Liver and Friends Flashcards
What is biliary colic?
A SYMPTOM!
- Pain due to obstruction of the cystic duct or the common bile duct with a gallstone
- Epigastric/RUQ pain, may radiate to R shoulder
What is acute cholecystitis?
Inflammation of the gallbladder as a result of obstruction of the cystic duct with a stone
What are the symptoms and signs of acute cholecystitis?
Symptoms:
- Biliary colic
- N+V
- Fever
Signs:
- Murphy’s sign (pain on inspiration when gallbladder is palpated)
- Local peritonism (tenderness, guarding)
Describe the investigation of acute cholecystitis
Bloods:
- LFTs: raised bilirubin, raised alkaline phosphatase (ALP) and rasied gamma-glutamyltransferase (GGT)
Abdominal US:
- Gallstones
Describe the management of acute cholecystitis
1st line = cholecystectomy
What is ascending cholangitis?
Inflammation/infection of the biliary tree, most commonly due to obstruction of the common bile duct by a gallstone
What are the symptoms and signs of ascending cholangitis?
Symptoms:
- Biliary colic
- N+V
- Fever
Signs:
- Jaundice
- Local peritonism (tenderness and guarding)
- Hypotension
- Confusion
Charcot’s triad = jaundice, biliary colic (RUQ pain), fever
Raynaud’s pentad = Charcot’s triad + hypotension and confusion
Describe the investigations of ascending cholangitis
Bloods:
- LFTs: raised bilirubin, alkaline phosphatase (ALP) and gamma-glutamyltransferase (GGT)
Abdominal US:
- Gallstones
Describe the pharmacological and interventional management of ascending cholangitis
Pharmacological:
- Analgesia
- IV Abx: Cefotaxime and Metronidazole
Interventional:
- ERCP (stone removal/stenting)
- Cholecystectomy
Briefly describe the pathophysiology of liver cirrhosis
- Hepatocyte necrosis
- Fibrosis
- Nodule formation
Give some signs of liver cirrhosis
- Hepatomegaly
- Ascites
- Jaundice
- Clubbing
- Leuconychia
- Spider naevi
- Dupuytren’s contracture
What are the causes of liver cirrhosis?
- Alcoholic liver disease
- Viral hepatitis
- Autoimmune, e.g. primary biliary cholangitis
- Metabolic, e.g. hereditary haemochromatosis, Wilson’s disease, alpha 1 antitrypsin deficiency
What is hereditary haemochromatosis?
An inherited condition in which iron levels in the body slowly build up over many years (iron overload) - this damages organs, e.g. heart, pancreas, liver
Describe the investigation of hereditary haemochromatosis
Bloods:
- Serum ferritin levels raised
- Transferrin saturation >45%
Liver biopsy:
- Perl’s stain = blue (iron present)
Describe the management of hereditary haemochromatosis
Conservative:
- Low iron diet
Interventional:
- Venesection (taking blood so that the body uses up its iron stored to make new RBCs)
Which organs does alpha 1 antitrypsin deficiency affect? How does it affect them?
- Lungs, causes emphysema
- Liver, causes cirrhosis and increased risk of hepatocellular carcinoma
Describe the investigation of alpha 1 antitrypsin deficiency
Bloods:
- Serum alpha 1 antitrypsin levels reduced
Liver biopsy:
- Put tissue samples through diastase treatment which should break down glycogen, however A1AD provides resistance to diastase treatment, so glycogen still present
- Use Periodic Acid Shiff (PAS) stain to show glycogen present (stains purple)
Describe the conservative management of A1AD
Smoking cessation
What is Wilson’s disease?
A genetic condition in which the levels of copper in the body are too high, so copper accumulates in organs (e.g. liver, brain) leading to organ damage
Describe a characteristic sign of Wilson’s disease
Kayser-Fleischer rings (dark rings that encircle the iris as a result of excess copper deposition)
Describe the investigation of Wilson’s disease
Urine:
- 24 hr copper excretion raised
Liver biopsy:
- Hepatic copper concentration raised
Describe the management of Wilson’s disease
Conservative:
- Low copper diet
Pharmacological:
- Penicillamine
- Zinc
What is primary biliary cholangitis?
Autoimmune destruction of the interlobar bile ducts, which leads to liver cirrhosis
Describe the investigation of primary biliary cholangitis
Blood tests:
- LFTs: raised bilirubin, raised ALP, low albumin
- Prolonged PT
- Autoantibody screen = anti-mitochondrial antibody (AMA)
Describe the management of primary biliary cholangitis
Pharmacological:
- Ursodeoxycholic acid (UDCA)
- Colestyramine
- Vitamin supplementation (fat soluble vitamins)
Interventional
- Consider liver transplant
Describe the investigation of alcoholic liver disease
Bloods:
- LFTS: raised bilirubin, low albumin, aspartate transaminase (AST) : alanine trasnaminase (ALT) >2, significantly raised GGT
- Prolonged PT
Other Ix = imaging, biopsy
Describe the management of alcoholic liver disease
Conservative:
- Abstinence from alcohol
Pharmacological:
- Drugs to help with alcohol withdrawal, e.g. naltrexone
Interventional:
- Liver transplant
Describe the symptoms of alcoholic liver disease
- N+V
- Anorexia
Describe the symptoms of viral hepatitis
- N+V
- Fatigue
- Weakness
- Lymphadenopathy
Describe the investigation of viral hepatitis
Viral serology and PCR to distinguish between different types
Distinguishing which hepatit virus…
a) Which hepatitis viruses are RNA/DNA?
b) How are they spread?
a) ALL RNA except hepatitis B (which is DNA)
b) Hep A and E = faeco-oral, hep B, C and D = bloodborne
What are the complications of liver cirrhosis?
- Portal hypertension (gastro-oesophageal varices, ascites/spontaneous bacterial peritonitis)
- Hepatocellular carcinoma
Describe the pathophysiology of portal hypertension and its complications
- Blood pressure in portal vein increases due to blockage/increased resistance to blood flow as a result of scarring (fibrosis)
- This causes a porto-systemic shunt: blood is shunted from portal vein to distal oesophageal veins
- This leads to dilatation of veins at the gastro-oesophageal junction (gastro-oesophageal varices) which can rupture
Portal hypertension also leads to ascites (collection of fluid in the peritoneal cavity)
Patients with ascites are at risk of…
Spontaneous bacterial peritonitis - infection of fluid in peritoneal cavity (ascitic patient)
Treatment:
- IV Cefotaxime and Metronidazole
What is the most common histological type of liver tumour?
Hepatocellular carcinoma
Describe the investigation of liver cancer
CT abdomen and biopsy
Describe the management of liver cancer
Resection
