Liver and Friends Flashcards
1
Q
What are the functions of the liver
A
Glucose and fat metabolism
Detoxification and excretion (Bilirubin, ammonia, drugs)
Protein synthesis (Albumin and clotting factors)
Defence against infection
2
Q
What are the two types of liver injury
A
Acute - damage to and loss of cells with death occurring by necrosis or apoptosis <6months
Chronic - chronic damage leading to fibrosis (Cirrhosis)
3
Q
What are the causes of acute liver injury
A
Viral (Hep A, B and EBV) Drugs Alcohol Vascular Obstruction Congestion
4
Q
What are the causes of chronic liver injury
A
Alcohol
Viral B and C
Autoimmune
Metabolic (iron, copper)
5
Q
What is the presentation of acute liver injury
A
Malaise Nausea Anorexia Jaundice Confusion - encephalopathy Bleeding - lack of clotting factors Liver Pain Hypoglycaemia
6
Q
What is the presentation of chronic liver injury
A
Ascites Oedema Haematemesis Malaise Weight loss Anorexia Wasting Easy bruising Itching Hepatomegaly Jaundice Confusion
7
Q
Name three serum liver function tests
A
Serum bilirubin
Serum albumin
Prothrombin time
8
Q
Do serum liver enzymes give an index of liver function
A
No
9
Q
Name enzymes that increase in the serum in cholestatic liver disease (Duct and obstructive)
A
Alkaline Phosphate (Raised in both intrahepatic and extra hepatic cholestactic)
Gamma-GT (Microsomal liver enzyme)
10
Q
What enzyme increases in serum hepatocellular liver disease
A
Transaminases (ALT and AST
11
Q
What do elevated transaminases indicate
A
Enzymes are contained in hepatocytes and leak into the blood with liver cell damage
12
Q
Anti-mitochondrial antibodies are seen in the serum with what condition
A
Primary billiary cirrhosis
13
Q
Anti-nuclear cytoplasmic antibodies are fond in the serum of patients with what condition
A
Primary sclerosis cholangitis
14
Q
What is a normal bilirubin concentration
A
3-17uM
15
Q
At what bilirubin concentration does jaundice become visible
A
50uM
16
Q
Describe the physiology of bile production
A
- Hb broken into globin and haem
- Haem broken down into biliverdin
- Biliverdin reduced by biliverdin reductase into unconjugated bilirubin which is transported to the liver bound to albumin
- Unconjugated bilirubin is converted to conjugated bilirubin by glucuronidation by uridine glucuronyl transferase in the liver
- Conjuagted bilirubin converted to urobilinogen which is reabsorbed and returned to the liver and re-excreted into the bile
- Some reabsorbed urobilinogen is excreted into the urine as urobilin
- Urobilinogen that remains in the GIT is converted to stercobilin and excreted
17
Q
What are the pre-hepatic causes of jaundice?
A
Excess unconjugated bilirubin production due to haemolytic anaemia or ineffective erythropoiesis (Thalassaemia)
18
Q
What are the unconjugated hepatic causes of jaundice
A
- Decreased bilirubin uptake due to drugs
2. Decreased bilirubin conjugation due to Gilberts syndrome or Crigler-Najjar or hypothyroidism
19
Q
What is Gilbert’s disease
A
Autosomal dominant condition resulting in a partial deficiency in UDP-GT which increases unconjugated bilirubin
20
Q
What is Crigler Najjar syndrome
A
Autosomal recessive condition resulting in a total UDP-GT deficiency
21
Q
What are the conjugated hepatic causes of jaundice
A
- Hepatocellular dysfunction
- Congenital (wilson’s, A1ATD)
- Infection Hep A/B/C, CMV and EBV
- Toxins (EtOH and drugs)
- Autoimmune hepatitis
- Hepatocellular carcinoma - Decreased hepatic bilirubin excretion
- Dubin-Johnson (MRP2 mutation)
22
Q
What are the post hepatic causes of jaundice
A
Obstruction
- Stones
- Drugs
- Primary biliary cirrhosis
- Primary sclerosing cholangitis
- mirrizi
- malignant
23
Q
What colour is the urine in pre-hepatic jaundice
A
Normal
24
Q
What colour is the urine in cholestatic (hepatic or post hepatic) jaundice
A
Dark
25
What colour are stools in pre hepatic jaundice
Normal
26
What colour are stools in cholestatic jaundice
Pale
27
Are liver tests normal or abnormal in prehepatic jaundice
Normal
28
Are liver tests normal or abnormal in cholestatic jaundice
Abnormal
29
What investigative tests would you carry out in a jaundiced patient
- Very high AST/ALT
- Dilated intrahepatic bile ducts on ultrasound
- CT
- MRI
30
Where do gall stones most commonly form
Gallbladder
31
Are gall stones more common in men or women
Women
32
Are gall stones normally symptomatic or asymptomatic
Asymptomatic
33
What are the risk factors for gall stones
Female
Fat
Fertile
Smoking
34
What are the two main types of gall stone
```
Cholesterol stones (80%)
Bile pigment stones
```
35
Why do cholesterol gall stones form
Consequence of cholesterol crystallisation
- Cholesterol supersaturation of bile
- Deficiency of bile salts and phospholipids
- Gall bladder stasis
36
Why do bile pigment stones form
Haemolysis - sickle cell
37
What are the two types of bile pigment stones
1. Black pigment - calcium bilirubinate + Salts
| 2. Brown pigment - calcium salts and fatty acids
38
What is bilary colic
Pain associated with temporary obstruction of cystic or common bile duct by stone migrating from gall bladder
39
What are the symptoms of biliary colic
Pain is severe and constant with crescendo
initial site of pain is epigastrium but may be RUQ
Nausea and vomiting accompanying severe attacks
40
What is acute cholecystitis
Gall bladder inflammation due to obstruction to gall bladder emptying
41
What investigations would you carry out in someone with gall stones
Serum bilirubin/alkaline phosphatase and amintransferase are elevated
Abdominal ultrasound
42
What is the management of gall stones
Laproscopic cholecystectomy
Bile acid dissolution therapy = ursodeoxycholic acid
Extracorpeal shock wave lithotripsy
43
What are the three types of drug induced liver injury
Hepatocellular
Cholestatic
Mixed
44
What drugs most commonly cause drug induced liver injury
1. Antibiotics (Flucoxacillin
2. CNS drugs (Chlorpromazine)
3. Analgesics (Diclofenac)
4. Gastrointestinal drugs
45
What is paracetamol conjugated with in its phase II reaction
Glucuronic acid
46
What enzyme is responsible for mopping up reactive intermediates of paracetamol so prevents toxicity
Glutathione transferase
47
What is the highly reactive toxic intermediate in paracetamol metabolism
NAPQI
48
What is the clinical presentation of paracetamol poisoning
Asymptomatic for first 24 hr followed by anorexia, nausea, vomiting and RUQ pain
Jaundice and encephalopathy due to liver damage
49
What is the management of paracetamol toxicity
N acetyl cysteine which repletes glutathione stores
Supportive care to correct for coagulation defects, renal failure, hypoglycaemia
50
What is liver failure
When the liver loses ability to regenerate or repair as decompensation occurs
51
What are the three types of liver failure
1. Acute = sudden liver failure with previously healthy liver
2. Chronic = Liver failure on background of cirrhosis
3. Fulminant = massive necrosis of liver cells
52
What are the causes of liver failure
Cirrhosis
Infection
- Hep A/B, CMV, EBV, Leptospirosis
Toxin
- EtOH, Paracetamol, isoniazid, halothane
Metabolic
- Wilsons, AIH, A1ATD, Haemochromatosis
Neoplastic = HCC
53
What are the signs of liver failure
```
Jaundice
oedema and ascites
Bruising
Encephalopathy
- Aterixis (Flapping tremor)
- Apraxia
Fetor Hepaticus (Breath smells sweet)
Signs or cirrhosis
```
54
What investigations would you carry out in someone with liver failure
AST:ALT >2 = EtOH
AST:ALT <1 = viral
Albumin is decreased in chronic liver failure
Prothrombin time increase in acute liver failure
55
What is the management of liver failure
Treat the underlying cause
Good nutrition
Thiamine supplements
56
Give three causes of iron overload
1. Genetic disorders (Haemochromatosis)
2. Multiple blod transfusions
3. Haemolysis
4. Alcoholic liver disease
57
What is cirrhosis
A chronic disease of the liver resulting from necrosis of the liver cells followed by fibrosis - the end result is impairment of hepatocyte function and distortion of liver architecture
58
What are the two types of cirrhosis
1. Micronodular - regenerating nodules <3mm all over liver
| 2. Macronodular - Nodules of variable size
59
What causes micro nodular cirrhosis
Chronic alcohol
| Biliary tract disease
60
What causes macro nodular cirrhosis
Chronic hepatitis
61
What are the causes of cirrhosis
```
Chronic alcohol
Chronic hepatitis C and B
Genetic
- Wilson's/ a1ATD
Autoimmune
- Autoimmune hepatitis
- Primary biliary cholangitis
Drugs
- Methotrexate, Amiodarone, methyldopa
Neoplasm
- HCC
```
62
What are the signs of cirrhosis in the hands
```
Clubbing
Leuconychia
Terry's nails
Palmar erythema
Dupuytron's Contracture
```
63
What are the sings of cirrhosis in the face
Pallor
| Xanthelasma
64
What are the signs of cirrhosis in the trunk
Spider naevi
Gynaecomastia
Loss of secondary sexual hair
65
What are the abdominal signs of cirrhosis
```
Striae
Hepatomegaly
Splenomegaly
Caput medusa
Testicular atrophy
```
66
What are the complications of cirrhosis
1. Decompensation = hepatic failure
- Jaundice
- Encephalopathy
- Hypoalbuminaemia
- Hypoglycaemia
- Coagulopathy
2. Spontaneous bacterial peritonitis
3. Portal hypertension
4. Increased risk of HCC
67
What investigations would you conduct in someone with cirrhosis
Decreased WCC
Increased LFTs
Decreased albumin and prolonged prothrombin time
Abdominal ultrasound showing small or largee liver with focal marginal nodularity
Liver biopsy to confirm the type and severity
68
What is the management for cirrhosis
```
Good nutrition - decrease Na+
EtOH abstinence
Colestyramine for pruritus
Avoid NSAIDs and aspirin
Screen for HCC with ultrasound
Fluid restriction with spironolocatone
```
69
Portal vein is formed by the union of what veins
Superior mesenteric and splenic veins
70
Describe the pathophysiology of portal hypertension
Liver cirrhosis increases resistance of blood flow in the liver increasing pressure into the portal system. When the venous pressure increases to 10-12mmHg the venous system dilates and collaterals form
71
What are pre-hepatic causes of portal hypertension
Blockage of portal vein before the liver due to portal vein thrombosis (Pancreatitis)
72
What are the hepatic causes of portal hypertension
Distortion of the liver architecture due to cirrhosis and schistosomiasis and sarcoidosis
73
What are the post-hepatic causes of portal hypertension
Blockage of the portal vein outside the liver due to Budd chiari, constrictive pericarditis and RHF
74
Where do varices form following portal hypertension
Gastro-oesophageal junction
Ileocaecal junction
Rectum
Anterior abdominal wall
75
What are the symptoms of portal hypertension
```
Splenomegaly
Ascites
Varices
Encephalopathy
Haematemesis
Breathlessness
```
76
What investigations would you carry out in someone with portal hypertension
Portal vein blockage can be identified on ultrasound with Doppler imaging
77
What are the potential consequences of portal hypertension induced varices
If they rupture = haemorrhage
78
What is the treatment for varices
Endoscopic therapy = banding
79
Describe the pathophysiology of encephalopathy
1. Decreased hepatic metabolic function
2. Diversion of toxins from the liver directly into the systemic circulation due to collaterals around the liver
3. Ammonia accumulates and passes to the brain where astrocytes Clear it causing glutamate conversion to glutamine
4. Increased glutamine alters osmotic imbalance and causes cerebral oedema
80
What are the 4 classification stages of encephalopathy
1. Confused (Irritable, confusion, sleep)
2. Drowsy (Disorientated, slurred speech, asterixis)
3. Stupor (rousable, incoherence)
4. Coma (Unrousable)
81
What is the presentation of encephalopathy
Asterixis (Coarse flapping tremor when hands are outstretched)
Ataxia
Fetor Hepaticus = sweet breath
confusion
Dysarthia
Constructional apraxia (Unable to write or draw)
Seizures
82
What are the precipitants of encephalopathy (remember hepatics)
```
Haemorrhage (Varicies)
Electrolytes (Decreased K+/Na+
Poisons (Diuretics, sedatives, anaesthetics)
Alcohol
Tumour (HCC)
Infection (SBP, Pneumonia)
Constipation
Sugar decrease
```
83
What investigation result would you expect to see in someone with encephalopathy
Increased plasma ammonia
84
What is the treatment for encephalopathy
Correct precipitants
Lactulose (limits ammonia absorption) and PO4 enemas to decrease nitrogen forming bowel bacteria
Consider rifaximin to kill intestinal microflora
85
What is ascites
An accumulation of fluid in the peritoneal cavity leading to abdominal distension
86
What is the pathophysiology of ascites
Portal hypertension leads to fluid exudation leading to an effective drop in circulating volume - this leads to RAAS activation causing Na+ and H2O retention
In cirrhosis a decrease in albumin leads to decreased plasma oncotic pressure and aldosterone metabolism is impaired
87
What are the causes of ascites
Local inflammation - peritonitis
Leaky vessels - imbalance between hydrostatic and oncotic pressure
Low flow - cirrhosis, cardiac failure and thrombosis
Low protein - hypoalbuminaemia
88
What are the symptoms of ascites
Distension - abdominal discomfort, swelling and anorexia
Dyspnoea
Decreased venous return
89
How do you determine the cause of ascites
Serum ascites albumin gradient
1. >1.1g/dL = Portal HTN (Pre-hepatic and post and cirrhosis )
2. <1.1g/dL = other causes
(Neoplasia, inflammation (peritonitis), nephrotic syndrome, infection (TB peritonitis)
90
how do you determine the serum ascites albumin gradient
Serum albumin - Ascites albumin
91
What investigations would you Carry out in someone with suspected ascites
Bloods
Ultrasound
Ascitic tap
Liver biopsy
92
What is the treatment for ascites
```
Weight reduction
Fluid restriction <1.5L/d
Low Na+ diet
Spironolatone (Aldosterone antagonist)
Therapeutic paracentesis
```
93
What is spontaneous bacterial peritonitis
Ascites and peritonitis abdomen
94
What are the causes of spontaneous bacterial peritonitis
E.Coli, Klebsiella, Steps, Enterococci
95
What are the three phases of alcoholic liver disease
1. Fatty change - hepatocytes contain triglycerides
2. Alcohol hepatitis
3. Cirrhosis - destruction of architecture and fibrosis
96
What might be seen histologically that indicates a diagnosis of alcoholic liver disease
Neutrophils and fat accumulation within hepatocytes
97
What are the effects of alcoholism on the GIT
```
Gastritis
Peptic Ulcer Disease
Varices
Pancreatitis
Carcinoma
```
98
What are the effects of alcoholism on the CNS
```
Poor memory
Peripheral polyneuropathy
Wernicke's Encephalopathy
- Confusion
- Ophthalmoplegia
- Ataxia
Korsakoffs - amnesia
```
99
What are the effects of alcoholism on the heart
Arrhythmia ie AF
Dilated cardiomyopathy
Increased Bp
100
What are the effects of alcoholism on the blood
Increased mean corpuscular volume
Folate deficiency - anaemia
101
What are the CAGE questions for alcoholism
Do you think you should cut down
Are you annoyed by peoples criticism's
Are you guilty about drinking
Do you need a drink to get up in the morning
102
What Is the treatment for alcoholism
Group therapy or self help
Baculofen and acamprosate to reduce cravings
Disulfiram = aversion therapy
103
What is the presentation of alcoholic hepatitis
```
Anorexia
Diarrhoea and vomiting
Tender hepatomegaly
Ascites
Severe jaundice, bleeding, encephalopathy
```
104
What investigations and results would you see in alcoholic hepatitis
Bloods= increased MCV, increased GTT
AST:ALT >2 = EtOH
Ascititic Tap
Abdo ultrasound
105
What is the treatment for alcoholic hepatitis
Stop EtOH
High does B vitamins (Thiamine)
Optimise nutrition
Manage the complications of failure
106
What is non alcoholic fatty liver disease
Cryptogenic cause of hepatitis and cirrhosis associated with insulin resistance and metabolic syndrome
107
What is the most severe form of non alcoholic fatty liver disease
Non alcoholic steatohepatitis
108
What are the risk factors for NAFLD
Obesity
Hypertension
T2DM
Hyperlipidaemia
109
What is the presentation of NAFLD
Mostly asymptomatic
| Hepatomegaly and RUQ discomfort
110
What investigations would you carry out in someone with NAFLD
BMI
Glucose
Increase transaminases AST:ALT <1
Liver biopsy to enable staging
111
What is the management of NAFLD
Lose weight
Control hypertension, diabetes mellitus and lipids
Exercise
112
What is budd-chiari syndrome
Hepatic vein obstruction --> Ischaemia and hepatocyte damage --> Liver failure
113
Give 4 reasons why liver patients are vulnerable to infection
1. Have impaired reticule-endothelial function
2. Reduced opsonic activity
3. Leukocyte function is reduced
4. Permeable gut wall
114
Name 3 metabolic disorders that can cause liver disease
1. Haemochromatosis
2. Alpha 1-antitrypsin deficiency
3. Wilson's disease
115
What is haemochromatosis
metabolic disorder resulting in excess Fe2+ deposits in organs leading to fibrosis and organ failure
116
What is the age of onset for haemochromatosis
40-60 years
117
What is the genetic cause of haemochromatosis
Autosomal recessive condition causing mutation in the Human haemochromatosis protein (HFE) --> C282Y
118
What is the pathophysiology of haemochromatosis
Increased intestinal Fe absorption resulting in deposition in liver heart joints endocrine, skin and pancreas leading to fibrosis and functional organ failure
119
What are the clinical features of haemochromatosis (Remember MEALS)
Myocardial
- dilated cardiomyopathy
- Arrhythmia
Endocrine
- DM
- Pituitary = hypogonadism
- Parathyroid = hypocalcaemia, osteoporosis
Arthritis
Liver
- Chronic liver disease leading to cirrhosis leading to HCC
- Hepatomegaly
Skin
- Slate grey discolouration
- bronze skin pigmentation
120
How might you diagnose someone with haemochromatosis
```
Raised ferritin
increasing LFT
Increased Fe
Liver biopsy - pearls stain to quantify the FE
MRI can estimate iron loading
ECHO and ECG for cardiac complications
X-ray shows chondrocalcinosis
HFE genotyping
```
121
What is the treatment for haemochromatosis
venesection - regular removal of blood to use up some excess iron to make new RBC's
In patients who cant have venesection they can have chelation therapy (Desferrioxamine) which prevents iron absorption
Low iron Diet
Treat DM complication
Look for transplant in cirrhosis and screen 1st degree relatives
122
What is the pathophysiology of alpha 1 antitrypsin deficiency
a1AT is serine involved in control of inflammatory cascade by inhibiting neutrophil elastase
A1AT is synthesised by the liver and a deficiency results in lung damage
123
What is the presentation of alpha 1 anti-trypsin
Neonatal and childhood hepatitis
15% adults develop cirrhosis
75% have emphysema
5% die of liver disease
124
What investigations and results would you see in someone with alpha 1 antitrypsin deficiency
decreased a1AT levels
Liver biopsy = +ve periodic acid shift
Emphysematous changes on CXR
Obstructive defect on spirometry
125
What is the management of alpha 1 anti-trypsin deficiency
Quit smoking
Mostly supportive for pulmonary and hepatic complications
Consider a1AT therapy from donors
Patients with hepatic decompensation should get liver transplant
126
What is Wilson's disease
Autosomal recessive disorder of copper metabolism where there is deposition of copper in the liver which can lead to fulminant hepatic failure and cirrhosis
127
When does Wilsons disease most commonly present
Between childhood and 30
128
What is the genetic cause of Wilsons disease
Autosomal recessive ATP7B gene on chromosome 13
129
Describe the pathophysiology of Wilson's disease
Mutation of Cu transporting ATPase leading to impaired hepatocyte incorporation of Cu into caeruloplasmin and excretion into bile causingg Cu accumulation in liver and other organs
130
What are the clinical features of Wilson's disease (Remember CLANKAH)
Cornea (Kayser-Fleischer rings)
Liver disease (Acute hepatitis in children and necrosis and cirrhosis in adults)
Arthritis
- Osteoporosis
Neurology
- Parkinsonism =bradykinesia, tremor, ataxia
Kidney
- Fanconi's syndrome
Haemolytic anaemia
131
What are the investigative results in Wilson's disease
Decreased copper and caeruloplasmin
increased urinay copper
Increased hepatic copper
MRI = basal ganglia degeneration
132
What is the management of Wilson's disease
Diet = avoid high Cu foods ie. liver, chocolate, nuts
Penicillamine (Cu chelator)
Liver transplant If severe disease
133
What are the side effects of penicillamine
```
Nausea
Rash
Decreased WCC
Decreased Hb
Decreased platelets
```
134
What is autoimmune hepatitis
Inflammatory disease of unknown cause characterised by Abs directed against hepatocyte surface antigens
135
What age group is autoimmune hepatitis commonly seen in
Young and middle age women
136
Describe the antibody classification of autoimmune hepatitis
T1 = Adult ( SMA+, ANA+ and IgG increase)
T2 = Young (LKM+)
T3 = Adult (SLA+)
137
What is the presentation of autoimmune hepatitis
```
Fatigue, fever, malaise
Hirsute, acne, striae
Hepatitis
Hepatosplenomegaly
Fever
Amenorrhoea
Polyarthritis
Pulmonary infiltration
```
138
What investigations would you carry out in autoimmune hepatitis
```
Increased LFTs
Increased IgG
Auto Abs
- SMA
- LKM
- SLA
- ANA
Decreased WCC and platelets
Liver biopsy
```
139
What is the management of autoimmune hepatitis
Immunosuppression
prednisolone
(Azithioprine as steroid sparer)
Liver transplant
140
What age group does primary biliary cirrhosis most commonly affect
50's
141
What is the pathophysiology of primary biliary cirrhosis
Intrahepatic bile duct destruction by chronic granulomatous inflammation leading to cirrhosis
Lymphocyte mediated attack on bile duct epithelial, destruction of the bile ducts leading to cholestasis and cirrhosis
142
What is the presentation of primary biliary cirrhosis
| Remember BILE EXCESS
```
Bone = osteoporosis
Itch = pruritus
Lethargy
Eyes yellow due to jaundice
Eyes dry due to sicca
Xanthelasma
Cholesterol increase
Enlarged liver
Skin pigmentation
Steatorrhoea
```
143
Name three diseases associated with primary biliary cirrhosis
```
Thyroiditis
Rheumatoid arthritis
Sjorgens syndrome
Coeliac disease
Renal tubular acidosis
```
144
What is the investigations and results for primary biliary cirrhosis
LFTs
- Increased GGT
Increased AST and ALT
+ve for anti-mitochondiral antibodies
Increased cholesterol
increased IgM
Liver biopsy to show non-caseating granulomatous inflammation
145
What is the treatment for symptomatic primary biliary cirrhosis
(Think about the symptoms)
Pruritus = colestyramine
Diarrhoea = codeine phosphate
Osteoporosis = bisphosphonates
Give vitamins ADEK
Ursodeoxcholic acid
Liver transplant
146
What is primary sclerosing cholangitis
inflammation, fibrosis and stricture of both the intra and extra hepatic bile ducts leading to chronic biliary obstruction, secondary biliary cirrhosis and liver failure
147
What is the pathogenesis of primary sclerosing cholangitis
Inflammation of the bile duct -> strictures and hardening -> progressive obliterating fibrosis of bile duct branches -> cirrhosis -> liver failure.
148
What is the presentation of primary sclerosing cholangitis
Jaundice (Dark urine, pale stools)
Pruritus and fatigue
Hepatosplenomegaly
Abdominal pain
149
What is primary sclerosing cholangitis associated with
Ulcerative colitis
| Crohns
150
What are the complications of primary sclerosing cholangitis
Bacterial cholangitis
Increased cholangiocarcinoma
Colorectal cancer
151
What are the investigations for primary sclerosing cholangitis
LFTs increase in ALP
Abs pANCA, ANA and SMA
ERCP/MRCP
Biopsy
152
What is the treatment for primary sclerosing cholangitis
```
Symptomatic
- Pruritus = colestyramine
- Diarrhoea = codeine phosphate
ADEK vitamins
Ursodeoxycholic acid
Liver transplant
Screen for cholagniocarcinoma
```
153
Where do 90% of liver tumours come from
2nd metastases from the stomach, lung and colon in men and breast, colon, stomach and uterus in women
154
What are the symptoms of liver tumours
```
Benign tumours are asymptomatic
fever
Malaise
Weight loss
Anorexia
RUQ pain
Jaundice (late)
```
155
What are the signs of liver cancer
Hepatomegaly
Abdominal mass
Hepatic bruit
Chronic liver disease signs
156
What are the causes of hepatocellular carcinoma
Viral hepatitis B + C
Cirrhosis (EtOH)
Aflatoxins produced by apsergillus
157
How do you investigate hepatocellular carcinoma
Imaging CT/MRI
| Biopsy can be diagnostic
158
What is the management of hepatocellular carcinoma
resection of solitary tumours
| Chemo
159
What is a cholangiocarcinoma
Biliary tree malignancy
160
What are the causes of cholangiocarcinoma
Flukes
primary sclerosing cholangitis
HBV and HCV
Congenital biliary cysts
161
What is the presentation of cholangiocarcinoma
```
Fever
Malaise
Abdomina pain
Ascites
Jaundice
```
162
What is the management of cholangiocarcinoma
Surgical resection is rarely possible
| Liver transplant is contraindicated
163
What is ascending cholangitis
Infection of the biliary tree normally ascending from duodenum
164
What are the causes of ascending cholangitis
```
Gallstones
Primary infection
- Klebsiella
- E.coli
Pancreatic head malignancy
```
165
What age group is ascending cholangitis most common in
50-60 with gall stone history
166
What are the signs and symptoms of ascending cholangitis
Charcot's triad
- Fever and chills
- RUQ pain
- Obstructive jaundice (Dark urine and pale stools and pruritus)
167
What are the investigations for ascending cholangitis
Blood test showing raised LFT
Imaging - ultrasound to look for blockage
ERCP
168
What is the management of ascending cholangitis
Fluid resuscitation and treat infection with IV antibiotics such as cefotaxime and metronidazole
169
What would be raised in the blood tests taken from someone with primary biliary cirrhosis?
1. Raised IgM.
2. Raised ALP.
3. Positive AMA.
170
What 4 features would you expect to see in the blood test results taken from someone who has overdosed on paracetamol.
1. Metabolic acidosis.
2. Prolonged pro-thrombin time (due to coagulability).
3. Raised creatinine (renal failure).
4. Raised ALT.
171
What 3 symptoms make up the triad of Wernicke's encephalopathy?
1. Ataxia.
2. Opthalmoplegia.
3. Confusion.
172
How can Wernicke's encephalopathy be reversed?
Give IV thiamine.
173
Where have most secondary liver cancers arisen from?
1. The Gi tract.
2. Breast.
3. Bronchus.
174
What investigations might you do on someone who you suspect has HCC?
1. Bloods: serum AFP may be raised.
2. US or CT to identify lesions.
3. MRI.
4. Biopsy if diagnostic doubt.
175
Describe the treatment for HCC.
1. Surgical resection of solitary tumours.
2. Liver transplant.
3. Percutaneous ablation.
176
Name 3 diseases that lead to heamolytic anaemia and so a raised unconjugated bilirubin and pre-hepatic jaundice.
Causes of haemolytic anaemia:
1. Sickle cell disease.
2. Hereditary spherocytosis/elliptocytosis.
3. GP6D deficiency.
4. Hypersplenism.
177
You do an ascitic tap in someone with ascites. The neutrophil count comes back as - Neutrophils > 250/mm3. What is the likely cause of the raised neutrophils?
Spontaneous bacterial peritonitis.
178
Describe the treatment for spontaneous bacterial peritonitis.
Cefotaxime and metronidazole
179
What distinctive feature is often seen on biopsy in people suffering from alcoholic liver disease?
Mallory bodies
180
A patient’s oedema is caused solely by their liver disease. State one possible pathophysiological mechanism for their oedema.
Hypoalbuminaemia.
181
What 2 products does haem break down in to?
Haem -> Fe2+ and biliverdin.
182
What enzyme converts biliverdin to unconjugated bilirubin?
Biliverdin reductase.
183
What is the function of glucuronosyltransferase?
It transfers glucuronic acid to unconjugated bilirubin to form conjugated bilirubin.
184
What protein does unconjugated bilirubin bind to and why?
Albumin.
| It isn't H2O soluble therefore it binds to albumin so it can travel in the blood to the liver.
185
What does conjugated bilirubin form?
Urobilinogen
186
What is responsible for the conversion of conjugated bilirubin into urobilinogen?
Intestinal bacteria.
187
What can urobilinogen form?
1. It can go back to the liver via the enterohepatic system.
2. It can go to the kidneys forming urinary urobilin.
3. It can form stercobilin which is excreted in the faeces.
188
Define hepatitis
Inflammation of the liver
189
Define actue hepatitis
Hepatitis within 6 months of onset
190
What are the symptoms of acute hepatitis
None or non specific
- malaise, lethargy, myalgia, fever
Gastrointestinal upset and stomach pain
Jaundice with pale stools and dark urine
191
What are the signs of acute hepatitis
Tender hepatomegaly and jaundice
Signs of fulminant hepatitis
- bleeding
- Ascites
- Encephalopathy
192
What are the blood test results in acute hepatitis
raised transaminases (AST/ALT) and raised bilirubin
Raised or normal alkaline phosphatase
Raised or normal albumin
193
What are the viral infective causes of acute hepatitis
Hep A, B+D, C+E
Human herpes virus
(HSV, VZV, CMV, EBV)
194
What are the non-viral infective causes of acute hepatitis
Spirochetes (Leptospirosis, syphillis)
Mycobacteria (Tuberculosos)
Bacteria (Bartonella)
Parasites (Toxoplasma)
195
What are the non-infective causes of acute hepatitis
```
Drugs
Alcohol
Other toxins and poisons
Pregnancy
NAFLD
Autoimmune hepatitis
Hereditary metabolic causes
```
196
Define chronic hepatitis
Hepatitis that lasts for 6 months or longer
197
What are the symptoms of chronic hepatitis
Can be asymptomatic or may have non specific symptoms
May have signs of chronic liver disease
- Clubbing
- Palmar erythema
- Dupuytren's Contracture
- Spider naevi
198
What do blood results of someone with chronic hepatitis show
Transaminase can be normal
199
What are the complications of chronic hepatitis
HCC
| Portal hypertension
200
What are the infective causes of chronic hepatitis
Viral Hep B+D and C+E
201
What are the non-infective causes of chronic hepatitis
```
Drugs
Alcohol
Other toxins
NAFLD
Autoimmune hepatitis
hereditary metabolic causes
```
202
What disease commonly causes hepatitis A? is it an RNA or DNA virus
Picornavirus
RNA
203
How is HAV transmitted
Faeco-oral transmission
- Contaminated food or water ingestion (Shellfish, traveller, infected food handlers)
Person to person contact
- Household
Sexual
Childcare
204
Who is at risk of HAV
Travellers
Household contact
Sexual contact
Injecting drug use
205
Is HAV acute or chronic
Acute, there is 100% immunity after infection
206
What is the clinical presentation of HAV
Non specific = nausea, anorexia and distaste for cigarettes
| After 1-2 weeks patients become jaundiced and urine dark and stools pale
207
How might you diagnose someone with HAV infection
Viral serology
| Initially anti-HAV IgM and then anti-HAV IgG
208
What is the management of HAV
Supportive
Monitor liver function
Manage close contacts using human normal immunoglobulin to contacts within 14 days as well as vaccination
209
What is the primary prevention of HAV
Vaccination - inactivated hepatitis A virus
210
Is hepatitis E an RNA or DNA virus
HEV is a small RNA virus
211
How is HEV transmitted
Faeco-orally
212
Is HEV acute or chronic
usually acute but there is a risk of chronic disease in immunocompromised
(Transplant recipients, HIV patients,)
213
What is the clinical presentation of HEV
95% are asymptomatic
Usually self limiting acute hepatitis
Extra-hepatic manifestations = neurological
214
How might you diagnose someone with HEV infection
Viral serology - Initially anti-HEV IgM and then anti-HEV IgG
215
Describe the primary prevention of HEV
Good food hygiene
| Vaccine in development
216
What is the management for acute HEV infection
Supportive
| Monitor for fulminant hepatitis
217
What is the management for chronic HEV infection
Reverse immunosuppression
| If HEV persists treat with ribavirin
218
Is HBV a RNA or DNA virus
HBV is caused by HEPADNAVIRUS and is a DNA virus which replicates in hepatocytes
219
How is HBV transmitted
```
Blood-borne virus
- Mother to child
-Sexual contact
- Household contact
Iatrogenic
Injecting drug use
Tattoos
```
220
Describe the natural history of HBV in 4 phases.
1. Immune tolerance phase: unimpeded viral replication -> high HBV DNA levels.
2. Immune clearance phase: the immune system ‘wakes up’. There is liver inflammation and high ALT.
3. Inactive HBV carrier phase: HBV DNA levels are low. ALT levels are normal. There is no liver inflammation.
4. Reactivation phase: ALT and HBV DNA levels are intermittent and inflammation is seen on the liver -> fibrosis.
221
What HBV protein triggers the initial immune response?
The core proteins.
222
How might you diagnose someone with HBV?
Viral serology: HBV surface antigen can be detected from 6w – 3m or anti-HBV core IgM after 3 months.
223
Describe the management of HBV infection.
1. Supportive.
2. Monitor liver function.
3. Manage contacts.
4. Follow up at 6 months to see if HBV surface Ag has cleared. If present -> chronic hepatitis.
Pegylated interferon alpha A2
Entecavir/tenofovir
224
How would you know if someone had acute or chronic HBV infection?
You would do a follow up appointment at 6 months to see if HBV surface Ag had cleared. If it was still present then the person would have chronic hepatitis
225
What are the potential consequences of chronic HBV infection?
1. Cirrhosis.
2. HCC.
3. Decompensated cirrhosis.
226
How can HBV infection be prevented?
Vaccination – injecting a small amount of inactivated HbsAg.
227
Describe two treatment options for HBV infection.
1. Alpha interferon – boosts immune system.
| 2. Antivirals e.g. tenofovir. They inhibit viral replications.
228
HBV treatment: give 3 side effects of alpha interferon treatment.
1. Myalgia.
2. Malaise.
3. Lethargy.
4. Thyroiditis.
5. Mental health problems.
229
Is HDV a RNA or DNA virus?
It is a defective RNA virus. It required HbsAG to protect it.
230
Infection with what virus is needed for HDV to survive?
HDV can’t exist without HBV infection! It needs HbsAg to protect it.
231
How is HDV transmitted?
Blood-borne transmission, particularly IVDU.
232
How do you test to see if someone has hepatitis D
Hepatitis D antibody
233
What is the treatment for HDV
Pegylated interferon alpha
234
Is HCV a RNA or DNA virus?
Flavivirus (RNA)
235
How is HCV transmitted?
```
Blood-borne
o IVDU
o Blood transfusion
o Tattoos/needlesticks
o Sexual
o Vertical
```
236
What percentage of HCV patients develop acute hepatitis
20%
237
What percentage of HCV patients develop chronic hepatitis
80%
238
How might you diagnose someone with current HCV infection?
Viral serology – HCV RNA tells you if the infection is still present.
239
You want to find out if someone has previously been infected with HCV. How could you do this?
Viral serology – anti-HCV IgM/IgG indicates that someone has either a current infection or a previous infection.
240
Describe the treatment for HCV.
Lots of new drugs have been developed recently for HCV infection. Direct acting antivirals (DAA) are currently in use e.g. NS5A and NS5B.
241
How can HCV infection be prevented.
1. Screen blood products.
2. Lifestyle modification.
3. Needle exchange.
There is currently no vaccination and previous infection does not confer immunity
242
What types of viral hepatitis are capable of causing chronic infection?
Hepatitis B (+/-D); C and E in the immunosuppressed.
243
Define diarrhoea
Abnormal passage of loose or liquid stool more than 3 times daily
244
Define acute diarrhoea
Defined as lasting less than 2 weeks
245
Define chronic diarrhoea
Lasting more than 2 weeks
246
Define an infective cause of diarrhoea
Sudden onset of bowel frequency associated with crampy abdominal pains and fever
247
Define an inflammatory cause of diarrhoea
Bowel frequency with loose and blood stained stools
248
Name some diarrhoeal GI infections
```
Traveller's diarrhoea
Viral (Rotavirus and norovirus)
Bacterial (E.coli)
Parasite (Helminths, protozoa)
Nosocomial (C.diff and norovirus)
```
249
Name some non diarrhoeal GIT infections
```
Gastritis/peptic ulcer disease (H.pylori)
Acute cholecystitis
Peritonitis
Typhoid - salmonella
Amoebic liver abscess
```
250
What are the causes of diarrhoea
```
Bacterial
Viral
Parasitic (Helminths and protozoa)
Nosocomial
Hepatobiliary infections
Travellers
Whipple's disease
Helicobacter pylori infection
```
251
What is the leading cause of diarrhoeal illness in young children
Rotavirus
252
Define traveller's diarrhoea
3 or more unformed stools per day and at least one abdominal pain/cramp/nausea/vomiting/dysentry which occurs within 2 weeks of arrival in a new country
253
What are the causative organism of travellers diarrhoea
Enterotoxigenic E.coli
Campylobacter
Norovirus
Giardia
254
Name the toxin producing E.coli and their mechanism of action
1. Enterotoxigenic E.coli (ETEC)
- heat labile and heat stable
Activate intestinal adenylate or guanylate cyclase
2. Enterohaemorrhagic E.coli (EHEC)
- Shiga like toxin
255
What sort of diarrhoea does enterotoxigenic E.coli produce
Travellers diarrhoea with watery diarrhoea
256
What sort of diarrhoea does enterohaemorrhagic E.coli produce
Bloody diarrhoea and haemolytic uremic syndrome
257
Name an invasive E.coli and what of disease does It cause
Enteroinvasive E.coli (EIEC)
Dysentery like illness
258
Name the three types of adherent E.Coli and their mechanisms
1. Enteropathogenic E.Coli (EPEC) - attach to epithelium
2. Enteroaggregative E.Coli (EAEC) - Biofilms
3. Diffusely adherent E.coli (DAEC) - afimbriate adhesion
259
What type of diarrhoea does enteropatheogenic E.coli cause
Infantile diarrhoea
260
What type of diarrhoea does enteroaggregative E.coli cause
Traveller's Diarrhoea
261
What type of diarrhoea does diffusely adherent E.coli cause
Persistent diarrhoea in children
262
What parasites can cause diarrhoea
Protozoa
- Entemoeba histolytica
- Giardia
- Cryptosporidium
Helminths
- Schistosomiasis
- Stronglyloides
263
What are the symptoms of schistosomiasis
```
Fever
Eosinophilia
Diarrhoea
Hepato-splenomegaly
Cough/wheeze
```
264
Name an antibiotic associated cause of diarrhoea
Clostridium difficile
265
Which antibiotics are associated with a clostridium difficile
Clindamycin
Ciprolfaxin (Quinolones)
Co-amoxiclav (Penicillins)
Cephalosporin
266
What can contribute to antibiotics induced clostridium difficile
Acid suppression PPI (Lansoprazole and omeprazole)
| H2 receptor antagonists
267
What is the treatment for anti-biotic induced C.diff
Metronidazole
Oral vancomycin
Rifampicin/rifaximin
268
Define peritonitis
Inflammation of the peritoneum
269
What are the causes of peritonitis
Surgical - secondary bacterial peritonitis due to perforation or trauma
Spontaneous bacterial peritonitis
Paediatric in absence of ascites
Infection secondary to peritoneal dialysis
Pelvic inflammatory disease as complication of chlamydia
Tuberculosis
270
What are 5 causes of diarrhoeal infection
1. traveller's diarrhoea
2. Viral (Rotavirus)
3. Bacterial (E.coli)
4. Parasites (Helminths)
5. Nosocomial (C.diff)
271
What are 5 causes of non diarrhoeal infection
```
Gastritis
Acute cholecystitis
Peritonitis
Typhoid
Ameobic liver disease
```
272
Name three ways in which diarrhoea can be prevented
1. Access to clean water
2. Good sanitation
3. Hand hygiene
273
What are 3 causes of traveller's diarrhoea
1. Enterotoxigenic E.coli
2. Campylobacter
3. Norovirus
274
Describe the pathophysiology of traveller's diarrhoea
Heat table ETEC modifies Gs and it is in permanent lock on state - adenylate cyclase is activated and there is increased production of cAMP which leads to increased secretion of Cl- into the intestinal lumen with water following down an osmotic gradient = diarrhoea
275
What type of E.coli can cause bloody diarrhoea and has shiga like toxin
Enterohaemorrhagic E.coli
276
What is the leading cause of diarrhoeal illness in young children
Rotavirus
277
Give 5 symptoms of helminth infection
```
Fever
Eosinophilia
Diarrhoea
Cough
Wheeze
```
278
Briefly describe the reproductive cycle of schistosomiasis
1. Fluke matures in blood vessels and reproduces sexually in host
2. Eggs expelled in faeces and enter water source
3. Asexual reproduction in an intermediate host
4. Larvae expelled and penetrate back into human host
279
Why is C.diff highly infectious
Spore forming bacteria (Gram positive)
280
Give 5 risk factors for C.diff infection
1. Increasing age
2. Co-morbidities
3. Antibiotic use
4. PPI
5. long hospital stays
281
What can helicobacter pylori infection cause
H pylori produces urease --> Ammonia --> Damage gastric mucosa --> Neutrophil recruitment and inflammation = gastritis, peptic ulcer disease and gastric cancer
282
What is acute pancreatitis?
An inflammatory process with release of inflammatory cytokines (TNF alpha, IL-6) and pancreatic enzymes (trypsin, lipase) resulting in auto-digestion of organ
283
What are the 3 different types of acute pancreatitis?
1. 70% are oedematous; acute fluid collection.
2. 25% are necrotising.
3. 5% are hemorrhagic.
284
Give 5 causes of acute pancreatitis.
1. Gallstones.
2. Alcohol.
3. Hyperlipidaemia.
4. Direct damage e.g. trauma.
5. Idiopathic.
6. Toxic e.g. drugs, infection, venom
285
Give 4 symptoms of acute pancreatitis.
1. Severe epigastric pain that radiates to the back.
2. Anorexia.
3. Nausea, vomiting.
4. Signs of septic shock e.g. fever, dehydration, hypotension
286
How can acute pancreatitis be diagnosed?
Pancreatitis is diagnosed on the basis of 2 out of 3 of the following:
1. Characteristic severe epigastric pain radiating to the back.
2. Raised serum amylase.
3. Abdominal CT scan pathology.
287
Describe the treatment for acute pancreatitis
1. ANALGESIA!
2. Catheterise and ABC approach for shock patients.
3. Drainage of oedematous fluid collections.
4. Antibiotics.
5. Nutrition.
6. Bowel rest.
288
Give 2 potential complications of acute pancreatitis.
1. Systemic inflammatory response syndrome.
| 2. Multiple organ dysfunction.
289
What is chronic pancreatitis?
Innapropriate activation of the pancreatic enzymes leading to protein plug and calcification leading to ductal hypertension and pancreatic damage and fibrosis
290
Describe how alcohol can cause chronic pancreatitis
Alcohol -> proteins precipitate in the ductal structure of the pancreas (obstruction) -> pancreatic fibrosis.
291
What immunoglobulin might be elevated in someone with autoimmune chronic pancreatitis?
IgG4.
292
How is autoimmune chronic pancreatitis treated?
It is very steroid responsive.
293
Give 5 symptoms of chronic pancreatitis.
1. Severe abdominal pain.
2. Epigastric pain radiating to the back.
3. Nausea, vomiting.
4. Decreased appetite.
5. Exocrine/endocrine dysfunction.
2. Diabetes mellutus
3. Steatorrhoea
4. Weight loss
294
A sign of chronic pancreatitis is exocrine dysfunction. What can be a consequence of this?
1. Malabsorption.
2. Weight loss.
3. Diarrhoea.
4. Steatorrhoea.
295
What is the treatment for chronic pancreatitis
Analgesics
No EtOH
Decrease fats and increase Carbs
Pancreatectomy
296
What are the complications of chronic pancreatitis
```
Pseudocyst
DM
Pancreatic Ca
Biliary obstruction
Splenic vein thrombosis
```
297
Define peritonitis
Inflammation of the peritoneum
298
What is the function of the peritoneum in health
Visceral lubrication
| Fluid and particulate absorption
299
What is the function of the peritoneum in disease
Pain perception
Inflammatory and immune responses
Fibrinolytic activity
300
How can we classify peritonitis
Onset (Acute or chronic)
Origin (Primary/secondary)
Cause (Bacterial, chemical, traumatic, Ischaemic and miscellaneous)
Location (Localised or generalised)
301
What are the primary causes of peritonitis
```
Liver disease
Spontaneous bacterial peritonitis
Ascites
Immunocompromised
Females
Peritoneal dialysis patient
```
302
What are the secondary causes of peritonitis
Gastrointestinal perforation (Perforated ulcer, appendix)
Transmural translocation - No perforation (Pancreatitis, Ischaemic bowel, primary bacterial peritonitis)
Exogenous contamination (Drains, open surgery, trauama, peritoneal dialysis)
Female genital tract infection
Haematogenous spread (Septicaemia)
303
What microorganisms from the GIT cause peritonitis
Escherichia coli
Streptococci
Enterococci
304
What bacteria other than those from the GIT can cause peritonitis
Chlamydia trachomatis
| Neisseria gonorrhoea
305
What are the signs and symptoms of localised peritonitis
```
Abdominal pain and nausea
Guarding
Rebound
Rigidity
Pyrexia
Tachycardia
Shoulder tip pain
Tender rectal and vaginal exam
```
306
What is guarding
Involuntary abdominal wall contraction to protect the viscus from examination
307
What is rigidity
Involuntary constant contraction of the abdominal wall over inflamed site
308
What are the signs and symptoms of EARLY diffuse peritonitis
```
Abdominal pain Mae worse my moving or breathing
Tenderness
Generalised guarding
Infrequent bowel sounds
Fever
Tachycardia
```
309
What are the signs and symptoms of LATE diffuse peritonitis
```
Generalised rigidity
Distension
Absent bowel sounds
Circulatory failure
Thready irregular pulse
Loss of consciousness
```
310
What are the signs and symptoms of end stage peritonitis
```
Circulatory failure
Cold and clammy extremities
Sunken eyes
Dry tongue
Thready irregular pulse and anxious face
```
311
What investigations would you conduct in someone with suspected peritonitis
```
FBC, U+E and amylase and LFTs
Blood/ascitic fluid culture (high lactate above 25mg/dL
Plain X-ray of chest and abdo
CT scan abdomen
urine dipstick for UTI
```
312
What is the management for peritonitis
Resuscitate and antibiotics
Plasma volume needs to be restored and electrolyte concentrations corrected as patient is often hypovolaemic
Urinary catheterisation and GI decompression
Surgical repair of abdomen
- Repair perforated viscus
Excision of perforated organ
313
What other forms of peritonitis exist
Bile peritonitis
Spontaneous bacterial peritonitis
Primary pneumococcal peritonitis
Tuberculosis peritonitis
314
What is familial Mediterranean fever characterised by
```
Abdominal pain
tenderness
Mild pyrexia
Polymorphonuclear leukocytosis
Pain in thorax and joints
```
315
What is spontaneous bacterial peritonitis
Acute bacterial infection of the ascitic fluid that is diagnosed by paracentesis
316
How is familial Mediterranean fever treated
Colchicine therapy
317
Define ascites
Effusion and accumulation of serous fluid in the peritoneal cavity
318
Do men normally have fluid in the peritoneal cavity
NO
319
How much fluid do women normally have in the peritoneal cavity
20ml
320
What is exudate
Fluid that leaks around cells due to inflammation (<25g/dl)
321
What is transudate
Fluid that is pushed through due to blockage of venous drainage
>25g/dl)
322
Describe the classification system for ascites
stage 1: detectable only after careful examination/US
Stage 2: Early detectable but of relatively small volume
Stage 3: Obvious but not tense
Stage 4: Tense ascites (Large)
323
What are the causes of ascites
```
Portal hypertension
Liver cirrhosis
Malignancy
HF
TB
Pancreatitis
```
324
What are the symptoms of ascites
```
Abdominal distension
Nausea
weight loss
Anorexia
Constipation
Pain/discomfort = malignancy
Painless = non malignant
```
325
What are the signs of ascites
```
Signs of liver failure (Jaundice)
Shifting dullness on percussion
Puddle sign (150ml)
Shifting dullness (500ml)
Abdominal distension (1.5L)
Flank fullness (>1.5L)
```
326
What are the investigations for someone with suspected ascites
```
Ascitic fluid aspiration for culture and microbiology
X-ray
Ultrasound
Biochemistry
- Serum ascites albumin gradient
(Serum albumin - ascites albumin)
```
327
What does a serum ascites albumin gradient of <1.1g/dl suggest
Non portal hypertensive causes
328
What does a serum ascites albumin gradient of >1.1g/dl suggest
Portal hypertensive causes
329
What is the management of ascites
Portal high BP treatment (diuretics, fluid/salt restriction, albumin replacement)
Paracentesis (4-6L/day with colloid replacement)
- portosystemic shunt
- Peritoneovenous shunt
