an individual has suspected hep C what test is carried out
hep C Ab
if someone has positive hep C Ab what test is carried out next and what does it show
PCR for Hep C RNA - positive indicates active infection and negative indicates past infection
hep A is more common than Hep E true/false
false Hep E is more common
