Case 3 - Liver disease - Progress Test

Question 1

What causes right upper quadrant pain provoked by eating a fatty meal?

Answer 1

Biliary colic

gallstone lodged in the bile duct

Question 2

What causes right upper quadrant pain, Murphy’s sign, fever and raised inflammatory markers?

Answer 2

Acute cholecystitis

inflammation / infection of the gallbladder secondary to impacted gallstones

Question 3

What causes right upper quadrant pain associated with fever and jaundice?

Answer 3

Ascending cholangitis

a bacterial infection of the biliary tree, commonly predisposed by gallstones

Question 4

What causes severe epigastric pain, radiating to the back.

Associated signs include tenderness, ileus and low grade fever

Answer 4

Acute pancreatitis

usually due to alcohol or gallstones

Question 5

What causes epigastric pain worse after eating?

Answer 5

Gastric ulcers

may be a history of NSAID use or alcohol excess

Question 6

What causes epigastric pain that improves after eating?

Answer 6

Duodenal ulcers

may be a history of NSAID use or alcohol excess

Question 7

What causes initially central abdominal pain that moves to the right fossa.

Associated features include: tachycardia, low-grade fever and tenderness in RIF

Answer 7

Appendicitis

Question 8

What causes left lower quadrant pain, which is colicky in nature.

Associated symptoms include diarrhoea (which is sometimes blood), fever, raised inflammatory markers and white cells

Answer 8

Acute diverticulitis

Question 9

What causes central abdominal pain associated with vomiting and tinking bowel signs?

Answer 9

Intestinal obstruction

may be history of malignancy or previous operations

Question 10

What causes a loin to groin pain?

Answer 10

Renal colic

pain is often severe but intermittent. Visible or non-visible haematuria may be present

Question 11

What causes loin pain, fever, rigors and vomiting?

Answer 11

Acute pyelonephritis

Question 12

What causes suprapubic pain in men?

Answer 12

Urinary rentention

Caused by obstruction to bladder flow

(often associated with BPH)

Question 13

What causes right or left iliac fossa pain, with assoicated amenorrhoea?

Answer 13

Ectopic pregnancy

Question 14

What causes central abdominal pain radiating to the back?

Answer 14

Ruptured AAA

may be assoicated with shock and have a history of cardiovascular disease

Question 15

What causes central abdominal pain associated with diarrhoea, rectal bleeding and a metabolic acidosis?

Answer 15

Mesenteric ischaemia

Patients often have a history of cardiovascular disease or AF

The metabolic acidosis is caused by dying tissue

Question 16

What antibodies are assoicated with auto-immune hepatitis?

Answer 16

Anti-nuclear antibodies

Smooth muscle antibodies

Question 17

How is auto-immune hepatitis managed?

Answer 17

Steroids

Other immuno supressants eg. azathioprine

Liver transplantation

Question 18

What are the most common causes of acute pancreatitis?

Answer 18

Alcohol

Gallstones

Question 19

What is the pathophysiology of acute pancreatitis?

Answer 19

autodigestion of pancreatic tissue by pancreatic enzymes, leading to necrosis

Question 20

What do investigations into acute pancreatitis show?

Answer 20

Raised serum amylase
Raised serum lipase
US - determine if there is gallstones or biliary obstruction

Can also use a contrast CT

Question 21

What scores are used to identify severe cases of acute pancreatitis?

Answer 21

Ranson
Glasgow
APACHE II

Question 22

What factors indicate severe pancreatitis?

Answer 22

age > 55 
hypocalcaemia 
hyperglycaemia 
hypoxia 
neutrophilia 
elevated LDH and AST

Question 23

What are the classifications of acute pancreatitis severity?

Answer 23

Mild
Moderate
Severe

Question 24

What determines mild acute pancreatitis?

Answer 24

No organ failure

No local complications

Question 25

What determines moderately severe acute pancreatitis?

Answer 25

No organ failure / organ failure < 48 hrs | Possible local complications

Question 26

What determines severe acute pancreatisis?

Answer 26

Persistent organ failure (>48hrs) | Possible local complications

Question 27

How is acute pancreatitis managed?

Answer 27

``` Fluid resuscitation (large quantities of cryastalloid) - Aiming for urine output > 0.5mls/kg/hr ``` Analgaesia (IV opioids) Nutrition - enteral nutrition should be offer to patients with moderately severe or severe acute pancreatitis within 72 hrs of presentation Surgery: - If acute pancreatitis due to gallstones - cholecystectomy / ERCP - If necrosis + worseing organ function - may require debridement - If infected necrosis - radiological drainage / surgical necrosectomy

Question 28

What are complications of acute pancreatitis?

Answer 28

- Peripancreatic fluid collections - Pseudocysts - Pancreatic necrosis - Pancreatic abscess - Haemorrhage - Acute respiratory distress sydrome

Question 29

What are the causes of chronic pancreatitis?

Answer 29

- 80% alcohol | - 20 % unknown cause

Question 30

What are the features of chronic pancreatitis?

Answer 30

Pain typically worse 15 to 30 minutes following a meal Steatorrhoea (develops 5-20 years after the onset of pain) DM develops in most patients (generally occurs more than 20 years after the symptoms begin)

Question 31

How is chronic pancreatitis investigated?

Answer 31

Abdominal XR / CT: pancreatic calcifications Faecal elastase may be used to assess exocrine function if imaging is inconclusive

Question 32

How is chronic pancreatitis managed?

Answer 32

Pancreatic enzyme supplementation Analgaesia Antioxidants (may only help in early disease)

Question 33

What do investigations into alcoholic liver disease show?

Answer 33

Gamma-GT raised | AST:ALT > 2 (if >3, strongly suggestive of acute alcoholic hepatitis)

Question 34

How is alcoholic liver disease managed?

Answer 34

Glucocorticoids - used during acute episodes of alcoholic hepatitis Pentoxyphylline is sometimes used

Question 35

What are the features of non-alcoholic fatty liver disease?

Answer 35

Usually asymptomatic Hepatomegaly ALT > AST Increased echogenicity on US

Question 36

How is non-alcoholic fatty liver disease managed?

Answer 36

- Lifestyle changes and weight loss | - Monitoring

Question 37

How is liver cirrhosis investigated?

Answer 37

Transient elastography Upper endoscopy to check for varicies Liver US (+/- alpha feto protein) every 6 months to check for hepatocellular cancer

Question 38

How is variceal haemorrhage managed?

Answer 38

Fluid resusitation prior to endoscopy Correct clotting: FFP and vitamin K Terlipressin Prophylactic antibiotics (quinolones) Endoscopy + band ligation Sengstaken-Blakemore tube if uncontrolled haemorrhage Transjugular intrahepatic portosystemic shunt if all else fails