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Y1 GI > Liver Disease + Gall Bladder + Pancreas > Flashcards

Liver Disease + Gall Bladder + Pancreas Flashcards

1
Q

What does excessive bilirubin level in blood cause

A

Jaundice

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2
Q

What is the prehepatic cause of jaundice

A

Haemolytic anaemia - excess breakdown of RBC, releasing excess bilirubin
Sickle cell disease

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3
Q

What organs breakdown RBC

A

spleen

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4
Q

How is bilirubin metabolised

A

Metabolised in the liver, undergoes phase 2 metabolism - glucoronidation, making bilirubin more water soluble so it can be excreted in bile

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5
Q

What is glucoronidation

A

Addition of glucuronic acid by glucuronosyltransferase (UGT1A1)

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6
Q

Two types of hepatic causes of jaundice

A

Unconjugated - abnormal metabolism of bilirubin

Conjugated - abnormal excretion of conjugated bilirubin

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7
Q

What are the unconjugated hepatic causes of jaundice

A

Gilbert’s syndrome
hyperthyroidism
high serum levels of gentamicin

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8
Q

What are the conjugated hepatic causes of jaundice

A

hepatocellular injury - viral hepatitis / autoimmune hepatitis / alcoholic hepatitis / non-alcoholic fatty liver disease/ drug induced liver injury

Cholestatic liver disease - PBC, PSC

Sarcoidosis / amyloidosis / tuberculosis

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9
Q

What are the post hepatic causes of jaundice

A

Cholestatic liver diseases (PBC, PSC, malignancy, gallstones)
biliary atresia
strictures of biliary duct

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10
Q

What are cholestatic liver diseases

A

Decrease in bile flow due to abnormal excretion or obstruction of the bile ducts

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11
Q

Examples of cholestatic diseases

A

Malignancy at head of pancreas
primary sclerosing cholangitis
primary biliary cholangitis
gallstones

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12
Q

What is acute liver failure

A

Loss of liver function due to acute massive necrosis of hepatocytes
In absence of chronic liver disease

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13
Q

Causes of acute liver failure

A

Drug induced liver injury
viral hepatitis
alcohol
Budd chiari syndrome

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14
Q

What is the most common cause of acute liver failure

A

Drug induced liver injury

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15
Q

What drugs can cause drug induced liver injury

A

Paracetamol overdose
Co-amoxiclav / flucloxacillin / NSAID
Statins, ecstasy

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16
Q

What are the characteristic findings of acute liver failure

A

Hepatic encephelopathy + coagulopathy + hypoglycaemia + jaundice

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17
Q

What is hepatic encephelopathy

A

Altered mental state
Confusion
Asterixis (liver flap)
Due to build up of toxic ammonia

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18
Q

Symptoms of ALF

A 
Jaundice 
HE
easy bruising (due to coagulopathy) 
Abdominal pain 
Infection 
circulatory failure
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19
Q

What causes circulatory failure

A

Massive necrosis leads to massive inflammation, massive vasodilation -> very low SVR

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20
Q

Diagnosis of ALF

A 
INR - coagulability 
Blood glucose level
Ammonia level 
LFT - albumin / ALP / gGT / bilirubin
Imaging
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21
Q

Treatment of ALF

A

IV fluids
Vitamin K and fresh plasma with clotting factors
Transplant
Sepsis 6 bundle if indicated

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22
Q

Complications of acute liver failure

A 
Infections 
Circulatory failure 
High output HF
Cerebral injury
Haemorrhage
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23
Q

Why does circulatory failure occur in ALF

A

Because massive necrosis -> inflammation -> vasodilation -> low SVR

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24
Q

What is the end stage of liver disease

A

Cirrhosis

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25
Timeline of liver disease
Chronic liver disease -> persistent inflammation -> fibrosis -> cirrhosis -> acute liver failure / decompensated cirrhosis
26
What does decompensated cirrhosis mean
The point where there is so much fibrosis and scarring causing the liver to fail ultimately
27
Examples of chronic liver diseases (conditions that can develop into chronic liver disease)
``` Alcoholic hepatitis Non-alcoholic fatty liver disease Viral hepatitis Autoimmune hepatitis Malignancy Primary biliary cholangitis / primary sclerosing ```
28
Development of alcoholic liver disease
Alcoholic fatty liver -> alcoholic hepatitis -> fibrosis -> cirrhosis Disease progresses as you continue drinking
29
Why should you treat alcoholic fatty liver / alcoholic hepatitis as soon as possible
Because they are reversible; once you stop drinking, they can resolve and not develop into cirrhosis
30
What causes alcoholic fatty liver
Metabolism of alcohol leads to excess fat deposits in the liver
31
What will be seen on histology of alcoholic fatty liver
fat vacuoles (steatosis)
32
What products from alcohol metabolism are toxic to the liver
Ethanol and acetaldehyde
33
How long does it usually take for alcoholic hepatitis to develop
Weeks or months of excessive alcohol consumption
34
What happens in alcoholic hepatitis
Toxic ethanol and acetaldehyde -> necrosis -> inflammation
35
What immune cells infiltrate the liver in alcoholic hepatitis
Neutrophils
36
What stain is used to identify collagen fibres
Masson Trichome
37
How long does it take for fibrosis to occur in alcoholic hepatiits
months to years of excessive alcohol consumption
38
Histological features of cirrhosis
Collagen fibres surrounding regenerative nodules of hepatocytes, cutting off blood supply
39
How does cirrhosis make the hepatocytes no longer functional
Because the collagen fibres surrounding the hepatocytes cuts off the blood supply to the hepatocytes, meaning that - the hepatocytes cannot receive portal blood from portal vein = cannot filter the nutrient rich blood - the hepatocytes cannot receive blood from hepatic artery = no oxygen so dies
40
Why are there regenerative nodules in cirrhosis
Because of the persistent liver injury and necrosis in that area, causing the hepatocytes have to proliferate
41
Symptoms of alcoholic hepatitis
``` Jaundice Pain tender on palpation hepatomegaly signs of decompensated cirrhosis / liver failure ```
42
What are the signs of decompensated cirrhosis
Ascites Portal hypertension Easy bruising - coagulopathy HE
43
Management of alcoholic hepatitis
Stop alcohol consumption Ensure good nutrition and hydration corticosteroid therapy for severe hepatitis
44
Complication of chronic liver disease
Cirrhosis Malnutrition Increase risk of hepatocellular carcinoma
45
What is NAFLD
Fatty liver in absence of excess alcohol consumption
46
Risk factors for NAFLD
Obesity Metabolic syndrome - hypertension / hyperlipidaemia / low HDL Diabetes Genetic changes
47
Changes in what genes are associated with NAFLD
PNPLA3 | TM6SF2
48
When should you suspect that the patient's NAFLD is caused by genetic changes
When the patient is young and lean
49
Symptoms of NAFLD
Usually asymptomatic Hepatomegaly Signs of decompensated cirrhosis / liver failure
50
Pathogen for hepatitis A
Ebstein Barr virus
51
Pathogen for hepatitis B
yellow fever virus
52
Pathogen for hepatitis C
Herpes simplex virus
53
Pathogen for hepatitis E
cytomegalovirus
54
Which type of viral hepatitis is least likely to cause chronic liver disease
Hepatitis A and E
55
Which type of viral hepatitis has a high chance of developing into chronic liver disease
``` Hepatitic B (the younger the patient is, the greater the risk) Hepatitis C ```
56
What is considered as chronic viral hepatitis B
Failure to clear hepatitis B, causing presence of HBsAg antigen for over 6 months
57
Does hepatitis B have a short or long incubation period
Long - takes 1 - 4months to develop symptoms
58
Transmission of hepatitis B
By blood or sexual fluids
59
Can hepatitis B be transmitted from mother to child? And why is it bad?
Yes (vertical transmission); bad because the younger the patient gets hepatitis B, the more likely it is to develop into chronic liver disease and eventually cause cirrhosis
60
How long is the incubation period of hepatiits C
2 to 12 weeks
61
Chronic hepatitis caused by which virus is more associated with increased risk of hepatocellular carcinoma
Hepatitis B
62
What may be a histological finding for hepatitis caused by hepatitis C
Steatosis | Infiltration of inflammatory cells
63
What is the LFT pattern for cholestatic disease
Raised ALP and gGT
64
What would the LFT result be for viral hepatitis
Raised ALT and AST, normal ALP and gGT Low albumin
65
Which hepatitis causes chronic hepatitis
Hepatitis C | Hepatitis B
66
Symptoms of acute hepatitis
``` Fever Jaundice Abdominal pain Nausea/vomiting Diarrhea ```
67
What is the most common cause of cirrhosis
Alcoholic hepatitis
68
Symptoms of chronic hepatitis
Usually asymptomatic till develop decompensated cirrhosis / ALF or exacerbations (symptoms of acute hepatitis) Signs of deceompensated cirrhosis: HE, ascites, easy bruising
69
What conditions increases the risk of hepatocellular carcinoma
Chronic viral hepatitis B Alcoholic hepatitis NAFLD PBC
70
Transmission of hepatitis A
Faecal-oral
71
Which age group does hepatitis A more commonly affect
young people
72
What needs to be done to confirm diagnosis for Hepatitis A
clotted blood for HAV IgM
73
Which group of hepatitis B patients need to be treated
Those with hepatitis B for more than 4 weeks Those with coagulopathy Those with acute liver failure
74
Diagnosis of hepatitis B
Serology and LFT
75
What would serology for active hepatitis B infection be
HBsAg positive HBeAg positive HBV DNA PCR positive IgM anti-HBc positive
76
What signifies a chronic hepatitis B
HBsAg for more than 6 months
77
Serology for chronic hepatitis B
``` IgM anti HBc negative IgG anti HBc positive HBsAg positive anti-Hbs negative HBV DNA PCR positive ```
78
How long will IgM anti HBc be present
6 months
79
Which anti HBc will be present after 6 months of infection (in chronic hepatitis)
IgG HBc
80
What does HBeAg indicate
Indicates high viral replication / infectivity
81
What does anti-HBs indicate
clearance of disease or vaccinated
82
What does anti HBe indicate
decrease in viral replication
83
Serology for hepatitis B vaccinated person
anti HBs positive | others negative
84
Risk factors for Hepatitis B
Infected mother Multiple sex partners IV drug usage (repeated use of needle / contaminated needle)
85
What type of PCR is used in hepatitis C
RNA PCR
86
Which hepatitis are detected by RNA PCR
Hepatitis C | Hepatitis D
87
Treatment for hepatitis B
Anti-virals: tenofovir / entecavir PegIFN-alpha
88
Examples of anti virals
tenofovir / entecavir | PegIFN-alpha
89
How is hepatitis C transmitted
By blood
90
Why is hepatitis C serious
Because there is low level of spontaneous clearance, most develop into chronic hepatitis
91
Diagnosis of Hepatitis C
HCV RNA PCR | presence of HCV IgG
92
What can HCV IgG indicate
If positive -> can be active or past infection Then test for HCV RNA by PCR If HCV RNA PCR is positive -> active infection If HCV RNA PCR is negative -> past infection
93
Management for hepatitis C
8-12 weeks of combination DAA (direct acting antivirals)
94
Which hepatitis cause acute hepatitis only
Hepatitis A | Hepatitis E
95
Transmission of hepatitis E
Faecal oral
96
Incubation period of Hepatitis E
15 to 60 days
97
What does hepatitis D need in order to be present
HBsAg, so it needs the presence of Hepatitis B as well
98
Treatment for hepatic encephalopathy
Lactulose - increases excretion of ammonia | Rifaximin
99
Cirrhosis mechanism
Liver injury -> activating Hepatic stellate cells -> HSC proliferate and cause fibrosis
100
Where are HSC found
space between hepatocytes and sinusoids
101
How does cirrhosis cause portal hypertension
Massive structural change, causing increase in vascular resistance
102
Hepatic portal vein carries blood from which organs back to liver
``` Spleen Small and large intestines Pancreas Stomach Oesophagus ```
103
What vessels drain into hepatic portal vein
superior and inferior mesenteric vein splenic vein gastrin vein
104
Blood flow from hepatic portal vein to right atrium
Hepatic portal vein -> sinusoids -> Central vein -> IVC -> right atrium
105
Location of anastamosis between portal and circulatory sytem
Oesophageal plexus Umbilical vein Haemorrhoidal venous plexus Retroperitoneal collateral vessels
106
What is the significance of the anastamoses between portal and systemic circulation
During portal hypertension, because there is an increased resistance of blood flowing into liver then back into the circulatory system, blood will flow to the collateral vessels, bypassing the liver, flowing back to circulatory system (so basically, blood is finding an alternate way to go back to the heart)
107
What occurs due to portal hypertension
Ascites Oesophageal varices Haemorrhoids
108
How does ascites occur
Portal hypertension; increase in pressure forces fluid out of vessels
109
What is the vicious cycle of portal hypertension
1) Portal hypertension 2) Formation of collateral vessels, increase in blood flow in collateral vessels 3) sphlanchic vasodilation to increase blood flow into portal vein to compensate the loss of portal blood to collateral vessels 4) decrease in MAP, SVR -> stimulate baroreceptors and RAAS 5) RAAS increases water and sodium retention 6) increases blood flow in portal system = worsening portal hypertension
110
What are the other causes of portal hypertensionW
Portal embolism / portal thrombosis | Budd Chiari syndrome
111
What are the common causes of cirrhosis
Alcoholic hepatitis NAFLD Chronic viral hepatitis (HCV , sometimes HBC)
112
Why do patients with cirrhosis need to be on heparin
Because they are likely to bleed or clot (imbalance) | If they are not bleeding, they are likely to clot hence need to be on anti-coagulant to prevent clotting
113
What is Budd Chiari syndrome
Blockage of hepatic vein that drains the liver
114
What is decompensated cirrhosis
When the extent of cirrhosis is so great, the liver fails to function normally anymore
115
Symptoms of compensated cirrhosis
``` Mostly asymptomatic Hepatomegaly Splenomegaly Varices Clubbing Gynaecomastia ```
116
Signs of decompensated cirrhosis
HE Coagulopathy - easy bruising Ascites Jaundice
117
Causes of ascites
Most commonly cirrhosis - portal hypertension Peritonitis Malignancy in peritoneal cavity
118
Types of ascitic fluid
``` Exudate = presence of proteins, immune cells; usually due to infection increasing vascular permeability Transudate = without presence of proteins and only a few cells; usually due to high pressure forcing fluid out of vessels ```
119
What type of ascitic fluid would portal hypertension cause
Transudate
120
Diagnosis of ascites
Dullness in percussion Ascitic tap Albumin level / WCC Ultrasound
121
Ascitic tap procedure
Insert small needle to get a sample of ascitic fluid and send for microbiological sampling.
122
What does elevated neutrophil in ascitic fluid mean
Spontaneous bacterial infection
123
Management of ascites without spontaneous bacterial infection
First line: Spironalactone Second line: Spironalactone + loop diuretics Paracentesis - drain fluid TIPSS
124
Management of ascites with spontaneous bacterial infection
Broad spectrum antibiotics | IV terlipressin
125
What drug is used to prevent varices from bleeding
Non selective Beta blockers - carvedilol / propanolol
126
What is cholelithiasis
Gall stones within gall bladder
127
What is choledocholithiasis
Gallstones escaped the gallbladder, lodges within biliary tree
128
Components of bile
Bile acids, cholesterol, water, bilirubin, phospholipid
129
How do cholesterol galltones form
Due to excess cholesterol in bile | Supersaturation in gallbladder causes crystallization of the cholesterol -> gallstone
130
Types of gallstones
Cholesterol Bilirubin Mixed cholesterol and bilirubin Calcium bilirubinate and calcium salts
131
What causes black gallstones
Gallstones formed due to excess bilirubin
132
What causes brown gallstones
Calcium bilirubinate and calcium salts
133
Risk factors for gallstones
``` Female Fat Middle age Crohn's disease family history of cholelithiasis Rapid weight loss / prolonged fasting diabetes Oral contraceptive pill ```
134
What is biliary colic
It is abdominal pain caused by gallbladder contracting while gallstone blocking the cystic duct, increasing pressure in gallbladder No infection
135
Symptoms of biliary colic
RUQ pain - colicky Worse after eating / eating fatty meal Pain may radiate to shoulder or interscapular region Nausea and vomiting
136
Biliary colic is commonly seen in
Fair (caucasian), Fat, Forty, Female
137
LFT for biliary colic
Normal, no signs of infection
138
Are gallstones usually symptomatic
No, usually asymptomatic till they cause other conditions
139
Imaging for symptomatic gallstones
USS (ultrasound) | MRCP
140
What does MRCP show
special type of MRI that shows the gallbladder, cystic duct, pancreas and pancreatic duct
141
Management for biliary colic
Analgesia (avoid morphine) Lifestyle modification Cholecystectomy
142
Why is cholecystectomy commonly performed in patients with biliary colic
Because once a gallstone forms, more will form so it is better to just remove the GB to prevent recurrence
143
What conditions can gallstones cause
``` Biliary colic Ascending cholangitis Cholecystitis Acute pancreatitis empyema Gallstone ileus ```
144
What is cholecystitis
Inflammation of the GB due to gall stones blocking the cystic duct
145
How do gallstones cause cholecystitis
Gallstones block cystic duct -> causing impaired drainage -> inflammation
146
Complications of cholecystitis
Empyema Rupture of GB Infection backing up to the liver
147
What may a GB with chronic cholecystitis look like
Thickened wall due to fibrosis
148
Symptoms of cholecystitis
``` RUQ pain Fever Nausea + vomiting Malaise Murphy's sign ```
149
What is Murphy's sign
inspiratory arrest upon palpation of RUQ Ask the patient to hold in a deep breath then palpate the RUQ, if pain occurs -> Murphy's sign
150
Diagnosis of Cholecystitis
USS + Murphy's sign is diagnostic | MRCP
151
What may USS show for cholecystitis
Cholelithiasis Thickening of gall bladder wall Pericholecystic fluid
152
management of Cholecystitis
``` IV antibiotics IV fluids Analgesia Cholecystectomy within 1 week of diagnosis Percutaneous cholecystostomy ```
153
When is percutaneous cholecystotomy used
to drain pus (empyema) / fluid
154
What should be done before cholecystectomy
Remove gallstones via ERCP
155
What can rupture of GB cause
release of contents into peritoneal cavity -> peritonitis
156
What is ascending cholangitis
Infection of the biliary tree | secondary to gallstones or biliary stricture
157
Is ascending cholangitis common
No
158
Causes of biliary strictures
PSC / malignancy at head of pancreas / cholangiocarcinoma
159
Symptoms of ascending cholangitis
Charcot's triad or Reynold's pentad Malaise Vomiting and nausea
160
What is Charcot's triad
RUQ pain Fever Jaundice
161
What is Reynold's pentad
``` RUQ pain fever jaundice Hypotension Confusion ```
162
When will shock and confusion show in ascending cholangitis
in Sepsis
163
Common pathogen causing ascending cholangitis
E.coli
164
LFT result for ascending cholangitis
Raised bilirubin , ALP Raised CRP Raised inflammatory markers
165
What would Ultrasound for ascending cholangitis show
Dilated bile duct | Gallstones at bile duct
166
Management of acute cholangitis
IV antibiotics IV fluids, analgesia ERCP for drainage / relieve obstruction (remove stones)
167
What antibiotics are used for cholecystitis
IV augmentin
168
What antibiotics are used for ascending cholangitis
IV augmentin or tazocin
169
What is primary biliary cholangitis (Primary biliary cirrhosis)
An autoimmune cholestatic liver disease that causes destruction of own bile ducts
170
How is cholestasis caused in PBC
Autoimmune destruction of bile ducts mediated by T cells -> bile duct loss -> cholestasis
171
How does cholestasis in PBC cause cirrhosis
Cholestasis -> build up of toxic substances in liver -> persistent inflammation -> fibrosis, cirrhosis
172
Characteristics of PBC
Anti-mitochondrial autoantibodies Increased IgM
173
LFT and serology findings of PBC
Cholestatic pattern LFT = raised ALP, gGT, albumin | Increased IgM
174
PBC is commonly seen in which group of people
Middle aged females
175
Risk factors of PBC
Age - 30-60 Female Family history of PBC
176
Symptoms of PBC
``` Pruritus (itchy skin) Fatigue RUQ pain Xanthomas, xanthelasmas Clubbing Hepatomegaly / splenomegaly Jaundice ```
177
Management of PBC
Ursodeoxycholic acid Obeticholic acid Liver transplantation
178
What is used to treat pruritus
cholestyramine (bile acid sequestrant)
179
Complications of PBC
Increases risk for HCC Osteoporosis Osteomalacia Decompensated cirrhosis
180
What is primary sclerosing cholangitis
Autoimmune disorder causing cholestatic liver disease due to persistent inflammation hence fibrosis of intra and extrahepatic bile ducts
181
What condition is associated to Primary sclerosing cholangitis
Ulcerative colitis | HIV
182
Risk factors for PSC
UC HIV Men Between 30-40 years old
183
Symptoms of PSC
Pruritus Jaundice Recurrent bacterial cholangitis
184
LFT of PSC
Raised ALP, gGT
185
Difference between PSC and PBC
PBC has raised IgM and presence of anti-mitochondrial antibodies whereas PSC does not PSC may have positive p-ANCA and anti-smooth muscle antibodies PBC only affects intrahepatic bile ducts whereas PSC affects intra and extra hepatic ducts PBC is more common among middle aged females whereas PSC is more common among middle aged males
186
Test for PSC
LFT | p-ANCA
187
What is p-ANCA
Test for Antineutrophil cytoplasmic antibodies
188
What may be seen on MRCP or ERCP in primary sclerosing cholangitis
Multiple biliary strictures - looks like beads
189
Management of PSC
Liver transplant
190
Primary sclerosing cholangitis increases the risk of
Cholangiocarcinoma
191
Cholangiocarcinoma type of carcinoma
Adenocarcinoma
192
Risk factors of cholangiocarcinoma
``` Cholelithiasis PSC UC smoking Obesity ```
193
Is the prognosis for cholangiocarcinoma good
No | Symptoms are often only presented at late stage
194
Symptoms of cholangiocarcinoma
Palpable mass at RUQ Persistent biliary colic symptoms Weight loss Anorexia
195
What is courvoisier sign
Palpable mass at RUQ, occurs in cholangiocarcinoma
196
How to obtain biopsy for cholangiocarcinoma
via ERCP
197
Management of cholangiocarcinoma
Cholecystectomy | Palliation
198
Signs of cholestasis
Darker urine | Pale stool
199
Pale stool is a sign of
not enough bile produced | Secretion of bile is blocked / reduced
200
What can amiodarone cause
It is toxic to hepatocytes, can cause hepatic jaundice
201
Characteristics of primary sclerosing cholangitis
Anti smooth muscle antibodies ANCA (anti nuclear antibodies)
202
Characteristics of autoimmune hepatitis
Anti smooth muscle antibodies | Maybe antinuclear antibodies
203
What conditions are at higher risk if the patient has primary sclerosing cholangitis
Cholangiocarcinoma | Colorectal cancer
204
What are the drugs that can cause prehepatic jaundice
Rifampicin (used in IE)
205
What are the drugs that can cause hepatic jaundice (drug induced liver injury)
``` Paracetamol overdose Statins Ecstasy Co-amoxiclav Flucloxacillin NSAID Amiodarone ```
206
What are the drugs that can cause post hepatic jaundice (cholestatic jaundice)
Co-amoxiclav Nitrofurantonin steroids Flucloxacillin
207
What is a marker for hepatocellular cancer
AFP
208
What may low albumin level indicate
Liver disease Inflammation Kidney disease

Y1 GI (6 decks)

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