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Liver and Friends > Red PTS > Flashcards

Red PTS Flashcards

1
Q

What is pancreatic cancer?

A

primary pancreatic ductal adenocarcinoma, which accounts for >85% of all pancreatic neoplasms. These adenocarcinomas usually affect the head of the pancreas, but sometimes the body and tail. Some are multifocal.

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2
Q

What are the risk factors for pancreatic cancer?

A

Old age (60+), smoking, obesity, T2DM, FHx, Chronic Pancreatitis

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3
Q

What is the pathophysiology of pancreatic cancer?

A

Adenocarcinoma typically in the head of the pancreas and can compress bile ducts
Pancreatic cancer develops from pre-invasive pancreatic intraepithelial neoplasia, which can eventually become an invasive ductal adenocarcinoma.

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4
Q

What is the presentation for pancreatic cancer?

A
  • Obstructive/Painless Jaundice,
  • pale stools
  • dark urine
  • generalized itching (pruritus)
  • weight loss
  • worsening of T2DM (or new onset)
  • Yellow skin
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5
Q

What is Courvoisier’s Sign?

A

A type of presentation of Pancreatic cancer
palpable gallbladder + jaundice
Can get epigastric pain that radiates to back (body and tail)

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6
Q

What is the gold standard investigation for pancreatic cancer?

A

CT of pancreas (identifies mass and helps with staging of cancer)

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7
Q

What other investigations can be done for pancreatic cancer?

A

Abdominal ultrasound
Tumour marker – Ca19-9 not diagnostic but helps with monitoring progression
Staging CT scan
MRCP - assess billiary system
ERCP - used to put a stent in and relieve obstruction - also obtain biopsy from the tumour
LFTs

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8
Q

What is the treatment for pancreatic cancer?

A

Surgery to remove tumour – Whipple procedure (pancreaticoduodenectomy + others)
Chemo/Radiotherapy

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9
Q

Complications for pancreatic cancer?

A
  • Venous Thromboembolism (VTE):pancreatic adenocarcinoma is thrombogenic and patients are at increased risk of DVT and PE
  • New-onset diabetes mellitus:reduced endocrine function due to cancer growth, as well as surgical resection
  • Cholangitis:obstruction of biliary drainage due to a head of pancreas cancer predisposes to biliary tree infection
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10
Q

What can happen in pancreatic cancer?

A

Once a tumour in the head of the pancreas grows large enough it can compress the bile ducts, resulting in obstructive jaundice.

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11
Q

Average survival for pancreatic cancer?

A

6 months with advanced disease

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12
Q

Referral for pancreatic cancer

A

Over 40 with jaundice – referred on a 2 week wait referral
Over 60 with weight loss plus an additional symptom (see below) – referred for a direct access CT abdomen

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13
Q

Different surgeries for pancreatic cancer

A

Total pancreatectomy
Distal pancreatectomy
Pylorus-preserving pancreaticoduodenectomy (PPPD) (modified Whipple procedure)
Radical pancreaticoduodenectomy (Whipple procedure)

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14
Q

What is the Whipple procedure?

A

surgical operation to remove a tumour of the head of the pancreas that has not spread. A Whipple procedure is a massive operation so patients need to be in good baseline health. It involves the removal of the:

Head of the pancreas
Pylorus of the stomach
Duodenum
Gallbladder
Bile duct
Relevant lymph nodes

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15
Q

2 types of primary liver cancer:

A

Primary liver cancer is cancer that originates in the liver.
hepatocellular carcinoma (80%) and cholangiocarcinoma (20%).

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16
Q

Secondary liver cancer

A

originates outside the liver and metastasises to the liver. Metastasis to the liver can occur in almost any cancer that spreads. There is a poor prognosis of any cancer with liver metastasis.

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17
Q

Risk factors for HCC

A

Liver cirrhosis due to:
Viral hepatitis (B and C)
Alcohol
Non alcoholic fatty liver disease
Other chronic liver disease

18
Q

What is cholangiocarcinoma assosciated with?

A

primary sclerosing cholangitis. However, only 10% of patients with cholangiocarcinoma had primary sclerosing cholangitis

Cholangiocarcinoma usually presents in patients > 50 years old unless related to primary sclerosing cholangitis.

19
Q

Who are most likely to get hepatocellular carcinoma?

A

Males (90%)

20
Q

Pathophysiology of hepatocellular carcinoma

A

Arise from liver parenchyma
It can metastasise via the hepatic or portal veins to the lymph nodes, bones and lungs

21
Q

Presentation of hepatocellular carcinoma

A

Liver: Jaundice, Ascites, HE, Pruritus
Non-specific symptoms: Weight Loss, Fatigue, Weakness, N+V

22
Q

Diagnosis and investigations for HCC?

A

1st Line: Abdominal Ultrasound
CT to confirm (GOLD STANDARD)
Serum Alpha-Fetoprotein (AFP) = tumour marker for HCC
CT and MRI

23
Q

HCC treatment

A

Poor prognosis unless diagnosed early
Resection of early disease in resectable area of liver can be curative
Liver transplant when HCC is isolated to liver can be curative

24
Q

Drugs used in HCC

A

Several kinase inhibitors:
work by inhibiting the proliferation of cancer cells. Some examples of these are sorafenib, regorafenib and lenvatinib. They can potentially extend life by months.

25
Q

What is HCC considered as?

A

resistant to chemo and radiotherapy. In certain circumstances they are used as part of palliative treatment or clinical trials.

26
Q

What are the causes of cholangiocarcinoma?

A
  • Liver Fluke Infections,
  • Chronic Viral Hep B/C,
  • Liver Cirrhosis,
  • Biliary Cysts
27
Q

What is the pathophysiology of cholangiocarcinoma?

A

Arise from biliary tree – usually adenocarcinomas

28
Q

Presentation of cholangiocarcinoma

A

Signs of cholestasis(impaired bile prod/secretion)
Jaundice, Pale Stools, Dark Urine, Weight Loss, Fatigue, Weakness, N+V Pruritus + Courvoisier’s Sign
Cholangiocarcinoma often presents with painless jaundice in a similar way to pancreatic cancer.

29
Q

Diagnosis and investigations for cholangiocarcinoma?

A

1st line – Abdominal Ultrasound and CT
ERCP – used to take biopsies - Gold Standard
CA19-9 – Tumour marker for Cholangiocarcinoma LFTs – raised bilirubin and ALP
MRCP - GS

30
Q

Treatment of cholangiocarcinoma

A

Cholangiocarcinomas have a very poor prognosis unless diagnosed very early. Early disease can potentially be cured with surgical resection.

ERCP can be used to place a stent in the bile duct where the cholangiocarcinoma is compressing the duct. This allows for drainage of bile and usually improves symptoms.

Cholangiocarcinoma is also generally considered resistant to chemo and radiotherapy.

31
Q

Pathophysiology of paracetamol overdose:

A

A pathway:
95%: P is conjugated with glucoronide sulfates to paracetamol conjugates> excretion in urine
5%: Paracetamol metabolised by CYP450 TO NAPQI> which is toxic > this is conjugated to glutathione which is non toxic and excreted in urine > if not NAPQI is hepatotoxic

B pathway:
Too much P > stores run out so no more glucuronide sulfates so forced to go down toxic pathway > so much NAPQI glutathione stores run out - get hepatotoxicity

32
Q

Presentation of paracetamol overdose

A
  • Sudden Onset Severe RUQ Pain
  • N + V
  • Jaundice
  • Confusion
  • Anorexia
33
Q

Diagnosis and investigations for paracetamol overdose:

A

Based off History
LFTs – ALT raised
Serum Paracetamol Concentration

34
Q

Treatment of paracetamol overdose

A

Acetylcysteine – give straight away – replenishes glutathione Activated Charcoal – helps absorb any paracetamol in the stomach

35
Q

What is Gilbert’s syndrome?

A

Liver’s ability to metabolize bilirubin is affected

36
Q

Cause of Gilbert’s syndrome?

A

Autosomal Recessive inheritance of UGT1A1 Gene
Males, FHx, Post-Pubertal Age

37
Q

Pathophysiology of Gilbert’s syndrome

A

1.Normal RBC breakdown
2.Reduced conjugation
3.Accumulation of bilirubin in blood
4. = JAUNDICE

38
Q

Presentation of Gilbert’s syndrome

A

Painless Jaundice (especially under physical/psychological stress)

39
Q

Diagnosis and investigations of Gilbert’s syndrome

A

Blood Tests – raised unconjugated bilirubin LFTs – Normal

40
Q

Treatment of Gilbert’s syndrome

A

None

Liver and Friends (17 decks)

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