Finals revision > Hepatobiliary > Flashcards

Hepatobiliary Flashcards

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1
Q

What is hepatitis and when is it classed as chronic?

A

Inflammation of the liver
Chronic = >6m

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2
Q

What is the criteria for acute hepatitis?

A

Prothrombin time ↑ 4-6s (or INR 1.5)
Hepatic encephalopathy
Without pre-existing cirrhosis
Illness <6m

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3
Q

What are signs/symptoms of hepatic encephalopathy?

A

Confusion
Mood changes
Asterixis (liver flap)
Insomnia/hypersomnia
Reduced GCS/Coma

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4
Q

What are the classifications of causes of acute hepatitis?

A

Infection
Drugs
Autoimmune
Metabolic
Alcohol

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5
Q

Which infections cause acute hepatitis?

A

Hepatitis ABCDE
EBV
CMV
TB

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6
Q

Which drugs cause acute hepatitis?

A

Paracetamol
MTX
Nitrofurantoin
Chlorpromazine
Flucloxacillin
OCP
Isoniazid
Co-amoziclav

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7
Q

Which autoimmune conditions can cause acute hepatits (3)?

A

Autoimmune hepatitis
Primary biliary cholangitis
Primary sclerosing cholangitis

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8
Q

Which metabolic conditions can cause acute hepatitis (3)?

A

Wilson’s
Haemochromatosis
Alpha-1antitrypsin deficiency

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9
Q

What are causes of chronic hepatitis?

A

Alcohol
NAFLD
Hepatitis B/C
Chronic drug use
autoimmune
Metabolic

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10
Q

Presentation of acute hepatitis?

A

Anorexia
Nausea
Vomiting
RUQ pain
+/- systemic sx

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11
Q

Presentation of chronic hepatitis?

A

Anorexia, fatigue, weight loss
Abnormal clotting - bruising/↑INR
Hyperaldosteronism - feminisation, ↑BP, ↓K+
Portal hypertension - hepatosplenomegaly, spider naevi, ascites
Encephalopathy - drowsy/confused

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12
Q

What are features of decompensated cirrhosis in chronic hepatitis (3)?

A

Jaundice
Ascites
Encephalopathy

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13
Q

Risk factors for viral hepatitis?

A

Blood transfusion
IVDU
Tattoos
Unprotected sex
Travel

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14
Q

Investigations for hepatitis? (acute or chronic)

A

Liver screen
Toxin screen
Albumin, clotting, PT, bilirubin
Alpha fetoprotein
USS
Liver biopsy

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15
Q

What is included in a liver screen?

A

FBC
LFTs
U&Es
Viral serology
Cureloplasmin
Transferritin/ferritin
Autoantibodies

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16
Q

When is liver biopsy contraindicated?

A

Clotting disorder
Profound anaemia
Marked ascites
Subphrenic infection

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17
Q

How are different hepatitis viruses transmitted?

A

A - faecal-oral
B - blood/bodily fluid
C - blood
D - blood/bodily fluid (always with B)
E - faecal-oral

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18
Q

Is viral hepatitis RNA or DNA virus?

A

All RNA viruses except B (DNA)

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19
Q

How does viral hepatitis present (7)?

A

Abdominal pain
Fatigue
Flu-like illness
Pruritus
Muscle/joint aches
N+V
Jaundice

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20
Q

Which LFTs rise in viral hepatitis?

A

ALT/AST

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21
Q

How is hepatitis A treated and is there a vaccine available?

A

Supportive management
Vaccine - yes

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22
Q

Who should have the hepatitis A vaccine?

A

Chronic liver disease
Haemophilia
MSM
IVDU
Occupational risk

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23
Q

How is hepatitis B treated and is there a vaccine available?

A

Antivirals/supportive management
Vaccine - yes

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24
Q

How many people become chronic hep B carriers?

A

5-15%
Most recover in 1-3 months

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25
Who should have the hepatitis B vaccine?
Now routine for children in the UK Occuptational risk Levels needed to check response
26
How is hepatitis C treated and is there a vaccine available?
Direct acting antivirals NO vaccine available
27
Without treatment, what percentage of people with the disease will develop chronic hepatitis C?
75%
28
What are the possible complications of hepatitis C (2)?
Liver cirrhosis Hepatocellular carcinoma
29
Which virus is hepatitis D co-infective with? is there a vaccine?
Hepatitis B No vaccine
30
How is hepatitis E treated and is there a vaccine available?
Supportive management No vaccine available
31
When is HBcAB IgM raised?
In acute infection
32
When is HBcAB IgG raised?
In chronic infection (and after cleared infection)
33
When is HBsAg raised?
During acute and chronic infection
34
When is anti-HBs raised?
In vaccination and past cleared infection
35
How to differentiate between past hepatitis B infection and hep B vaccination?
In vaccination only anti-HBs is raised In past infx, anti-HBs **and** HBcAb IgG is raised
36
What is liver cirrhosis?
Irreversible damage to liver cells due to chronic inflammation
37
What are the stages of liver disease?
Inflammation > fibrosis > cirrhosis > failure
38
Most common causes of liver cirrhosis?
Alcoholic liver disease NAFLD Hepatitis B/C
39
What are some examination findings in liver cirrhosis?
Jaundice Hepatomegaly Splenomegaly Ascites Palmar erythema Gynaecomastia Bruising Spider naevi Caput medusa Cachexia Leukonychia Asterixis
40
Which investigations can be carried out for liver cirrhosis (5)?
USS Enhanced liver fibrosis score (NAFLD) Transient elastography Endoscopy CT/MRI
41
Which scoring system assesses the severity of liver cirrhosis and what parameters are included in it (5)?
Child-Pugh score A – Albumin B – Bilirubin C – Clotting (INR) D – Dilation (ascites) E – Encephalopathy Score of 1-3 for each factor
42
What score should be used biannually in those with liver cirrhosis?
MELD score Model for End-stage Liver Disease Gives estimated 3-month mortality percentage
43
Management for liver cirrhosis?
Address underlying cause - alcohol/diet Assess for complications - ca, varices Manage complications - anaemia, clotting, varices, ascites Regular review and MELD score Liver transplant
44
What is portal hypertension?
Fibrosis/cirrhosis causes ↑pressure in hepatic portal vein > causes backpressure on system Results in: Splenomegaly Swollen and tortuous vessels at sites where collaterals form
45
Which signs/symptoms are a result of portal hypertension?
Oesophageal varices Caput medusae (abdomen)
46
What is ascites?
Fluid in the peritoneal cavity
47
Why does ascites occur in liver cirrhosis?
Increased pressure in portal system > causes fluid to leak out of capillaries
48
How is ascites managed?
Reduce dietary sodium Diuretics (spironolactone) Drainage TIPS (transjugular intrahepatic portosystemic shunt) Prophylactic antibiotics (if <15g/litre)
49
What is prophylactic treatment for oesophageal varices?
1st - Non-selective beta-blockers (propranolol) 2nd - Variceal band ligation
50
How should bleeding oesophageal varices be managed?
A-E management Correct clotting - FPP Give terlipressin (vasoconstriction) Prophylactic abx Urgent endoscopy and band ligation Consider intubation and intensive care
51
What is a TIPS procedure?
Transjugular intrahepatic portosystemic shunt Connection between portal vein and hepatic vein = relieve pressure
52
What is hepatorenal syndrome?
Impaired kidney function caused by changes in the blood flow to the kidneys due liver cirrhosis/portal hypertension.
53
What causes hepatic encephalopathy?
Build up of neurotoxins which affect the brain - ammonia
54
Which triggers can worsen hepatic encephalopathy (6)?
Constipation Dehydration Electrolyte disturbanec Infection GI bleeding High protein diet
55
How is hepatic encephalopathy managed?
Lactulose Antibiotics Nutritional support
56
How do lactulose and antibiotics help hepatic encephalopathy?
Reduce the ammonia produced by intestinal bacteria Lactulose: Clear ammonia before aborbed Lowers pH (kill bacteria producing it) Antibiotics: Reduce number of bacteria producing ammonia
57
What is the causes of palmar erythema in liver disease?
Elevated oestrogen levels (usually metabolised by liver)
58
What is the cause of leukonychia in liver disease?
Hypoalbuminaemia
59
What is the most appropriate investigation for monitoring response to treatment in hepatitis C?
Viral load
60
What findings on an ascitic tap would suggest spontaneous bacterial peritonitis?
WCC >250 and predominantly neutrophils
61
What is serum ascites albumin gradient (SAAG) and what is considered low/high?
Helps to determine the cause of ascites High >11g/L Low <11g/L
62
What does high SAAG score suggest?
That ascites is due to portal hypertension. Raised hydrostatic pressure forces water into peritoneal cavity but albumin stays inside vessels (=higher gradient)
63
What are some causes of high SAAG ascites (5)?
Cirrhosis Heart failure Budd Chiari syndrome Constrictive pericarditis Hepatic failure
64
What are the 4 grades of hepatic encephalopathy?
Grade I: Irritability Grade II: Confusion, inappropriate behaviour Grade III: Incoherent, restless Grade IV: Coma
65
What are the criteria for paracetamol induced liver failure (4)?
Arterial pH <7.3 24h after ingestion OR Pro-thrombin time >100s AND creatinine >300µmol/L AND grade III or IV encephalopathy
66
What are the criteria for non-paracetamol induced liver failure?
Prothrombin time >100s OR Any three of: Drug-induced liver failure Age under 10 or over 40 years 1 week from 1st jaundice to encephalopathy Prothrombin time >50s Bilirubin >300µmol/L
67
Acute pancreatitis can cause which electrolyte disturbance?
Hypocalcaemia
68
Raised ALT/AST are an indicator of what kind of liver damage?
Hepatocellular injuty/parenchymal disease
69
What is the classical liver enzyme derangement in alcoholic liver disease?
AST:ALT ratio ≥ 2:1 (AST twice as high as ALT)
70
An isolated elevated ALP is indicative of what?
Bone disease e.g. Paget's
71
What may elevated ALP and elevated GGT together indicate?
Bile duct obstruction/cholestasis
72
What is an isolated elevated GGT associated with?
Alcohol excess
73
Which type of bilirubin is raised in pre/intra/post-hepatic jaundice?
Unconjugated = pre-hepatic Conjugated = intra/post-hepatic
74
Most common cause of cholecystitis?
Gallstone in neck of gallbladder
75
Clinical presenting features of cholecystitis?
RUQ pain - may radiate to right shoulder Fever Murphy's sign +ve N+V
76
What do LFTs usually show in acute cholecystitis?
Usually normal
77
Investigations in suspected cholecystitis?
USS MRCP if biliary tree needed in more detail
78
Management options for acute cholecystitis?
Conservative = NBM, fluids, abx, ERCP to remove stone Cholecystectomy
79
When is cholecystectomy performed following acute cholecystitis?
NICE recommend early within 1 week (some cases 6-8w to allow inflammation to settle)
80
What causes biliary colic?
Gallstones in biliary tree
81
Risk factors for gallstones?
4 Fs Fat Female Fertile Forty
82
Presenting features of biliary colic?
Colicky RUQ pain Worse after fatty foods May radiate > right shoulder N+V common No fever
83
Management of gallstones/recurrent biliary colic?
Cholecystectomy
84
What is cholangiocarcinoma?
Bile duct cancer
85
Main risk factor for cholangiocarcinoma?
Primary sclerosing cholangitis
86
Features of cholangiocarcinoma?
Persistent biliary colic Jaundice Weight loss Mass in RUQ Periumbilical lymphadenopathy
87
Which blood test may be raised in cholangiocarcinoma?
CA 19-9
88
Risk factors for hepatocellular carcinoma?
Liver cirrhosis Hep B/C Haemochromatosis
89
Features of hepatocellular carcinoma?
Fx of liver cirrhosis: Jaundice Ascites RUQ pain Hepatomegaly Splenomegaly Pruritis Tends to present late
90
Which blood test may be raised in hepatocellular carcinoma?
AFP
91
Management of hepatocellular carcinoma?
Surgical resection Liver transplant Radiofrequency ablation
92
Investigations in suspected pancreatic cancer?
High resolution CT
93
What may imaging show in pancreatic cancer?
Double duct sign (dilatation of common bile and pancreatic ducts)
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