Week 10 - Hepatobiliary and Pancreatic Disease Flashcards
How can you differentiate acute v chronic liver disease?
What are the acute causes of liver disease?
Drugs (paracetamol, herbal, penicillins, thiopurines)
Alcohol
Viruses (Hep A, B & E, CMV, Covid, EBV)
Vascular (hepatic vein thrombosis)
Ischaemic liver disease
Wilsons’s disease
What are the chronic causes of liver disease?
Alcohol
Fatty liver disease
AI disease - (AI hepatitis, Primary biliary cirrhosis)
PSC
Viruses - Hep B&C
Congenital - Haemochromatosis, Wilsons, A1AT deficiency
If the liver is damages - what synthetic functions are limited causing Sx?
Failure to clear bilirubin -> Jaundice
Failure to produce clotting factors (2,7, 9 & 10) -> coagulopathy & raised INR
Failure to produce protein -> hypoalbuminaemia
Failure to get rid of toxins -> encephalopathy
Ascites
Which viruses that cause hepatitis tend to be self limiting?
Hep A, B & E,
CMV
EBV
Covid
Which viruses that cause hepatitis need treatment?
B, C & E
In viral hepatitis - what level will ALT usually be?
Usually >1000
Which is the only DNA hepatitis virus?
Hep B
What is the transmission of Hep E?
4 types (1-4)
3 & 4 = zoonotic
Rest = faecal-oral or blood
Which hepatitis is the most common cause of liver failure in pregnancy?
Hep E
How can Ps with Hep E present?
Mostly asymptomatic
S&S = jaundice, fever, myalgia, vomiting and abdo pain
Which serology can screen for Hep E infection?
anti-HEV IgM
What is the trouble of catching Hep E in the immunosuppressed?
Can cause chronic hepatitis (cirrhosis does not occur)
What is the most common method of transmission of Hep B?
Mother to baby
Also - sex, IVDU
What are the consequences of Hep B infection if untreated?
Can cause cirrhosis and hepatocellular cancer
What is the definition of chronic Hep B infection?
Hep B +ve for > 6 months
What are the 4 states of hepatitis B infection?
Born - and contract Hep B during delivery - have the virus until 25-30 - high viral load but liver doesn’t care = immunotolerant phase. Really high viral load but liver handles it ok.
Liver decides it doesn’t like it and tries to get rid of it - attacks the E antigen which makes it from positive to negative - viral load drops, liver function tests get raised and then normalise = inactive state - low viral load and normal LFTs. Around 30.
Cycle of viral load starts creeping up - liver gets angry - LFTs go up, viral load goes down again - cycle of inflammation and calming causes liver scarring - 10-30 years - develops into cirrhosis. 4 phases.
What are the S&S of acute Hep B infection?
Mostly asymptomatic
Many get jaundice and fever
Acute liver failure rare
How can you identify Hep B infection from serology?
ALT >1000 in acute
In chronic - ALT may be normal or slightly elevated
Can also look for
Hep B sAg (surface antigen) and sAb (surface antibody)
Hep B eAg (envelope antigen)
Hep B cAb (core AB)
When should you Rx Ps with drugs with Hep B?
When they are fibrotic, or HBV DNA >2000 or they have elevated ALT on more than 2 occasion
OR
In 3rd trimester to prevent transmission
OR If immunosuppressed
What does Hep D to a Hep B infection?
Makes it more aggressive and increases the risk of liver failure
How is Hep C transmitted?
Blood, sex or IVDU.
Vertical transmission low.
How can you confirm active Hep C infection?
Presence of Hep C IgC
Without Rx, what is the prognosis of a Hep C infection?
30% will progress to cirrhosis in 10-20 years, another 20% over 20-30 years and a further 30% over 30 years. So 90% will develop cirrhosis within 30 years
How can you test for EBV?
Positive monospot test
What is the Rx for CMV?
Ganciclovir if severe
What is the Rx for HSV 1 & 2?
Aciclovir
Which drugs can cause hepatitis?
Which drugs can cause cholestasis?
Which drugs can cause mixed hepatitis and cholestasis?
How does alcoholic hepatitis present histologically?
Steatohepatitis
Mallory denk bodies
Ballooning degeneration of hepatocytes
Neutrophillic inflammation
What is the Rx for alcoholic hepatitis?
Steriods
Nutrition
Abstinence
What does histology showing lymphoplasmacytic interface hepatitis with rosettes of hepatocytes indicate?
AI Hepatitis
Which ABs are liked to AI hepatitis?
Smooth muscle AB - anti-SMA
Liver kidney microsomal - anti-LKM1
Also - AMA and immunoglobulins which indicate PBC and AI hepatitis
What is Rx for AI hepatitis?
Steriods
Azathioprine
How will Ps with hyperacute, acute and subacute liver failure present?
Depends on time from jaundice to hepatic encephalopathy.
Hyperacute = happens less than 1w
Severe coagulopathy (+++), not so much jaundice (+) and raised intracranial HTN
- Paracetamol, Hep A &E
Acute = happens within 1 month (1-4w), less severe coagulopathy (++), more jaundice (++) and same levels of raised intracranial HTN
- Hep B
Subacute - happens over up to 3m (4w-12w), much less severe coagulopathy (+), but severe jaundice (+++), and may or may not have raised intracranial HTN
- Hep D
What causes ascites?
Leakage of fluid from portal vessels into the peritoneal cavity.
Which criteria is used to differentiate between transudate and exudate?
What is used to determine this?
Light’s criteria
Uses protein and LDH levels in fluid and blood
What type of fluid is found in ascites?
Transudate
Ascitic fluid can also be found where?
It can cross the diaphragm -> pleural effusions
What are the clinical signs of decompensated cirrhosis?
Ascites
Encephalopathy
Jaundice
GI Bleeding
Renal failure
What is the mean survival for 2 years after decompensated cirrhosis?
2 years
What can cause decompensated cirrhosis?
Infection - SBP
Hepatocellular carcinoma
Electrolyte abnormalities
GI bleeding
Natural progression of liver disease - e.g. cont drinking
What do raised ferritin and transferritin saturations indicate?
High iron levels - Hereditary haemochromatosis
What do raised caeruloplasmin and copper indicate?
Wilson’s disease
What does low levels of α 1 antitrypsin possibly indicate?
α 1 antitrypsin deficiency
What protein do we test for to exclude hepatocellular carcinoma?
AFP - alphafetoprotein
Typically most high in HCC - can get very elevated levels.
Can get less high increases with liver disease, pregnancy, pancreatic or GI cancers.
How can you determine whether a disease is causing hepatitis or cholestasis using serology?
Look at the ALP and ALT
Disease that causes hepatitis - typically raises ALT
Cholestasis - typically raises ALP
Look at R value
R value = ALT / ULN : ALP / ULN
If >5 = hepatocellular
If <2 = cholestatic
If 2-5 = mixed cause
What is transaminitis?
Raised ALT levels
What percentage of Ps are antibody negative but still have AI hepatitis?
20%
How is acute liver failure defined?
Acute liver injury
- so no underlying chronic liver disease
- Damage - ALT 2-3x ULN
- Impaired function -> jaundice or coagulopathy
and
Hepatic Encephalopathy
What normally causes
- Hyperacute liver failure
- Acute liver failure
- Subacute liver failure?
Hyperactive = Paracetamol, Hep A & E
Acute = Hep B
Subacute = Hep D
What does SBP stand for?
Spontaneous bacterial peritonitis
Which score is used to assess the progress of chronic liver disease?
Child Pugh Score
What are the endocrine and exocrine functions of the pancreas?
Endocrine = produce insulin and glucagon
Exocrine = produce faecal elastase
What are the causes of acute pancreatitis?
Which drugs can cause acute pancreatitis?
Azathioprine
Mesalazines
Thiazide diuretics
What can necrotising pancreatitis form?
Pseudocysts
A pseudocyst is a fluid-filled sac that forms in the abdomen, typically following an episode of acute pancreatitis or as a complication of chronic pancreatitis. Unlike true cysts, pseudocysts do not have an epithelial lining; instead, they are surrounded by a fibrous or granulation tissue.
Why does CF cause pancreatitis?
Ducts get block due to thicker fluid in the pancreas (due to Cl channel impairment due to CFTR gene problems).
-> Inflammation = pancreatitis
-> Fibrosis and atrophy
Can cause failure to thrive, steatorrhoea
