Liver And Friends Flashcards
1
Q
Definitive treatment if symptomatic gallstones
A
Cholecystectomy
2
Q
ERCP
A
Endoscopic retrograde cholangiopancreatography
Endoscope and X-Ray to look T the bile duct and pancreatic duct to search for and remove present gallstones
3
Q
Presentation of pancreatitis
A
Epigastric pain radiating to the back
Vomiting
Pain may be relieved by leaning forward
4
Q
Bile acid sequestrants
A
Bind to bile acids in the small intestine
Prevent their reabsorption into enterohepatic circulation
Reduction in bile acid levels causes hepatic conversion of LDL cholesterol to bile acids
5
Q
Three biliary tract diseases
A
Gallstones (biliary colic)
Cholecystitis
Cholangitis
6
Q
Distinguish between biliary colic, acute cholecystitis and ascending cholangitis using Charcot’s triad
A
Charcot’s triad: RUQ pain, fever, jaundice
Biliary colic: RUQ pain
Acute cholecystitis: RUQ pain, fever & increased WCC
Ascending cholangitis: RUQ pain, fever & increased WCC, Jaundice
7
Q
Biliary colic pathophysiology
A
Gallstone blocks the cystic or common bile duct
Without signs of cystic inflammation
8
Q
Components of bile
A
cholesterol, pigments and phospholipids
9
Q
Types of gall stone
A
Cholesterol: excess production (obesity and fatty diets)
Pigment: (haemolytic anaemia)
Mixed: made of both of the above
10
Q
Presentation of biliary colic
A
COLICKY RUQ PAIN
worse after eating large or FATTY meals (triggers gallbladder to contract AGAINST the blockage)
11
Q
Five risk factors of gallstones
A
5 F's: Fat Fertile Forty Female FHx
12
Q
Investigations for gallstones
A
Rule out:
- FBC & CRP: inflammatory response (cholecystitis)
- Amylase: pancreatitis can also give RUQ pain
- LFTs: raised ALP (bilirubin and ALT normal)
Diagnostic: ULTRASOUND
1) Stones
2) Gallbladder wall thickness (due to inflammation)
3) Duct dilation (distal blockage)
13
Q
Gallstone differential diagnoses
A
RUQ pain: cholecystitis cholangitis IBD pancreatitis GORD peptic ulcers
14
Q
Gallstone treatment
A
NSAIDs/analgesia
Cholecystectomy (optional to prevent recurrence)
15
Q
Cholecystitis pathophysiology
A
Inflammation of the gallbladder wall (cholecyst-itis) usually caused by a stone blocking the duct causing bile to build up and distend the gallbladder
16
Q
Presentation of cholecystitis
A
Generalised epigastric pain migrating to severe RUQ pain, fever
Pain associated with tenderness and guarding (inflamed gallbladder, local peritonitis)
17
Q
Murphys sign
A
elicited in acute cholecystitis: ask patient to take in and hold a deep breath whilst palpating RUQ
positive = pain on inspiration when the gallbladder comes into contact with examiners hand
18
Q
Ix cholecystitis
A
Positive Murphy’s sign
Inflammatory markers
Ultrasound (thick gallstone walls from inflammation)
19
Q
Cholecystitis treatment
A
IV Abx
Heavy analgesia
IV fluids
Cholecystectomy (if needed)
20
Q
Cholangitis
A
Bile DUCT inflammation caused by prolonged bile duct blockage
Bacteria can travel from the GI tract and not be flushed out with the bile, causing biliary tree infection
Jaundice: bile cannot enter the GI tract
Infection can travel to the pancreas as it shares the gallbladder ducts
Mortality: 5-10%
21
Q
Cholangitis presentation
A
severe RUQ pain with fever and jaundice
may also present with:
sepsis
pancreatitis
22
Q
Cholangitis investigations
A
FBC, LFTs, CRP: leukocytosis, raised ALP and bilirubin, raised CRP
Blood cultures/MC&S: for pathogen detection to use correct Ab
Ultrasound +/- ERCP (endoscopic retrograde cholangiopancreatography) = biliary tree contrast X-Ray
23
Q
Cholangitis treatment
A
Treat SEPSIS
ERCP + stenting to mechanically clear the blockage
Surgery/cholecystectomy (if possible)
24
Q
SEPSIS 6
A
- GIVE oxygen
- TAKE blood cultures
- GIVE IV Abx
- GIVE fluids
- TAKE lactate measurement
- TAKE urine output measurement
25
Causes of acute pancreatitis
```
I GET SMASHED
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune (prevalent in Japan)
Scorpion venom
Hyperlipidaemia
ERCP
Drugs - NSAIDs, corticosteroids, ACEis
```
26
Two main causes of acute pancreatitis and the pathophysiology
GALLSTONES: BLOCKAGE of bile duct = back up of pancreatic juices
- change in luminal concentration causes calcium release inside pancreatic cells = activated trypsinogen early = AUTODIGESTION OF PANCREAS
ALCOHOL: CONTRACTS THE AMPULLA OF VATER obstructing bile clearance = calcium homeostasis disrupted = trypsinogen = AUTODIGESTION OF PANCREAS
27
Why does Grey Turner's sign occur in acute pancreatitis
leaky and damaged pancreas = AUTODIGESTION to nearby structures = haemorrhage and Grey Turner's sign (abdominal skin discolouration from retroperitoneal bleeding)
28
Why does hyperglycaemia occur in pancreatitis
disrupted insulin production
29
Acute pancreatitis presentation
SEVERE EPIGASTRIC PAIN RADIATING TO THE BACK
Anorexia, fever, jaundice, Grey Turner's sign (flank bruising), N&V, tachycardia
30
Acute pancreatitis investigations
Serum amylase: raised
Urinalysis: raised urinary amylase
Serum lipase: raised (more specific than amylase)
CRP and FBC: raised CRP
Erect CXR: exclude gastroduodenal rupture
Abdo ultrasound, CT, MRI
31
Two scores used in acute pancreatitis
APACHE 2
| Glasgow & Ranson
32
Acute pancreatitis treatment
Nil by Mouth (decrease pancreatic stimulation)
Analgesics
Prophylactic Abx
Treat gallstones if underlying cause
33
causes of chronic pancreatitis
CHRONIC ALCOHOL USE
Hereditary
Autoimmune
CKD
34
Presentation of chronic pancreatitis
EPIGASTRIC PAIN 'BORING' THROUGH THE BACK: worse after alcohol, better on leaning forward
Typical patient: 50 odd year old MALE with an appropriate SHx (drinking)
N&V, decreased appetite, malabsorption (painless weight loss)
35
Chronic pancreatitis investigations
Serum amylase and lipase: may be raised if enough cells remain to make them
Ultrasound abdo, CT, MRI
36
Treatment of chronic pancreatitis
```
Stop drinking
Pancreatic enzyme supplements
PPI to help digestion
Insulin for DM
Duct drainage
```
37
Haemochromatosis
inherited condition where IRON LEVELS build up in the body
38
Pathophysiology of haemochromatosis
mutation in autosomal recessive HFE gene (c6)
causes increased intestinal iron absorption
iron accumulates in liver, joints, pancreas, heart, skin, gonads
ORGAN DAMAGE: liver fibrosis, cirrhosis, HCC (hepatocellular carcinoma)
39
Presentation of haemochromatosis
Fatigue, arthralgia (joint stiffness), weakness
Hypogonadism e.g erectile dysfunction
Slate-grey skin (brownish/bronze)
Chronic liver disease, heart failure, arrythmias
40
haemochromatosis investigations
Bloods: iron study, LFTs
Genetic testing
GOLD STANDARD: liver biopsy
MRI: detects iron overload
41
Wilson's disease
error of COPPER metabolism = copper deposition in organs, including liver, basal ganglia, cornea
42
Presentation of Wilson's disease
KAYSER-FLEISCHER RING: copper in cornea (green/brown pigment at outer edge)
Psychiatric: depression, neurotic behavioural patterns
CNS: tremor, dysarthria, involuntary movements, dysphagia
Liver: hepatitis, cirrhosis
43
Wilson's disease investigations
serum copper and ceruloplasmin reduced (but can be normal)
24 hour URINARY copper excretion HIGH
DIAGNOSTIC: LIVER BIOPSY
44
Wilson's disease management
Avoid high copper foods (liver, chocolate, nuts, mushrooms, shellfish)
Chelating agent: PENICILLAMINE
Liver transplant
45
Ascites
Excessive buildup of fluid in the peritoneal cavity
46
Ascites pathophysiology
Poor liver function = low albumin = low blood oncotic pressure = fluid leaks out into peritoneal cavity
47
Main cause of ascites
Liver failure/cirrhosis
48
Presentation of ascites
LARGE DISTENDED ABDOMEN
Shifting dullness
- DULLNESS OVER FLUID
- RESONANCE OVER AIR
49
Ascites treatment
Low sodium diet
Diuretics: Spironolactone + Furosemide
Identify cause + treat accordingly
50
Peritonitis aetiology
- Primary
- Secondary
- Causative organisms
Primary: spontaneous bacterial infection, ascites
Secondary: perforation (bowel, appendix, peptic ulcer), gastritis, ectopic pregnancy
Most common causative organisms: S. Aureus, Klebsiella, E.coli
51
Presentation of peritonitis
Perforations: SUDDEN ONSET SEVERE ABDO PAIN with generalised shock/collapse
Secondary: gradual onset: generalised abdo pain >> localised severe pain (visceral >> parietal)
Rigid abdomen
Pyrexia, tachycardia, potential confusion, N&V
Guarding, rebound tenderness, rigidity, SILENT ABDO
52
Peritonitis investigations
Bloods: FBC & CRP, Amylase (pancreatitis), hCG (ruptured ectopic pregnancy)
Erect CXR for air below the diaphragm, AXR to exclude bowel obstruction, CT for abdo ischaemia
Ascitic tap and blood cultures: pathogen
53
Treatment of peritonitis
ABCDE
Find and treat underlying cause (e.g. may be surgery for perforated bowels)
IV fluids
IV Abx (broad spec >> specific)
Peritoneal lavage (clean the cavity surgically)
54
Hernias
protrusion of organ through defect in wall of its containing cavity
55
Hernia classifications
- Reducible (flattens when you lie down or push against it)
- Irreducible (loop of intestine becomes trapped and the bulge cannot flatten out) - requires immediate medical attention >> Obstructed (intestinal flow stopped)
-Strangulated (tightly trapped intestine causing blood supply to be cut off) > ischaemia > gangrene
56
Inguinal hernia
protrusion of abdominal contents through inguinal canal
presents superior and medial to pubic tubercle
- swelling in groin
- impulse
20% are direct (medial to inferior epigastric artery through a weakened area)
80% are indirect (lateral to inferior epigastric artery through deep inguinal ring)
57
Femoral hernia
bowel comes through femoral canal
58
Hiatus hernia
herniation of stomach through oesophageal aperture of diaphragm
59
Incisional hernia
hernia through surgical scar
60
Epigastric hernia
hernia through linea alba above umbilicus
61
Management of hernias
SURGERY
62
Risk factors for inguinal hernia
Male
Chronic cough
Heavy lifting
Past abdo surgery
63
Investigations for an inguinal or femoral hernia
Clinical diagnosis
| USS/CT/MRI
64
Most likely classification in femoral hernia
Irreducible and strangulation (due to rigidity of canals borders)
65
Presentation of a femoral hernia
Mass in upper medial thigh
Neck of hernia is inferior and lateral to pubic tubercle
May be cough impulse
66
Types of hiatus hernia
Rolling: 20% - GOJ remains in abdo, part of fundus rolls up through hiatus, LOS
Sliding: 80% - GOJ and part of stomach slides up into chest, LOS less
67
Risk factors for hiatus hernia
```
Obesity
Female
Pregnancy
Ascites
Age
```
68
Hiatus hernia presentation
Heartburn/GORD
| Dysphagia
69
Hiatus hernia investigation
```
CXR
Barium swallow (oesophagogram)
Endoscopy
Oesophageal manometry
```
70
Functions of the liver
```
Oestrogen regulation
Detoxification
Carbohydrate metabolism
Albumin production
Clotting factor production
Bilirubin regulation
Immunity (Kupffer cells in reticuloendothelial system)
```
71
Pathophysiology of spider naevi and palmar erythema
Oestrogen dysregulation
72
Acute presentation of liver disease
Malaise
Nausea
Anorexia
Jaundice
73
Chronic presentation of liver disease
```
Ascites
Oedema
Pruritus
Clubbing
Palmar erythema
Xanthelasma
Spider naeivi
Hepatomegaly
Bleeding (haematemesis, bruising)
```
74
Causes of acute liver disease
```
Viral (Hep A, Hep B, EBV)
Drugs
Alcohol
Vascular
Obstruction
Congestion
```
75
Causes of chronic liver disease
Alcohol
Viral (Hep B, Hep C)
Autoimmune
Metabolic (Iron, Copper)
76
Causes of liver failure
```
Toxins (Paracetamol, ALCOHOL - most common cause)
Infection (viral HEPATITIS)
Metabolic (Wilson's/A1AT)
Autoimmune (PBC, PSC)
Neoplastic (HCC)
Vascular (Budd Chiari, ischaemia)
```
77
Signs of liver failure
Jaundice
Coagulopathy
Hepatic encephalopathy (altered mood, dyspraxia, asterixis)
Fetor hepaticus (sweet and musty breath/urine)
78
Characteristics of liver failure decompensation
Abnormal bleeding
Ascites
Hepatic encephalopathy
Jaundice
79
Investigations of liver failure
Clinical examination
Bloods (increased PT, increased AST/ALT, toxicology, FBC, U&E)
If ascites: peritoneal tap with MS&C
80
Management of liver failure
Conservative (fluids, analgesia)
Medical: treat complications
- Ascites: diuretics
- Bleeding: vitamin K
- Cerebral oedema: mannitol
- Encephalopathy: lactulose
- Sepsis: SEPSIS 6 (Abx)
- Hypoglycaemia: dextrose
Surgical: transplant
81
Hep A
```
Spread: faecal-oral (vowels = bowels)
Virus: RNA
Infection: acute + mild
Test: Bloods show raised AST/ALT, raised IgG and IgM
Management: supportive
Vaccine available
```
82
Hep B
Spread: blood products + bodily fluids (unprotected sex)
Virus: DNA (the only DNA one)
Infection: can be severe
Test: Hep B serology
Management: pegylated interferon alpha 2a, tenofovir (inhibits viral replication)
Vaccine available
83
Hep C
Spread: blood products + bodily fluids (IVDU)
Virus: RNA
Infection: very slow progressing
Test: HCV RNA, Anti-HCV serology
Management: direct acting anti-virals, ribavirin, sufosbuvir
84
Hep D
```
Spread: blood products + bodily fluids
Virus: RNA (requires Hep B)
Infection: makes HBV worse, likely to progress to cirrhosis or HCC
Test: HDV RNA, Anti-HDV
Management: treat HBV
```
85
Hep E
```
Spread: faecal-oral (vowels = bowels)
Virus: RNA
Infection: normally mild
Test: HVE RNA, Anti-HVE
Management: supportive
```
- only really get symptoms if PREGNANT
86
Complications of hepatitis (B, C, D, E)
Cirrhosis
| HCC
87
Hep B serology:
| Vaccinated
HB core Ab: -ve
HB surface Ab: +ve
HB surface Ag: -ve
88
Hep B serology:
| Previous HBV
HB core Ab: +ve
HB surface Ab: +ve
HB surface Ag: -ve
89
Hep B serology:
| Chronic HBV
HB core Ab: +ve
HB surface Ab: -ve
HB surface Ag: +ve
IgM negative, IgG positive = chronic
90
Paracetamol metabolism and toxicity
1. Glucuronidation = excretion
2. Sulfation = excretion
3. p450 > NAPQI [toxic] > NAPQI + glutathione = excretion
Overdose: too much toxic NAPQI without enough glutathione = liver damage
- nausea, vomiting, anorexia, RUQ pain
Treatment: activated charcoal, N-acetylcysteine
91
Non-alcoholic fatty liver disease (summary)
Healthy > Steatosis > Steatohepatitis > Fibrosis > Cirrhosis
Px: asymptomatic, nausea, vomiting, diarrhoea, hepatomegaly
Dx: biopsy (diagnostic), imaging
Tx: weight loss (reduce fat)
92
Alcoholic liver disease
Fatty liver > alcoholic hepatitis > cirrhosis
Ix:
- GGT high, AST and ALT mildly raised
- FBC: macrocytic anaemia
93
Calculation for units of alcohol
Strength (ABV) x volume (ml) / 1000 = units
94
Complications of alcoholic liver disease
Wernicke-Korsakoff encephalopathy (ataxia, confusion, nystagmus, memory; Tx: IV thiamine)
Acute/chronic pancreatitis
Mallory-Weiss tear
95
GGT (LFT)
Gamma-glutamyl transferase
96
Common causes of cirrhosis
Chronic alcohol abuse
NAFLD
Hepatitis (B & C)
97
Clinical Px of cirrhosis
```
Ascites
Clubbing
Palmar erythema
Xanthelasma
Spider naevi
Hepatomegaly
Peripheral oedema
```
98
Ix cirrhosis
Low platelets, high INR, low albumin
US + CT: hepatomegaly
Liver biopsy
99
Tx cirrhosis
```
Alcohol abstinence
Good nutrition
Liver transplantation
Screen for HCC every 6 months (increased AFP)
Symptoms e.g. spironolactone for ascites
```
100
Causes of portal hypertension
Prehepatic (portal vein thrombosis)
Intrahepatic (schistosomiasis, cirrhosis, Budd Chiari)
Post-hepatic (RH failure, IVC obstruction)
101
Pathophysiology of oesophageal varices
Portal hypertension pushes blood into surrounding vessels i.e. oesophageal varices
These are thin vessels and not meant to transport high pressure blood = easily ruptured
Rupture > haematemesis > digested blood > melaena
102
Tx oesophageal varices
Beta blocker (reduce CO > reduce portal HT)
Nitrate (reduce portal HT)
Terlipressin
Surgical: band ligation, TIPS shunt
103
Causes of prehepatic jaundice
Haemolytic anaemia = excessive red cell breakdown which overwhelms the liver’s ability to conjugate bilirubin = unconjugated hyperbilirubinaemia (jaundice)
104
Causes of hepatocellular jaundice
```
Liver failure
Liver disease
Hepatitis
Iatrogenic (toxicity)
Gilbert’s syndrome
```
105
Causes of post hepatic jaundice
Gallstones
106
Acute HBV infection serology
HB core Ab: +ve
HB surface Ab: -ve
HB surface Ag: +ve
IgM positive = acute
107
Blood results associated with alcoholic liver damage
Raised GGT
High AST:ALT ratio
Mallory bodies
108
Cholestatic picture
Dark urine
| Pale stools
109
Complications of acute pancreatitis
ACUTE RENAL FAILURE (due to dehydration)
Sepsis
Acute respiratory syndrome
Chronic pancreatitis
110
Pancreatic cancer Px
| tumour at head of pancreas
Painless obstructive jaundice
| Steatthorea
111
RBC breakdown
Heme
Biliverdin
Bilirubin
Large intestine: Urobilinogen > Urobilin (urine) / Stercobilin (faeces)
112
What is ERCP?
Endoscopic retrograde cholangio-pancreatography
113
Primary biliary cholangitis
Intrahepatic ducts
114
Primary sclerosing cholangitis
Intra and extra hepatic ducts
| Strong link with UC
115
Acute liver failure definition
Onset of less than 26 weeks duration and no previous liver disease
116
Medication used for delirium tremens/alcohol withdrawal
Chlordiazpoxide
| IV B-vitamins
117
How does cirrhosis cause
1) Splenomegaly
2) Upper GI bleed
1) Portal hypertension
| 2) Oesophageal varices
