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Stones in common bile duct + ascending acute cholangitis Flashcards

1
Q

What is acute cholangitis

A

Infection of the biliary tree + most often occurs secondary to common bile duct obstruction by gallstones

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2
Q

What causes stones in common bile duct

A
  1. Benign biliary structures following biliary surgery
    2 .Cancer of the pancreatic head = bile duct obstruction
  2. In far east + mediterranean biliary parasites can cause blockage and ascending/acute cholengitis
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3
Q

Clinical presentation of acute cholangitis

A
  1. Biliary colic
  2. Fever (rigors), Jaundice (proceeded by abdominal pain), right upper quadrant pain - may not alway see present
  3. CHolestatic jaundice (dark urine, pale stools and skin may itch)
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4
Q

What should show in blood tests for acute cholangitis

A
  1. ELEVATED neutrophil count
  2. Raised ESR and CRP
  3. Raised serum bilirubin - bile duct obstruction if very high
  4. Raised serum alkaline phosphatase
  5. Aminotransferase levels are elevated (ALTs are higher than ASTs normally)
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5
Q

What would show up in a transabdominal ultrasound for cholangitis

A
  1. Initial imaging choice
  2. Dilatation of common bile duct
  3. Mar or may not show cause of obstruction
  4. Distal common bile duct stones are easily missed
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6
Q

What would a Magnetic Resonance Cholangiography show for cholangitis

A
  1. Shows biliary, common bile duct stones and dilated ducts
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7
Q

Why do we use a CT to check for cholangitis

A
  1. Excludes pancreatic carcinomas

2. Easy to spot pigmented stones

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8
Q

How is cholangitis treated

A 
IV antibiotics (CEFOTAXIMME, METRONIDAZOLE)
Urgent biliary drainage using ERCP or spincterectomy
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9
Q

What is sphincterectomy

A

Cutting off biliary sphincter
Remove stones
crushing stones
stent placement

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10
Q

How long do we give patients with cholangitis IV antibiotics for

A

Until symptoms resolved (after biliary drainage)

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11
Q

When is surgery done for cholangitis

A

Large stones

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12
Q

Gallstones in gallbladder vs bile duct

A
  1. Biliary pain in GB and BD
  2. Cholecystitis in GB not BD
  3. Obstructive Jaundice in GB and BD
  4. Cholangitis not in GB but in BD
  5. Pancreatitis not in gallbladder but is in bile duct
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13
Q

Gallstone Compications in gallbladder + cystic duct

A
  1. Biliary colics
  2. Acute cholecystitis
  3. Empyema
  4. Mirizzi’s syndrome
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14
Q

What is Empyema

A

Gallbladder fills with puss

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15
Q

What is hepatitis

A

Inflammation of the liver

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16
Q

What define acute hepatitis

A

Within 6 months onset

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17
Q

What defines chronic hepatitis

A

Hepatitis lasting longer than 6 months

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18
Q

Symptoms of acute hepatitis

A
  1. Malaise
  2. Myalgia (muscle pain)
  3. GI upset
  4. Abdominal pain - right upper quadrant
  5. With/without cholestatic jaundice
  6. Tender hepatomegaly

Raised bilirubin

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19
Q

What causes acute hepatitis

A
  1. Viral: Hep A + E
    Herpesvirus
  2. Non-viral (Leptospirosis, toxoplasmosis, coxiella)
  3. Alcohol
  4. Drugs
  5. Toxins
  6. Pregnancy
  7. Autoimmune
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20
Q

Is chronic hepatitis symptomatic

A

can be

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21
Q

Signs of chronic liver disease

A
  1. Clubbing
  2. Palmar erythema
  3. Dupuytren’s contracture
  4. Spider naevi
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22
Q

What is Dupuytren’s contracture

A

One or more fingers bending into palm of the hand

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23
Q

Level of LFTs in the blood in chronic liver disease

A

AST and ALT normal

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24
Q

Can liver function be maintained during cirrhosis

A

Yes

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25
What happens if fibrosis is too severe
``` Jaundice Ascites Low albumin Coagulopathy Encephalopathy ```
26
Complications of Chornic hepatitis
Hepatocellular carcinoma Portal hypertension (varices + bleeding)
27
Causes of chronic hepatitis
Infection: 1. Hepatitis B/C Non-Infective: 1. Alcohol 2. Drugs 3. Autoimmune 4. Hereditary metabolic
28
Where is Hep A most common
Africa and South A
29
What time of the year does Hep A commonly occur
Autumn and affects children + young adults
30
How does Hep A occur
Ingestion of contaminated food or water (shellfish) Overcrowding or poor sanitation facilitate spread
31
How does Hep A spread
Faeco-Oral route
32
What virus causes Hep A
Picornavirus
33
Where does Picornavirus replicated
Liver
34
Where is Picornavirus excreted
Bile -> faeces about 2 weeks before onset of clinical ullness
35
When is Hep A maxmillay infectious
JUST BEFORE jaundice
36
Incubation period of Hep A
2-6 weeks
37
What does Hep A cause
Acute Hepatitis
38
How long is Hep A self-limiting for
3-6 weeks
39
Does acute hepatitis commonly cause fulminant hepatitis
No - RARE
40
What is fulminant hepatitis
Hepatitis that causes wick liver failure 100% immunity after infection n
41
Clinical presentation of Hep A
1. Viraemia causes patients to feel unwell, nausea, fever, malaise 2. Jaundice 3. Hepatosplenomegaly 4. Jaundice sessions after 6 weeks
42
How long does it take for patients to go jaundiced after have Hep A
1-2 weeks - symptoms often improve
43
Is Hep A jaundice common in children
No
44
How does jaundice effect symptoms seen in Hep A
Urine become darks Stool becomes pale Due to INTRAHEPATIC CHOLESTASIS
45
Differential diagnosis of Hep A
1. Jaundice | 2. Drug-induced hepatitis
46
How do we diagnose Hep A in the prodromal stage (Between initial symptoms + jaundice)
1. Serum bilirubin normal 2. Bilirubinuria + raised urinary urobilinogen 3. Raised serum AST or ALT
47
How do we diagnose Hep A in the Icteric stage (once jaundice has presented)
Serum bilirubin levels
48
Blood test result in Hep A
Lecupenia (reduced WBC) | Raised ESR
49
Viral markers seen in hep A
HAV antibodies Anti-HAV IgM
50
Prognosis of Hep A
Good
51
How is Hep A Treated
Avoid alcohol Monitor liver function to spot fulminant hepatic failure Manage close contacts by giving normal immunoglobulins for hep A
52
How is Hep A prevented
1. . Good hygiene 2. Resistant to chlorination but not boring water 3. Active immunisation
53
What virus is Hep E
RNA
54
What hepatitis does HEV cause
ACUTE only
55
Where is Hep E common
Indochina
56
What people does Hep E effect
Older men
57
When is mortality from Hep E high
Pregnancy
58
How does Hep E spread
Falco-Oral route of transmission
59
What can acute hepatitis caused by Hep E resulting
Fulminant hepatitis
60
Serology of Hep E
Similar to Hep A
61
How is Hep E treated
Vaccines HEV RNA to detect chronic infection
62
How is Hep E prevented
Good sanitation
63
How is Hep B caused
1. Tattoos 2. needles 3. Sexual 4. Blood products 5. IV drug abusers 6. Vertical transmission (mother to child
64
Where is horizontal transmission common
Children through minor abrasions or close contact with other children HBV can survive on household articles for prolonged time
65
Where is HBV common
Far east, africa and mediterranean
66
In what bodily fluids is HBV common in
Semen and Saliva
67
What can HBV result in
Chronic Hepatitis
68
Risk factors for HBV
1. Healthcare personnel 2. Emergency and rescue teams 3. CKD/Dialysis patients 4. Travellers 5. Homosexual men 6. IV drug users
69
What virus is HBV
DNA
70
How does HBV cause disease
HBsAg is produced in excess by infected hepatocytes After penetrating into hepatocyte, virus loses its coat and core is transported to the nucleus without processing
71
What percentage of patients will develop chronic Hep B
1-10% - can't clear whole viral population
72
Consequence of chronic Hep B
Cirrhosis and decompensated cirrhosis -> liver failure -> HEPATIC CARCINOMA
73
Clinical Presentation of Hep B
1. Viraemia causes patients to feel unwell, nausea, fever, malaise, anorexia and arthralgia
74
What is arthralgia
Joint Pain
75
Incubation period for Hep B
1-6 months
76
When do patients become jaundiced in Hep B
1-2 weeks after Jaundice depends when urine becomes dark and stool becomes pale due to intrahepatic cholestasis
77
What follows jaundice in Hep B
Hepatosplenomegaly
78
What is HBsAg
Hep B surface antigens
79
In Chronic HBC, what can happen
Cirrhosis Liver Failure Hepatocellular Carcinoma
80
How is Hep B diagnosed
HBsAG present 1-6 months after exposure Anti-HBs
81
What does HBsAg presence for more than 6 months imply
Carrier status
82
How is ACUTE Hep B treated
1. Supportive 2. Avoid Alcohol 3. Monitor Liver Function 4. Manage close contacts by giving human normal immunoglobulin for Hep B and vaccination 5. Monitor HBsAg at 6 months to ensure full clearance and no progression
83
Primary prevention of Hep B
Vaccination
84
treatment for chronic Hep B
1. SC PEGYLATED INF-alpha 2a | 2. Nucleotide analogues
85
how is SC PEGYLATED INF-alpha 2a given
Weekly subcutaneous injection
86
Side-effects of SC PEGYLATED INF-alpha 2a
``` Flu-like illness Fever Lethargy Autoimmune disease reduction in WBC and platelets Anxiety Mental Issues ```
87
How do nucleotide analogues function
1. Inhibit viral replication 2. One tablet a day 3. High barrier to resistance 4. Minimal side-effects
88
How often do we give nucleotide analogues for
Life-long (no immune response stimulated)
89
Name a nucleotide analogue
ORAL TENOFOVIR and ENTECAVIR
90
What extra thing do you need to do with ORAL TENOFOVIR
Renal monitoring
91
What virus causes Hep D
INCOMPLETE RNA VIRUS
92
Onset of Hep D
Chronic hepatitis
93
What other virus does Hep D require for assembly
HBV
94
Where is HDV common
Eastern Europe
95
How does HDV spread
Blood-borne transmission
96
Risk factors for HDV
IV drug users
97
What is the Hep D virus structurally
Incomplete RNA enclosed in a shell of Hep B surface antigen
98
How does Hep D co-infection occur
HBV + HBD
99
What condition can co-infection of HBV and HBD be mistaken for
Acute icteric (jaundice) HBV infection
100
What confirms co-infection
Serum IgM anti-HDV with IgM anti-HBV
101
How does superinfection by HDV occur
1. Chornic HBV (usually dormant) gets HBD
102
Consequence of Superinfection
Secondary acute hepatitis and increased rate of liver fibrosis progression
103
What risk is significantly increased by superinfection by HDV
Increased risk of fulminant hepatitis
104
Diagnosis of superinfection
Rise serum AST or ALT
105
How severe can superinfection become
Chronic hepatitis -> hepatocellular carcinoma
106
Clinical presentation of HDV
Same as Hep B
107
Diagnosis of HDV
Same as Hep B
108
Treatment of HDV
SC PEGYLATED INF alpha-2a
109
Where is HCV common
Egypt
110
How is HCV transmitted
Blood products
111
What people are most at risk of HCV
Haemophilia IV drug users STD
112
Is vertical transmission of HCV common
Rare
113
What virus is HCV
RNA flavivirus
114
How many genotypes does RNA flavivirus have
7
115
Most common HCV genotypes that infect people
1a and 1b
116
Why is it hard to make a vaccine for HCV
Rapid mutations change envelope proteins
117
What can HCV result in
Chronic hepatitis -> HEPATOCELLULAR CARCINOMA
118
Symptoms of HCV
Most asymptomatic 10% have flu Jaundice Rise in serum aminotransferases (ALT and AST)
119
Diagnosis of HCV
HCV antibody present in 4-6 weeks HCV RNA - indicates current + diagnosis acute infection
120
When would HCV antibody screening be negative
Immunosuppressed and acute infection (before 4 weeks)
121
How is acute HCv treated
If VIRAL LOAD DOES NOT FALL: SC PEGYLATED INF-alpha 2a/b + ORAL RIBAVIRIN
122
When is HCV treatment not needed
When viral load is falling
123
Side-effect of PEGYLATED INF-alpha 2a/b
Mental health side-effects
124
Side-effect of oral Ribavirin
Haemolytic anaemia + anxiety
125
Why are DAAs (direct acting antivirals) better than INF PEGYLATED
Because they don't cause mental health effects
126
How is DAA given
ORALLY + triple therapy
127
Describe triple therapy of DAA
1. NS5A inhibitor end in ASVIR (ritonasvir) 2. NS5B inhibitors (end in BUVIR) 3. ORAL RIBAVIRIN
128
Role of NS5A
Initiates viral replication
129
Role of NS5B
Needed or viral replication
130
Cons of DAA
Expensive
131
How is Hep C prevented
Precaution (no immunity so can get re-infected and no vaccine)

Year 2 (155 decks)

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