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Gastrointestinal System > Lecture 5.2: Diseases of the Liver and Pancreas > Flashcards

Lecture 5.2: Diseases of the Liver and Pancreas Flashcards

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1
Q

What part of the abdomen is the liver located?

A
  • RUQ
  • Right Hyperchondrium
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2
Q

Functions of the Liver (7)

A
  • Bile production
  • Carbohydrate, protein and lipid metabolism
  • Protein synthesis
  • Vitamin D synthesis
  • Detoxification
  • Vitamin and mineral storage
  • Phagocytosis
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3
Q

Types Liver Function Tests? (3)

A
  • Hepatocellular damage
  • Cholestasis (bile ducts)
  • Synthetic function
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4
Q

What LFTs test for Hepatocellular damage? (2)

A
  • Aminotransferases (ALT/AST)
  • γ-Glutamyl transpeptidase (γ-GT/GGT)
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5
Q

What LFTs test for Cholestasis (bile ducts)? (2)

A
  • Bilirubin
  • Alkaline phosphatase (ALP)
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6
Q

What LFTs test for synthetic function? (3)

A
  • Albumin
  • Prothrombin time (clotting)
  • Glucose
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7
Q

What is Jaundice?

A
  • Yellow pigmentation of the skin and sclera
  • Caused by accumulation of bilirubin in tissue
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8
Q

Why does Jaundice happen?

A

Normal metabolism of bilirubin disrupted (including uptake, transport, conjugation and excretion)

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9
Q

What are the 3 ways Jaundice is classifed?

A
  • Prehepatic (haemolytic)
  • Hepatic (parenchymal)
  • Post hepatic (cholestatic)
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10
Q

When is Bilirubin produced?

A

Breakdown product of RBCs

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11
Q

How is bilirubin normally processed? (5 Steps)

A
  • Unconjugated bilirubin bound to albumin in blood
  • Bilirubin conjugated in liver
  • Excreted in bile into duodenum
  • De-conjugated into urobilinogen
  • Urobilinogen oxidised to form urobilin and stercobilin
    → faeces
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12
Q

What is Pre-Hepatic Jaundice?

A
  • Excessive haemolysis
  • Liver unable to cope with excess bilirubin
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13
Q

Lab findings in Pre-Hepatic Jaundice (3)

A
  • Unconjugated hyperbilirubinaemia
  • Reticulocytosis
  • Anaemia
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14
Q

Causes of Pre-Hepatic Jaundice: Inherited (6)

A
  • Red cell membrane defects (thalassemia)
  • Haemoglobinopathies
  • Metabolic defects
  • Congenital hyperbilirubinaemias
  • Hereditary spherocytosis
  • Sickle Cell Disease
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15
Q

Causes of Pre-Hepatic Jaundice: Acquired (6)

A
  • Immune
  • Mechanical
  • Acquired membrane defects
  • Infections (malaria)
  • Drugs
  • Burns
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16
Q

What is Hepatocellular Jaundice?

A
  • Deranged hepatocyte function
  • Cell necrosis→ inabilty to metabolise or excrete
    bilirubin
  • Element of cholestasis
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17
Q

Lab findings in Hepatocellular Jaundice (4)

A
  • Mixed unconjugated & conjugated
    hyperbilirubinaemia
  • Increased liver enzymes (AST/ALT) reflecting liver
    damage
  • Normal/Increased ALP (cholestasis (swollen cells))
  • Abnormal clotting
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18
Q

Causes of Hepatocellular Jaundice: Inherited (3/5)

A
  • Congenital hyperbilirubinaemias
    • Gilbert’s syndrome (common)
    • Crigler-Najjar syndrome (rare)
    • Dubin-Johnson syndrome (rare)
  • Wilson’s Disease
  • Autoimmune hepatitis
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19
Q

Causes of Hepatocellular Jaundice: Acquired (6)

A
  • Hepatic inflammation
  • Alcohol
  • Drugs (i.e. paracetamol)
  • Cirrhosis
  • Hepatic tumours
  • Haemochromotosis
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20
Q

What is Post-Hepatic/Cholestatic/Obstructive Jaundice?

A
  • Obstruction of biliary system
    • Intrahepatic
    • Extrahepatic
  • Passage of conjugated bilirubin blocked
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21
Q

Lab findings in Post-Hepatic Jaundice? (6)

A
  • Conjugated hyperbilirubinaemia
  • Bilirubin in urine (dark)
  • Pale stools
  • No urobilinogen in urine (no bilirubin enters bowel
    and so is not converted to urobilinogen)
  • Increased canalicular enzymes (ALP)
  • Normal/increased liver enzymes (ALT and AST)
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22
Q

Causes of Post-Hepatic Jaundice: Extrahepatic (obstruction distal to bile canaliculi) (3/7)

A
  • Gallstones
    • Biliary stricture
  • Carcinoma
    • Head of pancreas
    • Ampulla
    • Cholangiocarcinoma (bile duct)
    • Portal hepatis lymph nodes
    • Liver metastases
  • Pancreatitis
    • Sclerosing cholangitis
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23
Q

Causes of Post-Hepatic Jaundice: Intrahepatic (hepatocyte swelling)

A
  • Hepatitis
  • Drugs
  • Cirrhosis
  • Primary biliary cirrhosis
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24
Q

What is Courvoisier’s Law?

A

In the presence of a non-tender palpable gallbladder,
painless jaundice is unlikely to be caused by
gallstones

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25
Gallstones formed over a long period of time result in...?
A shrunken fibrotic gallbladder
26
What is Hepatitis?
Inflammation of the Liver
27
Lab findings in acute hepatocyte breakdown (2)
* Aminotransferase release (AST/ALT) * Jaundice
28
Lab findings in prolonged/chronic hepatocyte damage (3)
* Synthetic failure * Decreased albumin * Decreased clotting factors
29
Causes of Hepatitis (7)
* Infections- viral * Toxins * Alcohol * Drugs * Wilsons Disease * Haemochromatosis * Autoimmune
30
How is Hepatitis A spread? It is acute of chronic?
* Faecal-oral route * Usually acute
31
How is Hepatitis B spread? It is acute of chronic?
* Blood/Body fluids/vertical spread * Acute and chronic * May progress to cirrhosis
32
How is Hepatitis C spread? It is acute of chronic?
* Blood spread * 50% chronic liver disease * 30% cirrhosis * 5% hepatocellular carcinoma
33
How is Hepatitis D spread?
Hep B co-infection
34
How is Hepatitis E spread? It is acute of chronic?
* Faecal-oral * Usually acute
35
What is Alcoholic Liver Disease?
Liver damage caused by excess alcohol intake
36
Pathology of Alcoholic Liver Disease (3)
* Fatty change * Alcoholic hepatitis * Cirrhosis
37
Complications of Alcoholic Liver Disease (6)
* Hepatocellular carcinoma * Liver failure * Wernicke-Korsakoff syndrome * Encephalopathy * Dementia * Epilepsy
38
What is Liver Cirrhosis?
* Liver cell necrosis → nodular regeneration and fibrosis * Increased resistance to blood flow * Deranged liver function
39
How much of liver parenchyma can be destroyed before any clinical signs present?
80-90%
40
Causes of Liver Cirrhosis (7)
* Alcohol * Hepatitis B or C * Non-alcoholic fatty liver disease * Primary biliary cirrhosis * Autoimmune hepatitis * Haemochromatosis * Wilson’s disease
41
Clinical Features of Liver Cirrhosis
* Liver dysfunction * Jaundice * Anaemia * Bruising * Palmar erythema * Dupuytren’s contracture * Portal hypertenision * Spontaneous bacterial peritonitis
42
Investigations for Liver Cirrhosis (6)
* →/↑ALT/AST * ↑ALP * ↑Bilirubin * ↓albumin * Deranged clotting * ↓ Na
43
Management of Liver Cirrhosis (3)
* Stop drinking * Treat complications * Transplantation
44
Signs and Symptoms of Liver Disease (9)
* Hepatic Flap * Clubbing * Leukonychia * Koilonychia * Jaundice * Gynacomastia * Dupuytren's Contracture * Odema * Spider Naevi
45
What is Portal Hypertension?
Portal venous pressure >12 mmHg due to intrahepatic or extrahepatic portal venous compression or occlusion
46
Causes of Portal Hypertension (3)
* Obstruction of portal vein * Obstruction of flow within liver * Cirrhosis
47
Clinical Manifestations of Portal Hypertension (5)
* Splenomegaly * Ascites * Spider Naevi * Caput medusa * Oesophageal/rectal varices
48
What is stored in the gallbladder?
* Liver produces bile * Stored in gallbladder
49
Pathological Processes in the Gallbladder and Biliary Tree (4)
* Obstruction * Infection * Inflammation * Neoplasia
50
Risk Factors for Gallstones (Cholelithiasis): 5 F's
Fair Fat Fertile Female Forty
51
Risk Factors for Gallstones (Cholelithiasis) (6)
* Increasing age * Positive family history * Sudden weight loss - eg, after obesity surgery * Loss of bile salts - eg, ileal resection, terminal ileitis * Diabetes * Oral contraception
52
Types of Gallstones
* Mixed (80%, Cholesterol with calcium & bile pigment) * Pure cholesterol (10%, usually solitar, up to 5cm) * Pigment stones/bilirubin stones (10%, calcium bilirubinate, multiple, small and black)
53
What percentage of gallstones are radio-opaque?
~10% are radio-opaque
54
What percentage of gallstones are asymptomatic?
~70%
55
Complications of Gallstones (13): Name 5
* Biliary colic * Impaction of stone in cystic duct * Gallbladder contraction * Cholecystitis * RUQ pain & fever * Sepsis * Local peritonism * Raised white cell count * Gallbladder mass * Recurrent acute attacks may become chronic * Ascending cholangitis * Obstructive jaundice * Acute pancreatitis
56
How does pain due to gallstones present?
* Sudden onset of epigastric/RUQ pain * Radiates to back * Lasts 15 minutes up to 24 hours * Resolves spontaneously or with analgesics * Associated nausea and vomiting
57
Management of (Complications of) Gallstones (4)
* Analgesia * NBM * IV Antibiotics and fluids * Surgery – laparoscopic cholecystectomy
58
What is Charcot’s Triad?
The manifestation of biliary obstruction with: * Upper Abdominal Pain * Fever * Jaundice
59
What is Ascending Cholangitis?
* A life-threatening condition caused by an ascending bacterial infection of the biliary tree * Inflammation/infection of the CBD * Bacteria ascend from CBD junction with the duodenum * Bile duct is already partially obstructed by gallstones
60
Management of Ascending Cholangitis (3)
* Resuscitate * IV broad spectrum antibiotics * Surgery – endoscopic drainage of CBD
61
What are the Contents of the Triangle of Calot?
* Right Hepatic artery * Cystic artery * Any aberrant/accessory ducts
62
Functions of the Pancreas: Endocrine
* Insulin * Glucagon * Somatostatin
63
Functions of the Pancreas: Exocrine
* Fluid (HCO3) * Enzymes * Proteolytic, amylase, lipolytic
64
What is Pancreatitis?
* Inflammation of the pancreas * Inflammatory process caused by effects of enzymes released from pancreatic acini
65
What changes occur in the Pancreas due to Acute Pancreatitis (3)
* Oedema * Haemorrhage * Necrosis
66
What changes occur in the Pancreas due to Chronic Pancreatitis (5)
* Fibrosis * Calcification * Loss of acini * Duct stenosis * Parenchymal destruction
67
Causes of Acute Pancreatitis: GET SMASHED
* Gallstones * Ethanol * Trauma * Steroids * Mumps * Autoimmune * Scorpion bite * Hyperlipidaemia * ERCP/Iatrogenic * Drugs
68
What causes 80% of Acute Pancreatitis cases? (2)
* Gallstones * Ethanol
69
Pathogenesis/Clinical Presentations of Pancreatitis (6)
* Duct obstruction (from juice & bile reflux) * Acinar damage (from reflux or drugs) * Tissue destruction (via proteases) * Fat necrosis (via lipases) * Blood vessel destruction (via elastases) * Enzymes digest pancreatic tissue
70
How does pain caused by acute pancreatitis present?
* Sudden severe epigastric pain * Penetrates to the back * Vomiting * Steadily decrease over 72 hours
71
What is Cullen’s Sign?
Superficial bruising in the subcutaneous fat around the umbilicus
72
What is Grey Turners Sign?
An uncommon subcutaneous manifestation of intra-abdominal pathology that manifests as ecchymosis or discolouration of the flanks
73
What conditions is Cullen’s Sign seen in? (7)
* Acute pancreatitis * Rectus sheath hematoma * Splenic rupture * Perforated ulcer * Intra-abdominal cancer * Ruptured ectopic pregnancy * Complication of anticoagulation
74
What condition is Grey Turners Sign seen in?
Severe acute necrotizing pancreatitis
75
Treatment of Acute Pancreatitis
* Supportive – NG tube and IVI (drip and suck) * Fluid balance
76
What biochemical changes occur in acute pancreatitis? (4)
* ↑Amylase * ↓Ca2+ * ↑Glucose * ↑ALP/Bilirubin
77
What are the clinical presentations of chronic pancreatitis? (5)
* Pain * Malabsorption * Steatorrhoea, wt loss * DM * Jaundice
78
When does pancreatic carcinoma present?
* Late presentation * Early metastases * Poor survival rates
79
Risk Factors for Pancreatic Carcinoma (7)
* Smoking * Over 60 * High Fat Diet * Alcohol * Chronic Pancreatitis * Diabetes * Family History
80
Clinical Features Pancreatic Carcinoma (9)
* Initially symptomless/vague * Painless progressive obstructive jaundice * Nausea * Vomiting * Pain * Weight Loss * Carcinomatosis * Malabsorption * Diabetes
81
How many pancreatic carcinomas are found in the head of the pancreas?
70% in head of pancreas
82
What is the most common type of pancreatic carcinoma? What percentage of pancreatic carcinomas does it make up?
* Ductal adenocarcinoma * 90%
83
What effect does pancreatic cancer invading the pancreatic head have on surrounding structures? (3)
* Can compress and obstruct the bile duct, * Can compress/obstruct hepatopancreatic ampulla * If cancer invades posteriorly, it can invade/block portal venous confluence of splenic vein + SMV
84
Treatment of Pancreatic Carcinoma
* Surgery (only 10-20%) * Chemotherapy * Palliative
85
Prognosis of Pancreatic Carcinoma
* 5th cause of cancer death in UK * 5-year survival rate less than 5%
86
What is Gilbert's Syndrome?
* Inherited condition * The faulty gene means that bilirubin isn't passed into bile at the normal rate * Thus bilirubin build up in blood
87
Name 5 causes of obstruction to flow of bile from the liver and gallbladder
* CBD gallstones * Carcinoma * Pancreatic Pseudocyst * Biliary Stricture * Sclerosing Cholangitis
88
What is HUS?
* Haemolytic Uremic Syndrome * A kidney condition that happens when red blood cells are destroyed and block the kidneys' filtering system
89
Symptoms of HUS?
* Vomiting * Bloody Diarrhea * Stomach Pain * Fever * Chills * Headache
90
What causes HUS?
In most cases, HUS occurs after a severe bowel infection with certain toxic strains of the bacteria called E. coli. It may also occur in response to certain medicines, but this is rare.
91
Treatment of HUS (6)
* Plasma Exchange * Treatment of high blood pressure * Maintaining specific levels of fluids and salts * Blood transfusions * Kidney dialysis * Medicine

Gastrointestinal System (22 decks)

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