Liver & friends / GU Exam deck Flashcards
1
Q
What is an AKI?
A
Sudden decline in renal function over hours or days
2
Q
Risk factors for AKI?
A
age > 65, cognitive impair
CKD, nephrotoxic meds e.g. NSAIDs & ACE inhibitors
liver disease, diabetes
contrast medium in scans
3
Q
General present - AKI?
A
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
4
Q
Key criteria to classify stages of AKI?
A
KDIGO criteria
5
Q
Stage 1 of KDIGO criteria?
A
Serum creatinine
> 26.5
= 1.5-1.9x baseline
Urine output
< 0.5ml/kg/hr for 6-12 hours
6
Q
Stage 2 of KDIGO criteria?
A
Serum creatinine
> 2.0 - 2.9 baseline
Urine output
< 0.5 ml/kg/hr
for ≥ 12 hours
7
Q
Stage 3 of KDIGO ceriteria?
A
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
8
Q
Name 3 pre-renal causes of AKI?
A
= most common!
= secondary to inadequately low blood supply to kidneys
dehydration
hypotension
heart failure
9
Q
Name 3 renal causes of AKI?
A
intrinsic disease = reduced filtration of blood
Renal artery stenosis / thrombosis
glomerulonephritis
interstitial nephritis
acute tubular necrosis
10
Q
Name 3 post renal causes of AKI?
A
= due to obstruction to outflow of urine from kidney
kidney stones
masses - cancer in abdo or pelvis
ureter or uretral strictures
prostate cancer
11
Q
Investigations for AKI?
A
Urinalysis
(dipstick / microscope / osmo & electro)
leukocytes & nitrites = infect
protein & blood = acute nephritis
glucose = diabetes
Ultrasound
of uri tract to look for obstruction
12
Q
Management principles AKI?
A
Volume dysregulation (as per need)
Regulate electrolytes
severe hyperkalaemia !!!
metabolic acidosis !!!
Stop nephrotoxic drugs
ACEi, NSAIDs, Spironolactone
13
Q
How might you treat a severe hyperkalaemia?
A
= > 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
14
Q
List complications of AKI?
A
15
Q
Chronic kidney disease - what is it?
A
Presence of kidney damage / reduced kidney function for ≥ 3 months
16
Q
Features of CKD?
A
Reduced GFR
< 60 ml / min = G3a - G5
Increased ACR
> 3 mg / mmol = A2-3
17
Q
KDIGO staging for GFR?
A
G1 = > 90
G2 60-89
G3a 45-59
G3b 30-44
G4 15-29
G5 <15
18
Q
KDIGO staging for ACR?
A
- *A1** < 3
- *A2** 3-30
- *A3** > 30
19
Q
Risk factors for CKD?
A
DM, hypertension nephropathies glomerulopathies
inherited kidney disorders → PCKD
ischaemic nephropathy
obstructive uropathy / tubular diseases
20
Q
Symptoms of CKD?
A
generally asymptomatic in earlier
non specific later
watch albumin:urea & radio abnormalities - e.g. abdominal masses, polycystic kidneys
21
Q
Investigations fo CKD?
A
urine
ACR can be spot test or 24 hour collection! order both!
bloods
specifically - LFT, UE
imaging
renal ultrasound, ECG
22
Q
Management for CKD?
A
TUC, slow progress
Renoprotective therapy = BP control for everyone!
→ if ACR ≤ 30 (A1-2), follow NICE
→ if proteinuria = ARB / ACEi
23
Q
When should you offer a renin-angiotensin system antagonist to patients of CKD?
A
= one of is enough not fulfill all
Diabetic and ACR ≥ 3 mg / mmol
Hypertension and ACR > 30 mg / mmol
ACR > 70 mg / mmol
24
Q
Complications of CKD?
A
Anaemia
= normocytic, usually multifacorial but can be EPO deficient
Hyperkalaemia & acidosis
Mineral & bone disorders
25
Indicators for & types of renal replacement therapy?
Haemodialysis / peritoneal dialysis & renal transplant
= end stage renal disease
26
What is ADPKD?
Autosomal dominant polycystic kidney disease
= common genetic disorder characterised by multiple renal cysts
27
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)
28
Risk of PKD / Associated?
| (very important!)
Hepatic cysts
Cerebral aneurysms
**_Renal family history_**
→ ADPKD, ESRF, hypertension, CKD
29
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)
30
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
31
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**
32
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
33
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)
34
Genes & chromosomes for ARPKD?
PKHD1 mutation on chromo 6
35
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
36
Diagnosis for ARPKD
**_Prenatal ultrasound_**
bilateral large kidneys
cysts
oligohydramnios
**_Neonatal ultrasound_**
cysts
**_CT / MRI_** to monitor liver disease
37
Complications ARPKD?
**_Congenital Hepatic fibrosis_**
Portal hypertension
eso varices, UGB, haemorrhoids, splenomegaly
**_Dilated ducts_**
= cholestasis & ascending cholangitis
38
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**
39
Nephrolithiasis - what are they?
Solutes in urine precipitate out and crystallise
→ when urine is too concentrated (supersaturation) → precipitate out of solution
40
3 locations at which you may find deposited kidney stones?
- **pelviureteric junction \*\***
- pelvic brim
- vesicoureteric junction
41
Risk factors & epidemiology - kidney stones?
**peak 20 - 40 years, males**
**dehydration, infection**
**Drugs** - diuretics, antacids, corticosteroids, aspirin, allopurinol
**primary renal disease, gout, fam hx**
42
Most common type of kidney stones?
Calcium oxalate
43
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
44
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)
45
Only type of kidney stones which will **_not_** show up on x ray (& other features)?
**_Uric acid stones!_**
= reddish-brown in colour
= radiolucent
46
Risk factors for uric acid stones?
**_dehydration_**
**_Purine - rich diet_**
= shellfish, anchovies, red / organ meat
**_Gout_**
47
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
48
Risk factors of struvite stones?
**_UTI = main_**
vesicoureteral reflux
obstructive uropathies
49
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
50
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
51
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_
52
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
53
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
54
Prostate cancer - aetiology - genes responsible etc?
**Genes**
= **HOXB13** predispose
= **BRCA2** = 5-7 higher risk
age, black. fam hx
increased testosterone
55
Prostate cancer - Type & area arise
**Adenocarcinomas**
**Peripheral** **prostate**
Androgen receptors on prostate responsible for cancerous growth
56
How might prostate cancer spread?
**Local** → seminal vesicle, bladder & rectum
**Via lymph**
**Haematologically** - **bone**
less common to brain, liver & lung
57
Presentation for prostate cancer?
LUTs if local disease
Weight loss, bone pain & anaemia = mets
58
DRE exam for prostate cancer vs for BPH?
Prostate cancer - hard & lumpy
BPH - large, smooth & firm
59
Investigations for prostate cancer?
**DRE**
**Raised PSA**
if mets = \> 16ng/ml
DIAGNOSTIC = **trans-rectal ultrasound & biopsy**
essential to have histological diag, gleason score used
60
What's the PSA & why is it not routinely used as a screening test?
**Prostate specific antigen**
produce by prostate, in normal & neoplastic tissue
**Unreliable** testing bc
small BMI, taller, recent ejaculate, black african, UTI
61
Treatment for prostate cancer?
Radical prostatectomy
radio / hormone therapy
if mets
Endocrine therapu = androgen deprivation
→ **LHRH agonist**
SC goserelin / leuprorelin
→ **Androgen receptor blockers**
62
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
63
Testicular cancer - serum tumour markers?
* *Alpha-Fetoprotein (AFP) &**
* *B-hCG**
raised in teratomas (infant)
B-hCG in seminomas (adult)
64
Diagnosis & tx - testicular cancer?
Ultrasound
radiotherapy / orchidectomy / chemo
sperm storage
65
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
66
Renal cell carcinoma - complications?
Varicocele
Hypertension!
renin secreted by tumour
Fever
Anaemia, polycythaemia
67
Risk factors for renal cell carcinoma?
male, \> 50 years, Czech
obesity hypertension smoking
renal failure, polycystic kidneys
Von Hippel Lindau
68
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
69
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
70
Transitional cell carcinoma?
= cell type in epithelium which lines calyx, renal pelvis, ureter, bladder & urethra
**bladder-c** is the most common tcc!!
71
Bladder cancer - cell type & spread? ;)
**Transitional cell carcinoma**
**Spread**
local → pelvic structures
lymphatic → iliac & para aortic nodes
haematogenous → liver & lungs
72
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
73
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
74
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!
75
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
76
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
77
5 primary causative organisms of UTI? (mneumonic)
KEEPS
Klebsiella spp.
E coli
Enterococci
Proteus spp.
Staphylococcus spp.
78
Cystitis in uncomplicated females
1st line tx?
2nd line tx?
1st = Nitrofuratoin / Trimethoprim
3 days
2nd = Nitro / Pivmecillinam / fosfomycin
79
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
80
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
81
Cystitis in men
tx?
1st line = trimethoprim or nitrofurantoin
No improve - think pyelonephritis / prostatitis
82
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
83
Chlamydia tx?
Oral azithromycin stat
OR 1 week oral doxycycline
**if preg**
oral erythromycin 14d
oral azithromycin stat
patient education
contact tracing
84
Gonorrhea tx?
IM ceftriaxone with oral azithromycin
partner notification
patient education
contact tracing
85
Free card
86
Main pancreatic enzymes? Produced by which cell type?
Amylase
Trypsin / chymotrypsin
Lipase
→ Pancreatic acinar cells
87
Endocrine component of the pancreas? Cell types?
Alpha cell = glucagon
Beta cell = insulin
D cell = somatostatin
PP cells = pancreatic polypeptide
Enterochromaffin cells = serotonin
88
Pancreatitis - pathophysiology?
**Trypsin & chymotrypsin** gets suddenly activated within the pancreas
= **autodigestion of pancreas**
→ inflammation & haemorrhaging
| (normally need to be activated by enteropeptidase in duodenum)
89
Which pancreatic enzymes are secreted in their active forms & don't need activation by trypsin?
Lipase & amylase
90
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
91
Causes of chronic pancreatitis?
**_similar to acute_**
gallstones
slow growing tumour
**long term alcohol use**
**autoimmune conditions**
cystic fibrosis
**hypertriglyceridemia / hypercalcemia**
92
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
93
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
94
Differentiate between acute vs chronic pancreatitis?
Acute = sudden abundance of enzymes
Chronic = lack of enzymes
95
Diagnostic criteria for acute pancreatitis?
2 of 3
acute epigastric pain → back
serum amylase or lipase levels
3x of normal
characteristic imaging findings
96
Imaging findings for acute pancreatitis?
usually **_ultrasound_**
Enlarged pancreas & hypoechoic
maybe - gallstone pancreatitis
if unsure = **_abdominal CT w/contrast_**
pancreatic necrosis, inflammation & retroperitoneal fluid
97
Which other condition could also raise serum amylase? How would you rule it out?
gastroduodenal perforation
use erect CXR!
98
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
99
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
100
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
101
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
102
Liver function tests on blood
What is a hepatic pattern? Causes?
raised transaminases = ALT & AST
= acute hepatitis = viral, immune, alcohol
103
Liver function tests on blood
What is a cholestatic pattern? Causes?
raised ALP & GGT
= biliary stasis or obstruction
= PSC, PBC, gallstone disease
104
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
105
Risk for PBC?
Women a lot more!!
\> 50, median 65 yo
**Genetic disposition = autoimmune diseases**
→ autoimmune hepatitis, Sjogren's syndrome
106
Antibodies associated with PBC?
**Anti-mitochondrial antibodies AMA**
= molecular mimicry
= non specific tho
in some: **anti-gp210 & anti-sp100**
107
If no tumour - cases of PBC?
= Secondary biliary cholangitis
→ tumour obstructing bile ducts
108
PBC symptoms?
```
**_hallmark = pruritus, fatigue_**
pruritus = bile salts in skin
```
RUQ pain
hepatomegaly
xanthomas / jaundice / chronic liver disease
109
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
110
Treatment for PBC?
```
1st = ursodeoxycholic acid UDCA
2nd = obeticholic acid OCA
```
for pruritus - colestyramine / naloxone (opioid)
**GOLD** = liver transplant
111
Complications for PBC?
**cholesterol → xanthomas**
when deposit in skin
**joint pain & arthropathy**
end = **chronic liver disease & cirrhosis**
112
What is primary sclerosing cholangitis?
immune mediated (T) **fibrosis and inflammation of the bile duct epithelial cells**
113
Risk factors for PSC?
**men**
**autoimmune association = IBD!**
both UC & crohn's
**Genetics - p-ANCA!! 80%**
perinuclear anti-neutrophil cytoplasmic antibody
**elevated IgM**
114
Presentation for PSC?
**Charcot's triad for cholangitis**
fever
RUQ pain
jaundice
Others
fatigue / hepatomegaly (from bilirubin!) / cirrhosis
115
Blood & urine results for PSC?
**raised ALP & GGT**
= enzymes in liver cells!
**bilirubinuria, no urobilinogen!**
bile flow obstructed
116
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
117
Treatment for PSC?
No effective meds
= liver transplant :\<
118
Complications of PSC?
Portal hypertension & cirrhosis
**_Cholangiocarcinoma_**
if suspected = Ca 19.9 = marker
119
Treatment for ascending cholangitis?
**IV antibiotics - cefotaxime / metronidazole** → symptom resolve
**Urgent ERCP - biliary drainage with sphincterectomy**
→ remove stone, stent palcement
→ surgery for larger ones
120
Composition of bile?
Water, bile salts, bilirubin & fats + cholesterol
121
Function of gallbladder?
Stores bile produced by the liver
122
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
123
What is cholelithiasis?
= gall stones
| (lol)
124
Types of gallstones?
Cholesterol gallstones = 80%
Pigment gallstones
Mixed gallstones
125
Risk factors for formation of cholesterol gallstones
females, age \>40, overweight
DM, high cholesterol diet
pregnancy (reduced gallbladder motility)
126
When do cholesterol stones form?
due to imbalance of bile
→ excess cholesterol
from cholesterol crystalisation
127
Risk factors for the formation of bile pigment stones?
Haemolysis = main
liver cirrhosis, sickle cell anaemia
128
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**
129
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
130
What is cholecystitis?
Bacteria infecting an obstructed gallbladder
→ obstruction in _cystic duct_
= prevents gallbladder emptying
131
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_
132
Differentiate biliary colic, cholecystitis & cholangitis?
(see pic)
133
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
134
Treatment for acute cholecystitis
Nil by mouth, IV fluids
Opiate analgesia
**Antibiotics = Cefuroxime / ceftriaxone**
→ bac = KEE
**Laparoscopic cholecystectomy** (remove) after a few days
135
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 :\>
136
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]
137
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 (?)
138
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
139
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**
140
Liver cards
141
Physiology of alcoholic liver disease?
= liver cell damage
TNF-alpha release by Kupffer cells
Acetaldehyde
decrease NADH/NAD ratio
142
What is alcoholic hepatitis?
Infiltration by polymorphonuclear leucocyte & hepatocyte necrosis
* *→ Mallory bodies in hepatocytes**
* *→ Giant mitonchondria**
143
What is alcoholic fatty liver?
cells swollen with fat → steatosis
**_reversible_**!
no cell damage
**stellate cells → collagen producing myofibroblast cells**
144
Complications of alcoholic liver disease?
Liver cirrhosis
Wernicke's encephalopathy
145
Drug to treat alcohol withdrawal?
Chlordiazepoxide (benzodiazepine)
→ esp if seizures / other symptoms
146
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
147
What is cirrhosis?
= irreversible liver damage
→ fibrosis = activation of stellate cells & Kupffer cells (tissue macrophages)
148
Types of liver cirrhosis?
**Micronodular**
= \<3mm, uniform involvement of liver
→ alcohol / biliary tract disease
**Macronodular**
= varying size
→ chronic viral hepatitis
149
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
150
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
151
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+
152
Indicator for hepatocellular carcinoma?
Alpha-fetoprotein!
153
Treatment of liver cirrhosis?
Hep A & B vaccine
Reduce salt intake, alcohol abstinate
ultrasound every 6 months → hepatocellular carcinoma
avoid NSAID / aspirin
154
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
155
Tx paracetamol overdose?
Activated charcoal
IV N-acetylcysteine
if rash = chlorphenamine
156
Aspirin overdose - features?
Respiratory alkalosis → hyper/o glycaemia
then early non specific warning features
157
Tx aspirin overdose?
Fluid & electrolyte replace - esp potassium
if severe metabolic acidosis = IV sodium bicarbonate
158
What is hereditary haemochromatosis?
Inherited disorder of iron metabolism = **increased absorption**
deposit into organs → fibrosis & organ failure
159
Genetics - hereditary haemochromatosis?
HFE gene mutation on **chromosome 6**
**=** auto recessive = most common
can also be auto dom
160
Other causes / differentials of hereditary haemochromatosis?
high intake of iron & chelating agents (ascorbic acid)
alcoholics
161
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)
162
Diagnosis of HH is based on?
Raised serum iron & ferritin → genetic testing
liver biochem often normal!
ECG / ECHO if needed
163
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
164
What is Wilson's disease?
Rare inherited disorder of biliary copper excretion
→ too much in liver & CNS
165
Genetical nature of Wilson's disease?
Autosomal recessive
Gene on chromosome 13
166
Risk of Wilson's disease?
Marrying first degree relatives (consanguinity)
Caucasians
family history
167
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
168
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
169
What s alpha-1-antitrypsin deficiency?
inherited auto recessive condition where **_neutrophil**_ _**elastase_** is not inhibited
= **lung** (empyema) & **liver** (cirrhosis & hepatocellular carcinoma) affected
170
Presentation a-1a deficiency?
children = liver
cirrhosis, hepatitis, cholestatic jaundice
adults = respiratory
emphysema
171
Diag & tx - a-1a deficiency?
Serum aloha 1 antitrypsin LOW
no tx - symptom management & liver transplant only
172
Liver failure - what is it?
When liver loses the ability to regenerate / repair → decompensation
173
Features of acute hepatic failure?
**Acute liver injury**
+ **encephalopathy**
**bleeding** / **deranged** **coagulation** (INR \> 1.5)
**ascites / jaundice**
→ in patient with previously normal liver
174
Histological presentation of hepatic failure?
Multiacinar necrosis involving a substantial part of liver
175
How might you reduce intracranial pressure?
IV mannitol
176
Hepatocellular carcinoma HCC - risk factors\>
Males, Chinese
HBV & HCV carriers
alcoholic cirrhosis, non alcoholic fatty liver disease & haemochromatosis
177
Where & how can a hepatocellular carcinoma spread
via hepatic / portal veins
→ lymph nodes, bones & lungs
178
Tx - hepatocellular carcinoma?
Surgical resection of lesion
**Cure = liver transplant**
→ Prevent HBV infection
179
Cholangiocarcinoma - what is it? Risk?
cancer of the biliary tree
_risk_
parasitic worm infestation
biliary cysts
**IBS! UC & Crohn's**
180
Tx cholangiocarcinoma?
Crap prognosis = 6 months
Liver transplant _contraindicated_
surgical rarely possible
181
Highest incidental sources for a secondary liver met?
= acc most common liver tumour
## Footnote
**GI tract (portal veins)**
**breast**
**lung**
182
Pancreatic adenocarcinoma - risk factors & incidences?
**Males, \> 60 years**
smoking, alcohol
excess aspirin!
Diabetes, chronic pancreatitis
* *PRSS-1 mutation**
* *fam hx**
183
Incidental pancreatic tumours by region/
**60% pancreatic head**
25% body
15% tail
184
How might head of pancreas adenocarcinoma present?
painless obstructive jaundice - pale stools, dark urine
+ weight loss
185
How might body & tail of pancreas adenocarcinoma present?
Epigastric pain radiating to the back and relieved by sitting forward
186
How might you diagnose pancreatic adenocarcinoma?
Abdominal CT!!
| (contrast to ultrasound = others)
187
Tx & prognostic, pancreatic adenocarcinoma?
5 year survival = 3%
Pancreato-duodectomy if fit & no mets + post op chemo
Palliative care
188
What is Gilbert syndrome?
Autosomal recessive disorder
= abnormal bilirubin processing in liver
189
Pathophysio of Gilbert?
Genetic defect → dysfunctional UGT enzyme which conjugates bilirubin
**= recurrent episodes of unconjugated hyperbilirubinaemia + jaundice**
precipitated by stressful events
190
What is Crigler-Najjar syndrome
autosomal recessive
= severe mutations in same gene as Gilbert = **lack of UGT**
**= daily phototherapy** / **phenobarbital**
191
Clinical features of Gilbert syndrome?
Asymptomatic until stressful event / illness
**Jaundice** → sclera!!
+ non specific symptoms
_Events can be_
fasting, haemolysis, physical exertion, stress, menses
192
Diagnosis & management - Gilbert syndrom?
**Blood test = LFT** = rise in unconjugated bilirubin
\*\*\* exclude haemolysis = FBC + reticulocyte count + film \*\*\*
no specific tx, patient education
