Liver, Biliary and Pancreas Flashcards
What are the main types of gallstones?
- Cholesterol containing (80%) - large, solitary
2. Pigment stones (calcium) - small, irregular, from haemolysis
What is cholestasis?
Biochemical abnormality (raised ALP) resulting from an abnormality in bile flow
What are the RF for cholesterol gallstones?
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
What causes pigment gallstones?
- Bacterial/parasitic biliary infection
- Haemolysis
What is biliary collic?
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
How is biliary collic managed?
- Analgesia - paracetamol, NSAIDS or IM diclofenac if severe
- Rehydration
- Elective laparoscopic cholecystectomy
How does acute cholecystitis occur?
Obstruction of gallbladder neck or cystic duct by a glalstone. Leads to gallbladder mucosal damage (usuallly not infective!)
What are the clinical features of acute cholecystitis?
- RUQ pain/epigastric pain (lasting over 6 hours)
- Right shoulder pain
- Fever
- Murphys sign (rigidity worse on inspiration)
- Palpable mass
- Vomiting
- Peritonism
RARELY JAUNDICE
What is Mirizzis syndrome?
Common hepatic duct obstruction caused by extrinsic compression from an impacted stone in the cystic duct or infundibulum of the gallbladder. Causes JAUNDICE.
What investigations should be done in acute cholecystitis?
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
How is acute cholecystitis managed?
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)
What are the clinical features of chronic cholecystitis?
Recurrent attacks of upper abdo pain, often at NIGHT or after a big MEAL.
Similiar to acute cholecystitis but milder.
How is chronic cholecystitis managed?
CONSERVATIVE - may recover spontaneously, diet, fluids
MEDICAL - analgesia (NSAIDS, paracetamol)
SURGICAL - electrive laparoscophic cholecystectomy
What is the difference between MRCP and ERCP?
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
How does acute cholangitis occur?
Bacterial infection of the bile ducts, most commonly due to choledocholithiasis or strictures, or after ERCP
What are the clinical features of acute cholangitis?
CHARCOTs triad:
- Fever
- Jaundice
- RUQ pain
May also have pale stools, hypotension, rigors, sepsi, itch
How is acute cholangitis investigated?
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
How is acute cholangitis managed?
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
What are the complications of acute cholangitis?
Repeated cholangitis
Pancreatitis
Bleeding
Perforation
What are the features of gallbladder cancer?
- 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
What are the features of cholangiocarcinoma?
- 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
What is Sphincter of Oddi dysfunction?
- 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
How is SOD diagnosed and managed?
Diagnosis - ERCP and manometry (measures the pressure!)
Management - depends on severity, nifedipine/amitriptylline/botox or endoscopic sphincterotomy
What causes pancreatitis?
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion
Hyperlipidaemia, hypothermia, hypercalcaemia
ERCP
Drugs
Pregnancy and neoplasia also!!
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))
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
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!
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
How is chronic pancreatitis managed?
Investigations:
AXR/CT - pancreatic calcification
Faecal elastase - to assess exocrine function
Management:
Pancreatic enzyme supplements
Analgesia
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
How is pancreatic cancer managed?
- Whipples (pancreaticoduodenectomy) + adjuvant chemotherapy
- ERCP + stent to palliate
SE of surgery: dumping syndrome, PUD
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
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
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
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
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
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
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)
What are the features of hepatitis D?
- Single stranded RNA, requires hep B surface antigen to replicate
- Coinfection or superinfection
- Treat with interferon
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
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
How is PBC diagnosed?
- Anti mitochondrial antibodies (AMA) M2 subtype
- Raised serum IgM
- USS or MRCP to exclude obstruction
‘Rule of M’s’
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
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
What is the pathophysiology of PSC?
Inflammation and fibrosis of intra and extra-hepatic bile ducts
How is PSC diagnosed?
- ERCP/MRCP shows beaded biliary strictures
- Positive p-ANCA
- Onion skin liver biopsy
How is PSC managed?
Liver transplant
No medicine slows progression
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
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
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
How should SBP be managed?
Acute - IV cefotaxime
Prophylactic - PO ciprofloxacin
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
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
What are the risk factors for cirrhosis?
- Chronic Hep B/C
- Alcohol misuse
- Obesity
- T2DM
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
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
What are the main risk factors for HCC?
- Cirrhosis
- Alcohol misuse
- Haemochromatosis
- Chronic HBC/HCV infection
- Primary biliary cirrhosis
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
How is HCC managed?
Early: surgical resection
Late: liver transplant
Also radiofrequency ablation, transarterial chemoembolisation and sorafenib
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
Which features of haemochromatosis are reversible/irreversible?
Reversible:
- Cardiomyopathy
- Skin pigmentation
Irreversible:
- Liver cirrhosis
- Diabetes
- Hypogonadotrophic hypogonadism
- Arthropathy
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
How is haemochromatosis managed?
1st line - venesection (aim transferrin saturation <50% and ferritin <50)
2nd line - desferrioxamine
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
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
How is Wilson’s disease managed?
1st line - penicillamine to chelate copper
2nd line - trientine hydrochoride
Which drugs can cause liver cirrhosis?
Methotrexate
Amiodarone
Methyldopa
MAM
What are carcinoid tumours?
Slow-growing tumours of the neuroendocrine system that grow in the bowel or appendix
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
What is a sister joseph nodule?
Umbilical metastatic nodule from an abdominal or pelvic malignancy
What is Blumberg sign?
Rebound tenderness indicative of peritonitis
What is Riedel’s lobe?
- Downward projection of the anterior edge of the right liver lobe to the right of the gallbladder
- Normal variant
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
