Upper GI and hepatobiliary Flashcards
what are the risk factors for biliary colic?
obesity
female
pregnancy
middle age
diabetes mellitus
Crohn’s disease
rapid weight loss, e.g. weight reduction surgery
drugs: fibrates, combined oral contraceptive pill
what are the features of biliary colic?
colicky RUQ pain - worse after eating fatty foods
pain may radiate to right shoulder
nausea and vomiting
no fever, normal CRP and LFTs
how is biliary colic investigated?
ultrasound
how is biliary colic treated?
elective laparoscopic cholecystecomy
what are the causes of chronic pancreatitis?
alcohol
cystic fibrosis
haemochromatosis
ductal obstruction: tumours, stones
what are the features of chronic pancreatitis?
pain typically worse 15 to 30 minutes after meal
steatorrhoea
diabetes mellitus - more than 20 years after symptoms begin
how is chronic pancreatitis investigated?
abdominal X-ray - shows calcification
CT scan (more sensitive, preferred diagnostic test)
faecal elastase - shows exocrine insufficiency
how is chronic pancreatitis treated?
pancreatic enzyme supplements
analgesia
what is ascending cholangitis?
bacterial infection (typically E. coli) of the biliary tree
what are the features of ascending cholangitis?
fever
jaundice
RUQ pain
hypotension, confusion
raised CRP
how is ascending cholangitis investigated?
ultrasound
how is ascending cholangitis treated?
IV antibiotics
ERCP after 24-48 hours to relieve obstruction
what are the causes of acute pancreatitis?
gallstones
ethanol
trauma
steroids
mumps
autoimmune
snake/scorpion bite
hypercalcaemia, hypothermia, hypertriglyceridaemia
ERCP
drugs
what drugs can cause acute pancreatitis?
azathioprine
mesalazine
bendroflumethiazide
furosemide
sodium valproate
steroids
what are the features of acute pancreatitis?
severe epigastric pain that radiates to the back
nausea, vomiting
fever
Cullen’s sign and Grey-Turner’s sign (rare)
how is acute pancreatitis investigated?
serum amylase and lipase (lipase more sensitive and specific)
ultrasound to determine aetiology
contrast-enhanced CT
what factors indicate severe pancreatitis?
age > 55 years
hypocalcaemia
hyperglycaemia
hypoxia
neutrophilia
elevated LDH and AST
what are the complications of acute pancreatitis?
peripancreatic fluid collections (most resolve, may develop into pseudocysts or abscesses)
pseudocyst (conservative management)
pancreatic necrosis
pancreatic abscess (infected pseudocyst)
haemorrhage
what is Boerhaave’s syndrome?
spontaneous rupture of the oesophagus as a result of repeated episodes of vomiting
what are the features of Boerhaave’s syndrome?
sudden onset severe chest pain that may complicate severe vomiting
subcutaneous emphysema on chest wall
how is Boerhaave’s syndrome diagnosed?
CT contrast swallow
how is Boerhaave’s syndrome managed?
thoracotomy and lavage
what are the features of acute cholecystitis?
RUQ pain that may radiate to right shoulder
fever
Murphy’s sign: pain on palpation of RUQ during inspiration
normal LFTs - deranged LFTs suggest Mirizzi syndrome
how is acute cholecystitis investigated?
ultrasound
how is acute cholecystitis treated?
IV antibiotics
early laparoscopic cholecystectomy, within 1 week of diagnosis
what is Mirizzi syndrome?
gallstone impacted in the distal cystic duct causing extrinsic compression of the common bile duct
how can the cause of ascites be determined?
calculate SAAG
if SAAG >11g/L, portal hypertension (transudate, low protein content)
if SAAG <11g/L, exudate
what are the causes of a high SAAG?
cirrhosis/alcoholic liver disease
acute liver failure
liver metastases
right heart failure
constrictive pericarditis
Budd Chiari syndrome
what are the causes of a low SAAG?
malignancy
infection
pancreatitis
nephrotic syndrome
what are the features of PSC?
cholestasis: jaundice, pruritus
raised bilirubin and ALP
RUQ pain
fatigue
increased risk of cholangiocarcinoma and colorectal cancer
how is PSC investigated?
ERCP or MRCP showing ‘beaded’ appearance
p-ANCA may be positive
what are the investigation findings of alcoholic liver disease?
raised gamma-GT
ratio of AST: ALT is normally > 2
how is alcoholic liver disease treated?
prednisolone - Maddrey’s discriminant function used to determine who would benefit (uses PT and bilirubin concentration)
sometimes pentoxyphylline
what is the inheritance pattern of haemochromatosis?
autosomal recessive - HFE gene
what are the features of haemochromatosis?
fatigue, erectile dysfunction, arthralgia
bronze skin pigmentation
diabetes mellitus
hepatomegaly, cirrhosis
cardiac failure (dilated cardiomyopathy)
hypogonadism
what are the investigation findings of haemochromatosis?
raised iron, ferritin and transferrin saturation (ts considered most useful)
low transferrin
low TIBC
genetic testing for HFE gene
how is haemochromatosis managed?
venesection
desferrioxamine second-line
what are the medical associations with primary biliary cholangitis?
Sjogren’s syndrome (seen in up to 80% of patients)
rheumatoid arthritis
systemic sclerosis
thyroid disease
what are the features of primary biliary cholangitis?
early: may be asymptomatic (e.g. raised ALP on routine LFTs) or fatigue, pruritus
cholestatic jaundice
hyperpigmentation, especially over pressure points
around 10% of patients have right upper quadrant pain
xanthelasmas, xanthomata
also: clubbing, hepatosplenomegaly
late: may progress to liver failure
how is primary biliary cholangitis investigated?
raised IgM and anti-mitochondrial antibodies
RUQ ultrasound or MRCP to exclude extrahepatic biliary obstruction
how is primary bilary cholangitis managed?
ursodeoxycholic acid
cholestyramine for pruritus
what is Budd-Chiari syndrome?
hepatic vein thrombosis
can be caused by polycythaemia rubra vera, thrombophilia, pregnancy
what are the features of Budd-Chiari syndrome?
acute hepatitis
sudden onset, severe abdominal pain
ascites
tender hepatomegaly
how is Budd-Chiari syndrome investigated?
ultrasound with Doppler flow studies
what are the features of autoimmune hepatitis?
acute hepatitis: fever, jaundice
signs of chronic liver disease
amenorrhoea
raised IgG
ALKM1/ANAs/ASMAs
