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Phase 2a Annabel > Liver + Friends > Flashcards

Liver + Friends Flashcards

1
Q

What are the 3 key markers of liver function?

A

Bilirubin
Albumin
Prothrombin time (PT/INR)

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2
Q

What levels of bilirubin indicate liver dysfunction?

A

Increased

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3
Q

What level of albumin indicates liver dysfunction?

A

Decreased

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4
Q

What liver enzymes indicate liver damage?

A

AST (aspartate aminotransferase)
ALT (alanine aminotransferase)
GGT
ALP

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5
Q

Where are liver enzymes found?

A

Hepatocytes- leak out when damage occurs

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6
Q

When are high AST levels seen?

A

Hepatic necrosis
MI
Muscle injury
Congestive cardiac failure

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7
Q

When are high ALT levels seen?

A

ONLY in liver disease

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8
Q

What is the typical AST:ALT ratio?

A

1

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9
Q

What does an AST:ALT ratio of >2:1 indicate?

A

Alcoholic liver disease especially with inc. GGT

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10
Q

What does an AST:ALT ratio of >4.5:1 indicate?

A

Wilsons
Hyperthyroid

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11
Q

What does an AST:ALT ratio of <0.9:1 indicate?

A

NAFLD

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12
Q

When is GGT increased?

A

ALD

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13
Q

When is ALP increased?

A

Biliary tree specific damage
Bone pathology

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14
Q

What are 7 functions of the liver?

A

MAD BICO

Metabolises carbs
Albumin production
Detoxification
Bilirubin regulation
Immunity and Kupffer cells
Clotting factor production
Oestrogen regulation

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15
Q

What are 3 disorders of oestrogen regulation?

A

Gynaecomastia in men
Spider naevi
Palmar erythema

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16
Q

What is one disorder of detoxification pathology?

A

Hepatic encephalopathy

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17
Q

What is one disorder of carbohydrate metabolism?

A

Hypoglycaemia

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18
Q

What are 3 disorders of albumin production?

A

Oedema
Leukonychia
Ascites

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19
Q

What is one consequence of clotting factor dysfunction?

A

Easy bleeding and bruising

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20
Q

What are 2 disorders of bilirubin regulation?

A

Pruritus
Jaundice

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21
Q

What is one consequence of Kupffer cell dysfunction?

A

Spontaneous bacterial infections

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22
Q

Define acute liver failure

A

Rapid decline characterised by jaundice, coagulopathy (INR > 1.5) and hepatic encelopathy in a patient with a previously normal liver

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23
Q

What are the 3 types of acute liver failure?

A

Hyperacute <7 days
Acute: 1-4 weeks
Subacute: 4-12 weeks

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24
Q

Why does acute liver failure mainly occur?

A

Massive hepatocytes necrosis

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25
Q

What are 5 causes of acute liver failure?

A

Drugs
Viral
Infiltrative
Budd Chiari
Acute fatty liver of pregnancy

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26
Q

What are 3 viral causes of acute liver failure?

A

Hepatitis A,B,D,E
EBV
HSV

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27
Q

What are 3 drugs that can cause acute liver failure?

A

Paracetamol
Alcohol
Ecstasy

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28
Q

What are the symptoms of acute liver failure?

A

Jaundice, coagulopathy, hepatic encephalopathy ascites

MC 4 symptoms: jaundice, nausea, anorexia, malaise

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29
Q

How is HE graded?

A

West Haven criteria grades 1-4

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30
Q

Define hepatic encephalopathy

A

Changes in the brain that occur in patients with liver failure, ranging from memory issues to coma

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31
Q

Define liver failure

A

Liver fails to regenerate and repair leading to decompensation

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32
Q

How is acute liver failure diagnosed?

A

LFTs (bilirubin ect)
EEG to grade HE
Microbiology for infection

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33
Q

How is acute liver failure treated?

A

Treat underlying cause
ABCDE if severe
Treat complications

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34
Q

What are 3 complications of acute liver failure?

A

MC: Infection
Renal failure
Progressive HE
Oedema

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35
Q

How is encephalopathy treated in liver failure?

A

Lactulose (increased ammonia excretion)
Consider mannitol

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36
Q

How is ascites treated in liver failure?

A

Diuretics
Fluid restriction

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37
Q

How is cerebral oedema treated in liver failure?

A

Mannitol

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38
Q

How is bleeding treated in liver failure?

A

Vitamin K

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39
Q

How is sepsis treated in liver failure?

A

Abx

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40
Q

How is hypoglycaemia treated in liver failure?

A

Dextrose

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41
Q

Define chronic liver failure

A

Progressive liver disease over 6+ months due to repeated liver insults

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42
Q

What are 3 causes of chronic liver failure?

A

Alcoholic liver disease (ALD)
Non- alcoholic fatty liver disease (NAFLD)
Viral (hep C)

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42
Q

What are 3 risk factors of chronic liver failure?

A

Alcohol
Obesity
T2DM
Drugs

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43
Q

Outline the pathophysiology of chronic liver failure

A

Hepatitis/cholecystitis -> reversible fibrosis -> irreversible cirrhosis -> compensated or decompensated

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44
Q

Define compensated cirrhosis

A

Liver function preserved, no evidence of compliance to portal HTN

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45
Q

Define decompensated cirrhosis

A

Complications of liver dysfunction with reduced hepatic synthetic function and portal HTN

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46
Q

How is chronic liver failure graded?

A

Child Pugh score

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47
Q

What are the symptoms of chronic liver failure?

A

ABCDDEFGHIJ

Ascites
Bruising
Clubbing and leuconychia
Dupuytrens contracture
Encelopathy and palmar erythema and spider naevi
Gynaecomastia
Hepatomegaly
Increased parotid
Jaundice

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48
Q

How is chronic liver failure diagnosed?

A

Biopsy to confirm cirrhosis
LFTs
Imagine
Tap of ascites

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49
Q

What causes liver cirrhosis?

A

Chronic liver inflammation and liver cell damage

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50
Q

How is chronic liver failure treated?

A

Prevent progression - lifestyle modifications
Consider transplant if decompensated
Mange complications

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51
Q

Define fulminant liver failure

A

Syndrome of massive hepatocyte necrosis

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52
Q

What is the most common cause of fulminant liver failure?

A

Paracetamol overdose

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53
Q

What is the most common cause of liver failure?

A

Alcoholic liver disease

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54
Q

Outline the pathophysiology of ALD

A

Steatosis (fatty liver) -> Alcohol hepatitis (inflammation + necrosis) -> alcoholic cirrhosis (irreversible scar tissue)

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55
Q

What are 3 risk factors of ALD?

A

Obesity
Smoking
Excessive alcohol use

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56
Q

What are the symptoms of ALD?

A

Early stages have very little symptoms
Later = chronic liver failure symptoms and alcohol dependency

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57
Q

How is alcohol dependency characterised?

A

CAGE and AUDIT

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58
Q

How is ALD diagnosed?

A

GS: liver biopsy
Elevated MCV
Ultrasound or CT
Elevated PT, bilirubin, ALT and AST

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59
Q

What CAGE score indicates alcohol dependency?

A

2 or more

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60
Q

How is ALD treated?

A

Stop drinking alcohol!
Short term steroids
Consider transplant

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61
Q

How are alcohol withdrawal symptoms treated?

A

Chlordiazepoxide or diazepam
IV vitamin D and thiamine

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62
Q

What is the major complication of alcohol withdrawal?

A

Delerium tremens

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63
Q

What is the maximum alcohol recommendation a week?

A

14 units

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64
Q

What are the complications of ALD?

A

Wernicke Korsakoff syndrome
Pancreatitis
HE
Ascites
HCC
Mallory Weiss tear

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65
Q

What are Mallory cytoplasmic inclusion bodies indicative of?

A

ALD

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66
Q

What is Wenicke Korsakoff syndrome?

A

Combined B1 deficiency and alcohol withdrawal symptoms

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67
Q

What are the 3 symptoms of Wernicke Korsakoff syndrome?

A

Ataxia
Nystagmus
Encelopathy

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68
Q

How is Wernicke Korsakoff syndrome treated?

A

IV thiamine

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69
Q

Define non alcoholic fatty liver disease

A

Fat deposited in liver cells which interfere with function which can progress to hepatitis and cirrhosis

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70
Q

What are 3 risk factors of NAFLD?

A

Obesity
HTN
T2DM
Hyperlipidaemia
FHx

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71
Q

Outline the pathophysiology of NAFLD

A

Non-alcoholic fatty liver disease -> Non-alcoholic Steatehepatitis (NASH) -> Fibrosis -> Cirrhosis

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72
Q

How common is NAFLD?

A

30% of adults have it

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73
Q

What are the symptoms of NAFLD?

A

Typically asymptomatic
Severe = liver failure signs
Hepatomegaly
Thrombocytopenia

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74
Q

How is NAFLD diagnosed?

A

Deranged LFTs (raised PT and bilirubin, dec albumin)
Liver ultrasound
Liver biopsy (GS)

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75
Q

What is transient elastography (fibroscan) used for?

A

Non-invasive test measuring liver stiffness, correlating to degree of fibrosis

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76
Q

How is NAFLD treated?

A

Lose weight
Control risk factors
Avoid alcohol

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77
Q

What are the complications of NAFLD?

A

HE
Ascites
HCC
Portal HTN and oesophageal ascites

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78
Q

Define hepatitis

A

Inflammation of the liver

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79
Q

Define viral hepatitis

A

Inflammation of the liver due to viral replication in hepatocytes

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80
Q

What type of virus is hepatitis A?

A

Single stranded RNA

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81
Q

Is Hep A acute or chronic?

A

Acute

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82
Q

Where is Hep A most prevalent?

A

Africa and South America
Seen in autumn

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83
Q

How is hep A spread?

A

Faeco-orally

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84
Q

What are 3 risk factors of Hep A?

A

Shellfish
Travel to Africa or South America
Overcrowding

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85
Q

What are the 2 phases of Hep A and B?

A

Prodromal phase
Icteric phase

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86
Q

What are the symptoms of Hep A and B?

A

Prodromal phase: N+V, fever, malaise, RUQ pain
Icteric phase: jaundice, dark urine, pale stools, pruritus

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87
Q

How is Hep A diagnosed?

A

FBC: leukopenia and raised ESR
Increased HAV IgM in infection, and anti HAV IgG after
Raised bilirubin

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88
Q

How is Hep A treated?

A

Usually self limiting
Anti-emetics and rest
Vaccine available

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89
Q

What type of virus is Hep B?

A

DNA virus

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90
Q

Is Hep B acute or chronic?

A

Acute and chronic

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91
Q

How is Hep B transmitted?

A

Blood
Bodily fluids
sharing needles (IVDU and tattoos)
Vertical transmission (mother to child in utero)

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92
Q

What are the complications of Hep B?

A

Fulminant hepatitis
HCC
Cirrhosis

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93
Q

What is the incubation period of Hep A?

A

2-6 weeks

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94
Q

What is the incubation period of Hep B?

A

1-6 months

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95
Q

What appears in initial Hep B infection on serology?

A

Hb S Ag

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96
Q

What are the antibodies against hep B?

A

Anti-HBs Ag

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97
Q

How is chronic Hep B treated?

A

SC pegylated interferon-alpha 2a (weekly subcutaneous)
Tenofovir
Can lead to transplant

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98
Q

What type of drug is Tenofovir?

A

nucleoside reverse transcriptase inhibitors (NRTIs)

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99
Q

What type of virus is Hep C?

A

RNA flavivirus

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100
Q

Is Hep C chronic or acute?

A

Acute and chronic

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101
Q

Where is Hep C most common?

A

Egypt

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102
Q

How is Hep C spread?

A

Transmitted by blood and blood products
Very high in IVDU
Limited sexual transmission

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103
Q

What are the symptoms of hep C?

A

Acute= usually asymptomatic may have flu-like symptoms
Chronic = cirrhosis, liver failure, HCC, hepatosplenomegaly

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104
Q

How is Hep C diagnosed?

A

HCV antibody = within 4-6 weeks
HCV RNA = active infection!

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105
Q

How is Hep C treated?

A

Direct acting antiviral (DAA)
Ribavirin

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106
Q

What are the 3 suffixes for DAAs?

A

Asvir
Previr
Buvir

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107
Q

Why is access to Hep C treatment limited?

A

Very very expensive

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108
Q

What type of virus is hep D?

A

Incomplete RNA virus

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109
Q

What is required for Hep D assembly?

A

Hep B
(HBsAg)

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110
Q

Where is Hep D common?

A

Eastern Europe
North Africa

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111
Q

How is Hep D diagnosed and treated?

A

Same as Hep B

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112
Q

What are the risk factors of Hep B?

A

Healthcare workers
dialysis patients
Travellers
Gay men
IVDU

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113
Q

Is hep D acute or chronic?

A

Acute and chronic

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114
Q

What type of virus is Hep E?

A

RNA

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115
Q

Is hep E acute or chronic?

A

acute and chronic

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116
Q

How is Hep E spread?

A

Faeco-orally- food or water
Rodents, pigs and dogs

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117
Q

What is a big risk factor for increased Hep E mortality?

A

Pregnancy

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118
Q

How is Hep E infection diagnose?

A

Similar to Hep A (IgM and IgG)
HEV RNA

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119
Q

Where is Hep E common?

A

Indochina

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120
Q

What are 2 types of hepatitis with 100% immunity after infection?

A

Hep A
Hep E

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121
Q

How is Hep E treated?

A

Usually self limiting
Vaccine in china

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122
Q

What would serology HBsAG and IgM indicate?

A

Acute Hep B

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123
Q

What would serology HBsAG and IgG indicate?

A

Chronic Hep B

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124
Q

What would serology HBsAg (maybe) and IgG indicate?

A

Carrier

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125
Q

What would serology anti-HBsAg and anti-HBc indicate?

A

Cleared Hep B

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126
Q

What would serology appear like if the patient has been vaccinated against hep B?

A

Anti-HBsAg

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127
Q

Define autoimmune hepatitis

A

Inflammatory liver disease of unknown cause characterised by abnormal T-cell function and autoantibodies against hepatocyte surface antigens

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128
Q

What are the risk factors of autoimmune hepatitis?

A

Female
HLA DR3/4
Autoimmune disease
Viral hepatitis

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129
Q

Is type 1 or type 2 autoimmune hepatitis more common?

A

Type 1 by far

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130
Q

Who is predominantly affected by type 1 autoimmune hepatitis?

A

Adult women

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131
Q

Who is predominantly affected by type 2 autoimmune hepatitis?

A

Young women/children

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132
Q

How is type 1 autoimmune hepatitis diagnosed?

A

ANA (anti nuclear antibodies)
ASMA (anti smooth muscle antibodies)
Anti-SLA

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133
Q

How is type 2 autoimmune hepatitis diagnosed?

A

Anti-LKM1
Anti-LC1

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134
Q

How is autoimmune hepatitis treated?

A

Prednisolone + Azathioprine
Hep A and B vaccine
If severe = transplant

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135
Q

Define cirrhosis

A

Result of chronic inflammation and damage to hepatocytes, replacing them with fibrosis and nodules of scar tissue

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136
Q

Is cirrhosis reversible?

A

No

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137
Q

What are 4 causes of cirrhosis?

A

ALD (MC in UK)
NAFLD
Hep B and C
Wilsons
Alpha-antitrypsin deficiency

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138
Q

What are the symptoms of cirrhosis?

A

Basically similar to chronic failure

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139
Q

How is liver cirrhosis diagnosed?

A

Fibroscan
Liver biopsy
Hepatomegaly on CT
Thrombocytopenia
Low albumin and raised PT

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140
Q

What are the complications of liver cirrhosis?

A

Coagulopathy
Encephalopathy
Portal HTN
Ascites
Oesophageal varices

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141
Q

How is liver cirrhosis treated?

A

Good nutrition and abstain from alcohol
Ultrasounds for HCC
May need transplant

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142
Q

How is unconjugated bilirubin synthesised?

A

Hb -> haem -> biliverdin ——————> unconjugated bilirubin Via biliverdin reductase

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143
Q

Where is unconjugated bilirubin synthesised?

A

Spleen

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144
Q

How is unconjugated bilirubin transported?

A

Albumin

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145
Q

Where is conjugated bilirubin synthesised?

A

Liver

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146
Q

Define jaundice

A

Yellowing of skin/eyes due to accumulation of bilirubin

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147
Q

What are the 3 categories of causes of jaundice?

A

Prehepatic
Intrahepatic
Post-hepatic

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148
Q

Define Prehepatic jaundice

A

Unconjugated hyperbilirubinaemia due to increased RBC breakdown

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149
Q

What are 3 causes of prehepatic jaundice?

A

Haemolytic anaemias
-Sickle cell
-G6PDH deficiency ect
Gilbert syndrome

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150
Q

What causes intrahepatic jaundice

A

Conjugated/unconjugated hyperbilirubinaemia

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151
Q

What are 3 causes of intrahepatic jaundice?

A

Hepatitis
HCC
ALD/NAFLD
Hepatotoxic drugs

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152
Q

What is Gilbert syndrome?

A

Autorecessive mutation of UGT1A1 gene causing under active UGT therefore causing a decrease in conjugated bilirubin

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153
Q

What is the function of UGT?

A

Converts unconjugated bilirubin to conjugated alongside glucaronic acid

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154
Q

How does unconjugated bilirubin cause unconjugated hyperbilirubinaemia?

A

Not water soluble so does not leave the body in urine

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155
Q

Where is conjugated bilirubin broken down?

A

Small intestine

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156
Q

What breaks down conjugated bilirubin?

A

Colonic flora

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157
Q

What is conjugated bilirubin broken down into?

A

Urobilinogen

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158
Q

What is urobilinogen broken down into?

A

Urobilin (makes wee yellow)
Stercobilin (makes poo brown)

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159
Q

Define post hepatic jaundice

A

Conjugated hyperbilirubinaemia due to biliary obstruction

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160
Q

What are 3 causes of post hepatic jaundice?

A

Gallstones/Cholelithiasis
Pancreatic cancer
Choleangiocarcinoma
Mirizzi syndrome
PBC
PSC

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161
Q

What would pale stools and dark urine indicate?

A

Intra/post hepatic jaundice

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162
Q

Would itching indicate pre hepatic or intra/post hepatic jaundice?

A

Intra/post

163
Q

What gene is mutated in Gilbert syndrome?

A

UGT1A1 chromosome 2
Recessive

164
Q

Outline the pathophysiology of HE

A

Liver fails -> nitrogenous waste builds up -> passes to brain -> neurotoxic so halts Krebs -> irreparable brain damage and neuron death

165
Q

How can HE cause cerebral oedema?

A

Astocytes try to clear ammonia -> excess glutamine -> osmotic imbalance -> shift of fluid into cells -> cerebral oedema

166
Q

How is jaundice often diagnosed?

A

Liver ultrasound

167
Q

What type of cancer affects the pancreas?

A

Adenocarcinoma

168
Q

Where do pancreatic cancers most commonly occur?

A

Exocrine pancreas
Mainly the head (closest to vessels)

169
Q

What are the risk factors of pancreatic cancer?

A

Smoking
Alcohol
DM
Chronic pancreatitis
FHx
Genetic mutation

170
Q

What genetic mutation increases the likelihood of pancreatic cancer?

A

PRSS-1

171
Q

Where do pancreatic cancers originate from?

A

Originate in ductal epithelium -> pre malignant lesions -> fully invasive cancer

172
Q

What are the symptoms of pancreatic cancer?

A

Obstructive/painless jaundice
Pale stool and dark urine
Courvoisiers sign (head)
Epigastric pain from back relieved by sitting forwards (body and tail)

173
Q

What is Courvosiers sign?

A

Palpable gallbladder and jaundice

174
Q

How is pancreatic cancer diagnosed?

A

1st: abdo ultrasound
GS: pancreatic CT with contrast

175
Q

What is the tumour marker of pancreatic cancer?

A

Ca19-9
Non diagnostic- just monitors progression

176
Q

How is pancreatic cancer treated?

A

Surgery to remove tumour
Chemo radio ect
5% 5 year survival so many -> palliative care

177
Q

Who is commonly affected by pancreatic cancer?

A

Males >
>60
Rare in people under 30

178
Q

What is the most common first degree liver cancer?

A

Hepatocellular carcinoma (HCC)

179
Q

Where do HCCs originate from?

A

Liver parenchyma

180
Q

What are 3 risk factors of HCC?

A

Chronic hep C and B
Cirrhosis from ALD, NAFLD, autoimmune
Male

181
Q

Where does HCC metastasise to?

A

Lymph nodes
Bones
Lungs

182
Q

How does HCC metastasise?

A

Hematogenous spread
- hepatic and portal veins

183
Q

What are the symptoms of HCC?

A

Signs of decompensated liver failure
Unexplained weight loss
Fatigue
Ache in R.Hypochondrium

184
Q

How is HCC diagnosed?

A

Increased serum AFP
1. Ultrasound of liver/abdo
GS: CT scan to confirm Dx

185
Q

How is HCC treated?

A

Sorafenib (kinase inhibitor)
Surgical resection
Liver transplant

186
Q

How is HCC prevented?

A

Hep B/HBV vaccine

187
Q

Define cholangiocarcinoma

A

Cancer of the biliary tree

188
Q

What are 3 risk factors of cholangiocarcinoma?

A

Parasitic flukeworm infestation
Biliary cysts
IBD

189
Q

What is the MC type of cholangiocarcinoma?

A

Adenocarcinoma

190
Q

What are the symptoms of cholangiocarcinoma?

A

Jaundice
Abdo pain and ascites
Pruritus
Raised alkaline phosphate

191
Q

Why do symptoms of cholangiocarcinoma appear late?

A

Slow growing

192
Q

How are cholangiocarcinomas diagnosed?

A
  1. Abdo USS and CT
    GS: MRCP (imaging of biliary tree)
    Raised CEA and CA19-9
    Raised bilirubin and ALP
193
Q

How are cholangiocarcinomas treated?

A

Usually untreatable and die <6 months
Resection or ERCP stent

194
Q

What is the tumour marker of HCC?

A

AFP

195
Q

What is the tumour marker of cholangiocarcinoma/

A

CA19-9

196
Q

What are 2 benign primary liver tumours?

A

Haemangionoma
Hepatic adenoma

197
Q

What are 3 causes of hepatic adenoma?

A

Oral contraceptives
Anabolic steroids
Pregnancy

198
Q

How does haemangioma present?

A

Strawberry mark on skin in first few weeks of life

199
Q

Are primary or secondary liver cancers more common?

A

Secondary

200
Q

What 3 locations most often metastasise to the liver?

A

GI tract
Breast
Bronchus

201
Q

How are secondary liver tumours diagnosed?

A

USS with CT or MR
Hepatomegaly without jaundice
Raised serum alkaline phosphate

202
Q

What are the 3 MC causes of drug induced liver injury?

A

Antibiotics
Analgesics
CNS drugs

203
Q

What are 3 drugs that don’t cause liver injury?

A

Low dose aspirin
NSAIDs (except diclofenac)
BBs
CCBs

204
Q

What level of paracetamol induces an overdose?

A

> 150mg/kg/ 12g / 24 tablets

205
Q

Outline the pathophysiology of paracetamol overdose

A

Liver glutathione depleted -> liver can not deactivate NAPQI -> hepatotoxicity and paracetamol induced KI

206
Q

When is liver damage due to paracetamol detectable on liver biochemistry?

A

> 18 hours after ingestion

207
Q

What are the symptoms of paracetamol overdose?

A

Sudden severe onset RUQ pain
N+V
Raised PT
Hypoglycaemia

208
Q

How is paracetamol overdose diagnosed?

A

History
Raised ALT
High paracetamol concentration

209
Q

What is the main complication of paracetamol overdose?

A

Fulminant liver failure

210
Q

How is paracetamol overdose treated?

A
  1. Activated charcoal (gastric decontamination less than 1 hour post ingestion)
  2. N-acetylcysteine (NAC)
211
Q

Outline the pathophysiology of Gilberts

A

Normal RBC breakdown -> reduced conjugation -> raised unconjugated bilirubin -> jaundice

212
Q

What are 3 risk factors of Gilberts syndrome?

A

Males
FHx
Post-pubertal

213
Q

What is the key presentation of Gilberts syndrome?

A

Painless jaundice at a young age worsened by physiological stress

214
Q

What is the MC cause of hereditary jaundice?

A

Gilberts

215
Q

How is Gilberts syndrome treated?

A

Should be okay without
Severe = phototherapy

216
Q

How does N-acetylcystiene work?

A

Replenishes glutathione

217
Q

What is the complication of Gilberts?

A

Kernicterus (accumulation of bilirubin in basal ganglia -> neurological defecit

218
Q

Define hernia

A

Profusion of a viscus/organ or part of it through a defect of the walls of its contained cavity into an abnormal position

219
Q

What are the 2 main classifications of hernia?

A

Reducible hernia
Irreducible hernia

220
Q

Define reducible hernia

A

Can be pushed back into the abdominal cavity with manual manoeuvring

221
Q

Define irreducible hernia

A

Cannot be pushed back into place

222
Q

What are the 3 types of irreducible hernia?

A

Obstructed
Incarcerated
Strangulated

223
Q

Define obstructed hernia

A

Intestine obstructed in the hernia due to pressure of edges of the hernia (non-ischemic)

224
Q

Define incarcerated hernia

A

Contents of the hernia are stuck inside by adhesions

225
Q

Define strangulated hernia

A

Blood supply of the sac is cut off causing ischemia -> gangrene/perforation of hernial contents

226
Q

Define inguinal hernia

A

Protrusion of abdominal contents through the inguinal canal

227
Q

What is the MC hernia?

A

Inguinal hernia

228
Q

What are the 2 types of inguinal hernia?

A

Indirect
Direct

229
Q

What is the MC type of inguinal hernia?

A

Indirect

230
Q

What are 3 risk factors of inguinal hernias?

A

Male
Heavy lifting
Chronic cough
Constipation
Ascites

231
Q

Where do inguinal hernias present?

A

Above and medial to pubic tubercle

232
Q

Define direct hernia

A

Peritoneal sac enters the inguinal canal through the posterior wall of the inguinal canal medial to inferior epigastric vessels

233
Q

Define indirect hernia

A

Peritoneal sec enters the inguinal canal through the deep inguinal ring

234
Q

What is the path of an indirect inguinal hernia?

A

Inguinal canal -> deep inguinal ring -> if large then out through superficial inguinal ring

235
Q

What are the symptoms of an inguinal hernia?

A

swelling in groin- pain indicates strangulation
Bulging with strain
Lump along groin margin pointing to groin

236
Q

How are inguinal hernias diagnosed?

A

Clinical exam
If unsure CT or MRI of groin area

237
Q

What are 3 differential diagnoses of inguinal hernia?

A

Femoral hernia
Testicular torsion
Undescended testes
Epididymitis
Groin abcess

238
Q

How are inguinal hernias treated?

A

Truss to prevent progression
Surgery if very bad:
- Open repair, prosthetic mesh, laparoscopy

239
Q

Define femoral hernia

A

Bowel comes through femoral canal below inguinal ligament

240
Q

Are femoral hernias more common in males or females?

A

Females

241
Q

How do femoral hernias present?

A

Swelling in upper thigh pointing down
Likely to strangulate = pain

242
Q

What are 2 differences between femoral and inguinal hernia?

A

Femoral points down,inguinal points towards groin
Neck of femoral hernia inferior and lateral to pubic tubercle, inguinal superior and medial

243
Q

How are femoral hernias treated?

A

Surgery
Herniotomy- ligation and excision of the sac
Herniorrhaphy - repair of defect

244
Q

Define incisional hernia

A

Tissue protrudes through a weak surgical scar

245
Q

What are 3 risk factor of an incisional hernia?

A

Emergency surgery
Wound infection
Coughing and heavy lifting
Poor nutrition

246
Q

Define umbilical hernia

A

Part of the bowel or tissue protrudes through the umbilicus (belly button)

247
Q

Who is most at risk of a hiatus hernia?

A

Obese women

248
Q

What are the 2 types of hiatus hernia?

A

Sliding
Rolling

249
Q

What is a sliding hiatus hernia?

A

GOJ and part of the stomach slides up into the chest via the hiatus so it lies above the diaphragm

250
Q

Define rolling hiatus hernia

A

GOJ remains in the abdomen but part of the fundus prolapses with the hiatus alongside the oesophagus (basically stomach elongating at the top)

251
Q

How is hiatus hernia diagnosed?

A

Barium swallow
Upper GI endoscopy

252
Q

How is hiatus hernia treated?

A

Lose weight
Treat reflux
Surgery

253
Q

Define Epigastric hernia

A

Hernia in the Epigastric area of the abdomen

254
Q

Define biliary colic

A

Pain associated with temporary obstruction of the cystic or common bile duct by a gallstone

255
Q

What are the 4 character of biliary colic?

A

Sudden onset
Severe
Constant
Crescendo

256
Q

What are 3 biliary tract diseases?

A

Biliary colic- gallstones
Cholecystitis
Cholangitis

257
Q

Where do most gallstones form?

A

Gallbladder

258
Q

What are 3 types of gallstones?

A

Cholesterol (>90%)
Pigmented (Bilirubin and calcium salts)
Mixed- cholesterol + pigment

259
Q

What are 3 complications of gallstones?

A

Acute Cholecystitis
Acute cholangitis
Pancreatitis

260
Q

What are 5 risk factors of gallstones?

A

Fat
Female
Forty
Fair
Fertile

261
Q

What are the symptoms of gallstones?

A

Colicky RUQ pain
- Worsened by eating large fatty meals
Nausea and vomiting

262
Q

What are 4 causes of gallstones?

A

Obesity and rapid weight loss (high in animals, low in fibre)
DM
Liver cirrhosis
Contraceptive pill

263
Q

How are gallstones diagnosed?

A
  1. Ultrasound
    GS: MRCP
    FBC and CRP shows inflammatory markers
    Raised ALP
264
Q

How are gallstones treated?

A

NSAIDs/analgesia
ERCP
PCT
Elective laparoscopic cholecystectomy

265
Q

What is a cholecystectomy?

A

Removal of gallbladder

266
Q

Define cholecystitis

A

Inflammation of the gallbladder (95% of time due to gallstone)

267
Q

Outline the pathophysiology of cholecystitis

A

Stone blocking duct -> bile builds up
THEN vascular supply reduced from distension
THEN transmural inflammation

268
Q

What are the symptoms of cholecystitis?

A

RUQ pain radiating to right shouder
Fever and fatigue
Positive Murphy sign

269
Q

What is the proper name for gallstones?

A

Cholelithiasis

270
Q

What is Murphys sign?

A

Severe pain on deep inhalation with a hand pressed into RUQ

CHOLECYSTITIS

271
Q

How is cholecystitis diagnosed?

A
  1. Abdo USS shows thickened gallbladder wall
    Normal LFT
    Leukocytosis and neutropenia
272
Q

How is cholecystitis treated?

A

Prepare for surgery: IV Abx, heavy analgesia, IV fluids
Cholecystectomy within one week

273
Q

What is the MC cause of cholecystitis?

A

E. Coli

274
Q

What is the other name for ascending cholangitis?

A

Acute cholangitis

275
Q

Define ascending cholangitis

A

Acute inflammation and infection of the biliary tree

276
Q

What are 3 causes of ascending cholangitis?

A

Gallstones
Benign biliary strictures
Malignancy

277
Q

Outline the pathophysiology of ascending cholangitis

A

Prolonged bile duct blockage -> bile stasis -> bacteria enters from duodenum ->biliary tree infection and consolidation

278
Q

What are the symptoms of ascending cholangitis?

A

Charcots triad
Raised neutrophil
Reynolds Pentad

279
Q

What is charcots (liver) triad?

A

Ascending cholangitis

RUQ pain
Jaundice
Fever

280
Q

What is Reynolds pentad?

A

Charcots triad
Confusion
Septic shock

281
Q

How is ascending cholangitis diagnosed?

A

USS (1) and MRCP (GS)
Blood cultures to find out bacterial cause
Leukocytosis, raised bilirubin, CRP and ALP

282
Q

How is ascending cholangitis treated?

A

Treat sepsis if needed
ERCP and stenting to clear blockage
Cholecystectomy when recovered a bit

283
Q

What does PBC stand for?

A

Primary biliary cholangitis/cirrhosis

284
Q

Define PBC

A

Intrahepatic autoimmune condition causing progressive destruction of small bile ducts

285
Q

Who is affected by PBC?

A

Almost always women
40-50 years
Smokers
Autoimmune disease

286
Q

What are 3 risk factors of PBC?

A

FHx
many UTIs
Smoking
Past pregnancy
Using hair dye and nail polish

287
Q

Is PBC or PSC more common?

A

PBC

288
Q

Outline the pathophysiology of PBC

A

Chronic autoimmune granulomatous inflammation -> cholestasis -> fibrosis and cirrhosis of small bile ducts

289
Q

How is PBC diagnosed?

A

95% have AMA (anti mitochondrial) antibodies on serology
Increased IgM, ALP, GGT
Ultrasound
Liver biopsy to stage

290
Q

What are the symptoms of PBC?

A
  1. Pruritus (itching)
  2. Then lethargy and fatigue
  3. Then jaundice and hepatomegaly
    Pigmented xanthelsaema (yellow deposits under skin usually around eyelids)
291
Q

What are 3 complications of PBC?

A

Cirrhosis
Osteoporosis
Malabsorption
Coagulopathy

292
Q

How is PBC treated?

A
  1. Ursodeoxycholic acid (improves bilirubin levels+ reduce cholestasis)
  2. Colestyramine for pruritus
    Transplant (may still return)
    Supplement vit ADEK
293
Q

What autoimmune condition is most associated with PBC?

A

Sjogrens

294
Q

Define cholestasis

A

Reduced or stopped bile flow

295
Q

What does PSC stand for?

A

Primary sclerosing cholangitis

296
Q

What causes pruritus in PBC?

A

Conjugated bilirubin leaking out

297
Q

Define PSC

A

Chronic cholestatic disorder characterised by inflammatory and fibrosis of intrahepatic and extrahepatic bile ducts

298
Q

What are 3 risk factors of PSC?

A

Men
40-50
IBD (UC)
FHx

299
Q

Outline the pathophysiology of PSC

A

Same as PBC but affects ALL ducts

300
Q

What are the symptoms of PSC?

A

RUQ pain
Jaundice
Pruritus
Hepatomegaly

301
Q

How is PSC diagnosed?

A

GS: MRCP- bile duct lesions or strictures (beaded)
positive ANCA
(Positive ANA and ASMA)

302
Q

How is PSC treated?

A

Cholestyramine - for pruritus
ERCP dilation and stenting
Transplant

303
Q

How is PSC monitored?

A

Colonoscopy and USS yearly
- bile duct, liver , gallbladder and colon cancer more common

304
Q

What are the complications of PSC?

A

Cholangiocarcinoma (10%)
Osteoporosis
Malabsorption
Strictures
Cancers

305
Q

What condition is linked to PSC?

A

IBD- UC

306
Q

Define acute pancreatitis

A

Reversible acute inflammation of the pancreas

307
Q

What are the causes of acute pancreatitis?

A

I GET SMASHED

Idiopathic
Gallstones (MC)
Ethanol (30%)
Trauma
Steroids
Mumps
Autoimmune
Scorpion venom
Hyperlipidaemia
ERCP
Drugs

308
Q

What 5 drugs can cause acute pancreatitis?

A

Azathioprine
Furosemide
Corticosteroids
NSAIDs
ACE inhibitors

309
Q

Outline the pathophysiology of acute pancreatitis

A

Premature activation of pancreatic enzymes -> host defences overwhelmed -> autodigestion of pancreas -> inflammation and enzymes leak in blood

310
Q

How do galllstones cause acute pancreatitis?

A

Trapped in ampulla of Vater -> blocks flow of bile -> reflux of bile into pancreatic duct -> prevents enzymes from being secreted -> causes inflammation in the pancreas

311
Q

How does alcohol cause pancreatitis?

A

Directly toxic to pancreatic cells

312
Q

What are the symptoms of acute pancreatitis?

A

Sudden severe abdo pain radiating to back better sitting fowards or lying fetal
N+V+ fever
Cullens sign
Grey turners sign
Abdo guarding and tenderness on examination

313
Q

What is Cullens sign?

A

Periumbilical ecchymosis
Skin discolouration around belly button

314
Q

What is Grey Turners sign?

A

Left flank bruising

315
Q

How is acute pancreatitis diagnosed?

A

Raised urinary and serum amylase
Raised lipase
CXR to exclude AAA
Abdo USS to find gallstones

316
Q

What systems are used to score acute pancreatitis?

A

Glasgow and Ranson scoring
APACHE II

317
Q

How is acute pancreatitis treated?

A

NEEDS SEVERITY ASSESSMENT

NBM and NG tube
IV fluid resus
Analgesia
Monitor complications

318
Q

What is the major complication of acute pancreatitis?

A

SIRS (systemic inflammatory response syndrome)

319
Q

How is SIRS diagnosed?

A

Any 2 of

Tachycardia >90
Tachypnoea >20
Pyrexia
High WCC

320
Q

Define chronic pancreatitis

A

Debilitating continuing inflammation in the pancreas causing a loss of tissue replacement by fibrosis of the endocrine and exocrine regions

321
Q

What history is required for chronic pancreatitis?

A

3 months

322
Q

What are 3 causes of chronic pancreatitis?

A

Long term alcohol excess (MC)
CKD
CF
Hereditary
Idiopathic

323
Q

Outline the pathophysiology of chronic pancreatitis

A

Obstruction of bicarbonate release -> pH rises -> damage and necrosis -> fibrosis

324
Q

What is the differential diagnosis of acute pancreatitis?

A

AAA

325
Q

What are the symptoms of chronic pancreatitis?

A

Epigastric pain boring to back, worsened by alcohol and fatty food
Exocrine dysfunction (steatorrhoea, weight loss)
Endocrine dysfunction (DM)

326
Q

What is the differential diagnosis of chronic pancreatitis?

A

Pancreatic cancer

327
Q

How is chronic pancreatitis diagnosed?

A

Unlike acute, amylase and lipase not as elevated
Abnormal faecal elastase
GS: abdo USS and contrast enhance CT

328
Q

How is chronic pancreatitis treated?

A

Alcohol cessation
Analgesia
Pancreatic enzyme supplements
Insulin for DM

329
Q

Where is autoimmune pancreatitis most common?

A

Japan

330
Q

Define autoimmune pancreatitis

A

Chronic pancreatic inflammation resulting from an autoimmune process

331
Q

What are the symptoms of autoimmune pancreatitis?

A

Similar to chronic

332
Q

How is autoimmune pancreatitis diagnosed?

A

Elevated IgG4
ANCA and rheumatoid factor may be elevated

333
Q

How is autoimmune pancreatitis treated?

A

Glucocorticoids (eg. Prednisolone) for 4-6 weeks

334
Q

Define ascites

A

Accumulation of free fluid in the peritoneal cavity

335
Q

What are the normal levels of fluid in the peritoneal cavity?

A

Healthy men- minimum few ml
Healthy women- up to 20ml

336
Q

What are the 4 stages of ascites?

A

1: only detectable by USS
2. Moderate causing abdo asymmetry
3. Large causing marked distension but not tense
4: tense

337
Q

What are the categories of causes of ascites?

A

Local inflammation
Low protein
Flow stasis

338
Q

What are 3 causes of local inflammation induced ascites?

A

Peritonitis
Abdo cancers (ovarian)
Infection such as TB

339
Q

What are 3 causes of low protein induced ascites?

A

Hypoalbuminaemia
Nephrotic syndrome
Malnutrition

340
Q

What are 3 causes of flow stasis induced ascites?

A

Cirrhosis!
Budd-Chiari
Heart failure

341
Q

What are the symptoms of ascites?

A

Abdo distension
Shifting dullness
Jaundice and pruritus
Flank fullness

342
Q

What are 2 signs of shifting dullness?

A

Supine = abdo resonant and flanks full
On side = flank resonant

343
Q

How is ascites diagnosed?

A

Shifting dullness
Ascitic tap
- find malignancy, infection, WCC
serum ascites albumin gradient (SAAG) to find cause

344
Q

What are the protein measurements indicating high SAAG?

A

> 1.1g/dL

345
Q

What does high SAAG in ascites indicate?

A

Portal HTN
Heart failure
Budd-Chiari
Pericarditis

346
Q

What does low SAAG in ascites indicate?

A

Malignancy
Peritonitis
TB
Pancreatitis

347
Q

How is ascites treated?

A

Treat underlying cause
Diuretic = Spironolactone
Paracentesis (drain fluid)
TIPS (shunt)
Liver transplant if something causing it is liver related

348
Q

Define portal hypertension

A

High blood pressure in the portal venous system

349
Q

Define Budd-Chiari syndrome

A

Hepatic vein obstruction by tumour or thrombosis

350
Q

What are 3 classifications of causes of portal hypertension?

A

Pre hepatic
Intra hepatic
Post hepatic

351
Q

What is a pre hepatic cause of portal hypertension?

A

Portal vein thrombosis

352
Q

What is an intrahepatic cause of portal hypertension?

A

Cirrhosis (MC UK)
Schistosomiasis (MC worldwide)
Budd-Chiari

353
Q

What are 3 post hepatic causes of portal hypertension?

A

Constrictive pericarditis
IVC obstruction
RHF

354
Q

Outline the pathophysiology of portal hypertension

A

Liver damage -> resistance -> drop in BP -> increase in CO and water retention -> increased portal flow -> shunts and portal HTN -> oesophageal varices

355
Q

What are the symptoms of portal HTN?

A

Usually asymptomatic
Splenomegaly
CLD = haematemesis and malaena ect

356
Q

Define oesophageal varices

A

Dilated collateral blood vessels that develop due to portal HTN

357
Q

Outline the pathophysiology of ruptured oesophageal varices

A

Small veins can not handle much pressure -> high pressure -> ruptured

358
Q

What are the symptoms of ruptured oesophageal varices?

A

Haematemesis (coffee ground vomit)
Melaena (tarry stools)

359
Q

How are oesophageal varices diagnosed?

A

Oesophagogastroduodenoscopy (OGD/upper GI endoscopy)

360
Q

How are ruptured oesophageal varices treated?

A

Resus until stable and consider transfusion if unstable
1. IV terlipressin
2. Variceal banding
3. TIPSS (shunt to larger veins)

361
Q

How is oesophageal varices rupture prevented?

A

BB and nitrates
Variceal banding
Liver transplant

362
Q

Define peritonitis

A

Inflammation of the peritoneal cavity caused by infection of ascitic fluid

363
Q

What are the 2 parts of the peritoneum?

A

Parietal (well localised sensation)
Visceral (poorly localised)

364
Q

What are the 2 categories of causes of peritonitis?

A

Bacterial/primary
Chemical/ secondary

365
Q

What is a gram positive cause of peritonitis?

A

Staph aureus

366
Q

What is a gram negative cause of peritonitis?

A

E. Coli
Klebscella

367
Q

What are 3 chemical causes of peritonitis?

A

Bile
Ruptured ectopic pregnancy
Intestinal perforation
Old clotted blood

368
Q

What are 3 risk factors of peritonitis?

A

Liver disease
Cirrhosis
Ascites

369
Q

What are the symptoms of peritonitis?

A

Sudden onset abdo pain -> collapse and shock
Being rigid helps
Pressing hurts less than releasing pressure
Ascites

370
Q

How is peritonitis diagnosed?

A

Ascitic tap
Cultures to show bacteria
Exclude pregnancy as a cause
CXR to see perforation

371
Q

How is peritonitis treated?

A

Metronidazole and cefotaxime
Surgery- clean peritoneum

372
Q

What is the major complication of peritonitis?

A

Septicaemia

373
Q

Define haemochromatosis

A

Iron storage disorder that results in excessive total body iron and deposition of iron in tissues.

374
Q

What are the causes of haemachromatosis?

A

HFE gene mutation on chromosome 6
High iron intake
Alcoholism

375
Q

Is the HFE gene mutation in haemochromatosis dominant or recessive?

A

Autosomal recessive

376
Q

Why are men more likely to have haemochromatosis?

A

Blood loss from menstrual cycle in females reduces Fe

377
Q

Outline the pathophysiology of haemochromatosis

A

HFE interacts with transferrin receptor 1 -> increased iron uptake -> decreased hepcidin -> iron overload -> taken up by liver and also deposited in other organs

378
Q

What is the function of hepcidin?

A

Controls iron absorption

379
Q

When does haemochromatosis usually present?

A

50s

380
Q

What are the symptoms of haemochromatosis?

A

Testicular atrophy
Hypogonadism
Slate grey/ bronze skin
Osteoporosis
Liver failure symptoms

381
Q

How is haemochromatosis diagnosed?

A

Raised serum Fe, ferritin
Genetic testing
Liver biopsy (Prussian blue/perl stain)

382
Q

How is haemochromatosis treated?

A

Venesection - regular removal of blood/ desferrioxamine (chelating agent)
Avoid alcohol
Treat complications

383
Q

Define Wilson’s disease

A

Excess accumulation of copper in body and tissues

384
Q

What causes Wilson’s disease?

A

Autorec mutation of ATP7B copper binding protein on chromosome 13

385
Q

What age does Wilson’s disease usually present?

A

Young- 20s
Usually males

386
Q

Outline the pathophysiology of Wilson’s disease

A

Impaired Cu biliary excretion -> CU accumulation in liver and basal ganglia

387
Q

What is copper usually bound?

A

Caeruloplasmin

388
Q

What are the symptoms of Wilson’s disease?

A

Hepatic issues
CNS issues
Kayser-Fleischer ring

389
Q

What is a Kayser-Fleischer ring?

A

Copper deposition in the cornea causing a greenish-brown ring around the iris

390
Q

How is Wilson’s disease diagnosed?

A

Reduced serum Cu and caeruloplasmin
GS: liver biopsy
High 24 hour urinary Cu excretion

391
Q

How is Wilson’s disease treated?

A

Avoid food high in Cu (liver, chocolate, nuts)
Lifelong chelating agent

392
Q

What is an example of a copper chelating agent?

A

D-Penicillamine

393
Q

Define A1AT deficiency

A

Deficiency of alpha 1 antitrypsin enzyme

394
Q

What causes A1AT deficiency?

A

Autorecessive mutation of protease inhibitor gene (SERPINA-1) on chromosome 14

395
Q

Outline the pathophysiology of A1AT deficiency

A

No inhibition of NE -> degradation of elastic tissue in the lungs
And
Deposition of A1AT in liver -> cirrhosis

396
Q

What is the function of A1AT?

A

Inhibits NE (neutrophil elastase) which degrades elastic tissue

397
Q

What are the effects of A1AT deficiency on the lungs?

A

Degrading elastic tissue -> emphysema, alveolar duct collapse, trapped air

398
Q

What are the symptoms of A1AT deficiency?

A

Young-mid aged male with COPD like symptoms and no smoking Hx
Liver disease in children (neonatal jaundice)

399
Q

How is A1AT deficiency diagnosed?

A

Decreased serum A1AT
Biopsy- Periodic acid Schiff positive globules
CT- emphysema
Genetic testing

400
Q

How is A1AT deficiency treated?

A

Stop smoking
Treat complications
Manage emphysema

401
Q

What are 2 complications of A1AT deficiency?

A

HCC
Cirrhosis

402
Q

What are the 3 symptoms of Budd Chiari syndrome?

A

Ascites
Hepatomegaly
Abdominal pain

403
Q

What are the 3 antigens in Hep B?

A

HBsAg- surface antigen
HBcAg- cord antigen
HbdAg- active disease marker

404
Q

What are 3 bacterial causes of cholecystitis?

A

E.coli
Klebsiella
Enterococcus

405
Q

How is portal hypertension treated?

A

Beta blocker (CI cirrhosis)
TIPSS shunt
Liver transplant

406
Q

how are alcohol units calculated?

A

ml of alcohol x ABV
——————————
1000

Phase 2a Annabel (12 decks)

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