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Y4 final checklist_ SURGERY > Liver Disease > Flashcards

Liver Disease Flashcards

1
Q

The most common organisms causing pyogenic liver abscess

A
  • Staphylococcus aureus → in children
  • Escherichia coli → in adults
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2
Q

Management of pyogenic liver abscess

A
  • drainage (typically percutaneous)

Antibiotics:

  • amoxicillin + ciprofloxacin + metronidazole
  • if penicillin allergic: ciprofloxacin + clindamycin
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3
Q

What’s amebiasis?

Can it cause liver abscess?

A

Amoebiasis

  • caused by Entamoeba histolytica (an amoeboid protozoan)
  • spread by the faecal-oral route
  • causes liver and colonic abscesses
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4
Q

Features of amoebic liver abscess

A

Amoebic liver abscess

  • usually a single mass in the right lobe (may be multiple). The contents are often described as ‘anchovy sauce’
  • features: fever, RUQ pain
  • serology is positive in > 90%
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5
Q

Amoebic liver abscess

  • associated to what condition
  • symptoms
  • Ix
  • treatment
A
  • Liver abscess is the most common extra intestinal manifestation of amoebiasis
  • Presenting complaints typically include fever and right upper quadrant pain
  • Ultrasonography → fluid filled structure with poorly defined boundaries
  • Aspiration → sterile odourless fluid which has an anchovy paste consistency

Treatment: metronidazole

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6
Q

Liver abscess

  • common cause
  • symptoms
  • Ix
A
  • Biliary sepsis → major predisposing factor
  • Structures drained by the portal venous system form the second largest source
  • Common symptoms include fever, right upper quadrant pain. Jaundice may be seen in 50%
  • Ultrasound will usually show a fluid filled cavity, hyperechoic walls may be seen in chronic abscesses
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7
Q

Risk factors for Hepatocellular Carcinoma

A

The main risk factor for developing HCC is: liver cirrhosis (secondary to hepatitis B & C, alcohol, haemochromatosis and primary biliary cirrhosis)

Other risk factors include:

  • alpha-1 antitrypsin deficiency
  • hereditary tyrosinosis
  • glycogen storage disease
  • aflatoxin
  • drugs: oral contraceptive pill, anabolic steroids
  • porphyria cutanea tarda
  • male sex
  • diabetes mellitus, metabolic syndrome
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8
Q
A
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9
Q

Features for hepatocellular carcinoma

A
  • tends to present late
  • features of liver cirrhosis or failure may be seen: jaundice, ascites, RUQ pain, hepatomegaly, pruritus, splenomegaly
  • possible presentation is decompensation in a patient with chronic liver disease
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10
Q

Screening for hepatocellular carcinoma

  • who and how
A

Screening with ultrasound (+/- alpha-fetoprotein) should be considered for high risk groups such as:

  • patients liver cirrhosis secondary to hepatitis B & C or haemochromatosis
  • men with liver cirrhosis secondary to alcohol
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11
Q

Management of hepatocellular carcinoma

A
  • early disease: surgical resection
  • liver transplantation
  • radiofrequency ablation
  • transarterial chemoembolisation
  • sorafenib: a multikinase inhibitor
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12
Q

Causes of Liver Cirrhosis

A
  • alcohol
  • non-alcoholic fatty liver disease (NAFLD)
  • viral hepatitis (B and C)
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13
Q

Diagnosis of liver cirrhosis

A
  • traditionally a liver biopsy was used. This procedure is however associated with adverse effects such as bleeding and pain
  • other techniques such as transient elastography and acoustic radiation force impulse imaging are increasingly used
  • for patients with NAFLD→ enhanced liver fibrosis score to screen for patients who need further testing
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14
Q

What’s transient elastography?

A
  • brand name ‘Fibroscan’
  • uses a 50-MHz wave is passed into the liver from a small transducer on the end of an ultrasound probe
  • measures the ‘stiffness’ of the liver which is a proxy for fibrosis
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15
Q

What further investigation a patient with liver cirrhosis needs? (2)

A
  • upper endoscopy → to check for varices in patient’s with a new diagnosis of cirrhosis
  • liver ultrasound every 6 months (+/- alpha-feto protein) → to check for hepatocellular cancer
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16
Q

What (2) scoring systems are used to classify the severity of liver cirrhosis?

A
  • Child-Pugh
  • MELD
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17
Q

Principle of MELD

A

MELD - one of the scores used to grade the severity of liver cirrhosis

MELD uses combination of a patient’s bilirubin, creatinine, and the international normalized ratio (INR) to predict survival. A formula is used to calculate the score.

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18
Q

What’s Child-Pough?

A

A score used to grade severity of liver cirrhosis

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19
Q
A
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20
Q

General composition of gallstones

A
  • Phospholipids: lecithin
  • Bile pigments (broken down Hb)
  • Cholesterol
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21
Q

What’s Admirand’s Triangle?

A

Increased formation of cholesterol gallstones

Admirand’sTrangle

  • ↓ bile salts
  • ↓ lecithin
  • ↑ cholesterol
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22
Q

Risk factors associated with development of cholesterol gallstones

A

Risk factors

  • Female
  • OCP, pregnancy
  • ↑ age
  • High fat diet and obesity
  • Racial: e.g. American Indian tribes
  • Loss of terminal ileum (↓ bile salts)
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23
Q

What types of gallstones is the most common?

A

Mixed Stones: 75%

  • Often multiple
  • Cholesterol is the major component

Cholesterol (20%) - second most common

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24
Q

What pigmented stones (gallstones) are associated with?

A

Pigment Stones: 5%

  • Small, black, gritty, fragile
  • Calcium bilirubinate
  • Associated with haemolysis
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25
Q

Complications of the gallstones

A

In the Gallbladder

  • Biliary Colic
  • Acute cholecystitis ± empyema
  • Chronic cholecytsitis
  • Mucocele
  • Carcinoma
  • Mirizzi’s syndrome

In the CBD

  • Obstructive jaundice
  • Pancreatitis
  • Cholangitis

In the Gut

• Gallstone ileus

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26
Q

Pathophysiology of biliary colic

A
  • Gallbladder spasm against a stone impacted in the neck of the gallbladder – Hartmann’s Pouch
  • Less commonly, the stone may be in the CBD
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27
Q

Presentation of Biliary Colic

A

Biliary colic

  • RUQ pain radiating → back (scapular region)
  • Assoc. with sweating, pallor, n/v
  • Attacks may be prompted by fatty food and last <6h
  • o/e may be tenderness in right hypochondrium
  • ± jaundice if stones passes in to CBD
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28
Q

Ix for biliary colic

  • urine
  • blood
A

Same work up as cholecystitis as may be difficult to differentiate clinically

  • Urine: bilirubin, urobilinogen, Hb
  • Bloods: FBC, U+E, amylase, LFTs, G+S, clotting, CRP
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29
Q

Imaging as Ix for Biliary colic (3)

What can be seen?

A

Imaging

  • AXR: 10% of gallstones are radio-opaque
  • Erect CXR: look for perforation
  • US:
  • Stones: acoustic shadow
  • Dilated ducts: >6mm
  • Inflamed GB: wall oedema
30
Q

If the diagnosis of biliary colic is uncertain after US, what next Ix to do?

A
  • HIDA cholescintigraphy: shows failure of GB filling (requires functioning liver)
  • If dilated ducts seen on US → MRCP

HIDA scan, also called cholescintigraphy or hepatobiliary scintigraphy, is an imaging test used to view the liver, gallbladder, bile ducts, and small intestine. The scan involves injecting a radioactive tracer into a person’s vein. The tracer travels through the bloodstream into the body parts listed above.

31
Q

Possible management options for biliary colic

A

Conservative

  • Rehydrate and NBM
  • Opioid analgesia: morphine

* High recurrence rate → surgical Rx favoured

Surgical

  • Laparoscopic cholecystectomy
32
Q

Pathophysiology of Acute cholecystitis

A
  • Stone or sludge impaction in Hartmann’s pouch → chemical and / or bacterial inflammation
  • 5% are acalculous: sepsis, burns, DM
33
Q

Possible progression/complications of acute cholecystitis (4)

A
  • Resolution ± recurrence
  • Gangrene and rarely perforation
  • Chronic cholecystitis
  • Empyema
34
Q

Presentation of Acute Cholecystitis

A

•Severe RUQ pain

  • Continuous
  • Radiates to right scapula and epigastrium
  • Fever
  • Vomiting
35
Q

Examination findings in acute cholecystitis

A
  • Local peritonism in RUQ
  • Tachycardia with shallow breathing
  • ± jaundice
  • Murphy’s sign
  • Phlegmon may be palpable→ mass of adherent omentum and bowel
  • Boas’ sign
36
Q

What’s Murphy’s sign?

A

Murphy’s sign → indicative of cholecystitis

  • 2 fingers over the GB and ask the patient to breathe in → pain and breath catch

( must be –ve on the L side)

37
Q

What’s Phlegmon?

A

Phlegmon → possible cholecystitis

Phlegmon may be palpable → mass of adherent omentum and bowel

38
Q

What’s Boas’ sign?

A

Boas’ sign → possible cholecystitis

  • Hyperaesthesia below the right scapula
39
Q

Urine and blood investigation for acute cholecystitis

A
  • Urine: bilirubin, urobilinogen
  • Bloods:
  • FBC: ↑ WCC
  • U+E: dehydration from vomiting
  • Amylase, LFTs, G+S, clotting, CRP
40
Q

Imaging Ix in acute cholecystitis

A

Imaging

  • AXR: gallstone, porcelain gallbladder
  • Erect CXR: look for perforation
  • US
  • Stones: acoustic shadow
  • Dilated ducts (>6mm)
  • Inflamed GB: wall oedema

If Dx uncertain after US → HIDA cholescintigraphy: shows failure of GB filling (requires functioning liver)
• MRCP if dilated ducts seen on US

41
Q

Management of Acute Cholecystitis

A

Conservative

  • NBM
  • Fluid resuscitation
  • Analgesia: paracetamol, diclofenac, codeine
  • Abx: cefuroxime and metronidazole
  • 80-90% settle over 24-48h
  • Deterioration: perforation, empyema

Surgical

  • elective surgery @ 6-12wks (↓inflammation)
  • if<72h, may perform lap chole in acute phase
42
Q

Management in empyema

A

Empyema - pus in the GB; complication of acute cholecystitis

  • High fever
  • RUQ mass

Managment: Percutaneous drainage: cholecystostomy

43
Q

Symptoms of chronic cholecystitis

A

Symptoms: Flatulent Dyspepsia /wzdety/

  • Vague upper abdominal discomfort
  • Distension, bloating
  • Nausea
  • Flatulence, burping
  • Symptoms exacerbated by fatty foods
44
Q

Ix for chronic cholecystitis

A
  • AXR: porcelain gallbladder
  • US: stones, fibrotic, shrunken gallbladder
  • MRCP
45
Q

Management of Chronic Cholecystitis

A

Medical

  • Bile salts (not very effective)

Surgical

  • Elective cholecystectomy
  • ERCP first if US shows dilated ducts and stones
46
Q

What’s Mucocele?

A

Mucocele

  • Neck of gallbladder blocked by stone but contents remains sterile
  • Can be very large → palpable mass
  • May become infected → empyema
47
Q

What’s Mirrizi’s syndrome?

A

Mirizzi’s Syndrome

  • Rare
  • Large stone in GB presses on the common hepatic duct → obstructive jaundice.
  • Stone may erode through into the ducts
48
Q

Appearance of the gallbladder in a gallbladder carcinoma

A

Gallbladder Carcinoma

  • Rare
  • Associated with gallstones and gallbladder polyps.
  • Calcification of gallbladder → porcelain GB
  • Incidental Ca found in 0.5-1% of lap choles
49
Q

What’s Gallstone Ileus?

A

Gallstone Ileus

  • Large stone (>2.5cm) erodes from GB → duodenum through a cholecysto-duodenal fistula secondary to chonic inflammation → may impact in distal ileum → obstruction
  • Rx: stone removal via enterotomy
  • NB. Bouveret’s syn. = duodenal obstruction
50
Q

What’s Rigler’s Triad?

A

Rigler’s Triad - combination of findings of AXR in gallstone ileus

  • Pneumobiliia
  • Small bowel obstruction
  • Gallstone in RLQ
51
Q

Risk factors for Biliary Colic

A

Risk factors

  • it is traditional to refer to the ‘4 F’s’:
    • Fat: obesity is thought to be a risk factor due to enhanced cholesterol synthesis and secretion
    • Female: gallstones are 2-3 times more common in women. Oestrogen increases activity of HMG-CoA reductase
    • Fertile: pregnancy is a risk factor
    • Forty
  • other notable risk factors include:
    • diabetes mellitus
    • Crohn’s disease
    • rapid weight loss e.g. weight reduction surgery
    • drugs: fibrates, combined oral contraceptive pill
52
Q

What’s Cholangiocarcinoma?

A
  • the second most common type of primary liver malignancy
  • tumours arise in the bile ducts
  • up to 80% of tumours arise in the extrahepatic biliary tree
53
Q

Presentation of cholangiocarcinoma

A

Most patients present with jaundice and by this stage the majority will have disease that is not resectable

54
Q

Risk factors for cholangiocarcinoma (2)

A
  • Primary sclerosing cholangitis
  • In deprived countries → typhoid and liver flukes
55
Q

Ix and Dx in cholangiocarcinoma

A
  • LFTs → an obstructive picture
  • CA 19-9, CEA and CA 125 → often elevated
  • CT/ MRI and MRCP → imaging methods of choice
56
Q

Treatment of Cholangiocarcinoma

A
  • Surgical resection → the best chance of cure

*Local invasion of peri hilar tumours is a particular problem and this coupled with lobar atrophy will often contra indicate surgical resection

  • Palliation of jaundice is important, although metallic stents should be avoided in those considered for resection.

Survival

Is poor, approximately 5-10% 5 year survival.

57
Q

What’s Primary Biliary Cholangitis (PBC)?

A

Primary biliary cholangitis (previously referred to as primary biliary cirrhosis)

  • chronic liver disorder
  • typically seen in middle-aged females (female:male ratio of 9:1)
  • thought to be an autoimmune condition
  • Interlobular bile ducts become damaged by a chronic inflammatory process causing progressive cholestasis which may eventually progress to cirrhosis
58
Q

The classic presentation of Primary Biliary Cholangitis (PBC)

A

The classic presentation is itching in a middle-aged woman

59
Q

Associations with PBC

A

Autoimmune, so:

  • Sjogren’s syndrome (seen in up to 80% of patients)
  • rheumatoid arthritis
  • systemic sclerosis
  • thyroid disease
60
Q

Diagnosis of PBC (3)

A
  • anti-mitochondrial antibodies (AMA) M2 → present in 98% of patients and are highly specific
  • smooth muscle antibodies → in 30% of patients
  • raised serum IgM
61
Q

Management of PBC

A
  • pruritus: cholestyramine
  • fat-soluble vitamin supplementation
  • ursodeoxycholic acid
  • liver transplantation e.g. if bilirubin > 100 (PBC is a major indication) - recurrence in graft can occur but is not usually a problem
62
Q

Complications of PBC

A
  • cirrhosis
  • osteomalacia and osteoporosis
  • significantly increased risk of hepatocellular carcinoma
63
Q

What’s PSC ?

A

Primary sclerosing cholangitis is a biliary disease of unknown aetiology characterised by inflammation and fibrosis of intra and extra-hepatic bile ducts

64
Q

Associations with PSC (3)

A
  • ulcerative colitis: 4% of patients with UC have PSC, 80% of patients with PSC have UC
  • Crohn’s (much less common association than UC)
  • HIV
65
Q

Features of PSC

A
  • cholestasis: jaundice and pruritus
  • right upper quadrant pain
  • fatigue
66
Q

Ix of PSC

A
  • endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP) are the standard diagnostic investigations, showing multiple biliary strictures giving a ‘beaded’ appearance
  • ANCA may be positive
  • there is a limited role for liver biopsy, which may show fibrous, obliterative cholangitis often described as ‘onion skin’
67
Q

Complications of PSC

A

Complications

  • cholangiocarcinoma (in 10%)
  • increased risk of colorectal cancer
68
Q

Triad and pentad seen in Ascending Cholangitis

A
  • Charcot’s triad: fever/rigors, RUQ pain, jaundice
  • Reynolds pentad: Charcot’s triad + shock + confusion
69
Q

What’s Ascending Cholangitis?

A

Ascending cholangitis is a bacterial infection (typically E. coli) of the biliary tree.

The most common predisposing factor is gallstones.

70
Q

Management of Ascending Cholangitis

A
  • intravenous antibiotics: Cef and Met
  • 1st line: ERCP after 24-48 hours to relieve any obstruction
  • 2nd line: Open or lap stone removal with T tube drain
71
Q

Management of PSB

A

Y4 final checklist_ SURGERY (25 decks)

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