Liver and Friends Flashcards
1
Q
What is liver failure?
A
The inability of the liver to perform its normal functions, and repair or regenerate. Recognised by development of coagulopathy and encephalopathy, can be chronic or acute
2
Q
Causes of liver failure
A
• Viral hepatitis, yellow fever
• Paracetamol overdose
• Poisonous mushrooms
• Alcohol, fatty liver disease, autoimmune
hepatitis
3
Q
Pathology of liver failure
A
Destruction of hepatocytes -> development of fibrosis in response to chronic inflammation -> destruction of architecture of the liver nodules -> liver can’t repair or regenerate or perform functions
4
Q
Signs of liver failure
A
- Jaundice
- Hepatic encephalopathy – confusion, drowsiness
- Bad breath
- Asterixis
- Bleeding, bruising
- Ascites
5
Q
Symptoms of liver failure
A
o Itchiness o Easy bruising o Abdominal swelling o URQ pain o Bad breath
6
Q
Investigations for suspected liver failure
A
• Bloods – FBC, clotting (↑PT), hepatitis,
autoantibodies, low glucose, LFT
• Microbiology – blood culture, urine culture, ascitic
tap
• Radiology – CXR, abdominal US
7
Q
Management of liver failure
A
- Treat underlying cause
- Liver transplant
- Treat complications
8
Q
Complications of liver failure
A
- Sepsis
- Hypoglycaemia
- GI bleeds/varices
- Encephalopathy
9
Q
Epidemiology of gallstones
A
o Oestrogen link - women > men, pill
o Obesity increases risk
o Prevalence increases with age
10
Q
What is Admirand’s triangle?
A
Increased risk of gallstones if ↓lecithin, ↓bile salts, ↑cholesterol
11
Q
What are the risk factors for cholesterol stones?
A
female, fat, forty, fertile
12
Q
What is a cause of bilirubin/pigment stones?
A
Haemolysis
13
Q
What are brown/mixed stones usually a sign of?
A
Infection
14
Q
What are the risk factors for gallstones becoming symptomatic?
A
Smoking and pregnancy
15
Q
What are the symptoms of gallstones?
A
o Most asymptomatic
o Biliary colic - RUQ pain
o Acute cholecystitis - RUQ pain and fever
16
Q
Investigations for suspected gallstones
A
US
17
Q
What is biliary colic?
A
Sudden abdominal pain due to a gallstone temporarily blocking the cystic duct
18
Q
Symptoms of biliary colic
A
RUQ pain, radiates to back
19
Q
Investigations for suspected biliary colic
A
Urinalysis, CXR and ECG
20
Q
Management of biliary colic
A
o Analgesia, rehydrate, NBM
o Laparoscopic cholecystectomy
21
Q
What is acute cholecystitis?
A
Inflammation of the gallbladder, usually caused by gallstones
22
Q
Symptoms of acute cholecystitis
A
o Continuous epigastric/RUQ pain
o Vomiting
o Fever, peritonism
23
Q
Signs of acute cholecystitis
A
o Murphy’s sign – lay 2 fingers over RUQ, ask patient
to breath in, pain on inspiration
o Palpable GB mass
24
Q
Investigations for suspected acute cholecystitis
A
o Bloods – high WBC
o US – thick-walled, shrunken GB, fluid, stones
25
Management of acute cholecystitis
o NBM, pain relief, IVI and antibiotics
o Laparoscopic cholecystectomy
o Open surgery if perforation
26
What is cholangitis?
Inflammation of the bile duct
27
What are the main causes of cholangitis?
Gallstones, infection (E. coli, Klebsiella, enterococcus)
28
Pathology of cholangitis
o Flow of bile prevents intestinal bacteria from
migrating up biliary tree
o Obstruction of the CBD -> inflammation and
susceptibility to infection -> infection ‘ascends’ from
junction with the duodenum
29
What are the signs and symptoms of cholangitis?
o Fever
o RUQ pain
o Jaundice (dark urine, pale stool, itching)
30
What is Charcot's triad?
Features of cholangitis: fever, RUQ pain, Jaundice
31
Investigations for suspected cholangitis
o Blood tests: LFTs + FBC (hgh WCC)
o US - detect stone/stent/stricture
o MRCP or ERCP - defintitive
32
Management of cholangitis
o IV fluids and antibiotics
o Pain relief
o Clear obstruction with ERCP
o Stenting
33
What is acute pancreatitis?
Sudden inflammation of the pancreas due to destruction by its own digestive enzymes – autodigestion
34
Pathology of acute pancreatitis
Acinar cells damaged or pancreatic ducts blocked -> zymogens prematurely converted to digestive enzymes -> digest the pancreas
35
List 10 causes of acute pancreatitis
```
o Gallstones
o Ethanol abuse
o Trauma
o Steroids
o Mumps
o Autoimmune
o Scorpion venom
o Hyperlipidaemia, hyperthermia, hypercalcaemia
o ERCP
o Drugs
```
36
Symptoms of acute pancreatitis
Severe epigastric pain (radiates to back, relived by sitting forward), vomiting
37
Signs of acute pancreatitis
o Tachycardia, fever, shock – hypocalcaemia
o Jaundice
o Ridged abdomen ± tenderness
o Periumbilical bruising
38
Investigations for suspected acute pancreatitis
o Bloods – raised serum amylase and lipase
o ABG – monitoring
o CT – inflammation, necrosis, pseudocysts
39
Management of acute pancreatitis
o Glasgow criteria for predicting severity
o NBM -> IVI
o Analgesia
o Antibiotics if needed
40
What is chronic pancreatitis?
A continuing, chronic, inflammatory process of the pancreas, characterized by irreversible morphologic changes
41
Signs and symptoms of chronic pancreatitis
o Epigastric pain ‘bores’ through to back – relieved by
sitting forward, hot water bottle
o Bloating, steatorrhoea, weight loss, brittle diabetes
o Symptoms relapse and worsen
42
Pathology of chronic pancreatitis
Repeated bouts of acute pancreatitis -> ductal dilatation and healthy tissue replaced by fibrosis, atrophy and calcification -> pancreatic insufficiency
43
Causes of chronic pancreatitis
o Alcohol
o Smoking
o Autoimmune
44
Investigations for suspected chronic pancreatitis
o US/CT – calcifications confirm diagnosis
o Bloods – sometimes high amylase and lipase
o ERCP/MRCP – image ducts
o AXR
45
Management of chronic pancreatitis
o Pharmacological – analgesia, lipase, fat
soluble vitamins, insulin if DM
o Diet – no alcohol, less meat, reduce obesity
o Surgery – if unremitting pain, narcotic abuse, weight
loss – pancreatectomy
46
Complications of chronic pancreatitis
DM, pancreatic pseudocysts, pancreatic carcinoma
47
What is alcoholic liver disease?
Chronic liver disease caused by an excess of alcohol
48
Epidemiology of alcohol liver disease
• Most common cause of chronic liver disease in
western world
• Usually presents in men 40-50yrs
49
Pathology of alcoholic fatty liver
o Acute/reversible
o Reduced NAD -> less oxidation of fat > so it
accumulates in hepatocytes
o Increased ROS damages hepatocytes, acetaldehyde
damages liver cell membranes -> inflammation and
eventually cirrhosis if drinking continues
50
Pathology of alcoholic hepatitis
o Bloated hepatocytes contain eosinophilic material
called Mallory bodies, neutrophils surround them
o Fibrosis and foamy degeneration of hepatocytes
o Usually coexists with cirrhosis
51
Pathology of alcoholic cirrhosis
o Final stage
o Destruction of liver architecture and fibrosis
o Mallory bodies
52
Sign and symptoms of alcoholic fatty liver
Asymptomatic
53
Signs and symptoms of alcoholic hepatitis
Malaise, ↑TPR, anorexia, D&V, jaundice, tender hepatomegaly, ascites, encephalopathy
54
Signs and symptoms of alcoholic cirrhosis
May be asymptomatic, usually present with complications of cirrhosis (varices, ascites, encephalopathy, hepatopulmonary hypertension, carcinoma), spider naevi
55
Investigations for suspected alcoholic liver disease
* LFTs: GGT very raised, AST and ALT mildly raised
* Bloods: elevated MCV
* Liver biopsy
56
What are the diagnostic features of cirrhosis on a liver biopsy?
Mallory bodies, fibrosis, scarring
57
Management of alcoholic liver disease
• Lifelong abstinence from alcohol:
o Chlordiazepoxide to help with withdrawal issues
o Counselling
o Acamprosate - relapse
o Disulfiram – unpleasant effects with alcohol
• Thiamine to treat malnutrition from alcohol
• Steroids – help inflammation
• Liver transplant if severe
58
Give a complication of alcoholic liver disease
Liver failure
59
Causes of cirrhosis
o Chronic alcohol abuse
| o Chronic HBV or HCV infection
60
What is cirrhosis?
Liver disease characterised by irreversible scarring
61
Pathology of cirrhosis
Chronic inflammation and damage -> necrosis of liver cells -> fibrosis
62
Histology of cirrhosis
Loss of normal hepatic architecture with bridging fibrosis and structurally abnormal nodular regeneration
63
Symptoms of cirrhosis
o Jaundice
o Ascites
o Easy bruising
o Encephalopathy
64
Signs of cirrhosis
```
o Splenomegaly
o Nail changes – clubbing
o Palmar erythema
o Loss of body hair
o Spider naevi
```
65
Investigations for suspected cirrhosis
o Liver biopsy – confirms diagnosis
o Lab tests – raised bilirubin, raised enzymes,
thrombocytopenia (low platelets)
66
Management of cirrhosis
o Treat underlying cause – alcohol abstinence,
antiviral treatment
o Liver transplant if severe – definitive treatment
(cirrhosis not reversible)
67
Complications of cirrhosis
o Hepatic failure
o Portal hypertension
o Hepatorenal syndrome
68
What are gastro-oesophageal varices?
Submucosal venous dilation secondary to portal hypertension
69
Causes of portal hypertension
Cirrhosis, schistosomiasis, portal vein thrombosis, right heart failure
70
Consequences of portal HTN
Varices (oesophageal, gastric), splenomegaly
71
Management of varices
o Oesophageal – endoscopic banding
o Gastric – sclerotherapy
o BB prophylaxis
72
What is jaundice?
Yellow discolouraton of the skin caused by high serum bilirubin level
73
Pathology of pre-hepatic jaundice
Increased RBC breakdown so increased levels of unconjugated bilirubin
74
Features of pre-hepatic jaundice
* No excess bilirubin in urine
* Stools brown and urine normal
* Enlarged spleen (due to excess breakdown)
75
Causes of pre-hepatic jaundice
Malaria, sickle cell disease, jaundice of the newborn
76
Pathology of hepatic jaundice
Hepatocellular swelling -> liver damaged -> build up in serum unconjugated bilirubin
77
Features of hepatic jaundice
* Raised serum unconjugated and conjugated bilirubin
* Decreased urobiligen
* Dark urine, pale stools
* Enlargement of spleen
78
Causes of hepatic jaundice
Hepatitis, drugs, cirrhosis, jaundice of the newborn
79
Pathology of post-hepatic jaundice
Biliary system is damaged, inflamed or obstructed
80
Features of post-hepatic jaundice
* Raised serum conjugated bilirubin
* Unconjugated bilirubin normal
* Dark urine, pale stools
81
What is hepatitis?
Inflammation of the liver
82
Causes of hepatitis
• Infection – hepatitis virus (A, B±D, C, E), herpes, TB,
parasites
• Non-infection – alcohol, non-alcohol fatty liver, drugs,
autoimmune, genetic, pregnancy
83
Symptoms of hepatitis
* Malaise
* Myalgia
* GI upset
* Jaundice
* Tender hepatomegaly
* Encephalopathy
* Coagulopathy
84
Signs of hepatitis
o Clubbing
o Palmar erythema
o Spider naevi
o Ascites
85
Complications of hepatitis
Hepatocellular carcinoma, portal hypertension –> varices, bleeding
86
Investigations for suspected hepatitis
* Serology – detecting antibodies/antigens
* Bloods – raised AST, ALT (GGT, ALP) +/- bilirubin
* LFTs can be normal if compensated chronic
87
Management of hepatitis
* Vaccines available: A (travellers) & B (immunisation)
* A&E: supportive as they are self-limiting
* Chronic B: Pegylated interferon-α 2a = pegasys
* Chronic C: antiviral: Velpatasvir/sofosbuvir
88
How is Hep A transmitted?
Faeco-oral, normally with travel history, contaminated food or water, associated with shellfish
89
Is Hep A acute or chronic?
Acute
90
How is Hep B transmitted?
Blood-borne - usually intercourse
91
Is Hep B acute or chronic?
Both
92
How is Hep C transmitted?
Blood-borne - usually shared needles
93
Is Hep C acute or chronic?
Both
94
How is Hep D transmitted?
Blood-borne (IVDU) - combines with B
95
Is Hep D acute or chronic?
Both
96
How is Hep E transmitted?
Faeco-oral, contaminated food or water, endemic in UK, undercooked pork
97
Is Hep E acute or chronic?
Acute - chronic risk if immuno-compromised
98
What is Wilson's disease?
Rare inherited disorder with excess copper deposition in liver and CNS
99
Cause of Wilson's disease
Autosomal reccessive disorder
100
Pathophysiology of Wilson's disease
Incorporation and excretion of iron into bile is impaired -> copper accumulates in liver, and later other organs
101
Signs and symptoms of Wilson's disease
o Children – hepatitis, cirrhosis, liver failure
o Young adults – tremor, dysphagia, Parkinsonism,
ataxia
o Mood changes
o Cognitive decline
o KF rings – copper in iris
o Haemolysis
102
Investigations for suspected Wilson's disease
o Bloods – low caeruloplasmin, high serum copper
| o Urine – high 24hr copper excretion
103
Management of Wilson's disease
o Lifelong penicillamine
| o Liver transplant
104
What is haemochromatosis?
Inherited disorder of iron metabolism - increased intestinal iron absorption leads to iron deposition in liver, joints and other organs
105
Epidemiology of haemochromatosis
Middle-aged men > women (menstruation protective), Northern European
106
Cause of haemochromatosis
Mutation in HFE gene
107
Signs and symptoms of haemochromatosis
```
o Slate-grey skin pigmentation
o Signs of chronic liver disease (cirrhosis)
o Cardiomyopathy
o DM
o Hypogonadism
```
108
Investigations for suspected haemochromatosis
o Bloods – high ferritin, high transferrin
o HFE genotyping
o Liver biopsy – Perl’s stain
109
Management of haemochromatosis
o Venesection for life (bloodletting)
| o Screen first degree relatives
110
What is alpha-1-antitrypsin deficiency?
Inherited disorder affecting the lungs (emphysema) and liver (cirrhosis)
111
What is alpha-1-antitrysin?
A glycoprotein and a serine protease inhibitor made in the liver that controls inflammatory cascades
112
Symptoms of A1AT deficiency
o Dyspnoea from emphysema
o Cirrhosis
o Cholestatic jaundice
113
Investigations for suspected A1AT deficiency
o Low serum A1AT
o Lung function tests
o Liver biopsy
o Phenotyping
114
Management of A1AT deficiency
o Smoking cessation
o Liver/lung transplantation
o Inhaled/IV A1AT
115
Epidemiology of pancreatic cancer
Male >70yrs
116
Risk factors for pancreatic cancer
Smoking, alcohol, DM, chronic pancreatitis, central obesity, KRA2 gene
117
Symptoms of pancreatic cancer
o Epigastric pain
o Weight loss, anorexia
o Diabetes
o Acute pancreatitis
118
Signs of pancreatic cancer
o Jaundice and palpable gallbladder
o Epigastric mass
o Hepato/splenomegaly
o Ascites
119
Management of pancreatic cancer
o Most present with mets
o Surgical resection
o Opiates
o Stenting for jaundice in palliation
120
Investigations for suspected pancreatic or hepatocellular cancer
o US/CT/MRI
| o Biopsy
121
Epidemiology of hepatocellular carcinoma
China and America, M:F 3:1
122
Signs and symptoms of hepatocellular carcinoma
```
o Fatigue
o Loss of appetite, weight loss
o RUQ pain
o Jaundice
o Ascites
o Haemobilia
```
123
Known causes of hepatocellular carcinoma
o HBV and HCV
o Cirrhosis
o Non-alcohol fatty liver
124
Management of hepatocellular carcinoma
o Surgical resection of solitary tumours
o Liver transplant
o Prevention - HBV vaccine
125
What is ascites?
Abnormal accumulation of fluid within the abdomen
126
Causes of ascites
* Chronic liver disease (most)
* Neoplasia (ovary, uterus, pancreas)
* Pancreatitis
* Cardiac causes
127
What is the characteristic LFT finding in alcoholic liver disease?
Severely raised GGT
128
What is Reynold's pentad?
Charcot's triad + shock + altered mental state
