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Phase 2a Gastrointestinal system > Liver + biliary > Flashcards

Liver + biliary Flashcards

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1
Q

Why do you get poor coagulation function in primary biliary sclerosis, biliary cholangitis, stone in the common bile duct?

A

Cholestasis - the bile salts aren’t released into the intestine and so there is no absorption of fat soluble vitamins (ADEK). Vitamin K is needed to make factors 1972

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2
Q

What auto-antibody is found in primary sclerosing cholangitis?

A

AMA (Anti-mitochondrial antibody)

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3
Q

What is the diagnostic finding for alcholic hepatitis?

A

AST:ALT ratio >2:1 (if you see this!!!)

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4
Q

What are AST and ALT

A

aminotransferases

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5
Q

What does ALP stand for?

A

Alkaline phosphatase

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6
Q

What are some of the signs you might see in primary biliary cirrhosis?

A

Xanthelasma (yellow fat deposits around eyes), ascites, hepatosplenomegaly

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7
Q

What is the treatment for primary biliary cirrhosis?

A

Ursodeoxycholic acid + cholestyramine + vit ADEK supplements

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8
Q

What is the difference between Wilson’s disease and haemochromatosis?

A

Wilson’s = copper deposition

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9
Q

How would you treat end stage liver disease?

A

Liver Tx

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10
Q

What is the difference between primary sclerosing cholangitis and primary biliary cirrhosis?

A

Primary biliary cirrhosis affects intra-hepatic ducts only whilst primary sclerosing cholangitis affects both intra and extra-hepatic bile ducts

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11
Q

What is the treatment for primary sclerosing cholangitis?

A

Ursodeoxycholic acid

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12
Q

What is the function of ursodeoxycholic acid and cholestyramine?

A

Reduces cholestatic itch (chelates bile salts)

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13
Q

What do iron studies show in haemochromatosis?

A

Decreased TIBC, ^ serum Fe and ferritin

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14
Q

What is the main cause of haemochromatosis?

A

Autosomal recessive mutation to HFE gene

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15
Q

What is the treatment for haemochromatosis?

A

Venesection

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16
Q

Does Wilson’s disease affect the basal ganglia? How?

A

Yes - causes Parkinson’s disease

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17
Q

What is the characteristic feature of Wilson’s disease?

A

Brown rings around iris (Kayser-Fleischer ring)

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18
Q

Give 3 metabolic causes of liver disease (cirrhosis)

A

Alpha1 anti-trypsin deficiency, haemochromatosis, Wilson’s disease

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19
Q

What investigations would you do to diagnose Wilson’s disease? What would you see?

A

Liver biopsy (^ copper), DECREASED serum copper, increased urinary 24hr copper

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20
Q

What is the treatment for Wilson’s disease?

A

Penicillamine or zinc (chelate copper)

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21
Q

What two diseases can alpha1 anti-trypsin deficiency cause?

A

COPD (emphysema specifically) and chronic liver disease

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22
Q

What is the role of alpha1 anti-trypsin?

A

Inhibits neutrophil elastase (+ other proteases)

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23
Q

Where is alpha1 anti-trypsin produced?

A

Liver

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24
Q

How might someone with alpha1 anti-trypsin deficiency present?

A

Neonatal jaundice

Adults: COPD or liver disease

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25
What would a liver biopsy show in alpha1 anti-trypsin def?
Hepatocytes with ^ intracellular globules of alpha1 anti-trypsin
26
What is budd-Chiari syndrome?
A veno-occlusive disease by which there is thrombosis in the hepatic vein causing portal HTN. Most commonly caused by a hypercoaguable state (oral contraceptives, malignancy...)
27
What are the best markers for demonstrating liver function?
PT (coagulopathy) and serum albumin
28
Why might you get an increase in infection in liver failure/cirrhosis? What might you give them?
Decreased production of complement proteins. Influenzae and pneumococcal vaccination
29
Why might you get oedema in liver failure/cirrhosis
Reduced albumin production --> decrease in oncotic pressure inside vessels
30
Why might someone bleed/bruise easily if they have liver cirrhosis?
Reduced production of clotting factors
31
What are the pre-hepatic causes of portal HTN?
Veno-occlusion
32
What are the hepatic causes of portal HTN?
Cirrhosis, alcoholic hepatitis, schistosomiasis, idiopathic
33
What are the post-hepatic causes of portal HTN?
RH F, constrictive pericarditis, Budd chiari
34
What is normal portal pressure?
5-8mmHg
35
Explain the progression of alcoholic liver disease
Fatty liver --> alcoholic hepatitis --> fibrosis --> cirrhosis (non-reversible)
36
What pressure is portal hypertension characterised by?
>10mmHg
37
Give 4 complications of liver failure (chronic or acute)
^ infections (reduced complement proteins), bleeding/brusing (reduced clotting factor production), oedema and ascites (reduced albumin), osteoporosis, portal HTN + varices, HCC, AKI, malnutrition, hepatic portosystemic encephalopathy
38
What is the tumour serum marker for HCC?
Alpha fetoprotein
39
Why might you become malnourished with liver disease?
Reduced production of bile - no absorption of fat + fat soluble vitamins
40
Why do those with liver failure/cirrhosis get hepatic porto-systemic encephalopathy?
Normally ammonia produced by gut bacteria is broken down in the liver to urea and CO2; however, due to reduced liver function this doesn't occur and the ammoia bypasses the liver to the brain (ammonia = toxic)
41
What does TIPS stand for and how does it cause hepatic encephalopathy?
Transjugular intrahepatic portosystemic shunt. Creates a shunt by which ammonia (produced by gut pathogens) can bypass the liver to the brain
42
What is the characteristic feature around the eyes in primary biliary cirrhosis?
Xanthelasma
43
Give 3 causes of ascites that are an exudate
Cirrhosis, R HF, Hepatic venous occlusion
44
Give 3 causes of ascites that are a transudate
malignancy, nephrotic syndrome, pancreatitis
45
How does cirrhosis, R HF and hepatic venous occlusion cause ascites?
They cause portal HTN -> decrease in effective arterial volume --> RAAS --> Na+/H2O retention
46
How do you determine whether someone this a transudate or exudate pleural fluid? Can this be applied to Ascites?
LIGHT's criteria
47
What is the difference between exudate and transudate?
Higher LDH (>200) and protein levels (>2.5g/dL) in exudate
48
How does malignancy cause ascites?
it causes hypoalbuminaemia --> decreased oncotic pressure
49
What might you ask in a liver/jaundice Hx?
Alcohol? Travel? IVDU/tattoos? Blood transfusion pre-90s? Residence of birth?
50
How would you treat ascites?
Treat the cause, low salt diet, water retention, k+ sparing diuretic (spironolactone), peritoneocentesis
51
What are the causes of acute liver failure?
HAV, HBV, Excessive alcohol, paracetamol OD, idiopathic, drug induced (TB drugs)
52
How does hepatic encephalopathy present?
Irritability/change in mood --> drowsiness --> confusion --> coma death
53
How might liver disease result in hyponatraemia?
It produces Ang I needed in the RAA system
54
What should you ask in a patient history if they present with acute liver disease?
Any drugs started recently?
55
Give an example of a drug that is hepatotoxic
TB drugs (rifampicin, isoniazid, pyrazinamide) and paracetamol
56
Why do patients with CLD get a coma/confusion? Give 3 reasons
Hepatic encephalopathy (build up of ammonia - as not broken down in the urea cycle by the liver), hypoglycaemia, intracranial event (bleed)
57
What infections are those with CLD most likely to get?
SPONTANEOUS BACTERIAL PERITONITIS
58
What is steatosis?
Fatty liver
59
What causes a cholestatic itch?
Cholestasis - build up of bile in skin
60
What liver tests give an idea of liver function?
PT and serum albumin
61
What is the treatment for varices?
Endoscopic ligation banding + propranolol
62
How do you treat hepatic encephalopathy?
decrease the absorption of ammonia (lactulose) and kill gut bacteria (Abx)
63
What investigations would you do to determine the cause of chronic liver disease (CLD)?
Viral serology, serology (auto-Ab's), biochem (iron/copper studies, alpha 1 -AT levels...), bilirubin, USS/CT, LFTs (ALT/AST, PT, serum albumin)
64
What are the causes of CLD?
Alcoholic Non-alcoholic fatty liver disease HBV, HCV Auto-immune (primary sclerosing cholangitis and primary biliary CIRRHOSIS) Matabolic causes (Wilson's disease, haemochromatosis, alpha1-AT def.) Vascular (Budd Chiari)
65
What type of cause for portal HTN is Budd Chiari syndrome?
post-hepatic (occlusion of hepatic veins)
66
What are the signs of chronic liver disease?
Ascites, oedema, haematemesis (varices), spider naevi, palmar erythema, jaundice, confusion/coma, itching, easy bruising, anorexia (not eating), wasting...
67
What are the causes of acute liver disease?
HAV, HBV, EBV, Paracetamol OD, TB drugs, excessive alcohol
68
What is charcot's triad?
Jaundice, fever and RUQ pain
69
What type of cancer is hepatocellular carcinoma?
Adenocarcinoma - malignant tumour of glandular epithelium
70
What is charcot's triad a feature of?
Ascending cholangitis
71
What is ascending cholangitis?
Infection of the biliary duct
72
Give 3 causes of ascending cholangitis
CBD gall stone, benign biliary strictures (primary sclerosing cholangitis, post-surgery/ERCP), cancer of the head of the pancreas
73
What type of jaundice occurs in ascending cholangitis?
Obstructive post-hepatic jaundice
74
What bacteria commonly cause ascending cholangitis?
E.coli and enterococci
75
What is biliary colic?
Pain of the upper abdomen that radiates the the R shoulder, associated with vomiting
76
Why does pain in biliary colic radiate to the R shoulder?
Radiation via the phrenic nerve
77
What is the presentation of gallstones?
Asymptomatic if in gall bladder
78
What are the complications of gallstones?
Acute pancreatitis (common duct), ascending cholangitis, cholecystitis, obstructive jaundice
79
What is acute cholecystitis?
Gallstone in the common bile duct causing inflammation of the gallbladder
80
Does acute cholecystitis show jaundice?
No
81
What is the presentation of cholecystitis
Biliary colic pain which then localises to the RUQ (with associated fever)
82
How would you detect acute cholecystitis? What would this show?
Abdominal USS (shows thickenning of the gall bladder wall + presence of gallstones
83
What is the treatment for acute cholecystitis?
Cholecystectomy
84
What is the presentation of a stone in the common bile duct?
Asymptomatic unless it leads to acute ascending cholangitis
85
Would you treat a stone in a common bile duct or gallstones in the gall bladder?
No unless they were symptomatic
86
What does USS show if a stone is in the common bile duct?
Dilated CBD + the stone itself
87
What is ascending cholangitis?
Bacterial infection of the biliary duct
88
What investigations would you carry out to determine whether someone had ascending cholangitis? What would you see?
^ WCC, Blood culture (E. coli or enterococci), USS (dilated CBD, stone, cancer...), ERCP
89
What type of features of jaundice would you see in biliary tract disease?
Dark urine + pale stools
90
What is the most useful imaging technique in ascending cholangitis?
ERCP (as you can drain the duct)
91
What is the treatment for ascending cholangitis?
IV fluids, analgesia, IV Abx, ERCP (biliary drainage + remove stone)
92
What clotting factors does the liver not make?
III (tissue factor) and IV (Ca2+)

Phase 2a Gastrointestinal system (4 decks)

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