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FINALS REVISION > Liver and friends > Flashcards

Liver and friends Flashcards

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1
Q

what is the pathophysiology of pancreatitis

A

autodigestion of pancreatic tissue by pancreatic enzymes leading to necrosis

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2
Q

what are the symptoms of pancreatitis

A

severe epigastric pain radiating to back
vomiting
on examination - tenderness, ileus, low grade fever

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3
Q

what signs of pancreatitis

A

cullen’s (periumbilical) and grey-turner’s (flank) discolouration

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4
Q

what investigations for pancreatitis

A 
serum amylase raised
serum lipase (more specific) - longer half-life
early ultrasound
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5
Q

why is early ultrasound important in acute pancreatitis?

A

determine cause - if gallstones, then surgical removal

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6
Q

what scoring systems for pancreatitis

A

Glasgow, Ranson, APACHE II

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7
Q

GET SMASHED for pancreatitis

A 
gallstones
ethanol
trauma
steroids
mumps
autoimmune
scorpion venom
hypothermia, hypercalcaemia
ERCP
drugs (azathioprine, mesalazine, diuretics)
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8
Q

how is acute pancreatitis treated

A

fluid resus 3-6L?
analgesia - IV opioids
enteral nutrition
surgical - remove gallstones via ERCP/cholecystectomy, debridement of necrotic pancreas

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9
Q

what mode of inheritance in wilsons disease and what gene

A

autosomal recessive

- atp7b copper binding protein

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10
Q

what symptoms in wilsons disease

A

excess copper deposition in liver and brain

  • liver - chronic hepatitis and cirrhosis
  • neuropsychiatric symptoms
  • kayser-fleischer rings - copper deposition in descemet membrane
  • blue nails
  • haemolytic anaemia
  • renal tubular acidosis
  • osteopaenia
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11
Q

what neuro symptoms in wilsons

A

neuro

  • dysarthria
  • dystonia
  • concentration and coordination problems
  • basal ganglia - parkinsonism, asymmetrical motor problems
  • asterixis
  • dementia
  • chorea
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12
Q

what psych symptoms in wilsons

A

psychiatric - depression to psychosis

dementia

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13
Q

what investigations for wilsons

A
  • low serum caeruloplasmin
  • low total serum copper
  • gold standard liver biopsy
  • increased 24hr urinary copper excretion
  • genetic analysis of ATP7B gene
  • slit lamp examination of keyser fleischer rings in eyes
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14
Q

what mgmt of wilsons

A

copper chelation with:
penicillamine
trientene

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15
Q

what is haemochromatosis and what mode of inheritance which genes

A

iron accumulation

autosomal recessive HFE gene on chromosome 6

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16
Q

how does haemochromatosis present

A

later in women due to menstruation

  • fatigue
  • arthritis
  • erectile dysfunction
  • bronze skin
  • liver symptoms - hepatomegaly, cirrhosis, asterixis
  • diabetes mellitus
  • hypogonadotrophic hypogonadism
  • cardiac failure (due to dilated cardiomyopathy)
  • cognitive: memory and mood disturbance
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17
Q

what are the reversible complications of hereditary haemochromatosis

A

skin pigmentation

cardiomyopathy

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18
Q

what are the irreversible complications of hereditary haemochromatosis

A
  • diabetes mellitus
  • cirrhosis
  • hypogonadotropic hypogonadism
  • arthropathy
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19
Q

what is biliary colic

A

gallstones obstructing flow of bile from gallbladder

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20
Q

what are the symptoms of biliary colic?

A
  • RUQ pain worse after eating, particularly fatty meals
  • colicky pain
  • associated with nausea and vomiting
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21
Q

what investigation for biliary colic

A

ultrasound scan

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22
Q

what RFs for biliary colic

A
  • 4 Fs
  • Diabetes
  • Rapid weight loss
  • Crohn’s
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23
Q

what complications of gallstones/biliary colic

A
  • acute cholecystitis
  • acute pancreatitis
  • obstructive jaundice
  • ascending cholangitis
  • gallstone ileus
  • gallbladder cancer
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24
Q

what treatment for biliary colic

A

elective lap cholecystectomy

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25
what is acute cholecystitis
inflammation of gallbladder due to bile being unable to drain usually because of gallstone in cystic duct
26
what are the symptoms of cholecystitis
``` RUQ pain nausea vomiting fever tachycardia tachypnoea Murphy's sign ```
27
what sign is associated with acute cholecystitis
Murphy's sign | - inspiratory attest on palpation of RUQ only (not on LUQ)
28
how are LFTs in cholecystitis
typically normal | just the cystic duct that's blocked
29
what investigations would you do for cholecystitis
USS FBC - raised WCC CRP raised MRCP if unable to visualise with USS
30
what would you see on USS for cholecystitis
- thickened gallbladder wall - sludge/gallstones in gallbladder - fluid around the gallbladder
31
what mgmt of cholecystitis
- admit - NBM, IV fluids - NG tube if vomiting severe - IV Abx according to local guidelines - ERCP to remove gallstones - cholecystectomy within 1 week of diagnosis
32
what are complications of acute cholecystitis
gallbladder perforation gallbladder empyema gangrenous gallbladder sepsis
33
what treatment of gallbladder empyema
IV Abx and either cholecystectomy or cholecystostomy
34
what is mirizzi syndrome
stone in cystic duct or in hartmann's pouch causes compression of hepatic duct/common bile duct leading to obstructive jaundice - deranged LFTs, jaundice etc.
35
what are the main causes of liver cirrhosis
1. Alcoholic liver disease 2. NAFLD 3. Hep B and C
36
what is the pathophys of liver cirrhosis
chronic inflammation of liver causes fibrosis and nodule formation in the liver
37
what are the symptoms of liver cirrhosis
1. ascites 2. telangiectasia 3. jaundice 4. hepatic encephalopathy 5. caput medusae 6. oesophageal varices 7. easy bruising 8. hepatosplenomegaly 9. asterixis 10. palmar erythema
38
what blood tests should be ordered for suspected cirrhosis?
thrombocytopaenia Enhanced Liver Fibrosis (ELF), NAFLD blood test 1. LFTs 2. Albumin low, prothrombin time increased 3. U+E for hepatorenal syndrome, hyponatraemia indicates severe fluid retention 4. Viral markers, autoantibodies 5. AFP as a marker for hepatocellular carcinoma
39
what investigations for cirrhosis
1. Bloods 2. liver ultrasound scan 3. fibroscan - transient elastography 4. liver biopsy 5. endoscopy to diagnose/treat oesophageal varices
40
what changes seen on USS of cirrhosis
1. nodularity to surface of vessels 2. splenomegaly 3. corkscrew vessels 4. ascites 5. enlarged portal vein with reduced flow
41
what screening investigation for people at risk of cirrhosis every 2 years
fibroscan (transient elastography)
42
what investigation in a patient newly diagnosed with cirrhosis
endoscopy to check for oesophageal varices
43
how should patients with cirrhosis be screened for HCC every 6 months
AFP and uss
44
what are the elements of the childpugh score for cirrhosis
``` ABCDE Albumin Bilirubin Clotting (INR) Distended abdomen (ascites) Encephalopathy ``` 1. ascites 2. bilirubin 3. albumin 4. INR 5. hepatic encephalopathy
45
what scoring systems can be used for cirrhosis
Child Pugh or MELD (helps guide referral for liver transplant)
46
what is the general management for cirrhosis
1. high protein, low sodium diet 2. endoscopy every 3 years for varices 3. MELD score every 6 months 4. manage complications 5. consider liver transplant
47
what are the complications of cirrhosis
1. ascites and SBP 2. portal HTN, varices and variceal bleeding 3. hepatorenal syndrome 4. hepatic encephalopathy 5. hepatocellular carcinoma 6. malnutrition
48
what is the mgmt of stable varcies
1. propranolol 2. endoscopic band ligation 3. injection of sclerosant into varices 5. TIPS (transjugular intrahepatic portosystemic shunt)
49
what is the mgmt of bleeding varices
1. A-E resuscitation 2. correct clotting - Vit K, FFP 3. terlipressin 4. IV Abx prophylactic 5. endoscopic variceal band ligation 6. insertion of sengstaken-blakemore tube 7. TIPS if all else fails
50
what is a common complication of TIPS
exacerbation of hepatic encephalopathy
51
what is the management of ascites in cirrhosis (transudative)
1. spironolactone 2. low sodium diet 3. paracentesis 4. ciprofloxacin as prophylaxis against SBP 5. TIPS or transplant in refractory ascites
52
how does sbp present
1. fever 2. abdominal pain 3. raised WCC and CRP, creatinine, metabolic acidosis 4. ileus 5. hypotension
53
what are the most common organisms in sbp
1. e. coli (gram neg rods) 2. klebsiella 3. gram +ve cocci (staph or enterococcus)
54
how is sbp diagnosed
paracentesis fluid microscopy culture sensitivity prior to administration of Abx
55
how is sbp managed
IV cefotaxime
56
what is hepatorenal syndrome
splanchnic vasodilation 1. portal hypertension leads to renal hypotension and hypoperfusion 2. this leads to RAAS activation and renal vasoconstriction 3. vasoconstriction and reduced circulating volume = reduced renal perfusion = CKD
57
what are the two types of hepatorenal syndrome
Type 1 - very poor prognosis, rapidly progressive | Type 2 - slightly better prognosis, slowly progressive
58
what is the mgmt of hepatorenal syndrome
liver transplant 1. terlipressin 2. volume expansion with 20% albumin 3. TIPS
59
what is hepatic encephalopathy
build up of toxins such as ammonia in blood | ammonia able to cross BBB
60
how is hepatic encephalopathy treated
lactulose add rifaximin embolisation of portosystemic shunts/liver transplant
61
what are the 4 grades of hepatic encephalopathy
1. irritability 2. confusion, inappropriate behaviour 3. incoherent, restless 4. coma
62
what can precipitate hepatic encephalopathy
``` constipation TIPS infection (eg. SBP) electrolyte disturbance GI bleed high protein diet medications (sedatives, diuretics) hypokalemia renal failure ```
63
how does hepatic encephalopathy
confusion, altered GCS asterixis constructional apraxia inability to draw 5 point star EEG - triphasic slow waves
64
name 4 causes of acute liver failure
1. alcohol 2. viral hepatitis (A or B) 3. paracetamol overdose 4. acute fatty liver of pregnancy
65
how does acute liver failure present
1. jaundice 2. coagulopathy (raised PTT) 3. hypoalbuminaemia 4. renal dysfunction (hepatorenal syndrome) 5. hepatic encephalopathy
66
what is the spectrum of alcoholic liver disease
1. alcoholic fatty liver disease 2. alcoholic hepatitis 3. cirrhosis
67
how does alcoholic hepatitis present?
``` abdo pain fatigue pruritus, jaundice myalgia nausea vomiting ```
68
what investigations for alcoholic hepatitis
LFTs raised GGT AST:ALT ratio >2, >3 = acute alcoholic hepatitis
69
what treatment of alcoholic hepatitis
- glucocorticoids | - pentoxyphylline
70
what is used to calculate chance of benefit with glucocorticoids in alcoholic hepatitis
maddreys discriminant function - bilirubin and prothrombin time
71
how is ascites classified
SAAG >11g/L | SAAG <11g/L
72
give some causes of SAAG >11g/L ascites
- liver problems (cirrhosis, liver mets, acute liver failure) - cardiac problems (RHF) - Budd Chiari, portal vein thrombosis, - myxoedema
73
give some causes of SAAG <11g/L ascites
- hypoalbuminaemia (nephrotic syndrome, kwashiorkor) - pancreatitis - peritoneal carcinomatosis
74
how is ascites managed
- low dietary sodium - spironolactone - therapeutic paracentesis (give albumin cover) - ciprofloxacin - TIPSS
75
what is a complication of large volume paracentesis and how can this be prevented
paracentesis-induced circulatory dysfunction | albumin cover
76
what can be seen on blood film in hyposplenism
howell-jolly bodies | siderocytes
77
how is hyposplenism managed
1. vaccines - PCV, flu, meningitis, haemophilus influenzae | 2. prophylactic antibiotics
78
what are the causes of hyposplenism
``` splenectomy coeliac sickle cell SLE graves amyloid ```

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