LIVER, BILARY AND PANCREATIC DISEASE Flashcards
what are the main causes of pre-hepatic jaundice? (4)
excessive production of bilirubin to the point that the liver cannot conjugate at a rate sufficient to clear the bilirubin
haemolytic anaemia
gilberts syndrome
drug reactions
hypersplenism
what LFT marker would you expect to be raised in a pt with pre-hepatic jaundice?
UNCONJUGATED BILIRUBIN
what are the main causes of intrahepatic jaundice? (6)
jaundice caused by pathology within the liver:
- cirrhosis
- alcoholic liver disease
- hepatitis C, B
- hepatocellular carcinoma
- cholangitis
- haemochromatosis
what investigations would help confirm /rule out intrahepatic differential diagnoses in a patient with jaundice?
LFTs
expect to see LFT derangement
what are the main causes of obstructive / post-hepatic jaundice?
anything that blocks the flow of bile distal to the liver;
- gallstones
- cholestasis
- pancreatic cancer
- fibrosis of head of pancreas
- abdominal masses
what are the typical obstructive jaundice signs in history or o/e?
pale stools
dark urine
itching
what are the signs / symptoms of delirium tremens?
agitation global confusion hypertension perfuse sweating autonomic overactivity tremor
which LFT is raised in the context of hepatocellular injury?
ALT
which LFT is raised in the context of cholestasis / obstructive injury?
ALP
which LFT is used to confirm a diagnosis of cholestatic / obstructive pathologies?
GGT
what would you expect to see in LFTs if a patient had an obstructive cause of jaundice?
ALT less than 10 x raised
ALP more than 3 x raised
what would you expect to see in LTFs if a patient had a hepatocellular cause of their jaundice?
ALT more than x 10 raised
ALP less than 3 x raised
which clinical sign can differentiate between unconjugated and conjugated hyperbilirubinaemia?
COLOUR OF URINE
unconjugated bilirubin water insoluble therefore colour not affected
conjugated bilirubin is soluble and makes urine dark
what would a raise in AST higher than ALT indicate in the context of liver disease?
ACUTE liver disease
what would a raise in ALT higher than ALT indicate in the context of liver disease?
CHRONIC liver disease
what is prothrombin time?
a measure of the blood coagulation tendency via the extrinsic pathway
how does INR relate to liver function?
INR is a standardised version of prothrombin time
increased INR indicates liver isn’t making sufficient clotting factors due to hepatic pathology
what is the difference between transudate and exudate?
TRANSUDATE fluid is caused by disturbances of hydrostatic or colloid oncotic pressure
EXUDATE fluid is caused by inflammation
on analysis, how do you differentiate between transudate and exudate?
Exudates have HIGH protein content
what molecule is responsible for the pathogenesis of hepatic encephalopathy?
Ammonium
in terms of LTF’s, what would a hepatitic picture look like?
marked raised in AST/ALT compared with moderate raise in ALP
transaminases are released from damaged hepatic tissues in response to inflammation
what are the signs of cirrhosis on examination?
hepatomegaly leuchonicia palmar erythema spider naevi clubbing palmar erythema ascites
what are the symptoms of viral hepatitis?
fever malaise anorexia nausea arthralgia - (joint pain) JAUNDICE
what is serum albumin ascitic gradient? (SAAG)
(serum albumin) - albumin in ascitic fluid
what does a high SAAG gradient indicate?
ascitic fluid is due to portal hypertension
what does a low SAAG gradient indicate?
ascitic fluid is due to infective cause (pancreatitis, peritonitis, tuberculosis)
what 3 conditions make up the spectrum of alcoholic liver disease?
alcohol related fatty liver
alcoholic hepatitis
cirrhosis
the histology report from a liver biopsy says ‘mallory bodies identified’. What would this indicate?
alcoholic hepatitis
thiamine replacement therapy is indicated in those with alcoholic liver disease. What condition does this prevent?
Wernicke’s encephalopathy
what drugs are used to treat infection with hepatitis C?
ledipasvir and sofosbuvir
other than pancreatitis, which conditions cause an increase in amylase?
Cholecystitis
GI perforation
Mesenteric infarction
how is pancreatitis diagnosed?
amylase MORE THAN 3 fold upper limit of normal
what criteria is used for predicting severity of pancreatitis?
glasgow scale;
P PaO2 less than 8 A Age + 55 N neutrophilia C calcium less than 2 R renal function (urea more than 16) E enzymes (liver derangement) A albumin less than 32 S sugar (hyperglycaemia)
3 + factors = liase with ICU
what investigations would you order if you expected acute pancreatitis?
Bloods (FBC, U + E, LFT, CRP, amylase, lipase)
ABG
US gallbladder
CT to assess severity
what is the management of acute pancreatitis?
NBM (rest pancreas, consider jej feeding)
IV fluids to replace 3rd space losses
analgesia - morphine
treat specific cause of pancreatitis e.g. ERCP to remove gallstones
what is charcots triad?
fever
RUQ pain
jaundice
CHOLANGITIS!!
what are the differentials between cholecystitis and bilary colic?
Same pain, but cholecystitis is constant, bilary colic is intermittant, usually after a fatty meal
cholecystitis will often present with fever / nausea too
