Liver and friends Flashcards
what is the pathophysiology of pancreatitis
autodigestion of pancreatic tissue by pancreatic enzymes leading to necrosis
what are the symptoms of pancreatitis
severe epigastric pain radiating to back
vomiting
on examination - tenderness, ileus, low grade fever
what signs of pancreatitis
cullen’s (periumbilical) and grey-turner’s (flank) discolouration
what investigations for pancreatitis
serum amylase raised serum lipase (more specific) - longer half-life early ultrasound
why is early ultrasound important in acute pancreatitis?
determine cause - if gallstones, then surgical removal
what scoring systems for pancreatitis
Glasgow, Ranson, APACHE II
GET SMASHED for pancreatitis
gallstones ethanol trauma steroids mumps autoimmune scorpion venom hypothermia, hypercalcaemia ERCP drugs (azathioprine, mesalazine, diuretics)
how is acute pancreatitis treated
fluid resus 3-6L?
analgesia - IV opioids
enteral nutrition
surgical - remove gallstones via ERCP/cholecystectomy, debridement of necrotic pancreas
what mode of inheritance in wilsons disease and what gene
autosomal recessive
- atp7b copper binding protein
what symptoms in wilsons disease
excess copper deposition in liver and brain
- liver - chronic hepatitis and cirrhosis
- neuropsychiatric symptoms
- kayser-fleischer rings - copper deposition in descemet membrane
- blue nails
- haemolytic anaemia
- renal tubular acidosis
- osteopaenia
what neuro symptoms in wilsons
neuro
- dysarthria
- dystonia
- concentration and coordination problems
- basal ganglia - parkinsonism, asymmetrical motor problems
- asterixis
- dementia
- chorea
what psych symptoms in wilsons
psychiatric - depression to psychosis
dementia
what investigations for wilsons
- low serum caeruloplasmin
- low total serum copper
- gold standard liver biopsy
- increased 24hr urinary copper excretion
- genetic analysis of ATP7B gene
- slit lamp examination of keyser fleischer rings in eyes
what mgmt of wilsons
copper chelation with:
penicillamine
trientene
what is haemochromatosis and what mode of inheritance which genes
iron accumulation
autosomal recessive HFE gene on chromosome 6
how does haemochromatosis present
later in women due to menstruation
- fatigue
- arthritis
- erectile dysfunction
- bronze skin
- liver symptoms - hepatomegaly, cirrhosis, asterixis
- diabetes mellitus
- hypogonadotrophic hypogonadism
- cardiac failure (due to dilated cardiomyopathy)
- cognitive: memory and mood disturbance
what are the reversible complications of hereditary haemochromatosis
skin pigmentation
cardiomyopathy
what are the irreversible complications of hereditary haemochromatosis
- diabetes mellitus
- cirrhosis
- hypogonadotropic hypogonadism
- arthropathy
what is biliary colic
gallstones obstructing flow of bile from gallbladder
what are the symptoms of biliary colic?
- RUQ pain worse after eating, particularly fatty meals
- colicky pain
- associated with nausea and vomiting
what investigation for biliary colic
ultrasound scan
what RFs for biliary colic
- 4 Fs
- Diabetes
- Rapid weight loss
- Crohn’s
what complications of gallstones/biliary colic
- acute cholecystitis
- acute pancreatitis
- obstructive jaundice
- ascending cholangitis
- gallstone ileus
- gallbladder cancer
what treatment for biliary colic
elective lap cholecystectomy
what is acute cholecystitis
inflammation of gallbladder due to bile being unable to drain
usually because of gallstone in cystic duct
what are the symptoms of cholecystitis
RUQ pain nausea vomiting fever tachycardia tachypnoea Murphy's sign
what sign is associated with acute cholecystitis
Murphy’s sign
- inspiratory attest on palpation of RUQ only (not on LUQ)
how are LFTs in cholecystitis
typically normal
just the cystic duct that’s blocked
what investigations would you do for cholecystitis
USS
FBC - raised WCC
CRP raised
MRCP if unable to visualise with USS
what would you see on USS for cholecystitis
- thickened gallbladder wall
- sludge/gallstones in gallbladder
- fluid around the gallbladder
what mgmt of cholecystitis
- admit
- NBM, IV fluids
- NG tube if vomiting severe
- IV Abx according to local guidelines
- ERCP to remove gallstones
- cholecystectomy within 1 week of diagnosis
what are complications of acute cholecystitis
gallbladder perforation
gallbladder empyema
gangrenous gallbladder
sepsis
what treatment of gallbladder empyema
IV Abx and either cholecystectomy or cholecystostomy
what is mirizzi syndrome
stone in cystic duct or in hartmann’s pouch causes compression of hepatic duct/common bile duct leading to obstructive jaundice
- deranged LFTs, jaundice etc.
what are the main causes of liver cirrhosis
- Alcoholic liver disease
- NAFLD
- Hep B and C
what is the pathophys of liver cirrhosis
chronic inflammation of liver causes fibrosis and nodule formation in the liver
what are the symptoms of liver cirrhosis
- ascites
- telangiectasia
- jaundice
- hepatic encephalopathy
- caput medusae
- oesophageal varices
- easy bruising
- hepatosplenomegaly
- asterixis
- palmar erythema
what blood tests should be ordered for suspected cirrhosis?
thrombocytopaenia
Enhanced Liver Fibrosis (ELF), NAFLD blood test
1. LFTs
2. Albumin low, prothrombin time increased
3. U+E for hepatorenal syndrome, hyponatraemia indicates severe fluid retention
4. Viral markers, autoantibodies
5. AFP as a marker for hepatocellular carcinoma
what investigations for cirrhosis
- Bloods
- liver ultrasound scan
- fibroscan - transient elastography
- liver biopsy
- endoscopy to diagnose/treat oesophageal varices
what changes seen on USS of cirrhosis
- nodularity to surface of vessels
- splenomegaly
- corkscrew vessels
- ascites
- enlarged portal vein with reduced flow
what screening investigation for people at risk of cirrhosis every 2 years
fibroscan (transient elastography)
what investigation in a patient newly diagnosed with cirrhosis
endoscopy to check for oesophageal varices
how should patients with cirrhosis be screened for HCC every 6 months
AFP and uss
what are the elements of the childpugh score for cirrhosis
ABCDE Albumin Bilirubin Clotting (INR) Distended abdomen (ascites) Encephalopathy
- ascites
- bilirubin
- albumin
- INR
- hepatic encephalopathy
what scoring systems can be used for cirrhosis
Child Pugh or MELD (helps guide referral for liver transplant)
what is the general management for cirrhosis
- high protein, low sodium diet
- endoscopy every 3 years for varices
- MELD score every 6 months
- manage complications
- consider liver transplant
what are the complications of cirrhosis
- ascites and SBP
- portal HTN, varices and variceal bleeding
- hepatorenal syndrome
- hepatic encephalopathy
- hepatocellular carcinoma
- malnutrition
what is the mgmt of stable varcies
- propranolol
- endoscopic band ligation
- injection of sclerosant into varices
- TIPS (transjugular intrahepatic portosystemic shunt)
what is the mgmt of bleeding varices
- A-E resuscitation
- correct clotting - Vit K, FFP
- terlipressin
- IV Abx prophylactic
- endoscopic variceal band ligation
- insertion of sengstaken-blakemore tube
- TIPS if all else fails
what is a common complication of TIPS
exacerbation of hepatic encephalopathy
what is the management of ascites in cirrhosis (transudative)
- spironolactone
- low sodium diet
- paracentesis
- ciprofloxacin as prophylaxis against SBP
- TIPS or transplant in refractory ascites
how does sbp present
- fever
- abdominal pain
- raised WCC and CRP, creatinine, metabolic acidosis
- ileus
- hypotension
what are the most common organisms in sbp
- e. coli (gram neg rods)
- klebsiella
- gram +ve cocci (staph or enterococcus)
how is sbp diagnosed
paracentesis fluid microscopy culture sensitivity prior to administration of Abx
how is sbp managed
IV cefotaxime
what is hepatorenal syndrome
splanchnic vasodilation
- portal hypertension leads to renal hypotension and hypoperfusion
- this leads to RAAS activation and renal vasoconstriction
- vasoconstriction and reduced circulating volume = reduced renal perfusion = CKD
what are the two types of hepatorenal syndrome
Type 1 - very poor prognosis, rapidly progressive
Type 2 - slightly better prognosis, slowly progressive
what is the mgmt of hepatorenal syndrome
liver transplant
- terlipressin
- volume expansion with 20% albumin
- TIPS
what is hepatic encephalopathy
build up of toxins such as ammonia in blood
ammonia able to cross BBB
how is hepatic encephalopathy treated
lactulose
add rifaximin
embolisation of portosystemic shunts/liver transplant
what are the 4 grades of hepatic encephalopathy
- irritability
- confusion, inappropriate behaviour
- incoherent, restless
- coma
what can precipitate hepatic encephalopathy
constipation TIPS infection (eg. SBP) electrolyte disturbance GI bleed high protein diet medications (sedatives, diuretics) hypokalemia renal failure
how does hepatic encephalopathy
confusion, altered GCS
asterixis
constructional apraxia inability to draw 5 point star
EEG - triphasic slow waves
name 4 causes of acute liver failure
- alcohol
- viral hepatitis (A or B)
- paracetamol overdose
- acute fatty liver of pregnancy
how does acute liver failure present
- jaundice
- coagulopathy (raised PTT)
- hypoalbuminaemia
- renal dysfunction (hepatorenal syndrome)
- hepatic encephalopathy
what is the spectrum of alcoholic liver disease
- alcoholic fatty liver disease
- alcoholic hepatitis
- cirrhosis
how does alcoholic hepatitis present?
abdo pain fatigue pruritus, jaundice myalgia nausea vomiting
what investigations for alcoholic hepatitis
LFTs
raised GGT
AST:ALT ratio >2, >3 = acute alcoholic hepatitis
what treatment of alcoholic hepatitis
- glucocorticoids
- pentoxyphylline
what is used to calculate chance of benefit with glucocorticoids in alcoholic hepatitis
maddreys discriminant function - bilirubin and prothrombin time
how is ascites classified
SAAG >11g/L
SAAG <11g/L
give some causes of SAAG >11g/L ascites
- liver problems (cirrhosis, liver mets, acute liver failure)
- cardiac problems (RHF)
- Budd Chiari, portal vein thrombosis,
- myxoedema
give some causes of SAAG <11g/L ascites
- hypoalbuminaemia (nephrotic syndrome, kwashiorkor)
- pancreatitis
- peritoneal carcinomatosis
how is ascites managed
- low dietary sodium
- spironolactone
- therapeutic paracentesis (give albumin cover)
- ciprofloxacin
- TIPSS
what is a complication of large volume paracentesis and how can this be prevented
paracentesis-induced circulatory dysfunction
albumin cover
what can be seen on blood film in hyposplenism
howell-jolly bodies
siderocytes
how is hyposplenism managed
- vaccines - PCV, flu, meningitis, haemophilus influenzae
2. prophylactic antibiotics
what are the causes of hyposplenism
splenectomy coeliac sickle cell SLE graves amyloid
