Liver Tumours + Benign + Genetic Disease + Acute GI bleed Flashcards
(79 cards)
1
Q
What is most common tumour in liver
A
Metastases from lung breast/ GI
Primary = cholangiocarcinoma / HCC
Hepatoblastoma / sarcoma = very rare
2
Q
What are symptoms of liver mets
A
Fever Weight loss RUQ pain due to stretch Jaundice late except cholangiocarcinoma Hepatomegaly CLD signs Decompensated if CKD Intraperitoneal haemorrhage if rupture
3
Q
How do you investigate mets
A
FBC, LFT, hepatitis serology, AFP USS or CT MRI to distinguish benign / malignanct ERCP for cholangiocarcinoma Liver biopsy Find primary
4
Q
How do you treat mets
A
Chemo
Resection
Radiofrequency ablation
Prognosis <6 months
5
Q
What is carcinoid syndrome
A
Release of serotonin due to lung or liver mets (from GI)
6
Q
What are symptoms of carcinoid syndrome
A
Abdo pain FLushing Palpitations DIarrhoea - proceeds Dx by 2 years Bronchospasm / wheeze Hypotension R valve stenosis and triscupid insufficiency ACTH / GnRH = CUshing's
7
Q
What is the Ddx for carcinoid
A
Phaeochromocytoma
8
Q
How do you Dx and treat carcinoid
A
Urinary 5-HIAA Somatostatin analogue (octeoride)
9
Q
What causes HCC
A
Cirrhosis - secondary to any cause HBV= most common HVC Autoimmune NAFLD AIH Steroid / drugs Alpha 1 anti-trypsin deficiency
10
Q
What are the symptoms of HCC
A
Cirrhosis + mass on screening Fatigue Anorexia Weight loss RUQ pain Jaundice Ascites HSM Pruritus Haemorrhage Decompensated CKD
11
Q
How do you Dx HCC
A
AFP + USS for surveillance if cirrhotic
CT / MRI
AVOID biopsy as risk of seeding
Examine testis as AFP raised in testicular tumour
12
Q
How do you treat HCC
A
early disease: surgical resection
liver transplantation
radiofrequency ablation
transarterial chemoembolisation
sorafenib: a multikinase inhibitor
13
Q
What is Wilson’s disease
A
Excess deposition of copper in the liver
Autosomal recessive
Onset usually between 10-25
14
Q
What are symotoms in children
A
LIver hepatitis / cirrhosis / failure
15
Q
How do adults with Wilsons present
A
CNS Signs Basal ganglia degeneration Tremor, dysarthria, dysphagia, dementia, Parkinsonism, ataxia Speech and behaviour Chorea - jerky
Other Dark ring round eyes due to copper Blue nails Astrexis - liver flap Altered mood - depresion / libido / mania / psychosis Fatigue Renal tubular acidosis Haemolysis Memory
16
Q
How do you Dx Wilson
A
Urine copper excretion increased Serum copper decreased Cereoplasmin decreased LFT Genetic test to confirm
17
Q
How do you treat Wilson’s
A
DIet
Penicillamine - chelator= 1st line
Liver transplant
18
Q
What is most common liver disease in children
A
Anti-trypsin deficiency
More likely to cause emphysema in adult
19
Q
What are signs of A1 anti-trypsin deficiency
A
SOB
CIrrhosis
Cholestatic jaudnice
20
Q
How do you Dx A1
A
A1AT level
Obstructive lung disease on spirometry
Liver biopsy
Dx pre-natal
21
Q
How do you treat A1AT deficienct
A
Smoking cessation
Liver transplant if decompensate
Lung transplat
22
Q
What is haemochromotosis
A
AR
Increased iron absorption whcih deposited in joints / liver / heart / pancreas / pituitary / adrenal and skin
23
Q
What are symtpoms
A
Fatigue Arthralgia Decreased libido and erectile dysfunction Bronzed skin DM Hypogonadism CLD / hepatomegaly / cirrhosis Dilated cardiomyopathy
24
Q
What are the reversible symptoms
A
Cardiomyopathy
Skin - pigmentation
25
What are irreversible
Cirrhosis
DM
Hypogonadism
Arthropathy
26
How do you Dx
```
Increased LFT, transferrin sat and ferritin - do these if any abnormal
Transferrin = most accurate >50%
Low total iron binding capacity
HFE genotype
MRI / liver biopsy to make Dx
Joint X-Ray for arthralgia
```
27
How do you treat
Venesection for life
Monitor LFT and glucose
HCC if cirrhotic
Iron chelation if can't do venesection (desoferoxiamine)
28
What is the chance of inheriting haemochromatosis if one parent affects
0% as AR
29
What are common causes of liver access
S.Aureus in children
| E.coli in adults
30
What are the symptoms of absces
```
RUQ pain
Fever
N+V
Rigors
Reduced E+D
Jaundice
Sepsis
```
31
What puts you at high risk of abscess
Biliary sepsis
32
How do you Dx abscess
USS
| CT
33
How do you treat
IV Ax
Amox + cipro + met
Percutaneous needle drainage - don't delay
Surgery if fails to resolve
34
What are benign liver tumour
Liver haemangioma - hyperchoiec USS
| Liver cell adenoma - linked to OCP
35
What is hydatid liver cyst
Caused by tapeworm
Common in the liver and lung
Type 1 hypersensiitivy
36
What are the symptoms of hydatid
```
RUQ pain
Unwell
Jaundice
Colic
Urticarial lesion
```
37
How do you Dx
CT
| Differentiate from amoebiasis
38
How do you treat
Surgery
39
What causes amoebiasis
Entamoeba Histolytica
40
What are the symptoms of amoebiasis
```
Mild diarrhoea - severe
Liver and colonic abscess
Bloody diarrhoea
Single mass filled with anchovy puss
Fever
Jaundice
RUQ pain
```
41
How do you Dx
Serology +Ve
42
How do you Rx
Metronidazole
| Amoebicide for cyst carriage
43
What are the symptoms of upper GI bleed [5]
| Sign of upper GI bleed [1]
Collapse, shock
Haematemesis - bright red or coffee
Malena
Epigastric discomfort, dyspepsia, reflux
NSAID use
Signs: increased urea but normal renal function
44
What causes upper GI
Esophageal [4]
Gastric [4]
Duodenum [3]
Esophageal:
- Esophagitis, cancer, Mallory Weiss Tear, varices
Gastric:
- Cancer, Dieulafoy lesion, Diffuse erosive gastritis, gastric ulcer
Duodenum:
- Duodenal ulcer
- Periampullary tumor
- Aortoenteric fistula
45
What puts you at increase risk of bleed [6]
```
Age
Co-morbid
Inpatient
NSAID
Aspirin
Liver disease
```
46
What imaging and tests in acute setting [3]
CXR / AXR
ECG
ABG
47
What anaemia is suggestive of bleed [2]
Iron deficiency
| DO ENDOSCOPY
48
What other imaging [4]
Balloon / MR enteroscopy - small bowel
CT angiogram
Meckelscan
CT CAP
49
What scoring systems are used in risk assessment for upper GI bleeding? [2]
Blatchford score at first assessment
| Full Rockall score done after endoscopy
50
What score suggest admission / endoscopy
>6
| Consider early discharge if 0
51
What does blatchford score take into account [8]
Sex
Urea
Hb
SBP
Hepatic / cardiac failure
Tachycardia
Malaena
Syncope
52
What does Rockall look at [7]
How is this score interpreted?
Pre-endoscopy scoring:
Age
Shock, tachy+1, hypotension +2
Comorbidity
Complete Rockall score - estimates mortality in patients with active upper GI bleed who have had endoscopy:
- Age, shock, comorbidity
- Diagnosis: Mallory Weiss tear, no lesion identified, upper GI malignancy
- Major stigmata of recent haemorrhage e.g., blood, adherent clot, visible spurting vessel
Final Rockall score (Maximum score: 11): <3 good prognosis; >8 poor.
53
How do you manage all upper GI bleed [6]
Keep head down
A - protect airway
B - high flow O2
C - 2 large bore cannula, IV fluids, blood, FBC, U+E, LFT, cross-match 6U, coag, transfusion
D - catheter / fluid restrict
E - NBM, glucose, urea levels
54
When do you transfuse [4]
o Red cells: Hb<10
o Platelets: actively bleeding and platelets 50x109/L
o FFP: actively bleeding, INR or APTT x1.5 ULN; if fibrinogen level remains <1.5g/L despite this, use cryoprecipitate as well
o Prothrombin complex concentrate: on warfarin and actively bleeding
55
Maintenance after resuscitation for Upper GI bleed [5]
- maintenance fluids
- catheter
- consider CV line
- correct any coagulopathy
- PABRINEX if alcoholic
56
Subsequent mx when stable?
Varices medical management [2]
Erosive esophagitis [4]
Varices: TERLIPRESSIN and prophylactic CIPROFLOXACIN before endoscopy
Erosive esophagitis or gastritis: PPI
- ADRENALINE injection + thermal coagulation/fibrin glue/ endoclips
57
Definitive treatment of varices [3]
- Endoscopic mx: banding for esophageal, sclerotherapy for gastric
Endoscopy if Blatchford >6
Immediate if severe
Or within 24 hours of admission
- Active bleeding: Sengaksten-Blakemore tube (gastric balloon inflated first then oesophageal balloon second and balloon deflated within next 12h to prevent necrosis
- TIPSS if can't be stopped endoscopically
58
What do you give after endoscopy as prophylaxis [2]
BB
| Band ligation and PPI continuous infusion until eradicated
59
Angiodysplasia
Ep
Ax
Sx
Ix [4]
Mx [2]
Ep: elderly
Ax: submucosal AV malformations
Sy/Si: fresh PR bleeding
Ix:
- FBC
- colonoscopy (excl. other causes)
- Tc radionuclide labelled red cell imaging during active bleeding to identify lesions (if >1mL/min)
- CT or mesenteric angiography
Mx:
- mesenteric angiography with therapeutic embolization during bleeding
- endoscopic laser argon photocoagulation or resection
60
What does terlipressin do [2]
Vasoconstriction of splanchnic blood supply
| Reduce portal tension
61
What investigations in rectal bleed [6]
QFIT
FBC, U+E, LFT, ferritin
Coeliac
CRP
Calprotectin
DRE
62
What are more common causes of rectal bleed [6]
Diverticulitis: large vol, dark blood
Malignancy
Haemorrhoids: fresh blood
IBD
Angiodysplasia: R colon
Gastroenteritis
63
What are rare causes [6]
Trauma
Ischameic colitis
Radiation proctitis
Aorta enteric fistula following AAA repair
Meckels
64
What are symptoms of lower GI bleed [3]
Magenta stool, brighter if L colon
Normal urea
Collapse
65
How do you investigate lower GI bleed [4]
DRE
Colonoscopy
Bloods
Angiogram if patient unstable to identify bleeding
66
What bloods for lower GI bleed?
FBC, U+E, LFT, Ca, TFT
Clotting
Amylase
CRP
Group and save
Stool MC+S
Coeliac
Calprotectin
QFIT
67
What imaging
AXR if sign of sepsis / peritonitis
68
Immediate mx lower GI bleed [7]
```
ABCDE
Proctoscopy
Insert 2 cannula
Catheter
Crystalloid resus
Blood transfusion
Ax if sepsis / perforation
```
69
Can you put bleeding down to haemorrhoids
Not without internal inspection as can be impalpable
70
What artery affected in lower GI bleeds?
Gastroduodenal
71
When should you consider admission [4]
>60
Co-morbid
Haemodynamically unstable
Aspirin / NSAID use
72
What does tips do
connect hepatic and portal vein
| reduce portal hypertension
73
Why do you do U+E
Colonoscopy require lots of laxatives before
74
Why is ferritin useful
Drops before Hb
75
For upper GI bleeding, when is surgery indicated? [4]
- >60y/o
- continued bleeding despite endoscopic intervention
- recurrent bleeding
- known CV disease with poor response to hypotension
76
Surgical mx for duodenal ulcer
laparotomy, duodenotomy (longitudinal (NOT transverse) to avoid stenosis) and under running of ulcer where large bites using 0 Vicryl taken above and below ulcer base to occlude vessel
77
Surgical mx for gastric ulcer [2]
Antral ulcer
Lesser curve ulcer involving left gastric artery
Bleeding persists
laparotomy, gastrostomy and underrunning of bleeding site
Antral ulcer: partial gastrectomy
Lesser curve ulcer (involving left gastric artery): partial gastrectomy or under running of ulcer
Bleeding persists: total gastrectomy
78
Subsequent mx of lower GI bleed
Hemorrhoidal bleeding
Haemodynamically stable/unstable
o Haemorrhoidal bleeding: proctosigmoidoscopy
o Haemodynamically stable: elective colonoscopy
o Haemodynamic instability:
- CT or percutaneous angiography to identify patch of angiodysplasia
+/- coiling (or surgery if unavailable)
79
Mx of lower GI bleed if vessel is identified
| What to do if there is an unidentified source of bleeding? [3]
o Selective mesenteric embolization: if identified vessel
| o Unidentified colonic source of bleeding: laparotomy, on table colonic lavage and attempt resection
