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MSRA > Liver, Biliary and Pancreas > Flashcards

Liver, Biliary and Pancreas Flashcards

1
Q

What are the main types of gallstones?

A
  1. Cholesterol containing (80%) - large, solitary

2. Pigment stones (calcium) - small, irregular, from haemolysis

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2
Q

What is cholestasis?

A

Biochemical abnormality (raised ALP) resulting from an abnormality in bile flow

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3
Q

What are the RF for cholesterol gallstones?

A

Increased cholesterol secretion - old age, female, pregnancy, obesity, rapid weight loss

Impaired gallbladder emptying - pregnancy, stasis, fasting, PEG tube, spinal cord injury

Decreased bile salt secretion - pregnancy

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4
Q

What causes pigment gallstones?

A
  • Bacterial/parasitic biliary infection

- Haemolysis

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5
Q

What is biliary collic?

A

Gallstones are syptomatic with cystic dust obstruction or CBD obstruction.

Causes pain in epigastrium/RUQ, radiating to back/scapula that occurs suddenly and lasts 2 hours, may cause jaundice

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6
Q

How is biliary collic managed?

A
  1. Analgesia - paracetamol, NSAIDS or IM diclofenac if severe
  2. Rehydration
  3. Elective laparoscopic cholecystectomy
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7
Q

How does acute cholecystitis occur?

A

Obstruction of gallbladder neck or cystic duct by a glalstone. Leads to gallbladder mucosal damage (usuallly not infective!)

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8
Q

What are the clinical features of acute cholecystitis?

A
  • RUQ pain/epigastric pain (lasting over 6 hours)
  • Right shoulder pain
  • Fever
  • Murphys sign (rigidity worse on inspiration)
  • Palpable mass
  • Vomiting
  • Peritonism

RARELY JAUNDICE

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9
Q

What is Mirizzis syndrome?

A

Common hepatic duct obstruction caused by extrinsic compression from an impacted stone in the cystic duct or infundibulum of the gallbladder. Causes JAUNDICE.

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10
Q

What investigations should be done in acute cholecystitis?

A

BEDSIDE: urine dip (exclude UTI?), obs
BLOODS: FBC, U&E (dehydration), amylase (exclude pancreatitis), LFTs (raised ALP), CRP
IMAGING: AXR (not that useful), US (gallstones/gallbladder thickening - key diagnosis), CT (sepsis, empyema,perforation), MRCP

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11
Q

How is acute cholecystitis managed?

A

Emergency admission, NBM, pain relief, IV access fluids

MEDICAL - analgeisa, ?antibiotics (cefuorzime)
SURGICAL - lap cholecystectomy, may need open surgery if perforation (ops should be within 4 days of symptom onset)

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12
Q

What are the clinical features of chronic cholecystitis?

A

Recurrent attacks of upper abdo pain, often at NIGHT or after a big MEAL.

Similiar to acute cholecystitis but milder.

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13
Q

How is chronic cholecystitis managed?

A

CONSERVATIVE - may recover spontaneously, diet, fluids
MEDICAL - analgesia (NSAIDS, paracetamol)
SURGICAL - electrive laparoscophic cholecystectomy

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14
Q

What is the difference between MRCP and ERCP?

A

MRCP consists of creating a magnetic resonance field generated by an MRI machine around the patient that then takes images which aid the diagnostic process.

ERCP involves the use of a contrast dye to be inserted while images are being taken - more invasive, uses endoscopy, can diagnose and treat

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15
Q

How does acute cholangitis occur?

A

Bacterial infection of the bile ducts, most commonly due to choledocholithiasis or strictures, or after ERCP

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16
Q

What are the clinical features of acute cholangitis?

A

CHARCOTs triad:

  1. Fever
  2. Jaundice
  3. RUQ pain

May also have pale stools, hypotension, rigors, sepsi, itch

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17
Q

How is acute cholangitis investigated?

A

BEDSIDE: urine dip, obs
BLOODS: FBC, U&E, CRP, LFT, amylase, ABG, blood cultures
IMAGING: US (shows dilated ducts), EUS, CT, ERCP (gold standard)/MRCP

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18
Q

How is acute cholangitis managed?

A

CONSERVATIVE: IV fluids, oxygen
MEDICAL: analgesia, broad spectrum abx (cefuroxime, metronidazole)
NON-SURGICAL: ERCP and placement of drainage stent, percutaneous transheptaic drainage, endoscopic lithiotripsy (these are all forms of biliary decompression)
SURGICAL: last resort!!! laparoscopic cholecystectomy/choledochotomy

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19
Q

What are the complications of acute cholangitis?

A

Repeated cholangitis
Pancreatitis
Bleeding
Perforation

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20
Q

What are the features of gallbladder cancer?

A
  • Adenocarcinoma
  • Gallstones usually present
  • Calcified PORCELAIN GALLBLADDER - high risk of malingnant change
  • May have had chronic infection with salmonella especially if endemic typhoid in the area
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21
Q

What are the features of cholangiocarcinoma?

A
  • Associated with gallstones, PSC, PBC
  • Presents with obstructive jaundice, upper abdo pain, weight loss
  • Elevated CA199
  • Manage by excision of extrahepatic biliary tree, stent insertion across malignant biliary stricture and chemo
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22
Q

What is Sphincter of Oddi dysfunction?

A
  • Increase in contractility of the sphincter located at the junfction of the bile duct and pancreatic duct in the duodenum
  • Usually occurs after gallbladder removal
  • Produces non-calculous obstruction
  • Deranged LFTs, pain, recurrent pancreatitis
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23
Q

How is SOD diagnosed and managed?

A

Diagnosis - ERCP and manometry (measures the pressure!)

Management - depends on severity, nifedipine/amitriptylline/botox or endoscopic sphincterotomy

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24
Q

What causes pancreatitis?

A

Gallstones
Ethanol
Trauma

Steroids
Mumps
Autoimmune
Scorpion
Hyperlipidaemia, hypothermia, hypercalcaemia
ERCP
Drugs

Pregnancy and neoplasia also!!

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25
What are the clinical features of pancreatitis?
- Gradual/acute epigastric.central abdo pain that radiates to the back - Vomiting - Tachycardia/fever/shock/ileus/rigidity/tenderness - Cullens (umbilical bruising)/Grey Turners sign (flank bruising))
26
What invesitgations should be done in suspected pancreatitis?
BEDSIDE; obs, urine dip, pregnancy test if female BLOODS: FBC, amylase (>3x upper limit), lipase, ABC, U&E, LFT, CRP IMAGING: AXR, erect CXR (exclude perforation), CT/MRI (gold standard), US (if gallstone and raised AST), ERCP
27
How is acute pancreatitis managed?
CONSERVATIVE: NBM (may need NG), fluids, oxygen MEDICAL: analgesia (pethidine/morphine), antiemetics, calcium/magnesium replcaememnt therapy, IV abx SOMETIMES NON-SURGICAL: ERCP and gallstone removal SURGICAL: none!
28
How is severity of pancreatitis measured?
GLASGOW CRITERIA 3 or more within 48h of onset indicate severe pancreatitis and the need for ITU/HDU: ``` Pa02 <8 Age >55 Neutrophilia WBC>15 Calcium <2 Renal function Urea>16 Enzymes LDH/AST high Albumin <32 Sugar BM >10 ```
29
How is chronic pancreatitis managed?
Investigations: AXR/CT - pancreatic calcification Faecal elastase - to assess exocrine function Management: Pancreatic enzyme supplements Analgesia
30
What are the features of pancreatic cancer?
- 80% adenocarcinoma at head of pancreas - Painless jaundice - Abdominal mass (most common is hepatomegaly from mets) - Loss of endocrine/exocrine function - Migratory thrombophleitis (Trousseau sign) - May have MEN/BRCA2/KRAS Diagnose on HRCT - shows double duct sign (simultaneous dilatation of common bile and pancreatic duct) Courvoisier's law states that in the presence of a palpable gall bladder, painless jaundice is unlikely to be caused by gallstones
31
How is pancreatic cancer managed?
- Whipples (pancreaticoduodenectomy) + adjuvant chemotherapy - ERCP + stent to palliate SE of surgery: dumping syndrome, PUD
32
What are the features and management of NAFLD?
Features: - Usually asymptomatic - Hepatomegaly - ALT >AST - Increased echogenicity on USS - Insulin resistance Management: - Weight loss - Enhanced liver fibrosis blood test to check for advanced fibrosis > refer to liver specialist for biopsy - There may be a role for gastric banding and metformin
33
What are the features and management of NASH?
Features: - Subtype of NAFLD with fat with inflammation - Similar to changes seen in alcohol hepatitis in the absence of alcohol
34
What are the features of autoimmune hepatitis? How is it managed?
Three types: 1 - ANA, SMA, adults and children 2 - LKM1, only children 3 - soluble liver kidney, middle aged adults - Associated with HLA B8, DR3 - Presents as chronic disease or acute hepatitis. - Amenorrhoea is common - Liver biopsy shows piecemeal necrosis - Manage with steroids, immunosuppresants and liver transplant
35
What are the features of hepatitis A?
- Acute fever, abdo pain, malaise and jaundice - Markedly elevated AST/ALT - IgM hep A positive - RNA virus - Treatment is supporitve - Not associated with chronic liver disease
36
What are the features of hepatitis B?
- Associated with IVDU and sexual transmission - May be asymptomatic - Some present with cirrhosis/HCC/liver failure - DNA virus - Supportive care, can treat with tenofovir/entecavir if chronic infection - Risk of chronic liver disease
37
What do the following mean: a) HbsAg? b) anti-HBs? c) anti-Hbc? d) IgM anti-Hbc? e) IgG anti-Hbc? f) HbeAg?
a) infection with hep B (acute or chronic if >6 months) b) Immunity (from exposure or immunisation, negative in chronic disease) c) Previous or current infection d) Acute or recent infection e) Infection over 6 months ago f) marker of infectivity
38
What are the features of hepatitis C?
- RNA flavavirus - Transmission via vertical transmission, IVDU or blood transfusion - No vaccine available - Usually asymptomatic - Can lead to chronic liver disease, cirrhossis and HCC - Treat with antiviral tables for 8-12 weeks; will clear infection in most people (sobosfuvir, daclatasvir) - Treat chronic infection with protease inhibitors + ribavirin (teratogenic)
39
What are the features of hepatitis D?
- Single stranded RNA, requires hep B surface antigen to replicate - Coinfection or superinfection - Treat with interferon
40
What are the features of hepatitis E?
- RNA hepevirus - Faecal oral transmission - PORK SAUSAGES! - Self-limiting and does not require specific treatment - Significant mortality in pregnancy
41
What are the features of primary biliary cholangitis/cirrhosis?
-Typically in middle aged females with AI associations - Sjogrens syndrome assoc! - Presents as cholestatic jaundice, hyperpigmentation, clubbing, hepatosplenomegaly - Chronic inflammation damages interlobular bile ducts causing progressive cholestasis and cirrhosis
42
How is PBC diagnosed?
- Anti mitochondrial antibodies (AMA) M2 subtype - Raised serum IgM - USS or MRCP to exclude obstruction 'Rule of M's'
43
How is PBC managed?
1st line - ursodeoxycholic acid (improves symptoms and slows disease progression Cholestyramine for itch Fat soluble vitamin supplementation Liver transplant if bilirubin >100
44
What are the features of primary sclerosing cholangitis?
- Associated with UC (75% of those with PSC will have UC) and HIV - Presents as cholestasis, RUQ and fatigue - Complications include cholangiocarcinoma and colorectal cancer
45
What is the pathophysiology of PSC?
Inflammation and fibrosis of intra and extra-hepatic bile ducts
46
How is PSC diagnosed?
- ERCP/MRCP shows beaded biliary strictures - Positive p-ANCA - Onion skin liver biopsy
47
How is PSC managed?
Liver transplant No medicine slows progression
48
What is ascites and how is it classified?
Accumulation of fluid in the abdomen Classified by serum-ascites albumin gradient SAAG>11 indicates portal htn: - Liver disorders - Heart failure - Budd-Chiari syndrome - Portal vein thrombosis - Myxoedema SAAG<11: - Hypoalbuminaemia - Malignancy - Tubeculous peritonitis - Pancreatitis - Bowel obstruction - Biliary ascites - Serositis assoc with CTD
49
How is ascites managed?
- Reduce dietary sodium - Fluid restrict if low sodium - Aldosterone antagonists - Drainage if TENSE(cover with albumin if large volume) - Prophylactic antibiotics (-floxacin) if protein <15 or cirrhotic - TIPS
50
What is spontaneous bacterial peritonitis?
- Form of peritonitis in pts with ascites and liver disease - Presents as fever, abdominal pain and ascites - Paracentesis shows high neutrophils (>250), often E.coli related
51
How should SBP be managed?
Acute - IV cefotaxime Prophylactic - PO ciprofloxacin
52
What are the biochemical markers of liver failure?
- Low clotting factors (except VIII which is synethesied elsewhere) - Reduced protein C/protein S PATIENTS ARE AT RISK OF BOTH BLEEDING AND THROMBOSIS
53
What is cirrhosis and how is it diagnosed?
- Cirrhosis is scarring of the liver due to long term liver damage - Diagnose with Fibroscan AKA transient elastography (screen if RF) - Liver biopsy 2nd line - Retest every 2 years if risk factors
54
What are the risk factors for cirrhosis?
- Chronic Hep B/C - Alcohol misuse - Obesity - T2DM
55
How is cirrhosis managed?
There is NO CURE. Management focuses on dietary change, diuretics, antihypertensives and managing complications Offer USS every 6 months to screen for HCC in those with cirrhosis
56
What are the features of hepatic encephalopathy?
- Caused by body's inability to remove ammonia from the blood stream - Presents as consuion, tremor, coma - Lactulose used in acute and prophylactic management - Rifaximin sometimes given for prevention
57
What are the main risk factors for HCC?
- Cirrhosis - Alcohol misuse - Haemochromatosis - Chronic HBC/HCV infection - Primary biliary cirrhosis
58
How does HCC usually present?
- Usually presents late with liver cirrhosis/failure or RUQ pain/jaundice/oedema/early satiety/weight loss - Raised AFP (by 75% or >400) - Focal liver lesion in a patient with cirrhosis is likely to be HCC
59
How is HCC managed?
Early: surgical resection Late: liver transplant Also radiofrequency ablation, transarterial chemoembolisation and sorafenib
60
What are the features of haemochromatosis?
- Autosomal recessive disorder of iron absorption/metabolism - Mutation in HFE gene on chromosome 6 - Presents as fatigue, ED, arthralgia, bronze skin, diabetes, cardiac failure, hypogonadism, liver stigmata -
61
Which features of haemochromatosis are reversible/irreversible?
Reversible: - Cardiomyopathy - Skin pigmentation Irreversible: - Liver cirrhosis - Diabetes - Hypogonadotrophic hypogonadism - Arthropathy
62
What do investigations show in haemochromatosis?
- High transferrin saturation (screening tool) - Raised ferritin - Low TIBC - C282Y/H63D mutations may be present - MRI to quantify liver/cardiac iron
63
How is haemochromatosis managed?
1st line - venesection (aim transferrin saturation <50% and ferritin <50) 2nd line - desferrioxamine
64
What are the features of Wilson's disease?
- Autosomal recessive disorder causing copper deposition in tissues - Defect in ATP7B gene on chromosome 13 - Onset of symptoms 10-25y as liver disease or neurological disease (young adults) - Liver, neurological features and Kayser-Fleischer rings in the iris, renal tubular acidosis, haemolysis, blue nails
65
What do investigations shows in Wilson's disease?
- Low caeruloplasmin and low serum copper - High free serum copper - ATP7B gene confirms diagnosis - Slit lamp exam for Kayser-Fleischer rings
66
How is Wilson's disease managed?
1st line - penicillamine to chelate copper 2nd line - trientine hydrochoride
67
Which drugs can cause liver cirrhosis?
Methotrexate Amiodarone Methyldopa MAM
68
What are carcinoid tumours?
Slow-growing tumours of the neuroendocrine system that grow in the bowel or appendix
69
What is carcinoid syndrome?
- Flushing, diarrhoea, bronchospasm and hypotension due to metastases in the liver which release serotonin into systemic circualtion - May also secrete ACTH and gnRH - Diagnosed by urinary 5-HIAA
70
What is a sister joseph nodule?
Umbilical metastatic nodule from an abdominal or pelvic malignancy
71
What is Blumberg sign?
Rebound tenderness indicative of peritonitis
72
What is Riedel's lobe?
- Downward projection of the anterior edge of the right liver lobe to the right of the gallbladder - Normal variant
73
How is alcoholic hepatitis diagnosed and managed?
Investigations: - High GGT - AST:ALT ratio >2 Management: - Predinsolone for acute attacks - Pentoxyphylline can be used if steroids not appropriate

MSRA (24 decks)

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