liver + friends Flashcards
1
Q
tumour marker for pancreatic cancer
A
CA-19-9
2
Q
hepatitis E brainstorm
A
- RNA hepevirus
- faecal-oral route
- incubation period: 3-8 weeks
- Central and South-East Asia, North and West Africa, and in Mexico
- similar disease to hep A, but carries a significant MORTALITY (20%) during PREGNANCY
- does not cause chronic disease or an increased risk of hepatocellular cancer
- CONSIDER IF PX HAS SIGNIF TRANSAMITIS IN 1ST TRIM PREG
- thrombocytopenia
- undercooked pork
3
Q
post splenectomy vaccines + prophylactic abx
A
Pneumococcal vaccination (with regular boosters every 5 years).
Seasonal influenza vaccination (yearly, typically every autumn).
Haemophilus influenza type B vaccination (one-off).
Meningitis C vaccination (one-off).
low-dose prophylactic antibiotics - phenoxymethylpenicillin
4
Q
what are some common causes of hepatomegaly
A
Cirrhosis: if early disease, later liver decreases in size. Associated with a non-tender, firm liver
Malignancy: metastatic spread or primary hepatoma. Associated with a hard, irregular. liver edge
Right heart failure: firm, smooth, tender liver edge. May be pulsatile
5
Q
presentation of hepatitis A
A
incubation period 2-4 weeks
flu-like prodrome
nausea, arthralgia
can progress to cause hepatosplenomegaly + jaundice
6
Q
common sources of hep A infection
A
contaminated water or food
shellfish
7
Q
how is hep A transmitted
A
faecal-oral route
8
Q
how is hep B transmitted
A
direct contact w/ blood or bodily fluids
ie sex
needle sharing (UVDU/tattoos)
can also be passed by sharing toothbrushes, razors or contact w open cuts
can be passed from mum to baby during preg
9
Q
how to screen for hep B
A
test for HBcAb (core antibodies implying past or current infection)
HBsAg (surface antigen implying current infection)
if +ve test
HBeAg (e antigen - a marker for viral replication + implies high infectivity)
viral load (HBV DNA)
10
Q
presentation of viral hepatitis
A
may be asymptomatic or present with non-specific symptoms of:
Abdominal pain
Fatigue
Flu-like illness
Pruritus (itching)
Muscle and joint aches
Nausea and vomiting
Jaundice
11
Q
how is hep C spread
A
blood and body fluids
12
Q
which viral hep are there vaccine’s for
A
A
B
13
Q
how to cure hep C
A
direct-acting antiviral meds - sofobuvir
14
Q
what type of virus is the diff viral heps
A
A = RNA
B = double stranded DNA
C = RNA
D = RNA
E = RNA
15
Q
mx of hep C
A
direct-acting antivirals (DAAs) - sofobuvir
16
Q
what is special about hep D
A
it can only survive in px who also have hep B
increases comps + severity of B
17
Q
tx of hep D
A
pegylated interferon alpha over at least 48 weeks - not v effective + signif SEs
18
Q
how is hepE transmitted
A
faecal-oral route
19
Q
tx for hep E
A
usually v mild illness + no tx req
20
Q
why might bilirubin be raised
A
obstruction of biliary tree
increased production
21
Q
what might low albumin mean
A
oedema
22
Q
what does a raised ALP mean
A
biliary obstruction
(or bone malignancy)
In patients with cholestasis (e.g., due to gallstones), ALT and AST can increase slightly, with a higher rise in ALP (“an obstructive picture”).
If ALT and AST are high compared with the ALP level, this is more indicative of a problem inside the liver with hepatocellular injury (“a hepatitic picture”).
other causes:
ALKPHOS pneumonic
Any fracture
Liver damage (post hepatic)
Kancer
Paget’s disease of bone and Pregnancy
Hyperparathyroidism
Osteomalacia
Surgery
23
Q
what do raised ALT and AST mean
A
markers of hepatocellular injury
In patients with cholestasis (e.g., due to gallstones), ALT and AST can increase slightly, with a higher rise in ALP (“an obstructive picture”).
If ALT and AST are high compared with the ALP level, this is more indicative of a problem inside the liver with hepatocellular injury (“a hepatitic picture”).
24
Q
mx of alcoholic hepatitis
A
steroids in acute eps
25
what are the causes of increased ferritin without iron overload
inflammation
alcohol excess
liver disease
CKD
malignancy
can see if iron overload is present using transferrin saturation
26
what are the causes of increased ferritin w iron overload
primary iron overload - hereditary haemochromatosis
secondary iron overload - following repeated transfusions
27
what is budd-chiari syndrome
blockage of the hepatic veins by a blood clot
28
budd-chiari syndrome presentation
The features are classically a triad of:
- abdominal pain: sudden onset, severe
- ascites → abdominal distension
- tender hepatomegaly
29
initial ix for budd-chiari
ultrasound with Doppler flow studies
30
what is gilbert's syndrome
an inherited (usually autosomal recessive) metabolic disorder
mild and intermittent elevation of unconjugated (indirect) bilirubin levels, due to defective conjugating enzymes in the liver
31
how to best assess acute liver failure
by looking at PROTHROMBIN time and albumin level
(prothrombin has shorter half-life so is best) Therefore INR is best
32
Type 1 autoimmune hepatitis antibodies and who gets it
Anti-nuclear antibodies (ANA) and/or anti-smooth muscle antibodies (SMA)
Affects both adults and children
Will have raised IgG levels
33
Type II autoimmune hepatitis antibodies and who gets it
Anti-liver/kidney microsomal type 1 antibodies (LKM1)
Affects children only
34
what is spontaneous bacterial peritonitis
form of peritonitis seen in patients with ascites secondary to liver cirrhosis
35
spontaneous bacterial peritonitis presentation
ascites
abdominal pain
fever
36
dx spontaneous bacterial peritonitis
paracentesis: neutrophil count > 250 cells/ul
the most common organism found on ascitic fluid culture is E. coli
37
tx spontaneous bacterial peritonitis
IV cefotaxime
abx prophylaxis after
38
what does cholecystokinin (CCK) do
Stimulates the gallbladder to contract + release stored bile upon detection of foods in stomach
39
what does bile contain
cholesterol
bile pigments - from broken down hb
phospholipids
40
causes of pre hepatic jaundice
excess haemolysis , increased unconjugated bilirubin
maleria
sickle cell anaemia
haemolytic disease of the newborn
gilberts syndrome
41
causes of hepatic jaundice
viral hepatitis
drugs
alcohol
cirrhosis
42
causes of post hepatic jaundice
obstruction of biliary system
gallstones
pancreatitis
43
risk factors for gallstones
F – Fat
F – Fair
F – Female
F – Forty
44
biliary colic
Severe, colicky epigastric or right upper quadrant pain
Often triggered by meals (particularly high fat meals)
Lasting between 30 minutes and 8 hours
May be associated with nausea and vomiting
45
first line ix for gallstones
transabdo USS
then MRCP to visualise biliary tree in more detail
46
acute cholecystitis
gallbladder inflammation due to dysfunc of emptying (blockage of cystic duct)
RUQ pain
fever
47
what sign on examination in cholecystitis
+ve murphy's sign = severe pain on deep inhalation when examiners hand is pressed into RUQ
48
mx acute cholecystitis
Nil by mouth
IV fluids
Antibiotics (as per local guidelines)
Endoscopic retrograde cholangio-pancreatography (ERCP) can be used to remove stones trapped in the common bile duct.
Cholecystectomy usually during the acute admission, within 72 hours. May be delayed for 6-8 weeks to allow the inflammation to settle.
49
Gallbladder Empyema
infected tissue and pus collecting in the gallbladder
50
Gallbladder Empyema tx
IV abx +
Cholecystectomy (to remove the gallbladder) OR
Cholecystostomy (inserting a drain into the gallbladder to allow the infected contents to drain)
51
acute cholangitis
inflammation + infect of bile ducts
surgical emergency
due to
- Obstruction in the bile ducts stopping bile flow (i.e. gallstones in the common bile duct)
- Infection introduced during an ERCP procedure
52
charcot's triad
Acute cholangitis presents with this:
Right upper quadrant pain
Fever
Jaundice (raised bilirubin)
53
mx acute cholangitis
Nil by mouth
IV fluids
Blood cultures
IV antibiotics (as per local guidelines)
Involvement of seniors and potentially HDU or ICU
ERCP
PTC if not suitable for above or above has failed
cholecystectomy
54
what is PBC
autoimmune condition where the immune system attacks the small bile ducts in the liver, resulting in obstructive jaundice and liver disease
55
PBC presentation
sx
white woman aged 40-60 years
Fatigue
Pruritus (itching)
Gastrointestinal symptoms and abdominal pain
Jaundice
Pale, greasy stools
Dark urine
signs
Xanthoma and xanthelasma (cholesterol deposits)
Excoriations (scratches on the skin due to itching)
Hepatomegaly
Signs of liver cirrhosis and portal hypertension in end-stage disease (e.g., splenomegaly and ascites)
56
ix PBC
raised ALP (first one to be)
Anti-mitochondrial antibodies (AMA) - most spec to PBC
Anti-nuclear antibodies are present in about 35%
Raised immunoglobulin M (IgM) is a non-specific blood result finding
Liver biopsy may be used in diagnosing and staging the disease.
57
mx PBC
Ursodeoxycholic acid
Cholestyramine for itching
Immunosupression in some
Liver transplant in end stage
58
what is Primary sclerosing cholangitis (PSC)
condition where the intrahepatic and extrahepatic bile ducts become inflamed and damaged, developing strictures that obstruct the flow of bile out of the liver and into the intestines
59
RFs PSC
Male
Aged 30-40
Ulcerative colitis
Family history
60
presentation PSC
Abdominal pain in the right upper quadrant
Pruritus (itching)
Fatigue
Jaundice
Hepatomegaly
Splenomegaly
61
ix PSC
raised ALP
Autoantibodies not helpful
Magnetic resonance cholangiopancreatography (MRCP) is the diagnostic imaging investigation
= bile duct strictures
Colonoscopy for UC
62
mx PSC
ERCP to treat dilate strictures
Liver transplant
Colestyramine for symptoms of pruritus
Replacement of fat-soluble vitamins
Monitoring for complications such as cholangiocarcinoma, cirrhosis and oesophageal varices
63
comps of PSC
Cholangiocarcinoma develops in 10-20% of cases
64
what are alpha cells for (in islets of langerhans)
glucagon production
65
what are beta cells for (in islets of langerhans)
insulin production
66
what are D cells for (in islets of langerhans)
somatostatin production
67
what are PP cells for (in islets of langerhans)
pancreatic polypeptide production
68
what are enterochrommaffin cells for (in islets of langerhans)
serotonin production
69
causes of pancreatitis
I – Idiopathic
G – GALLSTONES
E – Ethanol (ALCOHOL consumption)
T – Trauma
S – Steroids
M – Mumps
A – Autoimmune
S – Scorpion sting
H – Hyperlipidaemia
E – ERCP
D – Drugs (azathioprine, mesalazine, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate)
70
pancreatitis sx
Severe epigastric pain
- radiating through to the back
- relieved by sitting forwards
N&V
Abdominal tenderness
Systemically unwell (e.g., low-grade fever and tachycardia)
Anorexia
71
pancreatitis signs
cullens sign = bruising around periumbilical region
grey turners sign = bruising on flanks
72
pancreatitis ix
Amylase is raised more than 3 times the upper limit of normal in ACUTE
Lipase is raised
Raised CRP
USS for gallstones
CT abdomen can assess for complications of pancreatitis
73
Initial investigations are required as with any presentation of an acute abdomen
FBC (for white cell count)
U&E (for urea)
LFT (for transaminases and albumin)
Calcium
ABG (for PaO2 and blood glucose)
74
glasgow score
used to assess the severity of pancreatitis
0 or 1 – mild pancreatitis
2 – moderate pancreatitis
3 or more – severe pancreatitis
75
criteria for glasgow score
P – Pa02 < 8 KPa
A – Age > 55
N – Neutrophils (WBC > 15)
C – Calcium < 2
R – uRea >16
E – Enzymes (LDH > 600 or AST/ALT >200)
A – Albumin < 32
S – Sugar (Glucose >10)
76
mx pancreatitis
Moderate or severe cases should be considered for management on the high dependency unit (HDU) or intensive care unit (ICU).
Initial resuscitation (ABCDE approach)
IV fluids
Nil by mouth
Analgesia
Careful monitoring
Treatment of gallstones in gallstone pancreatitis (ERCP / cholecystectomy)
Antibiotics if there is evidence of a specific infection (e.g., abscess or infected necrotic area)
Treatment of complications (e.g., endoscopic or percutaneous drainage of large collections)
77
what is chronic pancreatitis
chronic inflam of pancreas
presents with similar symptoms to acute pancreatitis, but generally less intense and longer-lasting
78
most common cause of chronic pancreatitis
alcohol
79
comps of chronic pancreatitis
Chronic epigastric pain
- boring through back
- worse after fatty food
- better leaning forward
Loss of exocrine function -> lack of pancreatic enzymes (particularly lipase)
- malabsorbtion: weight loss, steatorrhoea, defs, diarrhoea
Loss of endocrine function -> diabetes
Damage and strictures to the duct system -> obstruction in the excretion of pancreatic juice and bile
Formation of pseudocysts or abscesses
80
majority of pancreatic cancers are
adenocacinomas
mostly in head of pancreas
dx late + poor prog
81
pancreatic cancer presentation
painless obstructive jaundice - tumour at the head of the pancreas compresses the bile ducts, blocking the flow of bile out of the liver
Non-specific upper abdominal or back pain
Unintentional weight loss
Palpable mass in the epigastric region
Change in bowel habit
N&V
New-onset diabetes or worsening of type 2 diabetes
82
when to refer for pancreatic cancer check
Over 40 with jaundice – referred on a 2 week wait referral
Over 60 with weight loss plus an additional symptom - referred for a direct access CT abdomen
additional sx:
Diarrhoea
Back pain
Abdominal pain
Nausea
Vomiting
Constipation
New-onset diabetes
83
Trousseau’s sign of malignancy
migratory thrombophlebitis as a sign of malignancy, particularly pancreatic adenocarcinoma
84
whipple
surgical operation to remove a tumour of the head of the pancreas that has not spread.
Involves the removal of the:
Head of the pancreas
Pylorus of the stomach
Duodenum
Gallbladder
Bile duct
Relevant lymph nodes
85
what is cholangiocarcinoma
type of cancer that originates in the bile ducts (intra or extra hepatic) - majority are adenocarcinomas
86
where is cholangiocarcinoma most common site
the perihilar region, where the right and left hepatic duct have joined to become the common hepatic duct
87
cholangiocarcinoma sx
Obstructive jaundice
- Pale stools
- Dark urine
- Generalised itching
Unexplained weight loss
Right upper quadrant pain
Palpable gallbladder (swelling due to an obstruction in the duct distal to the gallbladder)
Hepatomegaly
88
what is courvoisier's law
states that a palpable gallbladder along with jaundice is unlikely to be gallstones. The cause is usually cholangiocarcinoma or pancreatic cancer.
89
AST:ALT ratio for alcoholic hepatitis vs fatty liver
if the AST:ALT ratio is greater than 2, this suggests alcoholic hepatitis.
if the AST:ALT ratio is less than 1, this suggests non-alcoholic fatty liver disease.
90
what organism typically causes ascending colangitis
e coli
91
what is Fitz-Hugh-Curtis syndrome
complication of pelvic inflammatory disease in which the liver capsule becomes inflamed causing right upper quadrant pain -> scar tissue formation and peri-hepatic adhesions
usually occurs in women who have either chlamydia or gonorrhoea.
92
RFs cholangiocarcinoma
PSC
Liver flukes (a parasitic infection)
93
main type of primary liver cancer
hepatocellular carcinoma
94
RFs hepatocellular carcinoma.
liver cirrhosis due to:
Alcohol-related liver disease
Non-alcoholic fatty liver disease (NAFLD)
Hepatitis B
Hepatitis C
Rarer causes (e.g., primary sclerosing cholangitis)
95
what to screen px w liver cirrhosis for
offered screening for hepatocellular carcinoma every 6 months with:
Ultrasound
Alpha-fetoprotein
96
presentation hepatocellular carcinoma (HCC
asx for long time, presents late so poor prog
Weight loss
Abdominal pain
Anorexia
Nausea and vomiting
Jaundice
Pruritus
Upper abdominal mass on palpation
97
tumour marker for hepatocellular carcinoma
Alpha-fetoprotein
98
first line imaging for hepatocellular carcinoma
Liver ultrasound
99
marker for cholangiocarcinoma
CA19-9
100
what is a haemangioma
common benign tumours of the liver
no probs
101
what is Focal Nodular Hyperplasia
benign liver tumour made of fibrotic tissue
no probs
102
complications of hep B
chronic hepatitis (5-10%). 'Ground-glass' hepatocytes may be seen on light microscopy
fulminant liver failure (1%)
hepatocellular carcinoma
glomerulonephritis
polyarteritis nodosa
cryoglobulinaemia
103
Post splenectomy blood film features:
Howell- Jolly bodies
Pappenheimer bodies
Target cells
Irregular contracted erythrocytes
104
drugs that cause cholestasis
fluclox
co-amox
nitro
steroids
sulphonylureas
105
who does type one AI hepatitis usually affect
women in their late forties or fifties
106
presentation type one AI hepatitis
presents around or after menopause with fatigue and features of liver disease on examination
less acute than type 2.
107
who does type two AI hepatitis usually affect
children or young people, more commonly girls
108
presentation type two AI hepatitis
acute hepatitis with high transaminases and jaundice
109
tx AI hepatitis
high-dose steroids (e.g., prednisolone)
110
common factors indicating severe pancreatitis
age > 55 years
hypocalcaemia
hyperglycaemia
hypoxia
neutrophilia
elevated LDH and AST
