Liver diseases oxford Flashcards
(125 cards)
1
Q
Fulminant liver failure
A
Massive necrosis of liver cells
2
Q
signs of liver failure
A
jaundice, encephalopathy, aterixis, apraxia (5 pointed star drawing), fetor hepaticus (pear drop breath)
3
Q
Effects of warfarin in liver failure
A
enhanced
4
Q
Causes of liver cirrhosis
A
Chronic alcohol, chronic HBV or HCV, autoimmune (PBS, PSC, AIH), genetic disorder (haematomachrosis, alpha 1 antitrypsin deficiency, wilson’s disease), vascular (Budd chiari, hepatic vein thrombosis), drugs (amiodarone, methyldopa, methotrexate)
5
Q
Imaging for cirrhosis
A
USS and duplex
Ascitic tap
Can do MRI
Liver biopsy (if not CI)
6
Q
Hereditary haemochromatosis
A
Increased iron absorption gives deposition in joints, livre, heart, pancreas, pituitary, adrenal and skin
7
Q
Hereditary haemochromatosis presentation
A
Typically presents 10 years later in women due to protection via menstruation.
Asymptomatic early on, but leads to tiredness and arthalgia (esp MCP and large joints), then slate grey skin, DM (bronze diabetes), chronic liver disease, hepatomegaly, cirrhosis, cardiac failure (dilated cardiomyopathy), hypogonadism (pituitary deposits), osteoporosis
8
Q
hereditary haemochromatosis testing
A
LFT increase, increase serum ferritin, increase serum iron, decrease TIBC, transferrin sat >80%, may have hyperglycaemia
Chondrocarcinosis in xray
Perl stain in liver biopsy shows iron loading
ECG/echo for cardiomyopathy
Managed by venesection
9
Q
Secondary haemochromatosis
A
Can occur in recurrent blood transfusions
10
Q
PBC
A
Interlobular bile duct damage by chronic granulomatous inflammation causing progressive cholestasis
11
Q
Typical PBC presentation
A
9:1 F:M
Associated with thyroid disease, RA, sjogren’s syndrome, keratoconjunctivitis, systemic sclerosis, renal tubular acidosis, membranous glomerulonephririts
Peak age is 50
Often found at raised ALP on LFT. Lethargy, pruritis, jaundice, xanthalasma, xanthomata, hepatomegaly, splenomegaly
12
Q
PBC complications
A
oesoporosis is common (malabsorption of ADEK), also coagulopaty, portal HTN, ascites, varicoeal haemorrhage, hepatic encephalopathy, HCC
13
Q
Investigations for PBC
A
Raised ALP, GGT, mildly raised AST and ALT. AMA positive. raised IgM, may have raised TSH and cholesterol
Late disease has raised bilirubin, low albumin, raised PT time
USS and ERCP used to exclude extrahepatic cholestasis.
Biopsy shows granulomas
14
Q
PSC
A
Inflammation, fibrosis and strictures of intra and extrehaptic bile ducts. May have immunological cause
15
Q
Typical PSC presetation
A
More common in men
Associated with UC, HLA A1/B8/DR3, (rarely) Crohn’s disease), HIV infection
Chronic biliary gives cirrhosis and liver failure. Patient may be asymptomatic, often found with raised ALP on LFT.
Hepatomegaly, portal HTN, pruritis, jaundice, abdominal pain, fatigue
16
Q
PSC investigations
A
raised ALP, raised bilirubin, hypergammaglobulinaemia, AMA negative , ANA/SMA/ANCA may be positive.
ERCP/MRCP shows strictures of biliary tree with beading.
Biopsy shows fibrous, obliterative cholangitis
17
Q
PSC complications
A
Bacterial cholangitis, cholangiocarcinoma, increased risk of colorectal cancer
18
Q
Autoimmune hepatitis
A
Inflammatory disease. Autoantiodies directed against hepatocytes. Has Type 1 and Type 2 (Type 2 generally just affects children)
19
Q
Autoimmine hepatitis typical presentation
A
Young female
Acute hepatitis and features of autoimmune disease (fever, malaise, urticarial rash, polyartritis, pleurisy, pulmonary infiltration or glomerulonephritis).
Amenorrhoea is common
20
Q
Autoimmune hepatitis diagnosis
A
raised AST, hypergammaglobulinaemia (esp IgG), positive ANA, SMA, LKM1
Biopsy shows mononuclear infiltrate of portal/periportal areas, necrosis, fibrosis.
21
Q
Risk factors for HCC
A
Viral hepatitis (B or C), cirrhosis (alcohol induced, haemachromotosis), parasites, anabolic/contraceptive steroids, PBC
22
Q
Risk factors for Cholangiocarcinoma
A
Flukes, PSC, congenital biliary cysts
23
Q
Haemangiomas
A
Most common benign liver tumour, often incidental finding.
24
Q
Whipples procedure
A
Removes masses from head of pancreas by resecting lower portion of stomach, head of pancreas, upper duodenum cystic duct.
25
Causes of chronic pancreatitis
Alcohol, familial, CF, haemochromatosis, pancreatic duct obstruction, Hyperparathyroidism, congenital
26
Thiamine
B1. Absorbed in small intestine. Causes Wenicke's in deficiency
27
Riboflavin
B2. Absorbed in proximal small intestine. Defieincy causes angular stomatis and cheilitis
28
B12
Absorbed in terminal ileum. Deficiency causes macrocytic anaemia, neuropathy and glossitis
29
Vitamin D absorbed
Jejunum. Defieicny causes rickets/osteomalacia
30
Folic acid
Absorbed in jejunum. Deficiency causes macrocytic anaemia
31
Nicotinamide
Absorbed in jejunum. Deficiency causes pellagra.
32
Berger's disease (IgA nephropathy)
Most common glomerulonephritis. Episoding haematuria, often associated with viral infection. Secondary causes are alcoholic liver disease, ankylosing spondilitis, coeliac disease
33
Baker's cyst
Popliteal cyst. Causes pain and swelling. DDx is DVT can can distinguish with USS duplex
34
Buerger's disease
Thromboangiitis obliterans. Inflammation of arteries, veins and nerves with thrombosis. Often in heavy smokers. Can cause gangrene.
35
Budd Chiari syndrome
Hepatic vein obstruction by thrombosis/tumour. Causes ischaemia, hepatocyte damage. Can be liver failure or cirrhosis.
See abdo pain, ascites, raised ALT. Can be hypercoagulable state (coc, pregnancy, malignancy, paroxysmal noctural haemoglobinuria, polycythemia rubra vera, thrombophilia), liver/renal/adrenal tumour.
Diagnosis: USS doppler, CT, MRI
36
Dubin Johnson syndrome
Autosomal recessive. Defective excretion of conjugated bilirubin, intermittent jaundice with RUQ pain and no hepatomegaly.
37
Felty's syndrome
RA, splenomegaly and neutropoenia. See low platelets
38
Gilbert's syndrome
Intermittent failure of bilirubin conjugation
39
Henoch schonlein purpura
Small vessel vasculitis with purpura (purple non blanching nodules) over buttocks and extensor surface. More common in young men. Often glomerulonephritis, joint involvement, abdo pain
40
T1 Weighting MRI
Water is hypo, bone and fat are white
41
T2 Weighting MRI
Water is white, bone is black (TWO - The white ocean)
42
Diabetes insipidus biochemistry
Hypernatraemia, increased plasma osmolarity, decreased urine osmolarity
43
SIADH biochemistry
hyponatraemia, low/normal urea/creatinine, reduced plasma osmolarity, urine osmolarity raised and higher than plasma osmolarity.
44
Conn's vs Cushing's biochemistry
In conns, hypokalaemia, increased bicarb, HTN. Normal/raised sodium
In Cushing's, hypokalaemia, raised bicarb, raised sodium
45
False positive urobilinogen
Seen if urine is not resh.
46
Anion gap
Increase is acidosis
47
Metabolic acidosis with increased anion gap
Seen with increased organic acids (bicarb falls). Lactic acid, urate (renal failure), ketones (DM, alcohol), drugs/toxins (includes methanol)
48
Causes of metabolic acidosis with normal anion gap
Loss of bicarb, or ingestion of H+ .
| Seen in renal tubular acidosis, diarrhoea, drugs, addison's disease, pancreatic fistulae, ammonium chloride ingestion.
49
Hyperuricaemia causes
Drugs (cytotoxics, thoazies, pyrazinamide), increased cell turnover (lymphoma, leukaemia, psoriasis, haemolysis, muscle death), hout, chronic renal failure, lead nephropathy, hyperparathyroidism, pre eclapsia)
50
Hyponatraemia S+S
Confusion, seizure, HTN, cardiac failure, oedema, anorexia, nausea, muscle weakness
51
Hyponatraemia diagnosis
Check on patient volume status
If dehydrated, check urinary sodium. If >20mmol/L then sodium is lost through kidney (addison's, renal failure, diuretics, osmolar diuresis)
If urinary sodium is <20mmol/L then sodium and water is lost extra renal (Diarrhoea, vomit, fistulae, burn, villous adenoma, SBO, CF, heat exposure)
If not dehydrated and oedematous, then think nephrotic, cardiac failure, liver cirrhosis, renal failure
If not dehydrated and not oedematous, check urine osmolarity. If >500 then SIADH. If <500 then water overload, severe hypothyroid, glucocorticoid insuffieincy)
52
Hyponatraemia, dehydrated with high urine sodium
Think kidney loss (addison's, diuretics, renal disease, osmolar diuresis (high glucose and urea)
53
Hyponatraemia with dehydration and low urine sodium
Think extra renal loss such as vomiting, diarrhoea, burns, distulae, villous adenoma, trauma, CD, SBO
54
Hyponatraemia qith no dehydration and no oedema
If urine osmolarity >500 then SIADH, if now then water overload, severe hypothyroidism or glucocorticoid insufficiency
55
Hyponatraemia with no dehydration but does have oedema
Nephrotic, cardiac failure, liver failure, renal failure
56
Hypernatraemia symptoms and signs
Thirst, confusion, coma, fits, dehydration signs, postural hypotension, oliguria
57
Causes of hypernatraemia
Think water loss beyond sodium loss.
| Can be diarrhoea, vomit, burns, excess IV saline, Diabetes insipidus, osmotic diuresis, primary aldosteronism
58
Hyperkalaemia S+S
Cardiac arrythmias, sudden death, ECG (Tall T, small P, wide QRS - > VF)
59
Causes of hyperkalaemia
oliguric renal failure, K sparing diuretics, rhabdomyolysis, metabolic acidosis, excess potassium therapy, Addison's disease, massive blood transfusion, ACEi, suxamethonium, pseudohyperkalaemia (artefact)
60
Causes of hypokalaemia
Diuretics, vomiting, diarrhoea, pyloric stenosis, vilous adenoma rectum, intestinal fistulae, Cushging's (/steroids/ACTH), conn's, alkalosis, purgative and liquorice abuse, renal tubular failure.
61
Hypokalaemia S+S
Muscle weakness, hypotonia, cardiac arrythmias, cramps, tetany. on ECG, small/inverted T wave, prominent u wave, prolonged PR, depressed ST
Hypokalaemia worsens digoxin toxicity
62
Hypocalcaemia S+S
tetany, depression, perioral praesthesiae, carpo-pedal spasm, neuromuscular excitability . Prolonged QT. Cataracts if chronic
63
Hypercalcaemia S+S
Bone pain, weakness, tiredness, renal stones, renal failure, abdominal pain, polyuria, polydipsia, constipation, vomiting, depression, anorexia, weight loss, confusion, pyrexia. Cardiac arrest.. Short WT interval
64
Howell Jolley bodies
DNA nuclear remnants in RBCs (normally removed by the spleen). Seen in post splenectomy or hyposplenism (e.g. sickle cell disease, coeliac disease, UC/crohns, myeloproliferative disease, amyloid)
65
Target cells
RBC with central staining, pallour rim and outside staining. Seen in liver disease, hyposplenism, thalassaemia and IDA
66
Neutrophilia causes
Steroids, bacterial infection, inflammation (including MI), disseminated malignancy, stress, surgery, trauma, myeloproliferative disorders
67
Neutropoenia causes
Viral infection, chemi, cytotoxic agents, carbimazole, severe sepsis, neutrophil antibodies (SLE, haemolytic anaemia), Hypersplenism, Felty's, bone marrow failure
68
Lymphocytosis
Acute viral infection, chronic infection (TB, brucella, hepatitis, syphillis), leukaemia, lymphoma, EBV
69
Lymphocytopoenia
Steroid therapy, SLE, uraemia, legionnaire's disease, HIV infection marrow infiltration, post chemo/radio, HIV
70
myeloma
Malignant clonal proliferation of B lymphocyte derived plasma cells. Detected as monoclonal band on serum/urine electrophoresis. Classed based on Ig product (can be IgG in 60%, IgA in 30%). Often has Bence Jones protein.
Causes osteolytic bone lesions (back, vertebrae, ribs. Back pain. Punched out on imaging), anaemia, neutropoenia, thrombocytopoenia, recurrent bacterial infections, renal impairment, systemic amyloidosis.
71
Inherited thrombophilia (most common)
Most common cause is activated protein C resistance/Factor V Leiden. Clotting factor V mutation means wont be broken down by protein C. Thrombotic risk further increased in pregnancy or oestrogens
72
LEss common inherited thrombophilia
Prothrombin gene mutation (causes high prothrombin levels), protein C and S deficiency (needed to neutralise factor V and VIII), antithrombin deficiency
73
TTP
Thrombotic thrombocytopoenic purpura.
Pentad: fever, fluctuating CNS signs, haemolytic anaemia (may have jaundice), thrombocytopoenia, renal failure (haematuria/proteinuria)
Typically affects adult females. Lack of protease leads to aggregates of VWF and large scale platelet aggregation and deposition in small vessels, giving microthrombi. Often idiopathic, but associated with SLE, clopidogrel, cyclosporin, pregnancy, HIV.
74
HUS
Haemolyitic uraemic syndrome. Microangiopathic haemolytic anaemia.
Endothelial damage leads to platelet aggregation, thrombosis and fibrin deposition. Fibrin damages RBCs.
Leads to thrombocytopoenia and acute renal failure.
Commonly after E coli.
75
ITP
Idiopathic thrombocytopoenia purpura.
Antiplatelet autoantibodies, leading to phagocytic destruction. . Can be acute (typically in children) or chronic (in adult women).
Chronic has indefinite fluctuating coarse of bleeding, purpura, epistacis, menorrhagia
76
LEft sided valvular disease with displaced apex
Mitral regurgitation, aortic regurgitation
77
Cardiac catheterisation indications
Coronary artery disease (diagnosis to assess vessels, therapeutic for angioplasty and stent insertion)
Valvular disease (diagnostic to assess severity, therapeutic for valvuloplasty if not able for valve surgery)
Congenital heart disease (diagnostic and therapeutic)
78
Cardiac catheterisation uses
Sample blood to assess oxygen saturation, inject radiocontrast dye to image heart and blood vessels, perform angioplasty, valvuloplasty and biopsies, to perform intravascular USS
79
Cluster headache
Unilateral severe headache.
Has autonomic features (tearing of eyes, rhinorrhoea, sweating, tachycardia). Associated with alcohol consumption. Happens frequently.
80
MRI angiography
Can be done with or without gandolinium, and therefore can be used for patients with renal impairment and also means no need for femoral puncture.
81
SMA
Anti smooth muscle antibodies, associated with AIH, PBC, idiopathic cirrhosis
82
Anti Ro
SLE, Sjogren's, systemic sclerosis
83
AMA
Anti mitrochondrial antibody. PBC, but also AIH and idiopathic sclerosis
84
Pernicious anaemia Abs
Best is anti IF antibody (specific for pernicious anaemia) but can also do anti gastric parietal cell antibody (highly sensitive, but not as specific as also seen in atrophic gastritis)
85
Best testing for RA
Anti CCP is highly specific.
Anti RF is sensitive (70%) but not as specific.
ANA is positive in 30%
ESR and CPR are general inflammatory indicators
86
Best testing for coeliac disease
total immunoglobulin A (IgA) and IgA tissue transglutaminase (tTG) as the first choice
use IgA endomysial antibodies (EMA) if IgA tTG is weakly positive
consider using IgG EMA, IgG deamidated gliadin peptide (DGP) or IgG tTG if IgA is deficient
Biopsy if positive
87
Best testing for SLE
Anti DSDNA and anti smith antibodies are most specific - can also correlate to severity
Anti RF may be present
Anti Ro can be present (esp with Sjogren's syndrome)
ANA nearly always present but seen in other diseases too so not specific.
88
Thallium and cardiolite scintigraphy cardiac imaging
Used to assess myocardial perfusion (looks at capillary filling, rather than large vessel flow)
89
Cardiac catheterisation
Used to measure pressure in the heart as well as the shape of chambers
90
High resolution cardiac imaging
SPECT (loewr cost), PET is higher cost but even higher resolution
91
FL imaging for renal colic
USe CTKUB in adults
| USS if pregnant woman or children
92
Renal stone features
Oval/geometric (as opposed to phleboliths - round (rarely oval) but never goeometric). Central lucency also suggests phlebolith
93
Rim sign
Seen in KUB for renal colic. See oedematous tissue surrounding stone
94
Initial imaging for bowel obstruction
Plain AXR.
95
AAA imaging
URgent CT, or CT angiogram if tolerated by the patient
96
Appendicitis imaging
Clinical diagnosis, doesn't need imaging. CT or MRI are also useful
97
Appendicitis imaging
Best investigated in young patient with USS, CT also useful
98
Hydronephrosis diagnostic imaging
USS, but CTKUB can diagnose
99
Plain CT in neuro imaging
Most common neuro imaging, good for haemorrhage and acute issues
100
CT contrast in neuro imaging
Highlights tumours and abscesses
101
Cytotoxic oedema
Diffuse oedema seen in white and grey matter - think strokes
102
Vasogenic oedema
Localised oedema that's restricted to white matter - associated more with tumours
103
Intrahepatic dilatation on abdo USS only
Intrahepatic or hilar cholangiocarcinoma, intrahepatic gallstones (rare), Caroli's disease (rare and congenital)
104
Extrahepatic dilation on abdo USS only
Early distal CBD obstruction, sphincter of oddi dysfunction, choledochal cyst
105
Both intra and extrahepatic dilatation on abdo USS
Pancreatic/ampullary mass (doubt duct sign), distal CBD obstruction (gallstone, cholangiocarcinoma, lymph node, pseudocyst), minizzi syndrome, chronic pancreatitis
106
Can biliary strictures be visualised on CT?
No, so stricture based obstruction would be missed
107
Double duct sign on USS/CT
Dilated common bile duct and dilated pancreatic duct - head of pancreas tumours.
108
MRI gallstones
Stones appear dark on MRI
109
PTC
Percutaneous transhepatic cholaniopgraphy. Insert subcut into dilated hepatic duct and into common bile duct and duodenum (useful if blockage prevents duodenal access). Stent can be deployed and brushings can be taken)
110
which vessel supplies the basal ganglia
MCA (perforating)
111
CT contrast in A&E for stroke imaging?
Not useful as CT contast is bright and can mimic clots - use plain.
Contrast should be used to further visualise abnormalities already seen on CT (abscess or tumour), or can do CTA for vascular anatomy
112
Contrast reaching brain?
Not readily available, but if BBB breached then can cshow
113
Mnemonic for examining head CT with low GCS
Blood
Cisterns (present? squashed? haemorrhage?)
Brain tissue (colour? Sulci present? Gyri present?)
Ventricles (shape? squashed? haemorrhage? enlarged?)
ones and air spaces within
114
Possible causes of low GCS on CT
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Haemorrhage
Loss of grey-white differentiation (stroke)
swelling (/mass effect/hydrocephalus)
Infection
Trauma
```
115
Extra axial haemorrhage
outside parenchyma, so can be extra dural, sub dural or subarachnoid
116
Intra axial haemorrhage
cerebral (trauma, tumous, post infarct, spontaneous)
Deep cerebral (HTN bleed)
Cerebellar (HTN bleed)
Intraventricular (spontaneous or secondary)
117
CT blood visualisation
Clotted blood bright, active bleed is grey. Old blood is darker
Note that EDH is arterial, SDH is venous and blood in intergemispheric fissure indicates SA
118
Abscess on contast CT head
Enhances, but centre dark due to lack of vasculature. Oedema surrounds abscess
119
Red flag features suggesting IC abscess
immunocompromised, IVDU, infective endocarditis, TB
120
IC haemorrhage complications
Oedema, mass effect, intraventricular extension, hydrocephalus, vasospasm (blood irritating causing new focal neurology and rebleed)
121
Stroke on CT scan
Loss of grey/white matter differentiation. Infarcts tend to be dark in CT. Hyperdense clot signs are also a clue
122
Pseudosubarachnoid haemorrhage
Cortices compressed together, gives hyperdense area looking like SAH star. May be seen in generalised swelling
123
Causes of generalised IC swelling
metabolic issue (toxins, electrolytes, endocrine, organ failure, DKA)
Infection (sepsis)
Global cerebral insult (could be bilateral stroke, but might be diffuse axonal injury)
124
NICE criteria for CT scan
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GCS<13 on ED presentation
GCS<15 at 2h from injury
Suspected skull fracture
Signs of basal skull fracture
Post traumatic seizure
Focal neurological deficit
more than 1 episode of vomiting
```
But also elderly adults on anticoagulation with head injury
125
Fluid level in air spaces on imaging
Could be inflammation, but straight fluid level indicates fracture.
