Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

Final > Liver & Friends > Flashcards

Liver & Friends Flashcards

1
Q

Arteries of the foregut

A

Celiac trunk

  • Left gastric
  • Splenic
  • Common hepatic
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

AST:ALT ration

A

If over 1 = Ischaemia

If over 2.5 Alcoholic hepatitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

GGT

A

Sensitive to alcohol ingestion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

ALP

A

Elevated with

  • Cholestasis
  • Malignant hepatocellular damage
  • Marker of bone turnover (Paget’s)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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%)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Treatment Hereditary haemochromatosis

A

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

Monitor ferritin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

A1At deficiency

  • Hepatic features
  • Lung features (Presenting factors)
A

Hepatitis, cirrhosis, HCC

Dyspnoea wheeze, cough, COPD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Toxins causing Liver failure

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Infective liver failure

A 
Viral hepatitis (A, B, C, E)
EBV, CMV
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Neoplastic liver failure

A

Primary HCC

Secondary

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Metabolic liver failure causes

A

Haemochromatosis
Wilson’s
A1ATd

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Vascular Liver failure causes

A

Ischaemia (Atherosclerosis)

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Inflammatory Liver failure

A

Autoimmune hepatitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Hepatic encephalopathy pathophys + presentation + Tx
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)
26
Signs of chronic liver disease
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
27
In Liver failure: ``` FBC LFT Billirubin Ammonia Glucose Copper Paracetamol Creatinine INR Viral serology Doppler USS ```
``` 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? ```
28
Liver cirrhosis severity Classification & Markers
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
29
Liver failure management - If OD - Ammonia - Raised ICP (Hep encephalopathy) - AKI (hepatorenal) - Bleeding - Glucose - Ascites
- 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
30
Liver transplant complications
Hepatorenal syndrome Infection/sepsis - spontaneous bacterial peritonitis Cerebral oedema Haemorrhage form oesophageal varices
31
Ascites: - Def - Complications - Cause (4) - Presentation
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.
32
Ascites: - Investigation - Management - Complications
- 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
33
Spontaneous bacterial peritonitis - Def - Symp - Investigations - Organism - Tx + prevention
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
34
Precipitants for hepatic encephalopathy
``` AKI Infection Constipation Sedatives Diuretics ```
35
Hepatorenal syndrome - Assoc - Precipitants - Pathophys
End-stage liver disease with ascites. Events lowering BP e.g. SBP, GI bleeding. Splanchnic Vasodilation drops BP, activates SNS and RAAS
36
Hepatorenal syndrome Diagnostic criteria
Cirrhosis with ascites Creatinine over 133 micro mol No nephrotixics
37
Hepatorenal syndrome management
Admit to HDU, monitor urine output, stop diuretics Splanchnic vasoconstrictors e.g. terlipressin with albumin TIPS - reduces ascites in portal HTN
38
Cirrhosis - Def - Complications - Causes
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
39
Cirrhosis - RF - Pathophysiology
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
40
Signs (FLAPS) and symptoms Cirrhosis & Decompensated
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
41
Portal HTN signs
Ascites, splenomegaly, caput medusae (veins from umbilicus), hematemisis
42
Investigating Cirrhosis - general - for cause (Viral, Alc, NASH, Metabolic, AI)
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
43
Cirrhosis management
Delay progress, treat cause and complications Alcohol abstinence Antihistamines (pruritus) Prophylactic ciprofloxacin (SBP) Monitor Oesophageal varies and HCC Transplant is the only cure
44
Portal HTN - Def - Causes
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,
45
Portal HTN pathophysiology Complication Risk of TIPS
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
46
Portal HTN signs
Ascites, splenomegaly, dilated umbilical veins, signs of liver failure Haematemisis, melaena (bleeding varices)
47
Portal HTN investigations
``` Abdo USS (liver, spleen, ascites) Doppler USS Endoscopy for varices ```
48
Portal HTN Tx & Complicatios
Treat cause ± transplant Beta-blockers (Carvedilol) ± nitrates ± TIPS to reduce portal venous pressure Variceal bleeding, Ascites complications (Hepatorenal, SBP)
49
Oesophageal/Gestirc varices - Why important - Ix - Tx
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
Budd Chiari syndrome - Incidence - Def - Assoc - Pres
Rare Obstruction of Hepatic veins Myeloproliferative disorders, Hypercoagulable state (TB, Tumour, Preg) Sudden RUQ pain, rapid ascites, hepatomegaly, jaundice
51
Budd Chiari syndrome - Ix - Tx
Doppler USS Begin Warfarin, treat ascites e.g. TIPS
52
Liver: - Types - Common causes
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
Liver Ca - Pres - Screening (who&how) - Ix & Diagnosis
Anorexia, weight loss, night sweats, RUQ pain, symptoms of liver failure HBV/HCV ± cirrhosis, Alc cirrhosis USS + AFP (over 2cm mass + raised AFP)
54
Liver Ca Tx Prognosis
Surgical resection Radiofrequency ablation Systemic chemo. Transplant - according to Milan criteria 6month median survival. death from cachexia, variceal bleeding.
55
Liver Ca prevention
HBV vaccine Reduced alcohol Screen those with cirrhosis
56
What enzyme converts alcohol and what to?
Alcohol dehydrogenase converts alcohol to acetaldehyde
57
How doe alcohol cause liver damage?
Inc in NADH(from acetaldehyde) = Oxidative stress = hepatocyte injury Inhibited gluconeogenesis, carb/protein metabolism + Inc Lipogenesis = Fatty liver
58
Steatosis - Def - Types - When inflamed
Fat accumulation in Liver Alcohol related fatty liver and non-alcohol fatty liver Assoc with inflammation (steatohepatitis, NASH if non-alcoholic)
59
Fatty liver pathophys
Accumulation of triglycerides and lipids in hepatocytes | Defective fatty acid metabolism, excess intake, mitochondrial damage
60
Steatosis causes
Metabolic syndrome, PCOS, Excess alcohol, HBV/HCV, starvation, Wilson's, Meds (amiodarone, tamoxifen, glucocorticoids, methotrexate)
61
Steatosis Presentation
Generally asymptomatic. Fatigue, RUQ pain, Hepatomegaly Advanced disease have cirrhosis symptoms (Jaundice, oedema, ascites)
62
Steatosis Ix and Diagnosis
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
Steatosis/Steatohepatitis Management Complications
Abstain from alcohol will cause reversal Weight loss + exercise (inc insulin sensitivity) Progression to cirrhosis, liver failure, HCC
64
Triad in alcohol hepatitis/NAFLD
Fever + Mallory bodies + Steatosis
65
Architecture of liver
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
Viral hepatitis mechanism
Replication of virus in hepatocytes and secretion into bile Liver inflammation and necrosis caused by immune response
67
Hep A - Type of virus - Spread - Area - Course - Clinical pres - Ix - Tx + Prevent
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
Hep E - Virus type - Spread - Prev + Tx
RNA virus Faeco-oral (heavily assoc with pigs) Supportive Tx. Good hygiene, no vaccine exists
69
Hep B - Virus - Spread - RF
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
HBsAg HBsAb HBcAb HbeAg
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
Hep B - Clinical course - Pres (acute & chronic) - Ix
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
HBV serology in: - Acute - Chronic - Cleared - Vaccinated
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
Hep B prevention
Blood prod screening, Safe sex | Vaccination at risk (inc children)
74
Hep B Tx
Acute: Bed rest, fluids, antipyretics, cholestyramine Chronic: 48 wk injectable interferon alpha (1st line). 2nd line = tenofovir Screen HCC 6 monthly
75
Hep B complications
Fulminant hepatic failureRelapseCirrhosisHCCConcurrent HCV/HIV (increases progression to cirrhosis)
76
Hep C - Virus - Spread - At risk
RNA Parenteral: Blood, body fluids sex, IVDU, tattoos, blood transfusion, needle-stick IVDU, pre 1991 blood transfusion, needle stick
77
Hep c - Clinical course - Symptoms
Acute or chronic Acute is often asymptomatic malaise, nausea, RUQ pain, jaundice
78
Quicker disease progression in viral hepatitis:
Coinfection Hep B/C Alc HIV co-infection
79
Chances of end-stage liver disease in Hep C
⅓ at 25 years, ⅓ after, ⅓ never
80
Hep C - Ix - Tx
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
AI hepatitis: - Types of Ab - Pres - Ix - Tx
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
AI hepatitis assoc diseases
IBD, coeliac, proliferative glomerulonephritis, Grave’s, AI thyroiditis, T1DM Immunosuppression
83
Liver cysts: - Causes - Pres - Ix - Tx
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
Acute pancreatitis: - def - Causes
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
Acute pancreatitis: - Presentation - Signs
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
Acute pancreatitis: - Tx - Imaging - Ddx
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
Acute pancreatitis: - Tx (mild) - Tx (severe
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
Acute pancreatitis: severity criteria
Modified Glasgow score
89
Complications of Acute pancreatitis:
DIC, Shock, Hypovolaemia, Hypocalcemia/hypoglycaemia Renal dysfunction ARDS, pleural effusions
90
Chronic pancreatitis - Def - Typical Patient - Cause
Chronic inflammation/fibrosis and calcification of pancreases. impaired endocrine and exocrine functions 40y.o. drinker GETSMASHED
91
Chronic pancreatitis Presentation
Nausea and vomiting Exocrine: malabsorption, wt loss, diarrhoea, steatorrhoea (pale, loose, offensive) Endocrine: diabetes mellitus
92
Chronic pancreatitis - Ix - Tx
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
Retroperitoneal structures: SADPUCKER
``` Suprarenal Aorta/IVC Duodenum (2+3) Pancreas Ureter Colon Kidney Esophagus Rectum ```
94
Pancreatic cancer - Types - Better when.. - Worry - RF
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
Exocrine Pancreatic cancer - Pres - Ix
``` 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
Pancreatic cancer Tx
Only 10% resectable (often metastatic) Whipples procedure (proximal pancreaticoduodenectomy) Adjuvant chemo: 5-FU Palliation: stent in bile duct for pruritus/jaundice Chemo/radiotherapy
97
Endocrine Pancreatic cancer (3% of all) - Prognosis - Types and pres
Neuroendocrine tumours Better prognosis than exocrine tumours Mainly insulinoma (sweating, dizzy, hypoglycaemia) or Gastrinoma (severe peptic ulcer/diarrhoea due to high HCL)
98
Gallstones: - Presentation - Typical person - Types of stone
Biliary colic, Acute cholecystitis Fair, Fat, Fertile, Female, Forty Cholesterol: 80% Pigment: 10%, seen in haemolytic conditions Mixed: 10%, Calcium salts + pigment + Cholesterol
99
Result of Gallstones. how do they present? - Biliary colic - Acute cholecystitis - Ascending cholangitis Pancreatits (can be seen with distal CBD stone)
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
Biliary colic - Mech - Pres - Ix - When does Jaundice occur
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
Acute Cholecystitis - Cause - Pres - Ix
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
Managing Gall stone complications
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
Ascending cholangitis: - Pres - Mech - Organism - Causes
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
Ascending cholangitis: Ix and diagnosis
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
Ascending cholangitis Tx
Fluid resus, broad spec Abx Metroenidazole + Ceftriaxone If AKI, Shock, DIC --> Endoscopic biliary drainage
106
Primary sclerosing cholangitis: - Def - Assoc - Pres
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
Primary sclerosing cholangitis Ix
LFT (alk phos, GGT, raised transaminase), Imaging (USS shows bile duct dilatation and strictures) Biopsy for staging (onion skin fibrosis)
108
Primary sclerosing cholangitis Tx Complications
Baloon dilatation to treat strictures Colestyramine (pruritus) Supplement fat soluble Vits (low bile to emulsify fats in intestine) ``` Portal HTN (Varices) Cholangiocarcinoma ```
109
Primary biliary cirrhosis - Def - Pres - Assoc - Antibody
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
Primary biliary cirrhosis Ix
AMA, LFT (raised alk phos), MRCP, Liver biopsy (granulomatous infiltration of portal triad) Only transplant is curative Colestyramine (pruritus), Immunosuppression (MTX, Steroids)
111
PSC Vs PBC - AAb - Assoc dis - Affected vessels
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
Cholangiocarcinoma - Type of tumour - Pres - Tumour markers - Ix - Tx
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
Cholestasis symptoms mech
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
What is diff between prehepatic and post hepatic jaundice
Unconjugated bilirubinaemia higher in pre hepatic Conjugate higher in post hepatic
115
Bilirubin product excreted in gut and in kidneys
Gut = Stercobilin Kidneys = Urobilin
116
Types of Jaundice
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)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions