Liver Disease Flashcards
1
Q
The most common organisms causing pyogenic liver abscess
A
- Staphylococcus aureus → in children
- Escherichia coli → in adults
2
Q
Management of pyogenic liver abscess
A
- drainage (typically percutaneous)
Antibiotics:
- amoxicillin + ciprofloxacin + metronidazole
- if penicillin allergic: ciprofloxacin + clindamycin
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
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%
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
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
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
8
Q
A
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
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
11
Q
Management of hepatocellular carcinoma
A
- early disease: surgical resection
- liver transplantation
- radiofrequency ablation
- transarterial chemoembolisation
- sorafenib: a multikinase inhibitor
12
Q
Causes of Liver Cirrhosis
A
- alcohol
- non-alcoholic fatty liver disease (NAFLD)
- viral hepatitis (B and C)
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
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
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
16
Q
What (2) scoring systems are used to classify the severity of liver cirrhosis?
A
- Child-Pugh
- MELD
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.
18
Q
What’s Child-Pough?
A
A score used to grade severity of liver cirrhosis
19
Q
A
20
Q
General composition of gallstones
A
- Phospholipids: lecithin
- Bile pigments (broken down Hb)
- Cholesterol
21
Q
What’s Admirand’s Triangle?
A
Increased formation of cholesterol gallstones
Admirand’sTrangle
- ↓ bile salts
- ↓ lecithin
- ↑ cholesterol
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)
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
24
Q
What pigmented stones (gallstones) are associated with?
A
Pigment Stones: 5%
- Small, black, gritty, fragile
- Calcium bilirubinate
- Associated with haemolysis
25
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
26
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
27
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
28
**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
29
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
30
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.
31
Possible management options for biliary colic
**Conservative**
* Rehydrate and NBM
* Opioid analgesia: *morphine*
\* High recurrence rate → surgical Rx favoured
**Surgical**
* ***Laparoscopic cholecystectomy***
32
Pathophysiology of **Acute cholecystitis**
* Stone or sludge impaction in Hartmann’s pouch → chemical and / or bacterial inflammation
* 5% are acalculous: sepsis, burns, DM
33
Possible progression/complications of acute cholecystitis (4)
* Resolution ± recurrence
* Gangrene and rarely perforation
* Chronic cholecystitis
* Empyema
34
Presentation of **Acute Cholecystitis**
•Severe RUQ pain
* Continuous
* Radiates to right scapula and epigastrium
* Fever
* Vomiting
35
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
36
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)
37
What's Phlegmon?
***Phlegmon →*** possible cholecystitis
Phlegmon may be palpable → mass of adherent omentum and bowel
38
What's Boas' sign?
**Boas’ sign** → possible cholecystitis
* Hyperaesthesia below the right scapula
39
Urine and blood investigation for **acute cholecystitis**
* **Urine**: bilirubin, urobilinogen
* **Bloods:**
- FBC: ↑ WCC
- U+E: dehydration from vomiting
- Amylase, LFTs, G+S, clotting, CRP
40
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
41
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
42
Management in **empyema**
Empyema - pus in the GB; complication of acute cholecystitis
* High fever
* RUQ mass
Managment: Percutaneous drainage: ***cholecystostomy***
43
Symptoms of **chronic cholecystitis**
Symptoms: **Flatulent Dyspepsia /wzdety/**
* Vague upper abdominal discomfort
* Distension, bloating
* Nausea
* Flatulence, burping
* Symptoms exacerbated by fatty foods
44
Ix for **chronic cholecystitis**
* AXR: porcelain gallbladder
* US: stones, fibrotic, shrunken gallbladder
* MRCP
45
Management of **Chronic Cholecystitis**
**Medical**
* Bile salts (not very effective)
**Surgical**
* Elective cholecystectomy
* ERCP first if US shows dilated ducts and stones
46
What's Mucocele?
**Mucocele**
* Neck of gallbladder blocked by stone but contents remains sterile
* Can be very large → palpable mass
* May become infected → empyema
47
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
48
Appearance of the gallbladder in a gallbladder carcinoma
**Gallbladder Carcinoma**
## Footnote
* Rare
* Associated with gallstones and gallbladder polyps.
* Calcification of gallbladder → **porcelain GB**
* Incidental Ca found in 0.5-1% of lap choles
49
What's **Gallstone Ileus**?
**Gallstone Ileus**
## Footnote
* 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
What'**s Rigler's Triad**?
**Rigler's Triad** - combination of findings of AXR in gallstone ileus
* Pneumobiliia
* Small bowel obstruction
* Gallstone in RLQ
51
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
52
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
53
Presentation of **cholangiocarcinoma**
Most patients present with jaundice and by this stage the majority will have disease that is not resectable
54
Risk factors for cholangiocarcinoma (2)
* Primary sclerosing cholangitis
* In deprived countries → typhoid and liver flukes
55
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
56
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.
57
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
58
The classic presentation of **Primary Biliary Cholangitis (PBC)**
The classic presentation is **itching** in a middle-aged woman
59
Associations with PBC
Autoimmune, so:
* Sjogren's syndrome (seen in up to 80% of patients)
* rheumatoid arthritis
* systemic sclerosis
* thyroid disease
60
**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**
61
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
62
Complications of PBC
* cirrhosis
* osteomalacia and osteoporosis
* significantly increased risk of hepatocellular carcinoma
63
What's **PSC ?**
**Primary sclerosing cholangitis** is a biliary disease of unknown aetiology characterised by i**nflammation and fibrosis of intra and extra-hepatic bile ducts**
64
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**
65
Features of **PSC**
* cholestasis: jaundice and pruritus
* right upper quadrant pain
* fatigue
66
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'**
67
Complications of PSC
Complications
* cholangiocarcinoma (in 10%)
* increased risk of colorectal cancer
68
Triad and pentad seen in Ascending Cholangitis
* **Charcot’s triad**: fever/rigors, RUQ pain, jaundice
* **Reynolds pentad**: Charcot’s triad + shock + confusion
69
What's Ascending Cholangitis?
***Ascending cholangitis*** is a bacterial infection (typically *E. coli*) of the biliary tree.
The most common predisposing factor is gallstones.
70
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 remova**l with **T tube drain**
71
Management of PSB
* trial of **[ursodeoxycholic acid →](https://en.wikipedia.org/wiki/Ursodeoxycholic_acid)**to lower elevated LFTs (but does not lead to improved survival)
* **[antipruritics](https://en.wikipedia.org/wiki/Antipruritic)** (e.g. [bile acid sequestrants](https://en.wikipedia.org/wiki/Bile_acid_sequestrant) such as [cholestyramine](https://en.wikipedia.org/wiki/Cholestyramine))
* **[antibiotics](https://en.wikipedia.org/wiki/Antibiotic)** → to treat episodes of [ascending cholangitis](https://en.wikipedia.org/wiki/Ascending_cholangitis);
* [vitamin](https://en.wikipedia.org/wiki/Vitamin) supplements → ADEK
* Liver transplant
