Liver + Friends Flashcards
What are the 3 key markers of liver function?
Bilirubin
Albumin
Prothrombin time (PT/INR)
What levels of bilirubin indicate liver dysfunction?
Increased
What level of albumin indicates liver dysfunction?
Decreased
What liver enzymes indicate liver damage?
AST (aspartate aminotransferase)
ALT (alanine aminotransferase)
GGT
ALP
Where are liver enzymes found?
Hepatocytes- leak out when damage occurs
When are high AST levels seen?
Hepatic necrosis
MI
Muscle injury
Congestive cardiac failure
When are high ALT levels seen?
ONLY in liver disease
What is the typical AST:ALT ratio?
1
What does an AST:ALT ratio of >2:1 indicate?
Alcoholic liver disease especially with inc. GGT
What does an AST:ALT ratio of >4.5:1 indicate?
Wilsons
Hyperthyroid
What does an AST:ALT ratio of <0.9:1 indicate?
NAFLD
When is GGT increased?
ALD
When is ALP increased?
Biliary tree specific damage
Bone pathology
What are 7 functions of the liver?
MAD BICO
Metabolises carbs
Albumin production
Detoxification
Bilirubin regulation
Immunity and Kupffer cells
Clotting factor production
Oestrogen regulation
What are 3 disorders of oestrogen regulation?
Gynaecomastia in men
Spider naevi
Palmar erythema
What is one disorder of detoxification pathology?
Hepatic encephalopathy
What is one disorder of carbohydrate metabolism?
Hypoglycaemia
What are 3 disorders of albumin production?
Oedema
Leukonychia
Ascites
What is one consequence of clotting factor dysfunction?
Easy bleeding and bruising
What are 2 disorders of bilirubin regulation?
Pruritus
Jaundice
What is one consequence of Kupffer cell dysfunction?
Spontaneous bacterial infections
Define acute liver failure
Rapid decline characterised by jaundice, coagulopathy (INR > 1.5) and hepatic encelopathy in a patient with a previously normal liver
What are the 3 types of acute liver failure?
Hyperacute <7 days
Acute: 1-4 weeks
Subacute: 4-12 weeks
Why does acute liver failure mainly occur?
Massive hepatocytes necrosis
What are 5 causes of acute liver failure?
Drugs
Viral
Infiltrative
Budd Chiari
Acute fatty liver of pregnancy
What are 3 viral causes of acute liver failure?
Hepatitis A,B,D,E
EBV
HSV
What are 3 drugs that can cause acute liver failure?
Paracetamol
Alcohol
Ecstasy
What are the symptoms of acute liver failure?
Jaundice, coagulopathy, hepatic encephalopathy ascites
MC 4 symptoms: jaundice, nausea, anorexia, malaise
How is HE graded?
West Haven criteria grades 1-4
Define hepatic encephalopathy
Changes in the brain that occur in patients with liver failure, ranging from memory issues to coma
Define liver failure
Liver fails to regenerate and repair leading to decompensation
How is acute liver failure diagnosed?
LFTs (bilirubin ect)
EEG to grade HE
Microbiology for infection
How is acute liver failure treated?
Treat underlying cause
ABCDE if severe
Treat complications
What are 3 complications of acute liver failure?
MC: Infection
Renal failure
Progressive HE
Oedema
How is encephalopathy treated in liver failure?
Lactulose (increased ammonia excretion)
Consider mannitol
How is ascites treated in liver failure?
Diuretics
Fluid restriction
How is cerebral oedema treated in liver failure?
Mannitol
How is bleeding treated in liver failure?
Vitamin K
How is sepsis treated in liver failure?
Abx
How is hypoglycaemia treated in liver failure?
Dextrose
Define chronic liver failure
Progressive liver disease over 6+ months due to repeated liver insults
What are 3 causes of chronic liver failure?
Alcoholic liver disease (ALD)
Non- alcoholic fatty liver disease (NAFLD)
Viral (hep C)
What are 3 risk factors of chronic liver failure?
Alcohol
Obesity
T2DM
Drugs
Outline the pathophysiology of chronic liver failure
Hepatitis/cholecystitis -> reversible fibrosis -> irreversible cirrhosis -> compensated or decompensated
Define compensated cirrhosis
Liver function preserved, no evidence of compliance to portal HTN
Define decompensated cirrhosis
Complications of liver dysfunction with reduced hepatic synthetic function and portal HTN
How is chronic liver failure graded?
Child Pugh score
What are the symptoms of chronic liver failure?
ABCDDEFGHIJ
Ascites
Bruising
Clubbing and leuconychia
Dupuytrens contracture
Encelopathy and palmar erythema and spider naevi
Gynaecomastia
Hepatomegaly
Increased parotid
Jaundice
How is chronic liver failure diagnosed?
Biopsy to confirm cirrhosis
LFTs
Imagine
Tap of ascites
What causes liver cirrhosis?
Chronic liver inflammation and liver cell damage
How is chronic liver failure treated?
Prevent progression - lifestyle modifications
Consider transplant if decompensated
Mange complications
Define fulminant liver failure
Syndrome of massive hepatocyte necrosis
What is the most common cause of fulminant liver failure?
Paracetamol overdose
What is the most common cause of liver failure?
Alcoholic liver disease
Outline the pathophysiology of ALD
Steatosis (fatty liver) -> Alcohol hepatitis (inflammation + necrosis) -> alcoholic cirrhosis (irreversible scar tissue)
What are 3 risk factors of ALD?
Obesity
Smoking
Excessive alcohol use
What are the symptoms of ALD?
Early stages have very little symptoms
Later = chronic liver failure symptoms and alcohol dependency
How is alcohol dependency characterised?
CAGE and AUDIT
How is ALD diagnosed?
GS: liver biopsy
Elevated MCV
Ultrasound or CT
Elevated PT, bilirubin, ALT and AST
What CAGE score indicates alcohol dependency?
2 or more
How is ALD treated?
Stop drinking alcohol!
Short term steroids
Consider transplant
How are alcohol withdrawal symptoms treated?
Chlordiazepoxide or diazepam
IV vitamin D and thiamine
What is the major complication of alcohol withdrawal?
Delerium tremens
What is the maximum alcohol recommendation a week?
14 units
What are the complications of ALD?
Wernicke Korsakoff syndrome
Pancreatitis
HE
Ascites
HCC
Mallory Weiss tear
What are Mallory cytoplasmic inclusion bodies indicative of?
ALD
What is Wenicke Korsakoff syndrome?
Combined B1 deficiency and alcohol withdrawal symptoms
What are the 3 symptoms of Wernicke Korsakoff syndrome?
Ataxia
Nystagmus
Encelopathy
How is Wernicke Korsakoff syndrome treated?
IV thiamine
Define non alcoholic fatty liver disease
Fat deposited in liver cells which interfere with function which can progress to hepatitis and cirrhosis
What are 3 risk factors of NAFLD?
Obesity
HTN
T2DM
Hyperlipidaemia
FHx
Outline the pathophysiology of NAFLD
Non-alcoholic fatty liver disease -> Non-alcoholic Steatehepatitis (NASH) -> Fibrosis -> Cirrhosis
How common is NAFLD?
30% of adults have it
What are the symptoms of NAFLD?
Typically asymptomatic
Severe = liver failure signs
Hepatomegaly
Thrombocytopenia
How is NAFLD diagnosed?
Deranged LFTs (raised PT and bilirubin, dec albumin)
Liver ultrasound
Liver biopsy (GS)
What is transient elastography (fibroscan) used for?
Non-invasive test measuring liver stiffness, correlating to degree of fibrosis
How is NAFLD treated?
Lose weight
Control risk factors
Avoid alcohol
What are the complications of NAFLD?
HE
Ascites
HCC
Portal HTN and oesophageal ascites
Define hepatitis
Inflammation of the liver
Define viral hepatitis
Inflammation of the liver due to viral replication in hepatocytes
What type of virus is hepatitis A?
Single stranded RNA
Is Hep A acute or chronic?
Acute
Where is Hep A most prevalent?
Africa and South America
Seen in autumn
How is hep A spread?
Faeco-orally
What are 3 risk factors of Hep A?
Shellfish
Travel to Africa or South America
Overcrowding
What are the 2 phases of Hep A and B?
Prodromal phase
Icteric phase
What are the symptoms of Hep A and B?
Prodromal phase: N+V, fever, malaise, RUQ pain
Icteric phase: jaundice, dark urine, pale stools, pruritus
How is Hep A diagnosed?
FBC: leukopenia and raised ESR
Increased HAV IgM in infection, and anti HAV IgG after
Raised bilirubin
How is Hep A treated?
Usually self limiting
Anti-emetics and rest
Vaccine available
What type of virus is Hep B?
DNA virus
Is Hep B acute or chronic?
Acute and chronic
How is Hep B transmitted?
Blood
Bodily fluids
sharing needles (IVDU and tattoos)
Vertical transmission (mother to child in utero)
What are the complications of Hep B?
Fulminant hepatitis
HCC
Cirrhosis
What is the incubation period of Hep A?
2-6 weeks
What is the incubation period of Hep B?
1-6 months
What appears in initial Hep B infection on serology?
Hb S Ag
What are the antibodies against hep B?
Anti-HBs Ag
How is chronic Hep B treated?
SC pegylated interferon-alpha 2a (weekly subcutaneous)
Tenofovir
Can lead to transplant
What type of drug is Tenofovir?
nucleoside reverse transcriptase inhibitors (NRTIs)
What type of virus is Hep C?
RNA flavivirus
Is Hep C chronic or acute?
Acute and chronic
Where is Hep C most common?
Egypt
How is Hep C spread?
Transmitted by blood and blood products
Very high in IVDU
Limited sexual transmission
What are the symptoms of hep C?
Acute= usually asymptomatic may have flu-like symptoms
Chronic = cirrhosis, liver failure, HCC, hepatosplenomegaly
How is Hep C diagnosed?
HCV antibody = within 4-6 weeks
HCV RNA = active infection!
How is Hep C treated?
Direct acting antiviral (DAA)
Ribavirin
What are the 3 suffixes for DAAs?
Asvir
Previr
Buvir
Why is access to Hep C treatment limited?
Very very expensive
What type of virus is hep D?
Incomplete RNA virus
What is required for Hep D assembly?
Hep B
(HBsAg)
Where is Hep D common?
Eastern Europe
North Africa
How is Hep D diagnosed and treated?
Same as Hep B
What are the risk factors of Hep B?
Healthcare workers
dialysis patients
Travellers
Gay men
IVDU
Is hep D acute or chronic?
Acute and chronic
What type of virus is Hep E?
RNA
Is hep E acute or chronic?
acute and chronic
How is Hep E spread?
Faeco-orally- food or water
Rodents, pigs and dogs
What is a big risk factor for increased Hep E mortality?
Pregnancy
How is Hep E infection diagnose?
Similar to Hep A (IgM and IgG)
HEV RNA
Where is Hep E common?
Indochina
What are 2 types of hepatitis with 100% immunity after infection?
Hep A
Hep E
How is Hep E treated?
Usually self limiting
Vaccine in china
What would serology HBsAG and IgM indicate?
Acute Hep B
What would serology HBsAG and IgG indicate?
Chronic Hep B
What would serology HBsAg (maybe) and IgG indicate?
Carrier
What would serology anti-HBsAg and anti-HBc indicate?
Cleared Hep B
What would serology appear like if the patient has been vaccinated against hep B?
Anti-HBsAg
Define autoimmune hepatitis
Inflammatory liver disease of unknown cause characterised by abnormal T-cell function and autoantibodies against hepatocyte surface antigens
What are the risk factors of autoimmune hepatitis?
Female
HLA DR3/4
Autoimmune disease
Viral hepatitis
Is type 1 or type 2 autoimmune hepatitis more common?
Type 1 by far
Who is predominantly affected by type 1 autoimmune hepatitis?
Adult women
Who is predominantly affected by type 2 autoimmune hepatitis?
Young women/children
How is type 1 autoimmune hepatitis diagnosed?
ANA (anti nuclear antibodies)
ASMA (anti smooth muscle antibodies)
Anti-SLA
How is type 2 autoimmune hepatitis diagnosed?
Anti-LKM1
Anti-LC1
How is autoimmune hepatitis treated?
Prednisolone + Azathioprine
Hep A and B vaccine
If severe = transplant
Define cirrhosis
Result of chronic inflammation and damage to hepatocytes, replacing them with fibrosis and nodules of scar tissue
Is cirrhosis reversible?
No
What are 4 causes of cirrhosis?
ALD (MC in UK)
NAFLD
Hep B and C
Wilsons
Alpha-antitrypsin deficiency
What are the symptoms of cirrhosis?
Basically similar to chronic failure
How is liver cirrhosis diagnosed?
Fibroscan
Liver biopsy
Hepatomegaly on CT
Thrombocytopenia
Low albumin and raised PT
What are the complications of liver cirrhosis?
Coagulopathy
Encephalopathy
Portal HTN
Ascites
Oesophageal varices
How is liver cirrhosis treated?
Good nutrition and abstain from alcohol
Ultrasounds for HCC
May need transplant
How is unconjugated bilirubin synthesised?
Hb -> haem -> biliverdin ——————> unconjugated bilirubin Via biliverdin reductase
Where is unconjugated bilirubin synthesised?
Spleen
How is unconjugated bilirubin transported?
Albumin
Where is conjugated bilirubin synthesised?
Liver
Define jaundice
Yellowing of skin/eyes due to accumulation of bilirubin
What are the 3 categories of causes of jaundice?
Prehepatic
Intrahepatic
Post-hepatic
Define Prehepatic jaundice
Unconjugated hyperbilirubinaemia due to increased RBC breakdown
What are 3 causes of prehepatic jaundice?
Haemolytic anaemias
-Sickle cell
-G6PDH deficiency ect
Gilbert syndrome
What causes intrahepatic jaundice
Conjugated/unconjugated hyperbilirubinaemia
What are 3 causes of intrahepatic jaundice?
Hepatitis
HCC
ALD/NAFLD
Hepatotoxic drugs
What is Gilbert syndrome?
Autorecessive mutation of UGT1A1 gene causing under active UGT therefore causing a decrease in conjugated bilirubin
What is the function of UGT?
Converts unconjugated bilirubin to conjugated alongside glucaronic acid
How does unconjugated bilirubin cause unconjugated hyperbilirubinaemia?
Not water soluble so does not leave the body in urine
Where is conjugated bilirubin broken down?
Small intestine
What breaks down conjugated bilirubin?
Colonic flora
What is conjugated bilirubin broken down into?
Urobilinogen
What is urobilinogen broken down into?
Urobilin (makes wee yellow)
Stercobilin (makes poo brown)
Define post hepatic jaundice
Conjugated hyperbilirubinaemia due to biliary obstruction
What are 3 causes of post hepatic jaundice?
Gallstones/Cholelithiasis
Pancreatic cancer
Choleangiocarcinoma
Mirizzi syndrome
PBC
PSC
What would pale stools and dark urine indicate?
Intra/post hepatic jaundice
Would itching indicate pre hepatic or intra/post hepatic jaundice?
Intra/post
What gene is mutated in Gilbert syndrome?
UGT1A1 chromosome 2
Recessive
Outline the pathophysiology of HE
Liver fails -> nitrogenous waste builds up -> passes to brain -> neurotoxic so halts Krebs -> irreparable brain damage and neuron death
How can HE cause cerebral oedema?
Astocytes try to clear ammonia -> excess glutamine -> osmotic imbalance -> shift of fluid into cells -> cerebral oedema
How is jaundice often diagnosed?
Liver ultrasound
What type of cancer affects the pancreas?
Adenocarcinoma
Where do pancreatic cancers most commonly occur?
Exocrine pancreas
Mainly the head (closest to vessels)
What are the risk factors of pancreatic cancer?
Smoking
Alcohol
DM
Chronic pancreatitis
FHx
Genetic mutation
What genetic mutation increases the likelihood of pancreatic cancer?
PRSS-1
Where do pancreatic cancers originate from?
Originate in ductal epithelium -> pre malignant lesions -> fully invasive cancer
What are the symptoms of pancreatic cancer?
Obstructive/painless jaundice
Pale stool and dark urine
Courvoisiers sign (head)
Epigastric pain from back relieved by sitting forwards (body and tail)
What is Courvosiers sign?
Palpable gallbladder and jaundice
How is pancreatic cancer diagnosed?
1st: abdo ultrasound
GS: pancreatic CT with contrast
What is the tumour marker of pancreatic cancer?
Ca19-9
Non diagnostic- just monitors progression
How is pancreatic cancer treated?
Surgery to remove tumour
Chemo radio ect
5% 5 year survival so many -> palliative care
Who is commonly affected by pancreatic cancer?
Males >
>60
Rare in people under 30
What is the most common first degree liver cancer?
Hepatocellular carcinoma (HCC)
Where do HCCs originate from?
Liver parenchyma
What are 3 risk factors of HCC?
Chronic hep C and B
Cirrhosis from ALD, NAFLD, autoimmune
Male
Where does HCC metastasise to?
Lymph nodes
Bones
Lungs
How does HCC metastasise?
Hematogenous spread
- hepatic and portal veins
What are the symptoms of HCC?
Signs of decompensated liver failure
Unexplained weight loss
Fatigue
Ache in R.Hypochondrium
How is HCC diagnosed?
Increased serum AFP
1. Ultrasound of liver/abdo
GS: CT scan to confirm Dx
How is HCC treated?
Sorafenib (kinase inhibitor)
Surgical resection
Liver transplant
How is HCC prevented?
Hep B/HBV vaccine
Define cholangiocarcinoma
Cancer of the biliary tree
What are 3 risk factors of cholangiocarcinoma?
Parasitic flukeworm infestation
Biliary cysts
IBD
What is the MC type of cholangiocarcinoma?
Adenocarcinoma
What are the symptoms of cholangiocarcinoma?
Jaundice
Abdo pain and ascites
Pruritus
Raised alkaline phosphate
Why do symptoms of cholangiocarcinoma appear late?
Slow growing
How are cholangiocarcinomas diagnosed?
- Abdo USS and CT
GS: MRCP (imaging of biliary tree)
Raised CEA and CA19-9
Raised bilirubin and ALP
How are cholangiocarcinomas treated?
Usually untreatable and die <6 months
Resection or ERCP stent
What is the tumour marker of HCC?
AFP
What is the tumour marker of cholangiocarcinoma/
CA19-9
What are 2 benign primary liver tumours?
Haemangionoma
Hepatic adenoma
What are 3 causes of hepatic adenoma?
Oral contraceptives
Anabolic steroids
Pregnancy
How does haemangioma present?
Strawberry mark on skin in first few weeks of life
Are primary or secondary liver cancers more common?
Secondary
What 3 locations most often metastasise to the liver?
GI tract
Breast
Bronchus
How are secondary liver tumours diagnosed?
USS with CT or MR
Hepatomegaly without jaundice
Raised serum alkaline phosphate
What are the 3 MC causes of drug induced liver injury?
Antibiotics
Analgesics
CNS drugs
What are 3 drugs that don’t cause liver injury?
Low dose aspirin
NSAIDs (except diclofenac)
BBs
CCBs
What level of paracetamol induces an overdose?
> 150mg/kg/ 12g / 24 tablets
Outline the pathophysiology of paracetamol overdose
Liver glutathione depleted -> liver can not deactivate NAPQI -> hepatotoxicity and paracetamol induced KI
When is liver damage due to paracetamol detectable on liver biochemistry?
> 18 hours after ingestion
What are the symptoms of paracetamol overdose?
Sudden severe onset RUQ pain
N+V
Raised PT
Hypoglycaemia
How is paracetamol overdose diagnosed?
History
Raised ALT
High paracetamol concentration
What is the main complication of paracetamol overdose?
Fulminant liver failure
How is paracetamol overdose treated?
- Activated charcoal (gastric decontamination less than 1 hour post ingestion)
- N-acetylcysteine (NAC)
Outline the pathophysiology of Gilberts
Normal RBC breakdown -> reduced conjugation -> raised unconjugated bilirubin -> jaundice
What are 3 risk factors of Gilberts syndrome?
Males
FHx
Post-pubertal
What is the key presentation of Gilberts syndrome?
Painless jaundice at a young age worsened by physiological stress
What is the MC cause of hereditary jaundice?
Gilberts
How is Gilberts syndrome treated?
Should be okay without
Severe = phototherapy
How does N-acetylcystiene work?
Replenishes glutathione
What is the complication of Gilberts?
Kernicterus (accumulation of bilirubin in basal ganglia -> neurological defecit
Define hernia
Profusion of a viscus/organ or part of it through a defect of the walls of its contained cavity into an abnormal position
What are the 2 main classifications of hernia?
Reducible hernia
Irreducible hernia
Define reducible hernia
Can be pushed back into the abdominal cavity with manual manoeuvring
Define irreducible hernia
Cannot be pushed back into place
What are the 3 types of irreducible hernia?
Obstructed
Incarcerated
Strangulated
Define obstructed hernia
Intestine obstructed in the hernia due to pressure of edges of the hernia (non-ischemic)
Define incarcerated hernia
Contents of the hernia are stuck inside by adhesions
Define strangulated hernia
Blood supply of the sac is cut off causing ischemia -> gangrene/perforation of hernial contents
Define inguinal hernia
Protrusion of abdominal contents through the inguinal canal
What is the MC hernia?
Inguinal hernia
What are the 2 types of inguinal hernia?
Indirect
Direct
What is the MC type of inguinal hernia?
Indirect
What are 3 risk factors of inguinal hernias?
Male
Heavy lifting
Chronic cough
Constipation
Ascites
Where do inguinal hernias present?
Above and medial to pubic tubercle
Define direct hernia
Peritoneal sac enters the inguinal canal through the posterior wall of the inguinal canal medial to inferior epigastric vessels
Define indirect hernia
Peritoneal sec enters the inguinal canal through the deep inguinal ring
What is the path of an indirect inguinal hernia?
Inguinal canal -> deep inguinal ring -> if large then out through superficial inguinal ring
What are the symptoms of an inguinal hernia?
swelling in groin- pain indicates strangulation
Bulging with strain
Lump along groin margin pointing to groin
How are inguinal hernias diagnosed?
Clinical exam
If unsure CT or MRI of groin area
What are 3 differential diagnoses of inguinal hernia?
Femoral hernia
Testicular torsion
Undescended testes
Epididymitis
Groin abcess
How are inguinal hernias treated?
Truss to prevent progression
Surgery if very bad:
- Open repair, prosthetic mesh, laparoscopy
Define femoral hernia
Bowel comes through femoral canal below inguinal ligament
Are femoral hernias more common in males or females?
Females
How do femoral hernias present?
Swelling in upper thigh pointing down
Likely to strangulate = pain
What are 2 differences between femoral and inguinal hernia?
Femoral points down,inguinal points towards groin
Neck of femoral hernia inferior and lateral to pubic tubercle, inguinal superior and medial
How are femoral hernias treated?
Surgery
Herniotomy- ligation and excision of the sac
Herniorrhaphy - repair of defect
Define incisional hernia
Tissue protrudes through a weak surgical scar
What are 3 risk factor of an incisional hernia?
Emergency surgery
Wound infection
Coughing and heavy lifting
Poor nutrition
Define umbilical hernia
Part of the bowel or tissue protrudes through the umbilicus (belly button)
Who is most at risk of a hiatus hernia?
Obese women
What are the 2 types of hiatus hernia?
Sliding
Rolling
What is a sliding hiatus hernia?
GOJ and part of the stomach slides up into the chest via the hiatus so it lies above the diaphragm
Define rolling hiatus hernia
GOJ remains in the abdomen but part of the fundus prolapses with the hiatus alongside the oesophagus (basically stomach elongating at the top)
How is hiatus hernia diagnosed?
Barium swallow
Upper GI endoscopy
How is hiatus hernia treated?
Lose weight
Treat reflux
Surgery
Define Epigastric hernia
Hernia in the Epigastric area of the abdomen
Define biliary colic
Pain associated with temporary obstruction of the cystic or common bile duct by a gallstone
What are the 4 character of biliary colic?
Sudden onset
Severe
Constant
Crescendo
What are 3 biliary tract diseases?
Biliary colic- gallstones
Cholecystitis
Cholangitis
Where do most gallstones form?
Gallbladder
What are 3 types of gallstones?
Cholesterol (>90%)
Pigmented (Bilirubin and calcium salts)
Mixed- cholesterol + pigment
What are 3 complications of gallstones?
Acute Cholecystitis
Acute cholangitis
Pancreatitis
What are 5 risk factors of gallstones?
Fat
Female
Forty
Fair
Fertile
What are the symptoms of gallstones?
Colicky RUQ pain
- Worsened by eating large fatty meals
Nausea and vomiting
What are 4 causes of gallstones?
Obesity and rapid weight loss (high in animals, low in fibre)
DM
Liver cirrhosis
Contraceptive pill
How are gallstones diagnosed?
- Ultrasound
GS: MRCP
FBC and CRP shows inflammatory markers
Raised ALP
How are gallstones treated?
NSAIDs/analgesia
ERCP
PCT
Elective laparoscopic cholecystectomy
What is a cholecystectomy?
Removal of gallbladder
Define cholecystitis
Inflammation of the gallbladder (95% of time due to gallstone)
Outline the pathophysiology of cholecystitis
Stone blocking duct -> bile builds up
THEN vascular supply reduced from distension
THEN transmural inflammation
What are the symptoms of cholecystitis?
RUQ pain radiating to right shouder
Fever and fatigue
Positive Murphy sign
What is the proper name for gallstones?
Cholelithiasis
What is Murphys sign?
Severe pain on deep inhalation with a hand pressed into RUQ
CHOLECYSTITIS
How is cholecystitis diagnosed?
- Abdo USS shows thickened gallbladder wall
Normal LFT
Leukocytosis and neutropenia
How is cholecystitis treated?
Prepare for surgery: IV Abx, heavy analgesia, IV fluids
Cholecystectomy within one week
What is the MC cause of cholecystitis?
E. Coli
What is the other name for ascending cholangitis?
Acute cholangitis
Define ascending cholangitis
Acute inflammation and infection of the biliary tree
What are 3 causes of ascending cholangitis?
Gallstones
Benign biliary strictures
Malignancy
Outline the pathophysiology of ascending cholangitis
Prolonged bile duct blockage -> bile stasis -> bacteria enters from duodenum ->biliary tree infection and consolidation
What are the symptoms of ascending cholangitis?
Charcots triad
Raised neutrophil
Reynolds Pentad
What is charcots (liver) triad?
Ascending cholangitis
RUQ pain
Jaundice
Fever
What is Reynolds pentad?
Charcots triad
Confusion
Septic shock
How is ascending cholangitis diagnosed?
USS (1) and MRCP (GS)
Blood cultures to find out bacterial cause
Leukocytosis, raised bilirubin, CRP and ALP
How is ascending cholangitis treated?
Treat sepsis if needed
ERCP and stenting to clear blockage
Cholecystectomy when recovered a bit
What does PBC stand for?
Primary biliary cholangitis/cirrhosis
Define PBC
Intrahepatic autoimmune condition causing progressive destruction of small bile ducts
Who is affected by PBC?
Almost always women
40-50 years
Smokers
Autoimmune disease
What are 3 risk factors of PBC?
FHx
many UTIs
Smoking
Past pregnancy
Using hair dye and nail polish
Is PBC or PSC more common?
PBC
Outline the pathophysiology of PBC
Chronic autoimmune granulomatous inflammation -> cholestasis -> fibrosis and cirrhosis of small bile ducts
How is PBC diagnosed?
95% have AMA (anti mitochondrial) antibodies on serology
Increased IgM, ALP, GGT
Ultrasound
Liver biopsy to stage
What are the symptoms of PBC?
- Pruritus (itching)
- Then lethargy and fatigue
- Then jaundice and hepatomegaly
Pigmented xanthelsaema (yellow deposits under skin usually around eyelids)
What are 3 complications of PBC?
Cirrhosis
Osteoporosis
Malabsorption
Coagulopathy
How is PBC treated?
- Ursodeoxycholic acid (improves bilirubin levels+ reduce cholestasis)
- Colestyramine for pruritus
Transplant (may still return)
Supplement vit ADEK
What autoimmune condition is most associated with PBC?
Sjogrens
Define cholestasis
Reduced or stopped bile flow
What does PSC stand for?
Primary sclerosing cholangitis
What causes pruritus in PBC?
Conjugated bilirubin leaking out
Define PSC
Chronic cholestatic disorder characterised by inflammatory and fibrosis of intrahepatic and extrahepatic bile ducts
What are 3 risk factors of PSC?
Men
40-50
IBD (UC)
FHx
Outline the pathophysiology of PSC
Same as PBC but affects ALL ducts
What are the symptoms of PSC?
RUQ pain
Jaundice
Pruritus
Hepatomegaly
How is PSC diagnosed?
GS: MRCP- bile duct lesions or strictures (beaded)
positive ANCA
(Positive ANA and ASMA)
How is PSC treated?
Cholestyramine - for pruritus
ERCP dilation and stenting
Transplant
How is PSC monitored?
Colonoscopy and USS yearly
- bile duct, liver , gallbladder and colon cancer more common
What are the complications of PSC?
Cholangiocarcinoma (10%)
Osteoporosis
Malabsorption
Strictures
Cancers
What condition is linked to PSC?
IBD- UC
Define acute pancreatitis
Reversible acute inflammation of the pancreas
What are the causes of acute pancreatitis?
I GET SMASHED
Idiopathic
Gallstones (MC)
Ethanol (30%)
Trauma
Steroids
Mumps
Autoimmune
Scorpion venom
Hyperlipidaemia
ERCP
Drugs
What 5 drugs can cause acute pancreatitis?
Azathioprine
Furosemide
Corticosteroids
NSAIDs
ACE inhibitors
Outline the pathophysiology of acute pancreatitis
Premature activation of pancreatic enzymes -> host defences overwhelmed -> autodigestion of pancreas -> inflammation and enzymes leak in blood
How do galllstones cause acute pancreatitis?
Trapped in ampulla of Vater -> blocks flow of bile -> reflux of bile into pancreatic duct -> prevents enzymes from being secreted -> causes inflammation in the pancreas
How does alcohol cause pancreatitis?
Directly toxic to pancreatic cells
What are the symptoms of acute pancreatitis?
Sudden severe abdo pain radiating to back better sitting fowards or lying fetal
N+V+ fever
Cullens sign
Grey turners sign
Abdo guarding and tenderness on examination
What is Cullens sign?
Periumbilical ecchymosis
Skin discolouration around belly button
What is Grey Turners sign?
Left flank bruising
How is acute pancreatitis diagnosed?
Raised urinary and serum amylase
Raised lipase
CXR to exclude AAA
Abdo USS to find gallstones
What systems are used to score acute pancreatitis?
Glasgow and Ranson scoring
APACHE II
How is acute pancreatitis treated?
NEEDS SEVERITY ASSESSMENT
NBM and NG tube
IV fluid resus
Analgesia
Monitor complications
What is the major complication of acute pancreatitis?
SIRS (systemic inflammatory response syndrome)
How is SIRS diagnosed?
Any 2 of
Tachycardia >90
Tachypnoea >20
Pyrexia
High WCC
Define chronic pancreatitis
Debilitating continuing inflammation in the pancreas causing a loss of tissue replacement by fibrosis of the endocrine and exocrine regions
What history is required for chronic pancreatitis?
3 months
What are 3 causes of chronic pancreatitis?
Long term alcohol excess (MC)
CKD
CF
Hereditary
Idiopathic
Outline the pathophysiology of chronic pancreatitis
Obstruction of bicarbonate release -> pH rises -> damage and necrosis -> fibrosis
What is the differential diagnosis of acute pancreatitis?
AAA
What are the symptoms of chronic pancreatitis?
Epigastric pain boring to back, worsened by alcohol and fatty food
Exocrine dysfunction (steatorrhoea, weight loss)
Endocrine dysfunction (DM)
What is the differential diagnosis of chronic pancreatitis?
Pancreatic cancer
How is chronic pancreatitis diagnosed?
Unlike acute, amylase and lipase not as elevated
Abnormal faecal elastase
GS: abdo USS and contrast enhance CT
How is chronic pancreatitis treated?
Alcohol cessation
Analgesia
Pancreatic enzyme supplements
Insulin for DM
Where is autoimmune pancreatitis most common?
Japan
Define autoimmune pancreatitis
Chronic pancreatic inflammation resulting from an autoimmune process
What are the symptoms of autoimmune pancreatitis?
Similar to chronic
How is autoimmune pancreatitis diagnosed?
Elevated IgG4
ANCA and rheumatoid factor may be elevated
How is autoimmune pancreatitis treated?
Glucocorticoids (eg. Prednisolone) for 4-6 weeks
Define ascites
Accumulation of free fluid in the peritoneal cavity
What are the normal levels of fluid in the peritoneal cavity?
Healthy men- minimum few ml
Healthy women- up to 20ml
What are the 4 stages of ascites?
1: only detectable by USS
2. Moderate causing abdo asymmetry
3. Large causing marked distension but not tense
4: tense
What are the categories of causes of ascites?
Local inflammation
Low protein
Flow stasis
What are 3 causes of local inflammation induced ascites?
Peritonitis
Abdo cancers (ovarian)
Infection such as TB
What are 3 causes of low protein induced ascites?
Hypoalbuminaemia
Nephrotic syndrome
Malnutrition
What are 3 causes of flow stasis induced ascites?
Cirrhosis!
Budd-Chiari
Heart failure
What are the symptoms of ascites?
Abdo distension
Shifting dullness
Jaundice and pruritus
Flank fullness
What are 2 signs of shifting dullness?
Supine = abdo resonant and flanks full
On side = flank resonant
How is ascites diagnosed?
Shifting dullness
Ascitic tap
- find malignancy, infection, WCC
serum ascites albumin gradient (SAAG) to find cause
What are the protein measurements indicating high SAAG?
> 1.1g/dL
What does high SAAG in ascites indicate?
Portal HTN
Heart failure
Budd-Chiari
Pericarditis
What does low SAAG in ascites indicate?
Malignancy
Peritonitis
TB
Pancreatitis
How is ascites treated?
Treat underlying cause
Diuretic = Spironolactone
Paracentesis (drain fluid)
TIPS (shunt)
Liver transplant if something causing it is liver related
Define portal hypertension
High blood pressure in the portal venous system
Define Budd-Chiari syndrome
Hepatic vein obstruction by tumour or thrombosis
What are 3 classifications of causes of portal hypertension?
Pre hepatic
Intra hepatic
Post hepatic
What is a pre hepatic cause of portal hypertension?
Portal vein thrombosis
What is an intrahepatic cause of portal hypertension?
Cirrhosis (MC UK)
Schistosomiasis (MC worldwide)
Budd-Chiari
What are 3 post hepatic causes of portal hypertension?
Constrictive pericarditis
IVC obstruction
RHF
Outline the pathophysiology of portal hypertension
Liver damage -> resistance -> drop in BP -> increase in CO and water retention -> increased portal flow -> shunts and portal HTN -> oesophageal varices
What are the symptoms of portal HTN?
Usually asymptomatic
Splenomegaly
CLD = haematemesis and malaena ect
Define oesophageal varices
Dilated collateral blood vessels that develop due to portal HTN
Outline the pathophysiology of ruptured oesophageal varices
Small veins can not handle much pressure -> high pressure -> ruptured
What are the symptoms of ruptured oesophageal varices?
Haematemesis (coffee ground vomit)
Melaena (tarry stools)
How are oesophageal varices diagnosed?
Oesophagogastroduodenoscopy (OGD/upper GI endoscopy)
How are ruptured oesophageal varices treated?
Resus until stable and consider transfusion if unstable
1. IV terlipressin
2. Variceal banding
3. TIPSS (shunt to larger veins)
How is oesophageal varices rupture prevented?
BB and nitrates
Variceal banding
Liver transplant
Define peritonitis
Inflammation of the peritoneal cavity caused by infection of ascitic fluid
What are the 2 parts of the peritoneum?
Parietal (well localised sensation)
Visceral (poorly localised)
What are the 2 categories of causes of peritonitis?
Bacterial/primary
Chemical/ secondary
What is a gram positive cause of peritonitis?
Staph aureus
What is a gram negative cause of peritonitis?
E. Coli
Klebscella
What are 3 chemical causes of peritonitis?
Bile
Ruptured ectopic pregnancy
Intestinal perforation
Old clotted blood
What are 3 risk factors of peritonitis?
Liver disease
Cirrhosis
Ascites
What are the symptoms of peritonitis?
Sudden onset abdo pain -> collapse and shock
Being rigid helps
Pressing hurts less than releasing pressure
Ascites
How is peritonitis diagnosed?
Ascitic tap
Cultures to show bacteria
Exclude pregnancy as a cause
CXR to see perforation
How is peritonitis treated?
Metronidazole and cefotaxime
Surgery- clean peritoneum
What is the major complication of peritonitis?
Septicaemia
Define haemochromatosis
Iron storage disorder that results in excessive total body iron and deposition of iron in tissues.
What are the causes of haemachromatosis?
HFE gene mutation on chromosome 6
High iron intake
Alcoholism
Is the HFE gene mutation in haemochromatosis dominant or recessive?
Autosomal recessive
Why are men more likely to have haemochromatosis?
Blood loss from menstrual cycle in females reduces Fe
Outline the pathophysiology of haemochromatosis
HFE interacts with transferrin receptor 1 -> increased iron uptake -> decreased hepcidin -> iron overload -> taken up by liver and also deposited in other organs
What is the function of hepcidin?
Controls iron absorption
When does haemochromatosis usually present?
50s
What are the symptoms of haemochromatosis?
Testicular atrophy
Hypogonadism
Slate grey/ bronze skin
Osteoporosis
Liver failure symptoms
How is haemochromatosis diagnosed?
Raised serum Fe, ferritin
Genetic testing
Liver biopsy (Prussian blue/perl stain)
How is haemochromatosis treated?
Venesection - regular removal of blood/ desferrioxamine (chelating agent)
Avoid alcohol
Treat complications
Define Wilson’s disease
Excess accumulation of copper in body and tissues
What causes Wilson’s disease?
Autorec mutation of ATP7B copper binding protein on chromosome 13
What age does Wilson’s disease usually present?
Young- 20s
Usually males
Outline the pathophysiology of Wilson’s disease
Impaired Cu biliary excretion -> CU accumulation in liver and basal ganglia
What is copper usually bound?
Caeruloplasmin
What are the symptoms of Wilson’s disease?
Hepatic issues
CNS issues
Kayser-Fleischer ring
What is a Kayser-Fleischer ring?
Copper deposition in the cornea causing a greenish-brown ring around the iris
How is Wilson’s disease diagnosed?
Reduced serum Cu and caeruloplasmin
GS: liver biopsy
High 24 hour urinary Cu excretion
How is Wilson’s disease treated?
Avoid food high in Cu (liver, chocolate, nuts)
Lifelong chelating agent
What is an example of a copper chelating agent?
D-Penicillamine
Define A1AT deficiency
Deficiency of alpha 1 antitrypsin enzyme
What causes A1AT deficiency?
Autorecessive mutation of protease inhibitor gene (SERPINA-1) on chromosome 14
Outline the pathophysiology of A1AT deficiency
No inhibition of NE -> degradation of elastic tissue in the lungs
And
Deposition of A1AT in liver -> cirrhosis
What is the function of A1AT?
Inhibits NE (neutrophil elastase) which degrades elastic tissue
What are the effects of A1AT deficiency on the lungs?
Degrading elastic tissue -> emphysema, alveolar duct collapse, trapped air
What are the symptoms of A1AT deficiency?
Young-mid aged male with COPD like symptoms and no smoking Hx
Liver disease in children (neonatal jaundice)
How is A1AT deficiency diagnosed?
Decreased serum A1AT
Biopsy- Periodic acid Schiff positive globules
CT- emphysema
Genetic testing
How is A1AT deficiency treated?
Stop smoking
Treat complications
Manage emphysema
What are 2 complications of A1AT deficiency?
HCC
Cirrhosis
What are the 3 symptoms of Budd Chiari syndrome?
Ascites
Hepatomegaly
Abdominal pain
What are the 3 antigens in Hep B?
HBsAg- surface antigen
HBcAg- cord antigen
HbdAg- active disease marker
What are 3 bacterial causes of cholecystitis?
E.coli
Klebsiella
Enterococcus
How is portal hypertension treated?
Beta blocker (CI cirrhosis)
TIPSS shunt
Liver transplant
how are alcohol units calculated?
ml of alcohol x ABV
——————————
1000