Jaundice and Chronic Liver Disease/Hepato-Biliary Pathology

Question 1

What are the three classes of jaundice?

Answer 1

Pre-hepatic
Hepatic
Post Hepatic

Question 2

What is the cause of jaundice?

Answer 2

Increase in circulating bilirubin due to altered metabolism

Question 3

What part of haemoglobin is converted to bilirubin?

Answer 3

Haem part

Question 4

What is involved in the pre-hepatic phase?

Answer 4

Breakdown of haemoglobin -> haem and globin, haem is converted to bilirubin

Question 5

What is involved in the hepatic phase?

Answer 5

Uptake and conjugation of bilirubin by the hepatocytes and excretion of the conjugated bilirubin into the biliary system

Question 6

What is involved in the post-hepatic phase?

Answer 6

Transport of conjugated bilirubin in the biliary system , breakdown in the intestine and reabsorption

Question 7

What is cholestasis?

Answer 7

Accumulation of bile within the hepatocytes or bile canaliculi due to viral hepatitis, alcoholic hepatitis, liver failure or drugs

Question 8

What are the types of hepatic jaundice?

Answer 8

Predictable - dose related

Unpredictable - not dose related

Question 9

What causes hepatic jaundice?

Answer 9

Intra-hepatic bile duct obstruction 
Due to:
Primary biliary cholangitis 
Primary sclerosing cholangitis 
Tumours of the liver

Question 10

What is primary biliary cholangitis?

Answer 10

An organ specific auto-immune disease causing granulomatous inflammation involving the bile ducts, loss of intra-hepatic bile ducts and progression to cirrhosis

Question 11

What can be detected in serum for diagnosis of primary biliary cholangitis?

Answer 11

Anti-mitochondrial auto-antibodies

Raised alkaline phosphatase

Question 12

What is primary sclerosing cholangitis?

Answer 12

Chronic inflammation and fibrous obliteration of the bile ducts causing loss of intra-hepatic bile ducts and progression to cirrhosis

Question 13

Primary sclerosing cholangitis is associated with an increased risk of what?

Answer 13

Cholangiocarcinoma

Question 14

What is the cause of post-hepatic jaundice?

Answer 14

Gallstones and diseases of the gall bladder causing extra hepatic obstruction

Question 15

What is acute cholecystitis?

Answer 15

Acute inflammation of the gall bladder

Question 16

What is caused by acute cholecystitis?

Answer 16

Empyema leading to the perforation of the gall bladder, biliary peritonitis and eventual progression to chronic inflammation in which pus is formed in the gall bladder

Question 17

What is chronic cholecystitis?

Answer 17

Chronic inflammation and fibrosis of the gall bladder

Question 18

What are the causes of common bile duct obstruction?

Answer 18

Gallstones
Bile duct tumours
Benign strictures
External compression due to tumours

Question 19

What are the effects of common bile duct obstruction?

Answer 19

Jaundice
No bile excreted into duodenum
Infection of bile proximal to the obstruction
Secondary biliary cirrhosis if obstruction is prolonged

Question 20

What can cause an elevation in circulating bilirubin?

Answer 20

Haemolysis
Parenchymal Damage
Obstruction

Question 21

How are amino transferases used to determine liver function?

Answer 21

ALT and AST can indicate liver injury but are not specific to it, if AST levels > ALT levels alcoholic liver disease is indicated
May also indicate parenchymal involvement

Question 22

What is alkaline phosphatase and how is it used to determine liver function?

Answer 22

An enzyme present in the bile ducts which becomes elevated during obstruction or liver infiltration
However it is non-specific as it is also present in bone disease, placenta and the intestines

Question 23

What is gamma-GT and how is it used to determine liver function?

Answer 23

A non-specific liver enzyme which is elevated with alcohol consumption and some drugs
Can be useful to confirm a liver source of ALP
If alkaline phosphatase and gamma-GT levels are moth raised then liver disease is indicated

Question 24

How is albumin useful in detecting liver disease?

Answer 24

Important test for synthetic function of the liver

Low levels suggest chronic liver disease, kidney disorders or malnutrition

Question 25

How is prothrombin time useful in detecting liver disease?

Answer 25

Important test for liver function, tells the extent and prognosis of liver function Test of the clotting factors so if abnormal significant disease is indicated

Question 26

How is creatinine a useful test in the diagnosis of liver disease?

Answer 26

Creatinine tests kidney function, since kidney and liver function are closely related it helps to determine the prognosis of liver disease

Question 27

How is a platelet count a useful test in the diagnosis of liver disease?

Answer 27

Liver is an important source of thrombopoeitin, poor liver function will reduce bone marrow activity, also cirrhosis can result in splenomegaly - hypersplenism results in low platelets

Question 28

Give 5 things which would be tested for in the blood in investigation of liver disease

Answer 28

``` Immunoglobulins - IgA, IgG, IgM Autoantibodies - AMA, ASMA, ANA Caeruloplasmin copper Ferritin Alpha-1-antitrypsin Hepatitis serology Epstein Barr Virus Cytomegalovirus Leptospira Alphafoetoprotein Fatty liver disease - fasting glucose or lipid profile ```

Question 29

What are the typical presentations of liver failure?

Answer 29

Jaundice Ascites Variceal bleeding Hepatic encephalopathy

Question 30

When would a liver biopsy be indicated?

Answer 30

In unknown parenchymal disease or if an unknown focal liver lesion If the aetiology of disease is known but more information is required on inflammation, fibrosis or cirrhosis

Question 31

What imaging investigations might be done in suspected liver failure?

Answer 31

``` Ultrasound of liver and biliary tree CT of abdomen MRI of abdomen ERCP Endoscopic ultrasound MRCP ```

Question 32

Give the causes of acute liver injury

Answer 32

``` Hepatitis Viral Hepatitis - A, B, C or E Viruses Alcohol Drugs Bile duct obstruction ```

Question 33

What happens to the liver in viral hepatitis?

Answer 33

Live inflammation, cell damage and death

Question 34

What kinds of viral hepatitis might resolve and return to normal without treatment?

Answer 34

A or E

Question 35

What kinds of viral hepatitis can cause liver failure due to liver damage caused by severe hepatitis?

Answer 35

A, B or E

Question 36

What kinds of viral hepatitis can progress to chronic hepatitis and cirrhosis?

Answer 36

B or C

Question 37

What is alcoholic hepatitis?

Answer 37

Inflammatory response of the liver to alcohol causing acute inflammation, liver cell death and liver failure

Question 38

What can alcoholic hepatitis progress to?

Answer 38

Cirrhosis

Question 39

What are the causes of hepatic cirrhosis?

Answer 39

``` Alcohol Hepatitis B or C Autoimmune hepatitis Primary biliary cholangitis Primary haemachromatosis Wilson's disease Obesity/diabetes mellitus Idiopathic ```

Question 40

What is hepatic cirrhosis

Answer 40

A diffuse process involving the whole liver causing loss of normal liver structure which is replaced by nodules of hepatocytes and fibrous tissue

Question 41

Give the complications of hepatic cirrhosis

Answer 41

Liver failure caused by altered liver function Portal hypertension causing haemorrhage risk Increased risk of hepatocellular carcinoma

Question 42

What are the histological types of liver tumours?

Answer 42

Hepatocellular carcinoma Cholangiocarcinoma Metastatic tumours also commonly occur in the liver

Question 43

How does hepatocellular carcinoma usually develop and what cells does it affect?

Answer 43

Generally develops with cirrhosis | Malignant tumour of the hepatocytes

Question 44

What is cholangiocarcinoma?

Answer 44

A malignant tumour of the bile duct epithelium

Question 45

What are the common liver disorders?

Answer 45

``` Jaundice Liver failure Intrahepatic bile duct obstruction Cirrhosis Tumours ```

Question 46

What are the causes of cholestasis?

Answer 46

Viral hepatitis Alcoholic hepatitis Liver failure Drugs

Question 47

What are the causes of intra-hepatic bile duct obstruction?

Answer 47

Primary biliary cholangitis Primary sclerosing cholangitis Tumours

Question 48

How might gall stones present?

Answer 48

``` Asymptomatic Dyspeptic symptoms Biliary colic Acute cholecystitis Empyema Perforation Jaundice Gallstone ileus ```

Question 49

What investigations would be done if suspecting gallstones?

Answer 49

``` MRCP EUS CT Amylase and lipase WCC ```

Question 50

What would be done if diagnosis of gallstones had been confirmed as therapeutic management?

Answer 50

PTC or ERCP

Question 51

What is the best surgical procedure for removal of gallstones?

Answer 51

Laparoscopic cholecystectomy

Question 52

What is choledocholithiasis?

Answer 52

Presence of at least one gall stone in the common bile duct

Question 53

How might choledocholithiasis present?

Answer 53

Post-cholecystectomy pain Obstructive jaundice Acute pancreatitis Ascending cholangitis

Question 54

What is the management for choledocholithiasis?

Answer 54

Laparoscopic CBD exploration ERCP Transhepatic stone retrieval

Question 55

What are the risk factors for cholangiocarcinoma?

Answer 55

``` Increasing age Primary sclerosing cholangitis Congenital cystic disease Biliary enteric drainage Thorotrast (old contrast agent) Hepatolithiasis Carcinogen exposure ```

Question 56

What are the histological types of ampullary tumours?

Answer 56

Adenoma | Adenocarcinoma

Question 57

What is the treatment for ampullary tumours?

Answer 57

Endoscopic excision Trans-duodenal excision Pancreatico-duodenectomy