Liver Disease Flashcards
The most common organisms causing pyogenic liver abscess
- Staphylococcus aureus → in children
- Escherichia coli → in adults
Management of pyogenic liver abscess
- drainage (typically percutaneous)
Antibiotics:
- amoxicillin + ciprofloxacin + metronidazole
- if penicillin allergic: ciprofloxacin + clindamycin
What’s amebiasis?
Can it cause liver abscess?
Amoebiasis
- caused by Entamoeba histolytica (an amoeboid protozoan)
- spread by the faecal-oral route
- causes liver and colonic abscesses
Features of amoebic liver abscess
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%
Amoebic liver abscess
- associated to what condition
- symptoms
- Ix
- treatment
- 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
Liver abscess
- common cause
- symptoms
- Ix
- 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
Risk factors for Hepatocellular Carcinoma
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
Features for hepatocellular carcinoma
- 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
Screening for hepatocellular carcinoma
- who and how
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
Management of hepatocellular carcinoma
- early disease: surgical resection
- liver transplantation
- radiofrequency ablation
- transarterial chemoembolisation
- sorafenib: a multikinase inhibitor
Causes of Liver Cirrhosis
- alcohol
- non-alcoholic fatty liver disease (NAFLD)
- viral hepatitis (B and C)
Diagnosis of liver cirrhosis
- 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
What’s transient elastography?
- 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
What further investigation a patient with liver cirrhosis needs? (2)
- 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
What (2) scoring systems are used to classify the severity of liver cirrhosis?
- Child-Pugh
- MELD
Principle of MELD
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.
What’s Child-Pough?
A score used to grade severity of liver cirrhosis
General composition of gallstones
- Phospholipids: lecithin
- Bile pigments (broken down Hb)
- Cholesterol
What’s Admirand’s Triangle?
Increased formation of cholesterol gallstones
Admirand’sTrangle
- ↓ bile salts
- ↓ lecithin
- ↑ cholesterol
Risk factors associated with development of cholesterol gallstones
Risk factors
- Female
- OCP, pregnancy
- ↑ age
- High fat diet and obesity
- Racial: e.g. American Indian tribes
- Loss of terminal ileum (↓ bile salts)
What types of gallstones is the most common?
Mixed Stones: 75%
- Often multiple
- Cholesterol is the major component
Cholesterol (20%) - second most common
What pigmented stones (gallstones) are associated with?
Pigment Stones: 5%
- Small, black, gritty, fragile
- Calcium bilirubinate
- Associated with haemolysis
Complications of the gallstones
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
Pathophysiology of biliary colic
- Gallbladder spasm against a stone impacted in the neck of the gallbladder – Hartmann’s Pouch
- Less commonly, the stone may be in the CBD
Presentation of Biliary Colic
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
Ix for biliary colic
- urine
- blood
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
Imaging as Ix for Biliary colic (3)
What can be seen?
Imaging
- AXR: 10% of gallstones are radio-opaque
- Erect CXR: look for perforation
- US:
- Stones: acoustic shadow
- Dilated ducts: >6mm
- Inflamed GB: wall oedema
If the diagnosis of biliary colic is uncertain after US, what next Ix to do?
- 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.
Possible management options for biliary colic
Conservative
- Rehydrate and NBM
- Opioid analgesia: morphine
* High recurrence rate → surgical Rx favoured
Surgical
- Laparoscopic cholecystectomy
Pathophysiology of Acute cholecystitis
- Stone or sludge impaction in Hartmann’s pouch → chemical and / or bacterial inflammation
- 5% are acalculous: sepsis, burns, DM
Possible progression/complications of acute cholecystitis (4)
- Resolution ± recurrence
- Gangrene and rarely perforation
- Chronic cholecystitis
- Empyema
Presentation of Acute Cholecystitis
•Severe RUQ pain
- Continuous
- Radiates to right scapula and epigastrium
- Fever
- Vomiting
Examination findings in acute cholecystitis
- Local peritonism in RUQ
- Tachycardia with shallow breathing
- ± jaundice
- Murphy’s sign
- Phlegmon may be palpable→ mass of adherent omentum and bowel
- Boas’ sign
What’s Murphy’s sign?
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)
What’s Phlegmon?
Phlegmon → possible cholecystitis
Phlegmon may be palpable → mass of adherent omentum and bowel
What’s Boas’ sign?
Boas’ sign → possible cholecystitis
- Hyperaesthesia below the right scapula
Urine and blood investigation for acute cholecystitis
- Urine: bilirubin, urobilinogen
- Bloods:
- FBC: ↑ WCC
- U+E: dehydration from vomiting
- Amylase, LFTs, G+S, clotting, CRP
Imaging Ix in acute cholecystitis
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
Management of Acute Cholecystitis
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
Management in empyema
Empyema - pus in the GB; complication of acute cholecystitis
- High fever
- RUQ mass
Managment: Percutaneous drainage: cholecystostomy
Symptoms of chronic cholecystitis
Symptoms: Flatulent Dyspepsia /wzdety/
- Vague upper abdominal discomfort
- Distension, bloating
- Nausea
- Flatulence, burping
- Symptoms exacerbated by fatty foods
Ix for chronic cholecystitis
- AXR: porcelain gallbladder
- US: stones, fibrotic, shrunken gallbladder
- MRCP
Management of Chronic Cholecystitis
Medical
- Bile salts (not very effective)
Surgical
- Elective cholecystectomy
- ERCP first if US shows dilated ducts and stones
What’s Mucocele?
Mucocele
- Neck of gallbladder blocked by stone but contents remains sterile
- Can be very large → palpable mass
- May become infected → empyema
What’s Mirrizi’s syndrome?
Mirizzi’s Syndrome
- Rare
- Large stone in GB presses on the common hepatic duct → obstructive jaundice.
- Stone may erode through into the ducts
Appearance of the gallbladder in a gallbladder carcinoma
Gallbladder Carcinoma
- Rare
- Associated with gallstones and gallbladder polyps.
- Calcification of gallbladder → porcelain GB
- Incidental Ca found in 0.5-1% of lap choles
What’s Gallstone Ileus?
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
What’s Rigler’s Triad?
Rigler’s Triad - combination of findings of AXR in gallstone ileus
- Pneumobiliia
- Small bowel obstruction
- Gallstone in RLQ
Risk factors for Biliary Colic
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
What’s Cholangiocarcinoma?
- 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
Presentation of cholangiocarcinoma
Most patients present with jaundice and by this stage the majority will have disease that is not resectable
Risk factors for cholangiocarcinoma (2)
- Primary sclerosing cholangitis
- In deprived countries → typhoid and liver flukes
Ix and Dx in cholangiocarcinoma
- LFTs → an obstructive picture
- CA 19-9, CEA and CA 125 → often elevated
- CT/ MRI and MRCP → imaging methods of choice
Treatment of Cholangiocarcinoma
- 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.
What’s Primary Biliary Cholangitis (PBC)?
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
The classic presentation of Primary Biliary Cholangitis (PBC)
The classic presentation is itching in a middle-aged woman
Associations with PBC
Autoimmune, so:
- Sjogren’s syndrome (seen in up to 80% of patients)
- rheumatoid arthritis
- systemic sclerosis
- thyroid disease
Diagnosis of PBC (3)
- anti-mitochondrial antibodies (AMA) M2 → present in 98% of patients and are highly specific
- smooth muscle antibodies → in 30% of patients
- raised serum IgM
Management of PBC
- 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
Complications of PBC
- cirrhosis
- osteomalacia and osteoporosis
- significantly increased risk of hepatocellular carcinoma
What’s PSC ?
Primary sclerosing cholangitis is a biliary disease of unknown aetiology characterised by inflammation and fibrosis of intra and extra-hepatic bile ducts
Associations with PSC (3)
- 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
Features of PSC
- cholestasis: jaundice and pruritus
- right upper quadrant pain
- fatigue
Ix of PSC
- 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’
Complications of PSC
Complications
- cholangiocarcinoma (in 10%)
- increased risk of colorectal cancer
Triad and pentad seen in Ascending Cholangitis
- Charcot’s triad: fever/rigors, RUQ pain, jaundice
- Reynolds pentad: Charcot’s triad + shock + confusion
What’s Ascending Cholangitis?
Ascending cholangitis is a bacterial infection (typically E. coli) of the biliary tree.
The most common predisposing factor is gallstones.
Management of Ascending Cholangitis
- 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
Management of PSB
- trial of ursodeoxycholic acid →to lower elevated LFTs (but does not lead to improved survival)
- antipruritics (e.g. bile acid sequestrants such as cholestyramine)
- antibiotics → to treat episodes of ascending cholangitis;
- vitamin supplements → ADEK
- Liver transplant
