Week 3 Common Conditions Flashcards

1
Q

What is jaundice?

A

Yellow appearance of the skin, sclerae and mucous membranes

An important sign of liver disease, however, not always present

Extra-hepatic disorders can also cause jaundice

Produced by elevated bilirubin (bile pigment and waste product of RBC breakdown)

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2
Q

How is bilirubin metabolised?

A

Bilirubin is a pigment made during the normal breakdown of senescent RBCs

RBC lifespan: 100-120 days

Engulfed by macrophages in spleen & liver

Haemoglobin broken into heme + globin

Globin chains: broken into constituent AAs

Iron: recycled

Porphyrin ring: converted to unconjugated bilirubin and released into the bloodstream

Unconjugated bilirubin is hydrophobic and must travel bound to albumin in the circulation

In the liver, bilirubin is conjugated with glucuronic acid (enzyme: glucuronyl transferase)

Conjugated bilirubin is water-soluble & released by hepatocytes as a component of bile

Undergoes reduction by intestinal bacteria to urobilinogen

Most urobilinogen: excreted in faeces as stercobilin

A small proportion of urobilinogen enters the portal circulation and is re-excreted by liver

Remaining urobilinogen excreted by kidneys as urobilin

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3
Q

What are the classifications of jaundice?

A

Based on where bilirubin metabolism is affected:

HAEMOLYTIC JAUNDICE
Due to excessive RBC destruction
Overwhelms liver’s ability to form conjugated bilirubin

E.g. thalassaemia, drug reactions

HEPATIC JAUNDICE
Due to impaired hepatocyte function (various mechanisms)

Impaired uptake or intracellular transport of bilirubin
E.g. viral or alcoholic hepatitis, drug toxicity

Reduced enzymatic activity (glucuronyl transferase)
E.g. newborn with immature enzymes

NEONATAL JAUNDICE
Occurs in ~60% of full-term and 80% of pre-term babies within the first week of life

CHOLESTATIC JAUNDICE
Due to obstruction of intrahepatic or extrahepatic bile ducts.

Intrahepatic bile duct obstruction
E.g. cirrhosis, neoplasia

Extrahepatic bile duct obstruction
E.g. cholelithiasis, neoplasia, cystic fibrosis

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4
Q

What is the aetiology of viral hepatitis?

A

Most common: Hepatitis virus types A, B, C (pictured), D & E
Hepatitis F & G now known to exist

Other viruses: Epstein Barr virus, cytomegalovirus

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5
Q

What is the pathophysiology of viral hepatitis?

A

Virus induces an acute inflammatory reaction, leading to widespread hepatocyte necrosis

Usually, liver begins to recover before SSx disappear

Occasionally, severe destruction of whole lobes results in acute hepatic failure

Chronic hepatitis with cirrhosis (pictured) is particularly associated with HBV & HCV

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6
Q

Discuss the types of hepatitis viruses

A
HAV
Transmission: Faecal-oral route
Severity: Usually mild, worse in older patients
Chronicity: Very rare
Vaccination: Yes

HBV
Transmission: Parenteral, sexual contact, perinatal
Severity: Mild to severe (mortality ~10%)
Chronicity: Common
Vaccination: Yes

HCV
Transmission: Parenteral, perinatal, possibly sexual
Severity: Usually mild
Chronicity: Very common
Vaccination: Not available
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7
Q

What are the clinical features of acute hepatitis?

A

Stage 1: Preclinical
Asymptomatic, but virus actively replicating
Spread during this phase a concern

Stage 2: Prodromal/Pre-icteric
Anorexia, nausea, vomiting, malaise, headache
Mild fever, diarrhoea, upper abdominal discomfort

Stage 3: Icteric
Jaundice develops
Possibly tender hepatomegaly +/- splenomegaly
HBV: polyarthralgia affecting small joints, skin rash

Stage 4: Convalescent
Symptoms subside over a course of several weeks
Stage 1: Preclinical
Asymptomatic, but virus actively replicating
Spread during this phase a concern

Stage 2: Prodromal/Pre-icteric
Anorexia, nausea, vomiting, malaise, headache
Mild fever, diarrhoea, upper abdominal discomfort

Stage 3: Icteric
Jaundice develops
Possibly tender hepatomegaly +/- splenomegaly
HBV: polyarthralgia affecting small joints, skin rash

Stage 4: Convalescent
Symptoms subside over a course of several weeks

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8
Q

What are the clinical features of chronic hepatitis?

A

Persistence of inflammation > 6 months

A wide spectrum of disease exists:

The inflammation may be low-grade (mild, well-contained)

Chronic active hepatitis leads to widespread fibrosis and eventually cirrhosis

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9
Q

What is the management of hepatitis?

A

There is no specific treatment

Hep A: bed rest is advised

Diet: should be low in fats but relatively high in proteins

Avoid hepatic insults: drugs, esp. alcohol

Advice about reducing spread:

Not sharing needles
Not donating blood or body organs
Advising healthcare workers of health status

Covering wounds appropriately
Carefully disposing of blood stained material
Practising safe sex

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10
Q

What is alcoholic liver disease?

A

In the liver, it causes the induction of oxidases (these enzymes aid metabolism, but damage hepatocytes with chronic exposure)

Severity of the liver damage is dose related, although individual factors may play a role (? Amount of standard drinks required for hepatic changes to occur)

LIVER RESILIENCE
The liver has excellent potential for hypertrophy & hyperplasia

However, the new growth may not conform to normal cytoarchitecture – this leads to a range of issues

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11
Q

What is the pathophysiology of alcoholic liver disease?

A

STAGE 1: FATTY LIVER
Destruction of rough ER in hepatocytes reduces the amount of lipoproteins synthesied & secreted – this causes cells to become swollen with lipids

Mild to moderate changes are reversible

Clinical features: +/- hepatomegaly

STAGE 2: ALCOHOLIC HEPATITIS
Usually superimposed on fatty liver

Hepatocyte necrosis induces the infiltration of inflammatory cells

Clinical features: tender hepatomegaly, fever, jaundice, ascites
Severe cases: a heavy drinking bout may induce encephalopathy

STAGE 3: CIRRHOSIS
Irreversible: arises due to chronic inflammation and progressive fibrosis

Regenerating hepatocytes do not conform to normal cytoarchitecture (nodule formation)

The structural change obstructs nutrient flow (impaired hepatocyte function)
Death occurs due to complications (hepatocellular failure, portal hypertension)

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12
Q

What are other causes of cirrhosis? (alcohol ~60-70% of cases)

A

Non-alcoholic fatty liver disease
Risk factors include: obesity, insulin resistance, hyperlipidaemia

Viral & autoimmune hepatitis

Cholestasis

Metabolic disorders e.g. haemochromatosis

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13
Q

What are the clinical features of cirrhosis?

A

Jaundice, RUQ pain, hepatomegaly (liver shrinks in advanced stages), foetor hepaticus (late)

Constitutional symptoms: fever, anorexia, nausea, vomiting, weakness, fatigue, weight loss

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14
Q

What are the complications of cirrhosis?

A

Are related to portal hypertension and hepatocellular failure

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15
Q

What are manifestations of portal hypertension?

A

Ascites
Accumulation of fluid in peritoneal cavity
Abdominal distension with shifting dullness to percussion

Other causes of ascites: liver carcinoma, cardiac failure

Splenomegaly
Occurs due to passive congestion

Varicose veins
Oesophageal (haemorrhage risk)
Rectal
Caput medusae

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16
Q

What are manifestations of hepatocellular failure?

A

Hepatic encephalopathy
Failure to metabolise neurotoxic nitrogenous wastes from gut bacteria

Changes in intellect, mood, alertness
Asterixis (flapping tremor), hyper-reflexia, Babinksi

Coagulation defects
Failure to produce coagulation factors

Endocrine changes
Failure to deactivate hormones

Peripheral oedema
Failure to produce albumin

17
Q

What is the management of alcoholic liver disease?

A

Cease alcohol

Improve nutrition

Carefully monitor medications

Treat the complications: ascites, encephalopathy, varices

There is no treatment to reverse the cirrhosis

18
Q

What is the prognosis of alcoholic liver disease?

A

Poor overall - most people present in the later stages of the disease (5-year survival - 25%)

If liver function is good, 50% of patients survive for 5 years and 25% for 10 years

19
Q

What are the three types of liver tumours?

A

Benign tumours
Haemangiomas, adenomas
Focal nodular hyperplasia

Primary malignant liver tumours
Hepatocellular carcinoma – most common
Cholangiocarcinoma

Secondary malignant liver tumours
Are relatively common

Primary usually in lung, breast, GIT, skin (melanoma)
50% of cases: primary tumour is asymptomatic

20
Q

What is hepatocellular carcinoma? (hepatoma)

A

primary malignant tumour arising from liver epithelial cells (hepatocytes)

21
Q

What are the risk factors of hepatocellular carcinoma?

A

Cirrhosis, viral hepatitis (HBV & HCV)
Exposure to aflatoxins
More common in men

22
Q

What are the clinical features of hepatocellular carcinoma?

A

Irregular hepatomegaly, RUQ pain, jaundice
Symptoms of cirrhosis e.g. ascites
Constitutional symptoms e.g. anorexia, weight loss, fever

Can appear as a single mass or as multiple nodules
50% of cases: metastasis to regional lymph nodes, lungs, bone

23
Q

What is the management of hepatocellular carcinoma

A

Radiofrequency ablation and chemotherapy are the most common treatments

Partial hepatectomy is considered in some patients, dependent on tumour size, number and location

24
Q

What is the prognosis of hepatocellular carcinoma?

A

In Australia, the 5-year survival is 16%

25
Q

What is cholelithiasis?

A

Gallstones
Most common GB disorder of the Western world
Estimated to affect 11% of the population

26
Q

What are the risk factors of cholelithiasis?

A

In adults <40 years, stones are more common in women (no difference in elderly)

Obesity, increased age, multi-parity, diabetes, diets high in refined sugar, ileal disease

27
Q

What are the types of cholelithisasis?

A

Cholesterol variety
Most common type in Western countries
Linked to disturbed cholesterol balance

Pigment variety
More common in developing countries
Correlation with infection

28
Q

What is the pathophysiology of cholesterol stones?

A

The solubility of cholesterol in bile is determined by the ratio:
Cholesterol : Bile salts : Phospholipids

Many factors can alter this ratio
Crystals begin to form when bile is supersaturated with cholesterol - “lithogenic bile”

29
Q

What are the clinical features of cholesterol stones?

A

Most gallstones are asymptomatic, especially if the stone remains in the GB
Only 25% of stones have enough calcium to be radio-opaque

Pure cholesterol stones: often solitary
May be more than 3cm in length

More likely for a patient to present with a complication

30
Q

What are complications of cholelithiasis? (7)

A

Acute Cholecystitis
Impaction in the cystic duct results in biliary stasis

Acute inflammation arises from chemical irritation

Clinical features:
Sudden onset RUQ pain, +/- Rt shoulder referral
+/- fever or chills

Murphy’s sign: tenderness on RUQ palp., worse w. inspiration

Chronic cholecystitis
GB walls become fibrotic & shrunken following repeated bouts of acute inflammation

Clinical features: similar acute cholecystitis, but milder

Mucocele development
GB becomes distended with mucoid watery fluid
Due to cholestasis (bile pigments are reabsorbed through GB wall)

Infection
Increased risk of bacterial infection (especially E. coli)
Persistent inflammation and infection can result in empyema

Increased risk for carcinoma
Gallstones are seen in 80% of GB malignancies

Suggest that gallstones may play a role in neoplasia

Choledocholithiasis
Impaction of gallstone in the bile duct
Often results in inflammation of bile duct - cholangitis

Clinical features:
Biliary colic
Charcot’s triad of RUQ pain, jaundice, fever

Acute pancreatitis
Obstruction at hepatopancreatic ampulla generates back-pressure
Causes secretions to flow back up the pancreatic duct

Clinical features:
Severe abdominal pain (LUQ  Lt scapula)
Bloating, fever, sweating, nausea, vomiting

31
Q

What is the management of gallstones?

A

Surgery (Cholecystectomy)
For symptomatic cases
Open or laparoscopic

Oral bile acid therapy
Ursodeoxycholic acid
Chemical dissolution of stones
Not suitable for all patients

Extra-corporeal shockwave lithotripsy
Application of high frequency sound waves to fracture the stones
Followed by a course of bile salts to dissolve the fragments

32
Q

What is cystic fibrosis?

A

A disorder of exocrine glands, in which the secretions of the lungs, pancreas, bile ducts and reproductive tract have increased viscosity

33
Q

What is the pathophysiology of cystic fibrosis?

A

The gene responsible (CFTR) is located on chromosome 7 and codes for a membrane-bound chloride channel

There are nearly 2000 possible mutations

Affected chloride channels are non-responsive to intra-cellular signalling (cAMP second messenger system) that would normally open the channel

Secretions of affected cells contain inadequate amounts of chloride and water
The abnormal secretions are viscid and are retained by the affected gland

Secretions that may be affected:
Pulmonary mucous*
Pancreatic enzymes*
Sweat
Bile
Reproductive secretions
34
Q

What are the clinical features of cystic fibrosis?

A

PULMONARY FEATURES
Mucous plugging & impaired mucociliary function

Recurrent infections & chronic inflammation (fibrosis)

PANCREATIC FEATURES
Reduced or absent pancreatic enzymes

Malabsorption occurs due to impaired digestion
Failure to thrive/growth retardation
Steatorrhoea

Recurrent pancreatitis leads to extensive fibrosis
Exocrine portion: permanent pancreatic insufficiency
Endocrine portion: CF-induced diabetes

BILIARY FEATURES
Cholestasis can result in secondary biliary cirrhosis & cholelithiasis

REPRODUCTIVE FEATURES
Sub-fertility or infertility
98% affected men: Congenital bilateral absence of the vas deferens

35
Q

What is the management of cystic fibrosis?

A

PULMONARY SUPPORT
Chest physiotherapy

Inhalation of agents to reduce sputum viscosity (deoxyribonuclease)
or assist in mucus clearance (hypertonic saline)

Antibiotics for infections; Bronchodilator therapy

Lung transplantation: advanced CF

PANCREATIC SUPPORT
Pancreatic enzyme replacement – pancrelipase (Creon)

Vitamin therapy to correct any deficiencies
Insulin for CF diabetes