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Phase 2a > Liver + Friends > Flashcards

Liver + Friends Flashcards

1
Q

Liver functions

A 
Albumin production 
regulates excess oestrogen 
Produce clotting factors
Regulate bilirubin 
detoxification 
Immunity - reticuloendothelial 
Glycogen storage
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2
Q

When is GGT raised

A

Alcoholic liver disease

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3
Q

When is ALP raised

A

Biliary tree damage

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4
Q

when is AST/ALT Raised

A

Hepatocyte damage

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5
Q

Acute liver conditions

A

Viral hep - A, B
Drugs
Alcohol

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6
Q

Chronic liver conditions

A 
Viral hep - B,C,E
AIH 
PBC
PSC
Haemochromatosis 
Wilsons 
Alpha-1 antitrypsin 
NAFLD
Alcoholic liver disease
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7
Q

Acute liver conditions presentation

A 
Malaise 
lethargy 
fever
GI upset 
Abdo pain 
Signs:
Jaundice 
confusion - encephalopathy 
Ascites 
Bleeding
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8
Q

Chronic liver conditions presentation

+ decompensated

A

Clubbing
spider navaei
Palmar erythema
Duptruptens contracture

Decompensated:
Coagulopathy - Increase PT and INR
Jaundice 
HYpoalbuminaemia 
Ascites 
Encephalopathy
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9
Q

What is the liver’s synthetic function measured by

A
  • Prothrombin time
  • short half life
  • Vit K deficiency –> prolonged time
  • Serum Albumin
  • Serum bilirubin
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10
Q

When would you see councilman bodies

A

Viral hepatitis

  • lobules
  • portal tracts
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11
Q

Blood bourne Viral hepatitis

A

B
C
D

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12
Q

Hepatitis A

  • route of transmission
  • DNA or RNA
  • incubation
  • tx
  • prevention
A

Faeco-oral

  • normal with travel hx
  • contaminated food or water
  • RNA
  • 2/6wks incubation
  • resolves without tx and provides 100% immunity
  • vaccines available for travellers
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13
Q

Hepatitis E

  • route of transmission
  • incubation
  • tx
  • chronic
A

Faeco-oral

  • contaminated food or water
  • undercooked pork
  • RNA
  • 3-8weeks incubation
  • No tx - resolves in 1 month
  • Can develop in to CLD in:
    transplant pts and immunocompromised
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14
Q

what % Hepatitis B is chronic

A

20%

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15
Q

Hepatitis B routes of transmission

A 
Blood bourne 
Vertical - mother to child 
IVDU 
sharing blood products
sexual
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16
Q

Hepatitis B risk groups

A

IVDU - Sexual partners
Health workers
Gay sexually active men
Baby from HbsAg +ve mum

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17
Q

Chronic hepatitis complications

A

HCC

Portal HTN

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18
Q

What percentage of patients with Hep C will develop chronic infection

A

70%

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19
Q

Decompensated cirrhosis presentation

A 
jaundice 
ascites 
encephalopthy 
coagulopathy 
Low albumin 
Virical bleeding
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20
Q

Hepatitis C testing process

A
  • HCV Ab screening test
  • HCV RNA
    confirms diagnosis + shows current infection
  • HCV RNA is then used to:
  • calculate viral load
  • Assess for individual genotype
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21
Q

HCV Tx

A 
Direct acting antivirals 
- NS5A 
-NS5B 
\+ RIBAVIRIN 
Inhibit hep C:
. RNA production 
. New virus protein production 
.Viral assembling
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22
Q

Which hep can you be reinfected with

A

Hep C

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23
Q

Causes of hepatitis

A 
Viral 
AI 
NAFLD
Drug induced 
Alcoholic
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24
Q

What should you do if you identify a case of any Viral hepatits

A

Inform public health - notifiable disease

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25
Q

Heaptitis C

  • transmission
  • incubation
  • CLD?
  • complications
  • tx
A
  • blood bourne (blood and bodily fluids)
  • 1-3 months
  • Yes can progress to CLD in 70% of pts
  • Liver cirrhosis + HCC
  • Direct acting anti-virals
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26
Q

Heaptitis A management

A
  • supportive as it’s self limiting
    Avoid alcohol
    Basic analgesia
    Monitor liver - INR + Albumin

Active and passive immunisation

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27
Q

Hepatitis D

  • requirements
  • route of transmission
  • incubation
  • CLD?
  • tx
A
  • requires HBsAg to survive
  • Blood bourne
  • 2-6 months
  • Can progress to CLD
  • Interferon alpha
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28
Q

Hepatitis B

  • Incubation
  • DNA or RNA
  • tx
A
  • 1-5 months
  • DNA
  • alpha - inteferon
    induces IS response
  • Tenevofir
    supresses viral rep
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29
Q

Hepatitis B prevention

A
  • antenatal screening
  • blood screening
  • sterile equipment
  • immunise healthcare workers
  • Immunisation
  • screen sexual contacts
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30
Q

Hep B viral markers

A

HBsAg - active infection
HBeAg - marker of viral rep and implies high infectivity
HBcAb - Implies past or current infection
HBsAb - implies vaccination or past/current infection
HBV DNA - direct count of viral load

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31
Q

Hep B testing process

A
  1. HBcAg (previous infection) + HBsAg (Active infection)

If positive then do futher testing:

  1. HBeAg and viral load
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32
Q

Hep B surface antigen

A

HBsAg given in vaccine

- Positive HBsAb may indicate vaccination or infection

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33
Q

Hepatits B core Ab

A
  • Help distinguish between: acute, chronic and past infections
  • Measure IgM + IgG versions of HBcAb
    IgM - active infection
  • high titre - acute
    *low titre - chronic

IgG - past infection where HBsAg is negative

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34
Q

Hepatits B e antigen

A

Presence indicates acute phase of infection - virus actively replicating

Level correlates with infectivity

If HBeAg is -ve but but HBeAb is +ve
Benn through viral replication phase and virus has now stopped replicating and are less infectious

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35
Q

AI hepatitis forms

A 
Type 1: Adults 
- women 40-50y/o
- post menopausal 
- Less acute course 
- Anti-nuclear Ab (ANA)
  Anti - SM Ab (ASMA)
- Increased Albumin + PT
Type 2: Children 
- Anti-LKM1 
Ab against microsomes of liver/kidney 
- Anti-LC-1 Ab 
Anti liver cystolic-1 Ab 
- Young girls
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36
Q

Autoimmune Hep presentation based on forms

A

Type 1 -
Fatigue + features of liver disease

Type 2 -
acute hepatitis
high transaminases
jaundice

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37
Q

Autoimmune Hep investigations

A
  • Increased bilirubin
  • raised transaminases ALT/AST
  • Raised IgG levels
  • Auto Ab presence
  • FBC –> Anaemia
  • Liver biopsy *CONFIRMS
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38
Q

Autoimmune Hep tx

A
  • Prednisolone
    Steroids are gradually tapered off and replaced with:
  • Azathioprine
    Inhibits enzyme required for DNA synthesis
    High B+T cell proliferation during immune response
  • Transplant
    If end stage liver disease
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39
Q

Jaundice defenition

A

Yellowing of skin and sclera due to increased serum bilirubin (>50microlitres/L)

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40
Q

Pre heaptic jaundice causes

A

Gilberts
- UDP Glucuronyl transferase deficiency

Haemolysis

  • Sickle cell
  • Malaria
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41
Q

Precipitators to jaundice in Gilberts disease

A

Stress
Infection
Starvation

  • All lead to increased heamolysis
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42
Q

Intrahepatic jaundice causes

A 
Liver disease 
Hepatitis - AI + Viral 
Carcinoma 
Haemochromatosis 
Alcoholic LD
CCF --> Congestion
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43
Q

Post heaptic jaundice causes

A

Gallstones

Pancreatic cancer - head

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44
Q

Pre- heaptic jaudice presentation

  • urine
  • stools
  • itching
  • liver tests
A

All normal and no itching

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45
Q

Cholestatic jaudice presentation

  • urine
  • stools
  • itching
  • liver tests
A
  • Dark urine
  • Pale stools
  • Only itching if post hepatic
  • Abnormal liver tests
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46
Q

Alcoholic liver disease progression

A
  1. Alcoholic steatosis
    - fat build up in liver
    - reversible in 2wks if drinking stops
  2. Alcoholic heaptitis
    - drinking over long period of time causes inflamm
    mild heaptits is usually reversible with permanet abstinence
    -neutrophil infiltration
  3. Cirrhosis
    scar tissue
    stopping drinking prevents further damage
    poor prognosis if drinking continues
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47
Q

Alcohol metabolism routes (3) and end product

A
  1. CYP450 - 2E
    Microsomes
  2. Alcohol dehdrogenase
    (ADH)
    NAD+ –> NADH
    Remves H+ from alcohol
  3. Catalase
    Peroxisomes

end product: Acetaldehyde

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48
Q

Percenage of alcohol (%ABV)

A

Total volume of the drink

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49
Q

CAGE questions

  • use
  • meaning
A 
screen for harmful alcohol use 
C - cut down 
A - annoyed 
G - guilty 
E - eye opener
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50
Q

AUDIT Questionnaire

A

ALcohol Use Disorders Identifcation Test

  • screens for harmful alcohol use
  • score > 8 gives indication of harmful use
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51
Q

ALD pathophysiology

A
  • Decreased NAD+ due to alcohol excess leads to less fat oxidation
  • Accumilation of fat in heaptocytes
  • Increased ROS damages hepatocytes
  • Acetaldehyde damages liver CM
  • Leads to inflamm + neutophil infiltration
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52
Q

ALD organs affectd

  • CNS
  • Gut
  • Heart
  • Repro
A

CNS

  • dependance and withdrawl
  • Falls + Fits
  • Decrease memory and cognition
  • Wernickes encephalopathy

Gut

  • Cancer
  • PUD
  • D+V
  • Obesity
  • pancreatits

Heart

  • Increase BP
  • Sudden death in binge drinkers
  • Arrhythmias
  • cardiomyopathy

Repro

  • Testicular atrophy
  • increase oestrogen
  • foetal alcohol syndrome
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53
Q

Liver steatosis

  • sx
  • investigations
A

Asymptomatic

  • Abdo pain
  • Nausea
  • D+V

US of liver
- fatty changes - Increased echogenicity

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54
Q

Alcoholic heaptits

  • sx
  • signs
  • investigations
A

sx - mild jaundice
signs - CLD

  • Biopsy - DIAGNOSTIC
  • LFTs
    GGT - VERY RAISED
    AST/ALT mildy raised
  • FBC: Macrocytic anaemia
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55
Q

Signs of Liver disease

A 
Jaundice 
hepatomegaly 
spider naevi 
Palmar erythema 
Bruising 
Ascites 
Asterixis - decompensated
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56
Q

What is delirium tremens

A

Medical emergency assoc with alcohol withdrawl

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57
Q

Delirium tremens presentation

A 
Confusion 
agitation 
HTN 
Tahcycardia 
Tremor 
Ataxia
Arrhthymia
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58
Q

Delirium tremens tx

A

Librium - benzodiazepine

Diazepam

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59
Q

What is wenicke - korsakoff syndrome

A

Thiamine (B1) deficeincy - poorly absorbed in presence of alcohol

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60
Q

NAFLD stages

A
  1. NAFLD
  2. NASH
  3. Fibrosis
  4. Cirrhosis
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61
Q

Metabolic synromes leading to NAFLD

A 
Obesity 
HTN 
DM
Hyperlipdaemia 
Hypertrygyceraemia
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62
Q

NAFLD investigations

A

Liver biochemistry
- Raised ALT

Enhanced liver fibrosis test

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63
Q

NAFLD management

A 
weight loss 
excercise 
smoking cessation 
control DM/BP/choleterol 
Avoid alcohol
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64
Q

What is liver failure

A

Ability to regenrate and repair is lost

- recognised by development of coagulopathy (INR >1.5) and Encephalopathy

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65
Q

Difference between acute and chrnic liver failure

A

Acutte - occurs in previously normal liver

Chronic - occurs on the background of cirrhosis

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66
Q

Fulminant hepatic failure

A

clincial syndorme resulting from massive necrosis of liver cells
- Multiacinar necrosis of large parts of the liver

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67
Q

Liver failure aetiology

A 
Virla Hep -B/C/CMV
Alcohol 
Paracetamol overdose 
Haemochromatosis 
Fatty liver disease 
PBC 
Aplha 1 anti-trypsin 
Wilsons
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68
Q

Heaptic failure signs

A 
Jaundice 
Heaptic encephalopathy 
- confusion 
-coma
-drowsiness
Coagulopathy 
Aterixis
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69
Q

What is asterixis

A

tremor of hand when wrist is extended - bird flapping wings

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70
Q

Hepatic encephalopathy patho

A

Liver failure –> NH3 build up
- NH3 neurotoxic as it prevents krebs cycle leading to irreplaceable cell death + damage
- NH3 in brain is cleared by astrocytes
(Glutamate–> Glutamine)
- Increase osmotic imbalance due to excess glutamine
- shift of fluid into cells
- Cerebral oedema

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71
Q

Encephalopathy tx

A

Lactulose

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72
Q

Heaptotoxic drugs

A

paracetamol
methotrexate
Isoniazid

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73
Q

DILI drug causes

  • Abx
  • CNS drugs
  • Analgesics
A

Abx

  • Flucloxacillin
  • Erythromycin
  • TB drugs
  • Co-amoxiclav

CNS

  • Valporate
  • Carbamezapine

Analgesics
- Diclofenac

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74
Q

what dosage of paracetamol in adults ca be fatal

A

12g or more

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75
Q

Routes of paracetamol excretion (3)

A
  1. Glucuronidation
  2. Sulfation
  3. CYP450 –>
    NAPQI + Glutathione
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76
Q

Pathophysiology of overdose

A
  • Increased NAPQI levels leads to glutathione depletion

- build up of toxic metabolite in liver causes damage

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77
Q

Paracetamol overdose presentation

A

Nausea
Vomitting
R.U.Q pain
Anorexia

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78
Q

Factors that determine the severity of a paracetamol overdose (4)

A

Metabolic acidosis - pH <7.3
Hypoglycaemia
Prolonged PT
Raised creatinine

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79
Q

Paracetamol overdose tx

A
  • Fluids –> Prevent AKI
  • Activated charcoal within an hour of ingestion
  • IV N-Acetylcysteine
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80
Q

Why should you avoid alcohol during a paracetamol overdose

A

CYP450 inducers

- Metabolises paracetamol into toxic metabolites faster

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81
Q

Haemochromatosis

  • defenition
  • inheritence pattern
A
  • Excessive total body iron
  • AR
    HFE in chromosome 6
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82
Q

Haemochromatosis pathophysiology

A
  • Increase Fe2+ absorption from upper SI

- Can also be from mutation (HFE)

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83
Q

Haemochromatosis presentation

A 
Tiredness 
Arthralgia - Pseudogout 
decreased libido 
grey-skin discouloration 
mood disturbances 
Hair loss
Amenorrhoea
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84
Q

Haemochromatosis investigations

A 
- Serrum ferritin levels 
  AFR
- Raised trasferrin saturation 
- Liver biopsy 
   Perl's stain 
   Iron conc shown in liver cells
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85
Q

Haemochromatosis complications

A
  • restrictive cariomyopthy
  • Bronze DM T1
  • Hypogonaidism
  • Liver damage –> Cirrhosis –> HCC
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86
Q

Haemochromatosis tx

A 
- Venessection 
   (<50mcg/L)
  3-4 venessections/year
Normalisation assessed by:
- Serum ferrtin 
- Trasferrin saturation
  • Desferrioxamine to remove excess iron
  • Genetic testing for 1st degree relatives
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87
Q

Wilsons disease

  • defenition
  • Inheritance pattern
  • gene
A
  • Excess copper in the body with deposition in Liver + CNS
  • AR disorder of Chromosome 13 resulting in defect with Cu-trasporting ATPase
  • ATP7B gene
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88
Q

Wilsons presentation

A 
Hepatitis
Cirrhosis 
Tremor 
Dyshpagia 
Ataxia 
Parkinsonism 
Dementia
Depression 
Personality change 
Arthiritis 
Keyser-fleischer rings
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89
Q

Wilsons - CNS effects

A

Basal ganglia - parkonsinism

Cerebral cortex –> Neuronal cell death–> Dementia

90
Q

Wilsons - Cornea

A

Deposition in descements membrane

Kayser - Fleischer rings

91
Q

Wilsons investigations

A
  • Low serum cearuloplasmin
  • Urine: 24hr Cu excretion is high
  • Geneic testing - confirms
  • Liver biopsy
92
Q

Wilsons diet modifications

A

Avoid foods high in Cu

  • Choclate
  • Mushrooms
  • Shellfish
  • Check water pipes
93
Q

Wilsons disease tx

A
  • Copper chelators - PENICILLAMINE
  • Zinc salts
    Reduces Cu absorption
  • Transplant
94
Q

Penicillamine S/E

A 
Nausea
Rash 
Low WCC + Platelets 
Lupus 
Haematuria
95
Q

Wilsons complications

A

Hepatosplenomegaly
Renal disease - PCT damage
Haemolytic damage - Cu damages RBC’s

96
Q

Alpha 1 antitrypsin

A

Protease that inhibits elastase function

- Coded for on chromosome 14 (SERPINA1 gene)

97
Q

Alpha-1 antitrypsin deficiency pathophysiology

A

Elastin - provides strength + elasticity to alveoli

Alpha-1 antitrypsin no longer present to protect elastin –> Elastin breakdown
Alveoli loose elasticity and structural integrity
- Pan acinar emphysema

98
Q

Alpha-1 antitrypsin presentation

A 
Dyspnoea 
S.O.B
Mucous production
Wheeze 
Chronic cough 
Cirrohosis 
- Heaptic encephalopathy 
- Decrease coag factors 
- Portal HTN 
- Increase HCC
99
Q

Alpha-1 antitrypsin investigations

A
  • Serum alpha-1 antitrypsin LOW (AFR)
  • Lung function tests
    LOW FEV1
  • CXR –> Hyperinflation
  • Liver biopsy
    PAS (+ve)
    *Glycoproteins - pink
    Diastase resistant
100
Q

Alpha1 antitrypsin deficiency tx

A
  • IV infusion of Alpha1
  • Smoking cessation
  • Inhalers
101
Q

Ascites

  • definition
  • most common cause
A
  • accumulation of fluid in peritoneal cavity (>25ml)

- Cirrhosis most common cause

102
Q

Ascites pathophysiology in Cirrhosis

A
  • Peripheral arterial vasodilation (NO)
  • reduction in effective blood volume
  • Activation of RAAS and SNS
  • Promotes salt and fluid retention
  • Hypoalbuminaemia encourages oedema formation
  • Portal HTN localises fluid build up in cavity
103
Q

why is there a decrease in oncotic pressure in cirrhosis

A

Hypoalbuminaemia

104
Q

Why does hydrostatic pressure increase in the formation of ascites

A

Portal HTN

RAAS activation

105
Q

What is:

  • Transudate
  • Exudate
A
  • Ascitic albumin conc of 11g/L or more below serum albumin

- Ascitic albumin conc less than 11g/L below serum albumin

106
Q

Ascites: Transudate causes and apperance

A

Portal HTN - cirrhosis
Cardiac failure
Constricitve pericarditis

  • Clear fluid
107
Q

Ascites: Exudate causes and apperance

A 
Maliganacy 
Infections 
Pancreatitis 
Infammation - Increased vascualr permeability 
Nephrotic syndrome
  • Cloudy fluid
108
Q

Ascites signs

A 
fullness in flanks - Shifting Dullness 
Mildo abdo pain 
Discomfort
Tense ascites --> Resp distress 
Peripheral oedema 
Pleural effusion
109
Q

Ascites investigations

A

Ascitic tap

  • culture
  • gram stain + culture
  • cytology for malignancy
  • protein
  • Raised WCC shows bacterial peritonitis
  • Amylase to exclude pancreatic ascites
110
Q

Ascites tx

A
  • restict fluid and sodium intake
  • Spirinolactone
  • Tx underlying condition
111
Q

Causes of generalised peritonitis

A

Rupture of abdominal viscera

  • perforated duodenal ulcer
  • perforated appendix
112
Q

When should SBP be suspected

A

Any ascitic pt that deteriorates

113
Q

SBP Gram -ve coliforms causes

A

E.coli

Klebsiella

114
Q

SBP Gram +ve staphylococcus causes

A

S.aureus

115
Q

SBP Investigations and management

A
  • Ascitic tap
    neutrophil count > 250cells/mm3
  • Cefotaxamine initially whilst awaiting culture results
116
Q

SBP prophylaxis

A

Ciprofloxacin

117
Q

Hernia

- definition

A

petrusion of organ or part of an organ through the body wall that normally contains it

118
Q

types of irreducible hernias

A
  • Obstructed
    intestine obstructed due to pressure byt BF maintianesd
  • Incarcerated
    adhesions formed so tissue is trapped
  • Strangulated
    BF cut off
    Results in Iscaemia/gangrene w/without perforation
119
Q

Inguinal hernia

  • defenition
  • which is more common
A

Protrusion of abdo contents through inguinal canal - points towards groin
superior and medial to tubercle
- indirect more common

120
Q

Direct hernia

A

Through abdo wall –> Superficial ring

  • Medial to inferior epigastric artery
  • Occurs in Hesselbachs triangle
121
Q

Indirect hernia

  • defenition
  • pathway
  • location in relation to IEA
A

peritonael sac goes via deep inguinal ring –> superficial ring –> scrotum

  • follows spermatic cord
  • Lateral to Inferior epigastric artery
  • can strangulate
122
Q

Hesselbach’s triangle boarders

A

I - Inguinal ligament
L - IEA
M - Rectus abdominus

123
Q

Inguinal hernia presentation

A

Lump - enlarges when coughing
discomfort
pain + ache on exertion

124
Q

Hiatus hernia types

A

Sliding - 80%

  • Gatro- oesophageal junction slides up
  • acid reflux - LOS less competant

Rolling - 20%

  • bulge of stomach herniates into chest
  • Gastric volvus
125
Q

Hiatus hernia investigations and tx

A
  • barium swallow
  • GI endoscopy
  • weight loss
  • tx GORD sx
126
Q

Peritonitis presentation

A 
tender hard abdomen 
guarding - lies still 
fever
tachycardia 
absent bowel sounds 
nasuea 
vomitting
  • if perforation
  • sudden onset abdo pain
  • collapse
  • hypotension
  • hypoxia
127
Q

peritonitis investigations

A
  • Ascitic tap
  • Bloods: FBC/Amylase/LFT/U+E/Cultures
  • pregnancy test
  • USS
  • AXR
128
Q

Peritonitis Management

A
  • ABCDE
  • IV broad spectrum abx - Cephalosporin
  • fluids
129
Q

Difference between Acute and Chronic pancreatitis

A

A: pancreas returns back to normal - functionally + structurally

C: continuous inflamm
Irreversible structural changes

130
Q

Acute pancreatitis defenition +patho

A

Inflamm of pancreas - premature activation of pancreatic enzymes self perpetuating pancreatic mediated auto-digestion

131
Q

Pancreatitis aetiology

A 
I - Idiopathic 
G- Gallstones 
E- ethanol 
T - Trauma 
S - steroids 
M - Mumps 
A - AI (SLE)
S - Scorpion venom 
H - Hyper - Ca2+/lipids 
E - ERCP
D drugs: Azathioprine/Metronidazole/ tetracycline/ furosemide

Pregnancy
Neoplasia

132
Q

A. pancreatits presentation

A 
Abdo pain - radiates to back
* sitting foward relieves 
N+V
Fever
Abdo tenderness
Distension 
Tachycardia

Cullen’s sign - Periumbilical bruising

Turners sign - Flank bruising

133
Q

A. pancreatitis investigations

A

Bloods:

  • Serum amylase (3x normal)
  • Increase urinary amylase
  • Serum lipase increase (more specific)
  • CT abdo
  • Abdo US
134
Q

Why is lipase more specific than amylase in investigation for A.pancreatitis

A

Amylase also increased in GI diseases

  • perforated peptic ulcer
  • Cholecystisis
135
Q

A.pancreatits scoring system

A 
Modified glasgow criteria 
- Predicts severity 
P - pao2 (<8kpa)
A - age <55y/o
N - Neutrophilia 
C - Ca2+
R - Renal function 
E - Enzymes 
A - Albumin 
S - Sugar (BG>10mm/mol)
136
Q

A. pancreatitis management

A
  • Nil by mouth –> NG tube
  • Catheter
  • Analgesia - Tramadol
137
Q

Why is IV morphine avoided in A.pancreatitis

A

Causes sphincter of Oddi contraction aggrevating pancreatitis

138
Q

acute Pancreatitis complications

A

early:

  • shock
  • renal failure
  • sepsis
  • hupocalcaemia

late:

  • ARDS
  • DIC
  • Pancreatic necrosis
139
Q

Chronic pancreatits investigations

A

CT
- Pancreatic calcifications
- ductal dilation
Faecal elastase

140
Q

Liver cirrhosis defenition

A

result of chronic inflammation

Irreversible liver damage due to fibrosis

141
Q

Liver cirrhosis histology

A
  • Loss of normal architecture
  • Bridging fibrosis
  • Nodular regeneration
142
Q

Common Liver cirrhosis causes

A

ALD
NAFLD
Hep B
Hep C

143
Q

Features of compensated cirrhosis changing into decompensated cirrhosis

A

Jaundice
Ascites
Hepatic encephalopathy
Variceal haemorrhage

144
Q

Compenated liver cirrhosis

A

Liver can still function effectively and there is few clinical sx

  • weight loss
  • fatigue
  • weakness
145
Q

Cirrhosis diagnosis

A

Liver biopsy

NAFLD - enhanced liver fibrosis test

146
Q

What does decreased oestrogen lead to

A

Spider naveia

palmar erythema

147
Q

Portal HTN causes

  • pre
  • intra
  • post
A
  • Thrombosis (portal/splenic vein)
  • Cirrhosis
    Sarcoidosis
    PB Cirhhosis
  • RHF
    Constricitve pericarditis
    IVC obstruction
148
Q

Oesophageal varices rupture

A

Thin vessels that cannot withstand high pressure blood flow so rupture

rupture –> Haematemesis
rupture –> blood digested –> melaena

149
Q

Varices investigations

A

Upper GI endoscopy

150
Q

Varices tx

A 
Medical:
- Beta blocker - decrease CO
- Telipressin 
   ADH analogue 
vasoconstricition + slows bleeding

Surgical:

  • elastic band ligation
  • Transjugular intrahepatic portosystemic shunt (TIPSS)
151
Q

Gallstones RF

A

Fat
Female
Forty
Fertile

152
Q

Gallstone complications

A

Acute cholecystisis
-cystic duct

Biliary obstruction
- CBD

Gallstone pancreatitis
- Ampulls of Vater

153
Q

Biliary colic

A

Temp obstruction of cystic duct or CBD by stone

154
Q

Biliary colic presentation

A
  • recurrent episodes of sever abdo pain
  • pain subsides after few hours
  • Pain radiates –> back/R.shoulder
  • Pain follows fatty meal
  • Vomitting
155
Q

Biliary colic investigations

A
  • US shows gallstones
  • LFTs
  • Increase serum ALP
  • Increase bilirubin
  • Absence of inflamm features
156
Q

Acute cholecystisis

A

Inflamm of gallbladder

- Gallstone obstruction of CD or bile duct neck

157
Q

cholecystisis presentation

A
  • RUQ pain –> referred to R.shoulder
  • fever
  • nausea
  • vomitting
  • Murphy’s sign
    2 fingers on inferior boarder of liver
    pt inspires –> pain
  • Only +ve if no pain in LUQ
158
Q

Cholecystisis investigations

A
  • Bloods:
    Increase WCC
    Increase CRP
  • Abdo USS
    Thickened wall + shrunken GB
  • LFTs
159
Q

Cholecystisis tx

A
  • Laproscopic cholecystectomy
  • Analgesia
  • Fluids
  • Abx - Cefotaxime
160
Q

Ascending cholangitis defenition

A

Infection of biliary tree as stone is stuck in CBD

- Choledocholithiasis

161
Q

Ascending cholangitis aetiology

A
  • secondary to CBD obstruction

- Cncer of pancreatic head

162
Q

Ascending cholangitis common pathogens

A
  • E.coli
  • Klebsiells
  • Enterococcus (Group D step)
163
Q

Ascending cholangitis presentation

A 
- Charcots triad 
Fever/RUQ pain/ Jaundice 
- Pruritus 
- Dark urine 
-Pale stools
164
Q

Ascending cholangitis investigations

A
  • USS abdomen –> Dilated CBD
  • MRCP –> locate stone
  • Bloods: LFTs/ FBC
  • Blood culture
165
Q

MRCP

A

Magnetic resonance cholangio-pancreatography

- detailed image of biliary tree via MRI

166
Q

ERCP

A

Endoscopic retrograde cholangio-pancreatography

- endoscope to sphincter of Oddi

167
Q

Ascending cholangitis

A
  • ERCP
  • IV Abx
  • Cefotaxime + Metronidazole
168
Q

Primary sclerosing cholangitis defenition

A

Inflammation and fibrosis of intra and extra hepatic bile ducts leading to cirrhosis

169
Q

PSC assosciations

A

Ulcerative colitis

170
Q

PSC auto-antibodies

A

Anti-neutophilic cytoplasmic Ab (ANCA)

171
Q

PSC presentation

A

pruritus
jaundice
cholangitis
RUQ pain

172
Q

PSC investigations

A
  • MRCP
    *beaded apperance of ducts
  • Liver biopsy
    *Onion skin fibrosis around ducts
  • Bloods:
    LFTs - Raised ALP
173
Q

PSC tx

A
  • Manage CLD complications
  • transplant
  • Extrahepatic strictures may be fixed by ERCP
  • High dose ursodeoxycholic acid may slow down disease progression
174
Q

PSC - Complications

A
  • Increase risk of CRC
  • Cirrhosis
  • Cholangiocarcinoma
175
Q

Primary billiary cirrhosis

A

AI granulomatous inflammation destroying intrahepatic bile ducts

176
Q

PBC presentation

A

fatigue
pruritus
cholestatic labs

177
Q

PBC associations

A

Other AI disorders

  • SLE
  • RA
178
Q

PBC complications

A

Cirrhosis

179
Q

PBC autoantibodies

A

Anti-mitochondrial Ab (AMA) - Ab against subunit of pyruvate dehydrogenase kinase

180
Q

PSC and PBC gender prefernces

A

PSC - Males

PBC - Females

181
Q

What is acute gastritis + presentation

A
  • Inflammation of the stomach

- N +V

182
Q

What is enteritis + presentation

A
  • Inflammation of intestines

- Diarrhoea

183
Q

Viral gastroenteritis causes

A

Rotovirus

  • Vaccine available (12wks)
  • Affects children

Norovirus

  • All age groups
  • Endemic

Adenovirus
- less common and presents with subactute diarrhoea

184
Q

Gastroenteritis investigations + required individuals

A
  • Rutine stool samples for M&C for ova and parasites (3 seperate samples)
  • Stool testing for C.diff
Immunouppressed
IBD
Bloody diarrhoea 
persistent diarrhoea
severe sx
recent Abx tx/hospitalisation
185
Q

Management of acute diarrhoea

A
  • Hydration + electrolytes
  • Loperamide
  • Abx to pts with severe sx
186
Q

Name assosciated pathogen

  • Pets
  • small children
  • seafood
  • reheated rice
A
  • campylobacter
  • Rotovirus
  • Staph
  • Bacillus cereus
187
Q

Pregnancy main bacterial worry from food + tx

A

Listeriosis - non pasteurasied soft cheese

  • Increased risk of miscarraige/ premature delivery/ newborn infection
  • Ampicillin
188
Q

Travellers diarrhoea

  • common causes
  • diagnosis
  • presentation
  • tx
A
  • campylobacter jejuni
  • 3 unformed stools per day after recent travel
  • abdo pain
    cramps
    nausea
    dysentry
  • hydration
189
Q

E.coli - gastroenteritis

A
  • Shiga toxin production
    cramps
    bloody diarrhoea
    vomitting

Haemolytic uraemic syndrome - RBC destruction (Avoid Abx)

190
Q

Campylobacterjejuni - gastroenteritis

  • spread by:
  • sx
  • tx
A
  • raw poultry
  • cramps
    bloody diarrhoea
    vomitting
    fever
  • Azithromycin/Ciprofloxacin
191
Q

Shigella - gastroenteritis

  • sx
  • tx
A

Shiga toxin

  • bloody diarrhoea
  • cramps
  • fever
  • HUS

Azithromycin/Ciprofloxacin

192
Q

Clostridium difficile

  • bacteria
  • ingestion
  • RF
A
  • Gram +ve spore forming bacteria
  • faecal-oral route
  • Elderly
    Abx
    PPI
    Long hosp admissions
    Immnocompromised
193
Q

C.diff causative abx

A 
rule of c
Clindamycin
Ciprofloxacin
Co-amoxiclav
cephalosporins
194
Q

C.diff presentation

A

abdo pain
water diarrhoea - possibly bloody too
fever

195
Q

C.diff complications

A

Pseudomembranous colitis

Toxic megacolon + perforation–> multi organ failure

196
Q

Pseudomembranous colitis presentation

A

Yellow adherent plaques on inflammed non-ulcerated mucosa

197
Q

C.diff tx

A
  • Isolate pt to prevent cross-infection
  • stop offending Abx
  • Metronidazole
    Vancomycin
198
Q

C.diff investigations

A
  • Toxin A+B in stool samples
  • Bloods:
    Raised CRP and WCC
199
Q

Where does pancreatic adenocarcinoma arise from

A

Ductal epithelium

200
Q

Pancreatic Adenocarcinoma point mutation

A

KRAS2 gene

201
Q

Pancreatic adenocarcinoma presentation

A
  • Abdo pain
  • Painless obstructive jaundice
  • weight loss
  • Steatorrhoea
  • Pale stools (lack of bile)
  • Dark urine (o.jaundice)
  • mass in epigastric region
202
Q

Pancreatic adenocarcinoma signs

A 
- Courvoiser's law 
painless jaundice + a non tender palpable gallbladder is pancreatic until proven otherwise 
- Hepatomegaly
-Ascites 
- Epigastric mass
203
Q

Pancreatic adenocarcinoma DD

A 
Peptic ulcer
Gallstones 
Chronic pancreatitis 
Cholangitis
Cholecystisis
204
Q

Pancreatic adenocarcinoma investigations

A
  • Biopsy
  • US
    dialated bile ducts + lesion
  • Bloods
    increase lipase + amylase
  • CA19-9 Tumour marker
205
Q

Pancreatic adenocarcinoma tx

A

Pancreatoduodenoctomy

  • Whipple
  • Tumour of pancreas head
206
Q

HCC risk factors

A
  • Cirrhosis
    NAFLD
    AFLD
    Hep B + C

Screen for HCC every 6m

207
Q

Mets from HCC

A

Lungs
Bones
Lymph nodes

208
Q

Primary liver cancer

A

HCC

Cholangiocarcinoma

209
Q

HCC presentation

A 
weight loss
abdo pain 
N + V
Jaundice 
pruritus 
decreased appetitie
fatigue
210
Q

HCC investigations

A
  • alpha fetoprotein
  • Liver US
  • CT/MRI
  • Biopsy under US guidance to confirm (ERCP)
211
Q

Cholangiocarcinoma defenition

A

Cancer of biliary tree

212
Q

Cholangiocarcinoma assosciations

A
  • Biliary cysts

- PSC

213
Q

HCC management

A
  • Surgical resection
  • Radiofrequency ablation
  • Transarterial chemoembolisation therapy
  • chemotherapy
214
Q

Cholangiocarcinoma presentation

A
  • painless jaundice
  • fever
  • abdo pain
  • ascites
  • malaise

signs:

  • periumbilical lymphadenopathy (sister-mary jospeh nodes)
  • Supraclavicualr adenopathy (virchows node)
215
Q

Cholangiocarcinoma investigations

A
  • CA19-9 tumour marker
  • US/CT
    Bile duct stricitre
216
Q

Cholangiocarcinoma tx

A
  • surgical resection
  • ERCP –> stent
    • where cancer is obstructing the duct
  • chemo + radio resistant
217
Q

Benign hepatic tumours

A

Haemangiomas

Hepatic adenoma

218
Q

Hepatic adenoma assosciations

A

oral contraceptive pill
Anabolic steroids
pregnancy

219
Q

Hepatic adenoma tx

A

Surgical resection

- only for sx pts with tumours > 5cm

220
Q

C.diff tx

A

Metronidazole + vancomycin

Phase 2a (11 decks)

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