liver and pancreas Flashcards
1
Q
what is acute pancreatitis?
A
self-perpetuating pancreatic inflammation by enzyme-mediated autodigestion
2
Q
what is the aetiology of acute pancreatitis?
A
GET SMASHED •Gallstones •Ethanol (alcohol) •Trauma •Steroids Mumps •Autoimmune •Scorpion venom •Hyperlipidaemia, hypothermia, hypercalcaemia •ERCP and emboli •Drugs
3
Q
What are the signs and symptoms of acute pancreatitis?
A
- signs- tachycardia, fever, jaundice, shock
- symptoms- gradual sudden epigastric abdominal pain that radiates to the back, sitting forward relieves pain
4
Q
what are some differential diagnoses of acute pancreatitis?
A
- IBS
- MI
- Gastroenteritis
- Diabetic ketoacidosis
- Peritonitis
- Pneumonia
5
Q
how can acute pancreatitis be diagnosed?
A
- raised serum amylase
- serum lipase
- AXR- no psoas shadow
6
Q
what are the treatment options for a patient with acute pancreatitis?
A
- IV saline
- analgesia
- oxygen
- ABX If severe
7
Q
what is chronic pancreatitis?
A
inappropriate activation of enzymes within the pancreas resulting in the precipitation of protein plugs. this leads to fibrosis, atrophy and calcification of the pancreas resulting in an impairment in pancreatic function.
8
Q
what is the aetiology of chronic pancreatitis?
A
- Alcohol
- Tropical chronic pancreatitis
- Hereditary
- Autoimmune
- Cystic fibrosis
- Haemachromatosis
9
Q
what is the pathophysiology of chronic pancreatitis?
A
precipitation of protein plugs within the duct lumen forms a point for calcification
•duct blockage leads to ductal hypertension and further pancreatic damage.
This (+cytokine activation) leads to pancreatic inflammation, irreversible morphological change ± impaired pancreatic function
10
Q
how does chronic pancreatitis present clinically?
A
- epigastric pain radiating to back
- relieved by sitting forward
- bloating
- steatorrhoea
- weight loss
11
Q
how can chronic pancreatitis be diagnosed?
A
ultrasound and CT show pancreatic calcifications
12
Q
how can chronic pancreatitis be treated?
A
- drugs- analgesia, lipase, insulin
- no alcohol, low fat diet
- pancreatectomy
13
Q
describe pigment stones and what can cause them
A
small stones formed of unconjugated bilirubin- occur due to haemolytic
14
Q
describe cholesterol stones and name 3 risk factors for them
A
large, often solitary – age, obesity, female sex, OCP
15
Q
what can cause acute cholecystitis?
A
lodging of a stone in the gallbladder or impaction at the neck of the gallbladder resulting in inflammation and an increased pressure- this results in bacterial growth
16
Q
what are the symptoms of acute cholecystitis?
A
vomiting, fever, local peritonism, GB mass
17
Q
what is Murphy’s sign and what condition is it seen in?
A
2 fingers over the RUQ, ask patient to breath in- causes pain as inflamed GB is impacted on by diaphragm
- acute cholecystitis
18
Q
how can acute cholecystitis be tested for?
A
- high WCC
- US- shrunken GB, common bile duct dilation
- Murphy’s sign
19
Q
how is acute cholecystitis treated?
A
- pain relief
- IV fluids
- laparoscopic cholecystectomy
20
Q
what are the symptoms fo chronic cholecystitis?
A
flatulent dyspepsia
distension
nausea
RUQ pain
21
Q
what triad of symptoms of seen in ascending cholangitis?
A
Charcot’s triad- RUQ pain, jaundice, rigors
22
Q
what can cause unconjugated bilirubin to rise?
A
- overproduction- haemolysis
- impaired hepatic uptake- drugs, RHF
- impaired conjugation
- physical neonatal jaundice
23
Q
what can cause conjugated bilirubin to rise?
A
- hepatocellular dysfunction- viruses, drugs, alcohol, cirrhosis
- impaired hepatic excretion- primary biliary cirrhosis, primary sclerosing cholangitis
24
Q
what is hepatitis A?
A
RNA virus
faecal-oral spread
25
what are the symptoms of hepatitis A?
fever, malaise, anorexia, nausea, jaundice
26
what is HBV?
DNA virus
| spread- blood products, IVDU, sexual and direct contact
27
who are some at risk groups of HBV?
```
IVDUs
Their sexual partners/carer
Health workers
Haemophiliacs
Job exposure to blood e.g. morticians
Haemodialysis + chronic renal failure
Sexual promiscuity
```
28
How can HBV be tested for?
- HBsAg (surface antigen) presents 1-6 months after exposure- Persisting for >6 months = carrier status
- HBcAG- core antigen
- HBeAg (e antigen) – present for 1.5-3 months after acute illness – implies high infectivity- marker of active infection
29
what is HCV?
RNA flavivirus
| blood-transfusion, IVDU
30
how can you diagnose HCV?
anti-HCV antibodies
| HCV-PCR confirms on-going infection
31
how can you treat HCV?
3-serine protease inhibitors- telaprevir
| quit alcohol
32
what is HDV?
incomplete RNA virus that requires HBV for assembly
33
what is HEV?
RNA virus
34
what is cirrhosis?
irreversible liver damaging caused by loss of normal hepatic architecture with. bridging fibrosis
35
what is the aetiology of cirrhosis (liver failure)?
- chronic alcohol abuse
- HBV/ HCV
- haemochromatosis
- alpha1-antitrypsin deficiency
- Budd-Chiari
36
how does cirrhosis (liver failure) present clinically?
- leuconychia
- clubbing
- palmar eryhtema
- spider naevi
- xanthelasma
- gynaecomastia
37
what are the 2 main complications of cirrhosis (liver failure)?
- hepatic failure- coagulopathy, encephalopathy, sepsis
| - portal hypertension- ascites, splenomegaly
38
how is cirrhosis (liver failure) diagnosed?
- raised bilirubin
- hypoabluminaemia
- bloods- raised aspartate aminotransferase and alanine aminotransferase
- MRI- large caudate lobe
- ascitic tap
- liver biopsy
39
how can you treat a patient with cirrhosis (liver failure)?
- quit alcohol
- treat viral disease
- bed rest
- spironolactone
- liver transplant
40
what is primary biliary cirrhosis?
Interlobular bile ducts are damaged by chronic autoimmune granulomatous inflammation causing cholestasis
41
how does primary biliary cirrhosis present clinically?
- pruritis
- jaundice
- hepatosplenomegaly
- xanthelasma
42
what are some differential diagnoses of primary biliary cirrhosis?
sarcoidosis
TB
schistosomiasis
drug reactions
43
how can primary biliary cirrhosis be diagnosed?
- high alkaline phosphatase
| - raised Ig's
44
what are the treatment options for a patient with primary biliary cirrhosis?
if symptomatic- oral rifampicin and codeine phosphate
| - can also offer ursodeoxycholic acid, vitamins A,D,K
45
what is fatty liver?
* First change in the alcoholic liver
* Regular alcohol use results in fatty liver (steatosis)
this is reversible but can progress
46
what is alcoholic hepatitis?
fibrosis and foamy degeneration of hepatocytes
47
what are the clinical features of alcoholic hepatitis?
rapid onset jaundice
| nausea, anorexia, RUQ pain, encephalopathy, fever, ascites
48
how can alcoholic hepatitis be diagnosed?
- FBC- elevated MCV, leucocytosis
| - hyponatraemia on U&E
49
what is hereditary haemochromatosis?
autosomal recessive disorder of iron metabolism- increased intestinal iron absorption leads to iron deposits in joints, liver, heart, pancreas, pituitary, adrenals and skin
50
what is the clinical presentation of hereditary haemochromatosis?
- erectile dysfunction
- slate-grey skin
- hepatomegaly
- cirrhosis
- dilated cardiomyopathy
51
how can hereditary haemochormatosis be diagnosed?
- bloods- raised ferritin and transferrin saturation
- liver MRI shows iron overload
- liver biopsy- Perls stain
52
how would you treat a patient who presents with hereditary haemochromatosis?
phlebotomy
53
what is alpha1 antitrypsin deficiency?
autosomal recessive disorder which results in a deficiency in A1AT.
54
what is the clinical presentation of A1AT deficiency?
- dyspnoea
- SOB
- wheezing
- chronic cough
- mucus production
- cirrhosis
- cholestatic jaundice
55
how can A1AT be managed?
family screening, quit smoking, liver transplant
56
what is Wilsons disease?
Rare inherited disorder of biliary copper excretion with too much copper in liver and CNS
57
in Wilsons disease, where does the copper accumulate and what are the consequences of this?
Liver= fulminant hepatic failure and cirrhosis
Basal ganglia= parkinsonism
cerebral cortex= dementia
Cornea = greenish-brown rings (Kayser-Fleischer rings)
Renal tubules
58
how do patients with Wilson's disease present throughout their life?
children- liver disease- hepatitis, cirrhosis
young adults- CNS signs- tremor, dysarthria, dystonia, dementia
progressive mood changes and loss of cognitive function
59
how is Wilson's disease diagnosed?
- 24h copper excretion high
- LFT's raised
- raised serum copper
- serum caeruloplasmin decreased
60
what is the pharmacological treatment of Wilson's disease?
lifelong penicillamine
| liver transplant if severe
61
what is fulminant hepatic failure?
clinical syndrome resulting from massive necrosis of liver cells which cause a severe impairment of liver function
62
what can cause liver failure?
infections- viral hepatitis, leptospirosis
drugs- paracetamol overdose
vascular- budd-chiari syndrome
other- alcohol, haemcohromatosis, A1AT deficiency, Wilson's disease
63
what is hepatic encephalopathy?
- As liver fails ammonia builds up in circulation and passes to brain
- Astrocytes clear it- conversion of glutamate to glutamine
- Excess glutamine causes an osmotic imbalance and a shift of fluid into these cells – cerebral oedema
64
how is liver failure treated?
- ITU
- IV glucose
- lorazepam
- treat complications
65
what is ascites and what is the commonest cause of it?
presence of fluid in the peritoneal cavity
cirrhosis
66
what can cause ascites?
due to cirrhosis- peripheral arterial vasodilation leads to a reduction in effective blood volume.
this leads to activation of SNS and RAAS- promoting salt and water retention.
oedema is encouraged by hypoalbuminemia
67
what are some transudate causes of ascites?
- Portal hypertension e.g. cirrhosis
- Hepatic outflow obstruction
- Budd-Chiari syndrome
- Cardiac failure
68
what are some exudate causes of ascites?
- Peritoneal carcinomatosis
- Peritoneal TB
- Pancreatitis
- Nephrotic syndrome
- Lymphatic obstruction (chylous ascites)
69
how does ascites present clinically?
- fullness in flanks
- shifting dullness
- tense ascites= uncomfortable, respiratory distress
- pleural effusion
70
how is ascites treated?
hypertension- diuretics
paracentesis
71
where do secondary tumours of the liver most commonly arise from in men and women?
- men= stomach, lung, colon
| - women= breast, colon, stomach, uterus
72
what are some examples of malignant primary liver tumours?
- HCC
- Cholangiocarcinoma
- Angiosarcoma
- Hepatoblastoma
- Fibrosarcoma and hepatic gastrointestinal stromal tumours (GIST)
73
what are some examples of benign primary liver tumours?
- Cysts
- Haemangioma – common, F:M = 5:1
- Focal nodular hyperplasia
- Fibroma
- Benign GIST
74
what are the symptoms of liver tumours?
* Fever
* Malaise
* Anorexia
* Weight loss
* RUQ pain
* Jaundice is late – except with cholangiocarcinoma
* Benign tumours are asymptomatic
75
what is the aetiology of HCC?
```
o HBV – main cause
o HCV
o Autoimmune hepatitis
o Cirrhosis – alcohol, haemachromatosis, PBC
o Non-alcoholic fatty liver
```
76
where do pancreatic cancers most commonly arise?
60% = pancreatic head, 25% = body, 15% = tail
77
what clinical signs does pancreatic cancer present with?
- Jaundice + palpable gallbladder
- Epigastric mass
- Hepatomegaly
- Splenomegaly
- Lymphadenopathy
- Ascites
78
how is pancreatic cancer treated?
- pancreaticoduodenectomy
| - laparoscopic excision
79
what is the aetiology of liver abscesses?
- biliry sepsis
- trauma
- bacteraemia
- pyogenic abscess- E.coli, strep milleri
- amoebic obsess- spread of entamoeba histolytic from bowel
80
how do liver abscesses present clinically?
- non-specific- fever, lethargy, weight loss, abdominal pain
| - enlarged liver
81
how are liver abscesses treated?
- pyogenic- percutaneous aspiration
| - amoebic- metronidazole
82
what bacteria can cause acute cholecystitis?
E.coli, clostridium, enterococci
83
what is chronic cholecystitis?
chronic inflammation of the GB due to continuous presence of gall stones in either the cystic duct or the GB- epithelial damage results in inflammation
84
what causes cholesterol stones to occur?
- supersaturation of cholesterol in bile
| - not enough bile salts, acids or phospholipids- so less solution
85
what are some complications of gall stones in the GB or the cystic duct?
- biliary colic
- acute and chronic cholecystitis
- empyema
- carcinoma
86
what are some complications of gall stones in the GB or the cystic duct?
- obstructive jaundice
- cholangitis
- pancreatitis
87
what is biliary colic?
The term used for the pain associated with the temporary obstruction of the cystic or common bile duct by a stone migrating from the gall bladder
88
how is biliary colic treated?
- analgesia
- rehydrate
- laparoscopic cholecystectomy
89
what is ascending cholangitis?
Inflammation of the biliary tract caused by an obstruction of the common bile duct which allows bacteria from the intestine to work their way up into the bile duct
90
how is ascending cholangitis diagnosed?
- USS
- ERCP- endoscopic retrograde cholangiopancreatography
- positive anti-mitochondrial antibody present
91
how is ascending cholangitis treated?
- cefuroxime and metronidazole
| - cholecystectomy
92
what is the pathophysiology of acute pancreatitis?
- Aetiological basis (e.g. alcohol) causes increased trypsinogen release from acinar cells- pancreatic juices become viscous
- This forms plugs that block the pancreatic ducts
- Trypsinogen broken down into trypsin by lysosomal enzymes- results in autodigestion of pancreas
93
What can be found inside hepatocytes in a patient with alcoholic hepatitis?
- Mallory bodies
| - neutrophils
94
what is portal hypertension?
liver is unable to filter blood as well so pressure backs up, resulting in portal vein hypertension.
95
why does portal hypertension cause varices?
blood always takes the path of least resistance- so due to portal hypertension causing a back up of pressure there is increased flow in the systemic circulation
96
what can cause portal hypertension?
- Cirrhosis
- Fibrosis
- hepatitis
- Portal vein thrombosis
- Increased hepatic resistance, increased splanchnic blood flow
97
what are 2 consequences of portal hypertension?
varices
| splenomegaly
98
what are varices?
Local dilations of the veins
99
how are varices managed?
- correct clotting abnormalities with vitamin k and platelet transfusions
- endoscopic banding
100
how can HAV be diagnosed?
- HAV-IgM rises from day 25= active infection
| - HAV-IgG detectible forever= previous infection/ vaccination
101
how is HAV treated?
- alcohol cessation
| - alpha interferon used if patient develops fulminant hepatitis
102
how can HEV be diagnosed?
- HEV IgM antibody present= active infection
| - HEV IgG antibody present= previous infection
103
which types of hepatitis virus can cause acute hepatitis?
all can!
104
which types of hepatitis virus can cause chronic hepatitis?
HBV
| HCV
105
what is a cause of secondary haemochromatosis?
frequent blood transfusions
106
what are some complications of haemochromatosis?
- cirrhosis leading to hepatocellular carcinoma
- type 1 DM
- malabsorption
- cardiomyopathy
- amenorrhoea
- degenerative joint diseases
107
what is the function of A1AT and why does deficiency of this affect the lungs and liver?
Alpha1- antritrypsin is responsible for inactivating elastase- a protease. In the absence of A1AT, elastin is broken down- particularly damages the lungs and liver.
In the lungs, the structural integrity of the alveoli is lost- emphysema
108
how can A1AT be diagnosed?
- Serum alpha1-antitrypsin levels decreased
- Liver biopsy and liver US
- Pulmonary function tests
109
what is the key difference between cholangitis and cholecystitis?
there is NO JAUNDICE with cholecystitis
110
what clinical features does a patient with HCC Present with?
fatigue, appetite loss, RUQ pain, weight loss, jaundice, ascites
111
how is a HCC diagnosed?
CT, MRI, biopsy
112
how is a HCC treated?
resection of tumour
| liver transplant
113
what is a cholangiocarcinoma?
adenocarcinoma of the bile duct epithelium
114
what is the aetiology of cholangiocarcinoma?
primary sclerosis cholangitis
HBV
HCV
diabetes mellitus
115
how does a patient present with a cholangiocarcinoma?
fever
abdo pain
malaise
elevated bilirubin
116
how can ascites be diagnosed?
- diagnostic aspiration of 10-20ml of ascetic fluid
- gram stain and culture for bacteria
- cytology for malignancy
117
what are the symptoms of peritonitis?
pain, tenderness, dizziness, weakness, nausea, rigor, chills
118
how is peritonitis diagnosed?
general examination
abdo exam- guarding, rebound, rigidity, silent abdomen
investigations- CXR, CT abdo
119
how is peritonitis treated?
antibiotic prophylaxis
excise perforated organ
120
what are the 2 types of hiatus hernia?
sliding, rolling
121
what is a sliding hiatus hernia?
Where the gastro-oesophageal junction slides up into the chest
122
what is a rolling hiatus hernia?
Where the gastro-oesophageal junction remains in the abdomen but a bulge of stomach herniates up into the chest alongside the oesophagus
123
how are hiatus hernias treated?
weight loss
| surgery if intractable symptoms
124
what are the 2 types of inguinal hernia?
* Indirect hernias pas through the internal inguinal ring and (if large) out through the external inguinal ring
* Direct hernias push their way directly forward through the posterior wall of the inguinal canal, into a defect in the abdominal wall
125
what is a femoral hernia?
Bowel enters femoral canal, presenting as mass in upper medial thigh or above the inguinal ligament (points down leg, not into groin – this distinguishes it from inguinal)
126
what is an incisional hernia?
follows the breakdown of muscle closure after surgery
127
what can cause raised aspartate aminotransferase (AST) levels?
- hepatic necrosis
- myocardial infarction
- muscle injury
- congestive cardiac failure
128
what is the function of aspartate aminotransferase?
mitochondrial enzyme
129
what can cause raised alanine aminotransferase levels?
- viral hepatitis
| - alcoholic liver disease
130
what is the function of alanine aminotransferase?
cytosol enzyme specific to the liver
