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Liver + Biliary Disease Flashcards

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1
Q

Mechanism of chronic liver failure

A

Commonly due to cirrhosis

Progressive destruction + regeneration of liver parenchyma leads to fibrosis + cirrhosis

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2
Q

Causes of chronic liver failure

A

Hepatitis

Alcoholic liver disease

Methotrexate, amiodarone, nitrofurantoin

Fatty liver disease

Wilsons disease

Biliary cirrhosis

Sclerosing cholangitis

Right HF

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3
Q

RF of liver failure

A

Alcohol

Obesity

Metabolic syndrome

IVDUs

Unprotected sex with multiple partners

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4
Q

S+S liver failure

A

Ascites

Haematemesis

Itching

Gallstones

Jaundice

Loss of appetite

Easy bruising

Diarrhoea

Fatigue

Palmar erythema

Dupytrens contracture

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5
Q

Management of liver failure

A

Corticosteroids, interferons, antivirals, bile acids

Supportive: diuretics, albumin, vit K, abx

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6
Q

What causes a high serum urea?

A

Catabolic state

High protein intake

GI bleed

Dehydration

CV failure

Reduced renal function

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7
Q

What causes a low serum urea?

A

Liver failure

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8
Q

What causes a high serum creatinine?

A

Reduced renal function

Large muscle mass (young, male, muscular)

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9
Q

What causes a low serum creatinine?

A

Low muscle mass (elderly, wasting, females)

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10
Q

What are the causes of ascites?

A

Cirrhosis

Malignancy (GI tract)

HF

Nephrotic syndrome

TB

Pancreatitis

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11
Q

What is the management of ascites?

A

Spironolactone

Loop diuretics

Paracentesis

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12
Q

S+S gallstones

A

Biliary colic
N+V
Pain worse on eating fatty foods, may radiate to back
Positive Murphys sign = palpate liver border + pain on inhalation

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13
Q

Presentation of cholecystitis

A

Typically 2nd to gallstones

RUQ/ epigastric pain colicky, radiating to back

Fever + rigors

Vomiting

Murphys sign (pain in RUQ on inspiration)

Precipitated by consumption of fatty foods

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14
Q

Investigations + results for ?cholecystitis

A

FBC, U+Es LFTS (raised ALP + bilirubin)

Raised WCC

ECG, amylase, CXR

USS 1st line

MRCP if USS is inconclusive or EUS

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15
Q

Investigations + results for ?cholangitis

A

WCC+, CRP+, ALT+, ALP+

USS 1st line = shows bile duct dilatation

ERCP = diagnostic

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16
Q

What is Reynolds pentad?

A

Hypotensive + confused

Sign of cholangitis + septic shock

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17
Q

What is Charcot’s triad?

A

Sign of cholangitis

RUQ pain, jaundice, rigors

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18
Q

Management of cholecystitis

A

NBM, opioid/ diclofenac for severe pain, paracetamol/ NSAIDs for mild

IV co-amox/ metronidazole- cefurox

Lap cholecystectomy

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19
Q

Management of biliary colic

A

NBM, analgesia, rehydrate

Elective lap cholecystectomy

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20
Q

Management of cholangitis

A

IV cefuroxime/ co-amox + metronidazole

ERCP

Percutaneous transhepatic cholangiography - if pt too unwell for ERCP

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21
Q

RF for biliary tract infections

A

Fat

Fertile

Forty

Female

Fam hx

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22
Q

Complications of cholecystitis

A

Gallbladder empyema

Gangrenous cholecystitis

Perforation

Chronic cholecystitis

Cholecystenteric fistula

Bouveret’s syndrome + gallstone ileus

Obstructive jaundice

Pancreatitis

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23
Q

MRCP vs ERCP

A

MRCP = using MRI to get image

ERCP = use of contrast dye while images are being taken

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24
Q

Causes + presentation of cholangitis

A

Cholesterol stones

Charcot’s triad: jaundice, abdo pain + fever

Pruritis

Reynolds pentad: + hypotension + confusion

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25
What is serum ammonia useful for?
Diagnosing acute liver failure due to hepatic encephalopathy
26
Pathology of gallstones
Occur due to cholesterol supersaturation, accelerated cholesterol crystal nucleation + impaired gallbladder motiligy
27
RF for developing gallstones
Crohns, DM, high fat diet, females, increasing age, NAFLD, obesity, HRT
28
Complications of gallstones
Bilary colic, acute cholecystitis, cholangitis + pancreatitis Gallstone ileus, Mirizzi syndrome, gallbladder cancer
29
Pathology of cholecystitis vs cholangitis vs choledocholithiasis
Cholecystitis = inflammation of gallbladder, usually due to cholelithiasis (gallstones) Cholangitis = infection of biliary tract (usually due to stasis of bile) choledocholithiasis = presence of stones in CBD
30
RF for acalculous cholecystitis
Trauma, burns, immobility Starvation, sepsis, renal failure, DM, vascular disease
31
What is Mirizzi's syndrome?
Common hepatic duct obstruction from extrinsic pressure from gallstones Causes jaundice, fever + RUQ pain
32
Pathology of portal hypertension
Resistane to portal blood flow aggravated by increased portal collateral flow Resistance is usually within liver (cirrhosis) but can be pre-hepatic (portal vein thrombosis) or post-hepatic (Budd-Chiari syndrome)
33
Causes of portal hypertension
Cirrhosis Hepatic schistosomiasis Portal vein thrombosis
34
Presentation of portal hypertension
Asymptomatic until complications develop Splenomegaly, abdo wall collateral circulation + thrombocytopenia
35
What are the complications of portal hypertension?
Variceal hemorrhage, portal hypertensive gastropathy, ascites, SBP Hepatorenal syndrome, portopulmonary hypertension + cirrhotic cardiomyopathy
36
How is portal hypertension diagnosed?
Pt with known RF has clinical signs of portal hypertension Hepatic venous pressure gradient can be used to confirm diagnosis (\>6mmHg = PH)
37
Management of portal hypertension
Manage underlying cause Endoscopy to screen for varices Nonselective BB or endoscopic variceal ligation to prevent bleeding Sodium restriction + diuretics for ascites
38
What are the main causes of cirrhosis?
Alcohol, hep B + C, obesity, T2DM, NAFLD
39
Definition of acute liver failure
Development of acute liver injury with encephalopathy + impaired INR \>1.5 in a pt without cirrhosis or pre-existing disease \<26 weeks
40
Causes of acute liver failure
Paracetamol OD Viral, autoimmune or drug induced hepatitis Wilsons disease Ischaemic hepatopathy Budd-Chiari syndrome HELLP syndrome Malignancy Sepsis
41
Presentation of acute liver failure + lab results
Hepatic encephalopathy, abnormal LFTs, INR \>1.5 Jaundice, hepatomegaly, RUQ tenderness, thrombocytopenia
42
Initial investigations for acute liver failure
PT/ INR U+E, glucose, bicarb, Mg, Phosphate, lactate LFTs CBC Paracetamol level Tox screen Hepatitis serologies Autoimmune markers ABG inc lactate HIV testing Amylase + lipase Doppler US 1st line then CT or MRI
43
Classifications of cirrhosis
Compensated - liver still functions effectively Decompensated - cannot function, overt symptoms
44
What are the main complications of cirrhosis?
Ascites, hepatic encephalopathy, hemorrhage from oesophageal varices, infection
45
How to diagnose cirrhosis?
Transient elastography, US, biopsy
46
What is NAFLD?
Presence of hepatic steatosis with no other cause May progress to cirrhosis
47
What are the types of NAFLD?
Nonalcoholic fatty liver (NAFL) + nonalcoholic steatohepatitis (NASH) NAFL = hepatic steatosis present without inflammation NASH = inflammation present
48
S+S of NAFLD
Asymptomatic, fatigue, malaise, RUQ discomfort
49
Diagnosis of NAFLD
Demonstration of hepatic steatosis by imaging or biopsy Exclusion of significant alcohol consumption + other causes Absence of co-existing chronic liver disease
50
What imaging + lab results are consistent with NAFLD?
Elevations in ALT + AST (ALT higher than AST), increased echogenecity on US, decreased hepatic attenuation on CT, increased fat signal on MRI
51
What are other causes (than NAFLD) of hepatic steatosis?
Significant alcohol use Hep C - particularly genotype 3 Wilsons Lipodystrophy Starvation Parenteral nutrition Reyes syndrome HELLP syndrome
52
What is steatosis?
Excess triglycerides in the liver
53
Complications of NAFLD
Portal hypertension, variceal hemorrhage, liver failure, hepatocellular carcinoma, sepsis, CV disease, T2DM
54
55
Characteristics of simple liver cysts
Don’t communicate with biliary tree Asymptomatic or dull RUQ pain or bloating
56
Characteristics of choledochal cysts
Malformation of pancreaticobiliary tree High risk of malignancy Present before 10 y/o Causes recurrent abdo pain, intermittent jaundice, RUQ mass, cholangitis + pancreatitis
57
Characteristics of hydatid liver cysts
Infectious cysts Asymptomatic, maybe palpable RUQ mass
58
What are the benign liver neoplasms?
Hemangiomas Focular nodular hyperplasia Adenoma
59
What score is used for prognosis of liver disease?
Child-Turcotte-Pugh Score
60
61
Conditions leading to liver transplantation
Parenchymal disease = hepatitis, cirrhosis, liver failure, budd-Chiari syndrome Cholestatic disease = biliary atresia, sclerosing cholangitis Inborn errors = Wilsons, hemochromatosis Hepatocellular carcinoma
62
What is Mirizzi syndrome?
Complication of gall stones causing compression of CBD/ CHD
63
What is Rouviere’s sulcus?
Fissure between right lobe + caudate process of liver
64
What is Rigler’s triad?
Pneumobilia Small bowel obstruction Gallstone Causes gallstone ileus
65
What is Bouvert’s syndrome?
Gastric outlet obstruction caused by large gallstone
66
Courvoisier’s sign?
Palpable non-tender distended gallbladder due to CBD obstruction
67
What is a Klatskin tumor?
Cholangiocarcinoma located at bifurcation of common hepatic duct
68
What is Trousseau’s sign?
Spontaneous peripheral venous thrombosis, associated with pancreatic cancer
69
What is a Whipple resection?
Removal of CBD, gallbladder, duodenum, pancreatic head, distal stomach
70
What is Kehr’s sign?
Left shoulder pain due to diaphragmatic irritation from splenic rupture Worsens with inspiration
71
Indications for splenectomy
Splenic abscess Hereditary spherocytosis Immune thrombocytopenic purpura Rupture of spleen Thrombotic thrombocytopenic purpura Splenic vein thrombosis
72
What are the biochemical signs for differentiating jaundice?
Hepatocellular = high bilirubin, high ALT/ AST Cholestatic = high bilirubin, high ALP/GGT, duct dilatation on US Hemolysis = low haptoglobin, high lactate

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