Liver & Idiot friends Flashcards
What are examples of pancreatic exocrine secretions?
Acinar cells release:
Amylase,
Lipase,
colipase,
phospholipase
proteases (trypsinogen, chymotrypsinogen)
What are examples of pancreatic endocrine secretions? What cells are responsible?
Endocrine component is in the form of the pancreatic islets of Langerhans
Alpha cell - glucagon
Beta cell - insulin
D cell - somatostatin
PP cells - pancreatic polypeptide
Enterochrommaffin cells - serotonin
What are causes of acute pancreatitis?
IGETSMASHED
Idiopathic Gallstones (60%) Ethanol (30%) Trauma Steroids Mumps Autoimmune Scorpion Venom Hyperlipidaemia ERCP Drugs (azathioprine, furosemide,corticosteroids)
How would acute pancreatitis present?
differential for anyone with upper abdo pain
gradual or sudden severe epigastric or central abdo pain that radiates to the back
- sitting forward may relieve
Anorexia, nausea and vomiting Tachycardia Fever Jaundice Dehydration Hypotension Abdominal guarding and tenderness
Cullen’s sign - periumbilical ecchymosis
Grey Turner’s sign - Left flank bruising
How would you investigate acute pancreatitis?
serum lipase/amylase - 3 times the upper limit of the normal
aspartate aminotransferase/alanine aminotransferase - 3x upper limit of normal
FBC - leucocytosis
CRP
haematocrit - indicator of severity
ABG
Abdo plain film
What can be used to assess severity of acute pancreatitis?
APACHE II (acute physiology and chronic health evaluation)
How would you manage acute pancreatitis?
Iv fluids Morhpine/fentanyl nutritional support supplementary oxygen ondansetron calcium gluconate magnesium sulfate insulin
with gall stones - cholecystectomy
ERCP
alcohol induced - counselling + alcohol withdrawal prophylaxis
infected pancreatic necrosis - IV abx (imipenem), catheter drainage, necrosectomy
What is a major concern for a patient with acute pancreatitis? What criteria would you look out for?
Systemic Inflammatory response syndrome (sepsis syndrome)
tachycardia > 90 bpm
tachypnoea > 20bpm
pyrexia >38 degrees
high white cell count
What are the causes of chronic pancreatitis?
long-term alcohol excess
chronic kidney disease
defects in trypsinogen gene
cystic fibrosis
autoimmune pancreatitis
trauma
recurrent acute pancreatitis
How does chronic pancreatitis present?
epigastric pain that bores through to the back (relieved by sitting forward)
exarcebated by alcohol
N&V
exocrine dysfunction - malabsorption, weight loss, diarrhoea, steatorrhoea, protein deficiency
endocrine dyfunction - diabetes
How would you investigate chronic pancreatitis?
blood glucose - glucose intolerance/diabetes
CT scan - pancreatic calcifications
Abdo USS -
Abdo Xray
how would you manage chronic pancreatitis?
analgesia
pancreatin + omeprazole
enteral feeding
octreotide
What are the functions of the liver?
Glucose and fat metabolism
Detox and excretion : bilirubin, ammonia, drugs/hormones/pollutants
Protein synthesis : albumin, clotting factors
Defence against infection : reticulo-endothelial system
What is ALT an indicator of?
found in high concentration within hepatocytes - useful marker of hepatocellular injury
What is ALP an indicator of?
concentrated in the liver, bile duct and bone tissues
often raised in liver due to increased synthesis in response to cholestasis
What could cause an isolated rise in ALP?
bony metastases/primary bone tumours
vit d deficiency
recent bone fractures
renal osteodystrophy
When would you review GGT? What is it an indicator of?
When ALP raised = review GGT
raised GGT = biliary epithelial damage and bile flow obstruction, also raised in response to alcohol and drugs such a phenytoin
raised GGT + ALP = highly suggestive of cholestasis
What is indicative of, if patient if jaundiced but ALT and ALP levels are normal?
isolated rise in bilirubin suggestive of pre-hepatic cause of jaundice
gilberts syndrome
hemolysis
If patient is jaundiced, but normal urine and normal stools? What does this mean?
Pre-hepatic cause
as unconjugated bilirubin is water-soluble and wont affect urine or stools
If patient is jaundiced, but dark urine and normal stools ? What does this mean?
hepatic cause
If patient has dark urine and pale stools? What does this mean?
post-hepatic (obstructive)
bile and pancreatic lipases can’t reach fat = steatorrhoea
What are some causes of decreased albumin?
liver disease e.g. cirrhosis
Inflammation triggering an acute phase response = reduced albumin production
Protein-losing enteropathies or nephrotic syndrome
What does the ALT/AST ratio show?
ALT>AST seen in chronic liver disease
AST>ALT seen in cirrhosis and acute alcoholic hepatitis
What is biliary colic? How would you describe it?
Pain associate with temporary obstruction of the cystic or common bile duct by a stone migrating from the gall bladder
Pain is of sudden onset, severe but constant and has a crescendo characteristic
What is cholecystitis?
gallbladder inflammation
What are some risk factors for gall stones?
- obesity and rapid weight loss
- diet high in animal fat and low in fibre
- diabetes mellitus
- contraceptive pill
- liver cirrhosis
- multiparity
- smoking
What are they types of gallstones? Which more common
Cholesterol gallstone (80%)
Bile pigment stones
What are the causes of cholesterol gallstones?
cholesterol crystallisation in bile which has an excess of cholesterol
- relative deficiency in bile salts and phospholipids
- excess cholesterol in diabetes or high cholesterol diet
other causes
- reduced gallbladder motility and stasis (pregnancy and diabetes)
What are the two types of bile pigment stones? What are they made up of?
Black - calcium bilirubinate and a network of mucin glycoproteins that interlace with salts such as calcium bicarbonate
Brown - calcium salts (calcium bicarbonate), fatty acids and calcium bilirubinate
How do gallstones present?
majority asymptomatic
biliary/gallstone colic - sudden onset pain, severe but constant and has a crescendo
related to over-indulgence of fatty food
normally mid-evening till early hours of morning
epigastrium pain - radiation to shoulder and right sub scapular
nausea and vomiting
What are the causes of cholecystitis?
gallstones - 95%, that completely obstruct the cystic duct
bile inspissation (dehydration)
bile stasis (trauma or severe systemic illness)
How would cholecystitis present?
continuous epigastric pain
severe localised right upper quadrant abdominal pain
tenderness, muscle guarding or rigidity
vomiting, fever and local peritonitis
How would you differentiate acute cholecystitis and biliary colic?
Inflammatory component of acute cholecystitis (local peritonitis, fever and raised WBC)
What would happen if a gallstone moved from the cystic duct to the common bile duct?
obstructive jaundice and cholangitis
How would you investigate cholecystitis?
RUQ USS - distended gallbladder, thickened gallbladder wall, gallstones, positive Murphy’s sign
FBC - elevated WBC
CRP - raised
LFTs - elevated Alk Phos, gamma-GT and bilirubin
How would you treat cholecystitis?
Abx - cefuroxime + metronidazole
NSAIDs - diclofenac
laparoscopic cholecystectomy
percutaneous cholecystostomy tube
How would you investigate suspected gallstones?
FBC - normal in simple biliary colic
LFTs - cholelithiasis = normal, choledocholithiasis = elevated alk phos, elevated bilirubin
Lipase and amylase - elevated in acute pancreatitis
Abdo USS
How would you treat gallstones?
cholecystectomy
ERCP
What is ascending cholangitis? What are its causes?
infection of the biliary tree
- common bile duct obstructed by gallstones
- benign biliary stricture following biliary surgery
- cancer of head of pancreas = bile duct obstruction
- parasites
How would ascending cholangitis present?
biliary colic fever with rigors jaundice RUQ pain Jaundice is cholestatic - dark urine, pale stools and skin may itch
How would you investigate ascending cholangitis?
FBC - wbc raised
Serum urea - raised in patients with severe disease
Serum creatinine - raised in patients with severe disease
ABG - metabolic acidosis
LFTs - hyperbilirubinaemia, raised serum transaminases and alk phos
CRP
blood culture
ERCP
Transabdominal USS
How would you manage ascending cholangitis?
IV tazobactam/imipenem
biliary decompression
lithotripsy
morphine sulfate
What is Mirizzi’s syndrome?
stone in gallbladder presses on bile duct causing jaundice
What are some causes of acute hepatitis?
Infection - viral (hepatitis A & E, herpes viruses), non-viral (leptospirosis, toxoplasmosis)
Non-infective - alcohol, durgs, toxins, pregnancy, autoimmune, hereditary metabolic
How does acute hepatitis present?
general malaise myalgia GI upset Abdo pain - RUQ with/without cholestatic jaundice tender hepatomegaly
How does chronic hepatitis present?
clubbing
palmar erythema
dupuytrens contracture
spider naevi
What are some causes of chronic hepatitis?
Infection (hep B/C)
Alcohol
Drugs
Autoimmine
Hereditary metabolic
What may misleading about LFTs in chronic hepatitis?
AST and ALT can be normal
compensated liver function can be maintained with cirrhosis
What is Hepatitis A? How is it spread? What are some risk factors?
It is an RNA, picorna virus
spread via faeco-oral route
RFs - shellfish, travellers and food handlers
How would Hep A present?
Viraemia - unwell (nausea, fever, malaise)
Jaundice
Urine dark and stools pale = intrahepatic cholestasis
hepatosplenomegaly
How would you diagnose Hep A?
IgM anti-hepatitis A virus
Transaminases - elevated
Bilirubin - elevated
Serum creatinine/urea - renal failure uncommon but well recognised with Hep A
How would you manage Hep A?
in unvaccinated people - normal immunoglobulin or hepatitis A vaccine
otherwise - supportive care
What is Hepatitis B? How is it transmitted?
DNA virus
blood borne transmission
What ways can Hep B be transmitted?
IV drug abuse Needle stick Tattoos Sexual Blood products IV drug abusers Mother to child in-utero
How would Hep B present?
Incubation 1-6 months
Viraemia - unwell, nausea, fever, malaise, anorexia and arthralgia
Rashes - urticaria, polyarthritis
after 1-2 weeks patients can become jaundiced
urine dark and stools pale = intrahepatic cholestasis
hepatosplenomegaly
How would you investigate Hep B?
HBsAg - appears 2-10 weeks after exposure
anti-HBs - appears several weeks after HBaAg - suggestive of resolved infection, also detectable in those immunised with HBV vaccine
anti-HBc (IgM + IgG) - detectable in all patients who have been exposed to HBV - best single test for screening household contacts of HBV- infected individiuals
How to manage Hepatitis B?
Supportive
Anti-viral (lamivudine/entecavir/tenofovir)
FOR CHRONIC - Peginterferon alfa 2a weekly
What is Hepatitis D? How is it spread?
incomplete RNA virus
requires HBV for assembly
Blood-borne transmission
Acquired simultaneously with HBV
What are some complications associated with Hep D?
superinfection - someone with chronic HBV gets Hep BD
- secondary acute hepatitis and increased rate of liver fibrosis progression
increase risk of fulminant hepatitis - VERY BAD
can result in chronic hepatitis = hepatocellular carcinoma
What is Hep C? How is it spread?
RNA flavivirus
transmitted by blood and blood products - common in haemophiliacs before screening of blood products was introduced
How would Hep C present?
most acute infections = asymptomatic
10% = mild influenza-like illness with jaundice and rise in ALT and AST
can lead to cirrhosis, liver failure and HCC
How would you investigate Hepatitis C?
enzyme immunoassay or hepatitis antibodies
nucleic acid amplification tests
serum aminotransferases
viral genotyping
How would you treat Hep C?
Anti-viral - elbasvir + grazoprevir
SC PEGylated interferon-alpha2A/B
What is cirrhosis?
End stage of all progressive chronic liver diseases - once fully developed is irreversible and may be associated clinically with symptoms and signs of liver failure and portal hypertension
What are some causes of cirrhosis?
Chronic alcohol abuse
non-alcoholic fatty liver disease
Hep B+/- D
Hep C
Primary biliary cirrhosis
Autoimmune hepatitis
Wilson’s
Alpha-antitrypsin deficiency
Drugs
What are the two types of cirrhosis? What are their causes?
Micronodular - regenerating <3mm in size - alcohol or biliary tract disease
Macronodular - varying size may be seen within larger noules - chronic viral hepatits
How would cirrhosis present?
Leucochynia - white discolourations on nails
Clubbing Palmar Erythema Dupuytrens contracture Spider naevi Xanthelasma Loss of body hair Hepatomegaly Bruising Ankle swelling and oedema
Abdo pain due to ascites
What is the the Child-Pugh classification of cirrhosis?
Ascites, encephalopathy, bilirubin, albumin and prothrombin = given 1-3 and added up
<7 is best and >10 is bad prognosis
Can be used to predict chance of variceal bleed, mortality and need for liver transplant
How would you investigate cirrhosis?
Liver Biopsy LFTs GGT Albumin PT platelet count antibodies to hepatitis C hepatitis B antigen
What are some complications associated with Cirrhosis?
Coagulopathy - fall in clotting factors II, VII, IX & X
Encephalopathy - liver flap, confusion/coma
Hypoalbuminaemia - oedema
Portal hypertension - ascites, oesophageal varices
How would you manage cirrhosis?
treatment of underlying chronic liver disease
monitoring of complications - abdo USS
Sodium restriction and diuretic for ascites
Liver transplantation
What are pre-hepatic causes of Portal Hypertension?
Portal Vein Thrombosis
Portal Vein occlusion (malignancy)
Primary Biliary Cirrhosis
What are some intra-hepatic causes portal hypertension?
cirrhosis (80%)
schistosomiasis
sarcoidosis
acute hepatitis
What are some post-hepatic causes of portal hypertension?
right heart failure
constrictive pericarditis
IVC obstruction
Budd-chiari
How would a patient with portal hypertension present?
hematemesis and melena from ruptured gastro-oesophageal varice
clubbing
palmar erythema
dupuytrens contracture
spider naevi
How would you manage a variceal haemorrhage?
resuscitate until hemodynamically stable
if anaemic = blood transfusion
Vit K + platelet transfusion
Vasopressin - IV terlipressin
Prophylatic Abx - cephalosporin
Variceal banding
Balloon tamponade to reduce bleeding
Transjugular intrahepatic portoclaval shunt (TIPS)
What is Primary Biliary Cirrhosis? What are some risk factors?
Chronic disorder with progressive destruction of small bile ducts, leading to cirrhosis
Fam Hx Many UTIs Smoking Past Pregnancy Use of nail polish/hair dye Other Autoimmune
How would someone with primary biliary cirrhosis present?
asymp normally pruritus lethargy and fatigue jaundice hepatomegaly pigmented xanthelasma
How would you investigate primary biliary cirrhosis?
increased alkaline phosphate
gamma-GT - elevated
bilirubin - elevated
antimitochondrial antibody immunofluorescence
liver biopsy
abdo USS - obstructive duct lesions must be excluded before PBC diagnosis
How would you treat primary biliary cirrhosis?
ursodeoxycholic acid
prednisolone
antipruritic - colestyramine
What would a liver biopsy show in PBC?
portal tract infiltrate, mainly of lymphocytes and plasma cells
granulomas
damage to and loss of small bile ducts and ductular proliferation
portal tract fibrosis and eventually cirrhosis
What are the stages of alcoholic liver disease?
Fatty Liver disease
Alcoholic hepatitis
Alcoholic cirrhosis
How would fatty liver, alcoholic hepatitis and alcoholic cirrhosis present?
Fatty liver - often no symptoms and signs, nausea, vomiting, diarrhoea
hepatomegaly
Alcoholic Hepatitis - patient may be well, mild to moderate symptoms of ill health, mild jaundice, signs of chronic liver disease, deranged LFTs
Alcoholic Cirrhosis - can be very well with a few symptoms, ascites, bruising, clubbing and dupuytrens
How would you investigate alcoholic liver disease?
AST, ALT - elevated
AST/ALT ratio - >2 seen in 70% of cases, ALT>AST suggests viral hep or non-alcoholic fatty liver
alk phos - elevated
bilirubin - elevated
gamma-gt - elevated
FBC
U&Es
hepatic USS
What are some hepatotoxic drugs?
Abx - augmentin, flucloxacillin, TB drugs, erythromycin
CNS drugs - chlorpromazine, carbamazepine
immunosuppresants
analgesic - diclofenac
GI drugs - PPIs
What is hereditary haemochromatosis?
inherited disorder of iron metabolism in which there is increased intestinal iron absorption - leads to iron deposition in joints, liver, heart, pancreas, pituitary, adrenals and skin
- leads to eventual fibrosis and functional organ failure
- most common signle gene disorder in caucasians
What is the cause of hereditary haemochromatosis?
HFE gene mutation on chromosome 6 - autosomal recessive
high intake of iron and chelating agents
alcoholics
What is the clinical presentation of haemochromatosis?
men more affected - no menstruation and increased dietary iron
tiredness and arthralgia
hypogonadism
slate-grey skin pigmentation
chronic liver disease - ascites, oedema, bruising
heart failure and arrythmias
What is the classic triad in haemochromatosis?
bronze skin pigmentation
hepatomegaly
diabetes mellitus
How would you investigate haemochromatosis?
serum transferrin saturation - >45%
serum ferritin - raised
How would you treat haemochromatosis?
avoid iron or iron containing supplements
hep A and B vaccination
phlebotomy
iron chelation - desferrioxamine
What is Wilson’s disease?
Disorder of biliary copper excretion with too much copper in the liver and CNS
Autosomal recessive disorder of gene chromosome 13
Occurs more often in cultures with consanguinity
What is the presentation of Wilson’s disease?
children with hepatic problems - hepatitis, cirrhosis and fulminant liver failure
young adults with CNS problems - tremor, dysarthria, involuntary movements, dysphagia, dyskinesia
reduced memory
Kayser-Fleischer ring - copper deposition in cornea - greenish-brown pigment
How would you investigate Wilson’s disease?
LFTs
24 hour urine copper
slit-lamp examination - Kayser-Fleischer rings
How would you treat Wilson’s disease?
Zinc
Trientine
Penicillamine
What are some signs of liver failure?
Hepatic Encephalopathy - confusion, coma, liver flap
Abnormal bleeding
Ascites
jaundice
What is fulminant hepatic failure?
Clinical syndrome resulting from massive necrosis of liver cells leading to severe impairment of liver function
What are risk factors for hepatocellular carcinoma?
HBV and HCV
Cirrhosis
Haemochromatosis
How would HCC present?
Weight loss
Anorexia
Fever Fatigue Jaundice Ache Ascites
Rapid development of these in cirrhotic patients = HCC
How would you investigate HCC?
alpha fetoprotein - elevated USS of liver FBC U&Es LFTs - elevated aminotransferases, alk phos and bilirubin prothrombin time
What are the components of the Barcelona clinic liver cancer?
Tumor function - number, size , vascular invasion
Liver function - portal htn, bilirubin
Chris-Pugh score
How would you manage HCC?
chemo
liver transplant
What are risk factors for cholangiocarcinomas?
Parasitic worms
Biliary cysts
Inflammatory bowel disease
Where are the most common liver mets from?
GI tract
Breast
Bronchus
What kind of cancers are pancreatic? Which part of the pancreas normally affected?
adenocarcinoma
exocrine component of pancreas normally affected
What are risk factors for pancreatic adenocarcinomas?
smoking alcohol aspirin diabetes chronic pancreatitis genetic mutation - PRSS-1 fam hx
How would a pancreatic cancer present?
Anorexia Weight loss diabetes Acute pancreatitis painless obstructive jaundice
epigastric pain that radiates to the back - relieved by sitting forward
