Flashcards in HPB & Upper GI Deck (64):
Which LFT enzymes are raised in cholestasis?
Which LFT enzymes are raised in liver injury?
ALT and AST
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
What is raised ALT an indicator of?
Acute hepatocellular injury
What is raised AST an indicator of?
Acute hepatocellular injury
What is raised ALP an indicator of?
What does a rise in unconjugated bilirubin suggest?
A prehepatic cause eg
Haemolysis, resolving haematoma or Gilbert's syndrome
What does a rise conjugated bilirubin suggest?
Hepatocellular disease or cholestatic disease
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
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
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)
What are the most common causes of primary Budd-Chiari syndrome?
Paroxysmal nocturnal haemoglobinuria
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)
Complications of cholecystitis
Who is more at risk?
Gangrene leading to perforation
Diabetics, immunosuppressed patients, obese patients and those with haemoglobinopathies
Causes of acute pancreatitis?
AI (polyarteritis nodosa)
Scorpion toxin (Trinadad)
Which drugs can cause acute pancreatitis?
Steroids & sulphonamides
Azothioprine & antibiotics (metronidazole and tetracycline)
What is the Glasgow Scale for pancreatitis?
Neutrophillia (WBC > 15)
Ca > 2mmol/L
Renal (Urea > 16)
Enzymes (LDH > 600)
What should always be excluded in patients with suspected acute pancreatitis?
Perorated peptic ulcer
What does pain, jaundice and fever indicate?
Charcoals biliary triad
What is Charcots biliary triad?
What does this indicate?
Presence of fever, pain and jaundice
What are the causative organisms of ascending cholangitis?
E. coli, Klebsiella, Enterobacter, enterococci and Group D strep
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
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
What is Kehr's sign?
Shoulder tip pain caused by diaphragmatic irritation as a result of blood in the peritoneal cavity
What are the possible cause of smooth generalised enlargement of the liver?
Congestive heart failure
Hepatic vein obstruction (Budd-Chiari)
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
What are the possible cause of craggy generalised enlargement of the liver?
What are the possible cause of a localised swelling of the liver?
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
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)
What are the risk factors for oesophageal carcinoma?
Alcohol and smoking
Nitrosamines and aflatoxins
Deficiency of Vit A or C
Barrett's oesophagus (=> adenomcarcinoma)
What is Courvoisier's law?
That a palpable gall in the presence of jaundice is unlikely to be secondary to gallstones
What is Ca19.9 a tumour marker for?
What would the blood tests of someone with acute upper GI bleeding show?
Increased urea (due to protein absorption from the GI tract)
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
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
How can the causes of portal hypertension be separated?
Prehepatic, intra-hepatic and post-hepatic
What are the pre-hepatic causes of portal hypertension?
Portal vein thrombosis
What are the post-hepatic causes of portal hypertension?
Venous outflow obstruction
Right heart failure
What are the infra-hepatic causes of portal hypertension?
Congenital heart failure
What are the complications of portal hypertension?
Porto-systemic venous shunts - varices (OG junction in 65% of cirrhotics)
Spontaneous bacterial peritonitis
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
What is a gallstones ileus?
When a gallstone fistulates into the duodenum
It can reach the ileocaeval valve and cause obstruction
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
What are the complications of gallstones?
Perforation of gallbladder
Increased risk of gallbladder cancer
What are the histological changes associated with pancreatitis?
Microvascular leakage and oedema
Fat necrosis (saponification)
Destruction of parenchyma
Destruction of blood vessels and interstitium
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
What reaction does ALT catalyse?
Alanine + alpha-ketoglutarate
Pyruvic acid + glutamate
What reaction does AST catalyse?
Aspartate aminotransferase + alpha-ketoglutarate
Oxaloacetic acid + glutamate
Where is AST located?
Many tissues and is cytosolic and mitochondrial
Where is ALT located?
Liver only and is only cytosolic
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
At what stage does jaundice become evident?
35-70ymol/L bilirubin levels
What does a rise in unconjugated bilirubin mean?
What are the potential causes of this?
That there is a pre-hepatic cause of hyperbilirubinaemia
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
What are the complications of cirrhosis?
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
What are the clinical features of hepatopulomary syndrome?
Dyspnea, platypnea (breathlessness in the upright position), orthodeoxia (rapid desaturation when upright)
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)
What are the signs of portal hypertension?
What is the management of portal hypertension?
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)
Fracture of which ribs may lead to splenic rupture?
9th, 10th and 11th