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Final > Liver & Friends > Flashcards

Liver & Friends Flashcards

1
Q

Arteries of the foregut

A

Celiac trunk

  • Left gastric
  • Splenic
  • Common hepatic
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2
Q

What does ALT test show

A

Assoc with hepatocellular damage

e.g. paracetamol OD with hepatocellular necrosis, viral hepatitis, ischaemic necrosis, toxic hepatitis

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3
Q

AST:ALT ration

A

If over 1 = Ischaemia

If over 2.5 Alcoholic hepatitis

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4
Q

GGT

A

Sensitive to alcohol ingestion

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5
Q

ALP

A

Elevated with

  • Cholestasis
  • Malignant hepatocellular damage
  • Marker of bone turnover (Paget’s)
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6
Q

Metabolic liver diseases:

A

Hereditary haemochromatosis (Deficiency of iron regulatory hormone hepcidin)

Wilson’s (accumulation of copper at tissues)

A1AT deficiency (Lungs and liver, enzyme not able to leave liver)

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7
Q

Hereditary haemochromatosis

  • Inheritence
  • Mechanism
  • Organs affected
  • Gene
A

Autosomal recessive

Inc intestinal absorption of iron leading to tissue accumulation. Hepcidin deficient (blocks iron absorption when high levels detected)

  • Liver: fibrosis, cirrhosis, HCC,
  • Heart
  • Skin (bronzing)
  • Joints (arthropathy)
  • Pancreas (DM)

HFE (Chr 6)

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8
Q

Hereditary haemochromatosis

  • Symptoms
  • Age of onset
  • TIBC
A

Early: fatigue, weakness, arthralgia, erectile dysfunction
Late: bronzing, diabetes, cirrhosis, arrhythmia, arthropathy

TIBC dec, Ferritin inc, Transferrin saturated (over 45%)

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9
Q

Hereditary haemochromatosis Investigations

A 
Iron studies (high ferritin, Transferring over 45% saturated)
HFE genetic testing
LFTs
MRI: iron overload
Liver biopsy with Perls stain (blue)

Rule out Ddx: CRP (other cause of high ferritin - acute phase protein)

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10
Q

Treatment Hereditary haemochromatosis

A

Venesection/phlebotomy (4-500ml weekly)
Liver transplant in decompensation

Monitor ferritin

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11
Q

Wilson’s

  • Hepatic features
  • Psychiatric features
  • Neuro features
  • Opthalmological features
A

Liver failure, hepatitis,

Severe depression

Asymmetrical tremor, ataxia, clumsiness

Kayser-Fleisher ring

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12
Q

Wilson’s investigations

A

Copper studies:

  • low serum caeruloplasmin
  • high 24 hour urine copper
  • high free copper

slit lamp: Keyser-Fleisher

Liver biopsy: copper

MRI: density in BG

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13
Q

Wilson’s Treatment

A

Chelation agents (Penicillamine) binds copper to excrete in urine

Stop copper absorption: Zinc

Avoid copper dense food: mushrooms, liver, chocolate, nuts

Monitor: LFTs, Renal functionalists, FBC

Avoid alcohol and hepatotoxics

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14
Q

A1At deficiency

  • Inheritence
  • Mechanism
  • Consider when…
A

Autosomal recessive

A1AT is glycoprotein in the liver which controls inflammatory cascades and balances neutrophil elastase in the lung. Deficiency = alveolar destruction
Abnormal A1AT can not leave liver, congesting liver cells.

Young person with emphysema

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15
Q

A1At deficiency

  • Hepatic features
  • Lung features (Presenting factors)
A

Hepatitis, cirrhosis, HCC

Dyspnoea wheeze, cough, COPD

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16
Q

A1At deficiency

  • Investigations
  • Tx
A

Serum A1AT low
CXR and Lung functions (Peak flow and spirometry)

Smoking and alcohol advice
Treat like COPD (LABA)
Regular LFTs, screen for HCC

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17
Q

A1At deficiency

  • Investigations
  • Tx
A

Serum A1AT low

CXR and Lung functions (Peak flow and spirometry)

Smoking and alcohol advice
Treat like COPD (LABA)
Regular LFTs, screen for HCC

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18
Q

4 Things seen with Liver failure

A

Jaundice
Ascites
Abnormal Bleeding (dec clotting and varices)
Hepatic Encephalopathy

(when liver loses ability to regenerate)

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19
Q

Toxins causing Liver failure

A

Paracetamol,
Alcohol,
Medications (co-amoxiclav, Abx - cipro, doxy, erythro, methotrexate, gold)

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20
Q

Infective liver failure

A 
Viral hepatitis (A, B, C, E)
EBV, CMV
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21
Q

Neoplastic liver failure

A

Primary HCC

Secondary

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22
Q

Metabolic liver failure causes

A

Haemochromatosis
Wilson’s
A1ATd

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23
Q

Vascular Liver failure causes

A

Ischaemia (Atherosclerosis)

Budd-Chiari (hepatic vein thrombosis - triad 1) Abdo pain, 2) Ascites, 3) Hepatomegaly)

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24
Q

Inflammatory Liver failure

A

Autoimmune hepatitis

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25
Q

Hepatic encephalopathy pathophys + presentation + Tx

A

In liver failure ammonia builds up in circulation and crosses BBB causing cerebral oedema.

Altered mood, Drowsiness, Restlessness, Coma

Lactulose (removes Nitrogen from gut), Neomycin (lower nitrogen forming bacteria)

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26
Q

Signs of chronic liver disease

A

Finger clubbing

Fetor hepaticus

Leukonychia (white nails/milk spots)

Asterixis (flap)

Spider naevi

Hypoalbuminaemia = Ascites: shifting dullness, fluid thrills

Bleeding (Factor 1972 Fit K), Fibrinogen deficiency too

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27
Q

In Liver failure:

FBC
LFT 
Billirubin
Ammonia
Glucose
Copper
Paracetamol
Creatinine
INR
Viral serology
Doppler USS
A 
FBC: Thrombocytopenia
LFT: ALT + AST raised
Billirubin: Raised
Ammonia: Raised
Glucose: Dangerously low
Copper: High in Wilsons
Paracetamol: high in OD
Creatinine: hepatorenal syndrome = Raised
INR: Raised
Viral serology: viral hep, EBV, CMV
Doppler USS: Budd Chiari occlusion?
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28
Q

Liver cirrhosis severity Classification & Markers

A

Child-Pugh classification

BRAIN: 
Bilirubin (high)
Refractory ascites
Albumin low < 28
INR > 1.7
eNcephalopathy

Class A = least severe
Class C = Most severe

Consider transplant early

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29
Q

Liver failure management

  • If OD
  • Ammonia
  • Raised ICP (Hep encephalopathy)
  • AKI (hepatorenal)
  • Bleeding
  • Glucose
  • Ascites
A
  • If OD (para): N-Acetylecysteine
  • Ammonia: Lactulose
  • Raised ICP (Hep encephalopathy): IV mannitol
  • AKI (hepatorenal): Haemodialysis
  • Bleeding: FFP, Pts, Vit K
  • Glucose: IV glucose
  • Ascites: Diuretics, low salt
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30
Q

Liver transplant complications

A

Hepatorenal syndrome

Infection/sepsis - spontaneous bacterial peritonitis

Cerebral oedema

Haemorrhage form oesophageal varices

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31
Q

Ascites:

  • Def
  • Complications
  • Cause (4)
  • Presentation
A

Fluid collection in peritoneal cavity due to low oncotic pressure (hypo albumin)

Infection (SBP), Hepatorenal syndrome

75% cirrhosis (dec oncotic, portal hypertension - inc hydrostatic)
15% malignancy (GI tract, ovarian)
Heart failure
Nephrotic syndrome

Abdo distension + Umbilical herniation, dyspnoea (impaired lung function), weight gain.

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32
Q

Ascites:

  • Investigation
  • Management
  • Complications
A
  • Examination: Shifting dullness, fluid thrill (large ascites)
  • LFT: look for cirrhosis
  • Abdo USS (Ca Ovary, Liver mets)
  • CXR (HF, pleural effusion)

Tx cause
Diuretics: Spironolactone (beware hyperkalaemia)
Paracentesis (symptom relief)
TIPS (transjug intraheaptic shunt)

SBP, Hepatorenal syndrome

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33
Q

Spontaneous bacterial peritonitis

  • Def
  • Symp
  • Investigations
  • Organism
  • Tx + prevention
A

Intrabdo sepsis with 20% mortality

Fever, abdo pain (peritonism: gourding, rebound tenderness, pain on palpation), vomiting.

FBC (leukocytosis), LFT, U&E (hepatorenal), blood cultures.
Diagnostic paracentesis (culture and amylase)
Imaging: AXR (upright) and CXR

E.coli, Strep, enterococci

IV 3rd gen cephalosporin.
Prophylactic Abx

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34
Q

Precipitants for hepatic encephalopathy

A 
AKI
Infection
Constipation
Sedatives
Diuretics
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35
Q

Hepatorenal syndrome

  • Assoc
  • Precipitants
  • Pathophys
A

End-stage liver disease with ascites.

Events lowering BP e.g. SBP, GI bleeding.

Splanchnic Vasodilation drops BP, activates SNS and RAAS

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36
Q

Hepatorenal syndrome Diagnostic criteria

A

Cirrhosis with ascites
Creatinine over 133 micro mol
No nephrotixics

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37
Q

Hepatorenal syndrome management

A

Admit to HDU, monitor urine output, stop diuretics

Splanchnic vasoconstrictors e.g. terlipressin with albumin
TIPS - reduces ascites in portal HTN

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38
Q

Cirrhosis

  • Def
  • Complications
  • Causes
A

Fibrosis converting Liver architecture to nodules

hepatic/portal HTN (oesophageal varices), dec synthesis (clotting factors, albumin)

Common: Alcohol, Hep B/C, NAFLD, NASH (Non-Alp steatohepatitis

Uncommon: AI hep, PBC, PSC, sarcoidosis, Haemochromatosis

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39
Q

Cirrhosis

  • RF
  • Pathophysiology
A

Alcohol, Hepatitis, Obesity, T2DM

Cytokines activate stellate cells i space of disse
Normal Liver replaced with collagen
Loss of fenestration/sinusoid = imparted function Blood flow

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40
Q

Signs (FLAPS) and symptoms Cirrhosis

& Decompensated

A

Occur when 80% parenchyma destroyed - may be asymptomatic

Fatigue, malaise, anorexia, weight loss, gynaecomastia (inc oestrogen conversion as testosterone synthesis drop)

Signs: FLAPS: finger clubbing, Leukonychia, Asterixis, Palmar erythema, spider naevi)

Decompansated: Oedema, ascites, bruising, poor memory, Variceal bleeding, SBP

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41
Q

Portal HTN signs

A

Ascites, splenomegaly, caput medusae (veins from umbilicus), hematemisis

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42
Q

Investigating Cirrhosis

  • general
  • for cause (Viral, Alc, NASH, Metabolic, AI)
A

LFT: AST + ALT raised, GGT in alc, ALP + Bilirubin (PBC, PSC)
Albumin: low
FBC: Macrocytosis (alc)
U&E: Hig Cr - Hepatorenal
Imaging: USS, CXR (pleural effusion from ascites)
Biopsy: Gold standard for diagnosis (nodular, bridging fibrosis)

Viral screen: Hep B/C
Alc: GGT, MAcrocytosis, Carbohydrate deficient transaminase
NASH: fasting glucose
Metabolic: AIAT, Caeruloplasmin, transferrin sats (TIBC)
AAb screen - antimitochondrial

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43
Q

Cirrhosis management

A

Delay progress, treat cause and complications

Alcohol abstinence

Antihistamines (pruritus)

Prophylactic ciprofloxacin (SBP)

Monitor Oesophageal varies and HCC

Transplant is the only cure

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44
Q

Portal HTN

  • Def
  • Causes
A

Abnormally high hepatic portal vein pressure

Pre-hepatic: Portal thrombosis, Compression (e.g. tumour)

Hepatic: Cirrhosis, hepatitis, Sarcoid granuloma

Post-hepatic: Budd-Chiari, RHF/Congestive HF,

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45
Q

Portal HTN pathophysiology

Complication

Risk of TIPS

A

Due to either inc vascular resistance or inc blood flow

Pressure goes back to veins draining into portal vein

Causes varices e.g. in Gastro-oesophageal vein

May cause encephalopathy due to toxins bypassing liver

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46
Q

Portal HTN signs

A

Ascites, splenomegaly, dilated umbilical veins, signs of liver failure

Haematemisis, melaena (bleeding varices)

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47
Q

Portal HTN investigations

A 
Abdo USS (liver, spleen, ascites)
Doppler USS
Endoscopy for varices
48
Q

Portal HTN Tx & Complicatios

A

Treat cause ± transplant

Beta-blockers (Carvedilol) ± nitrates ± TIPS to reduce portal venous pressure

Variceal bleeding, Ascites complications (Hepatorenal, SBP)

49
Q

Oesophageal/Gestirc varices

  • Why important
  • Ix
  • Tx
A

Most common SE of portal HTN
Life threatening

Early endoscopy

1) Terlipressin at presentation + emergency endoscopy
2a) Oesophageal - band ligation, TIPs if not effective
2b) Gastric - Injection of surgical glue then TIPS

50
Q

Budd Chiari syndrome

  • Incidence
  • Def
  • Assoc
  • Pres
A

Rare

Obstruction of Hepatic veins

Myeloproliferative disorders, Hypercoagulable state (TB, Tumour, Preg)

Sudden RUQ pain, rapid ascites, hepatomegaly, jaundice

51
Q

Budd Chiari syndrome

  • Ix
  • Tx
A

Doppler USS

Begin Warfarin, treat ascites e.g. TIPS

52
Q

Liver:

  • Types
  • Common causes
A

90% secondary (Stomach, colon, lung, breast)
10% primary (HCC - 90%, Cholangiocarcinoma e.g. PSC - 10%)

90% have chronic liver cirrhosis

HCV leading cause in the UK (HBV worldwide commonest)

53
Q

Liver Ca

  • Pres
  • Screening (who&how)
  • Ix & Diagnosis
A

Anorexia, weight loss, night sweats, RUQ pain, symptoms of liver failure

HBV/HCV ± cirrhosis, Alc cirrhosis

USS + AFP (over 2cm mass + raised AFP)

54
Q

Liver Ca Tx

Prognosis

A

Surgical resection
Radiofrequency ablation
Systemic chemo.

Transplant - according to Milan criteria

6month median survival. death from cachexia, variceal bleeding.

55
Q

Liver Ca prevention

A

HBV vaccine
Reduced alcohol
Screen those with cirrhosis

56
Q

What enzyme converts alcohol and what to?

A

Alcohol dehydrogenase converts alcohol to acetaldehyde

57
Q

How doe alcohol cause liver damage?

A

Inc in NADH(from acetaldehyde) = Oxidative stress = hepatocyte injury

Inhibited gluconeogenesis, carb/protein metabolism
+ Inc Lipogenesis = Fatty liver

58
Q

Steatosis

  • Def
  • Types
  • When inflamed
A

Fat accumulation in Liver

Alcohol related fatty liver and non-alcohol fatty liver

Assoc with inflammation (steatohepatitis, NASH if non-alcoholic)

59
Q

Fatty liver pathophys

A

Accumulation of triglycerides and lipids in hepatocytes

Defective fatty acid metabolism, excess intake, mitochondrial damage

60
Q

Steatosis causes

A

Metabolic syndrome, PCOS, Excess alcohol, HBV/HCV, starvation, Wilson’s, Meds (amiodarone, tamoxifen, glucocorticoids, methotrexate)

61
Q

Steatosis Presentation

A

Generally asymptomatic.

Fatigue, RUQ pain, Hepatomegaly

Advanced disease have cirrhosis symptoms (Jaundice, oedema, ascites)

62
Q

Steatosis Ix and Diagnosis

A

Biopsy = Definitive

  • cells swollen with fatty inclusions
  • mallory bodies (eosinophilic cytoplasmic inclusions)

Liver USS echogenic liver
FBC (macrocytes in alcohol)
LFTs raised, ALT>AST

Ddx: viral studies, caerulopasmin, AI (ANA)

63
Q

Steatosis/Steatohepatitis
Management
Complications

A

Abstain from alcohol will cause reversal
Weight loss + exercise (inc insulin sensitivity)

Progression to cirrhosis, liver failure, HCC

64
Q

Triad in alcohol hepatitis/NAFLD

A

Fever + Mallory bodies + Steatosis

65
Q

Architecture of liver

A

Hepatocytes are arranged in Hexagonal lobules with central vein and portal triad (Vein artery and biliary ductiles) at each point of hex.

Sinusoids Connect portal vein and hepatic artery to central vein.

Zone 1-3 going from outer lobule edge –> central vein

66
Q

Viral hepatitis mechanism

A

Replication of virus in hepatocytes and secretion into bile

Liver inflammation and necrosis caused by immune response

67
Q

Hep A

  • Type of virus
  • Spread
  • Area
  • Course
  • Clinical pres
  • Ix
  • Tx + Prevent
A

RNA virus

Faeco-oral (hand-washing, shellfish)

India, Africa, Far East

Self limiting, acute. May take 6 months to recover.

Flu like prodrome.
Hepatitis: Dark urine, pale stool, jaundice, abdo pain, hepatomegaly, pruritus

Viral serology: IgM for Hep A- lasts 6M. IgG produced after 3w and persist years
LFT: rise in ALT, AST, ALP and bilirubin

Vaccinate travellers (live attenuated)
Supportive manage (fluids, antiemetics, rest, avoid alcohol, cholertyramine for itch)
68
Q

Hep E

  • Virus type
  • Spread
  • Prev + Tx
A

RNA virus

Faeco-oral (heavily assoc with pigs)

Supportive Tx.
Good hygiene, no vaccine exists

69
Q

Hep B

  • Virus
  • Spread
  • RF
A

DNA virus (commonest form of hepatitis in world)

Paraenteral (blood or body fluid)

  • Vertical: high (90%) if HbeAg +ve
  • Horizontal: Sexual, IVDU, Blood prods.

IVDU, sex workers, prisons, healthworkers

70
Q

HBsAg
HBsAb
HBcAb
HbeAg

A

HBsAg - Current infection

HBsAb - Shows clearance of infection

HBcAb - Shows immune response to infection. Could be acute/chronic/cleared

HbeAg - In those who are infective

71
Q

Hep B

  • Clinical course
  • Pres (acute & chronic)
  • Ix
A

Acute, if persists after 6m = Chronic

Acute

  • Prodrome (VANFAM - vomiting, anorexia, nausea, fever, arthralgia, malaise)
  • Hepatic: RUQ pain, hepatomegaly, jaundice, darki urine/light stools,
  • Occasionally fulminant necrosis (inc INR, need transplant)

Chronic (over 6m)

  • Fibrosis, Cirrhosis and HCC
  • fatigue, anorexia, nausea, RUQ pain

PCR for HBV, HBV serology
LFT

Screen for liver cancer

72
Q

HBV serology in:

  • Acute
  • Chronic
  • Cleared
  • Vaccinated
A

Positive for HB core antigen IgM and IgG antibod. HB surface antigen positive and high HBVDNA

Same as acute but no IgM, just IgG

There is anti-HBs (surface antigen) and IgG to core antigen (rest is cleared)

Just positive for antibody for HB surface antigen (Anti-HBs). There is no core antigen in vaccine

73
Q

Hep B prevention

A

Blood prod screening, Safe sex

Vaccination at risk (inc children)

74
Q

Hep B Tx

A

Acute: Bed rest, fluids, antipyretics, cholestyramine

Chronic: 48 wk injectable interferon alpha (1st line).
2nd line = tenofovir

Screen HCC 6 monthly

75
Q

Hep B complications

A

Fulminant hepatic failureRelapseCirrhosisHCCConcurrent HCV/HIV (increases progression to cirrhosis)

76
Q

Hep C

  • Virus
  • Spread
  • At risk
A

RNA

Parenteral: Blood, body fluids
sex, IVDU, tattoos, blood transfusion, needle-stick

IVDU, pre 1991 blood transfusion, needle stick

77
Q

Hep c

  • Clinical course
  • Symptoms
A

Acute or chronic

Acute is often asymptomatic

malaise, nausea, RUQ pain, jaundice

78
Q

Quicker disease progression in viral hepatitis:

A

Coinfection Hep B/C
Alc
HIV co-infection

79
Q

Chances of end-stage liver disease in Hep C

A

⅓ at 25 years, ⅓ after, ⅓ never

80
Q

Hep C

  • Ix
  • Tx
A

PCR Hep C RNA
LFT (AST:ALT over 1)
Degree of fibrosis (if PCR+Ve): Fibroscan, Biopsy

Pegylated interferon alpha + Ribavarin (for 6m)

Aim of Tx to prevent cirrhosis and HCC

81
Q

AI hepatitis:

  • Types of Ab
  • Pres
  • Ix
  • Tx
A

ANA, ASMA (anti smooth muscle), Anti-liver-kidney-microsomal

Prominent nausea, pruritus and jaundice. URQ discomfort.
Hepatomegaly, splenomegaly, ascites

LFT elevated, autoantibodyscreen (IgG polyclonal hypergammaglobulinaemia)

Prednisolone + Azathioprine
Will need transplant if end stage liver disease

82
Q

AI hepatitis assoc diseases

A

IBD, coeliac, proliferative glomerulonephritis, Grave’s, AI thyroiditis, T1DM
Immunosuppression

83
Q

Liver cysts:

  • Causes
  • Pres
  • Ix
  • Tx
A

Bacterial: Klebsiella, enterococcus
Amoebic: entamoeba histolytica
Polycytic liver disease (ADPKD assoc)

If large: RUQ pain, bloating

USS/CT/MRI, abnormal LFTs

Spontaneous resolution, aspirate
Abx: 3rd gen ceph + metronidazole (just met for amoeba)
ADPKD manage PKD

84
Q

Acute pancreatitis:

  • def
  • Causes
A

Acute inflammation of pancreas. Exocrine enzyme release = autodigestion of organ

GETSMASHED
Gallstones, Ethanol, Trauma, Steroids, Mumps, Autoimmune, Scorpion sting, Hyperlipid/Hypotherm/Hypercalcaemia, ERCP, Drugs

85
Q

Acute pancreatitis:

  • Presentation
  • Signs
A

Severe, sudden onset epigastric pain + vomiting
Pain radiates to back, relieved by sitting forward

Cullen’s signs: periumbilical bruising
Grey-Turner’s sign: Flank bruising - Retroperitoneal haemorrhage

Epigastric tenderness, Tachycardia, fever, hyperaemia, Jaundice (if cause is gallstones)

86
Q

Acute pancreatitis:

  • Tx
  • Imaging
  • Ddx
A

Seruma amylase (also rated in renal fail as renaly excreted), Serum lipase more specific
FBC (leukocytosis), CRP (pancreatic necrosis)
Raised bilirubin

CT w contrast = diagnostic
USS - swollen pancreas ± gallstones
ERCP
Abdo Xray - Retroperitoneal shadow = bleed, Pancreatic calcification

Dissecting AAA

87
Q

Acute pancreatitis:

  • Tx (mild)
  • Tx (severe
A

Pain: buprenorphine ± IV benzodiazepines
IV fluids, Nil by mouth (Stops pancreas stimulation)

HDU/ITU
NG enteral nutrition
ERCP for gallstones
IV antibiotics if evidence of necrosis

88
Q

Acute pancreatitis: severity criteria

A

Modified Glasgow score

89
Q

Complications of Acute pancreatitis:

A

DIC, Shock, Hypovolaemia, Hypocalcemia/hypoglycaemia
Renal dysfunction
ARDS, pleural effusions

90
Q

Chronic pancreatitis

  • Def
  • Typical Patient
  • Cause
A

Chronic inflammation/fibrosis and calcification of pancreases. impaired endocrine and exocrine functions

40y.o. drinker

GETSMASHED

91
Q

Chronic pancreatitis Presentation

A

Nausea and vomiting
Exocrine: malabsorption, wt loss, diarrhoea, steatorrhoea (pale, loose, offensive)
Endocrine: diabetes mellitus

92
Q

Chronic pancreatitis

  • Ix
  • Tx
A

Secretin stimulation test - Causes bicarb secretion by pancreas. 60% function loss = +ve result

Malabrosption: Serum trypsinogen, faecal elastase

Imaging: CT (atrophy), MRCP

Manage pain (tramadol) and malabrosption (replace enzymes)

93
Q

Retroperitoneal structures:

SADPUCKER

A 
Suprarenal
Aorta/IVC
Duodenum (2+3)
Pancreas
Ureter
Colon
Kidney
Esophagus
Rectum
94
Q

Pancreatic cancer

  • Types
  • Better when..
  • Worry
  • RF
A

Endocrine or Exocrine
95% Adenocarcinoma, most exocrine

Periampullary present early with obstructive jaundice (better prog)

High mortality, early mets, late pres.

Smoking, alcohol, obese, diabetes, FH, Syndromes (BRCA1/2, FAP, Lynch, MEN)

95
Q

Exocrine Pancreatic cancer

  • Pres
  • Ix
A 
Early = Vague - epigastric discomfort, dull backache 
Painless obstructive jaundice (dark urine, pale stools, pruritus) 
Epigastric pain (for tail lesions)
Gastric outlet obstruction (nausea/vom)
Rapid weight loss, Virchow's nod

LFT: Bilirubin, ALP, GGT = jaundice picture
Tumour marker: C19-9
USS liver
Abdo CT (diagnosis and staging)

96
Q

Pancreatic cancer Tx

A

Only 10% resectable (often metastatic)

Whipples procedure (proximal pancreaticoduodenectomy)

Adjuvant chemo: 5-FU

Palliation: stent in bile duct for pruritus/jaundice
Chemo/radiotherapy

97
Q

Endocrine Pancreatic cancer (3% of all)

  • Prognosis
  • Types and pres
A

Neuroendocrine tumours
Better prognosis than exocrine tumours

Mainly insulinoma (sweating, dizzy, hypoglycaemia) or Gastrinoma (severe peptic ulcer/diarrhoea due to high HCL)

98
Q

Gallstones:

  • Presentation
  • Typical person
  • Types of stone
A

Biliary colic, Acute cholecystitis

Fair, Fat, Fertile, Female, Forty

Cholesterol: 80%
Pigment: 10%, seen in haemolytic conditions
Mixed: 10%, Calcium salts + pigment + Cholesterol

99
Q

Result of Gallstones. how do they present?

  • Biliary colic
  • Acute cholecystitis
  • Ascending cholangitis
    Pancreatits (can be seen with distal CBD stone)
A

RUQ pain

RUQ pain + fever/WCC, Murphys sign, fatty meals = worse

Charcot’s triad: Jaundice, RUQ pain, Fever

Jaundice, Raised bilirubin/Alk phos/GGT

100
Q

Biliary colic

  • Mech
  • Pres
  • Ix
  • When does Jaundice occur
A

Temporary obstruction of Cystic/Common bile duct

Sudden onset RUQ pain, radiates to inter scapular region. Lasts 15 min-24hr
Can cause vomitng (GB distension)

USS 90-95% sensitive

When stone moves to CBD (obstruction of outflow)

101
Q

Acute Cholecystitis

  • Cause
  • Pres
  • Ix
A

Gallstones (95%), trauma and subsequent inflammatory response to retained bile

Continuous epigastric/RUQ -> R shoulder pain, fever and peritnoism. Fat stimulates CCK = inc pain

Murphy’s sign +ve
Raised WCC, abnormal LFT
USS - Thickened GB wall
ERCP/MRCP

102
Q

Managing Gall stone complications

A

Non-surgical:
NBM = stop CCK release
Pain - Parentral opioids or declofenac (NSAID)

Surgical:
Laparoscopic cholecystectomy to remove GB (this is now done early in cholecystitis)

103
Q

Ascending cholangitis:

  • Pres
  • Mech
  • Organism
  • Causes
A

Charcot’s triad: Fever, RUQ pain, Jaundice

If CBD obstruction flow of bile reduced = biliary stasis and infection.

E.coli, klebsiella, enterococci

Obstruction of GB/CBD: stones, ERCP, tumours (Ca pancreases, Cholangicarcinoma)

This is medical emergency

104
Q

Ascending cholangitis: Ix and diagnosis

A

Systemic inflammation:
Temp over 38
Elevated WCC or CRP

Cholestasis: Jaundice (high bilirubin), Abnormal LFT (ALP/ASt/ALT/GGT raised)

Imaging: AUSS, CT, MRCP (evidence stricture/stone, biliary dilatation)

U&E, amylase and blood cultures (worry about complications: pancreatitis, Sepsis, AKI)

105
Q

Ascending cholangitis Tx

A

Fluid resus, broad spec Abx
Metroenidazole + Ceftriaxone

If AKI, Shock, DIC –> Endoscopic biliary drainage

106
Q

Primary sclerosing cholangitis:

  • Def
  • Assoc
  • Pres
A

Chronic inflammation + fibrosis of intra/extrahepatic bile ducts.
Gives multifocal biliary strictures

Inflammatory bowel (UC), HCC

Abnormal LFT, Jaundice, pruritus, RUQ pain, Fever, Wt loss, Fatigue

107
Q

Primary sclerosing cholangitis Ix

A

LFT (alk phos, GGT, raised transaminase), Imaging (USS shows bile duct dilatation and strictures)

Biopsy for staging (onion skin fibrosis)

108
Q

Primary sclerosing cholangitis Tx

Complications

A

Baloon dilatation to treat strictures

Colestyramine (pruritus)

Supplement fat soluble Vits (low bile to emulsify fats in intestine)

Portal HTN (Varices)
Cholangiocarcinoma
109
Q

Primary biliary cirrhosis

  • Def
  • Pres
  • Assoc
  • Antibody
A

Slow progressive AI disease with destruction of small interlobular bile ducts

Fatigue, pruritus, RUQ pain, Cholestatic jaundice

Sjogren’s and other AI (thyroid)

Antimitochondiral antibody

110
Q

Primary biliary cirrhosis Ix

A

AMA, LFT (raised alk phos), MRCP, Liver biopsy (granulomatous infiltration of portal triad)

Only transplant is curative
Colestyramine (pruritus), Immunosuppression (MTX, Steroids)

111
Q

PSC Vs PBC

  • AAb
  • Assoc dis
  • Affected vessels
A

PBC - AMA antibodies
PSC - pANCA antibodies

PBC - Sjogrens and thyroid
PSC - UC and colon cancer

PBC - interlobular ducts
PSC - extra hepatic and intra hepatic ducts

112
Q

Cholangiocarcinoma

  • Type of tumour
  • Pres
  • Tumour markers
  • Ix
  • Tx
A

90% ductal adeno

URQ abdo pain + jaundice + cholestasis + pruritus + hepatomegaly + wt loss

Ca19-9 and CEA

MRI best. AlsoUSS/CT

Surgery but only 33% resectable.
Palliative: stent and ERCP

113
Q

Cholestasis symptoms mech

A

Bile cannot flow from GB (stored) to Duodenum.
Conjugated bilirubin regurgitation to serum (inc conc)

Pale stools/Dark urine: urobilinogen can not be formed in gut. High conjugated bilirubin is excreted in urine (dark)
Pruritus (Bile salt irritation)

114
Q

What is diff between prehepatic and post hepatic jaundice

A

Unconjugated bilirubinaemia higher in pre hepatic

Conjugate higher in post hepatic

115
Q

Bilirubin product excreted in gut and in kidneys

A

Gut = Stercobilin

Kidneys = Urobilin

116
Q

Types of Jaundice

A

Pre-hepatic: haemolytic (unconjugated hyperbilirubinaemia e.g. malaria, sickle cell, thalassaemia, G6PDD)

Hepatic: Hepatitis, fibrosis/cirrhosis, Para/rifampicin/statins

Post-hepatic: Cholestasis, Anabolic steroids

Final (26 decks)

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