Week 10 - Hepatobiliary and Pancreatic Disease

Question 1

How can you differentiate acute v chronic liver disease?

Answer 1

Question 2

What are the acute causes of liver disease?

Answer 2

Drugs (paracetamol, herbal, penicillins, thiopurines)
Alcohol
Viruses (Hep A, B & E, CMV, Covid, EBV)
Vascular (hepatic vein thrombosis)
Ischaemic liver disease
Wilsons’s disease

Question 3

What are the chronic causes of liver disease?

Answer 3

Alcohol
Fatty liver disease
AI disease - (AI hepatitis, Primary biliary cirrhosis)
PSC
Viruses - Hep B&C
Congenital - Haemochromatosis, Wilsons, A1AT deficiency

Question 4

If the liver is damages - what synthetic functions are limited causing Sx?

Answer 4

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

Question 5

Which viruses that cause hepatitis tend to be self limiting?

Answer 5

Hep A, B & E,
CMV
EBV
Covid

Question 6

Which viruses that cause hepatitis need treatment?

Answer 6

B, C & E

Question 7

In viral hepatitis - what level will ALT usually be?

Answer 7

Usually >1000

Question 8

Which is the only DNA hepatitis virus?

Answer 8

Hep B

Question 9

What is the transmission of Hep E?

Answer 9

4 types (1-4)

3 & 4 = zoonotic
Rest = faecal-oral or blood

Question 10

Which hepatitis is the most common cause of liver failure in pregnancy?

Answer 10

Hep E

Question 11

How can Ps with Hep E present?

Answer 11

Mostly asymptomatic
S&S = jaundice, fever, myalgia, vomiting and abdo pain

Question 12

Which serology can screen for Hep E infection?

Answer 12

anti-HEV IgM

Question 13

What is the trouble of catching Hep E in the immunosuppressed?

Answer 13

Can cause chronic hepatitis (cirrhosis does not occur)

Question 14

What is the most common method of transmission of Hep B?

Answer 14

Mother to baby

Also - sex, IVDU

Question 15

What are the consequences of Hep B infection if untreated?

Answer 15

Can cause cirrhosis and hepatocellular cancer

Question 16

What is the definition of chronic Hep B infection?

Answer 16

Hep B +ve for > 6 months

Question 17

What are the 4 states of hepatitis B infection?

Answer 17

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.

Question 18

What are the S&S of acute Hep B infection?

Answer 18

Mostly asymptomatic
Many get jaundice and fever
Acute liver failure rare

Question 19

How can you identify Hep B infection from serology?

Answer 19

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)

Question 20

When should you Rx Ps with drugs with Hep B?

Answer 20

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

Question 21

What does Hep D to a Hep B infection?

Answer 21

Makes it more aggressive and increases the risk of liver failure

Question 21

How is Hep C transmitted?

Answer 21

Blood, sex or IVDU.
Vertical transmission low.

Question 22

How can you confirm active Hep C infection?

Answer 22

Presence of Hep C IgC

Question 23

Without Rx, what is the prognosis of a Hep C infection?

Answer 23

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

Question 23

How can you test for EBV?

Answer 23

Positive monospot test

Question 24

What is the Rx for CMV?

Answer 24

Ganciclovir if severe

Question 25

What is the Rx for HSV 1 & 2?

Answer 25

Aciclovir

Question 26

Which drugs can cause hepatitis?

Answer 26

Question 27

Which drugs can cause cholestasis?

Answer 27

Question 28

Which drugs can cause mixed hepatitis and cholestasis?

Answer 28

Question 29

How does alcoholic hepatitis present histologically?

Answer 29

Steatohepatitis Mallory denk bodies Ballooning degeneration of hepatocytes Neutrophillic inflammation

Question 30

What is the Rx for alcoholic hepatitis?

Answer 30

Steriods Nutrition Abstinence

Question 31

What does histology showing lymphoplasmacytic interface hepatitis with rosettes of hepatocytes indicate?

Answer 31

AI Hepatitis

Question 32

Which ABs are liked to AI hepatitis?

Answer 32

Smooth muscle AB - anti-SMA Liver kidney microsomal - anti-LKM1 Also - AMA and immunoglobulins which indicate PBC and AI hepatitis

Question 33

What is Rx for AI hepatitis?

Answer 33

Steriods Azathioprine

Question 34

How will Ps with hyperacute, acute and subacute liver failure present?

Answer 34

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

Question 35

What causes ascites?

Answer 35

Leakage of fluid from portal vessels into the peritoneal cavity.

Question 36

Which criteria is used to differentiate between transudate and exudate? What is used to determine this?

Answer 36

Light's criteria Uses protein and LDH levels in fluid and blood

Question 37

What type of fluid is found in ascites?

Answer 37

Transudate

Question 38

Ascitic fluid can also be found where?

Answer 38

It can cross the diaphragm -> pleural effusions

Question 39

What are the clinical signs of decompensated cirrhosis?

Answer 39

Ascites Encephalopathy Jaundice GI Bleeding Renal failure

Question 40

What is the mean survival for 2 years after decompensated cirrhosis?

Answer 40

2 years

Question 41

What can cause decompensated cirrhosis?

Answer 41

Infection - SBP Hepatocellular carcinoma Electrolyte abnormalities GI bleeding Natural progression of liver disease - e.g. cont drinking

Question 42

What do raised ferritin and transferritin saturations indicate?

Answer 42

High iron levels - Hereditary haemochromatosis

Question 43

What do raised caeruloplasmin and copper indicate?

Answer 43

Wilson's disease

Question 44

What does low levels of α 1 antitrypsin possibly indicate?

Answer 44

α 1 antitrypsin deficiency

Question 45

What protein do we test for to exclude hepatocellular carcinoma?

Answer 45

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.

Question 46

How can you determine whether a disease is causing hepatitis or cholestasis using serology?

Answer 46

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

Question 47

What is transaminitis?

Answer 47

Raised ALT levels

Question 48

What percentage of Ps are antibody negative but still have AI hepatitis?

Answer 48

20%

Question 49

How is acute liver failure defined?

Answer 49

Acute liver injury - so no underlying chronic liver disease - Damage - ALT 2-3x ULN - Impaired function -> jaundice or coagulopathy and Hepatic Encephalopathy

Question 50

What normally causes - Hyperacute liver failure - Acute liver failure - Subacute liver failure?

Answer 50

Hyperactive = Paracetamol, Hep A & E Acute = Hep B Subacute = Hep D

Question 51

What does SBP stand for?

Answer 51

Spontaneous bacterial peritonitis

Question 52

Which score is used to assess the progress of chronic liver disease?

Answer 52

Child Pugh Score

Question 53

What are the endocrine and exocrine functions of the pancreas?

Answer 53

Endocrine = produce insulin and glucagon Exocrine = produce faecal elastase

Question 54

What are the causes of acute pancreatitis?

Answer 54

Question 55

Which drugs can cause acute pancreatitis?

Answer 55

Azathioprine Mesalazines Thiazide diuretics

Question 56

What can necrotising pancreatitis form?

Answer 56

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.

Question 57

Why does CF cause pancreatitis?

Answer 57

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