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HPB Flashcards

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1
Q

What are the screening questionnaires for alcohol consumption?

A

CAGE

AUDIT

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2
Q

What are the signs of alcoholic liver disease?

A 
Jaundice + scleral jaundice
Palmar erythema
Hepatomegaly
Spider naevi
Caput medusa
Flapping tremor (asterixis)
Ascites
Gynaecomastia
Unexplained bruising
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3
Q

How is alcoholic liver disease diagnosed?

A

Careful history taking and examination
LFTs: Raised AST/ALT, normal/mild raised ALP, raised gamma gt, low albumin, raised bilirubin
Clotting: prolonged PT
USS abdo: may show enlarged/fatty liver in acute inflammation or small, sclerotic liver
CT abdomen
Liver biopsy

OGD can be done to look for varices

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4
Q

What is the management of alcoholic liver disease?

A
  1. Stop drinking / detox programme
  2. Calorie and nutrition support- incl thiamine
  3. Consider suitability for transplant
  4. Symptomatic treatment
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5
Q

What are the stages of alcohol withdrawal?

A
  1. 6-12 hrs: tremors, sweating, headache, cravings and anxiety
  2. 12-24 hrs: hallucinations and tactile disturbance - characteristically insects crawling
  3. 24-48hrs: seizures
  4. 48-36 hrs: delirium tremens
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6
Q

What is delirium tremens?

A

Alcohol withdrawal syndrome - 48-36hr into withdrawal
Downregulation of GABA, up regulation of glutamate -> brain excitability and adrenergic overactivity

Sx: confusion, agitation, delusions and hallucinations
tremor, ataxia, tachycardia, hyperthermia, arrhythmia

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7
Q

What classification system is used in alcohol withdrawal?

A

CIWA-AR tool

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8
Q

How should you manage acute alcohol withdrawal?

A

Benzodiazepine e.g. chlordiazepoxide (librium) titrated regimen
Thiamine: IV pabrinex followed by oral thiamine
Manage any seizures/other symptoms

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9
Q

What are the 3 features of Wernicke’s encephalopathy?

A

Confusion
Ataxia
Occulomotor disturbance

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10
Q

What are the three features of Korsakoff’s syndrome?

A
  1. Amnesia- anterograde and retrograde
  2. Confabulation
  3. Behavioural change: lack of insight, apathy
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11
Q

What are the causes of liver cirrhosis?

A

Common:

  1. Alcoholic liver disease
  2. Non-alcoholic steatohepatitis
  3. Chronic viral hepatitis
  4. Drug causes

Less common

  1. a1-antitripsin deficiency
  2. Wilson’s disease
  3. Haemochromatosis
  4. Primary biliary cirrhosis
  5. Autoimmune hepatitis
  6. Cystic fibrosis
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12
Q

Which drugs most commonly cause liver cirrhosis?

A
  1. Methotrexate
  2. Amiodarone
  3. Sodium valproate
  4. Chemotherapy agents

TPN is also associated with liver injury and fibrosis.

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13
Q

What are the signs of liver cirrhosis?

A 
Palmar erythema
Asterixis 
Jaundice
Spider naevi, caput medusa
Ascites and oedema
Bruising and bleeding
Pale stool and dark urine
Splenomegaly
Gynaecomastia
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14
Q

What investigations should be done in liver cirrhosis?

A
  1. LFTs: raised AST/ALT, raised ALP, low albumin, high bilirubin, ?gamma gt
  2. Coagulation: prolong PT
  3. AFP: marker for HCC
  4. U&E: can cause deranged urea and creatinine, hyponatraemia due to dilution
  5. Hepatitis viral screen and autoantibody testing
  6. USS abdomen and Fibroscan
  7. CT scan and biopsy
  8. Endoscopy looking for varies

Enhanced liver fibrosis blood test= new test, not available in all centres

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15
Q

What are the scoring systems for liver cirrhosis?

A

Child-Pugh score - indicated severity

MELD score- done 6 monthly in those with compensated cirrhosis to estimate mortality and need for transplant

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16
Q

How should patients with liver cirrhosis be managed?

A

Avoid alcohol!

  1. Vitamin and nutrition replacement - high protein, low sodium, vitamin supplements
  2. Coagulopathy management
  3. Diuretics for ascites
  4. BP control for hepatorenal syndrome
  5. Consideration for transplant
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17
Q

What are the complications of cirrhosis?

A 
Ascites + SBP
Portal hypertension
Varices + variceal bleeding
Hepatorenal syndrome
Encephalopathy
Bleeding/bruising
Malnutrition
HCC
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18
Q

What is the blood marker for HCC?

A

AFP

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19
Q

How are stable varices managed?

A
  1. Stop drinking if alcohol-related / abstain either way
  2. Propranolol to reduce BP
  3. Elective banding procedure
  4. TIPS procedure
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20
Q

How are unstable varices managed?

A

A-E
Bloods: FBC, U&E, LFT, CRP, coagulation, group and save
Resuscitation if necessary
Correct any coagulopathy
IV terlipressin + IV Abx
if stable enough for endoscopy- endoscopic banding
Sengstaken-Blakemore tube / balloon tamponade in less stable patients

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21
Q

How does ascites form?

A

Less albumin produced by the liver -> lower osmotic pull of the bloodstream
Fluid loss into extracellular space
Reduced blood volume -> reduced renal perfusion -> activation of RAAS
Fluid and sodium retention

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22
Q

How should ascites be managed?

A
  1. Low sodium diet
  2. Spironolactone
  3. Ascitic tap / drain
    - > Sample should always be sent for analysis
    - > for every litre of fluid drained, a certain amount of albumin should be given to the patient to prevent immediate recurrence.
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23
Q

What are the most common organisms causing SBP?

A

Ecoli
Klebsiella
Gram positive cocci

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24
Q

What are the symptoms of SBP?

A 
May be asymptomatic
Ascites
Abdominal pain
Fever
Sepsis
Ileus
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25
How is SBP diagnosed?
Record all vital signs Bloods: FBC, CRP, U&E, LFT, coagulation Ascitic tap: send for MC&S, pH, glucose, protein, LDH Full infection work-up
26
How is SBP managed?
IV antibiotics - usually cefotaxime | Ascitic drain - albumin replacement for each L of fluid drained
27
What is hepatorenal syndrome?
In portal hypertension, due to the increased blood volume in the portal system there is dilation of the vessels to cope with the increased pressure and pooling of blood. This leads to reduced blood supply to the kidneys, activation of the RAAS as a result and renal vasoconstriction as a result. This constriction with the addition of blood pooling elsewhere leads to reduced renal blood supply and reduced function as a result. This is a fatal complication of cirrhosis if liver transplant is not obtained ASAP.
28
What is the cause of hepatic encephalopathy?
Increased ammonia in circulation due to reduced hepatic metabolism and increased collateral blood flow bypassing the liver. This ammonia is produced by intestinal bacteria and absorbed into circulation, crosses BBB to cause encephalopathy.
29
What are the symptoms of hepatic encephalopathy?
Flapping tremor Reduced GCS Confusion, change in behaviour/personality
30
How do you manage hepatic encephalopathy?
Laxatives to increase excretion of intestinal ammonia Enemas Oral rifampicin to kill bacteria and reduce ammonia production Nutritional support
31
What can precipitate hepatic encephalopathy?
1. Constipation 2. Renal impairment 3. Infection 4. GI bleed 5. Excess protein
32
How is non-alcoholic fatty liver disease diagnosed?
Often incidental LFT derangement Non-invasive liver screen: USS, hep B&C serology, autoantibodies, immunoglobulins, coeruloplasmin, a1 antitrypsin, ferritin + transferrin -> rules out other causes of hepatic disease Liver USS Enhanced liver fibrosis test / NAFLD fibrosis score / fibroscan
33
What is the management for non-alcoholic fatty liver disease?
Weight loss and nutrition support Stop smoking, control other RFs e.g. diabetes, BP, cholesterol Alcohol avoidance Vitamin E or pioglitazone for anti-oxidant/anti-fibrotic action
34
What is the inheritance pattern for a1-antitrypsin deficiency?
Autosomal recessive
35
How is hepatitis A diagnosed?
Symptom profile= N&V, anorexia, jaundice, cholestasis, hepatomegaly, fever HAV IgM
36
What percentage of HBV and HCV become chronic infections?
HBV: 10% HCV: 75%
37
What do each of the serology factors mean in HBV? | HBsAg, HBeAg, Anti-HBc, Anti-HBs, HBV DNA
``` HBsAG= presence of infection HBeAg= indication of viral replication and infectivity Anti-HBc= Current or past infection Anti-HBs= resolution of infection ```
38
What would you expect to see on serology in acute HBV infection?
1. HBsAg +ve 2. HBeAg +ve 3. Anti-HbC IgM 4. HBV DNA +ve Raised ALT
39
What would you expect to see on serology in chronic HBV infection?
1. HBsAg +ve 2. HBeAg +ve or -ve 3. Anti-HbC IgG 4. HBV DNA +ve Elevated ALT
40
What would you expect to see on serology in somebody who has recovered from HBV infection?
Anti-HBs Anti-HBc IgG Normal ALT No Antigens or DNA
41
What would you expect to see on serology for somebody who has been vaccinated against HBV?
Anti-HBs Normal ALT No antigens or DNA
42
How is HBV managed?
1. Testing for other BBVs, informing public health 2. Reduce risk factors: stop smoking, alcohol abstinence 3. Monitoring for complications: Fibroscan, USS 4. Antivirals to slow progression (no cure) 5. Transplant
43
How is HCV diagnosed?
Anti-HCV Ab = screening test | HCV RNA= diagnostic confirmation, viral load
44
How is HCV managed?
Direct-acting antivirals- 8-12 week course, curative in 90% Screen for other BBVs, inform PHE Reduce risk factors: stop smoking, drinking etc Monitoring for complications: Fibroscan, USS Transplant
45
What is the main complication of chronic hepatitis?
Hepatocellular carcinoma
46
When should you worry about HEV?
In pregnant women or immunocompromised -> can cause chronic hepatitis and liver failure in these populations
47
What are the two types of autoimmune hepatitis?
Type 1: most common affects women in 40-50s (around menopause) with fatigue and liver dysfunction Associated with ANA, anti-smooth muscle and anti-soluble liver antigen Type 2: most commonly affects teenagers/early 20s, causes acute hepatitis, raised enzymes & jaundice Associated with anti-liver antibodies
48
How is autoimmune hepatitis diagnosed and managed?
1. Liver biopsy + antibody testing | 2. Managed using high-dose prednisolone (tapering), azathioprine and transplant in end-stage disease
49
What are the symptoms of haemochromatosis?
Fatigue, Joint pain, Hair loss Bronze/grey pigmentation Mood/memory disturbance Amenorrhoea, erectile dysfunction
50
What is the inheritance pattern of haemochromatosis?
Autosomal recessive
51
How is haemochromatosis diagnosed?
``` Serum ferritin ^ Serum transferrin saturation ^ Genetic testing Liver biopsy with PERL'S STAIN- show's parenchymal iron concentration CT abdomen ```
52
What is the treatment for haemochromatosis?
1. Weekly venesection and serum iron monitoring 2. Genetic counselling 3. Monitor for complication e.g. liver cirrhosis and avoid alcohol
53
What are the complications of haemochromatosis?
``` Liver cirrhosis T1DM Endocrine disturbance e.g. DI HCC Cardiomyopathy Hypothyroidism ```
54
What is the inheritance pattern for Wilson's disease?
Autosomal recessive
55
What are the features of Wilson's disease?
Chronic hepatitis and liver cirrhosis Neurological: dysarthria, dystonia, Parkinsonism Psych: depression -> psychosis (wide spectrum) Haemolytic anaemia Renal tubular acidosis Osteopenia Kayser-Fleischer rings in the eyes
56
How is Wilson's disease diagnosed?
Liver biopsy for copper content= gold standard Serum caeruloplasmin = low (protein carrying copper) Serum copper Genetic testing
57
How is Wilson's disease managed?
Copper chelation: penicillamine
58
What is primary biliary cirrhosis?
Where the immune system attacks the small bile ducts, leading to cholestasis, fibrosis and cirrhosis of the ductal system. This leads to build-up of bile acids and cholesterol in the blood -> jaundice + xanthelasma This is associated with other autoimmune and rheumatological conditions
59
What are the symptoms of primary biliary cirrhosis?
``` RUQ pain Jaundice Fatigue Steatorrhoea + dark urine, itching Xanthelasma, xanthomata Signs of cirrhosis ```
60
How is primary biliary cirrhosis diagnosed?
LFTs: ALP raises first due to obstruction, followed by ALT/AST due to liver fibrosis + bilirubin due to reduced liver function. Autoantibody tests: anti-mitochondrial antibodies, ANA in some ESR + IgM Liver biopsy for diagnosis and staging
61
What is the antibody most associated with primary biliary cirrhosis?
Anti-mitochondrial antibody
62
How is primary biliary cirrhosis managed?
1. Ursedoxycholic acid to decrease intestinal cholesterol absorption 2. Cholestyramine to prevent bile acid absorption 3. Transplant in end-stage disease 4. Steroids used in some
63
What are the indications for liver transplant?
1. Acute liver failure - most commonly paracetamol OD 2. Chronic liver failure and cirrhosis 3. Hepatocellular carcinoma Contraindications: Alcohol, significant comorbidity, malnutrition, active infection, end-stage HIV
64
What condition is most commonly associated with primary sclerosing cholangitis?
Ulcerative colitis
65
What is primary sclerosing cholangitis?
Stricturing and fibrosis of the intra/extrahepatic ducts -> obstruction of bile flow Chronic obstruction -> hepatitis, fibrosis, cirrhosis
66
What is the triad of symptoms for primary sclerosing cholangitis?
RUQ pain Jaundice Pruritus
67
How is primary sclerosing cholangitis diagnosed?
1. LFTs: Cholestatic pictire 2. Autoantibodies: p-ANCA and ANA 3. MRCP - gold standard test
68
How is primary sclerosing cholangitis managed?
ERCP to dilate and stent ducts Cholestyramine to reduce bile acid absorption Vitamin supplementation Monitor complications - key = cholangiocarcinoma Transplant can be curative
69
What are the risk factors for HCC?
Alcoholic Liver Disease Chronic hepatitis Non-alcoholic fatty liver disease Liver cirrhosis of different aetiology
70
What are the symptoms of HCC?
Often asymptomatic / normal symptoms of liver disease RUQ pain, jaundice, ascites, nausea, pruritus Weight loss, malaise
71
How is HCC diagnosed?
AFP = serum marker LFTs USS liver CT scan and liver biopsy
72
How is HCC treated?
Resection if extremely localised Liver transplant if confined to liver Chemo/radiotherapy Kinase inhibitor can prolong survival
73
What is the main risk factor for cholangiocarcinoma?
Primary sclerosing cholangitis
74
What are the symptoms of cholangiocarcinoma?
Often asymptomatic until quite advanced Painless jaundice- like pancreatic cancer Weight loss, fatigue, night sweats
75
How is cholangiocarcinoma diagnosed?
``` CA19-9 = blood marker LFTs USS CT scan ERCP to take brushings/biopsy ```
76
How is cholangiocarcinoma managed?
Surgical resection if small and localised Chemo/radiotherapy - resistant disease, poor prognosis ERCP stenting of the bile ducts
77
What are the key risk factors for gallstones?
Female Fat Fair Forty
78
What are the symptoms of gallstones?
May be asymptomatic and incidentally found Biliary colic if temporary obstruction - RUQ/epigastric pain, triggered by meals (esp fatty ones) May be associated with nausea and vomiting
79
How are gallstones diagnosed?
LFT derangement USS abdo- first line: may see individual stones / dilation of ducts or gallbladder MRCP if suggestive sx but not seen on USS ERCP can be used in both diagnosis and management
80
How are gallstones managed?
1. If asymptomatic, no management required 2. ERCP removal of stones 3. Cholecystectomy
81
What is post-cholecystectomy syndrome?
Syndrome of diarrhoea, indigestion, abdominal pain, nausea, flatulence and intolerance of fatty food Occurs after cholecystectomy due to changes in bile flow Settles with time, no treatment needed- only symptomatic help
82
What are the symptoms of acute cholecystitis?
RUQ pain -> may be referred to R shoulder Fever, tachycardia, tachypnoea Nausea and vomiting
83
What are the signs of acute cholecystitis on examination?
^ RR, HR, temp RUQ tenderness and guarding Murphy's sign +ve - pain on inspiration Peritonism in severe disease
84
How would you investigate acute cholecystitis?
A-E assessment Bloods: FBC, U&E, LFT, CRP, lipase, USS abdo: thickened wall, stones / sludge in the gallbladder, fluid around the gallbladder MRCP
85
How to manage acute cholecystitis?
``` A-E Make NBM and get IV access NG tube if vomiting IV fluids, analgesia and antibiotics ERCP to remove stones Cholecystectomy: performed within 72 hours or may be delayed until inflammation resolves (6-8 w) ```
86
What are the main causes of ascending cholangitis?
Gallstones | ERCP
87
What are the most common causative organisms in ascending cholangitis?
E-coli Klebsiella Enterococci
88
What are the symptoms of ascending cholangitis?
Charcot's triad: | Fever, RUQ pain, Jaundice
89
How is ascending cholangitis diagnosed?
Symptom profile Bloods: Raised WCC and CRP, obstructive liver picture Blood cultures USS -> CT -> MRCP ERCP actually most sensitive but also most invasive
90
How is ascending cholangitis managed?
``` A-E Make NBM and get IV access NG tube if vomiting IV fluids, analgesia, antibiotics ERCP to remove any stones / stent ducts ```
91
What are the causes of pancreatitis?
``` Idiopathic Gallstones Ethanol Trauma Steroids Mumps Autoimmune Scorpion sting Hypercalcaemia, hyperlipidaemia ERCP Drugs ```
92
What are the common drugs causing pancreatitis?
``` Thiazide diuretics Furosemide Amiodarone Propofol Azathioprine ```
93
What are the symptoms of pancreatitis?
Epigastric pain radiating to the back, better when leant forwards Nausea and vomiting Fever, ^HR, RR Epigastric tenderness and guarding
94
What is the severity scoring for pancreatitis?
``` GLASGOW score- PANCREAS PaO2 Age Nutrophils Calcium levels R uRea Enzymes: LDH, liver enzymes, lipase Albumin Sugar ``` 0-1= mild 2=moderate 3+= severe
95
How is pancreatitis diagnosed?
1. Raised WBC, CRP, serum lipase/amylase ABG, LFT, calcium, U&E, blood cultures 2. USS 3. CT abdomen
96
How is pancreatitis managed?
A-E IV access: fluids, antibiotics, analgesia NBM if vomiting, feed asap to prevent malnutrition (may need enteral feed) Manage cause e.g. ERCP for stones, stop causative medication Most Improve in 3-7 days
97
What are the complications of acute pancreatitis?
``` Pseudocyst formation Abscess formation Perforation Sepsis Chronic pancreatitis Pancreatic necrosis ```
98
What are the complications of acute pancreatitis?
``` Pseudocyst formation Abscess formation Perforation Sepsis Chronic pancreatitis Pancreatic necrosis ```
99
What is the most common cause of chronic pancreatitis?
Alcohol excess
100
What are the symptoms of chronic pancreatitis?
``` Chronic epigastric pain Steatorrhoea Diabetes features Malnutrition Recurrent episodes of acute pancreatitis ```
101
How is chronic pancreatitis managed?
``` Stop alcohol and smoking Pancreatic enzyme supplements + nutrition support Analgesia ERCP and stunting of ducts Surgical removal of necrotic pancreas ```
102
What are the symptoms of pancreatic cancer?
Painless jaundice Dark urine, pale stool, itch Nausea and vomiting Weight loss, night sweats, fatigue
103
How is pancreatic cancer diagnosed?
CA 19-9 USS/MRCP ERCP and biopsy CT scan staging
104
How is pancreatic cancer managed?
MDT discussion Surgical removal of tumour if small/localised -> Whipple's procedure for pancreatic head tumour: removal of head, bile ducts, duodenum, pylorus, gallbladder, lymph nodes, Chemo/radiotherapy Palliative stenting
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