Liver & friends / GU Exam deck Flashcards
What is an AKI?
Sudden decline in renal function over hours or days
Risk factors for AKI?
age > 65, cognitive impair
CKD, nephrotoxic meds e.g. NSAIDs & ACE inhibitors
liver disease, diabetes
contrast medium in scans
General present - AKI?
Dehydration
dry mucuous membranes, reduced skin turgor & urine output
thirst, (orthostatic) hypotension,
and the other way - fluid overload
ankle swell, paro noc dyspnoea, raised JVP, ascites
Renal - as per UC
Post renal - loin to groin pain, haematuria, nausea vom // LUTS
Key criteria to classify stages of AKI?
KDIGO criteria
Stage 1 of KDIGO criteria?
Serum creatinine
> 26.5
= 1.5-1.9x baseline
Urine output
< 0.5ml/kg/hr for 6-12 hours
Stage 2 of KDIGO criteria?
Serum creatinine
> 2.0 - 2.9 baseline
Urine output
< 0.5 ml/kg/hr
for ≥ 12 hours
Stage 3 of KDIGO ceriteria?
Serum creatinine
≥ 353.6 or
≥ 3 x reference or on RRT
Urine output
< 0.3 ml/kg/hr for ≥ 24 hours
anuria for ≥ 12 hours
Name 3 pre-renal causes of AKI?
= most common!
= secondary to inadequately low blood supply to kidneys
dehydration
hypotension
heart failure
Name 3 renal causes of AKI?
intrinsic disease = reduced filtration of blood
Renal artery stenosis / thrombosis
glomerulonephritis
interstitial nephritis
acute tubular necrosis
Name 3 post renal causes of AKI?
= due to obstruction to outflow of urine from kidney
kidney stones
masses - cancer in abdo or pelvis
ureter or uretral strictures
prostate cancer
Investigations for AKI?
Urinalysis
(dipstick / microscope / osmo & electro)
leukocytes & nitrites = infect
protein & blood = acute nephritis
glucose = diabetes
Ultrasound
of uri tract to look for obstruction
Management principles AKI?
Volume dysregulation (as per need)
Regulate electrolytes
severe hyperkalaemia !!!
metabolic acidosis !!!
Stop nephrotoxic drugs
ACEi, NSAIDs, Spironolactone
How might you treat a severe hyperkalaemia?
= > 6.5 or 7 mmol/L
Myocardial protection
10 ml 10% calcium gluconate
Reduce extracell potassium
drive into cells
= Insulin (ACTRAPID) & dextrose
= beta agonists (neb salbutamol)
Additional
stop / adjust potassium sparing / containing meds
List complications of AKI?
Chronic kidney disease - what is it?
Presence of kidney damage / reduced kidney function for ≥ 3 months
Features of CKD?
Reduced GFR
< 60 ml / min = G3a - G5
Increased ACR
> 3 mg / mmol = A2-3
KDIGO staging for GFR?
G1 = > 90
G2 60-89
G3a 45-59
G3b 30-44
G4 15-29
G5 <15
KDIGO staging for ACR?
- *A1** < 3
- *A2** 3-30
- *A3** > 30
Risk factors for CKD?
DM, hypertension nephropathies glomerulopathies
inherited kidney disorders → PCKD
ischaemic nephropathy
obstructive uropathy / tubular diseases
Symptoms of CKD?
generally asymptomatic in earlier
non specific later
watch albumin:urea & radio abnormalities - e.g. abdominal masses, polycystic kidneys
Investigations fo CKD?
urine
ACR can be spot test or 24 hour collection! order both!
bloods
specifically - LFT, UE
imaging
renal ultrasound, ECG
Management for CKD?
TUC, slow progress
Renoprotective therapy = BP control for everyone!
→ if ACR ≤ 30 (A1-2), follow NICE
→ if proteinuria = ARB / ACEi
When should you offer a renin-angiotensin system antagonist to patients of CKD?
= one of is enough not fulfill all
Diabetic and ACR ≥ 3 mg / mmol
Hypertension and ACR > 30 mg / mmol
ACR > 70 mg / mmol
Complications of CKD?
Anaemia
= normocytic, usually multifacorial but can be EPO deficient
Hyperkalaemia & acidosis
Mineral & bone disorders
Indicators for & types of renal replacement therapy?
Haemodialysis / peritoneal dialysis & renal transplant
= end stage renal disease
What is ADPKD?
Autosomal dominant polycystic kidney disease
= common genetic disorder characterised by multiple renal cysts
Genes & chromosomes for autosomal dominant PKD? What does it mean by autosomal dominant?
PKD1 = chromo 16\*\* PKD2 = chromo 4
auto dom = only single gene needed to express phenotypes (clinical features of disease)
Risk of PKD / Associated?
(very important!)
Hepatic cysts
Cerebral aneurysms
Renal family history
→ ADPKD, ESRF, hypertension, CKD
PKD Diagnostic criteria related to age?
15-39 y/o ≥ 3 cysts (uni / bilateral)
40-59 y/o ≥ 2 cysts (each kidney)
60 years ≥ 4 cysts (each kidney)
Pathophysio of PKD?
PKD’s encode for polycystin, responsible for sensing flow (allow Ca2+ influx) in tubule
mutation = no sense,
= uncontrolled cell division & water transport into lumen of cyst → larger
Complications of ADPKD?
→ cysts in other parts of the body (as polycystin also in other pt of bod)
= liver, seminal vesicles, pancreas, diverticular, ovarian
= vasculature!!
→ aortic root dilate = heart failure
→ cerebral aneurysms = berry = subarach haemorr
Presentation ADPKD?
Hypertension!
Increase in size of kidneys
loin pain / discomfort
bilateral kidney enlargement
palpable
Complication of cysts
excessive water / salt loss (swing)
urinary stasis → kidney stones
haematuria ± rupture
renal insufficiency → renal failure
Diagnostic tests for ADPKD?
Ultrasound
Genetic testing for PKD 1 & 2
(but large gene & many so not preferred ??)
(only if atypical onset, prenatal, no fam hx)
(cannot exclude if < 30 years)
Genes & chromosomes for ARPKD?
PKHD1 mutation on chromo 6
Presentation for ARPKD
Infancy!
Renal failure before birth
oligohydramios = lack of aminotic urine
→ clubbed feet, flattened nose
→ pulmonary hypoplasia = resp insufficiency
Multiple renal cysts & congenital hepatitic fibrosis
Diagnosis for ARPKD
Prenatal ultrasound
bilateral large kidneys
cysts
oligohydramnios
Neonatal ultrasound
cysts
CT / MRI to monitor liver disease
Complications ARPKD?
Congenital Hepatic fibrosis
Portal hypertension
eso varices, UGB, haemorrhoids, splenomegaly
Dilated ducts
= cholestasis & ascending cholangitis
Treatment for PKD? How would you monitor disease progression?
= none that has shown to slow progression :<
monitor by serum creatinine
BP control → ACEi
- *Treat stones & analgesia**
- *Laparoscopic removal** (cyst or nephrectomy) for pain relief
- *Renal replacement**
- *Relative screening in 20’s**
Nephrolithiasis - what are they?
Solutes in urine precipitate out and crystallise
→ when urine is too concentrated (supersaturation) → precipitate out of solution
3 locations at which you may find deposited kidney stones?
- pelviureteric junction **
- pelvic brim
- vesicoureteric junction
Risk factors & epidemiology - kidney stones?
peak 20 - 40 years, males
dehydration, infection
Drugs - diuretics, antacids, corticosteroids, aspirin, allopurinol
primary renal disease, gout, fam hx
Most common type of kidney stones?
Calcium oxalate
How might you differentiate between the two types of calcium kidney stones
Calcium oxalate → acidic urine
= black / dark brown
Calcium phosphate → alkaline urine
= dirty white
Risk for calcium stones?
Hypercalcemia / hypercalciuria
increased GI absorption
endocrine = primary hyperparathyroidism
impaired renal tubular reabsorption (leave behind lots)
if oxalate = renal impairment, diet heavy in oxalate = rhubarb, spinach, choco, nuts & beer)
Only type of kidney stones which will not show up on x ray (& other features)?
Uric acid stones!
= reddish-brown in colour
= radiolucent
Risk factors for uric acid stones?
dehydration
Purine - rich diet
= shellfish, anchovies, red / organ meat
Gout
Struvite stones - features & association?
- *Staghorn** = branch into renal calyces
- *dirty white, radiopaque**
associated with UTI** **infections
= mixed composition from organism breaking urea using urease
Mg, ammonium, phosphate
Risk factors of struvite stones?
UTI = main
vesicoureteral reflux
obstructive uropathies
Stone with excessive urinary excretion (& its other features)?
Cystine stones
cause = cystinuria, auto recess affecting cysteine in GI tract
= yellow or light pink stones, radiopaque on x ray
Presentation of kidney stones?
Dull or localised flank pain
in mid - lower back
Renal colic
= excruciating sharp, constant pain
= cannot sleep / lie still
= dilation, stretching & spasm of ureter
Nausea & vomiting
Investigations for kidney stones?
Urine dipstick & specimen
haematuria - visible = 85% !!
1st line = Kidney, ureter, bladder x ray (KUBXR)
GOLD = Non-contrast Computerised Tomography (NCCT-KUB) = DIAGNOSTIC
CI is probably radiation?
Non acute can use ultrasound
Medical treatment for kidney stones?
Hydration
- *Medications**
- pain: strong analgesic = IV diclofenac
- *stop stone form**: potassium citrate, sodium bicarbonate
- *promote expulsion**: alpha blockers = tamsulosin, CCB = nifedipine
Surgical treatment for kidney stones? Size for natural passing?
stones < 5mm in lower will 90% pass spontaneously
Extracorporeal shockwave lithotripsy = ultrasound fragments stone
Endoscopy with YAG = laser for large stones
Percutaneous nephrolithotomy PCNL = keyhole to remove
Prostate cancer - aetiology - genes responsible etc?
Genes
= HOXB13 predispose
= BRCA2 = 5-7 higher risk
age, black. fam hx
increased testosterone
Prostate cancer - Type & area arise
Adenocarcinomas
Peripheral prostate
Androgen receptors on prostate responsible for cancerous growth
How might prostate cancer spread?
Local → seminal vesicle, bladder & rectum
Via lymph
Haematologically - bone
less common to brain, liver & lung
Presentation for prostate cancer?
LUTs if local disease
Weight loss, bone pain & anaemia = mets
DRE exam for prostate cancer vs for BPH?
Prostate cancer - hard & lumpy
BPH - large, smooth & firm
Investigations for prostate cancer?
DRE
Raised PSA
if mets = > 16ng/ml
DIAGNOSTIC = trans-rectal ultrasound & biopsy
essential to have histological diag, gleason score used
What’s the PSA &
Prostate specific antigen
produce by prostate, in normal & neoplastic tissue
Unreliable testing bc
small BMI, taller, recent ejaculate, black african, UTI
Treatment for prostate cancer?
Radical prostatectomy
radio / hormone therapy
if mets
Endocrine therapu = androgen deprivation
→ LHRH agonist
SC goserelin / leuprorelin
→ Androgen receptor blockers
Testicular cancer - 2 types & risk factors?
96% from germ cells
- *seminoma** = 25-40 yrs & 6- yrs
- *teratomas** = infancy
risks
undescended testis, infant hernia, infertility, family history
Testicular cancer - serum tumour markers?
- *Alpha-Fetoprotein (AFP) &**
- *B-hCG**
raised in teratomas (infant)
B-hCG in seminomas (adult)
Diagnosis & tx - testicular cancer?
Ultrasound
radiotherapy / orchidectomy / chemo
sperm storage
Renal cell carcinoma - type & spread?
Proximal convoluted tubular epithelium
Spread may be direct = renal vein, via lymph or haematogenous (bone, liver, lung)
25% mets at prez
Renal cell carcinoma - complications?
Varicocele
Hypertension!
renin secreted by tumour
Fever
Anaemia, polycythaemia
Risk factors for renal cell carcinoma?
male, > 50 years, Czech
obesity hypertension smoking
renal failure, polycystic kidneys
Von Hippel Lindau
What is Von Hippel Lindau syndrome?
auto dom,
mutation of chromo 3
loss of both copies of tumour suppressor gene
50% develop RCC = bilateral, multifocal
renal and pancreatic cysts + cerebella malignancy
Diagnosis & tx of renal cell carcinoma?
Ultrasound
distinguish simple cyst from complex / tumour
CT with contrast = sensitive
MRI = staging
if local = surgery, alt = radiotherapy
if mets = IL2 & interferon alpha
Transitional cell carcinoma?
= cell type in epithelium which lines calyx, renal pelvis, ureter, bladder & urethra
bladder-c is the most common tcc!!
Bladder cancer - cell type & spread? ;)
Transitional cell carcinoma
Spread
local → pelvic structures
lymphatic → iliac & para aortic nodes
haematogenous → liver & lungs
Bladder cancer - risk & present?
Occupational carcinogen exposure
benzidine, azo dyes, beta-napthylamine
petreoleum, chemical, cable & rubber industries
chronic UTIs & painless haematuria esp >40
drugs - cyclophosphamide
Bladder cancer - investigate & treat?
DIAGNOSTIC
- *cytoscopy with biopsy**
- *CT urogram**
tumour markers
other imaging
GOLD = Radical cystectomy
post op = chemo = m-trexate, vinblastine
radio if cannot surgery
1st line BPH treatment - class of med? name? mechanism? SE? CI?
Alpha 1 antagonist = oral tamsulosin
relax smooth muscle = increase flow rate, decrease obstructive symptoms
SE drowsy dizzy depression
ejaculatory failure, nasal congestion
CI postural hypotension!
Alt BPH treatment - class? name? mechanism? SE?
5-alpha reductase inhibitor = oral finasteride
blocks conversion of testosterone → dihydrotestosterone
use when very larger prostate
SE impotence, decreased libido
Gold standard treatment for BPH? Criteria?
Transurethral resection of prostate (TURP)
- if no response to meds
- if uri retention, recurrent gross haematuria, renal insuff etc
alt = change resection to incision
5 primary causative organisms of UTI? (mneumonic)
KEEPS
Klebsiella spp.
E coli
Enterococci
Proteus spp.
Staphylococcus spp.
Cystitis in uncomplicated females
1st line tx?
2nd line tx?
1st = Nitrofuratoin / Trimethoprim
3 days
2nd = Nitro / Pivmecillinam / fosfomycin
Cystitis in pregnant women
symptomatic - tx?
send for urine culture & use appropriate antibiotic
1st line - nitrofuratoin - avoid near term
2nd - cefalexin
amoxicillin if appropriate for culture
Cystitis in pregnant women
asymptomatic - tx?
- *urine culture**
- one should have been done at first antenatal visit
- one after tx
meds
immediate nitrofuratoin (avoid near term) / amoxicillin / cefalexin for 7 days
→ prevent progression to pyelonephritis
Cystitis in men
tx?
1st line = trimethoprim or nitrofurantoin
No improve - think pyelonephritis / prostatitis
Urethritis - nature of disease & tx?
Sexually acquired, common in men
DIAGNOSTIC = Nuclear acid amplification test
vaginal swab / first void volume
treat as per gonorrhoea / chlamydia
Chlamydia tx?
Oral azithromycin stat
OR 1 week oral doxycycline
if preg
oral erythromycin 14d
oral azithromycin stat
patient education
contact tracing
Gonorrhea tx?
IM ceftriaxone with oral azithromycin
partner notification
patient education
contact tracing
Free card
Main pancreatic enzymes? Produced by which cell type?
Amylase
Trypsin / chymotrypsin
Lipase
→ Pancreatic acinar cells
Endocrine component of the pancreas? Cell types?
Alpha cell = glucagon
Beta cell = insulin
D cell = somatostatin
PP cells = pancreatic polypeptide
Enterochromaffin cells = serotonin
Pancreatitis - pathophysiology?
Trypsin & chymotrypsin gets suddenly activated within the pancreas
= autodigestion of pancreas
→ inflammation & haemorrhaging
(normally need to be activated by enteropeptidase in duodenum)
Which pancreatic enzymes are secreted in their active forms & don’t need activation by trypsin?
Lipase & amylase
Causes of acute pancreatitis?
I - idiopathic
G - gallstones
E - Ethanol
T - trauma
S - scorpion stings
M - mumps
A - autoimmune (SLE, RA)
S - steroids
H - hypertriglyceridemia / hypercalcemia
E - ERCP
D - drugs
steroids, alcohol, valproic acid, azathioprine, diuretics
endoscopic retrograde cholangiopancreatography
Causes of chronic pancreatitis?
similar to acute
gallstones
slow growing tumour
long term alcohol use
autoimmune conditions
cystic fibrosis
hypertriglyceridemia / hypercalcemia
Symptoms of acute pancreatitis?
Epigastric pain that radiates to the back
→ eased by bending forward
Nausea & vomiting
Cullen sign & grey turner sign
severe: low bowel sounds / hypovolemic shock from liquid → 3rd space
Symptoms of chronic pancreatitis?
can be asymptomatic for a long time
epigastric pan → back
! exocrine & endocrine insufficiency !
= not enough insulin & other enzymes
→ px as fat malabsorption
= steatorrhea, fat soluble vitamin deficiency (A / D /E), diabetes, unintentional weight loss
Differentiate between acute vs chronic pancreatitis?
Acute = sudden abundance of enzymes
Chronic = lack of enzymes
Diagnostic criteria for acute pancreatitis?
2 of 3
acute epigastric pain → back
serum amylase or lipase levels
3x of normal
characteristic imaging findings
Imaging findings for acute pancreatitis?
usually ultrasound
Enlarged pancreas & hypoechoic
maybe - gallstone pancreatitis
if unsure = abdominal CT w/contrast
pancreatic necrosis, inflammation & retroperitoneal fluid
Which other condition could also raise serum amylase? How would you rule it out?
gastroduodenal perforation
use erect CXR!
Diagnostic features for chronic pancreatitis?
If tumour
bilirubin & alk phosphate +
= compression of duct
GOLD = 72 hour stool collection
for fat malabsorption
transabdominal ultrasound & CT scan = calcification of pancreas
also - ductal dilation, enlarge, fluid around
Pancreatic scoring systems - one to assess severity and one to predict severe attack?
APACHE II = severity
as early as 24 hrs after onset
Glasgow & Ranson = prognostic
predicts severe attack
only used 48hrs after onset
Treatment for acute pancreatitis?
Nil by mouth
Nasogastric tube w/ dietary supplements
Analgesia
IM pethidine / IV morphine !!!
Prophylactic antibiotics
beta lactams - cefuroxime / metronidazole to reduce risk of infected panc necrosis
Urinary catheter
drain of collections if needed
Treatment for chronic pancreatitis?
Lifestyle modifications
alcohol cessation, small non-fatty meals, lots of water
Supplementary pancreatic enzymes w/ PPI (help pass stomach)
Stomach pain = NSAIDs / opiates / TCA
TUC - gallstones, duct drainage, diabetes
Liver function tests on blood
What is a hepatic pattern? Causes?
raised transaminases = ALT & AST
= acute hepatitis = viral, immune, alcohol
Liver function tests on blood
What is a cholestatic pattern? Causes?
raised ALP & GGT
= biliary stasis or obstruction
= PSC, PBC, gallstone disease
What is primary biliary cholangitis?
autoimmune disease where T cells attack cells that line smaller bile ducts in liver → leakage of bile into blood and outside
Risk for PBC?
Women a lot more!!
> 50, median 65 yo
Genetic disposition = autoimmune diseases
→ autoimmune hepatitis, Sjogren’s syndrome
Antibodies associated with PBC?
Anti-mitochondrial antibodies AMA
= molecular mimicry
= non specific tho
in some: anti-gp210 & anti-sp100
If no tumour - cases of PBC?
= Secondary biliary cholangitis
→ tumour obstructing bile ducts
PBC symptoms?
**_hallmark = pruritus, fatigue_** pruritus = bile salts in skin
RUQ pain
hepatomegaly
xanthomas / jaundice / chronic liver disease
Investigations for PBC?
bloods = AMA 95%
bile in blood
LFT = raised ALP & GGT
if abnormal: 1st line = ultrasound
maybe biopsy - lymphocyte infiltrate, some have granulomas
Treatment for PBC?
1st = ursodeoxycholic acid UDCA 2nd = obeticholic acid OCA
for pruritus - colestyramine / naloxone (opioid)
GOLD = liver transplant
Complications for PBC?
cholesterol → xanthomas
when deposit in skin
joint pain & arthropathy
end = chronic liver disease & cirrhosis
What is primary sclerosing cholangitis?
immune mediated (T) fibrosis and inflammation of the bile duct epithelial cells
Risk factors for PSC?
men
autoimmune association = IBD!
both UC & crohn’s
Genetics - p-ANCA!! 80%
perinuclear anti-neutrophil cytoplasmic antibody
elevated IgM
Presentation for PSC?
Charcot’s triad for cholangitis
fever
RUQ pain
jaundice
Others
fatigue / hepatomegaly (from bilirubin!) / cirrhosis
Blood & urine results for PSC?
raised ALP & GGT
= enzymes in liver cells!
bilirubinuria, no urobilinogen!
bile flow obstructed
Diagnostic investigation for PSC? What will it show?
Endoscopic retrograde cholangiopancreatography ERCP
Shows
- *beaded apperance of the bile ducts** = bile duct strictures / dilatation
others: hepatic fibrosis, cholestasis
Treatment for PSC?
No effective meds
= liver transplant :<
Complications of PSC?
Portal hypertension & cirrhosis
Cholangiocarcinoma
if suspected = Ca 19.9 = marker
Treatment for ascending cholangitis?
IV antibiotics - cefotaxime / metronidazole → symptom resolve
Urgent ERCP - biliary drainage with sphincterectomy
→ remove stone, stent palcement
→ surgery for larger ones
Composition of bile?
Water, bile salts, bilirubin & fats + cholesterol
Function of gallbladder?
Stores bile produced by the liver
Name the bile ducts
- in the liver (individual & joined)
- in the gallbladder
- liver + gallbladder?
- pancreas?
Liver
R & L hepatic → common hepatic
Gallbladder = cystic duct
Common hepatic + cystic = common bile duct
Pancreas = pancreatic duct
What is cholelithiasis?
= gall stones
(lol)
Types of gallstones?
Cholesterol gallstones = 80%
Pigment gallstones
Mixed gallstones
Risk factors for formation of cholesterol gallstones
females, age >40, overweight
DM, high cholesterol diet
pregnancy (reduced gallbladder motility)
When do cholesterol stones form?
due to imbalance of bile
→ excess cholesterol
from cholesterol crystalisation
Risk factors for the formation of bile pigment stones?
Haemolysis = main
liver cirrhosis, sickle cell anaemia
When would pigment gallstones form? Composition?
imbalance of bile
→ too much bilirubin (main or calcium)
If biliary stasis / infection = brown
calcium bicarb, fatty acids etc
If blood disorder = black
calcium bilirubinate
What is biliary colic?
= constant pain associated with stone obstructing bile ducts
after fatty meals, n+v
may radiate over shoulder
= gallbladder contract against stones = compress cystic duct
What is cholecystitis?
Bacteria infecting an obstructed gallbladder
→ obstruction in cystic duct
= prevents gallbladder emptying
Presentation - acute cholecystitis?
basically obstruction + inflammatory component
RUQ pain + tenderness & guarding
+ Vomiting, fever and local peritonitis + raised WBC!
Murphy’s sign = gallbladder pain on deep breath
= NO jaundice
Differentiate biliary colic, cholecystitis & cholangitis?
(see pic)
Investigations - acute cholecystitis
Bloods
raised WBC & CRP → inflammation
raised serum bilirubin, ALP & ALT
Abdominal ultrasound = best for stones
thick walled, shrunken gallbladder
pericholecystic fluid
stones
Treatment for acute cholecystitis
Nil by mouth, IV fluids
Opiate analgesia
Antibiotics = Cefuroxime / ceftriaxone
→ bac = KEE
Laparoscopic cholecystectomy (remove) after a few days
What is ascending cholangitis? Does it affect the pancreas? or the liver?
= infection of obstructed common bile duct
→ liver bile cannot be excreted!
→ pancreatic fluid can still flow unobstructed :>
Presentation - ascending cholangitis?
Charcot’s triad for cholangitis
RUQ pain, deranged LFT (jaundice), fever - usually with rigors
dark urine, pale stools, itch
[rigors = shivering at high fever & chills]
Investigation & results for ascending cholangitis?
Bloods
+ neutrophil, ESR & CRP
+ bilirubin = bile duct obstruction
ALT > AST
Imaging
transabdominal ultrasound = 1st
→ dilatation of duct, ± obstruction
→ can miss distal cbd stones
Magnetic resonance cholangiography (MRC) = diagnostic (?)
General treatment for gallstones?
for pure cholesterol stones → increase bile salt content of bile
= oral ursodeoxycholic acid UDCA
Statins to lower cholesterol
Shock wave lithotripsy → shatter
Gallstone complications?
Biliary colic / acute cholecystitis
Empyema → gb filled with pus
- *carcinoma**
- *Mirizzi’s syndrome** - stone in gb presses on bile duct casing jaundice
Obstructive jaundice / cholangitis / pancreatitis
Liver cards
Physiology of alcoholic liver disease?
= liver cell damage
TNF-alpha release by Kupffer cells
Acetaldehyde
decrease NADH/NAD ratio
What is alcoholic hepatitis?
Infiltration by polymorphonuclear leucocyte & hepatocyte necrosis
- *→ Mallory bodies in hepatocytes**
- *→ Giant mitonchondria**
What is alcoholic fatty liver?
cells swollen with fat → steatosis
reversible!
no cell damage
stellate cells → collagen producing myofibroblast cells
Complications of alcoholic liver disease?
Liver cirrhosis
Wernicke’s encephalopathy
Drug to treat alcohol withdrawal?
Chlordiazepoxide (benzodiazepine)
→ esp if seizures / other symptoms
What is Wernicke’s encephalopathy? Presentation & prevention?
ataxia, confusion & nystagmus (uncontrolled repeated eye mvt)
= from alcohol withdrawal, 6-24hrs after last drink & lasts for a week
→ prevention = IV thiamine
→ tx = Thiamine + proper nutrition & fluids
What is cirrhosis?
= irreversible liver damage
→ fibrosis = activation of stellate cells & Kupffer cells (tissue macrophages)
Types of liver cirrhosis?
Micronodular
= <3mm, uniform involvement of liver
→ alcohol / biliary tract disease
Macronodular
= varying size
→ chronic viral hepatitis
Presentation - liver cirrhosis?
Hands
Leuconychia - white discolouration on nails
clubbing
palmar erythema
Dupuytren’s contracture - lump at base of fingers
Others
xanthelasma = yellow fat deposits under skin usually around eyelid
loss of body hair
hepatomegaly
ascites, oedema, bruising
How might you classify liver cirrhosis?
Child Pugh score
< 7 best
> 8 = risk of variceal bleeding
> 10 bad prognosis
predict mortality & need for liver transplant
Investigations of liver cirrhosis?
GOLD = liver biopsy
ultrasound / CT / MRI / Endoscopy
ALSO serum albumin & prothrombin time = best indicators of liver function (low & long = bad)
raised AST, ALT & creatinine
low Na+
Indicator for hepatocellular carcinoma?
Alpha-fetoprotein!
Treatment of liver cirrhosis?
Hep A & B vaccine
Reduce salt intake, alcohol abstinate
ultrasound every 6 months → hepatocellular carcinoma
avoid NSAID / aspirin
Drugs which may induce liver injury?
Antibiotics = main 30-40
flucloxacillin, TB drugs, erythromycin
CNS drugs
chiropromazine, carbamazepine
Analgesic - (just) Diclofenac
Immunosuppressant, GI drugs - PPI
Tx paracetamol overdose?
Activated charcoal
IV N-acetylcysteine
if rash = chlorphenamine
Aspirin overdose - features?
Respiratory alkalosis → hyper/o glycaemia
then early non specific warning features
Tx aspirin overdose?
Fluid & electrolyte replace - esp potassium
if severe metabolic acidosis = IV sodium bicarbonate
What is hereditary haemochromatosis?
Inherited disorder of iron metabolism = increased absorption
deposit into organs → fibrosis & organ failure
Genetics - hereditary haemochromatosis?
HFE gene mutation on chromosome 6
= auto recessive = most common
can also be auto dom
Other causes / differentials of hereditary haemochromatosis?
high intake of iron & chelating agents (ascorbic acid)
alcoholics
Present - hereditary haemochromatosis?
Men, middle aged
triad: bronze skin, hepatomegaly, DM
tiredness & arthralgia
Hypogonadism ± pituitary dysfunction → slate grey skin pigment, oedema
cardiac manifestations common (dilated cardiomyopathy)
(menstruation = protective)
Diagnosis of HH is based on?
Raised serum iron & ferritin → genetic testing
liver biochem often normal!
ECG / ECHO if needed
Tx - Hereditary Haemochromatosis?
Venesection - 3-4x / year
alt = chelation therapy = desferrioxamine
Testosteone replacement
Diet low in iron = tea coffe, red wine
First degree relative screen
What is Wilson’s disease?
Rare inherited disorder of biliary copper excretion
→ too much in liver & CNS
Genetical nature of Wilson’s disease?
Autosomal recessive
Gene on chromosome 13
Risk of Wilson’s disease?
Marrying first degree relatives (consanguinity)
Caucasians
family history
Presentation - Wilson’s disease?
Children = hepatic issues
hepatitis, cirrhosis, liver failure
Young adults = CNS → dementia
reduced memory
Kayser-Fleischer ring
copper deposition in cornea, greenish-brown pigment in corneoscleral junction
Tx Wilson’s disease?
Avoid food high in copper
liver, choco, nuts, mushrooms, shellfish (think brown!)
Lifelong chelating agent = penicillamine
SE rash, haematuria, renal, pancytopenia
Liver transplant if severe disease
Screen siblings
What s alpha-1-antitrypsin deficiency?
inherited auto recessive condition where neutrophil** **elastase is not inhibited
= lung (empyema) & liver (cirrhosis & hepatocellular carcinoma) affected
Presentation a-1a deficiency?
children = liver
cirrhosis, hepatitis, cholestatic jaundice
adults = respiratory
emphysema
Diag & tx - a-1a deficiency?
Serum aloha 1 antitrypsin LOW
no tx - symptom management & liver transplant only
Liver failure - what is it?
When liver loses the ability to regenerate / repair → decompensation
Features of acute hepatic failure?
Acute liver injury
+ encephalopathy
bleeding / deranged coagulation (INR > 1.5)
ascites / jaundice
→ in patient with previously normal liver
Histological presentation of hepatic failure?
Multiacinar necrosis involving a substantial part of liver
How might you reduce intracranial pressure?
IV mannitol
Hepatocellular carcinoma HCC - risk factors>
Males, Chinese
HBV & HCV carriers
alcoholic cirrhosis, non alcoholic fatty liver disease & haemochromatosis
Where & how can a hepatocellular carcinoma spread
via hepatic / portal veins
→ lymph nodes, bones & lungs
Tx - hepatocellular carcinoma?
Surgical resection of lesion
Cure = liver transplant
→ Prevent HBV infection
Cholangiocarcinoma - what is it? Risk?
cancer of the biliary tree
risk
parasitic worm infestation
biliary cysts
IBS! UC & Crohn’s
Tx cholangiocarcinoma?
Crap prognosis = 6 months
Liver transplant contraindicated
surgical rarely possible
Highest incidental sources for a secondary liver met?
= acc most common liver tumour
GI tract (portal veins)
breast
lung
Pancreatic adenocarcinoma - risk factors & incidences?
Males, > 60 years
smoking, alcohol
excess aspirin!
Diabetes, chronic pancreatitis
- *PRSS-1 mutation**
- *fam hx**
Incidental pancreatic tumours by region/
60% pancreatic head
25% body
15% tail
How might head of pancreas adenocarcinoma present?
painless obstructive jaundice - pale stools, dark urine
+ weight loss
How might body & tail of pancreas adenocarcinoma present?
Epigastric pain radiating to the back and relieved by sitting forward
How might you diagnose pancreatic adenocarcinoma?
Abdominal CT!!
(contrast to ultrasound = others)
Tx & prognostic, pancreatic adenocarcinoma?
5 year survival = 3%
Pancreato-duodectomy if fit & no mets + post op chemo
Palliative care
What is Gilbert syndrome?
Autosomal recessive disorder
= abnormal bilirubin processing in liver
Pathophysio of Gilbert?
Genetic defect → dysfunctional UGT enzyme which conjugates bilirubin
= recurrent episodes of unconjugated hyperbilirubinaemia + jaundice
precipitated by stressful events
What is Crigler-Najjar syndrome
autosomal recessive
= severe mutations in same gene as Gilbert = lack of UGT
= daily phototherapy / phenobarbital
Clinical features of Gilbert syndrome?
Asymptomatic until stressful event / illness
Jaundice → sclera!!
+ non specific symptoms
Events can be
fasting, haemolysis, physical exertion, stress, menses
Diagnosis & management - Gilbert syndrom?
Blood test = LFT = rise in unconjugated bilirubin
*** exclude haemolysis = FBC + reticulocyte count + film ***
no specific tx, patient education
