Liver + Biliary 2

Question 1

Liver failure definition and causes?

Answer 1

Severe liver dysfunction leading to jaundice, encephalopathy and coagulopathy

Acute: paracetomol overdoes (transaminitis +++) (50% of ALF)/viral

Acute on chronic : acute decompensation in patients with chronic liver disease

Question 2

Breakdown of Acute liver failures?

Answer 2

Hyperacute: encephalopathy <7 days after jaundice

Acute: Enceph 1-4 weeks after jaundice

Subacute: enceph 4-12 weeks after jaundie

Question 3

Ix for liver failure?

Answer 3

Identify cause e.g. viral serology, paracetomol levels, liver biopsy, bloods and coagulation screen

Question 4

What is a liver abscess/cyst and Hx?

Answer 4

Liver infection -> walled off collection of pus/cyst fluid

Fever, malaise, RUQ pain (referred to shoulder), jaundice and foreign travel

Question 5

Examination of liver abscess/cysts?

Answer 5

Jaundice, tender hepatomegaly, dullness on percussion, decreased breath sounds at right lung base

Question 6

Breakdown of liver abscess/cysts?

Answer 6

Pyogenic abscess: S aureus (kids), Ecoli (adults).
60% related to bilairy dises e.g gallstones, strictire

Amoebic Abscess: entamoeba histolytica (faeco-oral) from amoebic dysentery. Metronidazole Tx

Hyatid cyst: Tapeworm e.g. echinococcus grnaulosis infection. Can be large, sheep rearing countries. Mebendazole Tx

TB : extrapulmonary manifestaion

Question 7

Ix for liver abscess or cysts?

Answer 7

Bloods = FBC - mild anaemia, leukocytosis

Eosinophilia for hyatid cyst

Stool microscopy for entamoeba and echinococcus granulosis

Aspiration/culture for ascess: pyogenic = polymicrobial, amoebic = anchovy sauce with necrotic hepatocytes/trophozoites)

Question 8

What is cholangitis and triad associated?

Answer 8

ascending infection of the bile ducts, usually by E.coli, in stagnant bile

Charcots: pain, fever, jaundice

Question 9

Pancreatic cancer features?

Answer 9

Courvoisiers Law: painless jaundice + palpable gall bladder likely to be pancreatic cancer (head)

Marker is Ca19-9

Question 10

Cholangiocarcinoma features?

Answer 10

Gradual onset obstructive pattern and can originate from PSC

Question 11

PSC vs PBC?

Answer 11

Both From Autoimmune conditions but UC for PSC

Question 12

Ix for gallstones?

Answer 12

Biliary colic = cholelithiasis + pain

Acute cholecystitis = cholelithiasis + inflammation + secondary infection

None have jaundice

Ix - USS liver and biliary tree

Question 13

What is it if there is mild jaundice in acute cholecystitis?

Answer 13

Inflammation of the contiguous biliary ducts is Mirizzis syndrome

Question 14

Mx for gallstones?

Answer 14

Biliary colic = analgesia + electve lap chole

Acute cholecystitis = Inital: clear flids, analgesics, fluid resus and broad IV Abc
Lap Chole in a week

Question 15

What is a gallstone in the CBD and other conditions?

Answer 15

Choledocholithiasis

Choledocholithiasis +pain = biliary colic

^ + infection = ascending cholangitis

Question 16

Ix for choledocholithiasis and associated conditions?

Answer 16

May be jaundice/raised ALP and GGT

USS liver and biliary tree
ERCP if suspected acute cholangitis

Question 17

Management of choledocholithiasis and biliary colic?

Answer 17

Analgesia + ERCP + lap chole

Question 18

Management for ascending cholangitis?

Answer 18

Initial: clear fluids only, analgesics, fluid resusc, Broad IV ABx + ERCP

Lap Chole

Question 19

Complications of acute cholecystitis?

Answer 19

Gallblader empyema, porcelain gallbladder, GB cancer, gallstone ileus

Question 20

complications of acute chlangitis?

Answer 20

Bile duct perforation, bile peritonitis and sepsis

Question 21

Risk factors for gallstones and types?

Answer 21

Fair, fat, fertile, female, forty, +OCC, crohns

Cholesterol 10%
Mixed 80%
Pigment stones (5%) = calcium bilirubinate from haemolysis or liver fluke

Question 22

Primary Biliary cirrhosis features?

Answer 22

Intrahepatic ducts only
F>m
Histology = florid duct lesion
Associated with Sjorens and RA
Rasied AMA usually diagnostic

Complication = cirrhosis, HCC and GRANULOMAS

Question 23

PSC features?

Answer 23

Intra and extrahepatic ducts
M>F
Histology = concentric onion skin fibrosis
ASSOCIATED WITH UC

Diagnosis with MRCP = beaded appearance or segmental fibrosis with saccular dilatation
pANCA may be raised

Complications = irrhosis, HCC< cholangiocarcinoma

Question 24

Pancreatic cancer types and Rfs?

Answer 24

Coursevoirs
Mostly adenocarcinoma in head 75%
Ca19-9 and MEN1

Smoking, obesity, T2dm, chronic pancreatitis

Question 25

S+S of pancreatic cancer?

Answer 25

Commonl delayed presentation due to non-specific signs e.g. malaise, weight loss, abdo pain

Jaundice is later and hepatomgealy if mets

Question 26

Ix for pancreatic cancer>

Answer 26

1st = CT more sensitive, can do USS
Biopsy via ERCP/EUS is gold standard

Ca19-9

Question 27

Liver tumour types?

Answer 27

Secondary most common from bowel, breast, oesophagus, stomach and pancreas

Primary = HCC 90% and cholangiocarcinoma

Question 28

RFs for HCC (hepatoma)

Answer 28

Hep B (worldwide)/C (europe), Alcoholic liver disease, AIH, haemochromotisis, NAFLD, aflatoxin, PBC< smoking, obesity

Question 29

S+S HCC?

Answer 29

Malaise, weight loss, anorexia, RUQ pain, jaundice, ascites, cachexia, heatomgealy

Question 30

Ix for HCC?

Answer 30

LFTS and viral serology

Tumour marker = AFP

6 month USS for at high risk and 2ww for liver mass

Liver CT to confirm

Biopsy is gold standard

Question 31

Chongiocarcinoma Rfs and S+S?

Answer 31

PSC, worm infections and cirrhosis.

Same as pancreatic cancer symptoms but pancreatic more common

Question 32

Ix for cholangiocarcinoma?

Answer 32

1st - abdo uss (dilated intrahepatic ductss, mass lesion)

Biopsy via ERCP gold standard