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Flashcards in HPB & Upper GI Deck (64):
1

Which LFT enzymes are raised in cholestasis?

ALP

2

Which LFT enzymes are raised in liver injury?

ALT and AST

3

What are the problems with using the transaminase enzymes?

Only assess injury over past 1-2 days as enzymes are cleared efficiently from blood

May not accurately assess hepatocyte death from apoptosis

Magnitude of elevation does not necessarily correlate with extent of liver dysfunction

4

What is raised ALT an indicator of?

Acute hepatocellular injury

5

What is raised AST an indicator of?

Acute hepatocellular injury

6

What is raised ALP an indicator of?

Cholestasis

7

What does a rise in unconjugated bilirubin suggest?

A prehepatic cause eg
Haemolysis, resolving haematoma or Gilbert's syndrome

8

What does a rise conjugated bilirubin suggest?

Hepatocellular disease or cholestatic disease

9

What is Gilbert's syndrome?

What causes is?

A genetic disorder that causes hyperbilirubinaemia

Caused by insertion of TA in the promoter region of the UGT-1A gene

10

What is Budd-Chiari syndrome?

A condition caused by occlusion of the hepatic veins that drain the liver

It presents with the classical triad of abdominal pain. ascites and liver enlargement

11

What is the difference between primary and secondary Budd-Chiari syndrome?

Primary is occlusion of the hepatic veins due to thrombosis

Secondary is due to compression by an outside structure (eg tumour)

12

What are the most common causes of primary Budd-Chiari syndrome?

Polycythemia vera
Pregnancy
Postpartum state
OCP
Paroxysmal nocturnal haemoglobinuria
Hepatocellular carcinoma
Lupus anticoagulants

13

What is a transjugular intrahepatic portosystemic shunt? (TIPS)

TIPS is an interventional radiology procedure in which an artificial channel within the liver is created, establishing a communication between the portal vein and the hepatic vein

Used to treat portal hypertension (reduces the risk of varices bleeding and reduces ascites)

14

Complications of cholecystitis

Who is more at risk?

Empyema
Gangrene leading to perforation

Diabetics, immunosuppressed patients, obese patients and those with haemoglobinopathies

15

Causes of acute pancreatitis?

Idiopathic
Gallstones (Women)
Ethanol (Men)
Trauma (Kids)
Steroids
Mumps
AI (polyarteritis nodosa)
Scorpion toxin (Trinadad)
Hyperlipidaemia/Hypercalcaemia
ERCP
Drugs

16

Which drugs can cause acute pancreatitis?

Steroids & sulphonamides
Azothioprine & antibiotics (metronidazole and tetracycline)
NSAIDS
Diuretics

17

What is the Glasgow Scale for pancreatitis?

PaO2 55
Neutrophillia (WBC > 15)
Ca > 2mmol/L
Renal (Urea > 16)
Enzymes (LDH > 600)
Albumin 10

18

What should always be excluded in patients with suspected acute pancreatitis?

Perorated peptic ulcer

19

What does pain, jaundice and fever indicate?

Ascending colangitis

Charcoals biliary triad

20

What is Charcots biliary triad?

What does this indicate?

Presence of fever, pain and jaundice

Ascending colangitis

21

What are the causative organisms of ascending cholangitis?

E. coli, Klebsiella, Enterobacter, enterococci and Group D strep

22

How can the position of a peptic ulcer perforation be deduced?

If it perforated posteriorly, it will erode in to the gastroduodenal artery and lead to bleeding

If it perforated anteriorly it will lead to free gas in the diaphragm

23

What are the common causes of pneumoperitoneum

Ruptured hollow viscous: perforated peptic ulcer or duodenal ulcer, necrotising enterocolitis, IBD, toxic megaflop

Infection: Gas-forming organism and/rupture of an adjacent abscess

Iatrogenic: Recent abdominal surgery, abdominal surgery, leaking surgical anastomosis, misplaced chest drain, endoscopic perforation

24

What is Kehr's sign?

Shoulder tip pain caused by diaphragmatic irritation as a result of blood in the peritoneal cavity

25

What are the possible cause of smooth generalised enlargement of the liver?

Hepatitis
Congestive heart failure
Micronodular cirrhosis
Hepatic vein obstruction (Budd-Chiari)
Amyloidosis

26

What is Budd-Chiari syndrome?

Budd-Chiari syndrome is an uncommon condition induced by thrombotic or nonthrombotic obstruction of the hepatic venous outflow and is characterized by hepatomegaly, ascites, and abdominal pain

27

What are the possible cause of craggy generalised enlargement of the liver?

Metastases
Macronocular cirrhosis

28

What are the possible cause of a localised swelling of the liver?

Hepatocellular carcinoma
Riedel's lobe
Hydratid cyst
Liver abscess

29

What is Riedel's lobe?

A tongue-like, inferior projection of the right lobe of the liver beyond the level of the most inferior costal cartilage.

It is not considered a true accessory lobe of the liver but an anatomical variant of the right lobe of the liver

30

What are the two most common types of oesophageal cancer?

Squamous cell carcinoma (accounts for 90% worldwide)

Adenocarcinoma (now accounts for half of presentations in the UK & US)

31

What are the risk factors for oesophageal carcinoma?

Alcohol and smoking
Nitrosamines and aflatoxins
Deficiency of Vit A or C
Achalasia
Coeliac disease
Tylosis
Barrett's oesophagus (=> adenomcarcinoma)

32

What is Courvoisier's law?

That a palpable gall in the presence of jaundice is unlikely to be secondary to gallstones

33

What is Ca19.9 a tumour marker for?

Pancreatic cancer

34

What would the blood tests of someone with acute upper GI bleeding show?

Normocytic anaemia

Increased urea (due to protein absorption from the GI tract)

35

How can a splenic mass be differentiated from a renal mass on palpation?

It is not possible to palpate the upper border of splenic masses, whereas it is possible for renal masses

36

What is myelofibrosis?

How is diagnosis made?

There is progressive scarring of the bone marrow leading to blood formation in extra medullary sites (eg liver and spleen)

Cause is unknown and it develops slowly

Diagnosis is made by tear-drop shaped RBS on blood film or by marrow biopsy

37

How can the causes of portal hypertension be separated?

Prehepatic, intra-hepatic and post-hepatic

38

What are the pre-hepatic causes of portal hypertension?

Portal vein thrombosis

39

What are the post-hepatic causes of portal hypertension?

Venous outflow obstruction
Budd-Chiari syndrome
Veno-occlusive disease
Constrictive pericarditis
Right heart failure

40

What are the infra-hepatic causes of portal hypertension?

Cirrhosis
Schistosomiasis
Sarcoidosis
Congenital heart failure

41

What are the complications of portal hypertension?

Porto-systemic venous shunts - varices (OG junction in 65% of cirrhotics)

Splenomegaly

Ascites

Spontaneous bacterial peritonitis

Encephalopathy

42

What are the risk factors of gallstones?

Cholesterol stones: Obesity, female sex hormones, rapid weight loss, inborn errors of bile acid metabolism

Pigment stones: Chronic haemolytic syndromes, biliary infection, ileal disease, CF with pancreatic insufficiency

43

What is a gallstones ileus?

When a gallstone fistulates into the duodenum

It can reach the ileocaeval valve and cause obstruction

44

What is acalculous cholecystitis?

Why is it important?

What is it associated with?

Cholecystitis without obvious obstructive cause

10% lead to ischaemia (cystic artery is an end artery)

Sepsis, immunosuppression, trauma (and burns) and T2DM

45

What are the complications of gallstones?

5% pancreatitis
Acute cholescystitis
Empyema
Cholangitis
Perforation of gallbladder
Gallstone ileus
Increased risk of gallbladder cancer

46

What are the histological changes associated with pancreatitis?

Microvascular leakage and oedema

Fat necrosis (saponification)

Acute inflammation

Destruction of parenchyma

Destruction of blood vessels and interstitium

47

What are the acute and chronic causes of ischaemic colitis?

Acute: AAA, embolism of cardiac vegetations, atherosclerosis, thromboembolus (OCP/hypercoagulable states)

Chronic: Cardiac failure, shock, dehydration, Vasoconstrictive drugs

48

What reaction does ALT catalyse?

Alanine + alpha-ketoglutarate
III
V
Pyruvic acid + glutamate

49

What reaction does AST catalyse?

Aspartate aminotransferase + alpha-ketoglutarate
III
V
Oxaloacetic acid + glutamate

50

Where is AST located?

Many tissues and is cytosolic and mitochondrial

51

Where is ALT located?

Liver only and is only cytosolic

52

Origin of ALP and mechanism of increase in cholestatic liver disease?

1. Apical membrane of hepatocyte and bile duct cells
2. Very sensitive to any changes in bile flow
3. Amplified by bile acid retention
4. Easily released into blood as it is a GPI-anchored protein solubilized from membrane by detergents

53

At what stage does jaundice become evident?

35-70ymol/L bilirubin levels

54

What does a rise in unconjugated bilirubin mean?

What are the potential causes of this?

That there is a pre-hepatic cause of hyperbilirubinaemia

Haemolysis
Resolving haemotoma
Gilbert's syndrome

55

What is the rationale behind using PT in order to assess liver function?

Liver is the sole source of Vit K dependent clotting factors

Factor VII has very short half-life therefore changes rapidly with liver function

56

What are the complications of cirrhosis?

VARICES

Varices
Anaemia
Renal failure
Infection
Coagulopathy
Encephalopathy
Sepsis

57

What is hepatopulomary syndrome?

Thought to arise from a ventilation perfusion mismatch, intrapulmonary shunting and ventilation perfusion mismatch

Due to failure of the liver to clear circulating pulmonary vasodilators vs production of a vasodilator substance by the liver

58

What are the clinical features of hepatopulomary syndrome?

Hyperdynamic circulation

Dyspnea, platypnea (breathlessness in the upright position), orthodeoxia (rapid desaturation when upright)

59

What is the pathophysoilogy of portal hypertension?

3 sites of increased resistance:
- Pre-sinusoidal (eg portal vein thrombosis, schistosomiasis, sarcoidosis)
- Sinusoidal (eg cirrhosis, alcoholic hepatitis)
- Post-sinusoidal (eg RHF, hepatic vein thrombosis , be no-occlusive disease, constructive pericarditis)

60

What are the signs of portal hypertension?

Oesophageal varices
Splenomegaly
Melena
Haemorrhage
Ascites

61

What is the management of portal hypertension?

Betablockers
Nitrates
Shunts

62

What are the main causes of hereditary pancreatitis?

PRSS1 mutations - Gain of function in trypsinogen gene (autosomal dominant)

SPINK 1 - Trypsin inhibitor, loss of function mutations (autosomal recessive)

CFTR

63

Fracture of which ribs may lead to splenic rupture?

9th, 10th and 11th

64

What is an anular pancreas?

In normal development, the head and neck of the pancreas are formed from left and right ventral buds which fuse together and rotate round as a single entity

If they do not fuse initially, they may pass round opposite sides of the pancreas and then fuse together, thus forming a ring of pancreatic tissue round the duodenum