Biliary/Liver Flashcards
1
Q
Pre-hepatic causes of jaundice (2)
A
Haemolytic anaemia
Gilberts
2
Q
Post-hepatic causes of jaundice (2)
A
Gallstones
Obstructing cancer: head of pancreas, CBD
3
Q
Hepatic causes of jaundice (5)
A
Viral hepatitis Alcoholic hepatitis NAFLD AIH Genetic hepatitis
4
Q
Features of post hepatic jaundice
A
Pale stools
Dark urine
5
Q
Features of haemolytic anaemia (4)
A
HA: low Hb, raised bilirubin, low haptoglobins, raised lactate
Normal urine – unconjugated bilirubin is insoluble in water
6
Q
Causes of chronic liver disease (5)
A
Viral hepatitis Alcoholic hepatitis NAFLD AIH Genetic hepatitis
7
Q
Which hepatic virus’ are chronic
A
BCD but C is more likely to become chronic
8
Q
What is the typical population of AIH
A
Look for fat young women who are cushingoid post tx
9
Q
Congenital causes of chronic liver disease and what is their inheritance pattern (3)
A
A1AT, Wilsons, hereditary haemochromatosis
All are autosomal recessive
10
Q
AI causes of liver disease
A
AIH, PSC, PBC
11
Q
Hepatitis A:
Transmission route
Infection length
Symptoms (6)
A
Oro-anal sex; faeco-oral spread Acute (around 8 weeks) asymptomatic (usually) but can have: Nausea Vomiting (+ Diarrhoea) Fever Jaundice Abdominal pain (particularly RUQ)
12
Q
Hepatitis B:
Transmission route
Infection length
Symptoms
A
Blood, Semen, Vertically
Most adults clear it
13
Q
Hepatitis C:
Transmission route
A
Only through blood (e.g. drugs or tattoos)
14
Q
Which hepatic virus can cause HCC
A
HCV/HBV
15
Q
Which hepatic virus can only connect with another
A
D can only co-infect with B
16
Q
Which hepatic virus is a particular problem for pregnant women
A
HEV
17
Q
Which group of patients are particularly at risk of HEV
A
Pregnant women and immunocompromised
18
Q
Length of infection of HBV and HCV and difference in adults and children
A
B adults mostly clear, children stay as carriers
C adults mostly stay as carriers and children clear
19
Q
Incubation period of HAV
A
2 weeks
20
Q
Incubation period of HBV
A
4-12 weeks
21
Q
Incubation period of HCV
A
2 weeks - 6 months
22
Q
Incubation period of HDV
A
4-12 weeks
23
Q
Incubation period of HEV
A
5-6 weeks
24
Q
All viral hepatitis’ can cause acute hepatitis with transaminitis in 1000s except…..
A
Hepatitis B which is mostly cleared by adults
25
What is the triad for viral hepatitis
(Fever) + Jaundice + Raised AST/ALT (in the 1000's)
26
Where is HAV endemic to
Africa/Asia
27
Where is HBV endemic to
Africa
28
Where is HCV endemic to
Eastern Mediterranean
29
Where is HDV endemic to
Africa
30
Where is HEV endemic to
Poor water supply (India, most third world areas...)
31
Which is chronic and which is acute IgG and IgM
IgM MAN that’s acute!
| IgG Chronic
32
What does HbsAg mean
HBV is here/around NOW
Negative if been cleared/past vaccine
Positive in acute/chronic infection
33
What does HbeAg
| mean
Infective
34
What does Anti-HbS
| mean
```
Immune
Past clearance (ie got it in past, cleared it, ‘natural immunity’
```
35
What does Anti-Hbc
| mean
Caught in the past
| Positive if natural immunity and cleared
36
Mx of HAV
A: supportive care
37
Mx of HBV
B: supportive care for acute, antivirals +peg⍺-interferon for chronic.
38
Mx of HCV
C: supportive care for acute, direct acting antivirals for chronic.
Elbasvir/glecaprevir
Ritonvair + ribavirin
39
Which hepatic viruses can have serious complications and what are they
HBV HCV
| HCC and cirrhosis
40
What are causes of transaminitis in the 1000's (3)
Paracetamol overdose
Acute viral hepatitis (not B)
‘Ischaemic hit’
41
What does a raised GGT and ALP suggest
Cholestatic/obstructive picture, biliary damage GGT (EtOH)
42
What does a raised AST:ALT in a 2:1 ratio suggest
alcoholic hepatitis
43
What does low urea suggest
severe liver disease, (synthesised in liver), malnutrition, pregnancy
44
What does low albumin suggest
poor synthetic function of liver
45
What does a raised urea over 10 suggest (2)
UGIB (or large protein meal)
| Dehydration/AKI (urea excreted renally)
46
What LFT pattern suggests:
| paracetamol OD
Transaminitis in the 1000s
47
What LFT pattern suggests:
| ischaemic hit
Transaminitis in the 1000s
48
What LFT pattern suggests:
| viral hepatitis
Transaminitis in the 1000s
49
What LFT pattern suggests:
| Cholestatic/obstructive picture
Raised GGT and ALP
50
```
What LFT pattern suggests:
biliary damage (EtOH)
```
Raised GGT and ALP
51
What LFT pattern suggests:
| alcoholic hepatitis
AST:ALT 2:1
52
What LFT pattern suggests:
| poor synthetic function of liver
Low albumin
53
What LFT pattern suggests:
| severe liver disease
Low urea
54
What LFT pattern suggests:
| malnutrition
Low urea
55
What LFT pattern suggests:
| pregnancy
Low urea
56
What LFT pattern suggests:
| UGIB (or large protein meal)
Raised urea (>10)
57
What LFT pattern suggests:
| Dehydration/AKI
Raised urea (>10)
58
Typical NASH patient
Old fat man (metabolic syndrome)
59
Ix for NASH (4)
Elevated fasting triglycerides, low HDL
High ALT/AST
Incidental liver USS = Steatosis
60
RF for NAHS (6)
```
Obesity
Type 2 diabetes mellitus
Hypertension
Hypercholesterolaemia
Age > 50 yrs
Smoking
```
61
Symptoms of NASH (5)
```
Usually found as an incidental finding
Occasional symptoms include:
Dull or aching RUQ pain
Fatigue
Unexplained weight loss
Weakness
Symptoms of cirrhosis will be experienced in the most advanced stages of NASH
```
62
3 main signs of cirrhosis (3)
E.g. jaundice, ascites, pruritus
63
Mx of NASH (7)
```
Conservative - controlling risk factors:
Blood pressure
Diabetes
Cholesterol
Lose weight
Stop smoking
Exercise regularly
Reduce alcohol consumption (although it is NOT caused by excessive alcohol, drinking can make it worse)
```
64
Complications of NASH (6)
```
Cirrhosis
Ascites
Oesophageal varices
Hepatic encephalopathy
Hepatocellular carcinoma
End-stage liver failure
```
65
3 forms of liver disease caused by alcohol
Alcoholic fatty liver (steatosis)
Alcoholic hepatitis
Chronic cirrhosis
66
Mild symptoms of alcoholic hepatitis (4)
Nausea
Malaise
Epigastric pain
Right hypochondrial pain Low-grade fever
67
More severe symptoms of alcoholic hepatitis (4)
Jaundice
Abdominal discomfort or swelling
Swollen ankles
GI bleeding
68
How long do you need to be drinking to get alcoholic hepatitis
a long history of heavy drinking is required for the development of alcoholic hepatitis (around 15-20 years)
here may be events that trigger the disease (e.g. aspiration pneumonia, injury)
69
Signs of alcohol excess (10)
```
Malnourished
Palmar erythema
Dupuytren's contracture
Facial telangiectasia
Parotid enlargement
Spider naevi
Gynaecomastia
Testicular atrophy
Hepatomegaly
Easy bruising
```
70
Signs of severe alcoholic hepatitis (8)
```
Febrile (in 50% of patients)
Tachycardia
Jaundice
Bruising
Encephalopathy (e.g. liver flap, drowsiness, disorientation)
Ascites
Hepatomegaly
Splenomegaly
```
71
FBC in alcoholic hepatitis (4)
Low Hb
High MCV
High WCC
Low platelets
72
LFTs of alcoholic hepatitis (4)
High AST + ALT
High bilirubin
High ALP + GGT
Low albumin
73
U&E's in alcoholic hepatitis (2)
Urea and K+ tend to be low
74
What is a sensitive marker for significant liver damage
Prolonged PT/high INR
75
What is seen in the main Ix of EtOH related cirrhosis (5)
Low albumin, low platelet, high INR (prothrombin time), USS splenomegaly, ascetic fluid (portal HTN)
76
Ix for alcoholic hepatitis (8)
```
FBC
LFT
U&E's
PT/INR
US
Liver biopsy
EEG
Upper GI endoscopy
```
77
Mx of acute alcoholic hepatitis
Acute
Thiamine
Vitamin C and other multivitamins (can be given as Pabrinex)
Monitor and correct K+, Mg2+ and glucose
Ensure adequate urine output
Treat encephalopathy with oral lactulose or phosphate enemas
Ascites - manage with diuretics (spironolactone with/without furosemide) Therapeutic paracentesis
Glypressin and N-acetylcysteine for hepatorenal syndrome
• Nutrition
Via oral or NG feeding is important
Protein restriction should be avoided unless the patient is encephalopathic
Nutritional supplementation and vitamins (B group, thiamine and folic acid) should be started parenterally initially, and continued orally
Steroid Therapy - reduce short-term mortality for severe alcoholic hepatitis
78
How do you treat encephalopathy (2)
oral lactulose or phosphate enemas
79
Complications of alcoholic hepatitis (3)
Acute liver decompensation
Hepatorenal syndrome
Cirrhosis
80
What is a very good test for cirrhosis
Albumin and prothrombin time will definitely be abnormal in cirrhosis because these are markers of of the hepatic synthetic function which is less affected by fat build up than fibrosis.
81
Complications of cirrhosis (4)
portosystemic encephalopathy, hepatorenal and hepatopulmonary syndrome.
Development of hepatocellular carcinoma.
82
What is the pathology and inheritance behind Wilson's disease
Impaired excretion of copper from liver via bile through copper transporter, autosomal recessive
83
Where does Cu accumulate in Wilsons disease and what does that cause (3)
Liver: CLD
Basal ganglia: early onset neuropsychiatric sx/Parkinsonism
Cornea: Keyser Fleischer rings
84
Mx of Wilson's disease
penicillamine to chelate Cu
85
Ix for Wilson's disease (3)
LOW serum caereuloplasmin
High urinary copper
LOW serum Cu (paradoxical) – not reliable
86
Age of onset of Wilson's disease and difference in presentation between children and adults
10-25 years
| children present with liver disease, adults present with neurological disease
87
Symptoms of Wilson's disease (10)
Liver: Hepatitis, cirrhosis
Neurological: Basal ganglia degeneration, speech and behaviour problems , asterixis, chorea, dementia
Kayser-Fleischer rings
Renal tubular acidosis - fanconi syndrome
Haemolysis
Blue nails
88
What is the issue with haemochromatosis and pattern of inheritance (2)
dysregulated increased dietary iron absorption and increased iron release from macrophages.
autosomal recessive
89
Where is iron deposited in haemochromatosis (6)
Deposits in liver, pancreas, skin, joints, heart and pituitary gland
90
Haematinics of haemochromatosis
Transferrin LOW
High transferrin saturation
Serum Ferritin HIGH (storage)
TIBC LOW
91
Describe iron metabolism
Iron absorbed in duodenum where it is stored intracellullarly bound to ferritin or transported out of the cells by ferroportin, a transmembrane protein
Ferroportin then binds to transferrin in the blood
Hepcidin is a protein that inhibit ferroportin, thereby regulating the amount of iron entering the blood
92
Age of onset of haemochromatosis
40-60
93
Early symptoms of haemochromatosis (6)
Fatigue, arthralgias, weakness, arthropathy, ED, heart problems (vague)
94
Late symptoms of haemochromatosis (7)
Diabetes, bronzed skin, hepatomegaly, arrhythmias, cardiomyopathy, neuro/psych problems
Cirrhosis
95
Which Ab are positive in AIH (2)
AIH: anti smooth muscle antibodies, and sometimes anti-liver kidney microsomal antibodies
96
Common population of AIH
Consider in young fat women on lots of steroid
| Clusters with other autoimmune conditions
97
What does pituitary deposits of Cu cause
loss of libido, sexual dysfunction
98
Which gallbladder disease has a triad and what is it
Cholangitis
RUQ pain
Fever
Jaundice
99
What are the main symptoms of biliary colic
RUQ pain
100
What are the main symptoms of acute cholecystitis
RUQ pain and fever
101
What are the main symptoms of cholangitis
RUQ pain
Fever
Jaundice
102
Ix for gallbladder disease (3)
LFT 1st line, Abdo USS (gold-standard, Dx), then consider MRCP
103
What is Boas signs
Pain radiating to the scapula in cholecystitis (can also be present in gallstones)
104
Which two signs together strongly indicate acute chollecystitis
Boas and Murphys
105
Mx of cholelithiasis
Cholecystectomy
106
Mx of choledocholithiasis
ERCP
107
Pathology of PBC
Intrahepatic bile duct granulomatous destruction by Abs
108
Pathology of PSC
Intra- and extrahepatic bile destruction
Biliary obstruction
Backpressure to liver cirrhosis
109
Typical patient in PBC (3)
Itchy middle aged females (F:M 9:1), fatigue (dry eyes, mouth)
110
Typical patient in PSC (population and age)
People with IBD – UC
| 40-50s
111
Main symptoms of PBC
Fatigue
Weight loss
Pruritis
112
What does PBC lead to (2)
cholestasis, and, ultimately, cirrhosis
113
Pathogenesis of PSC (6)
```
Periductal inflammation with periductal concentric fibrosis (scarring)
Portal oedema
Bile duct proliferation
Expansion of portal tracts
Progressive fibrosis
Development of biliary cirrhosis
```
114
Ix for PBC (2)
Anti mitochondrial m2 antibodies
| Lipids also raised
115
Ix for PSC
MRCP: beads on a string
116
Associations in SBA's of PBC (3)
Hypercholestrolaemia: tendon xanthomata, xanthelasma peri-ocular
117
Associations in SBA's of PSC (2)
UC: most PSC patients have UC, most UC patients don’t have PSC
Cholangiocarcinoma (CBD cancer)
118
Age of pancreatic cancer
Peak incidence 65-75 years old.
119
Key symptoms of pancreatic cancer (7)
jaundice, non-specific abdo pain, FLAWS.
Also sudden onset DM
120
Ix for pancreatic cancer (4)
LFTs, Protocol CT scan
| If unclear offer PET/CT or EUS
121
What is Courvoisiers law
a palpable gallbladder in the presence of painless jaundice is unlikely to be due to stones
122
Associations of HCC (6)
Chronic liver damage (EtOH liver disease, HepB/C, AI), metabolic disease, alpha-1 antitrypsin deficiency
Aflatoxin
123
Which fungal toxin causes HCC
Aflatoxin
124
Ix for HCC
urgent direct access ultrasound scan
| LFT (marker of liver function: Albumin/Clotting – APPT/PT), alpha-fetoprotein (AFP) – tumour marker, hepatitis serology
125
Which tumour marker suggests HCC
AFP
126
What is the marker for pancreatic cancer
CA19-9
127
What is the marker for cholangiocarcinoma
CA19-9
128
What associations are with cholangiocarcinoma (2)
Ulcerative colitis + Primary sclerosing cholangitis
129
Which gender does liver cysts commonly affect
Women
