Week 7 Flashcards
What percentage of liver disease in Scotland is alcohol related?
80%
What are the recommendations for weekly alcohol intake?
Men and women shouldn’t have more than 14 units of alcohol per week and this should be spread over 3 or more days and drinkers should limit the amount they have on single occasions.
What are some of the clinical signs of alcoholic liver disease?
Portal hypertension Jaundice Ascites Encephalopathy Cirrhosis Hepatomegaly Fever Malaise Sepsis Deranged LFTs
What is ‘Childs - Turcotte - Pugh’?
A scoring system/ model for end stage liver disease which indicates COMPENSATION or DECOMPENSATION
What is ‘Maddney’s Discriminant Function?’
A model which predicts PROGNOSIS in alcoholic hepatitis
What is the ‘Glasgow Alcoholic Hepatitis Score’?
A model which predicts MORTALITY in alcoholic hepatitis patients
Which drug can be beneficial in for short-term prevention of mortality in alcoholic hepatitis but is not useful for medium/ long-term outcomes?
Prednisolone
What is the most common liver tumour in the absence of liver disease?
Haemangioma
List benign liver tumours
Haemangioma
Hepatic adenoma
Focal nodular hyperplasia
Liver cysts
List malignant liver tumours
Hepatocellular carcinoma
Cholangiocarcinoma
Hepatoblastoma
Fibro-lamellar carcinoma
Focal nodular hyperplasia tumours are benign tumours of the liver. What are they composed of?
They are nodules of normal liver tissue and contain all the liver ultrastructure (sinusoids e.t.c)
Hepatic adenomas are benign liver tumours. What are they composed of?
They are nodules purely composed of hepatocyte - they do not contain all the liver ultrastructure
Which has a higher risk of malignant degeneration and bleeding ; Focal nodular hyperplasia tumours or hepatic adenomas?
Hepatic adenomas
What are some of the benign liver cysts?
Simple cysts
Hydatid cysts
Liver abscesses
How is polycystic liver disease managed?
Somatostatin analogues (for symptom relief)
Defenestration/ aspiration
Liver transplantation
How are liver abscesses managed?
Antibiotics
Aspiration/ drainage
Resection
What is the most common primary liver cancer?
Hepatocellular carcinoma (HCC)
What are the risk factors for hepatocellular carcinoma?
CIRRHOSIS
- Hep B
- Hep C
- Alcohol
- Aflatoxins
What are the clinical features of HCC?
Weight loss
RUQ pain
RUQ mass
Liver bruit
What sites can primary liver tumours metastasise to?
The rest of the liver Portal vein Lymph nodes Lung Bone Brain
What tests are used for the diagnosis of HCC?
Elevated AFP Ultrasound CT MRI Biopsy
How is HCC managed/ treated?
Liver transplantation Resection (small tumours with preserved liver function) Local ablation Chemoembolisation Systemic therapies
Fibro- Lamellar carcinoma is a malignant liver tumour which is not associated with cirrhosis. How would this be diagnosed? What typical signs does it show on investigation?
Normal AFP
CT shows stellate scar and persistent enhancement of the radial septa
What are the common site for secondary metastases TO the liver?
Colon Breast Lung Stomach Pancreas Melanoma
Describe the appearance of urine and stools in the 3 different forms of jaundice
Prehepatic - Normal urine and stools
(Intra)Hepatic - Dark Urine + normal/ pale stools
Posthepatic - Dark urine and pale stools
What extra things should be asked about in a history of a patient who might have jaundice?
Travel history Drugs Sexual history Blood transfusions Tattoos PMH of jaundice
What are the useful tests that can be done for a patient with suspected jaundice?
U&Es FBC LFTs CRP Virology Ultrasound
Describe what is meant by prehepatic jaundice
Excess haemolytic - too much bilirubin is produced e.g haemolytic anaemia
Describe what is meant by intrahepatic jaundice
Hepatocytes are dead/ injured and therefore can’t conjugate and excrete bilirubin/ bile
What are some of the causes of intrahepatic jaundice?
Hepatitis
Cirrhosis
Drugs
Pregnancy
Describe what is meant by post hepatic jaundice
There is obstruction of drainage of bile - it can’t get into the small intestine
What other terms are used to describe post hepatic jaundice?
Extrahepatic jaundice
Obstructive jaundice
Define jaundice
Yellowing of the skin and sclera of the eyes due to increased bilirubin levels. = ‘Clinically apparent hyperbilirubinaemia’
Describe the typical LFT patterns of the different types of jaundice, focusing on bilirubin, ALT/AST and Alkaline phosphatase
Prehepatic - Increased bilirubin, Normal ALT/AST and ALP
Intrahepatic - Increased bilirubin, Very high ALT/AST, elevated ALP
Posthepatic - Increased bilirubin, Elevated ALT/AST, Very high ALP
What kind of LFTs will non-alcoholic fatty liver disease show?
Hepatic LFTs - increased ALT and AST
What kind of LFTs will viral hepatitis show?
Hepatic LFTs - increased ALT and AST
What kind of LFTs and other test results are associated with autoimmune hepatitis?
Hepatic LFTs - Increased ALT and AST
Increased PT
Increased IgG
Anti-smooth muscle antibodies
What kind of LFTs/ other results are associated with PBC?
Cholestatic LFTs - Increased ALP, Bilirubin and ALT
Increased IgM
Which things should be tested for in haemochromatosis?
- Serum iron
- Ferritin/ Transferrin saturations
Which things should be tested for in Wilson’s disease?
- Serum and urine copper
- Serum caeruloplasmin
What is meant by cardiac cirrhosis?
Liver cirrhosis secondary to high right sided heart pressure (incompetent tricuspid valve, congenital, rheumatic fever, constructive pericarditis)
What are the two classes of portal hypertension?
Prehepatic (blockage of the portal vein before the liver e.g portal vein thrombosis)
Intrahepatic (distortion of liver architecture e.g Budd Chiari)
What are some of the causes of post hepatic jaundice?
Gallstones
Carcinoma at the head of the pancreas
PSC
Strictures of the common bile duct
What is meant by colonisation, infection, bacteraemia and sepsis?
Colonisation - bug present but not necessarily an inflammatory response
Infection - Inflammation in response to a bug
Bacteraemia - Bug in the blood
Sepsis - Inflammatory systemic response to infection
Define sepsis and septic shock
Sepsis - life threatening organ dysfunction cause by a host response to infection
Septic shock is a subset of sepsis in which there is circulatory and metabolic dysfunction and a higher risk of mortality
List some of the causes of peritonitis
Perforated tumour
Perforated ulcer
Ruptured appendix
Pancreatitis
What criteria is used to determine whether a patient has sepsis?
The SIRS criteria
What 3 things are needed to diagnose septic shock?
Signs of sepsis + SIRS score + organ failure
What are coliforms?
Gram negative rod-like bacteria found normally in the GI tract
E.g E.coli
Name 3 bugs which can be found in the mouth
Strep viridians
Neisseria
Candida
What antibiotic treatment is given for intra-abdominal infections?
AMOXICILLIN
GENTAMICIN
METRONIDAZOLE
If a patient is allergic to penicillin, what can they be given instead of amoxicillin?
Vancomyin
Why can abscesses sometimes not be treated with antibiotics?
They have a low blood supply meaning antibiotics can’t always reach them
What is the clinical presentation of septic shock?
Lactate above normal levels
Hypotension
Confusion
Cold and clammy
What is included within the SEPSIS 6?
High glow oxygen IV fluids Take blood cultures IV antibiotics Measure lactate and FBC Monitor hourly urine output
What are the categories of gall stones, which is the most common and what colour are they?
Mixed (most common)
Cholesterol (yellow)
Pigment (black)
What are some of the risk factors for gallstones?
Caucasian >40 yrs old High fat diet / obesity Hyperlipidaemia Pregnancy
What tests are used to diagnose gallstones?
Ultrasound
CT
MRCP/ERCP
EUS
How are uncomplicated gallstones managed (e.g occasionally cause biliary colic after a heavy meal)
Lifestyle modifications and painkillers
How is acute cholecystitis managed?
IV antibiotics IV fluids Ultrasound Cholecystectomy ERCP
How can gallstones cause acute pancreatitis?
By blocking the sphincter of oddi there can be back-flow of bile up into the pancreas
How can gallstones cause gallstone ileus?
A fistula can form between the gall bladder and the duodenum - if a stone escapes into the S.I it can cause blockage in the distal ileum and cause intermittent colic
How is Hep A transmitted? Are there carrier states/ is it a chronic infection?
Faecal-oral spread
(poor hygiene and overcrowding)
- No carrier state
What investigation result can indicate acute Hepatitis A?
Hepatitis A IgM
Hep E is clinically very like Hep A, but how does it differ?
Hep E can cause *chronic infection
Where in the world is Hep E most common?
In the tropics
Hepatitis D can only be found alongside another form of viral hepatitis, which other Hep is this?
Hep B
- infection with Hep D exacerbates Hep B infection
How is Hepatitis B transmitted? Does it involve a chronic/ carrier state?
Sex
Vertical transmission
Blood
*It can involve carriers/chronic infection
What groups of people are at highest risk of contracting Hep B?
People born in areas of high prevalence
Multiple sexual partners
People who inject drugs
Children of infected mothers
What test results indicate infectious, low infectivity and chronic infection with Hep B?
HBsAG+ = infectious
- For more than 6 months = chronic
Anti-HBe = low infectivity
What is present in the blood of all patients infected with the hepatitis B virus?
HBsAg
What is the most common cause of acute viral hepatitis in Tayside?
Hepatitis E
How is Hep C transmitted?
It is less easily transmitted than Hep B (less infectious) but can be transmitted by similar ways (sex, blood)
Which is the rarest form of viral hepatitis?
Hep D
How many months define chronic infection with viral hepatitis?
6 months
What is the typical time span from infection with viral hepatitis to development of cirrhosis?
Typically >20 years
Name antivirals used for Hepatitis C
- What are some of the side effects?
Interferon Alfa and Ribavirin
Side effects of IA;
(LOTS)
Flu like symptoms, Autoimmune disease e.g SLE and pyschosis)
What is meant by Sustained virological Response / SVR in Hepatitis C therapy?
Loss of HCV RNA in blood, sustained for 6 months after the end of treatment
Name some of the newer antivirals for HCV therapy
Simeprevir, Ledipasvir
Describe the embryological development of the pancreatic duct?
The main pancreatic duct comes from the ventral bud
Describe the two main functions of the pancreas, what cells make up these and what the cells secrete
Exocrine - Acinar cells - Enzymes
Endocrine - Islets of Langerhan- Hormones
Within the Islets of Langheran, there are Alpha, Beta, Delta and F cells. What do these secrete?
Alpha - Glucagon
Beta - Insulin
Delta - Somatostatins (inhibit the release of gastric hormones)
F cells - Pancreatic polypeptides
How much pancreatic fluid is produced per day?
1 - 1.5 L
What are the causes of acute pancreatitis?
I GET SMASHED
IDIOPATHIC GALLSTONES ETHANOL (alcohol) STEROIDS MUMPS AUTOIMUNE STINGS/ SCORPIONS HYPERCALCAEMIA/HYPERLIPIDAEMIA ERCP DRUGS (E.g azathioprine)
What are the *MOST COMMON causes of acute pancreatitis?
Gallstones and alcohol
What signs visible on examination might pancreatitis present with?
Cullen’s sign
Grey Turner’s sign
Guarding
Which scoring systems can be used for pancreatitis?
Glasgow Criteria
Ranson’s Criteria
What are some of the possible complications of pancreatitis?
Pseudocysts Abscesses Necrosis Ascites Pleural effusion Pulmonary oedema
What are some of the possible causes of chronic pancreatitis?
Alcohol and smoking Genetics - (CF and Pancreas Divisum) Gallstones ERCP Drugs
What does ‘creons’ do in the management of chronic pancreatitis?
Replaces pancreatic enzymes
What are some of the complications of chronic pancreatitis?
- Splenic vein thrombosis
- Pseudoaneurysm over the splenic vein
- Duodenal/ bile duct obstruction
- Exocrine dysfunction
What is the most common pancreatic cancer?
Exocrine tumours (adenocarcinomas)
Describe the production of hormones and enzymes from the different parts of the pancreas, with reference to the specific cells
EXOCRINE - acing cells - enzymes
ENDOCRINE - Islets of Langerhan
- A cells - Glucagon
- B cells - Insulin
- D cells - Somatostatin
- F cells - Pancreatic polypeptide
