LIVER, BILARY AND PANCREATIC DISEASE

Question 1

what are the main causes of pre-hepatic jaundice? (4)

Answer 1

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

Question 2

what LFT marker would you expect to be raised in a pt with pre-hepatic jaundice?

Answer 2

UNCONJUGATED BILIRUBIN

Question 3

what are the main causes of intrahepatic jaundice? (6)

Answer 3

jaundice caused by pathology within the liver:

• cirrhosis
• alcoholic liver disease
• hepatitis C, B
• hepatocellular carcinoma
• cholangitis
• haemochromatosis

Question 4

what investigations would help confirm /rule out intrahepatic differential diagnoses in a patient with jaundice?

Answer 4

LFTs

expect to see LFT derangement

Question 5

what are the main causes of obstructive / post-hepatic jaundice?

Answer 5

anything that blocks the flow of bile distal to the liver;

• gallstones
• cholestasis
• pancreatic cancer
• fibrosis of head of pancreas
• abdominal masses

Question 6

what are the typical obstructive jaundice signs in history or o/e?

Answer 6

pale stools
dark urine
itching

Question 7

what are the signs / symptoms of delirium tremens?

Answer 7

agitation
global confusion
hypertension
perfuse sweating
autonomic overactivity
tremor

Question 8

which LFT is raised in the context of hepatocellular injury?

Answer 8

ALT

Question 9

which LFT is raised in the context of cholestasis / obstructive injury?

Answer 9

ALP

Question 10

which LFT is used to confirm a diagnosis of cholestatic / obstructive pathologies?

Answer 10

GGT

Question 11

what would you expect to see in LFTs if a patient had an obstructive cause of jaundice?

Answer 11

ALT less than 10 x raised

ALP more than 3 x raised

Question 12

what would you expect to see in LTFs if a patient had a hepatocellular cause of their jaundice?

Answer 12

ALT more than x 10 raised

ALP less than 3 x raised

Question 13

which clinical sign can differentiate between unconjugated and conjugated hyperbilirubinaemia?

Answer 13

COLOUR OF URINE

unconjugated bilirubin water insoluble therefore colour not affected
conjugated bilirubin is soluble and makes urine dark

Question 14

what would a raise in AST higher than ALT indicate in the context of liver disease?

Answer 14

ACUTE liver disease

Question 15

what would a raise in ALT higher than ALT indicate in the context of liver disease?

Answer 15

CHRONIC liver disease

Question 16

what is prothrombin time?

Answer 16

a measure of the blood coagulation tendency via the extrinsic pathway

Question 17

how does INR relate to liver function?

Answer 17

INR is a standardised version of prothrombin time

increased INR indicates liver isn’t making sufficient clotting factors due to hepatic pathology

Question 18

what is the difference between transudate and exudate?

Answer 18

TRANSUDATE fluid is caused by disturbances of hydrostatic or colloid oncotic pressure

EXUDATE fluid is caused by inflammation

Question 19

on analysis, how do you differentiate between transudate and exudate?

Answer 19

Exudates have HIGH protein content

Question 20

what molecule is responsible for the pathogenesis of hepatic encephalopathy?

Answer 20

Ammonium

Question 21

in terms of LTF’s, what would a hepatitic picture look like?

Answer 21

marked raised in AST/ALT compared with moderate raise in ALP

transaminases are released from damaged hepatic tissues in response to inflammation

Question 22

what are the signs of cirrhosis on examination?

Answer 22

hepatomegaly
leuchonicia
palmar erythema
spider naevi
clubbing
palmar erythema
ascites

Question 23

what are the symptoms of viral hepatitis?

Answer 23

fever
malaise
anorexia
nausea
arthralgia - (joint pain)
JAUNDICE

Question 24

what is serum albumin ascitic gradient? (SAAG)

Answer 24

(serum albumin) - albumin in ascitic fluid

Question 25

what does a high SAAG gradient indicate?

Answer 25

ascitic fluid is due to portal hypertension

Question 26

what does a low SAAG gradient indicate?

Answer 26

ascitic fluid is due to infective cause (pancreatitis, peritonitis, tuberculosis)

Question 27

what 3 conditions make up the spectrum of alcoholic liver disease?

Answer 27

alcohol related fatty liver
alcoholic hepatitis
cirrhosis

Question 28

the histology report from a liver biopsy says ‘mallory bodies identified’. What would this indicate?

Answer 28

alcoholic hepatitis

Question 29

thiamine replacement therapy is indicated in those with alcoholic liver disease. What condition does this prevent?

Answer 29

Wernicke’s encephalopathy

Question 30

what drugs are used to treat infection with hepatitis C?

Answer 30

ledipasvir and sofosbuvir

Question 31

other than pancreatitis, which conditions cause an increase in amylase?

Answer 31

Cholecystitis
GI perforation
Mesenteric infarction

Question 32

how is pancreatitis diagnosed?

Answer 32

amylase MORE THAN 3 fold upper limit of normal

Question 33

what criteria is used for predicting severity of pancreatitis?

Answer 33

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

Question 34

what investigations would you order if you expected acute pancreatitis?

Answer 34

Bloods (FBC, U + E, LFT, CRP, amylase, lipase)
ABG
US gallbladder
CT to assess severity

Question 35

what is the management of acute pancreatitis?

Answer 35

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

Question 36

what is charcots triad?

Answer 36

fever
RUQ pain
jaundice

CHOLANGITIS!!

Question 37

what are the differentials between cholecystitis and bilary colic?

Answer 37

Same pain, but cholecystitis is constant, bilary colic is intermittant, usually after a fatty meal

cholecystitis will often present with fever / nausea too