Liver & friends Flashcards
list 4 causes of acute pancreatitis
GET SMASHED Gallstones Ethanol (alcohol) Trauma Steroids Mumps/Malignancy Autoimmune Scorpion venom Hyperlipidaemia, hypothermia, hypercalcaemia ERCP and emboli Drugs
describe the pain of acute pancreatitis
gradual or sudden severe epigastric/central abdominal pain, radiates to back, may be relieved by sitting forward.
give 3 symptoms and signs of acute pancreatitis
pain, vomiting. tachycardia, fever, jaundice, shock, ileus, rigid abdomen ± local tenderness. Cullen’s and Grey Turner’s signs.
what are Cullen’s and Grey Turner’s signs? what causes them?
Cullen’s = periumbilical bruising Grey Turner’s = bruising of flanks. due to blood vessel autodigestion and retroperitoneal haemorrhage.
what 2 enzymes would you test for in acute pancreatitis? what would the results be?
serum amylase - raised. serum lipase - raised (more sensitive/specific).
what investigations would you carry out in acute pancreatitis?
serum amylase and lipase. ABG. CT. AXR.
give 3 criteria in the Modified Glasgow criteria for predicting severity of pancreatitis
PANCREAS: PaO2 low Age >55yrs Neutrophilia Calcium - low Renal function Enzymes Albumin Sugar (blood glucose)
how would you medically manage an acute pancreatitis patient?
Nil by mouth / NG tube. pethidine (antispasmodic), tramadol (pain relief). abx (if infective cause eg cholangitis or infected pancreatic necrosis) treat underlying cause.
main stay is supportive:
Iv fluid resus
Catheterisation
O2 (if below 94%)
Opiate analgesia
Early nutritional support
give 2 early and 2 late possible complications of acute pancreatitis
early: shock, ARDS, renal failure, DIC, sepsis, hypocalcaemia. late: pancreatic necrosis, abscesses, bleeding, thrombosis, fistulae.
explain the pathology of chronic pancreatitis
inappropriate activation of enzymes within the pancreas - leads to precipitation of protein plugs within duct lumen - forms a point for calcification - duct blockage - ductal hypertension + pancreatic damage - pancreatic inflammation + impaired function
give 3 causes of chronic pancreatitis
alcohol, tropical chronic pancreatitis, hereditary, autoimmune, cystic fibrosis, haemachromatosis, pancreatic duct obstruction (stones/tumour), hyperparathyroidism, congenital.
give 3 clinical features of chronic pancreatitis
epigastric pain boring through to back - relieved by sitting forward or hot water bottles on epigastrium/back. bloating, steatorrhoea, weight loss, brittle diabetes,
what would you expect serum pancreatic enzymes levels to be in chronic pancreatitis?
amylase and lipase are normal
what investigations would you run in chronic pancreatitis?
ultrasound + CT.
how would you treat a patient with chronic pancreatitis?
NSAIDs and tramdol for abdo pain (amitriptyline for more chronic episodes). lipase + fat-soluble vit supplements. no alcohol, low fat diet. surgery if pain can’t be controlled, or there’s weight loss.
give 2 possible complications of pancreatitis?
pseudocyst, diabetes, biliary obstruction, local arterial aneurysm, splenic vein thrombosis, gastric varices, pancreatic carcinoma
describe the 3 different types of gallstones and their causes
pigment stones - small, friable, irregular - haemolysis. cholesterol stones - large, often solitary - age, obesity, female sex. mixed stones - faceted (calcium salts, pigment and cholesterol).
what are the 2 risk factors for gallstones become symptomatic?
smoking and parity (having given birth).
how does acute cholecystitis develop from an obstruction?
obstruction to gall bladder emptying - increased glandular secretion in gall bladder - distension and inflammatory response to retained bile, leads to infection
what special test would you do on examination to confirm cholecystitis?
Murphy’s sign - 2 fingers over RUQ + ask patient to breathe in - causes pain and arrest of inspiration as inflamed gallbladder hits your fingers
how would you differentiate the pain of biliary colic from cholecystitis?
cholecystitis features an inflammatory component - local peritonism, fever, high WCC
what are the clinical features of acute cholecystitis?
epigastric/RUQ pain, referred to R shoulder. vomiting, fever, local peritonism, possibly a gallbladder mass.
what investigations would you perform in cholecystitis?
ultrasound - thick walled, shrunken gallbladder, pericholecystic fluid, stones, common bile duct dilation. FBC (high WCC).
how would you treat cholecystitis?
nil by mouth, analgesia, IV fluids. IV abx- metronidazole and cefuroxime. laparoscopic cholecystectomy.
describe the clinical features of chronic cholecystitis
chronic inflammation ± colic. flatulent dyspepsia - vague abdo discomfort, distension, nausea, flatulence and fat intolerance.
describe the pain of biliary colic
severe, constant, increasing pain in RUQ, can radiate to right shoulder/scapula.
how would you tell that a gallstone had moved to obstruct the common bile duct?
obstructive jaundice and cholangitis
what is the triad of symptoms for acute cholangitis?
Charcot’s triad - jaundice, fever, biliary colic.
what structure is being obstructed by gallstones if a patient has developed acute cholangitis?
common bile duct
what is the gold standard investigation in cholangitis?
transabdominal ultrasound - measure CBD dilatation.
how would you treat acute cholangitis?
laparoscopic cholecystectomy with IV abx - cefuroxime and metronidazole
list 3 complications of gallstones
in gallbladder and cystic duct: biliary colic, acute and chronic cholecystitis, mucocoele, empyema, carcinoma, Mirizzi’s syndrome. in bile ducts: obstructive jaundice, cholangitis, pancreatitis. in gut: gallstone ileus.
what is jaundice?
yellowing of the skin, sclerae and mucosae due to increased plasma bilirubin
give 3 causes of unconjugated hyperbilirubinaemia (pre-hepatic jaundice)
haemolysis - malaria, DIC. ineffective erythropoiesis. impaired hepatic uptake - drugs (contrast agents, rifampicin), RHF. impaired conjugation - Gilbert’s syndrome, Crigler-Najjar.
what will the urine and faeces look like in conjugated hyperbilirubinaemia (hepatic/post-hepatic jaundice)? why?
urine = dark - conjugated bilirubin is soluble, so excreted in urine. Faeces = pale - less conjugated bilirubin enters gut.
give 3 causes of conjugated hyperbilirubinaemia due to hepatocellular dysfunction
viruses - hep, CMV, EBC. drugs - paracetamol od, isoniazid, rifampicin, pyrazinamide, statins, sodium valproate. alcohol. cirrhosis. liver metastases/abscesses. haemachromatosis. autoimmune hepatitis. septicaemia. syphilis. alpha1-antitrypsin deficiency. Budd-Chiari. Wilson’s disease. Right heart failure.
give 3 causes of conjugated hyperbilirubinaemia due to impaired hepatic excretion (cholestatic / obstructive jaundice)
primary biliary cirrhosis, primary sclerosing cholangitis, drugs, common bile duct gallstones, pancreatic cancer, compression of the bile duct, choledochal cyst
how is hepatitis A spread? what are the risk factors?
faecal-oral route. poor sanitation, overcrowding, contaminated food/water. (fish in sewagey water)
what would you find when looking at viral markers for hepatitis A? what other blood test would you perform?
Anti-HAV IgM (acute) and IgG (raised for life - carrier). LFTs - AST/ALT are raised
how would you treat hepatitis A?
supportive treatment - self-limiting.
how would you prevent hepatitis A?
passive and active immunisation (inactivated protein) and good hygiene
what type of virus is hep A?
RNA
give 3 symptoms of hep A as well as 2 later signs
symptoms: fever, malaise, anorexia, nausea, arthralgia. later signs - jaundice, hepatosplenomegaly, lymphadenopathy.
what type of virus is hep B?
DNA
how is hep B spread?
blood products - vertical transmission, IVDU, found in semen and saliva - sexual/direct contact.
name 3 of the at-risk groups for hep B
IVDUs, their sexual partners/carers, health workers, haemophiliacs, job exposure to blood (morticians), haemodialysis patients, sexual promiscuity, foster carers, staff/residents of institutions/prisons, babies of +ve mothers
what are the clinical features of hep B?
resembles hep A - fever, malaise etc - plus arthralgia and urticaria (hives).
what antiviral agents would you give to treat a chronic HBV infection? what would you monitor?
interferon alpha, lamivudine, adefovir. monitor HBV levels and platelets.
describe how vaccination is used in hep B
passive immunisation is given to non-immune contacts after high-risk exposure. Hep B vaccine given (UK) to children born to +ve mothers, chronic liver patients, haemophilia patients, offered as a travel vaccine, and to healthworkers.
list 2 possible complications of hepatitis B
cirrhosis, HCC, fulminant hepatic failure, cholangiocarcinoma, cryoglobulinaemia
what type of virus is hep C?
RNA flavivirus
how is hep C transmitted and can the spread be prevented?
blood products, mainly IVDU (also transfusions, sexual etc) Can’t prevent spread - vaccination impossible due to rapid change of proteins.
what haematological disorder is associated with hep C?
Non-Hodgkin’s lymphoma
give 3 risk factors for progression of hepatitis C to cirrhosis
male, older, higher viral load, alcohol use, HIV, HBV
what viral markers would you look for in hepatitis C at 8 weeks?
HCV RNA at 8weeks.
if you took a liver biopsy of a hepatitis C patient, what might you see?
lymphoid follicles in portal tracts and fatty change
how would you treat a chronic infection with hepatitis C? what major problem should be noted about one of the drugs?
serine protease inhibitors (boceprevir, telaprevir) - directly acting antivirals against genotype 1 HCV. combine with: interferon alpha. ribavirin - very teratogenic.
give 3 possible complications of hepatitis C
glomerulonephritis, cryoglobulinaemia, thyroiditis, autoimmune hepatitis, PAN, polymyositis, porphyria cutanea tarda
what other virus is needed for hep D to infect someone? why?
hep B. hep D is an incomplete RNA that needs hep B for assembly.
how can hepatitis D be prevented?
hep B vaccine
how can you test for hepatitis D?
test for anti-HDV antibody
what can hep D cause?
acute liver failure/cirrhosis
how can you treat a hep D infection?
may need liver transplant as interferon alpha has limited success.
what type of virus is hep E? what infection is it similar to?
RNA. hep A.
how is hep E transmitted?
enterally - contaminated water.
what can you detect in blood and stools to confirm a diagnosis of hep E?
hep E RNA
what collagen type is deposited in the liver in cirrhosis?
type 1 and 3
what is the difference between macro and micronodular cirrhosis?
macronodular - variable nodule size, normal acini within, tends to follow hepatitis. micronodular - uniform involvement of liver and regenerating nodules