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Phase 2a Annabel > Liver + Friends > Flashcards

Liver + Friends Flashcards

1
Q

What are the 3 key markers of liver function?

A

Bilirubin
Albumin
Prothrombin time (PT/INR)

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2
Q

What levels of bilirubin indicate liver dysfunction?

A

Increased

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3
Q

What level of albumin indicates liver dysfunction?

A

Decreased

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4
Q

What liver enzymes indicate liver damage?

A

AST (aspartate aminotransferase)
ALT (alanine aminotransferase)
GGT
ALP

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5
Q

Where are liver enzymes found?

A

Hepatocytes- leak out when damage occurs

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6
Q

When are high AST levels seen?

A

Hepatic necrosis
MI
Muscle injury
Congestive cardiac failure

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7
Q

When are high ALT levels seen?

A

ONLY in liver disease

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8
Q

What is the typical AST:ALT ratio?

A

1

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9
Q

What does an AST:ALT ratio of >2:1 indicate?

A

Alcoholic liver disease especially with inc. GGT

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10
Q

What does an AST:ALT ratio of >4.5:1 indicate?

A

Wilsons
Hyperthyroid

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11
Q

What does an AST:ALT ratio of <0.9:1 indicate?

A

NAFLD

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12
Q

When is GGT increased?

A

ALD

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13
Q

When is ALP increased?

A

Biliary tree specific damage
Bone pathology

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14
Q

What are 7 functions of the liver?

A

MAD BICO

Metabolises carbs
Albumin production
Detoxification
Bilirubin regulation
Immunity and Kupffer cells
Clotting factor production
Oestrogen regulation

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15
Q

What are 3 disorders of oestrogen regulation?

A

Gynaecomastia in men
Spider naevi
Palmar erythema

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16
Q

What is one disorder of detoxification pathology?

A

Hepatic encephalopathy

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17
Q

What is one disorder of carbohydrate metabolism?

A

Hypoglycaemia

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18
Q

What are 3 disorders of albumin production?

A

Oedema
Leukonychia
Ascites

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19
Q

What is one consequence of clotting factor dysfunction?

A

Easy bleeding and bruising

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20
Q

What are 2 disorders of bilirubin regulation?

A

Pruritus
Jaundice

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21
Q

What is one consequence of Kupffer cell dysfunction?

A

Spontaneous bacterial infections

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22
Q

Define acute liver failure

A

Rapid decline characterised by jaundice, coagulopathy (INR > 1.5) and hepatic encelopathy in a patient with a previously normal liver

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23
Q

What are the 3 types of acute liver failure?

A

Hyperacute <7 days
Acute: 1-4 weeks
Subacute: 4-12 weeks

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24
Q

Why does acute liver failure mainly occur?

A

Massive hepatocytes necrosis

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25
What are 5 causes of acute liver failure?
Drugs Viral Infiltrative Budd Chiari Acute fatty liver of pregnancy
26
What are 3 viral causes of acute liver failure?
Hepatitis A,B,D,E EBV HSV
27
What are 3 drugs that can cause acute liver failure?
Paracetamol Alcohol Ecstasy
28
What are the symptoms of acute liver failure?
Jaundice, coagulopathy, hepatic encephalopathy ascites MC 4 symptoms: jaundice, nausea, anorexia, malaise
29
How is HE graded?
West Haven criteria grades 1-4
30
Define hepatic encephalopathy
Changes in the brain that occur in patients with liver failure, ranging from memory issues to coma
31
Define liver failure
Liver fails to regenerate and repair leading to decompensation
32
How is acute liver failure diagnosed?
LFTs (bilirubin ect) EEG to grade HE Microbiology for infection
33
How is acute liver failure treated?
Treat underlying cause ABCDE if severe Treat complications
34
What are 3 complications of acute liver failure?
MC: Infection Renal failure Progressive HE Oedema
35
How is encephalopathy treated in liver failure?
Lactulose (increased ammonia excretion) Consider mannitol
36
How is ascites treated in liver failure?
Diuretics Fluid restriction
37
How is cerebral oedema treated in liver failure?
Mannitol
38
How is bleeding treated in liver failure?
Vitamin K
39
How is sepsis treated in liver failure?
Abx
40
How is hypoglycaemia treated in liver failure?
Dextrose
41
Define chronic liver failure
Progressive liver disease over 6+ months due to repeated liver insults
42
What are 3 causes of chronic liver failure?
Alcoholic liver disease (ALD) Non- alcoholic fatty liver disease (NAFLD) Viral (hep C)
42
What are 3 risk factors of chronic liver failure?
Alcohol Obesity T2DM Drugs
43
Outline the pathophysiology of chronic liver failure
Hepatitis/cholecystitis -> reversible fibrosis -> irreversible cirrhosis -> compensated or decompensated
44
Define compensated cirrhosis
Liver function preserved, no evidence of compliance to portal HTN
45
Define decompensated cirrhosis
Complications of liver dysfunction with reduced hepatic synthetic function and portal HTN
46
How is chronic liver failure graded?
Child Pugh score
47
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
48
How is chronic liver failure diagnosed?
Biopsy to confirm cirrhosis LFTs Imagine Tap of ascites
49
What causes liver cirrhosis?
Chronic liver inflammation and liver cell damage
50
How is chronic liver failure treated?
Prevent progression - lifestyle modifications Consider transplant if decompensated Mange complications
51
Define fulminant liver failure
Syndrome of massive hepatocyte necrosis
52
What is the most common cause of fulminant liver failure?
Paracetamol overdose
53
What is the most common cause of liver failure?
Alcoholic liver disease
54
Outline the pathophysiology of ALD
Steatosis (fatty liver) -> Alcohol hepatitis (inflammation + necrosis) -> alcoholic cirrhosis (irreversible scar tissue)
55
What are 3 risk factors of ALD?
Obesity Smoking Excessive alcohol use
56
What are the symptoms of ALD?
Early stages have very little symptoms Later = chronic liver failure symptoms and alcohol dependency
57
How is alcohol dependency characterised?
CAGE and AUDIT
58
How is ALD diagnosed?
GS: liver biopsy Elevated MCV Ultrasound or CT Elevated PT, bilirubin, ALT and AST
59
What CAGE score indicates alcohol dependency?
2 or more
60
How is ALD treated?
Stop drinking alcohol! Short term steroids Consider transplant
61
How are alcohol withdrawal symptoms treated?
Chlordiazepoxide or diazepam IV vitamin D and thiamine
62
What is the major complication of alcohol withdrawal?
Delerium tremens
63
What is the maximum alcohol recommendation a week?
14 units
64
What are the complications of ALD?
Wernicke Korsakoff syndrome Pancreatitis HE Ascites HCC Mallory Weiss tear
65
What are Mallory cytoplasmic inclusion bodies indicative of?
ALD
66
What is Wenicke Korsakoff syndrome?
Combined B1 deficiency and alcohol withdrawal symptoms
67
What are the 3 symptoms of Wernicke Korsakoff syndrome?
Ataxia Nystagmus Encelopathy
68
How is Wernicke Korsakoff syndrome treated?
IV thiamine
69
Define non alcoholic fatty liver disease
Fat deposited in liver cells which interfere with function which can progress to hepatitis and cirrhosis
70
What are 3 risk factors of NAFLD?
Obesity HTN T2DM Hyperlipidaemia FHx
71
Outline the pathophysiology of NAFLD
Non-alcoholic fatty liver disease -> Non-alcoholic Steatehepatitis (NASH) -> Fibrosis -> Cirrhosis
72
How common is NAFLD?
30% of adults have it
73
What are the symptoms of NAFLD?
Typically asymptomatic Severe = liver failure signs Hepatomegaly Thrombocytopenia
74
How is NAFLD diagnosed?
Deranged LFTs (raised PT and bilirubin, dec albumin) Liver ultrasound Liver biopsy (GS)
75
What is transient elastography (fibroscan) used for?
Non-invasive test measuring liver stiffness, correlating to degree of fibrosis
76
How is NAFLD treated?
Lose weight Control risk factors Avoid alcohol
77
What are the complications of NAFLD?
HE Ascites HCC Portal HTN and oesophageal ascites
78
Define hepatitis
Inflammation of the liver
79
Define viral hepatitis
Inflammation of the liver due to viral replication in hepatocytes
80
What type of virus is hepatitis A?
Single stranded RNA
81
Is Hep A acute or chronic?
Acute
82
Where is Hep A most prevalent?
Africa and South America Seen in autumn
83
How is hep A spread?
Faeco-orally
84
What are 3 risk factors of Hep A?
Shellfish Travel to Africa or South America Overcrowding
85
What are the 2 phases of Hep A and B?
Prodromal phase Icteric phase
86
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
87
How is Hep A diagnosed?
FBC: leukopenia and raised ESR Increased HAV IgM in infection, and anti HAV IgG after Raised bilirubin
88
How is Hep A treated?
Usually self limiting Anti-emetics and rest Vaccine available
89
What type of virus is Hep B?
DNA virus
90
Is Hep B acute or chronic?
Acute and chronic
91
How is Hep B transmitted?
Blood Bodily fluids sharing needles (IVDU and tattoos) Vertical transmission (mother to child in utero)
92
What are the complications of Hep B?
Fulminant hepatitis HCC Cirrhosis
93
What is the incubation period of Hep A?
2-6 weeks
94
What is the incubation period of Hep B?
1-6 months
95
What appears in initial Hep B infection on serology?
Hb S Ag
96
What are the antibodies against hep B?
Anti-HBs Ag
97
How is chronic Hep B treated?
SC pegylated interferon-alpha 2a (weekly subcutaneous) Tenofovir Can lead to transplant
98
What type of drug is Tenofovir?
nucleoside reverse transcriptase inhibitors (NRTIs)
99
What type of virus is Hep C?
RNA flavivirus
100
Is Hep C chronic or acute?
Acute and chronic
101
Where is Hep C most common?
Egypt
102
How is Hep C spread?
Transmitted by blood and blood products Very high in IVDU Limited sexual transmission
103
What are the symptoms of hep C?
Acute= usually asymptomatic may have flu-like symptoms Chronic = cirrhosis, liver failure, HCC, hepatosplenomegaly
104
How is Hep C diagnosed?
HCV antibody = within 4-6 weeks HCV RNA = active infection!
105
How is Hep C treated?
Direct acting antiviral (DAA) Ribavirin
106
What are the 3 suffixes for DAAs?
Asvir Previr Buvir
107
Why is access to Hep C treatment limited?
Very very expensive
108
What type of virus is hep D?
Incomplete RNA virus
109
What is required for Hep D assembly?
Hep B (HBsAg)
110
Where is Hep D common?
Eastern Europe North Africa
111
How is Hep D diagnosed and treated?
Same as Hep B
112
What are the risk factors of Hep B?
Healthcare workers dialysis patients Travellers Gay men IVDU
113
Is hep D acute or chronic?
Acute and chronic
114
What type of virus is Hep E?
RNA
115
Is hep E acute or chronic?
acute and chronic
116
How is Hep E spread?
Faeco-orally- food or water Rodents, pigs and dogs
117
What is a big risk factor for increased Hep E mortality?
Pregnancy
118
How is Hep E infection diagnose?
Similar to Hep A (IgM and IgG) HEV RNA
119
Where is Hep E common?
Indochina
120
What are 2 types of hepatitis with 100% immunity after infection?
Hep A Hep E
121
How is Hep E treated?
Usually self limiting Vaccine in china
122
What would serology HBsAG and IgM indicate?
Acute Hep B
123
What would serology HBsAG and IgG indicate?
Chronic Hep B
124
What would serology HBsAg (maybe) and IgG indicate?
Carrier
125
What would serology anti-HBsAg and anti-HBc indicate?
Cleared Hep B
126
What would serology appear like if the patient has been vaccinated against hep B?
Anti-HBsAg
127
Define autoimmune hepatitis
Inflammatory liver disease of unknown cause characterised by abnormal T-cell function and autoantibodies against hepatocyte surface antigens
128
What are the risk factors of autoimmune hepatitis?
Female HLA DR3/4 Autoimmune disease Viral hepatitis
129
Is type 1 or type 2 autoimmune hepatitis more common?
Type 1 by far
130
Who is predominantly affected by type 1 autoimmune hepatitis?
Adult women
131
Who is predominantly affected by type 2 autoimmune hepatitis?
Young women/children
132
How is type 1 autoimmune hepatitis diagnosed?
ANA (anti nuclear antibodies) ASMA (anti smooth muscle antibodies) Anti-SLA
133
How is type 2 autoimmune hepatitis diagnosed?
Anti-LKM1 Anti-LC1
134
How is autoimmune hepatitis treated?
Prednisolone + Azathioprine Hep A and B vaccine If severe = transplant
135
Define cirrhosis
Result of chronic inflammation and damage to hepatocytes, replacing them with fibrosis and nodules of scar tissue
136
Is cirrhosis reversible?
No
137
What are 4 causes of cirrhosis?
ALD (MC in UK) NAFLD Hep B and C Wilsons Alpha-antitrypsin deficiency
138
What are the symptoms of cirrhosis?
Basically similar to chronic failure
139
How is liver cirrhosis diagnosed?
Fibroscan Liver biopsy Hepatomegaly on CT Thrombocytopenia Low albumin and raised PT
140
What are the complications of liver cirrhosis?
Coagulopathy Encephalopathy Portal HTN Ascites Oesophageal varices
141
How is liver cirrhosis treated?
Good nutrition and abstain from alcohol Ultrasounds for HCC May need transplant
142
How is unconjugated bilirubin synthesised?
Hb -> haem -> biliverdin ——————> unconjugated bilirubin Via biliverdin reductase
143
Where is unconjugated bilirubin synthesised?
Spleen
144
How is unconjugated bilirubin transported?
Albumin
145
Where is conjugated bilirubin synthesised?
Liver
146
Define jaundice
Yellowing of skin/eyes due to accumulation of bilirubin
147
What are the 3 categories of causes of jaundice?
Prehepatic Intrahepatic Post-hepatic
148
Define Prehepatic jaundice
Unconjugated hyperbilirubinaemia due to increased RBC breakdown
149
What are 3 causes of prehepatic jaundice?
Haemolytic anaemias -Sickle cell -G6PDH deficiency ect Gilbert syndrome
150
What causes intrahepatic jaundice
Conjugated/unconjugated hyperbilirubinaemia
151
What are 3 causes of intrahepatic jaundice?
Hepatitis HCC ALD/NAFLD Hepatotoxic drugs
152
What is Gilbert syndrome?
Autorecessive mutation of UGT1A1 gene causing under active UGT therefore causing a decrease in conjugated bilirubin
153
What is the function of UGT?
Converts unconjugated bilirubin to conjugated alongside glucaronic acid
154
How does unconjugated bilirubin cause unconjugated hyperbilirubinaemia?
Not water soluble so does not leave the body in urine
155
Where is conjugated bilirubin broken down?
Small intestine
156
What breaks down conjugated bilirubin?
Colonic flora
157
What is conjugated bilirubin broken down into?
Urobilinogen
158
What is urobilinogen broken down into?
Urobilin (makes wee yellow) Stercobilin (makes poo brown)
159
Define post hepatic jaundice
Conjugated hyperbilirubinaemia due to biliary obstruction
160
What are 3 causes of post hepatic jaundice?
Gallstones/Cholelithiasis Pancreatic cancer Choleangiocarcinoma Mirizzi syndrome PBC PSC
161
What would pale stools and dark urine indicate?
Intra/post hepatic jaundice
162
Would itching indicate pre hepatic or intra/post hepatic jaundice?
Intra/post
163
What gene is mutated in Gilbert syndrome?
UGT1A1 chromosome 2 Recessive
164
Outline the pathophysiology of HE
Liver fails -> nitrogenous waste builds up -> passes to brain -> neurotoxic so halts Krebs -> irreparable brain damage and neuron death
165
How can HE cause cerebral oedema?
Astocytes try to clear ammonia -> excess glutamine -> osmotic imbalance -> shift of fluid into cells -> cerebral oedema
166
How is jaundice often diagnosed?
Liver ultrasound
167
What type of cancer affects the pancreas?
Adenocarcinoma
168
Where do pancreatic cancers most commonly occur?
Exocrine pancreas Mainly the head (closest to vessels)
169
What are the risk factors of pancreatic cancer?
Smoking Alcohol DM Chronic pancreatitis FHx Genetic mutation
170
What genetic mutation increases the likelihood of pancreatic cancer?
PRSS-1
171
Where do pancreatic cancers originate from?
Originate in ductal epithelium -> pre malignant lesions -> fully invasive cancer
172
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)
173
What is Courvosiers sign?
Palpable gallbladder and jaundice
174
How is pancreatic cancer diagnosed?
1st: abdo ultrasound GS: pancreatic CT with contrast
175
What is the tumour marker of pancreatic cancer?
Ca19-9 Non diagnostic- just monitors progression
176
How is pancreatic cancer treated?
Surgery to remove tumour Chemo radio ect 5% 5 year survival so many -> palliative care
177
Who is commonly affected by pancreatic cancer?
Males > >60 Rare in people under 30
178
What is the most common first degree liver cancer?
Hepatocellular carcinoma (HCC)
179
Where do HCCs originate from?
Liver parenchyma
180
What are 3 risk factors of HCC?
Chronic hep C and B Cirrhosis from ALD, NAFLD, autoimmune Male
181
Where does HCC metastasise to?
Lymph nodes Bones Lungs
182
How does HCC metastasise?
Hematogenous spread - hepatic and portal veins
183
What are the symptoms of HCC?
Signs of decompensated liver failure Unexplained weight loss Fatigue Ache in R.Hypochondrium
184
How is HCC diagnosed?
Increased serum AFP 1. Ultrasound of liver/abdo GS: CT scan to confirm Dx
185
How is HCC treated?
Sorafenib (kinase inhibitor) Surgical resection Liver transplant
186
How is HCC prevented?
Hep B/HBV vaccine
187
Define cholangiocarcinoma
Cancer of the biliary tree
188
What are 3 risk factors of cholangiocarcinoma?
Parasitic flukeworm infestation Biliary cysts IBD
189
What is the MC type of cholangiocarcinoma?
Adenocarcinoma
190
What are the symptoms of cholangiocarcinoma?
Jaundice Abdo pain and ascites Pruritus Raised alkaline phosphate
191
Why do symptoms of cholangiocarcinoma appear late?
Slow growing
192
How are cholangiocarcinomas diagnosed?
1. Abdo USS and CT GS: MRCP (imaging of biliary tree) Raised CEA and CA19-9 Raised bilirubin and ALP
193
How are cholangiocarcinomas treated?
Usually untreatable and die <6 months Resection or ERCP stent
194
What is the tumour marker of HCC?
AFP
195
What is the tumour marker of cholangiocarcinoma/
CA19-9
196
What are 2 benign primary liver tumours?
Haemangionoma Hepatic adenoma
197
What are 3 causes of hepatic adenoma?
Oral contraceptives Anabolic steroids Pregnancy
198
How does haemangioma present?
Strawberry mark on skin in first few weeks of life
199
Are primary or secondary liver cancers more common?
Secondary
200
What 3 locations most often metastasise to the liver?
GI tract Breast Bronchus
201
How are secondary liver tumours diagnosed?
USS with CT or MR Hepatomegaly without jaundice Raised serum alkaline phosphate
202
What are the 3 MC causes of drug induced liver injury?
Antibiotics Analgesics CNS drugs
203
What are 3 drugs that don’t cause liver injury?
Low dose aspirin NSAIDs (except diclofenac) BBs CCBs
204
What level of paracetamol induces an overdose?
>150mg/kg/ 12g / 24 tablets
205
Outline the pathophysiology of paracetamol overdose
Liver glutathione depleted -> liver can not deactivate NAPQI -> hepatotoxicity and paracetamol induced KI
206
When is liver damage due to paracetamol detectable on liver biochemistry?
>18 hours after ingestion
207
What are the symptoms of paracetamol overdose?
Sudden severe onset RUQ pain N+V Raised PT Hypoglycaemia
208
How is paracetamol overdose diagnosed?
History Raised ALT High paracetamol concentration
209
What is the main complication of paracetamol overdose?
Fulminant liver failure
210
How is paracetamol overdose treated?
1. Activated charcoal (gastric decontamination less than 1 hour post ingestion) 2. N-acetylcysteine (NAC)
211
Outline the pathophysiology of Gilberts
Normal RBC breakdown -> reduced conjugation -> raised unconjugated bilirubin -> jaundice
212
What are 3 risk factors of Gilberts syndrome?
Males FHx Post-pubertal
213
What is the key presentation of Gilberts syndrome?
Painless jaundice at a young age worsened by physiological stress
214
What is the MC cause of hereditary jaundice?
Gilberts
215
How is Gilberts syndrome treated?
Should be okay without Severe = phototherapy
216
How does N-acetylcystiene work?
Replenishes glutathione
217
What is the complication of Gilberts?
Kernicterus (accumulation of bilirubin in basal ganglia -> neurological defecit
218
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
219
What are the 2 main classifications of hernia?
Reducible hernia Irreducible hernia
220
Define reducible hernia
Can be pushed back into the abdominal cavity with manual manoeuvring
221
Define irreducible hernia
Cannot be pushed back into place
222
What are the 3 types of irreducible hernia?
Obstructed Incarcerated Strangulated
223
Define obstructed hernia
Intestine obstructed in the hernia due to pressure of edges of the hernia (non-ischemic)
224
Define incarcerated hernia
Contents of the hernia are stuck inside by adhesions
225
Define strangulated hernia
Blood supply of the sac is cut off causing ischemia -> gangrene/perforation of hernial contents
226
Define inguinal hernia
Protrusion of abdominal contents through the inguinal canal
227
What is the MC hernia?
Inguinal hernia
228
What are the 2 types of inguinal hernia?
Indirect Direct
229
What is the MC type of inguinal hernia?
Indirect
230
What are 3 risk factors of inguinal hernias?
Male Heavy lifting Chronic cough Constipation Ascites
231
Where do inguinal hernias present?
Above and medial to pubic tubercle
232
Define direct hernia
Peritoneal sac enters the inguinal canal through the posterior wall of the inguinal canal medial to inferior epigastric vessels
233
Define indirect hernia
Peritoneal sec enters the inguinal canal through the deep inguinal ring
234
What is the path of an indirect inguinal hernia?
Inguinal canal -> deep inguinal ring -> if large then out through superficial inguinal ring
235
What are the symptoms of an inguinal hernia?
swelling in groin- pain indicates strangulation Bulging with strain Lump along groin margin pointing to groin
236
How are inguinal hernias diagnosed?
Clinical exam If unsure CT or MRI of groin area
237
What are 3 differential diagnoses of inguinal hernia?
Femoral hernia Testicular torsion Undescended testes Epididymitis Groin abcess
238
How are inguinal hernias treated?
Truss to prevent progression Surgery if very bad: - Open repair, prosthetic mesh, laparoscopy
239
Define femoral hernia
Bowel comes through femoral canal below inguinal ligament
240
Are femoral hernias more common in males or females?
Females
241
How do femoral hernias present?
Swelling in upper thigh pointing down Likely to strangulate = pain
242
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
243
How are femoral hernias treated?
Surgery Herniotomy- ligation and excision of the sac Herniorrhaphy - repair of defect
244
Define incisional hernia
Tissue protrudes through a weak surgical scar
245
What are 3 risk factor of an incisional hernia?
Emergency surgery Wound infection Coughing and heavy lifting Poor nutrition
246
Define umbilical hernia
Part of the bowel or tissue protrudes through the umbilicus (belly button)
247
Who is most at risk of a hiatus hernia?
Obese women
248
What are the 2 types of hiatus hernia?
Sliding Rolling
249
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
250
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)
251
How is hiatus hernia diagnosed?
Barium swallow Upper GI endoscopy
252
How is hiatus hernia treated?
Lose weight Treat reflux Surgery
253
Define Epigastric hernia
Hernia in the Epigastric area of the abdomen
254
Define biliary colic
Pain associated with temporary obstruction of the cystic or common bile duct by a gallstone
255
What are the 4 character of biliary colic?
Sudden onset Severe Constant Crescendo
256
What are 3 biliary tract diseases?
Biliary colic- gallstones Cholecystitis Cholangitis
257
Where do most gallstones form?
Gallbladder
258
What are 3 types of gallstones?
Cholesterol (>90%) Pigmented (Bilirubin and calcium salts) Mixed- cholesterol + pigment
259
What are 3 complications of gallstones?
Acute Cholecystitis Acute cholangitis Pancreatitis
260
What are 5 risk factors of gallstones?
Fat Female Forty Fair Fertile
261
What are the symptoms of gallstones?
Colicky RUQ pain - Worsened by eating large fatty meals Nausea and vomiting
262
What are 4 causes of gallstones?
Obesity and rapid weight loss (high in animals, low in fibre) DM Liver cirrhosis Contraceptive pill
263
How are gallstones diagnosed?
1. Ultrasound GS: MRCP FBC and CRP shows inflammatory markers Raised ALP
264
How are gallstones treated?
NSAIDs/analgesia ERCP PCT Elective laparoscopic cholecystectomy
265
What is a cholecystectomy?
Removal of gallbladder
266
Define cholecystitis
Inflammation of the gallbladder (95% of time due to gallstone)
267
Outline the pathophysiology of cholecystitis
Stone blocking duct -> bile builds up THEN vascular supply reduced from distension THEN transmural inflammation
268
What are the symptoms of cholecystitis?
RUQ pain radiating to right shouder Fever and fatigue Positive Murphy sign
269
What is the proper name for gallstones?
Cholelithiasis
270
What is Murphys sign?
Severe pain on deep inhalation with a hand pressed into RUQ CHOLECYSTITIS
271
How is cholecystitis diagnosed?
1. Abdo USS shows thickened gallbladder wall Normal LFT Leukocytosis and neutropenia
272
How is cholecystitis treated?
Prepare for surgery: IV Abx, heavy analgesia, IV fluids Cholecystectomy within one week
273
What is the MC cause of cholecystitis?
E. Coli
274
What is the other name for ascending cholangitis?
Acute cholangitis
275
Define ascending cholangitis
Acute inflammation and infection of the biliary tree
276
What are 3 causes of ascending cholangitis?
Gallstones Benign biliary strictures Malignancy
277
Outline the pathophysiology of ascending cholangitis
Prolonged bile duct blockage -> bile stasis -> bacteria enters from duodenum ->biliary tree infection and consolidation
278
What are the symptoms of ascending cholangitis?
Charcots triad Raised neutrophil Reynolds Pentad
279
What is charcots (liver) triad?
Ascending cholangitis RUQ pain Jaundice Fever
280
What is Reynolds pentad?
Charcots triad Confusion Septic shock
281
How is ascending cholangitis diagnosed?
USS (1) and MRCP (GS) Blood cultures to find out bacterial cause Leukocytosis, raised bilirubin, CRP and ALP
282
How is ascending cholangitis treated?
Treat sepsis if needed ERCP and stenting to clear blockage Cholecystectomy when recovered a bit
283
What does PBC stand for?
Primary biliary cholangitis/cirrhosis
284
Define PBC
Intrahepatic autoimmune condition causing progressive destruction of small bile ducts
285
Who is affected by PBC?
Almost always women 40-50 years Smokers Autoimmune disease
286
What are 3 risk factors of PBC?
FHx many UTIs Smoking Past pregnancy Using hair dye and nail polish
287
Is PBC or PSC more common?
PBC
288
Outline the pathophysiology of PBC
Chronic autoimmune granulomatous inflammation -> cholestasis -> fibrosis and cirrhosis of small bile ducts
289
How is PBC diagnosed?
95% have AMA (anti mitochondrial) antibodies on serology Increased IgM, ALP, GGT Ultrasound Liver biopsy to stage
290
What are the symptoms of PBC?
1. Pruritus (itching) 2. Then lethargy and fatigue 3. Then jaundice and hepatomegaly Pigmented xanthelsaema (yellow deposits under skin usually around eyelids)
291
What are 3 complications of PBC?
Cirrhosis Osteoporosis Malabsorption Coagulopathy
292
How is PBC treated?
1. Ursodeoxycholic acid (improves bilirubin levels+ reduce cholestasis) 2. Colestyramine for pruritus Transplant (may still return) Supplement vit ADEK
293
What autoimmune condition is most associated with PBC?
Sjogrens
294
Define cholestasis
Reduced or stopped bile flow
295
What does PSC stand for?
Primary sclerosing cholangitis
296
What causes pruritus in PBC?
Conjugated bilirubin leaking out
297
Define PSC
Chronic cholestatic disorder characterised by inflammatory and fibrosis of intrahepatic and extrahepatic bile ducts
298
What are 3 risk factors of PSC?
Men 40-50 IBD (UC) FHx
299
Outline the pathophysiology of PSC
Same as PBC but affects ALL ducts
300
What are the symptoms of PSC?
RUQ pain Jaundice Pruritus Hepatomegaly
301
How is PSC diagnosed?
GS: MRCP- bile duct lesions or strictures (beaded) positive ANCA (Positive ANA and ASMA)
302
How is PSC treated?
Cholestyramine - for pruritus ERCP dilation and stenting Transplant
303
How is PSC monitored?
Colonoscopy and USS yearly - bile duct, liver , gallbladder and colon cancer more common
304
What are the complications of PSC?
Cholangiocarcinoma (10%) Osteoporosis Malabsorption Strictures Cancers
305
What condition is linked to PSC?
IBD- UC
306
Define acute pancreatitis
Reversible acute inflammation of the pancreas
307
What are the causes of acute pancreatitis?
I GET SMASHED Idiopathic Gallstones (MC) Ethanol (30%) Trauma Steroids Mumps Autoimmune Scorpion venom Hyperlipidaemia ERCP Drugs
308
What 5 drugs can cause acute pancreatitis?
Azathioprine Furosemide Corticosteroids NSAIDs ACE inhibitors
309
Outline the pathophysiology of acute pancreatitis
Premature activation of pancreatic enzymes -> host defences overwhelmed -> autodigestion of pancreas -> inflammation and enzymes leak in blood
310
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
311
How does alcohol cause pancreatitis?
Directly toxic to pancreatic cells
312
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
313
What is Cullens sign?
Periumbilical ecchymosis Skin discolouration around belly button
314
What is Grey Turners sign?
Left flank bruising
315
How is acute pancreatitis diagnosed?
Raised urinary and serum amylase Raised lipase CXR to exclude AAA Abdo USS to find gallstones
316
What systems are used to score acute pancreatitis?
Glasgow and Ranson scoring APACHE II
317
How is acute pancreatitis treated?
NEEDS SEVERITY ASSESSMENT NBM and NG tube IV fluid resus Analgesia Monitor complications
318
What is the major complication of acute pancreatitis?
SIRS (systemic inflammatory response syndrome)
319
How is SIRS diagnosed?
Any 2 of Tachycardia >90 Tachypnoea >20 Pyrexia High WCC
320
Define chronic pancreatitis
Debilitating continuing inflammation in the pancreas causing a loss of tissue replacement by fibrosis of the endocrine and exocrine regions
321
What history is required for chronic pancreatitis?
3 months
322
What are 3 causes of chronic pancreatitis?
Long term alcohol excess (MC) CKD CF Hereditary Idiopathic
323
Outline the pathophysiology of chronic pancreatitis
Obstruction of bicarbonate release -> pH rises -> damage and necrosis -> fibrosis
324
What is the differential diagnosis of acute pancreatitis?
AAA
325
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)
326
What is the differential diagnosis of chronic pancreatitis?
Pancreatic cancer
327
How is chronic pancreatitis diagnosed?
Unlike acute, amylase and lipase not as elevated Abnormal faecal elastase GS: abdo USS and contrast enhance CT
328
How is chronic pancreatitis treated?
Alcohol cessation Analgesia Pancreatic enzyme supplements Insulin for DM
329
Where is autoimmune pancreatitis most common?
Japan
330
Define autoimmune pancreatitis
Chronic pancreatic inflammation resulting from an autoimmune process
331
What are the symptoms of autoimmune pancreatitis?
Similar to chronic
332
How is autoimmune pancreatitis diagnosed?
Elevated IgG4 ANCA and rheumatoid factor may be elevated
333
How is autoimmune pancreatitis treated?
Glucocorticoids (eg. Prednisolone) for 4-6 weeks
334
Define ascites
Accumulation of free fluid in the peritoneal cavity
335
What are the normal levels of fluid in the peritoneal cavity?
Healthy men- minimum few ml Healthy women- up to 20ml
336
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
337
What are the categories of causes of ascites?
Local inflammation Low protein Flow stasis
338
What are 3 causes of local inflammation induced ascites?
Peritonitis Abdo cancers (ovarian) Infection such as TB
339
What are 3 causes of low protein induced ascites?
Hypoalbuminaemia Nephrotic syndrome Malnutrition
340
What are 3 causes of flow stasis induced ascites?
Cirrhosis! Budd-Chiari Heart failure
341
What are the symptoms of ascites?
Abdo distension Shifting dullness Jaundice and pruritus Flank fullness
342
What are 2 signs of shifting dullness?
Supine = abdo resonant and flanks full On side = flank resonant
343
How is ascites diagnosed?
Shifting dullness Ascitic tap - find malignancy, infection, WCC serum ascites albumin gradient (SAAG) to find cause
344
What are the protein measurements indicating high SAAG?
>1.1g/dL
345
What does high SAAG in ascites indicate?
Portal HTN Heart failure Budd-Chiari Pericarditis
346
What does low SAAG in ascites indicate?
Malignancy Peritonitis TB Pancreatitis
347
How is ascites treated?
Treat underlying cause Diuretic = Spironolactone Paracentesis (drain fluid) TIPS (shunt) Liver transplant if something causing it is liver related
348
Define portal hypertension
High blood pressure in the portal venous system
349
Define Budd-Chiari syndrome
Hepatic vein obstruction by tumour or thrombosis
350
What are 3 classifications of causes of portal hypertension?
Pre hepatic Intra hepatic Post hepatic
351
What is a pre hepatic cause of portal hypertension?
Portal vein thrombosis
352
What is an intrahepatic cause of portal hypertension?
Cirrhosis (MC UK) Schistosomiasis (MC worldwide) Budd-Chiari
353
What are 3 post hepatic causes of portal hypertension?
Constrictive pericarditis IVC obstruction RHF
354
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
355
What are the symptoms of portal HTN?
Usually asymptomatic Splenomegaly CLD = haematemesis and malaena ect
356
Define oesophageal varices
Dilated collateral blood vessels that develop due to portal HTN
357
Outline the pathophysiology of ruptured oesophageal varices
Small veins can not handle much pressure -> high pressure -> ruptured
358
What are the symptoms of ruptured oesophageal varices?
Haematemesis (coffee ground vomit) Melaena (tarry stools)
359
How are oesophageal varices diagnosed?
Oesophagogastroduodenoscopy (OGD/upper GI endoscopy)
360
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)
361
How is oesophageal varices rupture prevented?
BB and nitrates Variceal banding Liver transplant
362
Define peritonitis
Inflammation of the peritoneal cavity caused by infection of ascitic fluid
363
What are the 2 parts of the peritoneum?
Parietal (well localised sensation) Visceral (poorly localised)
364
What are the 2 categories of causes of peritonitis?
Bacterial/primary Chemical/ secondary
365
What is a gram positive cause of peritonitis?
Staph aureus
366
What is a gram negative cause of peritonitis?
E. Coli Klebscella
367
What are 3 chemical causes of peritonitis?
Bile Ruptured ectopic pregnancy Intestinal perforation Old clotted blood
368
What are 3 risk factors of peritonitis?
Liver disease Cirrhosis Ascites
369
What are the symptoms of peritonitis?
Sudden onset abdo pain -> collapse and shock Being rigid helps Pressing hurts less than releasing pressure Ascites
370
How is peritonitis diagnosed?
Ascitic tap Cultures to show bacteria Exclude pregnancy as a cause CXR to see perforation
371
How is peritonitis treated?
Metronidazole and cefotaxime Surgery- clean peritoneum
372
What is the major complication of peritonitis?
Septicaemia
373
Define haemochromatosis
Iron storage disorder that results in excessive total body iron and deposition of iron in tissues.
374
What are the causes of haemachromatosis?
HFE gene mutation on chromosome 6 High iron intake Alcoholism
375
Is the HFE gene mutation in haemochromatosis dominant or recessive?
Autosomal recessive
376
Why are men more likely to have haemochromatosis?
Blood loss from menstrual cycle in females reduces Fe
377
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
378
What is the function of hepcidin?
Controls iron absorption
379
When does haemochromatosis usually present?
50s
380
What are the symptoms of haemochromatosis?
Testicular atrophy Hypogonadism Slate grey/ bronze skin Osteoporosis Liver failure symptoms
381
How is haemochromatosis diagnosed?
Raised serum Fe, ferritin Genetic testing Liver biopsy (Prussian blue/perl stain)
382
How is haemochromatosis treated?
Venesection - regular removal of blood/ desferrioxamine (chelating agent) Avoid alcohol Treat complications
383
Define Wilson’s disease
Excess accumulation of copper in body and tissues
384
What causes Wilson’s disease?
Autorec mutation of ATP7B copper binding protein on chromosome 13
385
What age does Wilson’s disease usually present?
Young- 20s Usually males
386
Outline the pathophysiology of Wilson’s disease
Impaired Cu biliary excretion -> CU accumulation in liver and basal ganglia
387
What is copper usually bound?
Caeruloplasmin
388
What are the symptoms of Wilson’s disease?
Hepatic issues CNS issues Kayser-Fleischer ring
389
What is a Kayser-Fleischer ring?
Copper deposition in the cornea causing a greenish-brown ring around the iris
390
How is Wilson’s disease diagnosed?
Reduced serum Cu and caeruloplasmin GS: liver biopsy High 24 hour urinary Cu excretion
391
How is Wilson’s disease treated?
Avoid food high in Cu (liver, chocolate, nuts) Lifelong chelating agent
392
What is an example of a copper chelating agent?
D-Penicillamine
393
Define A1AT deficiency
Deficiency of alpha 1 antitrypsin enzyme
394
What causes A1AT deficiency?
Autorecessive mutation of protease inhibitor gene (SERPINA-1) on chromosome 14
395
Outline the pathophysiology of A1AT deficiency
No inhibition of NE -> degradation of elastic tissue in the lungs And Deposition of A1AT in liver -> cirrhosis
396
What is the function of A1AT?
Inhibits NE (neutrophil elastase) which degrades elastic tissue
397
What are the effects of A1AT deficiency on the lungs?
Degrading elastic tissue -> emphysema, alveolar duct collapse, trapped air
398
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)
399
How is A1AT deficiency diagnosed?
Decreased serum A1AT Biopsy- Periodic acid Schiff positive globules CT- emphysema Genetic testing
400
How is A1AT deficiency treated?
Stop smoking Treat complications Manage emphysema
401
What are 2 complications of A1AT deficiency?
HCC Cirrhosis
402
What are the 3 symptoms of Budd Chiari syndrome?
Ascites Hepatomegaly Abdominal pain
403
What are the 3 antigens in Hep B?
HBsAg- surface antigen HBcAg- cord antigen HbdAg- active disease marker
404
What are 3 bacterial causes of cholecystitis?
E.coli Klebsiella Enterococcus
405
How is portal hypertension treated?
Beta blocker (CI cirrhosis) TIPSS shunt Liver transplant
406
how are alcohol units calculated?
ml of alcohol x ABV —————————— 1000

Phase 2a Annabel (12 decks)

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