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Phase 2A > Liver & friends / GU Exam deck > Flashcards

Liver & friends / GU Exam deck Flashcards

1
Q

What is an AKI?

A

Sudden decline in renal function over hours or days

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2
Q

Risk factors for AKI?

A

age > 65, cognitive impair

CKD, nephrotoxic meds e.g. NSAIDs & ACE inhibitors

liver disease, diabetes

contrast medium in scans

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3
Q

General present - AKI?

A

Dehydration
dry mucuous membranes, reduced skin turgor & urine output
thirst, (orthostatic) hypotension,

and the other way - fluid overload
ankle swell, paro noc dyspnoea, raised JVP, ascites

Renal - as per UC

Post renal - loin to groin pain, haematuria, nausea vom // LUTS

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4
Q

Key criteria to classify stages of AKI?

A

KDIGO criteria

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5
Q

Stage 1 of KDIGO criteria?

A

Serum creatinine
> 26.5
= 1.5-1.9x baseline

Urine output
< 0.5ml/kg/hr for 6-12 hours

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6
Q

Stage 2 of KDIGO criteria?

A

Serum creatinine
> 2.0 - 2.9 baseline

Urine output
< 0.5 ml/kg/hr
for ≥ 12 hours

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7
Q

Stage 3 of KDIGO ceriteria?

A

Serum creatinine
≥ 353.6 or
≥ 3 x reference or on RRT

Urine output
< 0.3 ml/kg/hr for ≥ 24 hours
anuria for ≥ 12 hours

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8
Q

Name 3 pre-renal causes of AKI?

A

= most common!
= secondary to inadequately low blood supply to kidneys

dehydration

hypotension

heart failure

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9
Q

Name 3 renal causes of AKI?

A

intrinsic disease = reduced filtration of blood

Renal artery stenosis / thrombosis

glomerulonephritis
interstitial nephritis

acute tubular necrosis

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10
Q

Name 3 post renal causes of AKI?

A

= due to obstruction to outflow of urine from kidney

kidney stones

masses - cancer in abdo or pelvis

ureter or uretral strictures
prostate cancer

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11
Q

Investigations for AKI?

A

Urinalysis
(dipstick / microscope / osmo & electro)
leukocytes & nitrites = infect
protein & blood = acute nephritis
glucose = diabetes

Ultrasound
of uri tract to look for obstruction

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12
Q

Management principles AKI?

A

Volume dysregulation (as per need)

Regulate electrolytes
severe hyperkalaemia !!!
metabolic acidosis !!!

Stop nephrotoxic drugs
ACEi, NSAIDs, Spironolactone

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13
Q

How might you treat a severe hyperkalaemia?

A

= > 6.5 or 7 mmol/L

Myocardial protection
10 ml 10% calcium gluconate

Reduce extracell potassium
drive into cells
= Insulin (ACTRAPID) & dextrose
= beta agonists (neb salbutamol)

Additional
stop / adjust potassium sparing / containing meds

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14
Q

List complications of AKI?

A
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15
Q

Chronic kidney disease - what is it?

A

Presence of kidney damage / reduced kidney function for ≥ 3 months

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16
Q

Features of CKD?

A

Reduced GFR
< 60 ml / min = G3a - G5

Increased ACR
> 3 mg / mmol = A2-3

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17
Q

KDIGO staging for GFR?

A

G1 = > 90
G2 60-89
G3a 45-59
G3b 30-44
G4 15-29
G5 <15

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18
Q

KDIGO staging for ACR?

A
  • *A1** < 3
  • *A2** 3-30
  • *A3** > 30
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19
Q

Risk factors for CKD?

A

DM, hypertension nephropathies glomerulopathies

inherited kidney disorders → PCKD

ischaemic nephropathy

obstructive uropathy / tubular diseases

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20
Q

Symptoms of CKD?

A

generally asymptomatic in earlier
non specific later

watch albumin:urea & radio abnormalities - e.g. abdominal masses, polycystic kidneys

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21
Q

Investigations fo CKD?

A

urine
ACR can be spot test or 24 hour collection! order both!

bloods
specifically - LFT, UE

imaging
renal ultrasound, ECG

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22
Q

Management for CKD?

A

TUC, slow progress

Renoprotective therapy = BP control for everyone!
→ if ACR ≤ 30 (A1-2), follow NICE
→ if proteinuria = ARB / ACEi

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23
Q

When should you offer a renin-angiotensin system antagonist to patients of CKD?

A

= one of is enough not fulfill all

Diabetic and ACR ≥ 3 mg / mmol

Hypertension and ACR > 30 mg / mmol

ACR > 70 mg / mmol

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24
Q

Complications of CKD?

A

Anaemia
= normocytic, usually multifacorial but can be EPO deficient

Hyperkalaemia & acidosis

Mineral & bone disorders

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25
Q

Indicators for & types of renal replacement therapy?

A

Haemodialysis / peritoneal dialysis & renal transplant

= end stage renal disease

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26
Q

What is ADPKD?

A

Autosomal dominant polycystic kidney disease

= common genetic disorder characterised by multiple renal cysts

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27
Q

Genes & chromosomes for autosomal dominant PKD? What does it mean by autosomal dominant?

A 
PKD1 = chromo 16\*\*
PKD2 = chromo 4

auto dom = only single gene needed to express phenotypes (clinical features of disease)

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28
Q

Risk of PKD / Associated?

(very important!)

A

Hepatic cysts

Cerebral aneurysms

Renal family history
→ ADPKD, ESRF, hypertension, CKD

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29
Q

PKD Diagnostic criteria related to age?

A

15-39 y/o ≥ 3 cysts (uni / bilateral)

40-59 y/o ≥ 2 cysts (each kidney)

60 years ≥ 4 cysts (each kidney)

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30
Q

Pathophysio of PKD?

A

PKD’s encode for polycystin, responsible for sensing flow (allow Ca2+ influx) in tubule

mutation = no sense,
= uncontrolled cell division & water transport into lumen of cyst → larger

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31
Q

Complications of ADPKD?

A

→ cysts in other parts of the body (as polycystin also in other pt of bod)
= liver, seminal vesicles, pancreas, diverticular, ovarian
= vasculature!!
→ aortic root dilate = heart failure
→ cerebral aneurysms = berry = subarach haemorr

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32
Q

Presentation ADPKD?

A

Hypertension!

Increase in size of kidneys
loin pain / discomfort
bilateral kidney enlargement
palpable

Complication of cysts
excessive water / salt loss (swing)
urinary stasis → kidney stones
haematuria ± rupture
renal insufficiency → renal failure

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33
Q

Diagnostic tests for ADPKD?

A

Ultrasound

Genetic testing for PKD 1 & 2
(but large gene & many so not preferred ??)
(only if atypical onset, prenatal, no fam hx)

(cannot exclude if < 30 years)

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34
Q

Genes & chromosomes for ARPKD?

A

PKHD1 mutation on chromo 6

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35
Q

Presentation for ARPKD

A

Infancy!

Renal failure before birth
oligohydramios = lack of aminotic urine
→ clubbed feet, flattened nose
→ pulmonary hypoplasia = resp insufficiency

Multiple renal cysts & congenital hepatitic fibrosis

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36
Q

Diagnosis for ARPKD

A

Prenatal ultrasound
bilateral large kidneys
cysts
oligohydramnios

Neonatal ultrasound
cysts

CT / MRI to monitor liver disease

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37
Q

Complications ARPKD?

A

Congenital Hepatic fibrosis
Portal hypertension
eso varices, UGB, haemorrhoids, splenomegaly

Dilated ducts
= cholestasis & ascending cholangitis

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38
Q

Treatment for PKD? How would you monitor disease progression?

A

= none that has shown to slow progression :<
monitor by serum creatinine

BP control → ACEi

  • *Treat stones & analgesia**
  • *Laparoscopic removal** (cyst or nephrectomy) for pain relief
  • *Renal replacement**
  • *Relative screening in 20’s**
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39
Q

Nephrolithiasis - what are they?

A

Solutes in urine precipitate out and crystallise

→ when urine is too concentrated (supersaturation) → precipitate out of solution

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40
Q

3 locations at which you may find deposited kidney stones?

A
  • pelviureteric junction **
  • pelvic brim
  • vesicoureteric junction
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41
Q

Risk factors & epidemiology - kidney stones?

A

peak 20 - 40 years, males

dehydration, infection

Drugs - diuretics, antacids, corticosteroids, aspirin, allopurinol

primary renal disease, gout, fam hx

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42
Q

Most common type of kidney stones?

A

Calcium oxalate

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43
Q

How might you differentiate between the two types of calcium kidney stones

A

Calcium oxalate → acidic urine
= black / dark brown

Calcium phosphate → alkaline urine
= dirty white

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44
Q

Risk for calcium stones?

A

Hypercalcemia / hypercalciuria

increased GI absorption

endocrine = primary hyperparathyroidism

impaired renal tubular reabsorption (leave behind lots)

if oxalate = renal impairment, diet heavy in oxalate = rhubarb, spinach, choco, nuts & beer)

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45
Q

Only type of kidney stones which will not show up on x ray (& other features)?

A

Uric acid stones!
= reddish-brown in colour
= radiolucent

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46
Q

Risk factors for uric acid stones?

A

dehydration

Purine - rich diet
= shellfish, anchovies, red / organ meat

Gout

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47
Q

Struvite stones - features & association?

A
  • *Staghorn** = branch into renal calyces
  • *dirty white, radiopaque**

associated with UTI** **infections
= mixed composition from organism breaking urea using urease

Mg, ammonium, phosphate

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48
Q

Risk factors of struvite stones?

A

UTI = main

vesicoureteral reflux

obstructive uropathies

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49
Q

Stone with excessive urinary excretion (& its other features)?

A

Cystine stones
cause = cystinuria, auto recess affecting cysteine in GI tract

= yellow or light pink stones, radiopaque on x ray

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50
Q

Presentation of kidney stones?

A

Dull or localised flank pain
in mid - lower back

Renal colic
= excruciating sharp, constant pain
= cannot sleep / lie still
= dilation, stretching & spasm of ureter

Nausea & vomiting

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51
Q

Investigations for kidney stones?

A

Urine dipstick & specimen
haematuria - visible = 85% !!

1st line = Kidney, ureter, bladder x ray (KUBXR)

GOLD = Non-contrast Computerised Tomography (NCCT-KUB) = DIAGNOSTIC
CI is probably radiation?

Non acute can use ultrasound

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52
Q

Medical treatment for kidney stones?

A

Hydration

  • *Medications**
  • pain: strong analgesic = IV diclofenac
  • *stop stone form**: potassium citrate, sodium bicarbonate
  • *promote expulsion**: alpha blockers = tamsulosin, CCB = nifedipine
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53
Q

Surgical treatment for kidney stones? Size for natural passing?

A

stones < 5mm in lower will 90% pass spontaneously

Extracorporeal shockwave lithotripsy = ultrasound fragments stone

Endoscopy with YAG = laser for large stones

Percutaneous nephrolithotomy PCNL = keyhole to remove

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54
Q

Prostate cancer - aetiology - genes responsible etc?

A

Genes
= HOXB13 predispose
= BRCA2 = 5-7 higher risk

age, black. fam hx
increased testosterone

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55
Q

Prostate cancer - Type & area arise

A

Adenocarcinomas

Peripheral prostate

Androgen receptors on prostate responsible for cancerous growth

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56
Q

How might prostate cancer spread?

A

Local → seminal vesicle, bladder & rectum

Via lymph

Haematologically - bone

less common to brain, liver & lung

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57
Q

Presentation for prostate cancer?

A

LUTs if local disease

Weight loss, bone pain & anaemia = mets

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58
Q

DRE exam for prostate cancer vs for BPH?

A

Prostate cancer - hard & lumpy

BPH - large, smooth & firm

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59
Q

Investigations for prostate cancer?

A

DRE

Raised PSA
if mets = > 16ng/ml

DIAGNOSTIC = trans-rectal ultrasound & biopsy
essential to have histological diag, gleason score used

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60
Q

What’s the PSA &

A

Prostate specific antigen
produce by prostate, in normal & neoplastic tissue

Unreliable testing bc
small BMI, taller, recent ejaculate, black african, UTI

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61
Q

Treatment for prostate cancer?

A

Radical prostatectomy
radio / hormone therapy

if mets
Endocrine therapu = androgen deprivation
→ LHRH agonist
SC goserelin / leuprorelin
→ Androgen receptor blockers

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62
Q

Testicular cancer - 2 types & risk factors?

A

96% from germ cells

  • *seminoma** = 25-40 yrs & 6- yrs
  • *teratomas** = infancy

risks
undescended testis, infant hernia, infertility, family history

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63
Q

Testicular cancer - serum tumour markers?

A
  • *Alpha-Fetoprotein (AFP) &**
  • *B-hCG**

raised in teratomas (infant)
B-hCG in seminomas (adult)

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64
Q

Diagnosis & tx - testicular cancer?

A

Ultrasound

radiotherapy / orchidectomy / chemo
sperm storage

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65
Q

Renal cell carcinoma - type & spread?

A

Proximal convoluted tubular epithelium

Spread may be direct = renal vein, via lymph or haematogenous (bone, liver, lung)

25% mets at prez

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66
Q

Renal cell carcinoma - complications?

A

Varicocele

Hypertension!
renin secreted by tumour

Fever

Anaemia, polycythaemia

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67
Q

Risk factors for renal cell carcinoma?

A

male, > 50 years, Czech

obesity hypertension smoking

renal failure, polycystic kidneys

Von Hippel Lindau

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68
Q

What is Von Hippel Lindau syndrome?

A

auto dom,
mutation of chromo 3

loss of both copies of tumour suppressor gene

50% develop RCC = bilateral, multifocal

renal and pancreatic cysts + cerebella malignancy

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69
Q

Diagnosis & tx of renal cell carcinoma?

A

Ultrasound
distinguish simple cyst from complex / tumour

CT with contrast = sensitive

MRI = staging

if local = surgery, alt = radiotherapy
if mets = IL2 & interferon alpha

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70
Q

Transitional cell carcinoma?

A

= cell type in epithelium which lines calyx, renal pelvis, ureter, bladder & urethra

bladder-c is the most common tcc!!

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71
Q

Bladder cancer - cell type & spread? ;)

A

Transitional cell carcinoma

Spread
local → pelvic structures
lymphatic → iliac & para aortic nodes
haematogenous → liver & lungs

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72
Q

Bladder cancer - risk & present?

A

Occupational carcinogen exposure
benzidine, azo dyes, beta-napthylamine
petreoleum, chemical, cable & rubber industries

chronic UTIs & painless haematuria esp >40

drugs - cyclophosphamide

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73
Q

Bladder cancer - investigate & treat?

A

DIAGNOSTIC

  • *cytoscopy with biopsy**
  • *CT urogram**

tumour markers
other imaging

GOLD = Radical cystectomy
post op = chemo = m-trexate, vinblastine
radio if cannot surgery

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74
Q

1st line BPH treatment - class of med? name? mechanism? SE? CI?

A

Alpha 1 antagonist = oral tamsulosin

relax smooth muscle = increase flow rate, decrease obstructive symptoms

SE drowsy dizzy depression
ejaculatory failure, nasal congestion

CI postural hypotension!

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75
Q

Alt BPH treatment - class? name? mechanism? SE?

A

5-alpha reductase inhibitor = oral finasteride

blocks conversion of testosterone → dihydrotestosterone

use when very larger prostate

SE impotence, decreased libido

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76
Q

Gold standard treatment for BPH? Criteria?

A

Transurethral resection of prostate (TURP)

  • if no response to meds
  • if uri retention, recurrent gross haematuria, renal insuff etc

alt = change resection to incision

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77
Q

5 primary causative organisms of UTI? (mneumonic)

A

KEEPS

Klebsiella spp.

E coli

Enterococci

Proteus spp.

Staphylococcus spp.

78
Q

Cystitis in uncomplicated females

1st line tx?
2nd line tx?

A

1st = Nitrofuratoin / Trimethoprim
3 days

2nd = Nitro / Pivmecillinam / fosfomycin

79
Q

Cystitis in pregnant women

symptomatic - tx?

A

send for urine culture & use appropriate antibiotic

1st line - nitrofuratoin - avoid near term

2nd - cefalexin
amoxicillin if appropriate for culture

80
Q

Cystitis in pregnant women

asymptomatic - tx?

A
  • *urine culture**
  • one should have been done at first antenatal visit
  • one after tx

meds

immediate nitrofuratoin (avoid near term) / amoxicillin / cefalexin for 7 days

→ prevent progression to pyelonephritis

81
Q

Cystitis in men

tx?

A

1st line = trimethoprim or nitrofurantoin

No improve - think pyelonephritis / prostatitis

82
Q

Urethritis - nature of disease & tx?

A

Sexually acquired, common in men

DIAGNOSTIC = Nuclear acid amplification test
vaginal swab / first void volume

treat as per gonorrhoea / chlamydia

83
Q

Chlamydia tx?

A

Oral azithromycin stat
OR 1 week oral doxycycline

if preg
oral erythromycin 14d
oral azithromycin stat

patient education
contact tracing

84
Q

Gonorrhea tx?

A

IM ceftriaxone with oral azithromycin

partner notification
patient education
contact tracing

85
Q

Free card

A
86
Q

Main pancreatic enzymes? Produced by which cell type?

A

Amylase

Trypsin / chymotrypsin

Lipase

→ Pancreatic acinar cells

87
Q

Endocrine component of the pancreas? Cell types?

A

Alpha cell = glucagon

Beta cell = insulin

D cell = somatostatin

PP cells = pancreatic polypeptide

Enterochromaffin cells = serotonin

88
Q

Pancreatitis - pathophysiology?

A

Trypsin & chymotrypsin gets suddenly activated within the pancreas

= autodigestion of pancreas

→ inflammation & haemorrhaging

(normally need to be activated by enteropeptidase in duodenum)

89
Q

Which pancreatic enzymes are secreted in their active forms & don’t need activation by trypsin?

A

Lipase & amylase

90
Q

Causes of acute pancreatitis?

A

I - idiopathic

G - gallstones
E - Ethanol
T - trauma

S - scorpion stings
M - mumps
A - autoimmune (SLE, RA)
S - steroids
H - hypertriglyceridemia / hypercalcemia
E - ERCP
D - drugs
steroids, alcohol, valproic acid, azathioprine, diuretics

endoscopic retrograde cholangiopancreatography

91
Q

Causes of chronic pancreatitis?

A

similar to acute

gallstones
slow growing tumour

long term alcohol use

autoimmune conditions
cystic fibrosis

hypertriglyceridemia / hypercalcemia

92
Q

Symptoms of acute pancreatitis?

A

Epigastric pain that radiates to the back
→ eased by bending forward

Nausea & vomiting

Cullen sign & grey turner sign

severe: low bowel sounds / hypovolemic shock from liquid → 3rd space

93
Q

Symptoms of chronic pancreatitis?

A

can be asymptomatic for a long time

epigastric pan → back

! exocrine & endocrine insufficiency !
= not enough insulin & other enzymes
→ px as fat malabsorption
= steatorrhea, fat soluble vitamin deficiency (A / D /E), diabetes, unintentional weight loss

94
Q

Differentiate between acute vs chronic pancreatitis?

A

Acute = sudden abundance of enzymes

Chronic = lack of enzymes

95
Q

Diagnostic criteria for acute pancreatitis?

A

2 of 3

acute epigastric pain → back

serum amylase or lipase levels
3x of normal

characteristic imaging findings

96
Q

Imaging findings for acute pancreatitis?

A

usually ultrasound
Enlarged pancreas & hypoechoic
maybe - gallstone pancreatitis

if unsure = abdominal CT w/contrast
pancreatic necrosis, inflammation & retroperitoneal fluid

97
Q

Which other condition could also raise serum amylase? How would you rule it out?

A

gastroduodenal perforation

use erect CXR!

98
Q

Diagnostic features for chronic pancreatitis?

A

If tumour
bilirubin & alk phosphate +
= compression of duct

GOLD = 72 hour stool collection
for fat malabsorption

transabdominal ultrasound & CT scan = calcification of pancreas
also - ductal dilation, enlarge, fluid around

99
Q

Pancreatic scoring systems - one to assess severity and one to predict severe attack?

A

APACHE II = severity
as early as 24 hrs after onset

Glasgow & Ranson = prognostic
predicts severe attack
only used 48hrs after onset

100
Q

Treatment for acute pancreatitis?

A

Nil by mouth
Nasogastric tube w/ dietary supplements

Analgesia
IM pethidine / IV morphine !!!

Prophylactic antibiotics
beta lactams - cefuroxime / metronidazole to reduce risk of infected panc necrosis

Urinary catheter
drain of collections if needed

101
Q

Treatment for chronic pancreatitis?

A

Lifestyle modifications
alcohol cessation, small non-fatty meals, lots of water

Supplementary pancreatic enzymes w/ PPI (help pass stomach)

Stomach pain = NSAIDs / opiates / TCA

TUC - gallstones, duct drainage, diabetes

102
Q

Liver function tests on blood

What is a hepatic pattern? Causes?

A

raised transaminases = ALT & AST

= acute hepatitis = viral, immune, alcohol

103
Q

Liver function tests on blood

What is a cholestatic pattern? Causes?

A

raised ALP & GGT

= biliary stasis or obstruction
= PSC, PBC, gallstone disease

104
Q

What is primary biliary cholangitis?

A

autoimmune disease where T cells attack cells that line smaller bile ducts in liver → leakage of bile into blood and outside

105
Q

Risk for PBC?

A

Women a lot more!!
> 50, median 65 yo

Genetic disposition = autoimmune diseases
→ autoimmune hepatitis, Sjogren’s syndrome

106
Q

Antibodies associated with PBC?

A

Anti-mitochondrial antibodies AMA
= molecular mimicry
= non specific tho

in some: anti-gp210 & anti-sp100

107
Q

If no tumour - cases of PBC?

A

= Secondary biliary cholangitis

→ tumour obstructing bile ducts

108
Q

PBC symptoms?

A 
**_hallmark = pruritus, fatigue_**
pruritus = bile salts in skin

RUQ pain

hepatomegaly

xanthomas / jaundice / chronic liver disease

109
Q

Investigations for PBC?

A

bloods = AMA 95%
bile in blood

LFT = raised ALP & GGT

if abnormal: 1st line = ultrasound
maybe biopsy - lymphocyte infiltrate, some have granulomas

110
Q

Treatment for PBC?

A 
1st = ursodeoxycholic acid UDCA
2nd = obeticholic acid OCA

for pruritus - colestyramine / naloxone (opioid)

GOLD = liver transplant

111
Q

Complications for PBC?

A

cholesterol → xanthomas
when deposit in skin

joint pain & arthropathy

end = chronic liver disease & cirrhosis

112
Q

What is primary sclerosing cholangitis?

A

immune mediated (T) fibrosis and inflammation of the bile duct epithelial cells

113
Q

Risk factors for PSC?

A

men

autoimmune association = IBD!
both UC & crohn’s

Genetics - p-ANCA!! 80%
perinuclear anti-neutrophil cytoplasmic antibody

elevated IgM

114
Q

Presentation for PSC?

A

Charcot’s triad for cholangitis
fever
RUQ pain
jaundice

Others
fatigue / hepatomegaly (from bilirubin!) / cirrhosis

115
Q

Blood & urine results for PSC?

A

raised ALP & GGT
= enzymes in liver cells!

bilirubinuria, no urobilinogen!
bile flow obstructed

116
Q

Diagnostic investigation for PSC? What will it show?

A

Endoscopic retrograde cholangiopancreatography ERCP

Shows

  • *beaded apperance of the bile ducts** = bile duct strictures / dilatation
    others: hepatic fibrosis, cholestasis
117
Q

Treatment for PSC?

A

No effective meds
= liver transplant :<

118
Q

Complications of PSC?

A

Portal hypertension & cirrhosis

Cholangiocarcinoma
if suspected = Ca 19.9 = marker

119
Q

Treatment for ascending cholangitis?

A

IV antibiotics - cefotaxime / metronidazole → symptom resolve

Urgent ERCP - biliary drainage with sphincterectomy
→ remove stone, stent palcement
→ surgery for larger ones

120
Q

Composition of bile?

A

Water, bile salts, bilirubin & fats + cholesterol

121
Q

Function of gallbladder?

A

Stores bile produced by the liver

122
Q

Name the bile ducts

  • in the liver (individual & joined)
  • in the gallbladder
  • liver + gallbladder?
  • pancreas?
A

Liver
R & L hepatic → common hepatic

Gallbladder = cystic duct

Common hepatic + cystic = common bile duct

Pancreas = pancreatic duct

123
Q

What is cholelithiasis?

A

= gall stones

(lol)

124
Q

Types of gallstones?

A

Cholesterol gallstones = 80%

Pigment gallstones

Mixed gallstones

125
Q

Risk factors for formation of cholesterol gallstones

A

females, age >40, overweight

DM, high cholesterol diet

pregnancy (reduced gallbladder motility)

126
Q

When do cholesterol stones form?

A

due to imbalance of bile
→ excess cholesterol

from cholesterol crystalisation

127
Q

Risk factors for the formation of bile pigment stones?

A

Haemolysis = main
liver cirrhosis, sickle cell anaemia

128
Q

When would pigment gallstones form? Composition?

A

imbalance of bile
→ too much bilirubin (main or calcium)

If biliary stasis / infection = brown
calcium bicarb, fatty acids etc

If blood disorder = black
calcium bilirubinate

129
Q

What is biliary colic?

A

= constant pain associated with stone obstructing bile ducts

after fatty meals, n+v
may radiate over shoulder

= gallbladder contract against stones = compress cystic duct

130
Q

What is cholecystitis?

A

Bacteria infecting an obstructed gallbladder

→ obstruction in cystic duct
= prevents gallbladder emptying

131
Q

Presentation - acute cholecystitis?

A

basically obstruction + inflammatory component

RUQ pain + tenderness & guarding

+ Vomiting, fever and local peritonitis + raised WBC!

Murphy’s sign = gallbladder pain on deep breath

= NO jaundice

132
Q

Differentiate biliary colic, cholecystitis & cholangitis?

A

(see pic)

133
Q

Investigations - acute cholecystitis

A

Bloods
raised WBC & CRP → inflammation
raised serum bilirubin, ALP & ALT

Abdominal ultrasound = best for stones
thick walled, shrunken gallbladder
pericholecystic fluid
stones

134
Q

Treatment for acute cholecystitis

A

Nil by mouth, IV fluids
Opiate analgesia

Antibiotics = Cefuroxime / ceftriaxone
→ bac = KEE

Laparoscopic cholecystectomy (remove) after a few days

135
Q

What is ascending cholangitis? Does it affect the pancreas? or the liver?

A

= infection of obstructed common bile duct

→ liver bile cannot be excreted!

→ pancreatic fluid can still flow unobstructed :>

136
Q

Presentation - ascending cholangitis?

A

Charcot’s triad for cholangitis
RUQ pain, deranged LFT (jaundice), fever - usually with rigors

dark urine, pale stools, itch

[rigors = shivering at high fever & chills]

137
Q

Investigation & results for ascending cholangitis?

A

Bloods
+ neutrophil, ESR & CRP
+ bilirubin = bile duct obstruction
ALT > AST

Imaging
transabdominal ultrasound = 1st
→ dilatation of duct, ± obstruction
→ can miss distal cbd stones

Magnetic resonance cholangiography (MRC) = diagnostic (?)

138
Q

General treatment for gallstones?

A

for pure cholesterol stones → increase bile salt content of bile

= oral ursodeoxycholic acid UDCA

Statins to lower cholesterol

Shock wave lithotripsy → shatter

139
Q

Gallstone complications?

A

Biliary colic / acute cholecystitis

Empyema → gb filled with pus

  • *carcinoma**
  • *Mirizzi’s syndrome** - stone in gb presses on bile duct casing jaundice

Obstructive jaundice / cholangitis / pancreatitis

140
Q

Liver cards

A
141
Q

Physiology of alcoholic liver disease?

A

= liver cell damage

TNF-alpha release by Kupffer cells
Acetaldehyde
decrease NADH/NAD ratio

142
Q

What is alcoholic hepatitis?

A

Infiltration by polymorphonuclear leucocyte & hepatocyte necrosis

  • *→ Mallory bodies in hepatocytes**
  • *→ Giant mitonchondria**
143
Q

What is alcoholic fatty liver?

A

cells swollen with fat → steatosis
reversible!

no cell damage

stellate cells → collagen producing myofibroblast cells

144
Q

Complications of alcoholic liver disease?

A

Liver cirrhosis

Wernicke’s encephalopathy

145
Q

Drug to treat alcohol withdrawal?

A

Chlordiazepoxide (benzodiazepine)
→ esp if seizures / other symptoms

146
Q

What is Wernicke’s encephalopathy? Presentation & prevention?

A

ataxia, confusion & nystagmus (uncontrolled repeated eye mvt)

= from alcohol withdrawal, 6-24hrs after last drink & lasts for a week

→ prevention = IV thiamine
→ tx = Thiamine + proper nutrition & fluids

147
Q

What is cirrhosis?

A

= irreversible liver damage

→ fibrosis = activation of stellate cells & Kupffer cells (tissue macrophages)

148
Q

Types of liver cirrhosis?

A

Micronodular
= <3mm, uniform involvement of liver
→ alcohol / biliary tract disease

Macronodular
= varying size
→ chronic viral hepatitis

149
Q

Presentation - liver cirrhosis?

A

Hands
Leuconychia - white discolouration on nails
clubbing
palmar erythema
Dupuytren’s contracture - lump at base of fingers

Others
xanthelasma = yellow fat deposits under skin usually around eyelid
loss of body hair
hepatomegaly
ascites, oedema, bruising

150
Q

How might you classify liver cirrhosis?

A

Child Pugh score
< 7 best
> 8 = risk of variceal bleeding
> 10 bad prognosis

predict mortality & need for liver transplant

151
Q

Investigations of liver cirrhosis?

A

GOLD = liver biopsy
ultrasound / CT / MRI / Endoscopy

ALSO serum albumin & prothrombin time = best indicators of liver function (low & long = bad)

raised AST, ALT & creatinine
low Na+

152
Q

Indicator for hepatocellular carcinoma?

A

Alpha-fetoprotein!

153
Q

Treatment of liver cirrhosis?

A

Hep A & B vaccine

Reduce salt intake, alcohol abstinate

ultrasound every 6 months → hepatocellular carcinoma

avoid NSAID / aspirin

154
Q

Drugs which may induce liver injury?

A

Antibiotics = main 30-40
flucloxacillin, TB drugs, erythromycin

CNS drugs
chiropromazine, carbamazepine

Analgesic - (just) Diclofenac

Immunosuppressant, GI drugs - PPI

155
Q

Tx paracetamol overdose?

A

Activated charcoal

IV N-acetylcysteine

if rash = chlorphenamine

156
Q

Aspirin overdose - features?

A

Respiratory alkalosis → hyper/o glycaemia

then early non specific warning features

157
Q

Tx aspirin overdose?

A

Fluid & electrolyte replace - esp potassium

if severe metabolic acidosis = IV sodium bicarbonate

158
Q

What is hereditary haemochromatosis?

A

Inherited disorder of iron metabolism = increased absorption

deposit into organs → fibrosis & organ failure

159
Q

Genetics - hereditary haemochromatosis?

A

HFE gene mutation on chromosome 6
= auto recessive = most common

can also be auto dom

160
Q

Other causes / differentials of hereditary haemochromatosis?

A

high intake of iron & chelating agents (ascorbic acid)

alcoholics

161
Q

Present - hereditary haemochromatosis?

A

Men, middle aged

triad: bronze skin, hepatomegaly, DM

tiredness & arthralgia

Hypogonadism ± pituitary dysfunction → slate grey skin pigment, oedema

cardiac manifestations common (dilated cardiomyopathy)

(menstruation = protective)

162
Q

Diagnosis of HH is based on?

A

Raised serum iron & ferritin → genetic testing

liver biochem often normal!
ECG / ECHO if needed

163
Q

Tx - Hereditary Haemochromatosis?

A

Venesection - 3-4x / year
alt = chelation therapy = desferrioxamine

Testosteone replacement

Diet low in iron = tea coffe, red wine
First degree relative screen

164
Q

What is Wilson’s disease?

A

Rare inherited disorder of biliary copper excretion
→ too much in liver & CNS

165
Q

Genetical nature of Wilson’s disease?

A

Autosomal recessive

Gene on chromosome 13

166
Q

Risk of Wilson’s disease?

A

Marrying first degree relatives (consanguinity)

Caucasians

family history

167
Q

Presentation - Wilson’s disease?

A

Children = hepatic issues
hepatitis, cirrhosis, liver failure

Young adults = CNS → dementia

reduced memory

Kayser-Fleischer ring
copper deposition in cornea, greenish-brown pigment in corneoscleral junction

168
Q

Tx Wilson’s disease?

A

Avoid food high in copper
liver, choco, nuts, mushrooms, shellfish (think brown!)

Lifelong chelating agent = penicillamine
SE rash, haematuria, renal, pancytopenia

Liver transplant if severe disease
Screen siblings

169
Q

What s alpha-1-antitrypsin deficiency?

A

inherited auto recessive condition where neutrophil** **elastase is not inhibited

= lung (empyema) & liver (cirrhosis & hepatocellular carcinoma) affected

170
Q

Presentation a-1a deficiency?

A

children = liver
cirrhosis, hepatitis, cholestatic jaundice

adults = respiratory
emphysema

171
Q

Diag & tx - a-1a deficiency?

A

Serum aloha 1 antitrypsin LOW

no tx - symptom management & liver transplant only

172
Q

Liver failure - what is it?

A

When liver loses the ability to regenerate / repair → decompensation

173
Q

Features of acute hepatic failure?

A

Acute liver injury

+ encephalopathy

bleeding / deranged coagulation (INR > 1.5)

ascites / jaundice

→ in patient with previously normal liver

174
Q

Histological presentation of hepatic failure?

A

Multiacinar necrosis involving a substantial part of liver

175
Q

How might you reduce intracranial pressure?

A

IV mannitol

176
Q

Hepatocellular carcinoma HCC - risk factors>

A

Males, Chinese

HBV & HCV carriers

alcoholic cirrhosis, non alcoholic fatty liver disease & haemochromatosis

177
Q

Where & how can a hepatocellular carcinoma spread

A

via hepatic / portal veins

→ lymph nodes, bones & lungs

178
Q

Tx - hepatocellular carcinoma?

A

Surgical resection of lesion

Cure = liver transplant

→ Prevent HBV infection

179
Q

Cholangiocarcinoma - what is it? Risk?

A

cancer of the biliary tree

risk
parasitic worm infestation
biliary cysts
IBS! UC & Crohn’s

180
Q

Tx cholangiocarcinoma?

A

Crap prognosis = 6 months

Liver transplant contraindicated

surgical rarely possible

181
Q

Highest incidental sources for a secondary liver met?

A

= acc most common liver tumour

GI tract (portal veins)

breast

lung

182
Q

Pancreatic adenocarcinoma - risk factors & incidences?

A

Males, > 60 years

smoking, alcohol

excess aspirin!

Diabetes, chronic pancreatitis

  • *PRSS-1 mutation**
  • *fam hx**
183
Q

Incidental pancreatic tumours by region/

A

60% pancreatic head

25% body

15% tail

184
Q

How might head of pancreas adenocarcinoma present?

A

painless obstructive jaundice - pale stools, dark urine
+ weight loss

185
Q

How might body & tail of pancreas adenocarcinoma present?

A

Epigastric pain radiating to the back and relieved by sitting forward

186
Q

How might you diagnose pancreatic adenocarcinoma?

A

Abdominal CT!!

(contrast to ultrasound = others)

187
Q

Tx & prognostic, pancreatic adenocarcinoma?

A

5 year survival = 3%

Pancreato-duodectomy if fit & no mets + post op chemo

Palliative care

188
Q

What is Gilbert syndrome?

A

Autosomal recessive disorder

= abnormal bilirubin processing in liver

189
Q

Pathophysio of Gilbert?

A

Genetic defect → dysfunctional UGT enzyme which conjugates bilirubin

= recurrent episodes of unconjugated hyperbilirubinaemia + jaundice
precipitated by stressful events

190
Q

What is Crigler-Najjar syndrome

A

autosomal recessive

= severe mutations in same gene as Gilbert = lack of UGT

= daily phototherapy / phenobarbital

191
Q

Clinical features of Gilbert syndrome?

A

Asymptomatic until stressful event / illness

Jaundice → sclera!!
+ non specific symptoms

Events can be
fasting, haemolysis, physical exertion, stress, menses

192
Q

Diagnosis & management - Gilbert syndrom?

A

Blood test = LFT = rise in unconjugated bilirubin
*** exclude haemolysis = FBC + reticulocyte count + film ***

no specific tx, patient education

Phase 2A (12 decks)

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