LIVER & FRIENDS Flashcards
JAUNDICE
Why are liver patients vulnerable to infection?
- Impaired reticuloendothelial function
- Reduced opsonic activity
- Leucocyte function
- Permeable gut wall
GALLSTONES
Give 3 causes of Gallstones
- Obesity and rapid weight loss
- DM
- Contraceptive pill
- Liver cirrhosis
PORTAL HYPERTENSION
Give 3 causes of portal hypertension
- Pre-hepatic = blockage of hepatic portal vein before the liver (portal vein thrombosis)
- Hepatic = distortion of liver architecture (cirrhosis, schistosomiasis, Budd Chiari syndrome)
- Post-hepatic = venous blockage outside the liver (RHF, IVC obstruction)
PORTAL HYPERTENSION
what is the clinical presentation of portal hypertension?
- often asymptomatic
- splenomegaly
- spider naevi
- GI bleeding
- ascites
- hepatic encephalopathy
ASCITES
what are the causes of ascites with serum ascites albumin gradient (SAAG) >11g/L?
Indicates portal hypertension
LIVER (most common cause)
- cirrhosis/alcoholic liver disease
- acute liver failure
- liver mets
CARDIAC
- right HF
- constrictive pericarditis
OTHER
- budd-chiari syndrome
- portal vein thrombosis
- veno-occlusive disease
- myxoedema
ASCITES
Describe the pathophysiology of ascites
- Increased intra-hepatic resistance leads to portal hypertension –> ascites
- Systemic vasodilation leads to secretion of RAAS, NAd and ADH –> fluid retention
- Low serum albumin also leads to ascites
Transudate = blockage of venous drainage
Exudate = inflammation
ASCITES
Describe the treatment for ascites
- Restrict sodium and fluids
- Aldosterone antagonist (SPIRONOLACTONE) +/- loop diuretic (FUROSEMIDE)
- Paracentesis
- prophylactic antibiotics (CIPROFLOXACIN or NORFLOXACIN) to prevent spontaneous bacterial peritonitis
HEPATITIS
Describe the natural history of HBV in 4 phases
- Immune tolerance phase: unimpeded viral replication –> high HBV DNA levels.
- Immune clearance phase: the immune system ‘wakes up’ = liver inflammation and high ALT
- Inactive HBV carrier phase: HBV DNA levels are low = ALT levels are normal, no liver inflammation
- Reactivation phase: ALT and HBV DNA levels are intermittent and inflammation is seen on the liver –> fibrosis
HEPATITIS
Give 3 side effects of alpha interferon treatment for HBV
- Myalgia
- Malaise
- Lethargy
- Thyroiditis
- Mental health problems
HEPATITIS
Describe the treatment for HCV
Direct acting antivirals (sofosbuvir or daclatasvir)
contact tracing
BUDD-CHIARI SYNDROME
What is Budd-Chiari syndrome?
Hepatic vein occlusion –> ischaemia and hepatocyte damage –> liver failure or insidious cirrhosis
HAEMOCHROMATOSIS
90% of people with haemochromatosis have a mutation in which gene?
HFE - chromosome 6
HAEMOCHROMATOSIS
Give 4 signs of haemochromatosis
- Fatigue, arthralgia, weakness
- Hypogonadism – eg erectile dysfunction
- SLATE-GREY SKIN (brownish/bronze)
- Chronic liver disease, heart failure, arrythmias
WILSONS DISEASE
What CNS changes are seen in a patient with Wilson’s disease?
Tremor Dysarthria Dyskinesia Ataxia Parkinsonism Dementia Depression
WILSONS DISEASE
What is the treatment for Wilson’s disease?
Lifetime treatment with penicillamine (chelating agent)
Low Cu diet - no liver, nuts, chocolate, mushrooms, shellfish
Liver transplant
AUTOIMMUNE HEPATITIS
How does autoimmune hepatitis present?
Fatigue, fever, malaise Hepatitis Hepatosplenomegaly Amenorrhoea Polyarthritis Pleurisy Lung infiltrates Glomuleronephritis
AUTOIMMUNE HEPATITIS
What diseases are associated with autoimmune hepatitis?
Autoimmune thyroiditis
DM
Pernicious anaemia
PSCUC
PRIMARY BILIARY CHOLANGITIS
what other conditions are associated with primary biliary cholangitis?
sjogrens syndrome
raynauds disease
autoimmune thyroid disease
rheumatoid arthritis
systemic sclerosis
PRIMARY BILIARY CHOLANGITIS
what are the clinical features of primary biliary cholangitis?
classic presentation = significant itching in middle-aged female
SYMPTOMS
- pruritus
- fatigue + weight loss
- dry mouth + eyes (sjogrens)
- obstructive jaundice (icteric, pale stool + dark urine)
SIGNS
- skin hyperpigmentation (increased melanin)
- clubbing
- mild hepatosplenomegaly
- xanthelsma + xanthomata
- scleral icterus
PRIMARY BILIARY CHOLANGITIS
What are the investigations?
- antimitochondrial antibodies (AMA)
- antinuclear antibodies (ANA)
- smooth muscle antibodies
- LFTs = obstructive jaundice (raised ALP, GGT + bilirubin, AST + ALT mildy deranged)
- coagulation profile = deranged in advanced disease
- serum immunoglobulin = raised IgM
- transabsominal USS (exclude other causes)
to consider:
- MRCP
- liver biopsy
PRIMARY BILIARY CHOLANGITIS
What is the treatment for primary biliary cholangitis?
1st line:
- ursodeoxycholic acid
- fat-soluble vitamin supplement (ADEK)
- cholestyramine (for symptomatic relief of pruritus)
2nd line
- liver transplantation (indicated in severe disease)
PRIMARY SCLEROSING CHOLANGITIS
what are the investigations?
-LFTs = raised ALP + GGT, raised conjugated bilirubin, ALT/AST may or may not be elevated
- albumin = decreased in later disease
- viral hepatitis screen
- pANCA
- anti-mitochcondrial antibodies (AMA) (to rule out PBC)
- abdominal USS (to exclude other causes)
- MRCP = beaded appearance (due to multiple biliary strictures)
to consider
- ERCP (gold standard)
- liver biopsy
PRIMARY SCLEROSING CHOLANGITIS
What is the treatment for primary sclerosing cholangitis?
1st line
- observation + lifestyle optimisation (alcohol cessation, exercise)
- cholestyramine for pruritus (rifampicin = 2nd line)
- ADEK vitamin supplement
END STAGE LIVER DISEASE
- liver transplant
ASCENDING CHOLANGITIS
What investigations might you do in someone who you suspect might have ascending cholangitis?
- trans-abdominal USS
- Blood tests - LFTS (ALP>ALT + raised bilirubin), CRP, FBC,
- MRCP = gold standard
ASCENDING CHOLANGITIS
Describe the management of ascending cholangitis
INITIAL
- IV broad spectrum antibiotics (cefotaxime + metronidazole)
- IV fluids
BILIARY DECOMPRESSION
- ERCP (first line)
- surgical drainage
ELECTIVE CHOLECYSTECTOMY
PERITONITIS
What is the management for peritonitis?
1st line:
- broad spectrum antibiotics (piperacillin-tazobactam or metronidazole with cetriaxone)
- fluid resuscitation via IV fluids
- analgesia (paracetamol + opioids)
- NG tube for feeding
2nd line
- surgery +/- peritoneal lavage
SPONTANEOUS BACTERIAL PERITONITIS
Name a bacteria that can cause spontaneous bacterial peritonitis
- E. coli
- S. pneumoniae
SPONTANEOUS BACTERIAL PERITONITIS
Describe the treatment for spontaneous bacterial peritonitis
Cefotaxime and metronidazole
ACUTE PANCREATITIS
Describe the pathophysiology of acute pancreatitis
Main two causes are alcohol and gallstones:–
Gallstones:
Blockage of bile duct = backup of pancreatic juices. This change in luminal concentration causes Ca2+ release inside pancreatic cells and cause them to activate trypsinogen early which digests the pancreas.
Alcohol:
Contracts the Ampulla of Vater obstructing the bile clearance and also messes with Ca2+homeostasis causing the same as above.
* Leaky and damaged pancreas an auto digest nearby structures causing haemorrhage and Grey
Turner’s sign abdominal skin discolouration from retroperitoneal bleeding.
* Deranges pancreatic function so can cause hyperglycemia from reduction of insulin production
ACUTE PANCREATITIS
What are the causes of acute pancreatitis?
I GET SMASHED – remember
I = Idiopathic
G = Gallstones (60%)
E = Ethanol = alcohol (30%)
T = Trauma
S = Steroids
M = Mumps
A = Autoimmune
S = Scorpion venom
H = Hyperlipidaemia/ hypothermia/ high Ca
E = ERCP (endoscopic retrograde cholangiopancreatography)
D = Drugs (furosemide, corticosteroid, NSAIDs, ACEi)
~~~
CHRONIC PANCREATITIS
Name 3 causes of chronic pancreatitis
- Excess alcohol - most common
- CKD
- Idiopathic
- Recurrent acute pancreatitis
- hereditary
- CF - all have it from birth
- autoimmune
- tropical
CHRONIC PANCREATITIS
what is the clinical presentation of chronic pancreatitis?
SYMPTOMS
- epigastric pain (dull, radiating to back, improved by leaning forwards, occurs 15-30 mins after eating)
- steatorrhoea + diarrhoea (foul smelling + difficult to flush)
- N+V
- weight loss + fatigue
- features of diabetes (polydipsia + polyuria)
SIGNS
- epigastric tenderness
- signs of liver disease (jaundice + ascites)
- skin nodules
CHRONIC PANCREATITIS
What immunoglobulin might be elevated in someone with autoimmune chronic pancreatitis?
IgG4
CHRONIC PANCREATITIS
What 2 enzymes, if raised, suggest pancreatitis?
LDH (lactate dehydrogenase) and AST>ALT
CHOLECYSTITIS
what is the management of cholecystitis?
1st line
- IV fluids + analgesia
- IV antibiotics (CERFUOXIME or METRONIDAZOLE)
- early laparoscopic cholecystectomy (within 1 week of diagnosis, often within 72hrs)
2nd line
- urgent cholecystectomy (if sepsis/gangrene/perforation suspected)
PORTAL HYPERTENSION
what are the pre-hepatic causes of portal hypertension?
portal vein thrombosis
PORTAL HYPERTENSION
what are the intrahepatic causes of portal hypertension?
- schistosomiasis
- cirrhosis
- budd-chiari syndrome
PORTAL HYPERTENSION
what are the post-hepatic causes of portal hypertension?
- RH failure
- IVC obstruction
PORTAL HYPERTENSION
what is the pathophysiology of portal hypertension?
- Increased resistance to blood flow leads to portal hypertension causes splanchnic vasodilation
- This results in a drop in BP
- CO increases to compensate for BP resulting in salt and water retention
- Hyperdynamic circulation/increased portal flow leads to the formation of collaterals between portal and systemic systems
WILSONS DISEASE
what are the side-effects of chelating agents?
skin rash,
fall in WCC, HB and platelets,
haematuria,
renal damage
NON-ALCOHOLIC FATTY LIVER
which drugs increase the risk of developing non-alcoholic fatty liver disease?
Amiodarone, Tetracycline ,Methotrexate
NON-ALCOHOLIC FATTY LIVER
what are the investigations for non-alcoholic fatty liver disease?
- LFTs = raised ALT
- liver USS = confirm hepatic steatosis (seen as increased echogenicity)
- enhanced liver fibrosis (ELF) blood test = 1st line (>10.51= advanced fibrosis)
- NAFLD fibrosis score
- fibrosis-4 score
- fibroscan
- liver biopsy = gold standard
ALCOHOLIC LIVER DISEASE
what is the pathophysiology of alcoholic liver disease?
chronic excessive alcohol consumption leads to liver impairment
- alcohol is metabolised into acetaldehyde and then to acetate
- excessive NADH leads to greater fatty acid oxidation and subsequently fatty infiltration of the liver
- the production of free radicals results in increase in TNF-alpha causing hepatic inflammation
- chronic inflammation leads to liver fibrosis and eventually cirrhosis
HEPATITIS
what do the following serological markers indicate in HBV infection?
- HBsAg
- HBeAg
- HBV-DNA
- anti-HBs
- anti-HBc IgM
- anti HBc IgG
- anti HBe
- HBsAg = acute infection (persistence after >6months implies chronic infection)
- HBeAg = acute infection (persistence implies active viral replication) - can distinguish between active and inactive chronic infection
- HBV-DNA = implies viral replication (present in acute and chronic)
- anti-HBs = immunity to HBV from immunisation or previous cleared infection
- anti-HBc = implies previous or current infection
- anti-HBc IgM = recent infection within last 6 months
- anti-HBc IgG = persists long term
- anti-HBe = seroconversion and is present for life
CHRONIC PANCREATITIS
what are the investigations for chronic pancreatitis?
CT or MRI - pancreatic duct dilation, calcification, atrophy or pseudocysts
endoscopic ultrasound
fecal elastase test - decreased elastase
ACUTE PANCREATITIS
what are the risk factors?
- advancing age
- afro-caribbean ethnicity
- sex (female = gallstone related, male = alcohol related)
- high glycaemic diet
- obesity
- T2DM
- family history
ACUTE PANCREATITIS
how is the severity calculated?
- modified Glasgow score
- PANCREAS
- P02 <8kpa
- Age >55
- Neutrophils >15x109/L
- Calcium <2mmol/L
- Renal function (urea >16mmol/L)
- Enzymes (AST>200U/L or LDH>600U/L)
- Albumin <32g/L
- Sugar (blood glucose>10mmol/L)
CHRONIC PANCREATITIS
what are the investigations?
- LFTs
- HbA1c
- transabdominal USS = first line imaging
- CT abdomen
to consider
- faecal elastase
- IgG4
- MRCP
- ERCP
PBC VS PSC
what are the differences between primary biliary cholangitis + primary sclerosing cholangitis
PRIMARY BILIARY CHOLANGITIS
- more common in middle aged women
- destruction of intrahepatic ducts only
- associated with autoimmune conditions
- often asymptomatic or fatigue, pruritus, jaundice + hepatomegaly
- raised ALP + GGT +/- conjugated bilirubin, anti mitochondrial antibodies (AMA)
- diagnosed via cholestatic LFTs, abdominal USS, history + exam
- treat with ursodeoxycholic acid, colestyramine + ADEK vita
PRIMARY SCLEROSING CHOLANGITIS
- more common in middle aged men
- inflammation of intrahepatic + extrahepatic ducts
- associated with ulcerative cholitis (UC)
- has symptoms of IBD + ascending cholangitis
- raised ALP + GGT +/- conjugated bilirubin, pANCA
- diagnosed via cholestatic LFTs, MRCP, history + exam
- treat with observation, colestyramine + ADEK vits
PANCREATIC CANCER
what are the risk factors?
- increasing age (65-75yrs)
- male
- smoking
- diabetes
- chronic pancreatitis
- genetic (hereditary non-polyposis colorectal cancer, BRCA1 + 2
- multiple endocrine neoplasia
PANCREATIC CANCER
what are the clinical features?
SYMPTOMS
- painless jaundice
- epigastric or atypical back pain
- anorexia
- weight loss
- new onset diabetes (thirst, polyuria, nocturia)
- nausea + vomiting
- steatorrhoea
- pale stool + dark urine
SIGNS
- positive Courvoisier’s sign (palpable gallbladder in the presence of painless jaundice)
- Trousseau sign of malignancy (migratory thrombophlebitis, blood vessels get inflamed with associated clot)
PANCREATIC CANCER
what are the investigations?
- LFTs = obstructive (raised ALP + GGT + bilirubin)
- coagulation profile (assess for liver mets)
- abdominal USS
- CT (or MRI) pancreas = double duct sign (simultaneous dilation of pancreatic + common bile ducts)
- CA 19-9
to consider:
- PET scan (for staging)
- endoscopic USS
- ERCP
PANCREATIC CANCER
when would you refer someone for 2ww?
- over 40 with jaundice = 2ww
- over 60 plus one of following (diarrhoea, back pain, abdo pain, N+V, constipation or new diabetes) = direct access CT abdomen
NOTE - pancreatic cancer is the only situation where a GP can do a direct access CT abdomen referral
PANCREATIC CANCER
where does it tend to spread to?
liver
peritoneum
lungs
bones
HEPATITIS
what is the management of HDV?
pegylated interferon alpha
NON-ALCOHOLIC FATTY LIVER
what are the different stages?
- non-alcoholic fatty liver disease
- non-alcoholic steatohepatitis (NASH)
- fibrosis
- cirrhosis
ASCITES
what are the causes of ascites that cause serum ascites albumin gradient (SAAG) <11g/L?
HYPOALBUMINAEMIA
- nephrotic syndrome
- severe malnutrition (e.g. kwashiorkor)
MALIGNANCY
- peritoneal carcinomatosis
INFECTION
- Tuberculous peritonitis
OTHER CAUSES
- pancreatitis
- bowel obstruction
- biliary ascites
- postoperative lymphatic leak
- serositis in connective tissue diseases
