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Hepatology+ Flashcards

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1
Q

Define jaundice

A

Raised serum bilirubin causing yellowing of the skin, sclerae, and mucosae

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2
Q

Describe what happens to bilirubin, and the pathophysiology of jaundice

A

Bilirubin is produced from the breakdown of haemoglobin, 95% is unconjugated and circulates bound to albumin
In hepatocytes, the albumin is removed and bilirubin is converted to conjugated bilirubin by adding glucuronic acid (using glucuronosyltransferase enzyme), then excreted in bile
It is deconjugated by colonic bacteria into urobilinogen, which is oxidised into urobilin (then excreted in urine) and stercobilin (then excreted in the stools) or reabsorbed to the liver
Jaundice is caused by interference of the uptake, transport, conjugation, or excretion of bilirubin

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3
Q

What are the causes of jaundice?

A

Pre hepatic:
- haemolysis (haemolytic anaemias)
- Gilberts (impaired conjunction)
Intra hepatic:
- viral (hepatitis, EBV)
- drugs or alcohol
- autoimmune
- ischemia
- neoplasm
- congestion (CCF)
- primary biliary cholangitis
Post hepatic (obstructive):
- gallstones (bile duct)
- malignant
- ischemia
- inflammatory

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4
Q

What are the signs/symptoms of jaundice?

A

Dark urine (intra/post-hepatic cause)
Pale stools (post-hepatic cause)
Itching (intra/post hepatic cause)
Biliary pain
Abdominal swelling
Weight loss

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5
Q

What investigations are needed for jaundice?

A

LFTs
Conjugated bilirubin (high in pre-hepatic and sometimes intra-hepatic causes)
Unconjugated bilirubin (high in post-hepatic causes)
FBC: check for haemolysis
Blood cultures: check for viral infection
Imaging: ultrasound to detect hepatosplenomegaly and gall stones, CT/MRI if malignancy suspected

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6
Q

What type of bilirubin is elevated, and what happens to the urine/stools in each type of jaundice?

A

Pre-hepatic:
- elevated unconjugated bilirubin
- normal/pale urine
- dark stools
Hepatic:
- elevated conjugated and unconjugated bilirubin
- dark urine
- normal stools
Post-hepatic:
- elevated conjugated bilirubin
- dark urine
- pale stools

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7
Q

What is the treatment for jaundice?

A

Treat the cause
Ensure adequate hydration
Lifestyle advice
Monitor for ascites, encephalopathy

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8
Q

Define cirrhosis

A

Irreversible liver damage and the final stage of any chronic liver disease, characterised by fibrosis and the conversion of normal hepatic architecture into structurally abnormal nodules

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9
Q

What are the causes of cirrhosis?

A

Alcohol abuse (AFLD) - most common in developed countries
NAFLD
Hepatitis B and C
Metabolic liver disease
Autoimmune (PBC, PSC, hepatitis)
Hepatic vein events (Budd-Chiari)
Drugs (e.g. methotrexate, amiodarone)

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10
Q

What are the signs/symptoms of cirrhosis?

A

Often asymptomatic until complications
- oedema
- ascites
- easy bruising
- bleeding oesophageal varices
- spontaneous bacterial peritonitis
- jaundice
- pruritis
- spider naevi
- palmar erythema
- white nails
- clubbing
- dupuytren’s contracture
- hepatomegaly

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11
Q

What investigations are needed for cirrhosis?

A

LFTs: raised ALT
FBC: low platelets
Low albumin
Raised PT/INR
Imaging: ultrasound/MRI - show large liver with nodules
Liver biopsy: diagnostic

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12
Q

What are the treatments of cirrhosis?

A

Treat underlying cause
Manage complications
Ensure adequate nutrition
Alcohol abstinence
Prophylactic antibiotics
Liver transplant (for end-stage disease)

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13
Q

What are the complications or cirrhosis?

A

Anaemia, thrombocytopaenia, coagulopathy
Oesophageal varices
Ascites
Spontaneous bacterial peritonitis
Hepatocellular carcinoma
Hepatic encephalopathy

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14
Q

Define fatty liver disease

A

The accumulation of fat in the liver (steatosis) which can progress and be associated with inflammation (steatohepatitis), divided into:
- alcoholic fatty liver disease (AFLD)
- non-alcoholic fatty liver disease (NAFLD) which can progress to non-alcoholic steatohepatitis (NASH)

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15
Q

Describe the pathophysiology of fatty liver disease

A

Defective fatty acid metabolism because of mitochondrial damage (from alcohol), insulin resistance, or impaired receptor or enzymes involved, leads to the accumulation of triglycerides and other lipids in the hepatocytes leads

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16
Q

Describe the progression of AFLD

A

90% of heavy drinkers will develop steatosis , which is reversible with abstinence from alcohol
If abstinence is not achieved, alcoholic steatohepatitis (fibrosis) will develop, which can lead to cirrhosis, and hepatocellular carcinoma
Some will develop alcoholic hepatitis, which can be resolved with abstinence, corticosteroids or liver transplant, but can lead back to cirrhosis

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17
Q

What are the risk factors for AFLD?

A

Female sex
Binge drinking pattern
High quantity of alcohol consumed
Obesity
Hepatitis C infection
Genetics

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18
Q

What are the associations of NAFLD?

A

Obesity (central)
Abnormal glucose tolerance (T2DM)
Dyslipidaemia
PCOS
Hypertension
Family history

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19
Q

What are the signs/symptoms of fatty liver disease?

A

The majority of patients with steatosis have no symptoms
Patients with steatohepatitis may have fatigue, malaise, or RUQ pain
Advanced disease: signs/symptoms or cirrhosis (jaundice, ascites, etc.)

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20
Q

What investigations are needed for fatty liver disease?

A

LFTs: abnormal (raised GGT if alcohol is cause)
FBC: low platelets in advanced liver fibrosis
Hepatitis viral serology
Auto-antibodies: check for autoimmune hepatitis (raised ANA and ASMA) or PBC (raised AMA)
Ultrasound: detects steatosis
Liver biopsy: diagnostic

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21
Q

What are the treatments of fatty liver disease?

A

AFLD: abstinence, adequate diet
Lifestyle changes (weight loss, regular exercise, healthy diet, avoid alcohol)
Control risk factors (hypertension, T2DM)
Drugs: for non-diabetic patients - vitamin E supplements (can improve histology), pioglitazone (increase insulin sensitivity)

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22
Q

Define liver failure

A

When the liver loses the ability to regenerate or repair:
- acute liver failure: occurs suddenly in a previously healthy liver (1-3 weeks)
- chronic liver failure: occurs with a background of cirrhosis (over 6 months)

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23
Q

What are the causes of acute and chronic liver disease?

A

Acute:
- viral (hepatitis A, B, EBV)
- drugs (antibiotics e.g. co-amoxiclav, paracetamol overdose)
- alcohol
- vascular (Budd-Chiari syndrome, veno-occlusive disease, ischemia)
- obstruction
- congestion (congestive cardiac failure)
Chronic:
- viral (hepatitis A, B, EBV)
- drugs (antibiotics and common)
- autoimmune (primary biliary cholangitis, primary sclerosing cholangitis)
- metabolic (iron or copper overload)
- neoplastic
- fatty liver disease (alcoholic and non-alcoholic)

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24
Q

What are the signs/symptoms of acute and chronic liver failure ?

A

Acute:
- may be asymptomatic
- generalised symptoms (malaise, nausea, anorexia)
- jaundice as disease progresses
- rare: confusion, bleeding, RUQ pain, hypoglycaemia
Chronic:
- ascites/oedema
- jaundice/pruritis
- bleeding (easy bruising, haematemesis)
- gynaecomastia
- spider naevi
- clubbing
- palmar erythema
- hepatosplenomegaly
- hepatic encephalopathy

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25
What investigations are needed for liver failure?
FBC: check for signs of infection Viral serology LFTs: transaminases = high, alkaline phosphate = high/normal Clotting: raised PT and INR (coagulopathy) Doppler ultrasound: check hepatic vein, look for neoplasms and ascites Imaging of head, EEG: check for cerebral oedema, check level of encephalopathy
26
What is the treatment for liver failure?
Treat cause if known Monitor for infection, hypoglycaemia, bleeds Haemofiltration/haemodialysis if AKI develops Liver transplant
27
What are the complications of liver failure?
Prone to infection (spontaneous peritonitis, opportunistic) Portal hypertension Cerebral oedema (intracranial hypertension, death) Haemorrhage (e.g. from oesophageal varices)
28
Define ascites
Abnormal collection of fluid in the peritoneal cavity, can be mild (only detectable on US) to severe (clearly visible from examination)
29
What are the causes of ascites?
Cirrhosis (most common) Malignancies (mostly gynaecological) Heart failure Pancreatitis Nephrotic syndrome Malnutrition Portal hypertension
30
Describe the pathophysiology of ascites
Portal hypertension - increased hydrostatic pressure Hypoalbuminaemia - reduced plasma oncotic pressure Renal fluid and sodium retention - due to secretion of renin, angiotensin, vasopressin, causing peripheral arterial vasodilation
31
What are the signs/symptoms of ascites?
Abdominal distension Weight gain Shifting dullness on percussion Fluid thrill/wave Signs of liver disease (e.g. jaundice) Signs of respiratory distress (pleural effusion)
32
What are the investigations needed for ascites?
Aspiration (diagnostic) Imaging: ultrasound to assess degree of ascites, and may show cause Bloods: FBC, renal function, LFTs, clotting screen, albumin (show underlying cause)
33
What is the treatment for ascites?
Treat underlying cause (e.g. alcohol abstinence) Fluid and salt restriction Diuretics (spironolactone +/- furosemide) Large-volume paracentesis (drains fluid) + albumin replacement Indwelling drain: home paracentesis, smaller volumes Surgical: transjugular intrahepatic portosystemic shunt (TIPS)
34
Define hepatic encephalopathy
Cerebral oedema and neuropsychiatric abnormalities caused by the build up of ammonia due to liver failure leading to the passage of neurotoxins to the brain
35
What are the causes of hepatic encephalopathy?
AKI Electrolyte imbalance GI bleed Infection Constipation Sedative drugs Diuretics
36
What are the signs/symptoms of hepatic encephalopathy?
Mild: confusion, forgetfulness, mood changes, sleep disturbance, dyspraxia Severe: lethargy, severe personality changes, seizures, severe disorientation and confusion, incompressible speech Very severe: coma
37
What investigations are needed for hepatic encephalopathy?
Psychometric tests: draw a 5-pointed star, count in 7s Ammonia: raised MRI/CT: exclude other causes of altered mental function
38
What are the treatments for hepatic encephalopathy?
Antibiotics (e.g. rifaximin) Lactulose - increases use of ammonia Liver transplant (for recurrent cases)
39
What are the causes of portal hypertension?
Cirrhosis (80%) Fibrosis Thrombosis (portal or splenic vein) Schistosomiasis (parasitic worm infection) Budd-Chiari syndrome (blocked/narrowed hepatic veins) Right-sided heart failure
40
Describe the pathophysiology of portal hypertension
Increased hepatic resistance and/or increased splanchnic blood flow causing the blood pressure in the portal system to rise, leading to varices (oesophageal, gastric) and splenomegaly
41
What are the signs/symptoms of portal hypertension?
Asymptomatic Symptoms of complications: ascites, bleeding varices (gastro-oesophageal)
42
What is the treatment for portal hypertension?
Endoscopic banding (oesophageal) or sclerotherapy (gastric) of varices Fluid resuscitation if large bleed Beta-blocker (e.g. propranolol)
43
Define ascending cholangitis
Bacterial infection (Klebsiella spp., E. coli, Enterobacter spp.) of the biliary system (often common bile duct) due to partial or complete obstruction of ducts
44
What are the causes of ascending cholangitis
Gallstones ERCP Tumours Bile duct stricture or stenosis Parasitic infection
45
What are the signs/symptoms of ascending cholangitis?
Charcot's triad: - jaundice - fever - right upper quadrant pain (colicky) Additional features (Reynold's pentad): - hypotension (septic shock) - mental confusion
46
What investigations are needed for ascending cholangitis?
FBC: raised WBC ESR, CRP: may be raised LFTs: raised ALP, show obstructive jaundice U&E: associated renal dysfunction Blood culture (and culture of bile if available) Imaging: ultrasound (shows obstruction), ERCP
47
What is the treatment needed for ascending cholangitis?
Fluid resuscitation Antibiotics e.g. piperacillin/tazobactam ERCP (treat obstruction)
48
Define biliary colic
Gallstones causing obstruction of the cystic or common bile duct, resulting in pain (but no fever or inflammation)
49
What are the signs/symptoms of biliary colic?
Pain: - RUQ or epigastric - may radiate to back - intermittent Rare: may have jaundice if stone is passed into common bile duct
50
What are the investigations needed for biliary colic?
FBC: normal Ultrasound ERCP
51
What are the treatments for biliary colic?
Analgesia Surgical removal (ERCP)
52
Define cholecystitis
Gallstone obstruction causing distention of the gall bladder, with subsequent inflammation and necrosis of the mucosal wall
53
What are the risk factors for cholecystitis?
Female Forty Fat (obesity) Fertile (had more than 1 child, increase oestrogen) Family history Fair (Caucasian)
54
What are the signs/symptoms of cholecystitis?
Pain: - RUQ or epigastric - continuous - referred to shoulder tip or around side - worse on inspiration Murphy's sign: pressing on RUQ while breathing in causes pain + arrest of inspiration, but no pain on left Fever Vomiting Jaundice (if stone moves to common bile duct)
55
What are the investigations needed for cholecystitis?
FBC: raised WBC Ultrasound: shows thick-walled, shrunken gall bladder + stones
56
What are the treatments for cholecystitis?
Analgesia Antibiotics Surgical removal or drain
57
Define primary biliary cirrhosis/cholangitis
Progressive autoimmune destruction of the small bile ducts of the liver, with granulomatous inflammation leading to fibrosis and eventually cirrhosis
58
What are the causes of primary biliary cholangitis?
Autoimmune Thought to be environmentally triggered in genetically predisposed individuals
59
What are the risk factors for primary biliary cholangitis?
Female Family history Smoking Other autoimmune conditions (e.g. thyroid disease, RA) Hepatocellular carcinoma
60
What are the signs/symptoms of primary biliary cholangitis?
Very non-specific: Itching Fatigue Dry eyes Joint pains Hepatosplenomegaly Jaundice Liver failure in advanced disease: ascites, spider naevi, portal hypertension
61
What are the investigations needed for primary biliary cholangitis?
FBC: often normal LFTs: abnormal Raised IgM Antimitochondrial antibodies in 98% Imaging: ultrasound/CT to exclude obstruction
62
What is the treatment for primary biliary cholangitis?
Treat symptoms Ursodeoxycholic acid (reduces inflammation, delays damage) Liver transplant (can recur in transplanted liver)
63
Define primary sclerosing cholangitis
Progressive inflammation and fibrosis of the biliary tree, resulting in strictures (narrowing due to scarring)
64
What are the risk factors of primary sclerosing cholangitis?
Male IBD (present in 80%, mostly UC) Cholangiocarcinoma Colorectal cancer
65
What are the signs/symptoms of primary sclerosing cholangitis?
Mostly asymptomatic Non-specific: pruritis, fatigue Advanced: ascending cholangitis, cirrhosis, liver failure
66
What are the investigations for primary sclerosing cholangitis?
LFTs: abnormal IgM/G may be raised p-ANCA antibodies Cholangiopancreatography: visualise intra and extrahepatic bile ducts
67
What are the treatments for primary sclerosing cholangitis?
Treat symptoms Ursodeoxycholic acid (can improve LFTs, but no survival benefit) Liver transplant
68
Define haemochromatosis
A genetic disorder (autosomal recessive inheritance) causing iron overload
69
Describe the pathophysiology of haemochromatosis
Defects in the HFE gene cause uncontrolled intestinal iron absorption with deposition in the liver, heart, and pancreas
70
What are the signs/symptoms of haemochromatosis?
Initial: non-specific, fatigue, weakness, arthropathy, abdominal problems Advanced disease: diabetes, cirrhosis, hepatomegaly, bronzing of skin, arrhythmias, cardiac myopathy, hypogonadism
71
What are the investigations needed for haemochromatosis?
LFTs: raised Ferritin: raised Transferrin saturation: raised HFE genetic testing
72
What are the treatments for haemochromatosis?
Phlebotomy Liver transplant (for end-stage disease)
73
Define Wilson's disease
A genetic disorder (autosomal recessive disorder) causing deposition of copper in the liver and CNS
74
What are the signs/symptoms of Wilson's disease?
Hepatic features: liver failure, cirrhosis, hepatomegaly Psychiatric features: depression, behavioural problems, poor memory, slow problem solving Neurological features: tremor, difficulty speaking and swallowing, ataxia, clumsiness Ophthalmological features: Kayser-Fleisher ring - brown/green ring on cornea
75
What are the investigations needed for Wilson's disease?
Serum caeruloplasmin: low 24-hr urine excretion of copper: high Liver biopsy
76
What are the treatments of Wilson's disease?
Avoid high-copper foods (liver, chocolate, nuts, shellfish) Penicillamine (copper chelation) Liver transplant (if in liver failure, or end-stage disease)
77
Define alpha-1 antitrypsin deficiency
An inherited disorder affecting the lungs and liver, caused by a genetic misfolding in the SERPINA1 gene, meaning that a1AT can't be transported out of the liver: - accumulating in the liver causes inflammation and cell destruction (cirrhosis) - lack of a1AT in the lungs allows the destruction of elastin in the alveolar walls (emphysema)
78
What are the signs/symptoms of alpha-1 antitrypsin deficiency?
Lung disease: similar to COPD, early-onset (30-40 y/o) emphysema: - dyspnoea - wheezing - cough Liver disease: doesn't occur in all cases, usually presents in children: - neonatal jaundice and hepatitis - older children my develop hepatitis, cirrhosis, liver failure
79
What are the investigations needed for alpha-1 antitrypsin deficiency?
Serum levels of a1AT CXR and lung function testing (reduced FEV1 with obstructive pattern) LFTs and liver biopsy Phenotyping
80
What are the treatments of alpha-1 antitrypsin deficiency?
Lung disease: - smoking cessation - bronchodilators - lung volume reduction or transplant - vaccination against lung infection Liver disease: - monitor liver function - screen for hepatocellular carcinoma - liver transplant for liver failure a1AT replacement: not yet recommended by NICE
81
Define hepatitis
Inflammation of the liver Acute = 1st 6 months Chronic = any inflammation after 6 months
82
What are the signs/symptoms of acute hepatitis?
None or non-specific (malaise, lethargy, myalgia) GI upset Abdominal pain Jaundice + pale stools/dark urine Tender hepatomegaly Sings of acute liver failure (bleeding, ascites, encephalopathy)
83
What are the causes of acute hepatitis?
Viral infection: - hepatitis A, B +/- D, C, E - herpes viruses (VZV, EBV) - influenza - SARS-CoV-2 Non-viral infection: - spirochaetes (leptospirosis) - mycobacteria (M. tuberculosis) - bacteria - parasites Non-infection: - drugs, alcohol - toxins/poisoning - NAFLD - pregnancy - autoimmune - hereditary metabolic causes
84
What are the signs/symptoms of chronic hepatitis?
Can be asymptomatic or have non-specific symptoms only Clubbing Palmar erythema Spider naevi Coagulopathy Jaundice Ascites Encephalopathy Portal hypertension (varices, bleeding)
85
What are the causes of chronic hepatitis?
Infection: - hepatitis B +/- D, C, E Non-infection: - drugs, alcohol - toxins/poisoning - NAFLD - autoimmune - hereditary metabolic causes
86
Describe the causes, clinical course, testing, and management for Hepatitis A
Causes: faeco-oral transmission, contaminated food and water Clinical course: usually symptomatic, acute liver failure is rare, self-limiting - no chronic disease , 100% immunity after infection Testing: anti-HAV IgM is high in acute phase, high anti-HAV IgG detectable after 5-10 days and persist, HAV RNA in immunocompromised patients Management: supportive treatments, monitor liver function, treat close contacts, vaccination (for high risk, and contacts)
87
Describe the causes, clinical course, testing, and management for Hepatitis E
Cause: faeco-oral transmission, contaminated food and water, undercooked meat Clinical course: usually symptomatic and self-limiting, extra-hepatic manifestations, risk of chronic infection in immunosuppressed patients, high mortality in pregnancy Testing: anti-HEV IgM is high in acute phase, high anti-HEV IgG will persist after acute infection Management: supportive treatments, monitor liver function, reverse immunosuppression in chronic infection, treat with ribavirin if persistent HEV RNA
88
Describe the natural history of hepatitis B in an immunocompetent adult or neonates/infants
- 95% of immunocompetent adults but 10% of neonates/infants will be symptomatic, and have spontaneous resolution, but with risk of reactivation is immunosuppressed - 5% of immunocompetent adults but 90% of neonates/infants will be asymptomatic and have chronic infection, increasing the risk of cirrhosis and hepatocellular carcinoma
89
Describe the causes, clinical course, testing, and management for Hepatitis B
Causes: blood-borne (needles, blood transfusions/products, sexual transmission, vertical transmission) Clinical course: if symptomatic - self-limiting, chronic infection - asymptomatic, can cause cirrhosis and hepatocellular carcinoma Testing: HB surface antigen (will persist in chronic infection), anti-HB IgM, anti-HB IgG, anti-HB surface antibody (shows recovery and immunity after vaccination) Management: supportive treatment of symptoms, pegylated interferon-alpha 2a, or nucleotide analogues (e.g. tenofovir), vaccination (at risk groups and contacts)
90
Describe the causes, clinical course, testing, and management for Hepatitis D
Causes: blood borne, acquired simultaneously with, or after HBV infection Clinical course: worse outcomes than HBV alone Testing: HDV antibody, the HDV RNA Management: pegylated interferon-a (limited success), liver transplant may be needed
91
Describe the causes, clinical course, testing, and management for Hepatitis C
Cause: blood borne (needles, blood transfusions/products, sexual transmission, vertical transmission) Clinical course: 30% spontaneously clear the infection but can be reinfected, 70% develop chronic infection leading to complications (cirrhosis, hepatocellular carcinoma) Testing: HCV antibody, then RNA, then genotype Management: directly-acting antiviral therapy, no vaccine
92
Define autoimmune hepatitis
An inflammatory liver disease of unknown cause, characterised by abnormal cell function and autoantibodies directed against hepatocyte surface antigens
93
What are the associations of autoimmune hepatitis?
Female (most commonly affecting young or middle aged) Other autoimmune conditions: UC, T1DM, pernicious anaemia, autoimmune thyroiditis
94
What are the signs/symptoms of autoimmune hepatitis?
40% present with acute hepatitis and signs of autoimmune disease: - fatigue, myalgia - pruritis - nausea - upper abdominal discomfort - anorexia, diarrhoea - skin rashes - hepatosplenomegaly - jaundice Others present with... - gradual jaundice - signs of chronic liver disease - no symptoms
95
What investigations are needed for autoimmune hepatitis?
LFTs: raised Positive autoantibodies (ASMA and ANA) Raised IgG FBC: anaemia, low WBC, low platelets Exclusion of viral, drug-induced, and metabolic liver disease Liver biopsy
96
What are the treatments for autoimmune hepatitis?
Immunosuppressant steroid therapy (prednisolone), followed by azathioprine to maintain remission Liver transplant (for terminal phases, may recur in transplanted liver)
97
Define acute pancreatitis
Sudden inflammation of the pancreas, releasing exocrine enzymes that cause autodigestion of the gland, which can sometimes be reversed
98
What are the causes of acute pancreatitis?
I GET SMASHED Idiopathic Gallstones Ethanol Trauma Steroids Mumps, malignancy Autoimmune Scorpion venom Hyperlipidaemia, hypercalcaemia ERCP and emboli Drugs (tobacco, thiazides)
99
What are the signs/symptoms of acute pancreatitis?
Severe central abdominal pain (sudden onset radiates to back, sitting forwards may relieve) Vomiting Jaundice (if caused by gallstones) Mild fever Absent bowel sounds in later stages Bruising around umbilicus (Cullen's sign), or flanks (Grey Turner's sign)
100
What investigations are needed for acute pancreatitis?
Serum amylase and lipase: raised (lipase is more specific for pancreatitis) ABG: low O2 Calcium: low Abdominal X-ray: exclude other causes (intestinal obstruction, perforation) Ultrasound: shows gallstones CT: shows severity of disease
101
What are the treatments of acute pancreatitis?
Analgesia (very strong) Antiemetics IV fluids Nil by mouth - bowel rest Prophylactic antibiotics (if necrosis) ERCP for gallstone removal
102
What are the complications of acute pancreatitis?
Shock Acute respiratory distress syndrome Renal failure Sepsis Pancreatic necrosis and pseudocyst Abscesses Bleeding Thrombosis Hypocalcaemia (breakdown of peri-pancreatic fat by enzymes, releasing free fatty acids which react with calcium)
103
Define chronic pancreatitis
Long-standing inflammation causing irreversible damage to the pancreas
104
What are the causes of chronic pancreatitis?
Alcohol Smoking Autoimmune Familial Cystic fibrosis
105
What are the signs/symptoms of chronic pancreatitis?
Abdominal (epigastric, radiating to back) Nausea and vomiting Decreased appetite Exocrine dysfunction (malabsorption with weight loss, diarrhoea, steatorrhoea) Endocrine dysfunction (diabetes mellitus)
106
What investigations are needed for chronic pancreatitis?
Secretin stimulation test Ultrasound/CT: detects calcification
107
What are the treatments for chronic pancreatitis?
Management of pain and malabsorption (replacement of pancreatic enzymes with Creon, vitamins ADEK) Lifestyle advice (smoking, alcohol intake) ERCP (remove pancreatic duct stones) or surgical resection
108
What are the complications of chronic pancreatitis?
Diabetes mellitus Pericardial, peritoneal, or pleural effusions Pseudocysts GI haemorrhage Pancreatic carcinoma Malabsorption
109
What causes gallstone formation?
Cholesterol supersaturation (diet/weight loss, hormonal influence) Genetics (gallbladder motility) Increased haemoglobin turnover (haemolytic anaemia, cirrhosis, sickle cell)
110
Define peritonitis
Inflammation of the peritoneum (visceral and/or parietal), which can be classified as acute or chronic, primary or secondary, generalised or localised, and by cause
111
What are the causes of peritonitis?
Bacterial (most common) Chemical (e.g. bile, barium) Traumatic (e.g. operative handling) Ischemia (e.g. strangulated bowel, vascular occlusion) Miscellaneous (e.g. familial Mediterranean peritonitis)
112
Describe the pathways to peritoneal infection
GI perforation (e.g. perforated ulcer, appendix, diverticulum) Transmural translocation (e.g. pancreatitis, ischemic bowel, primary/spontaneous bacterial peritonitis) Exogenous contamination (e.g. drains, open surgery, trauma, peritoneal dialysis) Female genital tract infection (e.g. pelvic inflammatory disease) Haematogenous spread (e.g. septicaemia)
113
What are the signs/symptoms of peritonitis?
Localised: - signs/symptoms of the underlying condition - pain (localised or generalised guarding, rebound tenderness, referred shoulder tip pain) - nausea and vomiting - fever - tachycardia - tender rectal/vaginal examination if pelvic peritonitis - infrequent/absent bowel sounds (in generalised peritonitis) - circulatory failure and loss of consciousness in late presentation of generalised peritonitis
114
What are the investigations needed for peritonitis?
Urine dipstick: for UTI ECG: rule out cardiac causes of abdominal pain U&Es FBC: high WBC Serum amylase: shows acute pancreatitis/perforated duodenal ulcer Imaging: erect CXR (shows free air under diaphragm), CT (shows cause), US (limited use) Aspiration: shows high neutrophils in spontaneous bacterial peritonitis
115
What are the treatments of peritonitis?
Correction of fluid loss Urinary catheter Abdominal decompression (NG tube) Antibiotics (broad-spectrum e.g. piperacillin + tazobactam) Analgesia (allows early mobilisation to prevent DVT) Surgical treatment of cause
116
Define spontaneous bacterial peritonitis
Also called primary bacterial peritonitis Acute bacterial infection of ascitic fluid Diagnosed by aspiration (showing high neutrohpils)

Phase 2a (14 decks)

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