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LIVER & FRIENDS Flashcards

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1
Q

LIVER FUNCTION
Give 4 functions of the liver

A
  1. Glucose and fat metabolism
  2. Detoxification and excretion
  3. Protein synthesis (e.g. albumin, clotting factos)
  4. Bile production
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2
Q

LIVER FUNCTION
Name 3 things that liver function tests measure

A
  1. Serum bilirubin
  2. Serum albumin
  3. Pro-thrombin time
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3
Q

LIVER FUNCTION
Name an enzyme that increases in the serum in cholestatic liver disease (duct and obstructive disease)

A

Alkaline phosphate (ALP)

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4
Q

LIVER FUNCTION
What enzymes increase in the serum in hepatocellular liver disease?

A

Transaminases - e.g. AST and ALT

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5
Q

LIVER FUNCTION
What tests give no index of liver function and why?

A

Liver enzymes - alkaline phosphate, GGT, AST, ALT Released by damaged cells

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6
Q

JAUNDICE
Define jaundice

A

Raised serum bilirubin

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7
Q

JAUNDICE
Name the 3 broad categories of jaundice

A
  1. Pre-hepatic (unconjugated)
  2. Hepatic (conjugated)
  3. Post-hepatic (conjugated)
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8
Q

JAUNDICE
what are the causes of pre-hepatic jaundice?

A

excess bilirubin production
- sickle cell disease
- hereditary spherocytosis
- autoimmune haemolytic anaemia
- iatrogenic

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9
Q

JAUNDICE
Give 4 causes of hepatic jaundice

A
  1. Liver disease
  2. Hepatitis - viral, drug, immune, alcohol
  3. Ischaemia
  4. Neoplasm - HCC, mets
  5. Congestions - CCF
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10
Q

JAUNDICE
Give 3 causes of post-hepatic jaundice

A

Duct obstruction

  1. Gallstones
  2. Stricture - Malignancy, ischaemia, inflammatory
  3. Blocked stent
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11
Q

JAUNDICE
What colour is the urine and stools in pre-hepatic jaundice?

A

Both are normal

No itching and the LFTs are normal

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12
Q

JAUNDICE
What colour is the urine and stools in someone with cholestatic jaundice (hepatic and post hepatic)?

A

Dark urine
Pale stools
Itching
LFTs are abnormal

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13
Q

JAUNDICE
What can cause raised unconjugated bilirubin?

A

A pre-hepatic problem (haemolysis, hypersplenism)

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14
Q

JAUNDICE
What can cause raised conjugated bilirubin?

A

Indicated cholestatic problem

[liver disease (hepatic) or bile duct obstruction (post hepatic)]

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15
Q

JAUNDICE
Give 3 symptoms of jaundice

A
  1. Biliary pain
  2. Rigors - indicate an obstructive cause
  3. Abdomen swelling
  4. Weight loss
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16
Q

JAUNDICE
Why are liver patients vulnerable to infection?

A
  1. Impaired reticuloendothelial function
  2. Reduced opsonic activity
  3. Leucocyte function
  4. Permeable gut wall
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17
Q

GALLSTONES
what is biliary colic?

A

Pain associated with the temporary obstruction of the cystic or common bile duct by a stone

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18
Q

GALLSTONES
Give 3 causes of Gallstones

A
  1. Obesity and rapid weight loss
  2. DM
  3. Contraceptive pill
  4. Liver cirrhosis
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19
Q

GALLSTONES
what are the risk factors for gallstones

A
  1. Female
  2. Fat
  3. Fertile
  4. Forty
  5. Family history

rapid weight loss/prolonged fasting
diabetes

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20
Q

GALLSTONES
Name 2 types of gallstones

A
  1. Cholesterol (70%)

2. Pigment (30%)

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21
Q

GALLSTONES
Describe the pathophysiology of cholesterol gallstones

A

Excess cholesterol/lack of bile salts –> cholesterol crystals –> gallstone formation, precipitated by reduced gallbladder motility

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22
Q

GALLSTONES
Describe the pathophysiology of pigment gallstones

A

Excess bilirubin –> polymers and calcium bilirubinate –> stones
seen in haemolytic anaemia

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23
Q

GALLSTONES
what are the clinical features of biliary colic from gallstones?

A

Most are asymptomatic

SYMPTOMS
- RUQ/epigastric pain (constant, >30 mins, worse after fatty foods, worse after meals)
- referred pain to right shoulder
- nausea + vomiting

SIGNS
- murphy’s sign negative (pain after eating but not on palpation)

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24
Q

GALLSTONES
what are the investigations for biliary colic?

A
  • abdominal USS (1st line imaging)
  • LFTs (to identify evidence of biliary obstruction)

to consider
- FBC and CRP
- amylase level
- MRCP

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25
GALLSTONES what is the management of biliary colic?
MILD-MODERATE PAIN - oral NSAID or paracetamol whilst awaiting cholecystectomy SEVERE PAIN - IM diclofenac or IM opioid (morphine, pethidine or buprenorphine) - elective cholecystectomy - lifestyle changes (avoid fatty foods, increase fibre) - surgery not recommended if gallstones found incidentally and patient is asymptomatic
26
GALLSTONES How can gallstones be removed from the gallbladder?
Laparoscopic cholecystectomy ERCP with removal or destruction (mechanical lithotripsy) or stent placement Bile acid dissolution therapy (for people not suitable for surgery)
27
LIVER FAILURE What is liver failure?
When the liver has lost the ability to regenerate to repair, so that decompensation occurs
28
LIVER FAILURE Name 3 types of liver failure
1. Acute = sudden failure in previously healthy liver 2. Chronic = liver failure on the background cirrhosis 3. Fulminant = massive necrosis of liver cells --> severe liver function impairment
29
LIVER FAILURE Give 5 causes of acute liver disease
1. Viral hepatitis 2. Drug induced hepatitis (e.g. paracetamol) 3. Alcohol induced hepatitis 4. Vascular - Budd-Chiari 5. Obstruction most common cause in UK is paracetamol overdose
30
LIVER FAILURE what are the risk factors for acute liver failure?
- alcohol abuse - age >40 - female gender - poor nutritional status - pregnancy - chronic hep B - excess paracetamol ingestion
31
LIVER FAILURE Give 2 possible outcomes of acute liver disease
1. Recovery | 2. Liver failure
32
LIVER FAILURE Give 5 causes of chronic liver disease
1. Alcohol 2. NAFLD 3. Viral hepatitis (B,C,E) 4. Autoimmune diseases 5. Metabolic 6. Vascular - Budd-Chairi
33
LIVER FAILURE what is compensated chronic liver failure?
- liver still carries out essential functions despite damage - may be asymptomatic or have non-specific symptoms such as malaise or fatigue
34
LIVER FAILURE what are triggers for liver decompensation?
- alcohol excess - acute viral infection (hep A or B) - drug induced liver injury (e.g. paracetamol overdose) - development of HCC - sepsis or systemic infection
35
LIVER FAILURE what are the risk factors for chronic liver failure?
- alcohol excess - obesity - hyperlipidaemia - DM - chronic viral hepatitis - family history of metabolic disease e.g. wilson's + haemochromatosis
36
LIVER FAILURE Give 2 possible outcomes of chronic liver disease
1. Cirrhosis | 2. Liver failure
37
LIVER FAILURE what are the clinical features of acute liver failure?
SYMPTOMS - abdominal pain - nausea + vomiting - malaise - chronic pain (risk of paracetamol toxicity) SIGNS - jaundice - hepatic encephalopathy (confusion, inappropriate behaviour) - RUQ tenderness - depression or suicidal
38
LIVER FAILURE what are the clinical features of chronic liver disease
SYMPTOMS - fatigue - anorexia - jaundice - bruising/bleeding - confusion SIGNS - weight loss - ascites - caput medusae - rectal haemorrhoids - spider naevi - gynaecomastia + hypogonadism - hepatomegaly
39
LIVER FAILURE What are the investigations for acute liver failure?
- LFTs = hyperbilirubinaemia, raised ALT + AST - PT/INR >1.5 - U&Es = electrolyte imbalance - FBC - group + save (in case of transfusion or transplant) - hep screen - autoimmune screen - pregnancy test - abdominal USS with doppler
40
LIVER FAILURE what are the investigations for chronic liver disease?
- LFTs - coagulation screen - abdominal USS with doppler - hep serology - autoimmune screening - serum ferritin + transferrin - serum caeruloplasmin -ascitic tap
41
LIVER FAILURE Describe the treatment for acute liver failure
- treat underlying cause - close monitoring electrolytes + blood glucose - consider transplant paracetamol = n-acetylcysteine viral hep = aciclovir autoimmune hep = methylprednisolone wilson's = plasmapheresis, copper chelation
42
LIVER FAILURE what is the management of chronic liver failure?
- lifestyle changes (weight loss, alcohol cessation) - patient education - surveillance (regular HCC screening) - prevention of oesophageal varices (PROPRANOLOL) - prevention of hepatic encephalopathy (RIFAXIMIN) - manage ascites (SPIRONOLACTONE or FUROSEMIDE) - liver transplantation
43
LIVER FAILURE Give 4 complications of of liver failure
1. Hepatic encephalopathy 2. Abnormal bleeding 3. Jaundice 4. Ascites
44
LIVER FAILURE What drugs should be avoided in liver failure?
Constipators Oral hypoglycaemics Warfarin has enhanced effects Opiates
45
CIRRHOSIS What is cirrhosis?
Loss of normal hepatic architecture with fibrosis - liver injury causes necrosis and apoptosis- irreversible
46
CIRRHOSIS what are the causes of cirrhosis?
- alcoholic liver disease - non-alcoholic fatty liver disease (NAFLD) - chronic viral hepatitis (B, C or D) - autoimmune hepatitis - haemochromatosis - primary biliary cirrhosis - wilson's disease - alpha-1-antitrypsin deficiency (A1AT) - primary sclerosing cholangitis - long term hepatotoxic drug use (methotrexate, isoniazid, methyldopa, amiodarone)
47
CIRRHOSIS what are the clinical features of cirrhosis?
SYMPTOMS - weight loss - malaise - fatigue - easy bruising SIGNS - palmar erythema - Dupuytren's contracture - leukonychia - jaundice - ascites - spider naevi - confusion + asterixis - caput medusae - haematemesis
48
CIRRHOSIS What investigations are done in someone with cirrhosis?
- FBC = anaemia + thrombocytopaenia - U&Es = renal failure in acute - LFTs = deranged, AST>ALT, raised GGT - serum bilirubin = raised - blood glucose = uncontrolled DM in NAFLD - clotting = may be deranged - hepatitis screen - autoantibodies - serum caeruloplasmin (screen for wilson's) - A1AT levels - serum ferritin + transferrin (to screen for haemochromatosis) - abdominal USS - transient elastography to consider - AFP (to screen for HCC) - liver biopsy (to grade + stage liver disease) - UGI endoscopy (to assess for oesophageal varices)
49
CIRRHOSIS What is the treatment for liver cirrhosis?
1. Good nutrition and alcohol abstinence 2. Treat underlying cause 3. Fluid and salt restriction for ascites --> spironolactone, furosemide, prophylactic ciprofloxacin 4. liver transplant = definitive 5. Screen for HCC - increased AFP
50
CIRRHOSIS Give 4 complications of cirrhosis
Ascites portal hypertension 1. Decompensation 2. SBP 3. Increased risk of HCC
51
PORTAL HYPERTENSION Approximately what percentage of blood flow to the liver is provided by the portal vein?
75%
52
PORTAL HYPERTENSION Give 3 causes of portal hypertension
1. Pre-hepatic = blockage of hepatic portal vein before the liver (portal vein thrombosis) 2. Hepatic = distortion of liver architecture (cirrhosis, schistosomiasis, Budd Chiari syndrome) 3. Post-hepatic = venous blockage outside the liver (RHF, IVC obstruction)
53
PORTAL HYPERTENSION what is the clinical presentation of portal hypertension?
- often asymptomatic - splenomegaly - spider naevi - GI bleeding - ascites - hepatic encephalopathy
54
PORTAL HYPERTENSION Why can portal hypertension lead to varices?
Obstruction to portal blood flow | Blood is diverted into collaterals and so causes varices
55
PORTAL HYPERTENSION What are the potential consequences of varices?
If they rupture --> haemorrhage | blood is then digested -> melaena
56
PORTAL HYPERTENSION What is the primary treatment for varices?
Variceal banding – band put around varices using endoscope – after few days the banded varix degenerates and drops off leaving a scar
57
HEPATIC ENCEPHALOPATHY Describe the pathophysiology of hepatic encephalopathy
Ammonia accumulates and crosses the BBB causing cerebral oedema
58
HEPATIC ENCEPHALOPATHY Name 4 conditions that can develop as a result of having hepatic encephalopathy
SAVE 1. Splenomegaly 2. Ascites 3. Varices 4. Encephalopathy
59
ASCITES What is ascites?
Chronic accumulation of fluid in the peritoneal cavity that leads to abdominal distension
60
ASCITES what are the causes of ascites with serum ascites albumin gradient (SAAG) >11g/L?
Indicates portal hypertension LIVER (most common cause) - cirrhosis/alcoholic liver disease - acute liver failure - liver mets CARDIAC - right HF - constrictive pericarditis OTHER - budd-chiari syndrome - portal vein thrombosis - veno-occlusive disease - myxoedema
61
ASCITES what are the causes of ascites that cause serum ascites albumin gradient (SAAG) <11g/L?
HYPOALBUMINAEMIA - nephrotic syndrome - severe malnutrition (e.g. kwashiorkor) MALIGNANCY - peritoneal carcinomatosis INFECTION - Tuberculous peritonitis OTHER CAUSES - pancreatitis - bowel obstruction - biliary ascites - postoperative lymphatic leak - serositis in connective tissue diseases
62
ASCITES Describe the pathophysiology of ascites
1. Increased intra-hepatic resistance leads to portal hypertension --> ascites 2. Systemic vasodilation leads to secretion of RAAS, NAd and ADH --> fluid retention 3. Low serum albumin also leads to ascites Transudate = blockage of venous drainage Exudate = inflammation
63
ASCITES Give 3 signs of ascites
1. Distension 2. Dyspnoea 3. Shifting dullness on percussion 4. Signs of liver failure
64
ASCITES What investigations might you do in someone who you suspect has ascites?
1. USS 2. ascitic tap
65
ASCITES Describe the treatment for ascites
1. Restrict sodium and fluids 2. Aldosterone antagonist (SPIRONOLACTONE) +/- loop diuretic (FUROSEMIDE) 3. Paracentesis 4. prophylactic antibiotics (CIPROFLOXACIN or NORFLOXACIN) to prevent spontaneous bacterial peritonitis
66
ALCOHOLIC LIVER DISEASE Describe the effects of alcoholic liver disease
1. Fatty liver --> hepatitis --> cirrhosis and fibrosis 2. GIT --> gastritis, varices, peptic ulcers, pancreatitis , carcinoma 3. CNS --> Degreased memory and cognition, wernicke's encephalopathy 4. Folate deficiency --> anaemia 5. Reproduction --> testicular atrophy, reduced testosterone/progesterone 6. Heart --> dilated cardiomyoapthy, arrhythmias
67
ALCOHOLIC LIVER DISEASE What might be seen histologically that indicates a diagnosis of alcoholic liver disease?
Neutrophils and fat accumulation within hepatocytes
68
ALCOHOLIC LIVER DISEASE What type of anaemia do you associate with alcoholic liver disease?
Macrocytic anaemia
69
ALCOHOLIC LIVER DISEASE What blood test might show that someone has alcoholic liver disease?
Serum GGT will be elevated
70
ALCOHOLIC LIVER DISEASE What distinctive feature is often seen on biopsy in people suffering form alcoholic liver disease?
Mallory bodies
71
ALCOHOLIC LIVER DISEASE What are the CAGE questions?
1. Cut down? 2. Annoyed at criticism? 3. Guilty about drinking? 4. Eyeopener?
72
ALCOHOLIC LIVER DISEASE How do you treat alcoholic liver disease?
● Stop alcohol – treat delirium tremens with diazepam ● IV thiamine to prevent Wernicke-Korsakoff encephalopathy ● High vitamin and protein diet ● Fatty liver – if alcohol stopped fat disappears ● Hepatitis o Nutrition maintained with enteral feeding and vitamin supplements o Steroids show short term benefit – reduce inflammation o Infections treated and prevented ● Cirrhosis o Reduce salt intake, stop drinking for life o Avoid aspirin and NSAIDS o Liver transplant
73
ALCOHOLIC LIVER DISEASE How does alcoholic hepatitis present?
``` Jaundice Anorexia Nausea and vomiting Fever Encephalopathy Cirrhosis Hepatomegaly Ascites, bruising, clubbing ```
74
HEPATITIS How long does hepatitis persist for to be deemed chronic?
6 months
75
HEPATITIS Give 4 types of hepatitis?
1. Viral - A,B,C,D,E 2. Drug induced 3. Alcohol induced 4. Autoimmune
76
HEPATITIS Give 3 infective causes of acute hepatitis
1. Hepatitis A-E infections 2. EBV 3. CMV
77
HEPATITIS Give 3 non-infective causes of acute and chronic hepatitis
1. Alcohol 2. Drugs 3. Toxins 4. Autoimmune
78
HEPATITIS Give 3 symptoms of acute hepatitis
1. General malaise 2. Myalgia 3. GI upset 4. Abdominal pain 5. Raised AST, ALT 6. +/- jaundice
79
HEPATITIS What are the potential complications of chronic hepatitis?
Uncontrolled inflammation --> fibrosis --> cirrhosis --> HCC
80
HEPATITIS If HAV a RNA or DNA virus?
RNA virus - PicoRNAvirus
81
HEPATITIS How is HAV transmitted?
Faeco-oral transmission - contaminated food/water, shellfish
82
HEPATITIS Who could be at risk of HAV infection?
Travellers and food handlers
83
HEPATITIS Is HAV acute or chronic?
Acute 100% immunity after infection
84
HEPATITIS How might you diagnose someone with HAV infection?
bloods - ALT/AST raised raised IgG and IgM
85
HEPATITIS Describe the management of HAV infection
1. Supportive 2. Monitor liver function to ensure no fulminant hepatic failure 3. Manage close contacts
86
HEPATITIS What is the primary prevention of HAV?
Vaccination
87
HEPATITIS Is HBV a RNA or DNA virus?
double stranded DNA virus Replicates in hepatocytes
88
HEPATITIS How is HBV transmitted?
Blood borne transmission - blood products and bodily fluids IVDU, needle-stick, sexual, vertical Highly infectious Vertical transmission from mother to child during parturition is most common method of transmission
89
HEPATITIS Describe the natural history of HBV in 4 phases
1. Immune tolerance phase: unimpeded viral replication --> high HBV DNA levels. 2. Immune clearance phase: the immune system ‘wakes up’ = liver inflammation and high ALT 3. Inactive HBV carrier phase: HBV DNA levels are low = ALT levels are normal, no liver inflammation 4. Reactivation phase: ALT and HBV DNA levels are intermittent and inflammation is seen on the liver --> fibrosis
90
HEPATITIS what are the investigations for HBV?
- surface antigen (HBsAg) = active infection - E antigen (HBeAg) = marker of viral replication + implies high infectivity - core antibodies (HBcAb) = past or current infection - surface antibody (HBsAb) = implies vaccination or past or current infection - Hep B virus DNA (HBV DNA) = direct count of viral oea
91
HEPATITIS Describe the management of HBV infection
- screen for other viral infections (HIV, hep A, C and D) - refer to gastro, hepatology or infectious diseases for specialist management - avoid alcohol - education to reduce transmission - contact tracing - test for complications (fibroscan for cirrhosis + USS for HCC) - antiviral medication - liver transplant
92
HEPATITIS How would you know if someone had acute or chronic HBV infection?
Follow up appointment at 6 months to see if HBsAg still present still present = chronic hepatitis
93
HEPATITIS What are the potential consequences of chronic HBV infection?
1. Cirrhosis 2. HCC 3. Decompensated cirrhosis
94
HEPATITIS How can HBV infection be prevented?
Vaccination - injecting a small amount of inactivated HbsAg
95
HEPATITIS Give 3 side effects of alpha interferon treatment for HBV
1. Myalgia 2. Malaise 3. Lethargy 4. Thyroiditis 5. Mental health problems
96
HEPATITIS Give 2 HBV specific symptoms
Arthralgia | Urticaria (hives)
97
HEPATITIS If HCV a RNA or DNA virus?
RNA virus - flavivirus
98
HEPATITIS How is HCV transmitted?
Blood borne + bodily fluids
99
HEPATITIS Give 4 risk factors for developing HBV/HCV infection
1. IVDU 2. People who have required blood products - blood transfusion 3. Needle stick injuries 4. Unprotected sex 5. Vertical transmission
100
HEPATITIS what are the investigations?
hepatitis C antibody = screening test hep C RNA testing = confirm diagnosis, calculate viral load + genotype
101
HEPATITIS Describe the treatment for HCV
Direct acting antivirals (sofosbuvir or daclatasvir) contact tracing
102
HEPATITIS What percentage of people with acute HCV infection will progress onto chronic infection?
WITHOUT TREATMENT - 25% make full recovery, - 75% develop chronic Hep C WITH TREATMENT - 90% are cured with direct-acting antivirals (sofosbuvir and daclatasvir)
103
HEPATITIS What percentage of people with acute HBV infection will progress onto chronic infection?
Approximately 5%
104
HEPATITIS How can HCV infection be prevented?
1. Screen blood products 2. Lifestyle modification 3. Needle exchange No vaccination, and previous infection doesn't confer immunity
105
HEPATITIS Is HDV a RNA or DNA virus?
Incomplete RNA virus Needs Hep B for assembly
106
HEPATITIS How is HDV transmitted?
Blood borne transmission - particularly IVDU it is transmitted in the same way as HBV
107
HEPATITIS what is the management of HDV?
pegylated interferon alpha
108
HEPATITIS Is HEV a RNA or DNA virus?
Small RNA virus
109
HEPATITIS what is the management for HDV?
pegylated interferon alpha over at leadt 48 weeks - not very effective - lots of side effects
110
HEPATITIS How is HEV transmitted?
Faeco-oral transmission
111
HEPATITIS Is HEV acute or chronic?
Usually acute but there is a risk of chronic disease in the immunocompromised
112
HEPATITIS How might you diagnose someone with HEV infection?
HEV RNA - HEV IgM, IgGanti-HEV
113
HEPATITIS Describe the primary prevention of HEV
Good food hygiene
114
HEPATITIS What types of viral hepatitis are capable of causing choric infection?
Hepatitis B (+/- D), C and E in the immunosuppressed
115
NON-ALCOHOLIC FATTY LIVER what are the different stages?
1. non-alcoholic fatty liver disease 2. non-alcoholic steatohepatitis (NASH) 3. fibrosis 4. cirrhosis
116
NON-ALCOHOLIC FATTY LIVER What is non alcoholic steatoheptitis (NASH)?
An advanced form of non-alcoholic fatty liver disease
117
BUDD-CHIARI SYNDROME What is Budd-Chiari syndrome?
Hepatic vein occlusion --> ischaemia and hepatocyte damage --> liver failure or insidious cirrhosis
118
LIVER DISEASE Name 3 metabolic disorders that can cause liver disease
1. Haemochromatosis - iron overload 2. Alpha 1 anti-trypsin deficiency 3. Wilson's disease - disorder of copper metabolism
119
HAEMOCHROMATOSIS 90% of people with haemochromatosis have a mutation in which gene?
HFE - chromosome 6
120
HAEMOCHROMATOSIS Haemochromatosis is a genetic disorder, how is it inherited?
Autosomal recessive inheritance
121
HAEMOCHROMATOSIS Describe the pathophysiology of haemochromatosis
Uncontrolled intestinal iron absorption --> deposition of iron in liver, heart, pancreas, joins, skin --> fibrosis and functional organ failure
122
HAEMOCHROMATOSIS Give 4 signs of haemochromatosis
* Fatigue, arthralgia, weakness * Hypogonadism – eg erectile dysfunction * SLATE-GREY SKIN (brownish/bronze) * Chronic liver disease, heart failure, arrythmias
123
HAEMOCHROMATOSIS How might you diagnose someone with haemochromatosis?
1. bloods - Raised ferritin, LFTs 2. HFE genotyping - C282Y 3. Liver biopsy - gold standard
124
HAEMOCHROMATOSIS What is the treatment for haemochromatosis?
1. Iron removal - venesection 2. Monitor DM 3. Low iron diet 4. Screening for HFE 5. iron-chelating drugs (desferrioxamine)
125
HAEMOCHROMATOSIS Give 2 complications of haemochromatosis?
Liver cirrhosis --> failure/cancer | DM due to pancreatic depositions
126
A1AT How is alpha 1 anti-trypsin deficiency inherited?
Autosomal recessive mutation in serine protease inhibitor gene
127
A1AT How does Alpha 1 anti-trypsin deficiency present?
Liver disease in the young - cirrhosis, jaundice Lung disease in the old (smokers) - emphysema
128
A1AT What is the treatment for Alpha 1 anti-trypsin deficiency?
Smoking cessation | Liver/lung transplant
129
WILSONS DISEASE What is Wilson's disease?
An autosomal recessive disorder of copper metabolism | Excess deposition of copper in the liver
130
WILSONS DISEASE Describe the pathophysiology of Wilson's disease
Impaired incorporation of Cu into caeruloplasmin --> Cu accumulation in liver
131
WILSONS DISEASE How does Wilson's disease present?
Children = liver disease - hepatitis, cirrhosis, fulminant liver failure Adults = CNS problems, mood changes, and Kayser-Fleischer rings
132
WILSONS DISEASE What are Kayser-Fleischer rings?
Cu in iris and cornea --> bronze ring
133
WILSONS DISEASE What CNS changes are seen in a patient with Wilson's disease?
``` Tremor Dysarthria Dyskinesia Ataxia Parkinsonism Dementia Depression ```
134
WILSONS DISEASE What is the treatment for Wilson's disease?
Lifetime treatment with penicillamine (chelating agent) Low Cu diet - no liver, nuts, chocolate, mushrooms, shellfish Liver transplant
135
AUTOIMMUNE HEPATITIS Describe the pathophysiology of autoimmune hepatitis
Abnormal T cell function and autoantibodies vs hepatocyte surface antigens
136
AUTOIMMUNE HEPATITIS What people are more likely to present with autoimmune hepatitis?
Young (10-30) and middle aged (>40) women
137
AUTOIMMUNE HEPATITIS How does autoimmune hepatitis present?
``` Fatigue, fever, malaise Hepatitis Hepatosplenomegaly Amenorrhoea Polyarthritis Pleurisy Lung infiltrates Glomuleronephritis ```
138
AUTOIMMUNE HEPATITIS What diseases are associated with autoimmune hepatitis?
Autoimmune thyroiditis DM Pernicious anaemia PSCUC
139
AUTOIMMUNE HEPATITIS What results would you see from the investigations of someone who you suspect has autoimmune hepatitis?
Raised LFTs - increased bilirubin, AST, ALT, ALP Hypersplenism = low WCC and platelets Autoantibodies = +ve anti-nuclear antibody Liver biopsy = mononuclear infiltrate
140
AUTOIMMUNE HEPATITIS How is autoimmune hepatitis treated?
Prednisolone - immunosuppression | Liver transplant
141
PRIMARY BILIARY CHOLANGITIS What is primary biliary cholangitis?
an autoimmune condition characterised by granulomatous destruction of intrahepatic biliary ducts this leads to cholestasis and subsequent leakage of bile into circulation
142
PRIMARY BILIARY CHOLANGITIS what is the epidemiology of primary biliary cholangitis?
more common in females family history increases risk 10 x
143
PRIMARY BILIARY CHOLANGITIS what other conditions are associated with primary biliary cholangitis?
sjogrens syndrome raynauds disease autoimmune thyroid disease rheumatoid arthritis systemic sclerosis
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PRIMARY BILIARY CHOLANGITIS what are the clinical features of primary biliary cholangitis?
classic presentation = significant itching in middle-aged female SYMPTOMS - pruritus - fatigue + weight loss - dry mouth + eyes (sjogrens) - obstructive jaundice (icteric, pale stool + dark urine) SIGNS - skin hyperpigmentation (increased melanin) - clubbing - mild hepatosplenomegaly - xanthelsma + xanthomata - scleral icterus
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PRIMARY BILIARY CHOLANGITIS What are the investigations?
- antimitochondrial antibodies (AMA) - antinuclear antibodies (ANA) - smooth muscle antibodies - LFTs = obstructive jaundice (raised ALP, GGT + bilirubin, AST + ALT mildy deranged) - coagulation profile = deranged in advanced disease - serum immunoglobulin = raised IgM - transabsominal USS (exclude other causes) to consider: - MRCP - liver biopsy
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PRIMARY BILIARY CHOLANGITIS What is the treatment for primary biliary cholangitis?
1st line: - ursodeoxycholic acid - fat-soluble vitamin supplement (ADEK) - cholestyramine (for symptomatic relief of pruritus) 2nd line - liver transplantation (indicated in severe disease)
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PRIMARY BILIARY CHOLANGITIS what are the complications?
- malabsorption of vitamins ADEK - hypercholesterolaemia - liver cirrhosis - hepatocellular carcinoma - metabolic bone disease (osteoporosis + osteomalacia
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PRIMARY SCLEROSING CHOLANGITIS What is Primary sclerosing cholangitis?
Autoimmune inflammation and narrowing of intra and extra hepatic bile ducts
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PRIMARY SCLEROSING CHOLANGITIS Describe the pathophysiology of primary sclerosing cholangitis
Inflammation of the bile duct --> stricture and hardening --> progressive obliterating fibrosis of bile duct branches --> cirrhosis --> liver failure damage to the bile ducts leads to: - cholestasis - bile + toxins build up in the liver - bile duct strictures
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PRIMARY SCLEROSING CHOLANGITIS what is the epidemiology?
- more common in men - more common in northern europe + north america - typically occurs in middle age (40-50) - usually have history of ulcerative cholitis (UC)
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PRIMARY SCLEROSING CHOLANGITIS what are the clinical features of primary sclerosing cholangitis?
SYMPTOMS - pruritus - fatigue - abdominal pain (usually epigastric or RUQ) - symptoms of underlying IBD (bloody stools, tenesmus, diarrhoea, steatorrhoea) SIGNS - jaundice - signs of complications (Charcots triad, chronic liver disease)
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PRIMARY SCLEROSING CHOLANGITIS what are the investigations?
-LFTs = raised ALP + GGT, raised conjugated bilirubin, ALT/AST may or may not be elevated - albumin = decreased in later disease - viral hepatitis screen - pANCA - anti-mitochcondrial antibodies (AMA) (to rule out PBC) - abdominal USS (to exclude other causes) - MRCP = beaded appearance (due to multiple biliary strictures) to consider - ERCP (gold standard) - liver biopsy
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PRIMARY SCLEROSING CHOLANGITIS What is the treatment for primary sclerosing cholangitis?
1st line - observation + lifestyle optimisation (alcohol cessation, exercise) - cholestyramine for pruritus (rifampicin = 2nd line) - ADEK vitamin supplement END STAGE LIVER DISEASE - liver transplant
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PRIMARY SCLEROSING CHOLANGITIS What complications might occur due to primary sclerosing cholangitis?
- cholangitis - biliary strictures - choledocholithiasis - metabolic bone disease - end stage liver disease - cholangiocarcinoma - HCC - colorectal tumour
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PBC VS PSC what are the differences between primary biliary cholangitis + primary sclerosing cholangitis
PRIMARY BILIARY CHOLANGITIS - more common in middle aged women - destruction of intrahepatic ducts only - associated with autoimmune conditions - often asymptomatic or fatigue, pruritus, jaundice + hepatomegaly - raised ALP + GGT +/- conjugated bilirubin, anti mitochondrial antibodies (AMA) - diagnosed via cholestatic LFTs, abdominal USS, history + exam - treat with ursodeoxycholic acid, colestyramine + ADEK vita PRIMARY SCLEROSING CHOLANGITIS - more common in middle aged men - inflammation of intrahepatic + extrahepatic ducts - associated with ulcerative cholitis (UC) - has symptoms of IBD + ascending cholangitis - raised ALP + GGT +/- conjugated bilirubin, pANCA - diagnosed via cholestatic LFTs, MRCP, history + exam - treat with observation, colestyramine + ADEK vits
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ASCENDING CHOLANGITIS What is ascending cholangitis?
- also known as acute cholangitis - Obstruction of biliary tract causing bacterial infection - usually caused by bacteria ascending from its junction with the duodenum - Regarded as a medical emergency
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ASCENDING CHOLANGITIS what is the pathophysiology?
obstruction (most commonly caused by gallstones) causes cholestasis and promotes bacteria growth
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ASCENDING CHOLANGITIS what is the most common causative organism?
e.coli
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ASCENDING CHOLANGITIS what are the causes of ascending cholangitis?
- gallstones (most common) - biliary strictures - sclerosing cholangitis - cholangiocarcinoma - iatrogenic injury (e.g. ERCP)
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ASCENDING CHOLANGITIS Name the triad that describes the 3 common symptoms of ascending cholangitis
Charcot's triad 1. Fever 2. RUQ pain 3. Jaundice
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ASCENDING CHOLANGITIS What other symptoms can present with Charcot's triad with ascending cholangitis?
Reynolds pentad: - Charcot's triad (fever, RUQ pain, jaundice) - Hypotension - Confusion/altered mental state - dark urine and pale stool
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ASCENDING CHOLANGITIS What investigations might you do in someone who you suspect might have ascending cholangitis?
- trans-abdominal USS - Blood tests - LFTS (ALP>ALT + raised bilirubin), CRP, FBC, - MRCP = gold standard
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ASCENDING CHOLANGITIS what would the LFTs look like?
raised bilirubin ALP>ALT
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ASCENDING CHOLANGITIS Describe the management of ascending cholangitis
INITIAL - IV broad spectrum antibiotics (cefotaxime + metronidazole) - IV fluids BILIARY DECOMPRESSION - ERCP (first line) - surgical drainage ELECTIVE CHOLECYSTECTOMY
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ASCENDING CHOLANGITIS What is the difference between the clinical presentation of ascending cholangitis and acute cholecystitis?
A patient with acute cholecystitis would not have signs of jaundice
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ASCENDING CHOLANGITIS What is the main difference between biliary colic and acute cholecystitis?
Acute cholecystitis has an inflammatory component
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ASCENDING CHOLANGITIS What complications can occur due to acute ascending cholangitis?
- biliary sepsis - acute pancreatitis - hepatic abscess
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PERITONITIS What is peritonitis?
Inflammation of the peritoneal lining
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PERITONITIS what are the different types of peritonitis?
1. Primary = spontaneous bacterial peritonitis, ascites, immunocompromised 2. Secondary = Bowel perforation, abdomen organ inflammation, TB, bowel ischaemia
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PERITONITIS what are the risk factors?
- ascites - low ascitic fluid protein concentration - upper GI bleeding - prior episode of SBP
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PERITONITIS what are the clinical features of peritonitis?
SYMPTOMS - abdominal pain - nausea + vomiting - abdominal bloating - anorexia SIGNS - abdominal tenderness - guarding - rigidity - rebound tenderness - fever
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PERITONITIS What are the investigations?
- FBC + CRP = raised inflammatory markers - serum amylase (to rule out pancreatitis) - ABG/VBG (to get serum lactate, see how unwell) - paracentesis (ascitic tap) to consider - erect CXR (if perforation suspected) - abdominal USS or CT (to identify abscess or obstruction) - blood cultures
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PERITONITIS What is the management for peritonitis?
1st line: - broad spectrum antibiotics (piperacillin-tazobactam or metronidazole with cetriaxone) - fluid resuscitation via IV fluids - analgesia (paracetamol + opioids) - NG tube for feeding 2nd line - surgery +/- peritoneal lavage
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PERITONITIS what are the complications of peritonitis
- sepsis - abscess formation - bowel obstruction or ileus - AKI - adhesions and chronic pain - multiple organ dysfunction syndrome
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SPONTANEOUS BACTERIAL PERITONITIS What is the commonest serious infection in those with cirrhosis?
Spontaneous bacterial peritonitis
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SPONTANEOUS BACTERIAL PERITONITIS Name a bacteria that can cause spontaneous bacterial peritonitis
1. E. coli 2. S. pneumoniae
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SPONTANEOUS BACTERIAL PERITONITIS How can spontaneous bacterial peritonitis be diagnosed
By looking for the presence of neutrophils in ascitic fluid
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SPONTANEOUS BACTERIAL PERITONITIS Describe the treatment for spontaneous bacterial peritonitis
Cefotaxime and metronidazole
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SPONTANEOUS BACTERIAL PERITONITIS What investigation is it important to do in someone with chronic liver disease and ascites? Explain why it is important
Ascitic tap to rule out spontaneous bacterial peritonitis
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SPONTANEOUS BACTERIAL PERITONITIS You do an ascitic in someone with ascites. The neutrophil count comes back as - Neutrophils > 250/mm3. What is the likely cause of the raised neutrophils?
Spontaneous bacterial peritonitis
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ACUTE PANCREATITIS What is acute pancreatitis?
inflammation of the pancreas the pancreas returns to functionally and structurally normal after the episode Occurs as isolated or recurrent attacks
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ACUTE PANCREATITIS Describe the pathophysiology of acute pancreatitis
Main two causes are alcohol and gallstones:– Gallstones: Blockage of bile duct = backup of pancreatic juices. This change in luminal concentration causes Ca2+ release inside pancreatic cells and cause them to activate trypsinogen early which digests the pancreas. Alcohol: Contracts the Ampulla of Vater obstructing the bile clearance and also messes with Ca2+homeostasis causing the same as above. * Leaky and damaged pancreas an auto digest nearby structures causing haemorrhage and Grey Turner’s sign abdominal skin discolouration from retroperitoneal bleeding. * Deranges pancreatic function so can cause hyperglycemia from reduction of insulin production
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ACUTE PANCREATITIS What are the causes of acute pancreatitis?
I GET SMASHED – remember I = Idiopathic G = Gallstones (60%) E = Ethanol = alcohol (30%) T = Trauma S = Steroids M = Mumps A = Autoimmune S = Scorpion venom H = Hyperlipidaemia/ hypothermia/ high Ca E = ERCP (endoscopic retrograde cholangiopancreatography) D = Drugs (furosemide, corticosteroid, NSAIDs, ACEi) ```
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ACUTE PANCREATITIS what are the risk factors?
- advancing age - afro-caribbean ethnicity - sex (female = gallstone related, male = alcohol related) - high glycaemic diet - obesity - T2DM - family history
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ACUTE PANCREATITIS what are the symptoms of acute pancreatitis
SYMPTOMS - severe upper abdominal pain (epigastric, RUQ or LUQ radiating to back) - N+V, anorexia - steatorrhoea - poor urinary output SIGNS - abdo tenderness + guarding - abdo distension - tachycardic/hypotensive - cullen's sign (periumbilical bleeding) - Grey turners sign (flank bleeding) - fox's sign (bleeding over inguinal ligament)
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ACUTE PANCREATITIS What investigations are done on someone you think has acute pancreatitis?
- serum amylase - serum lipase FOR SEVERITY SCORING bloods - FBC, U&Es, LFTs ABG glucose LDH serum calcium TO CONSIDER - CXR - AXR - abdominal USS
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ACUTE PANCREATITIS what is the diagnostic criteria?
2/3 of following need to be met: - clinical features consistent with pancreatitis - elevation of serum amylase OR serum lipase - radiological features consistent with pancreatitis
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ACUTE PANCREATITIS how is the severity calculated?
- modified Glasgow score - PANCREAS - P02 <8kpa - Age >55 - Neutrophils >15x109/L - Calcium <2mmol/L - Renal function (urea >16mmol/L) - Enzymes (AST>200U/L or LDH>600U/L) - Albumin <32g/L - Sugar (blood glucose>10mmol/L)
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ACUTE PANCREATITIS Describe the treatment for acute pancreatitis
1st line - IV fluid resuscitation - catheterisation - oxygen supplementation if required - opiate analgesia - early nutritional support (oral if mild, NG or TPN) SPECIFIC TREATMENT - ERCP if gallstone related - cholecystectomy - alcohol cessation and withdrawal
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ACUTE PANCREATITIS Give 2 potential complications of acute pancreatitis
LOCAL - necrotising pancreatitis - chronic pancreatitis - pancreatic abscess SYSTEMIC - ARDS - renal failure - hypocalcaemia - hyperglycaemia
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ACUTE PANCREATITIS Why is morphine contraindicated in acute pancreatitis?
Morphine increases sphincter of Oddi pressure and so aggravates pancreatitis
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CHRONIC PANCREATITIS What is chronic pancreatitis?
Chronic inflammation of the pancreas leads to irreversible damage - Progressive loss of exocrine pancreatic tissue which is replaced by fibrosis
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CHRONIC PANCREATITIS Describe the pathogenesis of chronic pancreatitis
Pancreatic duct obstruction leads to activation of pancreatic enzymes --> necrosis --> fibrosis
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CHRONIC PANCREATITIS Name 3 causes of chronic pancreatitis
1. Excess alcohol - most common 2. CKD 3. Idiopathic 4. Recurrent acute pancreatitis 5. hereditary 6. CF - all have it from birth 7. autoimmune 8. tropical
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CHRONIC PANCREATITIS Describe how alcohol can cause chronic pancreatitis
Alcohol --> proteins precipitate in the ductal structure of the pancreas (obstruction) --> pancreatic fibrosis
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CHRONIC PANCREATITIS what is the clinical presentation of chronic pancreatitis?
SYMPTOMS - epigastric pain (dull, radiating to back, improved by leaning forwards, occurs 15-30 mins after eating) - steatorrhoea + diarrhoea (foul smelling + difficult to flush) - N+V - weight loss + fatigue - features of diabetes (polydipsia + polyuria) SIGNS - epigastric tenderness - signs of liver disease (jaundice + ascites) - skin nodules
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CHRONIC PANCREATITIS A sign of chronic pancreatitis is exocrine dysfunction, what can be consequence of this?
1. Malabsorption 2. Weight loss 3. Diarrhoea 4. Steatorrhoea
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CHRONIC PANCREATITIS A sign of chronic pancreatitis is endocrine dysfunction, what can be consequence of this?
DM
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CHRONIC PANCREATITIS What immunoglobulin might be elevated in someone with autoimmune chronic pancreatitis?
IgG4
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CHRONIC PANCREATITIS Why can pancreatitis cause malabsorption?
Pancreatitis result in pancreatic insufficiency and so lack of pancreatic digestive enzymes Defective intra-luminal digestion leads to malabsorption
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CHRONIC PANCREATITIS What 2 enzymes, if raised, suggest pancreatitis?
LDH (lactate dehydrogenase) and AST>ALT
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CHRONIC PANCREATITIS what are the investigations?
- LFTs - HbA1c - transabdominal USS = first line imaging - CT abdomen to consider - faecal elastase - IgG4 - MRCP - ERCP
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CHRONIC PANCREATITIS what is the management?
1st line - lifestyle modifications (alcohol + smoking cessation) - diet (low fat, high calorie diet with ADEK supplementation) - analgesia (paracetamol + NSAIDs) - pancreatic enzyme replacement (creon) 2nd line - endoscopic stenting - coeliac plexus nerve blocks - drainage of pseudocysts
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CHRONIC PANCREATITIS Give 3 complications of chronic pancreatitis
- malabsorption - duct obstruction - pseudocysts - DM - pancreatic cancer - metabolic bone disease (osteoporosis)
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LIVER FAILURE Name a drug that can cause drug induced liver injury
1. Co-amoxiclav 2. Flucloxacillin 3. Erythromycin 4. TB drugs
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JAUNDICE what investigations should be undertaken for jaundice?
- liver enzymes - very high ALT/AST- MRCP or ERCP - urine - bilirubin absent in pre-hepatic, in obstructive urobilinogen absent - FBC - ultrasound
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JAUNDICE what is the treatment for jaundice?
treat the underlying cause
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CHOLECYSTITIS what is cholecystitis?
inflammation of the gallbladder ● Follows the impaction of a stone in the cystic duct or neck of the gallbladder ● Can occasionally occur without stones
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CHOLECYSTITIS what are the risk factors?
- female - fat - fertile - forties - crohn's disease
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CHOLECYSTITIS what is the clinical presentation of cholecystitis?
SYMPTOMS - RUQ pain (severe + lasting >30 mins) - referred right shoulder tip pain - fever - nausea + vomiting - NOT jaundiced SIGNS - murphy's sign positive (palpating RUQ whilst pt breathes in deeply causes pain) - abdominal mass
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CHOLECYSTITIS what are the investigations for cholecystitis?
- FBC = leukocytosis with neutrophilia - LFTs = usually normal in uncomplicated disease - U&Es = may be deranged with AKI secondary to infection - Coagulation profile (to assess synthetic function of liver) - VBG (to assess lactic acidosis) - CRP = elevated - Transabdominal USS (1st line imaging) = positive murphy's sign, thickened gallbladder wall, distended with presence of stones to consider - CT abdomen - MRCP
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CHOLECYSTITIS what is the management of cholecystitis?
1st line - IV fluids + analgesia - IV antibiotics (CERFUOXIME or METRONIDAZOLE) - early laparoscopic cholecystectomy (within 1 week of diagnosis, often within 72hrs) 2nd line - urgent cholecystectomy (if sepsis/gangrene/perforation suspected)
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CHOLECYSTITIS what is the pathophysiology of cholecystitis?
* Stone is blocking the ducts. Bile builds up, distending the gallbladder. Vascular supply may be reduced from this distension. Inflammation follows these events secondary to the retained bile, inflaming the gall bladder.
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CHOLECYSTITIS what are the complications of cholecystitis?
- gallbladder empyema - gallstone ileus - acute (ascending) cholangitis | ● Perforation with peritonitis
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PRIMARY BILIARY CHOLANGITIS what is the pathophysiology of primary biliary cholangitis?
* Due to prolonged bile duct blockage, bile isn’t ‘flushing’ out the tubes so bacteria can climb up from the GI tract and cause biliary tree infection and consolidation. * This prevents bile entering the GI tract and causes jaundice. * 5-10% mortality and infection can affect the pancreas too since it shares ducts with the gallbladder.
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PRIMARY BILIARY CHOLANGITIS what are the causes of primary biliary cholangitis?
● CBD obstruction ● Benign biliary strictures ● Pancreatic or bile duct carcinoma
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PRIMARY SCLEROSING CHOLANGITIS what is primary sclerosing cholangitis?
a disease of the bile ducts that causes inflammation and obliterative fibrosis of bile ducts inside and/or outside of the liver. - This pathological process impedes the flow of bile to the intestines and can ultimately lead to cirrhosis of the liver, liver failure, and bile duct and liver cancer
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ALCOHOLIC LIVER DISEASE what happens to fatty liver on cessation of alcohol intake?
the fat disappears
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PORTAL HYPERTENSION what are the pre-hepatic causes of portal hypertension?
portal vein thrombosis
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PORTAL HYPERTENSION what are the intrahepatic causes of portal hypertension?
- schistosomiasis - cirrhosis - budd-chiari syndrome
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PORTAL HYPERTENSION what are the post-hepatic causes of portal hypertension?
- RH failure | - IVC obstruction
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PORTAL HYPERTENSION what is the pathophysiology of portal hypertension?
- Increased resistance to blood flow leads to portal hypertension causes splanchnic vasodilation - This results in a drop in BP - CO increases to compensate for BP resulting in salt and water retention - Hyperdynamic circulation/increased portal flow leads to the formation of collaterals between portal and systemic systems
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GI VARICES what is the treatment of GI varices?
● fluid resuscitation until haemodynamically stable ● If anaemic – blood transfusion ● Correct clotting abnormalities – vitamin K and platelet transfusion ● Vasopressin – IV terlipressin or octreotide ● Prophylactic antibiotics ● Variceal banding ● Balloon tamponade ● TIPS
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GI VARICES what is the clinical presentation of varices?
``` o Haematemesis o Abdominal pain o Shock o Fresh rectal bleeding o Hypotension and tachycardia o Pallor o Suspect varices as cause of GI bleeding if alcohol abuse or cirrhosis Splenomegaly and hyponatraemia ```
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GI VARICES what investigations should be done for varices?
endoscopy - find source
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GI VARICES what is the prevention of varices?
o Nonselective B blockade – propranolol – reduced resting pulse and decrease portal pressure o Variceal banding repeated to obliterate varices o TIPSS o Liver transplant
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CHRONIC PANCREATITIS what investigations are undertaken for chronic pancreatitis?
- serum amylase and lipase - may be raised | - abdominal US, CT and MRI
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A1AT what is alpha 1 antitrypsin deficiency?
- rare cause of cirrhosis - autosomal recessive condition - mutation of alpha-1-antitrypsin gene on chromosome 14
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A1AT what is the pathophysiology of alpha-1-antitrypsin deficiency?
● A mutation in the alpha-1-antitrypsin gene on chromosome 14 leads to reduced hepatic production of alpha-1-antitrypsin which normally inhibits the proteolytic enzyme, neutrophil elastase ● Deficiency results in emphysema, liver cirrhosis and hepatocellular carcinoma
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A1AT what are the investigations for alpha-1-antitrypsin deficiency?
Serum alpha-1-antitrypsin levels are low
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A1AT what is the treatment for alpha-1-antitrypsin deficiency?
● No treatment ● Treat complications such as liver disease ● Stop smoking ● Those with hepatic decompensation should be assessed for liver transplant ● Manage emphysema
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GALLSTONES what is the treatment for gallstones?
● Analgesics and elective cholecystectomy | ● CBD stone removed at ERCP
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GALLSTONES what investigations are undertaken for gallstones?
FBC and CRP: Looking for signs of an inflammatory response - suggestive of cholecystitis * LFTs: Raised ALP - Bilirubin and ALT usually normal. * Amylase: Check for pancreatitis * Ultrasound = diagnostic: 1.Stones 2.Gallbladder wall thickness (inflammation) 3.Duct dilation (suggests distal blockage)
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WILSONS DISEASE what are the side-effects of chelating agents?
skin rash, fall in WCC, HB and platelets, haematuria, renal damage
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WILSONS DISEASE what are the investigations for wilsons disease?
* Serum copper and ceruloplasmin reduced (but can be normal) * 24hr urinary copper excretion high * Liver biopsy – diagnostic
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PERITONITIS what are the causes of peritonitis?
bacterial = most common - gram -ve coliforms - e.coli - gram +ve staphylococcus chemical - bile, old clotted blood
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HEPATITIS what is the clinical presentation of HAV?
nausea, anorexia, distaste for cigarettes some become jaundiced - dark urine and pale stool
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HEPATITIS what is the epidemiology of HEV?
● Common in Indochina ● More common in older men ● Commoner than Hep A in UK ● High mortality rate in pregnancy
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HEPATITIS what is the management of HEV?
● Prevention via good sanitation and hygiene, vaccine also available ● Once you’ve had it once you cannot become infected again
240
HEPATITIS what are the test results for HBV?
● HBsAg is present 1-6 months after exposure ● HBsAg presence for more than 6 months implies carrier status ● Anti-HBs – antibodies
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HEPATITIS what are the clinical features of HDV?
similar to HBV
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HEPATITIS what are the investigations for HDV?
similar to HBV HDV-RNA anti-HDV
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HEPATITIS what is the treatment for HDV?
treat HBV SC pegylated interferon-alpha-2a
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HEPATITIS what is the epidemiology of HCV?
● High incidence in Egypt due to failed public health initiative ● Transmitted by blood and blood products ● Very high incidence in IV drug users ● Limited sexual transmission ● Vertical transmission is rare
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HEPATITIS how do you remember the viral hepatitis information?
● A is Acquired by mouth from Anus, is Always cleared Acutely and only ever Appears once ● E is Even in England and can be Eaten (found in pigs), if not always beaten ● B is Blood-Borne and if not Beaten can be Bad ● B and D is DastarDly ● C is usually Chronic but Can be Cured at Cost
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NON-ALCOHOLIC FATTY LIVER what are the risk factors for non-alcoholic fatty liver disease?
- middle age onwards - obesity - poor diet + low activity levels - T2DM - high cholesterol - HTN - smoking
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NON-ALCOHOLIC FATTY LIVER which drugs increase the risk of developing non-alcoholic fatty liver disease?
Amiodarone, Tetracycline ,Methotrexate
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NON-ALCOHOLIC FATTY LIVER what are the clinical features of non-alcoholic fatty liver disease?
Usually no symptoms; liver ache in 10% Fat, sometimes with inflammation & fibrosis
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NON-ALCOHOLIC FATTY LIVER what are the investigations for non-alcoholic fatty liver disease?
- LFTs = raised ALT - liver USS = confirm hepatic steatosis (seen as increased echogenicity) - enhanced liver fibrosis (ELF) blood test = 1st line (>10.51= advanced fibrosis) - NAFLD fibrosis score - fibrosis-4 score - fibroscan - liver biopsy = gold standard
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NON-ALCOHOLIC FATTY LIVER what is the treatment for non-alcoholic fatty liver disease?
- weight loss - healthy diet - exercise - avoid/limit alcohol - stop smoking - control diabetes, blood pressure + cholesterol - refer patients to specialists - specialist teatment (vitamin E, pioglitazone, bariatric surgery + liver transplant)
251
ALCOHOLIC LIVER DISEASE what is the pathophysiology of alcoholic liver disease?
chronic excessive alcohol consumption leads to liver impairment - alcohol is metabolised into acetaldehyde and then to acetate - excessive NADH leads to greater fatty acid oxidation and subsequently fatty infiltration of the liver - the production of free radicals results in increase in TNF-alpha causing hepatic inflammation - chronic inflammation leads to liver fibrosis and eventually cirrhosis
252
ALCOHOLIC LIVER DISEASE what is the progression of alcoholic liver disease?
- fatty liver (steatosis) - alcoholic hepatitis - alcoholic liver cirrhosis
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ALCOHOLIC LIVER DISEASE what are the risk factors for alcoholic liver disease?
- chronic alcohol consumption (40-80g/day for males and 20-40g/day for females) - concomitant liver disease (e.g. hep C) - obesity - smoking
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ALCOHOLIC LIVER DISEASE what are the clinical features?
SYMPTOMS - malaise - weight loss - weakness - RUQ abdominal discomfort - pruritus - easy bruising SIGNS - palmar erythema - dupuytren's contracture - jaundice - ascites - spider naevi - confusion - asterixis - hepatosplenomegaly - caput medusae - parotid gland enlargement - gynaecomastia, hypogonadism - hepatic mass - haematemesis (variceal bleed)
255
ALCOHOLIC LIVER DISEASE what are the investigations for alcoholic hepatitis?
LFTs - raised bilirubin, AST:ALT ratio>2, low albumin, raised GGT FBC - macrocytic anaemia, thrombocytopaenia Folate - may be deficient Clotting - may be deranged (in advanced disease) Exclude secondary causes - viral hep, autoimmune, HCC to consider - liver USS - hyperechoic + coarse echotexture - fibroscan - liver biopsy
256
ALCOHOLIC LIVER DISEASE what is the management for alcoholic liver disease?
- alcohol abstinence - weight loss - smoking cessation - immunisation (flu, pneumococcal, hep B) - nutritional supplementation - corticosteroids (prednisolone) if Maddrey's discriminant function score >32 - N-acetylcysteine for 5 days in advanced disease - liver transplantation (requires 3 months abstinence before consideration)
257
PRIMARY SCLEROSING CHOLANGITIS which condition is associated with primary sclerosing cholangitis?
IBD - especially ulcerative colitis
258
HEPATITIS what do the following serological markers indicate in HBV infection? - HBsAg - HBeAg - HBV-DNA - anti-HBs - anti-HBc IgM - anti HBc IgG - anti HBe
- HBsAg = acute infection (persistence after >6months implies chronic infection) - HBeAg = acute infection (persistence implies active viral replication) - can distinguish between active and inactive chronic infection - HBV-DNA = implies viral replication (present in acute and chronic) - anti-HBs = immunity to HBV from immunisation or previous cleared infection - anti-HBc = implies previous or current infection - anti-HBc IgM = recent infection within last 6 months - anti-HBc IgG = persists long term - anti-HBe = seroconversion and is present for life
259
LIVER FUNCTION TESTS what do the following liver function tests indicate? | ALT, ALP, AST, GGT
``` ALT = liver specific ALP = bile duct specific AST = alcohol specific GGT = differentiate between bone and liver ```
260
BILE what are the primary bile salts?
colic acid and chenodeoxycholic acid`
261
BILE what are the secondary bile salts?
deoxycholic acid and lithocholic acid
262
BILE how are primary bile salts turned into secondary bile salts?
Primary bile salts turn into secondary bile salts by dehydroxylation by bacteria in the gut
263
BILE where is bile synthesised?
in the liver and stored in the gallbladder
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BILE what is the role of bile?
emulsification of lipids to aid absorption
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BILE where is the primary site of lipid digestion and absorption?
small intestine
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BILE what is the process of lipid absorption?
Bile salts emulsify fats and pancreatic lipase hydrolyses fats into monoglycerides and fatty acids Pancreatic lipase makes fatty acids form micelles which diffuse through epithelial cells This forms chylomicrons which are absorbed into lymphatic system
267
PORTAL HYPERTENSION what structures make up the portal triad?
portal vein hepatic artery hepatic bile duct
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NON-ALCOHOLIC FATTY LIVER how can you tell the difference between NAFLD and alcoholic liver disease?
AST:ALT ratio ratio close to 1 = NAFLD 2:1 ratio = alcoholic liver disease
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JAUNDICE what are the symptoms of pre-hepatic jaundice?
pallor fatigue exertional dyspnoea
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JAUNDICE what are the symptoms of intra-hepatic jaundice?
anorexia fatigue nausea abdominal pain
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JAUNDICE what are the symptoms of post-hepatic jaundice?
``` pale stools dark urine pruritus steatorrhea RUQ pain hepatomegaly ```
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PRIMARY BILIARY CHOLANGITIS what conditions are associated with primary biliary cholangitis?
IBD
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CHRONIC PANCREATITIS which vitamins are people with chronic pancreatitis at risk of becoming deficient in?
fat soluble vitamins | ADEK
274
CHRONIC PANCREATITIS what are the investigations for chronic pancreatitis?
CT or MRI - pancreatic duct dilation, calcification, atrophy or pseudocysts endoscopic ultrasound fecal elastase test - decreased elastase
275
HCC what cancer marker is present in hepatocellular carcinoma?
alpha-fetoprotein
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PANCREATIC CANCER what is the most common type?
adenocarcinoma - most commonly occuring at the head of the pancreas
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PANCREATIC CANCER what are the risk factors?
- increasing age (65-75yrs) - male - smoking - diabetes - chronic pancreatitis - genetic (hereditary non-polyposis colorectal cancer, BRCA1 + 2 - multiple endocrine neoplasia
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PANCREATIC CANCER what are the clinical features?
SYMPTOMS - painless jaundice - epigastric or atypical back pain - anorexia - weight loss - new onset diabetes (thirst, polyuria, nocturia) - nausea + vomiting - steatorrhoea - pale stool + dark urine SIGNS - positive Courvoisier's sign (palpable gallbladder in the presence of painless jaundice) - Trousseau sign of malignancy (migratory thrombophlebitis, blood vessels get inflamed with associated clot)
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PANCREATIC CANCER what are the investigations?
- LFTs = obstructive (raised ALP + GGT + bilirubin) - coagulation profile (assess for liver mets) - abdominal USS - CT (or MRI) pancreas = double duct sign (simultaneous dilation of pancreatic + common bile ducts) - CA 19-9 to consider: - PET scan (for staging) - endoscopic USS - ERCP
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PANCREATIC CANCER when would you refer someone for 2ww?
- over 40 with jaundice = 2ww - over 60 plus one of following (diarrhoea, back pain, abdo pain, N+V, constipation or new diabetes) = direct access CT abdomen NOTE - pancreatic cancer is the only situation where a GP can do a direct access CT abdomen referral
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PANCREATIC CANCER what is the management?
LOCALISED TUMOUR - surgical resection (whipples resection) - adjuvant chemotherapy LOCALLY ADVANCED OR METASTATIC: - palliative management - ERCP with stenting - chemotherapy / chemoradiotherapy
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PANCREATIC CANCER what is the prognosis?
very poor as it is often diagnosed late cancer tends to spread + metastasise early, particularly to liver, peritoneum, lungs and bones average survival for advanced disease = 6 months when caught early, 5yr survival = <25%
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PANCREATIC CANCER where does it tend to spread to?
liver peritoneum lungs bones

MY REVISION - ALL PHASES (36 decks)

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