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TCD Cases > Liver, Biliary and Pancreatic Disease > Flashcards

Liver, Biliary and Pancreatic Disease Flashcards

1
Q

Define acute liver failure

A

Rapid decline in hepatic function characterised by jaundice, coagulopathy and hepatic encephalopathy in patients with no prior evidence of liver disease.

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2
Q

Define coagulopathy

A

INR > 1.5

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3
Q

What are the clinical characteristics of fulminant hepatitis?

A

Patient presenting with both jaundice and coagulopathy

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4
Q

What is the main clinical presentation of a patient with conjugated hyperbilirubinaemia?

A

Dark urine and pale stools

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5
Q

Define obstructive jaundice

A

Blockage of flow of bile through bile ducts or intrahepatic/ extra hepatic ducts

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6
Q

Name the 2 subcategories of conjugated hyperbilirubinaemia

A
  1. Obstructive jaundice

2. Hepatocellular jaundice

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7
Q

Outline the 4 common causes of obstructive jaundice

A
  1. Gallstones
  2. Biliary colic
  3. Cholecystitis
  4. Carcinoma of the head of the pancreas
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8
Q

Outline the 4 common causes of hepatocellular jaundice

A
  1. Alcoholic hepatitis
  2. Viral hepatitis
  3. Drug induced (e.g. paramcetemaol overdose)
  4. Non-alcoholic fatty liver disease
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9
Q

Define steatohepatitis

A

The accumulation of fat in the liver that induces inflammation

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10
Q

What are the two subcategories of steatohepatitis?

A
  1. Alcohol related fatty liver disease

2. Non-alcoholic fatty liver disease (NAFLD)

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11
Q

Give 2 more uncommon causes of obstructive jaundice

A
  1. Sclerosing cholangitis

2. Cholangiocarcinoma

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12
Q

Give 3 uncommon causes of hepatocellular jaundice

A
  1. Autoimmune liver disease
  2. Haemochromatosis
  3. Wilson’s disease
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13
Q

Describe the positioning of pain associated with Biliary Colic

A

Right upper quadrant

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14
Q

What are the three clinical components of cholangitis?

A
  1. Biliary colic
  2. Jaundice
  3. Fever
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15
Q

Describe the positioning of pain associated with pancreatitis

A

Severe epigastric pain radiating to the back

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16
Q

What are the 2 most common causes of pancreatitis?

A
  1. Alcohol excess

2. Obstruction of the common bile duct by gallstones

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17
Q

What is the most important differential associated with painless jaundice?

A

Possible liver or pancreatic cancer

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18
Q

What is the difference in the ratio of transaminases to Alk Phos on an LFT panel for Hepatocellular damage compared to an obstructive cause?

A
  1. Hepatocellular damage: Rise in transaminases is much greater than the rise in all phos
  2. Obstructive cause: Rise in Alk Phos is much greater than the rise in the transaminases.
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19
Q

In what patient cohort does carcinoma of the head of the pancreas need to be actively excluded as a differential with imaging tests?

A

Patients over 40 who have painless obstructive jaundice

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20
Q

Which biomarker is used for the investigation of primary hepatocellular cancer?

A

alpha-fetoprotein

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21
Q

Primary hepatocellular cancer is more common in which patient cohort?

A

Patients with liver cirrhosis

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22
Q

Define 1 alcohol unit

A

10mls or 8g of pure ethanol

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23
Q

Abrupt alcohol withdrawal can be associated with which clinical syndrome?

A

Delirium Tremens

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24
Q

Give the 5 most common differentials for leukonychia

A
  1. Minor trauma
  2. Hypoalbuminaemia in chronic liver disease
  3. Chronic kidney disease
  4. Fungal infection
  5. Lymphoma
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25
Q

Give the 2 most common differentials for koilonychia

A
  1. Trauma

2. Iron deficiency

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26
Q

What is the differential for angular stomatitis that is particularly relevant in an abdominal exam?

A

Iron/B12 deficiency

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27
Q

In the context of abdominal pathology, mouth ulcers can indicate one of which 2 conditions?

A
  1. Crohn’s disease

2. Coeliac disease

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28
Q

Excoriations on abdominal exam are an indications of which pathology?

A

Cholestasis

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29
Q

What are the 3 main causes of asterexis?

A
  1. Hepatic encephalopathy
  2. Uraemia
  3. CO2 retention
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30
Q

Name the 3 main abdominal differentials associated with clubbing on clinical examination

A
  1. Inflammatory bowel disease
  2. Cirrhosis
  3. Coeliac disease
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31
Q

In caucasians, jaundice becomes clinically evident at approximately what level of bilirubin?

A

50umol/L

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32
Q

What are the 2 main causes of unconjugated hyperbilirubinaemia

A
  1. Haemolysis

2. Gilbert’s syndrome

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33
Q

Gilbert’s syndrome is often associated with which other clinical condition?

A

Haemolytic anemia

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34
Q

Severe cases of acute hepatitis are associated with which 2 complications?

A
  1. Coagulopathy

2. Renal Impairment

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35
Q

What is the technical definition of Fulminant hepatitis?

A

Encephalopathy within 28 days of developing jaundice secondary to acute liver disease (i.e. liver failure)

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36
Q

What are the clinical consequences of portal hypertension secondary to liver cirrhosis (5)

A
  1. Varices
  2. Piles
  3. Ascites
  4. Encephalopathy
  5. Renal Failure
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37
Q

List the symptoms associated with loss of hepatic function seen in patients with significant liver cirrhosis (5)

A
  1. Jaundice
  2. Coagulopathy
  3. Decreased drug metabolism
  4. Decreased hormone metabolism
  5. Increased sepsis rate
38
Q

Which 2 drug classes become particularly dangerous in patients with liver cirrhosis due to decreased physiological tolerance?

A
  1. Sedatives

2. Opioids

39
Q

Which hormone is particularly raised in patients with severe liver cirrhosis?

A

oestrogen

40
Q

Give 4 clinical signs associated with elevated oestrogen levels in men with liver cirrhosis

A
  1. Palmar erythema
  2. Spider nevi
  3. Gynaecomastia
  4. Loss of secondary body hair
41
Q

Outline the 6 main causes of liver cirrhosis

A
  1. Alcohol Excess
  2. Chronic hepatitis B + C
  3. Autoimmune liver disease
  4. Haemachromatosis
  5. Wilson’s disease
  6. Chronic obstruction
42
Q

Give the 4 main clinical stigmata of cirrhosis

A
  1. Palmar erythema
  2. Leukonychia
  3. Spider nave
  4. Caput medusa
43
Q

Define and differentiate between bile pigments and bile salts

A

Bile pigments = breakdown products of haemoglobin

Bile acids = acids derived from cholesterol metabolism that are conjugated with either glycine or taurine

44
Q

With what substance is bilirubin conjugated with in order to make the molecule water soluble?

A

Glucuronic acid

45
Q

Suggest 4 potential causes of haemolytic jaundice

A
  1. RBC abnormalities e.g. sickle cell
  2. Due to incompatible blood transfusions
  3. Drug reactions
  4. Hypersplenism
46
Q

What are the 5 components of metabolic syndrome?

A
  1. Obesity
  2. Hypertension
  3. Diabetes
  4. Hypertriglyceridemia
  5. Hyperlipidaemia
47
Q

Define steatohepatitis

A

Combination of steatosis and inflammation in the liver

48
Q

What are Mallory-Denk bodies?

A

Tangles of intermediate filaments seen on histopathology of fatty liver disease

49
Q

How does fibrosis occur in chronic steatohepatitis?

A

Stellate cells lay down fibrotic tissue

50
Q

What type of anemia is most commonly associated with liver disease?

A

Macrocytic (normoblastic)

51
Q

Which electrolyte imbalance is most closely associated with liver cirrhosis?

A

Hyponatraemia

52
Q

What are the most common causes of hepatocellular carcinoma worldwide and in Europe respectively?

A

Worldwide - Chronic hepatitis B

Europe - Chronic hepatitis C

53
Q

The liver and pancreas are derived from which embryological layer?

A

Endoderm

54
Q

Name the blood-film abnormality that is associated with Liver disease

A

Target cells

55
Q

Which peritoneal ligament attaches the liver to the anterior abdominal wall?

A

Falciform Ligament

56
Q

Name a drug that is associated with causing liver fibrosis

A

Methotrexate

57
Q

Name 2 infectious diseases that can cause deranged LFT’s

A
  1. Legionella pneumophilia

2. Infectious mononucleosis

58
Q

What are the two potential treatment options for unconjugated hyperbilirubinaemia?

A
  1. Phototherapy

2. Exchange transfusion

59
Q

Define kernicterus

A

Form of bilirubin encephalopathy that can be either chronic or acute in presentation.

60
Q

Give 3 treatment options for hepatitis C

A
  1. Interferon
  2. Ribavirin
  3. Protease inhibitors
61
Q

What is unique about hepatitis delta?

A

An imperfect virus i.e. requires co-infection with hepatitis B in order to replicate in the body

62
Q

Name 2 hereditary causes of hepatitis

A
  1. Wilson’s disease

2. Haemochromatosis

63
Q

What is the most common clinical manifestation of EBV?

A

Infectious mononucleosis

64
Q

Recall 4 types of cancer that have an increased incidence in patients that have been infected with EBV

A
  1. B cell lymphoma
  2. T cell lymphoma
  3. Hodgkin’s lymphoma
  4. Nasopharyngeal carcinoma
65
Q

What is another name for infectious mononucleosis?

A

Glandular fever

66
Q

Name 7 systemic viruses which may affect the liver and lead to viral hepatitis

A
  1. Herpes virus
  2. EBV
  3. CMV
  4. Varicella Virus
  5. Adenovirus
  6. Yellow fever
  7. Haemorrhagic viruses
67
Q

All viruses that can cause viral hepatitis are RNA viruses apart from which virus?

A

Hepatitis B - DNA virus

68
Q

Wernicke’s encephalopathy is brought about by a deficiency in which vitamin?

A

Vitamin B1 - Thiamine

69
Q

What are the 4 principle characteristics of Wernicke’s encephalopathy?

A
  1. Ataxia
  2. Ophthalmoplegia
  3. Confusion
  4. Short term memory loss
70
Q

Excluding alcohol addiction, give 5 potential causes of Wernicke’s encephalopathy

A
  1. Eating disorders
  2. Prolonged vomiting
  3. GI malignancy
  4. Amphetamine addiction
  5. Crohn’s disease
71
Q

Give 3 brain structures which are damaged in Wernicke’s encephalopathy

A
  1. Thalamic nuclei
  2. Brainstem nuclei
  3. Cerebellum
72
Q

What is Pabrinex?

A

An injection that administered the B vitamins + Vitamin C

73
Q

Excluding alcohol abuse, give 2 other potential causes of Korsakoff’s syndrome

A
  1. Subarachnoid haemorrhage

2. Brain tumours in the thalamic region

74
Q

Define anterograde memory loss

A

Inability to acquire new memories

75
Q

Define retrograde memory loss

A

Loss of old memories

76
Q

Briefly outline the pathology of Wilson’s disease

A

Copper incorporation into caeruplasmin in hepatocytes and excretion in the bile is impaired. This leads to copper accumulation first in the liver and then the basal ganglia

77
Q

What is the classical clinical sign associated with Wilson’s disease?

A

Kayser Fleischer rings ( gold rings around iris)

78
Q

What is the treatment for Wilson’s disease?

A

Life long Penicillamine (copper chelation)

79
Q

What are the 2 most common gene mutations associated with haemochromatosis?

A

C282Y and H63D mutations of the HFE gene

80
Q

Name the 3 processes which may lead to the formation of pigment gallstones

A
  1. Increase in bilirubin load as a result of haemolytic anemia
  2. Pigments become less water soluble once in the bile as a result of the action of glucuronidases
  3. Cirrhosis - as this leads to the depletion of glucuronidases inhibitors in the bile
81
Q

Suggest 3 potential symptomatic manifestations of gallstones

A
  1. Biliary colic
  2. Cholecystitis
  3. Pancreatitis
82
Q

Suggest 5 differentials for biliary colic

A
  1. GORD
  2. Peptic ulcer disease
  3. IBS
  4. Pancreatitis
  5. Malignancy e.g. Stomach, pancreas, large bowel
83
Q

Name 3 anti-emetic drugs

A
  1. Domperidone
  2. Metoclopramide
  3. Cyclizine
84
Q

Name the antibiotic commonly prescribed prophylactically in elective cholecystectomy

A

Cefuroxime - 2nd generation cephalosporin

85
Q

Suggest 7 potential causes of intrinsic bile duct obstruction

A
  1. Common bile duct gallstones
  2. Cholangitis
  3. Carcinoma of the bile duct
  4. Carcinoma of the gallbladder
  5. Benign post-traumatic stricture
  6. Sclerosing cholangitis
  7. Haemobilia
86
Q

Define Caroli’s disease

A

Congenital intrahepatic biliary dilatation

87
Q

Epigastric pain relieved by sitting forward / by a hot water bottle to the epigastrium is characteristic of what disease process?

A

Chronic pancreatitis

88
Q

Recall 7 complications associated with chronic pancreatitis

A
  1. Pseudocysts
  2. Diabetes
  3. Biliary obstruction
  4. Local arterial aneurysm
  5. Splenic vein thrombosis
  6. Gastric varices
  7. Pancreatic carcinoma
89
Q

Name the principle gene implicated in carcinoma of the pancreas

A

KRAS2 gene

90
Q

Which class of drugs may cause jaundice as a result of haemolysis?

A

Antimalarials e.g. dapsone

91
Q

Name 6 drugs which may induce jaundice as a result of drug related hepatitis

A
  1. Paracetamol overdose
  2. Tuberculosis therapy - specifically: Isoniazid, rifampicin and pyrazinamide
  3. Monoamine oxidase inhibitors e.g. selegiline
  4. Sodium valproate
  5. Halothane
  6. Statins
92
Q

Suggest 6 drugs which may cause jaundice as a result of drug induced cholestasis

A
  1. Flucloxacillin
  2. Fusidic acid, co-amoxiclav, nitrofurantoin
  3. Steroids
  4. Sulphonylureas
  5. Prochlorperazine
  6. Chlorperazine

TCD Cases (25 decks)

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