Liver & Biliary system conditions Flashcards
1
Q
Transmission of viral hepatitis A (2)
A
Food/water: faecal-oral
Body fluids - sexual fluids, blood to blood
2
Q
Which hepatitis viruses are associated with chronic liver disease (3)
A
B,C,D
3
Q
Hepatitis A risk factors (4)
A
Age 5-14
Sex between men
Living in endemic region
Contact with infected person
4
Q
Hepatitis A symptoms (4) /signs (4)
A
Symptoms: Nausea/vomiting - ABRUPT ONSET RUQ pain - ABRUPT ONSET Malaise - ABRUPT ONET Jaundice - typically 2 wks after infection/other symptoms
Signs: Fever - ABRUPT ONSET Hepatomegaly Steatorrhoea Dark urine
JAUNDICE APPEARS IN HEP A MUCH QUICKER THAN ALL THE OTHER TYPES
5
Q
Hepatitis A investigations (2)
A
Diagnostic - IgM anti-hepatitis A antibodies
LFTs - elevated serum transaminases, elevated bilirubin
6
Q
Hepatitis A treatment (2)
A
NO SPECIFIC TREATMENT; ONLY SUPPORTIVE; body will clear virus itself
If not vaccinated for hep A:
-hep A vaccine or normal immunoglobulin
If confirmed hepatitis A:
-Supportive care - rest, analgesia
7
Q
Who is the hepatitis A immunisation targeted at (5)
A
Travellers to endemic regions Patients with chronic liver disease Haemophiliacs (have impaired clotting ability) Occupational exposure Men who have sex with men
8
Q
How is hepatitis B transmitted
A
Through body fluids - blood to blood or sexual fluid
9
Q
Hepatitis B infection pathophysiology
A
Virus doesn’t actually kill hepatocytes
Host immune response (particularly cellular) to the viral antigens causes the liver injury
10
Q
Hepatitis B risk factors (5)
A
HBV infected mother passing onto baby IV drug use Sex between men Multiple sexual partners Family history of HBV/chronic liver disease
11
Q
Antigens of HBV + what do they indicate if detected (4)
A
Hepatitis B surface antigen (HBsAg) - indicates active replication; disappears after acute infection
Hepatitis B early antigen (HBeAg) - indicates active replication of HBV; in early acute stage then disappears
Hepatitis B core antigen (HBcAg) - indicates active replication of HBV, not detected in blood
HBV DNA - indicates active replication of HBV
12
Q
Hepatitis B symptoms (5)/ signs (5)
*but what’s the important thing to remember
A
*MAJORITY ASYMPTOMATIC until cirrhotic
Symptoms: Fever/chills Fatigue Arthralgia RUQ pain Nausea/vomiting
Signs: Hepatomegaly Jaundice Dark urine Ascites Spider naevi
13
Q
Hepatitis B investigations
- bloods (3)
- specific serology (antigen, PCR, 4 antibodies)
A
- LFTs (elevated aminotransferases (ALT/AST), alk phos)
- FBC
- U+Es - hyponatraemia, high urea
- Serum HBsAg (surface antigen) - FIRST TEST; disappears after acute infection
- HBV DNA
- Serum anti-HBs (anti hep B surface antigen antibody) - appears wks after surface antigen disappears; suggests resolved acute infection
- Serum IgM anti-HBc (IgM anti hep B core antigen antibody) - appears during acute infection
- Serum IgG anti-HBc - develops after IgM
- Serum anti-HBe (hepatitis B envelope antibody)
14
Q
4 antibodies produced against HBV + do they indicate acute or chronic infection
A
Anti-HBs (hep B surface antigen antibody) - suggest resolved infection, lifelong immunity
IgM anti-HBc (IgM hep B core antigen antibody) - indicate acute infection
IgG anti-HBc - indicate resolved acute or chronic infection
Anti-HBe (hepatitis B envelope antibody) - indicate inactive infection if HBeAg negative
15
Q
Hepatitis B treatment (5)
- acute infection (2)
- chronic infection (3)
A
Acute infection
-supportive care (rest, analgesia)
+/- oral antivirals - if progresses to very SEVERE or liver failure
Hepatitis B vaccine (only works to prevent or in very recent exposure before person has been infected)
Chronic infection:
- Oral antivirals (entacovir) OR pegylated interferon
- Liver transplant - if decompensating cirrhosis
16
Q
Complications of hepatitis B, C + D infection (3)
A
Chronic hepatitis –> liver cirrhosis –> HCC/ESLD
17
Q
Transmission of hepatitis C
A
Body fluids - blood, sexual
18
Q
Which hepatitis viruses are RNA (4) /DNA (1) viruses
A
RNA virus - A,C,D,E
DNA virus - B
19
Q
What enzyme do RNA viruses need to replicate
A
Reverse transcriptase
20
Q
Hepatitis C risk factors (5)
A
IV DRUG USE BLOOD TRANSFUSIONS Unsafe medical practices Heavy alcohol use HIV
21
Q
Hepatitis C symptoms (3) /signs (4) + do they appear in acute or chronic HCV
A
Asymptomatic until cirrhotic
Symptoms -
fatigue (acute + chronic hep C),
arthralgia/myalgia (chronic hep C)
Signs - fever (acute hep C), jaundice (chronic), ascites (chronic), HE (chronic)
22
Q
Hep C investigations (3)
- serology (antibody, antigen)
- bloods
A
ELISA for serum anti-HCV antibody
PCR for HCV RNA
LFTs - elevated aminotransferases, esp ALT (alanine aminotransferase)
23
Q
Hep C treatment (2)
A
Oral antiviral combo x2
Liver transplant - if liver failure
24
Q
Transmission of hepatitis D
A
Transmitted by body fluids - blood or sexual contact
25
What is special about hepatitis D infection
Only infects those that are already infected with HBV as it needs HBV to be able to survive inside body
26
Surface antigen of HDV (hint: HDV can only exist with HBV infection as well)
Same as surface antigen of HBV:
| HBsAg
27
Hepatitis D risk factors (3)
Carrying HBV
IV drug use
Sex between men
28
Hepatitis D symptoms/signs
Same as HBV
29
Hepatitis D investigations (3)
| -serology (2 antibodies, 1 antigen)
Serum IgM anti-HDV
Serum IgG anti-HDV
HDV RNA - by doing PCR
30
Hepatitis D treatment
- prevention
- medical
INCURABLE
Prevented by HBV vaccine
Pegylated interferon alpha (slows spreading but doesn't cure)
31
Transmission of hepatitis E
Food/water: faecal-orcal transmission
32
What is the commonest hepatitis infection in grampian
Hep E
33
Hepatitis E risk factors (3)
Poor sanitation areas
Undercooked meat/contaminated meat
Pregnant women/infected mother to child
34
What is fulminant hepatitis + when is it likely to occur
Acute liver failure
| Occurs more frequently when hepatitis E occurs during pregnancy
35
Hepatitis E symptoms (5) /signs (4)
```
Symptoms -
Fever,
nausea/vomiting,
anorexia,
fatigue,
RUQ pain
```
```
Signs-
Jaundice
--> dark urine
-->steatorrhoea
Hepatomegaly
```
36
Hepatitis E investigations (2)
| -serology (antibody, antigen)
Serum IgM anti-HEV
| HEV RNA
37
Hepatitis E treatment (3)
No specific treatment
Very resistant to treatment
Maintain good hygiene
38
Complications of hepatitis E
Acute liver failure (fulminant hepatitis)
39
What is alcoholic liver disease + 3 stages of alcoholic liver disease
Direct alcohol toxicity causing fatty change of liver
* Steatosis --> alcoholic hepatitis --> cirrhosis
* STILL REVERSIBLE AT THIS STAGE
40
Cause of alcoholic liver disease
CHRONIC ALCOHOL
41
Alcoholic liver disease pathophysiology
Abnormal lipid retention in hepatocytes (steatosis) --> large triglyceride fat vacuoles accumulate --> fatty liver
May be accompanied by progressive inflammation --> steatohepatitis
42
Alcoholic liver disease risk factors (4)
Chronic alcohol
Female
Hepatitis C
Obesity
43
Alcoholic liver disease symptoms (3) /signs (4)
Symptoms:
Abdominal pain - RUQ
Fatigue/malaise
Anorexia
```
Signs:
Hepatomegaly
Ascites
Weight loss OR gain
Dupuytren's contracture - in advanced disease
```
44
Alcoholic liver disease investigations
- LFTs (5)
- imaging (1)
LFTs
- AST, ALT (AST: ALT = >2:1)
- gamma GT - high
- bilirubin - high
- albumin - low as synthetic liver function decreased
Liver ultrasound
45
What is the AST:ALT ratio in alcoholic liver disease/ alcoholic hepatitis
AST: ALT = >2:1
46
Alcoholic liver disease treatment (5)
-lifestyle - most important one of all
-medical (3)
+/- medical
ALCOHOL ABSTINENCE - 1st line
Treat alcohol withdrawal - benzodiazepine
Nutritional supplements (thiamine)
Immunisations - for flu, hep A/B
+/- Steroids (prednisolone) if:
- Glasgow alcoholic hepatitis score >9
- Maddrey's discrimination function >32
47
What is the criteria for giving steroids in ALD (2)
Glasgow alcoholic hepatitis score >9
| Maddrey's discrimination function >32
48
Complications of ALD (3)
Hepatic encephalopathy
Portal hypertension
GI bleed
49
What is autoimmune hepatitis
Chronic inflammatory disease caused by auto-antibodies attacking hepatocytes
50
Cause of autoimmune hepatitis
Idiopathic
51
Pathophysiology of autoimmune hepatitis
| -combination of what factors
Interaction between genetics, environmental trigger, and immune dysregulation
In the genetically predisposed, environmental agent can trigger a pathogenic process leading to liver necrosis and fibrosis
52
Autoimmune hepatitis risk factors (2)
Female
| Genetic predisposition
53
Autoimmune hepatitis symptoms (4) /signs (4)
```
Symptoms:
Fatigue/malaise
Anorexia
RUQ pain
Pruritus - MILD
```
```
Signs:
Jaundice
Fever
Hepatomegaly
Spider naevi
```
54
Autoimmune hepatitis investigations
- LFTs (4)
- autoantibodies (2)
- definitive diagnosis
LFTs
- ALT - high
- AST - high
- albumin - low
- bilirubin - high
Anti nuclear antibodies
Smooth muscle antibodies
LIVER BIOPSY
55
What liver function test is more specific for alcohol related liver injury
Gamma GT - raised
56
Autoimmune hepatitis treatment (1 +/- 1)
Steroids - prednisone
+/- other immunosuppressant (azathioprine)
57
Complications of autoimmune hepatitis
- of long term corticosteroids
- of the disease itself
Osteoporosis, diabetes, hypertension due to corticosteroids
Acute/chronic liver failure
End stage liver disease and HCC are unlikely
58
What is non-alcoholic fatty liver disease + the 3 stages of NAFLD
Fatty change of the liver not due to alcohol
Steatosis --> non-alcoholic steatohepatitis (NASH) --> fibrosis + cirrhosis
59
Hypothesised cause of NAFLD, although not 100% clear
Insulin resistance
60
Pathophysiology of NAFLD (5)
Insulin resistance --> fatty accumulation in liver (steatosis) --> inflammation (NASH) --> healing of inflammation by fibrosis --> cirrhosis
61
NAFLD risk factors (4)
Obesity
Diabetes
Hypercholesterolaemia
Hypertension
62
NAFLD/hepatic steatosis (3)/ signs (2)
Symptoms:
Fatigue
Malaise
RUQ pain
Signs:
Hepatosplenomegaly
Truncal/central obesity
ASYMPTOMATIC until advanced
63
NAFLD investigations
- gold standard
- LFTs (4) + is ALT or AST higher
- other bloods
- imaging
- scoring system for NAFLD
LIVER BIOPSY - gold standard
LFTs
- ALT > AST = NAFL
- bilirubin - high
- gamma GT - high
- AlkP - high
FBC, U+Es, Lipid panel - high total cholesterol
Ultrasound
NAFLD score (age, diabetes, AST:ALT, platelet, albumin)
64
NAFLD treatment
- lifestyle (2)
- medical (2)
- surgical if
```
Weight loss
Diet change
Insulin sensitiser - metformin (if have diabetes)
Statins (if have high cholesterol)
Liver transplant (if ESLD)
```
65
What is jaundice and what is it caused by
Increased circulating bilirubin due to altered metabolism of bilirubin in any of the 3 pathways of bilirubin metabolism (pre-hepatic, hepatic or post-hepatic)
66
Pathophysiology of pre-hepatic jaundice
Increased release of haemoglobin from RBCs due to increased haemolysis --> increased circulating bilirubin
67
Pathophysiology of hepatic jaundice + name the 2 causes of hepatic jaundice
Defective uptake of bilirubin --> defective conjugation of bilirubin --> defective excretion of bilirubin
DUE TO:
Cholestasis (bile accumulation in liver --> reduced bile flow to duodenum)
or
intra-hepatic bile duct obstruction (PSC, PBC, tumours)
68
Pathophysiology of post-hepatic jaundice + name the 3 causes of post-hepatic jaundice
Defective transport of bilirubin by the biliary ducts due to:
Gallstones (cholelithiasis), gallbladder disease,
extra-hepatic duct obstruction
69
Jaundice risk factors (4)
Chronic alcohol
IV drug use
Travel history to endemic regions
Sexual activity with hep C/D people
70
Jaundice symptoms (3)/ signs (3)
```
Yellow eyes and skin
Symptoms-
fatigue, anorexia, pruritus
Signs-
Steatorrhoea, dark urine, weight loss
```
71
Jaundice investigations (2)
Serum bilirubin
| Ultrasound
72
Jaundice treatment (2)
No treatment for jaundice in adults
| Treat cause to get rid of jaundice, e.g. treat hepatitis, gallstone blockage
73
What is cirrhosis
End stage liver disease caused by progressive fibrosis, response of liver to chronic injury
74
Causes of cirrhosis (7)
Chronic injury from:
Chronic alcohol/ alcoholic liver disease
Chronic hepatitis B + C
Metabolic disorders - NAFLD, OBESITY, excess copper (haemochromatosis, Wilson's disease)
Autoimmune - autoimmune hepatitis, PBC, PSC
Drugs - methotrexate
75
Pathophysiology of cirrhosis
Healing of chronic inflammation by fibrosis --> liver tissue replaced by scar tissue --> loss of normal liver structure --> impaired function --> liver failure
Stellate cells activated, collagen produced
76
Cirrhosis symptoms (2) /signs (11)
Symptoms:
Fatigue/weak
Pruritus
```
Signs:
Jaundice - late stage
Hepatosplenomegaly
Bruising
Ascites
Abdo distension
Peripheral oedema
Hepatic fetor
Spider naevi
Palmar erythema
Leukonychia (white nails)
Clubbing
```
77
Cirrhosis investigations
- LFTs
- other bloods (3)
- imaging (2)
- most specific and sensitive test (but don't always need this if other investigations are suffice)
LFTs - AST > ALT, GGT, AlkP, bilirubin, albumin, PT time
U+Es - low sodium
Platelet count - LOW
Serology (for hep B/C)
Abdo USS
Abdo CT
Liver biopsy
78
Cirrhosis treatment
- medical (2)
- lifestyle (2)
- surgical if
Treat underlying chronic liver disease (hep C/D, ALD, autoimmune etc)
Diuretics (furosemide + spironolactone) - for ascites
Stop alcohol
Restrict sodium in diet
Liver transplant - if very decompensated
79
Complications of cirrhosis (5)
```
Portal hypertension
Ascites
Variceal bleeding
HCC
Hepatic encephalopathy
```
80
Main preceding cause of hepatocellular carcinoma
Liver cirrhosis
81
HCC risk factors (6)
```
Cirrhosis
Chronic hepatitis B + C
Chronic alcohol
Obesity
Diabetes
Family history of HCC
```
82
HCC symptoms (3)/ signs (7)
Symptoms:
RUQ pain
Anorexia
Early satiety - due to ascites compressing stomach
```
Signs:
Weight loss
Palpable abdo mass
Signs of decompensated cirrhosis
-Abdo distension/ASCITES
-Jaundice
-Variceal bleeding
-Splenomegaly
-HE --> fetor hepaticus, asterixis (flapping tremor)
```
83
HCC investigations (6)
- bloods (3)
- cancer marker
- imaging (2)
FBC
LFTs - elevated aminotransferases, AlkP, bilirubin; low albumin
U+Es
Alpha foetal protein
USS
Contrast CT/MRI
84
HCC treatment (8) - curative (4) /palliative (4)
```
Curative:
Partial/full hepatectomy
Liver transplant
Radiofrequency ablation
Radiotherapy
```
```
Palliative:
Chemotherapy
Radiotherapy
Tyroskine kinase inhibitor - sorafenib
Hormone therapy - tamoxifen
```
85
Where does HCC metastasise to (3)
Lung, lymph, bone
86
What is a cholangiocarcinoma
Malignant tumour of bile duct epithelium (BILE DUCT CANCER)
87
What type of tumour are most cholangiocarcinomas
Adenocarcinoma
88
Cholangiocarcinoma risk factors (5)
```
Age >50
Cholangitis/ PSC
Choledocho-lithiasis (CBD stone)
Ulcerative colitis
Chronic liver disease - alcoholic liver disease, hep C/D
```
89
Cholangiocarcinoma symptoms (2)/ signs (1)
PAINLESS JAUNDICE
Abdominal pain
Weight loss
90
Cholangiocarcinoma investigations
- LFTs
- tumour markers (2)
- imaging (4)
LFTs - elevated bilirubin, AlkP, AST, ALT etc
Tumour markers - CA 19-9, CEA
Abdo USS - INITIAL
Abdo CT/MRI
ERCP + biopsy
MRCP - if can't do above
91
Cholangiocarcinoma treatment
- if resectable (2)
- if unresectable (2)
Partial liver resection (if intrahepatic tumour)
OR
tumour excision (if extrahepatic tumour)
+/- pre-op biliary stenting
If unresectable:
Liver transplant
+ neoadjuvant chemotherapy +/- radiotherapy
92
Complications of cholangiocarcinoma (2)
Biliary obstruction
| Cholangitis
93
What is cholelithiasis
Gallstones present in gallbladder
94
How are gallstones formed
Bile is supersaturated with cholesterol
| Excess cholesterol precipitates out of solution as solid microcrystals --> crystals aggregate + grow --> gallstones
95
3 types of gallstones
Cholesterol (most common)
Pigmented (bilirubin)
Mixed
96
Gallstones risk factors (5)
```
Obesity
Diabetes
Female
Family history of gallstones
Pregnancy
```
97
Cholelithiasis symptoms (2) /signs (1) + percentage asymptomatic
80% asymptomatic
RUQ/epigastric pain (biliary colic) - SUDDEN INTENSE >30mins
Postprandial pain
RUQ tenderness
98
Cholelithiasis investigations
- imaging (2)
- bloods (2)
Abdo USS
ERCP/MRCP
LFTs - normal but if progresses to choledocholithiasis then AlkP, bilirubin elevated
Serum lipase/amylase - to see if the pain is pancreatitis
FBC - usually normal
99
Cholelithiasis treatment (4)
- asymptomatic
- symptomatic
If asymptomatic = no treatment
If non-operable:
- dissolution (with ursodeoxycholic acid tablets)
- ERCP + lithotripsy (shock waves to break up gallstones)
If operable:
Laparascopic cholecystectomy
100
Cholelithiasis complications (6)
ERCP induced pancreatitis
Cholecystitis
Choledocho-lithiasis
Gallstone ileus (gallstones causing small intestine obstruction)
Mirizzi syndrome --> obstructive jaundice
101
Pathophysiology of acute cholecystitis
usually when gallstone blocks cystic duct --> bile trapped in gallbladder --> increased pressure in GB --> inflammation in GB --> PAIN
90% resolves itself as stone dislodges itself
102
Cause of cholecystitis
Symptomatic gallstones
103
Pathophysiology of chronic cholecystitis
Recurrent acute inflammation due to GALLSTONES REPEATEDLY BLOCKING CYSTIC DUCT --> chronic inflammation and FIBROSIS of gallbladder wall
Contractile function lost so GB can't release bile
104
Risk factors of cholecystitis (think risk factors of gallstones)
Gallstones
Diabetes
Obesity
Female
105
Symptoms (3) /signs (3) of cholecystitis
+ where does the pain spread to
RUQ pain - can spread to right shoulder
Postprandial pain
Nausea
Fever
MURPHY'S SIGN
-RUQ tenderness during deep inspiration; tenderness suddenly becomes worse and causes BREATHING TO STOP
Palpable mass - distended GB
106
Investigations of cholecystitis
- initial imaging
- bloods (3)
- further imaging if initial imaging unclear
RUQ USS
FBC - high WBC
CRP - high
LFTs - elevated AlkP, bilirubin, gamma GT
HIDA scan if USS unclear - shows cystic duct obstruction
107
Treatment of acute cholecystitis (4)
- medical (3)
- surgical
IV fluids
Antibiotics
Analgesia - NSAIDs
Cholecystectomy
108
What is choledocho-lithiasis + pathophysiology
Common bile duct stones
Gallstones can move out from gallbladder into bile duct and block the bile duct --> BILE DUCT STONES
or stones can form in CBD itself
109
Risk factor of choledocho-lithiasis (CBD stones)
Gallstone
110
Causes of extra-hepatic bile duct obstruction (i.e. bile ducts outwith the liver, e.g. CBD) (4)
Migrated gallstones
Bile duct tumours - e.g. cholangiocarcinoma
Benign stricture
External compression (e.g. head of pancreas tumour compressing CBD)
111
Symptoms (2) /signs (3) of CBD obstruction/ choledocholithiasis
Abdo pain
Nausea/vomiting
PAINFUL jaundice
Dark urine
Steatorrhoea
112
Investigations of CBD obstruction
- bloods (1)
- imaging (3)
LFTs - elevated AlkP, bilirubin
USS
MRCP/ ERCP
+/- CT
113
Treatment of CBD obstruction (2)
Therapeutic ERCP + lithotripsy (shock waves)
or Laparascopic CBD exploration
114
Complication of CBD obstruction
Ascending cholangitis (bile proximal to obstruction infected) - due to bacteria ascending
115
Name 3 autoimmune liver diseases
Autoimmune hepatitis
Primary biliary cholangitis
Primary sclerosing cholangitis
116
Name 3 diseases that cause intra-hepatic bile duct obstruction
Primary biliary cholangitis
Primary sclerosing cholangitis
Liver tumours
117
What is primary biliary cholangitis
AUTOIMMUNE LIVER DISEASE
Chronic disease of the small intrahepatic bile ducts that is characterised by progressive bile duct damage --> intra-hepatic bile duct obstruction
118
Pathophysiology of primary biliary cholangitis
| -what autoantibodies involved
Anti-mitochondrial autoantibodies attack liver
GRANULOMATOUS inflammation of bile ducts --> loss of intra-hepatic bile ducts --> bile acids build up in liver (CHOLESTASIS) --> fibrosis --> cirrhosis
119
Symptoms (3) /signs (1) of PBC
Fatigue
Pruritus
Dry eyes + mouth
Hepatomegaly
120
Investigations of PBC (3)
LFTs - all raised, low albumin
Anti-mitochondrial antibody immunofluorescence
Abdo USS - to exclude obstructive lesion
121
Name the liver function tests (7)
```
Alkaline phosphatase
Gamma GT
Bilirubin
Alanine aminotransferase
Aspartate aminotransferase
Albumin
Prothrombin time
Platelet count
```
122
When is alkaline phosphatase (ALP) raised + what is it
In intra or extra hepatic obstruction, e.g. PBC, PSC, CBD obstruction
It's an enzyme produced and present in bile ducts
123
Treatment of PBC (3)
| -medical
Ursodeoxycholic acid (UDCA) - bile acid analogue to dissolve
Prednisolone - if significant inflammation
Antipruritics
124
What is primary sclerosing cholangitis (PSC)
Autoimmune liver disease
Chronic progressive cholestatic liver disease --> destruction of the intrahepatic AND/OR extrahepatic bile ducts
Predominantly affects young and middle-aged men, often with underlying IBD
125
Pathophysiology of primary sclerosis cholangitis (PSC)
Autoantibodies (no specific autoantibody for PSC) attacking liver --> chronic inflammation + fibrosis of intra/extrahepatic bile ducts --> stricturing of ducts --> cholestasis
Ultimately intra-hepatic ducts are completely destroyed
126
What GI disease is PSC associated with
IBD, predominantly MALES
127
Risk factors of PSC (3)
Male - unlike most autoimmune diseases
Existing IBD
Genetics
128
Symptoms (3) /signs (3) of PSC
Abdo pain - RUQ or epigastric
Fatigue
Pruritus
Jaundice
Weight loss
Fever - episodic
129
Elevation of which 2 LFTs suggest bile duct injury/obstruction
ALP
| Gamma GT
130
Investigations of PSC (4)
- bloods (2)
- imaging (2)
LFTs - elevated AlkP, gamma GT
Serum autoantibodies - no specific one for PSC
Abdo USS
MRCP or ERCP
131
Treatment of PSC (5)
- asymptomatic
- symptomatic
NO EFFECTIVE MEDICAL THERAPY
If asymptomatic – just observe + lifestyle change
- Antipruritics
- Immunosuppressants, e.g. prednisolone (if have autoimmune hepatitis as well)
- ERCP + stent - if symptomatic biliary stricture
- Liver transplant if end stage liver
132
Complications of PSC (3)
Cholangiocarcinoma
Liver failure/cirrhosis
Hepatic encephalopathy
133
What is hepatic encephalopathy + most commonly due to what
Decline in brain function that occurs in patients with advanced, acute or chronic liver disease
Commonly due to cirrhosis/liver failure
134
Pathophysiology of hepatic encephalopathy
Liver malfunction/failure --> liver can't adequately remove toxins from blood (lack of ammonia conversion to urea) --> build up of ammonia in blood --> brain dysfunction when ammonia crosses the BBB
135
Causes/risk factors of HE (6)
```
Cirrhosis
Hypovolaemia
GI bleed
Hypokalaemia
Hypoxia
Acute liver failure
```
136
Signs of HE (5)
Confusion,
Flapping tremor (asterixis)
foetor hepaticus (bad breath)
mood/sleep disturbances
Signs of chronic liver disease/cirrhosis - hepatomegaly etc
137
Investigations of HE
- bloods (3)
- imaging (2)
LFTs - abnormal
Blood/urine culture - maybe bacteraemia, SBP, UTI
Urine toxin screen
Abdo USS
CT head
138
Treatment of HE (3)
Lactulose - laxative
Enema - to clear out bowel
Antibiotics (Rifaximin or neomycin) - only if lactulose not working
139
3 causes of acute liver injury
Hepatitis - caused by viruses, alcohol or drugs
Bile duct obstruction
Alcoholic liver disease
140
Which hepatitis viruses usually resolve (2)
A, E
141
What is cholestasis
Accumulation of bile within hepatocytes or bile canaliculi --> reduced bile flow to duodenum
142
Causes of intra-hepatic bile duct obstruction (3)
Primary biliary cholangitis
Primary sclerosing cholangitis
Tumours of liver
143
What is spontaneous bacterial peritonitis (SBP) (2)
Acute bacterial infection of ascitic fluid
Can be a feature of advanced end stage liver disease or kidney disease
144
Diagnostic investigation of spontaneous bacterial peritonitis
Ascitic tap - to get fluid protein/glucose/WBC level (IF HIGH WHITE CELL THEN DIAGNOSTIC OF BACTERIAL PERITONITIS)
145
Treatment of spontaneous bacterial peritonitis (3)
IV Antibiotics
Ascitic Fluid Drainage
IV Albumin Infusion – improves perfusion of kidneys if cause was associated with kidney failure
146
3 stages of alcohol related liver disease
Alcoholic fatty liver disease
Alcoholic hepatitis (nothing to do with infectious hepatitis)
Cirrhosis
147
What is liver steatosis
Fatty change of the liver, primarily by obesity
148
Is AST or ALT higher in NAFLD
ALT
149
Elevated alkaline phosphatase suggests obstruction of what ducts
Cystic or bile duct
150
Malignant tumours causing jaundice other than cholangiocarcinoma (3)
Gallbladder cancer
Ampullary cancer
Cancer of head of pancreas
151
Name some benign biliary tract diseases (3)
Biliary atresia - congenital
Choledochal cysts - congenital
Benign biliary stricture
152
What drugs induce cholestasis
Antibiotics, NSAIDs,
153
What tumour is PSC likely to cause
Cholangiocarcinoma
154
Tumour marker of HCC
Alpha foetal protein
155
What drugs induce liver cirrhosis (2)
Amiodarone
| Methotrexate
156
What is Charcot's triad + what condition does it indicate
Jaundice, fever and right upper quadrant pain indicating ascending cholangitis
