Hepatobilliary + Pancreas Flashcards
(101 cards)
1
Q
What is cholangiocarcinoma
A
Cancer of the bile ducts
2
Q
What are the sings
A
Obstructive Jaundice - dark urine, pale stools, pruitis Pallapble gallbladder - non tender Painless Abdominal fullness or pain systemic symptoms - fever, malaise etc
3
Q
what is courvosier’s law?
A
Courvoisier’s law states that in the presence of a palpably enlarged gallbladder which is non-tender and accompanied with mild painless jaundice, the cause is unlikely to be gallstones –> usually pancreatic carcinoma or colangiocarcinoma
4
Q
Where can colangiocarcinoma occur and what one is more common
A
intrahepatic or extrahepatic ducts-
Extrahpeatic = 90%
5
Q
what is cholangiocarcinoma associated w/
A
Chronic inflammation and cholestasis
Primary sclerosising cholagnitis
Choledochral cysts
6
Q
What is the Rx for cholangiocacinoma
A
If intrahepatic - partial liver resection +/- protal vein embolisaion If distal (extrahepatic) - rescetion --> whipple's procedure (proximal pancreaticduodenectomy w/ choledocho or hepaticojejustomy) Repsonse to chemo is poor but can be used as adjunct Intracavity Brachytherapy (put radioactive source in patient) can help
7
Q
What does a whipple’s procedure remove
What is joined together?
A
Distal stomach (except in pylrous preserving surgery)
Dudodenum
Head of Pancreas
Distal common bile duct
Gallbladder
rest of pancreas and jejunum, rest of bile duct and jejonum, rest of stomach and jejunum
8
Q
what is dumping syndrome, what are the signs
A
Rapid gastric transit post abdo surgery
N+V, abdo pain and cramping, diarrhoea, post-prandial bloating, weakness, sweating, dizziness, flushing of face
9
Q
What increases the risk of gallbladder hypomobility
A
Pregnancy
OCP
TPN
Fasting
10
Q
What is the most common type of gallstone, and what are the other type
A
75% are mixed –> mainly cholesterol
20% are cholesteral –> large, usually solitary, more likely in females, OCP, pregnancy, high fat diet
5% are pigment stones –> associated w/ haemolysis
11
Q
What is admirand’s triangle w/ relation to gallstones
A
Decreased bile salts, decresased lecitin and increased cholesterol caused increased chancxe of forming a cholesterol stone
12
Q
What are complications of gallstones in the gallbladder
A
Biliary colic
Acute cholecystitis
Chronic cholsystitis
gallblader carcinoma –> calcification causes “procelain GB”
Muocele –> neck of gallbladder blocked, can become large, may become infected
Mirizzi’s syndrome –> large stone in Gb pressed on common hepatic duct causing obstructive jaundice –> can erode through
13
Q
what are the complications of gallstones in the CBD
what about the gut?
A
Obstructive jaundice Pancreatitis Cholangitis (cholangitis = bile duct inflammation, cholecysitits = GB inflammation)
In the gut = gallstone illeus –> large stone erodes form GB to dudoenum through fistula (formed secondary to chronic inflammation) causing obstruction in distal ileum –> look for pneumobilia, small bowel obstruction and gallstone in RLQ [riggler’s triad]
if it gets stuck in duodenum instead of ileum = Bouveret’s syndrome
14
Q
what is biliary colic and what are the signs
A
gallbladder spasming against a stone impacted in the neck of the gallbladder (hartman’s pouch)
Causes episodes of severe acute onset RUQ pain which is constant
Pain can radiate to scapula (back)
Attacks are precipiatated by fatty foods and last <6hr
Also get tenderness in right hypochondrium
may be associated w/ nausea and vomiting
15
Q
what is the Ix for biliary colic
A
Urine - biloirubin, urobilogen, Hb
AXR - 10% gallstones are radiopaque
USS - look for stones, dilated ducts (>6mm) and inflammaed GB
If inflammed ducts - MRCP
If uncertain - HIDA cholescinitgraphy if liver works (GB doesn’t fill)
16
Q
What is the Rx for biliary colic
A
Conservative - rehydrate, NBM, morphine
Surgery - urgent or elective (6-12w later) lap cholecystectomy
17
Q
What is acute cholcystitis
A
Infeciton of the gallbladder
usuaully due to stone or sludge impaction in Hartman’s pouch causing chemical and/or bacterial inflammation
5% are acalous - no stone –> sepsis, burns, DM
18
Q
What are the features of acute cholecystits
A
Severe RUQ pain –> continuous, radiating to right scapula and epigastrum
tachycardia and SOb
fever
vomiting
+/- jaundice
Murphy’s sign
Boas sign –> hyperaesthesia below right scapula
Might palpate phlegmon –> oedema of adherent omentum and bowel can be felt as a mass
Might get empyema –> high fever, RUQ mass, requires drainage (cholecystostomy)
19
Q
What is Murphy’s sign, what condition does it relate to
A
place 2 fingers over GB and ask patient to breathe in –> feel pain and will catch breath
Must be negative on left
Seen in acute cholecystitis
20
Q
What are the Ix for acute cholecystitis
A
USS - show stones, dilated ducts and inflammed GB
if see dilated ducts, need MRCP
FBC - raised WCC
U+E - show dehydration from vomiting
Amylase - rule out pancreatitis
HIDA chelscintigraphy if diagnosis unsure
21
Q
What is the Rx for acute cholecystitis
A
Conservative - NBM, fluid resus, analgesia
Abx - usually cefuroxime and metronidazole but check local guidelines
80-90% settle over 24-48hrs
May require elective lap chole once inflammation has settled - 6-12 weeks later –> if <72h from onset, can perform in acute phase
If empyema, need percutaneous drainage - cholecstostomy
22
Q
What are the symptoms, Ix and Rx for chronic cholecystitis
A
Vague upper GI discomfort, flatulence, dyspepsia, distension/bloating, nausea
Symptoms exacerbated by fatty foods (CCK stimulates GB)
AXR shows procelain GB (can see it on AXR)
US might show stones, fibrosis or a shrunken GB
Might need MRCP
Mx = elective cholecystectomy or ERCP if US shows dilated ducts + stones
23
Q
what are the causes of obstructive jaundice
A
stones Ca head of pancreas LN @ porta hepatis (where ducts come out) - TB, Ca Inflammatory - PBC, PSC Drugs - OCP, sulphonyureas, fluclox Neoplastic - cholangiocarcinoma
24
Q
what are the clinical features of obstructive jaundice
A
Jaundice - seen @ tongue frenulum first
Dark urine
Pale stools
Itchy
25
What is the Ix for obstructive jaundice
Urine test - dark, increased bilirubin, decreased urobilogen
LFTs - raised ALP, slightly less raised AST, increased, increased conugated bilirubin
Vit K is decreased - raised INR
Hepatorenal syndrome - raising Creatinine (no proteinuria)
Increased WCC if cholangitis
USS - dialted ducts, stone, tumours
MRCP or ERCP - Magnetic resonance/ Endoscopic retrograde cholangiopancreatography
Can do percutaneous transhepatic cholangiography
26
What is the Rx for stones in obstructive jaundice
Conservative - montior LFTs, vitamins ADEK, analgesia, Colestyramine (stop bile acid reabsoprtion)
Can do ERCP w/ sphincterotomy and stone extraction if worsening LFTs, no resolution or cholangitis
Surgical = open/lap stone removal with T tube placement (need to cholangiogram 8d later to ensure stone has come out)
Might need delayed cholecstectomy to prevent recurrence
27
What is ascending cholangitis
Inflammation of the bile ducts caused by CBD obstrction
28
What are the signs of ascending cholangitis
Charcot's triad - fever/rigors, RUQ pain and jaundice
| Reynold's pentad = above + shock + confusion
29
What is Charcot's triad, what condition is it linked w/
Charcot's triad - fever/rigors, RUQ pain and jaundice
| Ascending cholangitis
30
What is Reynold's pentad, what condition is it linked w/
Reynold's pentad = Fever/rigors + RUQ pain + jaundice + shock + confusion
Ascending cholangitis
31
what are the risk factors for pancreatic carcinoma (SINED)
```
Smoking
Inflammation- chronic pancreatitis
Nutrition - high fat diet
ETOH
DM
```
32
what are the most common type and location of pancreatic ca
90% ductal adenocarcinomas
| 60% in head
33
what are the symptoms and signs of pancreatic Ca
Male >60
Painless obstructive jaundice - dark urine pale stool
might have epigastric pain --> radiates to back, relived sitting forwards
Anorexia, wt loss, malabsorption
Actue pancreatitis,
Sudden onset DM
Palpable GB
Epigastric mass
Thrombophlebitis migrant (Trousseau sign) --> phlebitis caused by thrombus in different areas
Splenomegaly, ascitites (PV thrombus)
34
what tumour marker is used for pancreatic cancer
Ca19-9
35
What Ix is required for pancreatic ca
```
USS/ EUS (Endoscopic USS, which is better for staging than CT/MRI)
Might need CXR, laparoscopy for mets
ERCP
Raised Calcium
LFTs
```
36
What is the Rx for pancreatic cancer
If fit, no mets and tumour less than 3cm, can have Whipple's procedure or distal pancreatectomy + chemo
if not fit for surgery --> stenting of CBD, palliative bypass surgery (cholecysrtojujostomy + gastrojujostomy).
Need pain relief = might need coeliac plexus block
mean survival <6m
37
what is I GET SMASHED an acronym for
Acute pancreatitis
38
What are the causes of acute pancreatitis (I GET SMASHED)
```
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps/Malignancy
Autoimmune (e.g PAN)
Scorpion bite
Hyperlipiademia
ERCP
Drugs (thiazides, azathioprine, valproate)
```
39
What are the signs and symptoms of acute pancreatitis
Severe epigastric pain, radiating to back, relieved by sitting forwards
Vomiting
Increased HR and RR
Shock
Fever
Epigastric tenderness
Jaundice
Ileus (failure of peristalsis) = absent bowel sounds
Ecchymoses - Grey Turner (flank), Cullens (periumbilical)
40
What is the modified Glasgow criteria used for in acute pancreatitis, and what does it contain?
```
Valid for ETOh and gallstones
Used to assess severity and predict mortality
PaO2 <8
Age >55
Neutrophils >15
Ca <2
Renal function (urea >16)
Enzymes LDH >600, AST >200
ALbumin <32
Sugar >10
```
41
what Ix is required for Acute pancreatitis
```
Amylase >1000 or 3x normal
Increased lipase
Increased WCC
Decreased Ca2+
Increased glucose
Increased CRP
Urine - glucose, raised conjugated bilirubin, decreased urobilogen
CXR - check for ARDS (also decreased O2)
USS
Contrast CT
```
42
What is the management of acute pancreatitis
Need constant reassessment
Aggressive fluid resus - keep UO >30ml/hr, use catheter
NBM
NG tube if vomiting
Pethidine via PCA or morphine for analgesic
Penem ABx if suspcisious of infection or before ERCP
ERCP + spihincterectomy if dilated ducts due to gallstones
Might need laparotomy if infected pancreatic necrosis, pseudocyst or abscess
43
what are the early systemic complications of acute pancreatitis
```
ARDS, pleural effusion
Shock - hypovolaemic or septic
Renal failure
DIC
Metabolic - decreased Ca, increased glucose, metabolic acidosis
```
44
What are the late local complications of pancreatits
```
Necrosis
Infection
abscess
Bleeding e/g from splenic artery
Thrombosis - splenic artery, gsstroduodenal artery, superior mesenteric artery - may cause bowel necrosis
Portal vein thrombosis --> portal HTN
Fistula formation e.g pancreato-cutaneous --> may cause skin breakdown
pancreatic pseudocysts
```
45
How does pancreatic pseudocysts presnet
```
Collection of pancreatic fluid surrounded by granulation tissue in lesser sac - Omental cavity
esp in ETOH pancreatitis
occurs 4-6w after acute pancreatits
Persisting abdominal pain
Epigastric mass
Early satiety
Persistanty raised amylase
Us/CT to see
<6cm will spontaneously resolve
>6cm percutaneous drainage under US/CT
```
46
What are the causes of chronic pancreatitis
```
Alcohol
Cystic fiborisis
Hereditary haemochromatosis
Lympoplasmacytic sclerosing pancreatitis
Increased triglycerides
Obstruction by tumour
```
47
What are the features of chronic pancreatitis
Epigastric pain, radiating to back, relieved by sitting forward or hot water bottle (erythema ab igne = rash caused by recurrent hot water bottle use )
Pain is exacerbated by fatty food or ETOPH
Steatorrhoea
Wieght loss
DM - polyuria, polydipsia
epigastric mass - psuedocyst
48
what are the IX for chronic pancreatitis
increased glucose
decreased foecal elastase - decreased exocrine function
USS - look for pseduocysts
AXR/CT - calcifications
49
What is the Rx for chronic pancreatitis
No ETOh
Reduce fat and increase carbs in diet
Analgesia - may need coeliac plexus block
Enzyme supplements - pancreatin
ADEK vitamins
DM management
Surgery if unremitting pain, wt loss or duct blockage --> Distal pancreatectomy, whiles, pancreaticojejuonostomy, endoscopic stenting
50
what are the signs of an insulinoma
Fasting or exercising induced hypoglycaemioa
Stupor, confusion, LOC
Increased insulin, increased C pepitde
51
What are the signs of a glucagonoma
Mild DM
Necrolytic migratory erythema --> red, blistering rash that spreads across the skin. It particularly affects the skin around the mouth and distal extremities
52
What are the signs of a gastronoma, where are they found, what is the treatment
(Zollinger-Ellison syndrome)
Often found in small intestine or pancreas
Secrete gastrin
Ulcers - duodenum, stomach, SI --> refractory
chronic diarrhoea (inactivation of pancreatic enzymes) & steatorrhoea
hypergastraenima (high gastrin)
Abdo pain and dyspepsia
Rx = high dose PPI, ± tumour resection or Roux en Y
53
VIPoma / WDHA syndrome signs
Watery diarrhoea
Hypokalaemia
Achloyhdria - absence of HCl in stomach secretions
Acidosis
54
stomatostatinoma signs
DM --> inhibits insulin release
Steatorrhoea --> inhibits pancreastic enzyme release
Gall stones
(also inhibits glucagon release)
55
what are the signs of hereditary haemochromatosis
May be asymptomatic
Non specific symptoms
Large/small joint pains - most commonly 2nd or 3rd MCP
Slate grey skin - increased melanin deposition
Symptoms of liver disease (hepatosplenomegaly), DM, cardiac failure (& arrhythmia)
Hypogonadism - testicle atrophy, loss of hair, gynaecomastia
56
What are the Ix for Hereditary haemochromatosis
Increased Iron, decreased TIBC, increased ferritin and transferrin saturation (increased intestinal iron absorption is the pathogenesis of HH)
Gene testing - HFE gene mutation on Chr 6p
Liver - LFTs, biopsy, visualise iron with Perls stain, MRI
Pancreas - FBG/RBG
Heart - ECG, echo
Pituitary function tests - decreased testosterone, decreased or inappropriately normal LH, FSH (2º hypogonadism)
Joint X-ray - linear calcifications
57
What is the Rx for hereditary haemochromatosis
if no symptoms/evidence of end organ disease - annual review
If end organ disease = weekly/twice weekly phlebotomy (1 unit - 450ml) until ferritin <50ng/ml, then every 2-4 months to maintain
If can't tolerate phleb - chelation
Limit ETOH intake; avoid iron, vit C supplements and uncooked seafood
58
what is primary biliary cirrhosis associated w/
```
Sjogren's syndrome
Arthritis (e.g RA)
Reynaud's phenomenom - Sjogren's, CREST/ scleroderma SLE
autoimmune thyroid disease
more common in women (9:1)
```
59
What is primary biliary cirrhosis
Chronic inflammatory liver disease involving destruction of intrahepatic bile ducts, causing cholestasis and eventually cirrhosis
60
What are the signs of PBC
initially may be asymptomatic - can be incidental finding on blood test w/ raised All phos and cholesterol
Pruruits & skin excoriations
Jaundice
hepatomegaly
Liver decompensation = ascieites, variceal haemorrhage
Signs of chronic liver disease - palmar erythema, clubbing, spider naive
fatigue, wt loss
xanthomas (yellow nodule on skin) 2º to hypercholesteraiema
signs of related conditions e.g dry eyes and mouth
61
What Ix are needed for PBC
LFTs - Raised Alkphos, raised GGT, bilirubin &AST/ALT may rise in later stages, prolongation of PT,
Antimitochondrial antibodies, raised IgM and raised cholesterol are typical
USS - exclude extra hepatic biliary obstruction
Liver biopsy - inflammatory cells and granulomas around intrahepatic bile ducts, w/ destruction and fibrosis
Ca, phosphate and Vit D - can develop metabolic bone disease
62
What are the Rx for PBC
Ursodeoxycholic acid = bile acid, reduces toxicity and increase elimination of retained bile acids
Pred/azathioprine/mycophenolate -if inflammatory component (overlap w/ AI hepatitis)
Pruritis - colestryarmine (binds bile acids in GI tract), rifampicin (unregulated liver enzyme which metabolise things causing pruritus), naltrexone
Bones - Ca, Vit D, bisphosphonates
Replace Vit ADEK
Portal HTN - β blockers, endoscopic banding of varicose, trans jugular intrahepatic portasystemic shunt (hepatic --> portal vein to decompress portal vein)
Liver transplant
63
What is primary sclerosis cholangitis
Chronic cholestatic liver disease caused by progressive fibrosis and obliteration in both intrahepatic and extra hepatic ducts
64
What is PSC associated w/
IBD, esp UC
65
what are the features of PSC
May be asymptomatic and diagnosed after persistently raised AlkPhos
May present w/ intermittent jaundice, pruritus, RUQ pain (n/b don't really get with PBC , wt loss, fever
Ask about cholitis
May have hepatospelnomegalt, spider naive, palmar erythema, ascites
Can get recurrent cholangitis -fever, rigors
Can also get cholangicarcinoma, and metabolic liver disease
66
What are the Ix for PSC
Blood - raised Al;k phos, raised GGT, mild raised transaminases, later decreased albumin and increased bilirubin
Serology - raised IgM , Anti smooth muscle and ANA present in 30%, pANCA in 70% ]
**ERCP - stricturing and dilation of intrahepatic duct (and occasionally extra hepatic duct) - looks like beads**
MRCP - same as ERCP
Liver biopsy - stages disease
67
What is the Rx for PSC
IF cholangitis - fluid resus, ABx (cephlasporin + metronidazole)
CHolesytrymine or phototherapy for pruritus
Vit AEDK, Calcium intake
Endoscopic/percutaenous transhepatic stenting or dilatation of major extra hepatic bile duct strictures
Liver transplant for end stage disease
68
What is Wilson's disease
AR disease where there is decreased biliary excretion of copper, leading to accumulation in liver and brain, due to gene mutation of copper transporting ATPASE on Chr13
69
What are the signs of Wilsons disease
Liver - hepatitis, liver failure, cirrhosis --> easy bruising, variceal bleeding, encephalopathy, hepatosplenomegaly, jaundice, ascites, gynaecomastia
Neurological - dyskinesia, rigidity, tremor, dystonia, dysarthria, dysphagia, drooling, dementia, ataxia
Psychiatric - conduct disorder, personality change, psychosis
Eyes - green or brown Kayser flesher rings, sunflower cataract (copper accumulation in lens on slit lamp)
Copper can also damage renal tubules causing hypercalcuria, phosphaturia and renal tubular acidosis
70
what are the Ix for Wilson's disease
Raised AST, ALT and all phos
Serum caeruloplasmin - low
Copper (inc 24hr urinary copper) - high
Liver biopsy - increased coppper
71
What is the Rx for Wilson's disease
```
Manage in specialist unit
Copper chelators (e.g d-penicillaimine)
Oral zinc - stops absorption
Liver and neuro care
Liver transplant may be necessary
```
72
what is a tumour marker for HCC
Alpha fetoproptein
73
what is a tumour marker for colorectal cancer
CEA
74
what the fuck is Budd-chiari syndrome
hepatic vein thrombosis
The features are classically a triad of:
abdominal pain: sudden onset, severe
ascites
tender hepatomegaly
```
Causes
polycythaemia rubra vera
thrombophilia: activated protein C resistance, antithrombin III deficiency, protein C & S deficiencies
pregnancy
oral contraceptive pill
```
75
Alcoholic hepatitis Hx + Ex
May be asymptomatic
May be mild - nausea, malaise, RUQ pain
May be severe - jaundice, abode swelling, swollen ankles, GI bleeding
Signs of ETOH excess - malnourished, palmar erythema, duprytrens contracture, facial telangiectasia, parotid enlargement, spider naeviae, gynaecomastia, testicular atrophy, hepatomegaly, easy bruising
Signs of severe alcoholic hepatitis - febrile, tachy, jaundice, bruising, encephalopathy (liver flap, drowsiness, can't copy 5 pointed star), fetorhepatiticus, ascites
76
What is a significant marker of poor liver function
Prolonged PT
77
What do you see on biopsy of alcoholic hepatitis
```
Centrilobular ballooning
degeneration and necrosis of hepatocytes
Steatosis
Neutrophillic inflammation
Cholestasis
```
78
What is the Rx for alcoholic liver disease
Thiamine, Vit C and others (Pabrinex)
Correct K, MG, glucose
Treat encephalopathy w/ oral lactulose and phosphate enemas
Manage ascites w/ spironolactone ± frusemide
Nitrition support (protein restriction if encephalophic)
Steroids
79
what is Wernicke's encephalopathy
acute neurological condition characterized by a triad of ophthalmoparesis/opthalmoplegia with nystagmus, ataxia, and confusion + disorientation and disturbed memory
caused by thiamine deficiency
Reversible w/ treatment
80
What is Korsakoff's psychosis
Permanent impairment of retrograde and anterograde memory w/ confabulation
Caused by untreated thiamine deficiency
81
What is liver failure
severe liver dysfunction w/ jaundice, encephalopathy and coagulopathy
Jaundice - deficient uptake, conjugation and secretion of bilirubin by liver
Encephalopathy - decreased extraction of nitrogenous products by liver --> delivered to brain
Coagulopathy --> decreased synth of clotting factors + decreased platelets (due to hypersplenism or abnormal function)
82
What are the time frames for hyper acute, acute, subacute and chronic liver failure
Hyper acute <7d
Actue 1-4w
Subacute 4-12w
Acute on chronic = decompensation in patients w/ chronic liver disease
83
What causes liver failure
```
Viral - hepatitis
Drugs e.g paracetamol --> paracetamol level, n-acetylcysteine
Autoimmune
Budd chiari
hameochromatosis
Wilson's
```
84
what are the symptoms of liver failure
Jaundice
Encephalopathy
liver asteroids
fetor hepaticus
brusing/ bleeding
cities and splenomegaly less common in acute or hyper acute
can get hepatorenal syndrome, cerebral oedema, hypoglycaemia
85
What is the Rx for liver failure
Resus
Treat cause
Monitor vital signs, PT etc
Lactulose and phosphate enema for encephalopathy
Vit K, FFP or platelet infusions for coagulopathy
PPI for gastric mucosa protection
Avoid drugs metabolised by liver
If cerebral oedema - nurse at 30º, hyperventilate, IV manitol
86
what is spontaneous bacterial peritonitis
Spontaneous bacterial peritonitis (SBP) is infection of ascitic fluid without an apparent source
Neutrophis >250 in an ascitic tap
Rx = cefuroxime + metranidazole
Prophylaxis = ciprofloxacin
87
What are the indications for liver transplant
If paracetamol OD - arterial pH <7/3 or Pt>100&creatinine>300&severe encephalopathy
For others (need 3 out of 5)
- age <10 or >40
- bilirubin >300
- Caused by Non A, non E viral hepatitis or drugs
- Interval from jaundice onset to encephalopathy >7d
- Pt >100
88
What is cirrhosis
End stage of chronic liver disease
| replacement of normal liver architecture w/ diffuse fibrosis and nodules of regeneration
89
What are the causes of cirrhosis
```
Chronic alcohol misuse
Chronic viral hepatitis - B, C
Autoimmune hepaititis
Drugs - methotrexate, hepatotoxic drugs
Inheritied - α1 antitrypsin deficiency, haemochromatosis, wilson's disease, CF
Vascular - Budd chiari
PBC
PSC
NASH
```
90
What causes decompensation off cirrhosis
```
Infection
Gi bleeding
constipation
high protein meal
electrolyte imabalance
alcohol
drugs
tumour development
portal vein thrombosis
```
91
What are the signs and symptoms of cirrhosis
```
Early non-specific symptoms --> anorexia, nausea, fatigue, wt loss
Symptoms caused by decreased synthetic function - easy bruising, abdomen swelling, ankle oedema
Symptoms caused by reduced detoxification - jaundice, personality change, altered sleep pattern, amenorrhoea
Symptoms caused by portal HTN - abdomen swelling, haematemesis, PR bleeding, malaena, splenomegaly
Asterixis (liver flap)
Bruises
Clubbing
Duprtrynes contract
Palmar erythema
Jaundice
leuconychia
Gynaecomastia
Scratch marks
Ascities
Liver can be large or small
Caput medusa
testicular atrophy
```
92
What Ix is needed for cirrhosis
```
FBC - reduced Hb and platelets (due to hypersplenism)
Decreased albumn
Prolonged PT
Serum AFP raised (can point to HCC)
Determine cause (e.g antimitochondrial ABs for PBC, SMA for autoimmune hepatitis,)
Ascitic tap
Liver biopsy
Imaging
```
93
What is the child-Pugh score used for and what does it contain
Cirrhosis - 5-6 is grade A, 7-9 is B, 10-15 is C
Albumin >35, 28-35, <28
Bilirubin - <2, 2-3, >3
PT - <4, 4-6, >6
Ascities - None, mild mod
Encephalopathy - none, grade 1-2, grade 3-4
94
Rx for cirrhosis
Treat cause
Avoid alcohol, sedative, opiates, NSAIDs
Encephalopathy - lactulose, phosphate enema
Ascites - Spironolactone ± furosomide, sodium restriction, therapeutic paracentesis w/ albumin replacement
SBP - ABx --> cefuorxime and metronidazole
Surgical - consider insertion of Transjugular intrahepatic portosystemic shunt to reduce portal HT
Transplant
95
What antibodies are linked w/ autoimmune hepatitis
| What might you see with regards to Abs on Ix of autoimmune hepatitis
```
Anti-smorh muscle
ANA
Anti-actin antibodies (AAA)
Anti-soluble liver antigen (antiSLA)
Anti Liver/kidney microsomes (ALKM1) - more young women
```
They normally have a polyclonal hypergammaglobulinaemia
96
What are the symptoms of autoimmune hepatitis
Classic liver stuff + systemic features
Some get amenorrhoea
Might get serum sickness - arthralgia, polyarthritis, maculopapular rash
ask about other autoimmune disease
can get cushinoid features before admin of steroids
97
When do you treat autoimmune hepatitis, and what is the treatment
Aminotransferase >10x normal, symptomatic, or hepatitis/necrosis on histology
Induce immunesupression w/ steroids, then gradually reduce dose for maintinece
Can add azathioprine/mercaptopurine as steroid sparing maintainence
Monitor USS and α fetoprotein every 6-12m in patients w/ evidence of cirrhosis to detect HCC
Repeat liver biopsies for evidence of disease progression every ~2y
Hep A and B vaccines
Liver transplant
98
what are the difference in signs between hepatitis A, B and C
Hep A = 3-6w after infection, following prodrome of malaise, anorexia, distaste for cigarettes, nausea; get jaundice lasting 3w
Hep B = Incubation period 3-6m, then 1-2w prodrome w/ RUQ pain and diarrhoea, then get jaundiced lasting 4-8w (but can end up w/ chronic carriage)
Hep C =mostly asymptomatic, 10% get jaundiced, but lasts chronically causing end stage liver disease, can cause GN and skin rash (caused by mixed cryoglobilinaemia causing a small vessel vasculitis)
99
what can you treat chronic hep B with
Peginterferon or tonofovir
100
how can you treat Hep C
elbasvir/grazoprevir, pegylated interferon α, ribavarin
If HCV 1 or 4 - treat for 24-48w
If HCV 2 or 3 treat for 12-24w
101
what is the most common cause of liver abscess, what is the signs
Amoebic (entamoebea histolytica) is most common worldwide
otherwise can be pygoenic e.g E. coli
Fever (continuous or spiking)
Jaundice
Tender hepatomegaly - right lobe more affected
RUQ or epigastric pain, can refer to shoulder if diaphragm irritated
Can cause reactive pleural effusion
Needle aspirate/catheter drain if pyogenic + cef + met
Metronidazole and diloxanide furoate if amoebic
