L10: Liver, Pancreas and Biliary Tract

Question 1

List 3 primary benign liver tumours

Answer 1

1. Hepatic Adenoma (Hepatocellular Adenoma)
2. Bile Duct Adenoma
3. Haemangioma

Question 2

List 1 risk factor for a hepatic adenoma

Answer 2

anabolic steroids (e.g. oral contraceptive pill - OCP)

Question 3

List 3 primary malignant tumours

Answer 3

1. Hepatocellular Carcinoma
2. Intrahepatic Cholangiocarcinoma
3. Haemangiosarcoma

Question 4

What is another term for an intrahepatic cholangiocarcinoma?

Answer 4

intrahepatic bile duct adenocarcinoma

Question 5

Are primary or secondary tumours of the liver more common?

Answer 5

secondary tumours (liver mets)

Question 6

List 3 of the most common cancers that metastasize to the liver

Answer 6

Carcinoma of the…

1. GIT
2. Lung
3. Breast

Question 7

What is a hepatocellular carcinoma?

Answer 7

primary, malignant liver tumour

Question 8

List some of the risk factors/aetiology for hepatocellular carcinoma

Answer 8

• cirrhosis
• chronic hepatitis
• HBV
• Aflatotoxins

Question 9

What tumour marker is a/w hepatocellular carcinoma?

Answer 9

Alpha-Fetoprotein (AFP)

Question 10

What are aflatotoxins? What are they a/w?

Answer 10

• fungal contaminants of food stores

- a/w the risk of developing HCC

Question 11

List 3 possible treatments for HCC

Answer 11

• resection (if early)
• OLT
• local ablative treatments (radiofrequency, arterial chemo-embolisation)

Question 12

List 2 cancers of the biliary tract

Answer 12

1. Cholangiocarcinoma

2. Gall Bladder Adenocarcinoma

Question 13

What is a cholangiocarcinoma?

Answer 13

• carcinoma of the bile duct
• mainly extrahepatic (but can be intrahepatic)
• commonest site: hilum of liver
• a/w PSC

Question 14

What is the commonest site for a cholangiocarcinoma?

Answer 14

hilum of the liver

Question 15

What is a Klatskin tumour?

Answer 15

• a cholangiocarcinoma

- obstructing tumour at bifurcation of the common hepatic duct

Question 16

What is the principal cause of gall bladder adenocarcinoma?

Answer 16

long standing gallstones

Question 17

What would an ultrasound of gall bladder adenocarcinoma show?

Answer 17

“polyps” of the gall bladder

Question 18

Is the pancrine mainly exocrine or endocrine?

Answer 18

exocrine

Question 19

Where does the pancreatic duct enter the duodenum?

Answer 19

• at the Ampulla of Vater

- surrounded by the Sphincter of Oddi

Question 20

Pancreatic enzymes are secreted in their inactive form. How do they become activated?

Answer 20

require activation by gut enzymes

Question 21

What cancer is common in the exocrine pancreas?

Answer 21

malignant: pancreatic (ductal) adenocarcinoma

Question 22

What cancers may be present in the endocrine pancreas?

Answer 22

pancreatic neuroendocrine tumours

Question 23

What is a pancreatic carcinoma?

Answer 23

• malignant
• adenocarcinoma
• ductal (arises in ducts)
• usually affects the head of the pancreas

Question 24

MEN Type 1 is associated with cancer of which 3 organs?

Answer 24

1. parathyroid gland
2. islet cells of pancreas
3. pituitary gland

Question 25

List some of the risk factors for pancreatic carcinoma

Answer 25

- smoking - diabetes mellitus - chronic pancreatitis - family history

Question 26

Which part of the pancreas do pancreatic carcinomas normally affect?

Answer 26

head of the pancreas

Question 27

Pancreatic carcinomas are typically only symptomatic with advanced disease. List some of the possible symptoms of pancreatic cancer.

Answer 27

- anorexia - weight loss - painless obstructive jaundice* - vague abdominal pain (may radiate to the back) - Trousseau's Sign*

Question 28

What is Trousseau's Sign and what type of cancer is it a/w?

Answer 28

Trousseau's Sign = migratory thrombophlebitis (moving inflammation of superficial veins) -- a/w pancreatic carcinoma

Question 29

The serum marker CA 19-9 is a/w which type of cancer?

Answer 29

pancreatico-biliary cancer

Question 30

Which tumour serum marker is associated with pancreatico-biliary cancer?

Answer 30

CA 19-9

Question 31

What is the MAIN treatment of a pancreatic carcinoma?

Answer 31

Palliation (stenting, analgesia)

Question 32

If a patient has an extrahepatic cholestasis/obstructive jaundice and weight loss, what should be suspected?

Answer 32

pancreatico-biliary malignancy

Question 33

The liver has a central role in drug metabolism. What are conjugation enzymes?

Answer 33

the liver takes insoluble compounds and stick it to something to make it soluble (so that it can be excreted)

Question 34

What are the 2 types of drug-induced liver injury? Explain them

Answer 34

Type 1: predictable, dose-related injury Type 2: not dose-related; hypersensitivity rxn or metabolic defect

Question 35

Give an example of a type 2 drug-induced liver injury

Answer 35

Halothane | - causes acute hepatic necrosis on repeat exposure in sensitized individuals

Question 36

What is halothane and what does it cause?

Answer 36

- causes type 2 drug-induced liver injury | - causes acute hepatic necrosis on repeat exposure in sensitized individuals

Question 37

List some of the possible consequences of drug induced liver injury [6]

Answer 37

- hepatocellular injury - acute liver failure - chronic hepatitis - cholestatic reactions - fatty change/steatohepatitis - fibrosis

Question 38

List some of the drugs that may cause hepatocellular drug-induced liver injury

Answer 38

- antibiotics - NSAIDs - statins - anti-epileptics - isoniazid

Question 39

List 2 drugs that may cause chronic hepatitis

Answer 39

- methyldopa | - nitrofurantoin

Question 40

List 3 drugs that may cause cholestatic reactions (drug-induced liver injury)

Answer 40

- erythromycin - chlorpromazine - augmentin

Question 41

List 1 drug that may lead to fatty change in the liver/steatohepatitis

Answer 41

amiodarone

Question 42

List 1 drug that may cause fibrosis in the liver

Answer 42

methotrexate

Question 43

Lower doses of paracetamol can be toxic if the patient has...

Answer 43

glutathione depletion (e.g. fasting, alcohol, anti-convulsants)

Question 44

NAPQI is a toxic by-product of the metabolism of paracetamol. How is it gotten rid of?

Answer 44

rendered inactive by -SH portion of glutathione (which is stored in hepatocytes)

Question 45

If NAPQI accumulates due to overdose of paracetamol, where would acute liver necrosis occur in the liver?

Answer 45

in zone 3 - closest to central vein

Question 46

What are the 2 possible treatment for paracetamol toxicity?

Answer 46

if < 2 hours = oral activated charcoal | if up to 8-10 hours: N-Acetylcysteine effective

Question 47

What is N-Acetylcysteine and what is it used to treat?

Answer 47

- treats paracetamol toxicity up to 8-10 hours - is an -SH group donor - replenishes glutathione stores (reduces NAPQI)

Question 48

What is another name for acetaminophen?

Answer 48

paracetamol

Question 49

List some of the causes of acute liver failure

Answer 49

- drugs (paracetamol, anticonvulsants, isoniazid, rare antibiotics, rare NSAIDs) - acute hepatitis A or E - mushroom poisoning - Budd-Chiari Syndrome - Wilson's Syndrome - pregnancy-associated

Question 50

What is biliary atresia and what may be required to treat this condition?

Answer 50

- congenital condition - occurs when the bile ducts inside or outside the liver do not develop normally - so there is a blockage in the ducts Liver Transplant may be required

Question 51

List some of the indications of an orthotopic liver transplant

Answer 51

- decompensated cirrhosis - acute liver failure - biliary atresia (in childhood) - metabolic disorders (in childhood)