Liver, Biliary and Pancreatic Disease Flashcards
(92 cards)
1
Q
Define acute liver failure
A
Rapid decline in hepatic function characterised by jaundice, coagulopathy and hepatic encephalopathy in patients with no prior evidence of liver disease.
2
Q
Define coagulopathy
A
INR > 1.5
3
Q
What are the clinical characteristics of fulminant hepatitis?
A
Patient presenting with both jaundice and coagulopathy
4
Q
What is the main clinical presentation of a patient with conjugated hyperbilirubinaemia?
A
Dark urine and pale stools
5
Q
Define obstructive jaundice
A
Blockage of flow of bile through bile ducts or intrahepatic/ extra hepatic ducts
6
Q
Name the 2 subcategories of conjugated hyperbilirubinaemia
A
- Obstructive jaundice
2. Hepatocellular jaundice
7
Q
Outline the 4 common causes of obstructive jaundice
A
- Gallstones
- Biliary colic
- Cholecystitis
- Carcinoma of the head of the pancreas
8
Q
Outline the 4 common causes of hepatocellular jaundice
A
- Alcoholic hepatitis
- Viral hepatitis
- Drug induced (e.g. paramcetemaol overdose)
- Non-alcoholic fatty liver disease
9
Q
Define steatohepatitis
A
The accumulation of fat in the liver that induces inflammation
10
Q
What are the two subcategories of steatohepatitis?
A
- Alcohol related fatty liver disease
2. Non-alcoholic fatty liver disease (NAFLD)
11
Q
Give 2 more uncommon causes of obstructive jaundice
A
- Sclerosing cholangitis
2. Cholangiocarcinoma
12
Q
Give 3 uncommon causes of hepatocellular jaundice
A
- Autoimmune liver disease
- Haemochromatosis
- Wilson’s disease
13
Q
Describe the positioning of pain associated with Biliary Colic
A
Right upper quadrant
14
Q
What are the three clinical components of cholangitis?
A
- Biliary colic
- Jaundice
- Fever
15
Q
Describe the positioning of pain associated with pancreatitis
A
Severe epigastric pain radiating to the back
16
Q
What are the 2 most common causes of pancreatitis?
A
- Alcohol excess
2. Obstruction of the common bile duct by gallstones
17
Q
What is the most important differential associated with painless jaundice?
A
Possible liver or pancreatic cancer
18
Q
What is the difference in the ratio of transaminases to Alk Phos on an LFT panel for Hepatocellular damage compared to an obstructive cause?
A
- Hepatocellular damage: Rise in transaminases is much greater than the rise in all phos
- Obstructive cause: Rise in Alk Phos is much greater than the rise in the transaminases.
19
Q
In what patient cohort does carcinoma of the head of the pancreas need to be actively excluded as a differential with imaging tests?
A
Patients over 40 who have painless obstructive jaundice
20
Q
Which biomarker is used for the investigation of primary hepatocellular cancer?
A
alpha-fetoprotein
21
Q
Primary hepatocellular cancer is more common in which patient cohort?
A
Patients with liver cirrhosis
22
Q
Define 1 alcohol unit
A
10mls or 8g of pure ethanol
23
Q
Abrupt alcohol withdrawal can be associated with which clinical syndrome?
A
Delirium Tremens
24
Q
Give the 5 most common differentials for leukonychia
A
- Minor trauma
- Hypoalbuminaemia in chronic liver disease
- Chronic kidney disease
- Fungal infection
- Lymphoma
25
Give the 2 most common differentials for koilonychia
1. Trauma
| 2. Iron deficiency
26
What is the differential for angular stomatitis that is particularly relevant in an abdominal exam?
Iron/B12 deficiency
27
In the context of abdominal pathology, mouth ulcers can indicate one of which 2 conditions?
1. Crohn's disease
| 2. Coeliac disease
28
Excoriations on abdominal exam are an indications of which pathology?
Cholestasis
29
What are the 3 main causes of asterexis?
1. Hepatic encephalopathy
2. Uraemia
3. CO2 retention
30
Name the 3 main abdominal differentials associated with clubbing on clinical examination
1. Inflammatory bowel disease
2. Cirrhosis
3. Coeliac disease
31
In caucasians, jaundice becomes clinically evident at approximately what level of bilirubin?
50umol/L
32
What are the 2 main causes of unconjugated hyperbilirubinaemia
1. Haemolysis
| 2. Gilbert's syndrome
33
Gilbert's syndrome is often associated with which other clinical condition?
Haemolytic anemia
34
Severe cases of acute hepatitis are associated with which 2 complications?
1. Coagulopathy
| 2. Renal Impairment
35
What is the technical definition of Fulminant hepatitis?
Encephalopathy within 28 days of developing jaundice secondary to acute liver disease (i.e. liver failure)
36
What are the clinical consequences of portal hypertension secondary to liver cirrhosis (5)
1. Varices
2. Piles
3. Ascites
4. Encephalopathy
5. Renal Failure
37
List the symptoms associated with loss of hepatic function seen in patients with significant liver cirrhosis (5)
1. Jaundice
2. Coagulopathy
3. Decreased drug metabolism
4. Decreased hormone metabolism
5. Increased sepsis rate
38
Which 2 drug classes become particularly dangerous in patients with liver cirrhosis due to decreased physiological tolerance?
1. Sedatives
| 2. Opioids
39
Which hormone is particularly raised in patients with severe liver cirrhosis?
oestrogen
40
Give 4 clinical signs associated with elevated oestrogen levels in men with liver cirrhosis
1. Palmar erythema
2. Spider nevi
3. Gynaecomastia
4. Loss of secondary body hair
41
Outline the 6 main causes of liver cirrhosis
1. Alcohol Excess
2. Chronic hepatitis B + C
3. Autoimmune liver disease
4. Haemachromatosis
5. Wilson's disease
6. Chronic obstruction
42
Give the 4 main clinical stigmata of cirrhosis
1. Palmar erythema
2. Leukonychia
3. Spider nave
4. Caput medusa
43
Define and differentiate between bile pigments and bile salts
Bile pigments = breakdown products of haemoglobin
| Bile acids = acids derived from cholesterol metabolism that are conjugated with either glycine or taurine
44
With what substance is bilirubin conjugated with in order to make the molecule water soluble?
Glucuronic acid
45
Suggest 4 potential causes of haemolytic jaundice
1. RBC abnormalities e.g. sickle cell
2. Due to incompatible blood transfusions
3. Drug reactions
4. Hypersplenism
46
What are the 5 components of metabolic syndrome?
1. Obesity
2. Hypertension
3. Diabetes
4. Hypertriglyceridemia
5. Hyperlipidaemia
47
Define steatohepatitis
Combination of steatosis and inflammation in the liver
48
What are Mallory-Denk bodies?
Tangles of intermediate filaments seen on histopathology of fatty liver disease
49
How does fibrosis occur in chronic steatohepatitis?
Stellate cells lay down fibrotic tissue
50
What type of anemia is most commonly associated with liver disease?
Macrocytic (normoblastic)
51
Which electrolyte imbalance is most closely associated with liver cirrhosis?
Hyponatraemia
52
What are the most common causes of hepatocellular carcinoma worldwide and in Europe respectively?
Worldwide - Chronic hepatitis B
| Europe - Chronic hepatitis C
53
The liver and pancreas are derived from which embryological layer?
Endoderm
54
Name the blood-film abnormality that is associated with Liver disease
Target cells
55
Which peritoneal ligament attaches the liver to the anterior abdominal wall?
Falciform Ligament
56
Name a drug that is associated with causing liver fibrosis
Methotrexate
57
Name 2 infectious diseases that can cause deranged LFT's
1. Legionella pneumophilia
| 2. Infectious mononucleosis
58
What are the two potential treatment options for unconjugated hyperbilirubinaemia?
1. Phototherapy
| 2. Exchange transfusion
59
Define kernicterus
Form of bilirubin encephalopathy that can be either chronic or acute in presentation.
60
Give 3 treatment options for hepatitis C
1. Interferon
2. Ribavirin
3. Protease inhibitors
61
What is unique about hepatitis delta?
An imperfect virus i.e. requires co-infection with hepatitis B in order to replicate in the body
62
Name 2 hereditary causes of hepatitis
1. Wilson's disease
| 2. Haemochromatosis
63
What is the most common clinical manifestation of EBV?
Infectious mononucleosis
64
Recall 4 types of cancer that have an increased incidence in patients that have been infected with EBV
1. B cell lymphoma
2. T cell lymphoma
3. Hodgkin's lymphoma
4. Nasopharyngeal carcinoma
65
What is another name for infectious mononucleosis?
Glandular fever
66
Name 7 systemic viruses which may affect the liver and lead to viral hepatitis
1. Herpes virus
2. EBV
3. CMV
4. Varicella Virus
5. Adenovirus
6. Yellow fever
7. Haemorrhagic viruses
67
All viruses that can cause viral hepatitis are RNA viruses apart from which virus?
Hepatitis B - DNA virus
68
Wernicke's encephalopathy is brought about by a deficiency in which vitamin?
Vitamin B1 - Thiamine
69
What are the 4 principle characteristics of Wernicke's encephalopathy?
1. Ataxia
2. Ophthalmoplegia
3. Confusion
4. Short term memory loss
70
Excluding alcohol addiction, give 5 potential causes of Wernicke's encephalopathy
1. Eating disorders
2. Prolonged vomiting
3. GI malignancy
4. Amphetamine addiction
5. Crohn's disease
71
Give 3 brain structures which are damaged in Wernicke's encephalopathy
1. Thalamic nuclei
2. Brainstem nuclei
3. Cerebellum
72
What is Pabrinex?
An injection that administered the B vitamins + Vitamin C
73
Excluding alcohol abuse, give 2 other potential causes of Korsakoff's syndrome
1. Subarachnoid haemorrhage
| 2. Brain tumours in the thalamic region
74
Define anterograde memory loss
Inability to acquire new memories
75
Define retrograde memory loss
Loss of old memories
76
Briefly outline the pathology of Wilson's disease
Copper incorporation into caeruplasmin in hepatocytes and excretion in the bile is impaired. This leads to copper accumulation first in the liver and then the basal ganglia
77
What is the classical clinical sign associated with Wilson's disease?
Kayser Fleischer rings ( gold rings around iris)
78
What is the treatment for Wilson's disease?
Life long Penicillamine (copper chelation)
79
What are the 2 most common gene mutations associated with haemochromatosis?
C282Y and H63D mutations of the HFE gene
80
Name the 3 processes which may lead to the formation of pigment gallstones
1. Increase in bilirubin load as a result of haemolytic anemia
2. Pigments become less water soluble once in the bile as a result of the action of glucuronidases
3. Cirrhosis - as this leads to the depletion of glucuronidases inhibitors in the bile
81
Suggest 3 potential symptomatic manifestations of gallstones
1. Biliary colic
2. Cholecystitis
3. Pancreatitis
82
Suggest 5 differentials for biliary colic
1. GORD
2. Peptic ulcer disease
3. IBS
4. Pancreatitis
5. Malignancy e.g. Stomach, pancreas, large bowel
83
Name 3 anti-emetic drugs
1. Domperidone
2. Metoclopramide
3. Cyclizine
84
Name the antibiotic commonly prescribed prophylactically in elective cholecystectomy
Cefuroxime - 2nd generation cephalosporin
85
Suggest 7 potential causes of intrinsic bile duct obstruction
1. Common bile duct gallstones
2. Cholangitis
3. Carcinoma of the bile duct
4. Carcinoma of the gallbladder
5. Benign post-traumatic stricture
6. Sclerosing cholangitis
7. Haemobilia
86
Define Caroli's disease
Congenital intrahepatic biliary dilatation
87
Epigastric pain relieved by sitting forward / by a hot water bottle to the epigastrium is characteristic of what disease process?
Chronic pancreatitis
88
Recall 7 complications associated with chronic pancreatitis
1. Pseudocysts
2. Diabetes
3. Biliary obstruction
4. Local arterial aneurysm
5. Splenic vein thrombosis
6. Gastric varices
7. Pancreatic carcinoma
89
Name the principle gene implicated in carcinoma of the pancreas
KRAS2 gene
90
Which class of drugs may cause jaundice as a result of haemolysis?
Antimalarials e.g. dapsone
91
Name 6 drugs which may induce jaundice as a result of drug related hepatitis
1. Paracetamol overdose
2. Tuberculosis therapy - specifically: Isoniazid, rifampicin and pyrazinamide
3. Monoamine oxidase inhibitors e.g. selegiline
4. Sodium valproate
5. Halothane
6. Statins
92
Suggest 6 drugs which may cause jaundice as a result of drug induced cholestasis
1. Flucloxacillin
2. Fusidic acid, co-amoxiclav, nitrofurantoin
3. Steroids
4. Sulphonylureas
5. Prochlorperazine
6. Chlorperazine
