1
Q
Give four functions of the liver.
A
- Glucose and fat metabolism
- Detoxification and excretion
- Protein synthesis
- Defence against infection (R-E system)
2
Q
Give three things that the liver detoxifies/excretes.
A
- Bilirubin
- Ammonia
- Drugs/hormones/pollutants
3
Q
Give two proteins that are produced by the liver.
A
- Albumin
- Clotting factors
4
Q
Describe the hepatocyte zones within the liver lobule.
A
Zones 1-3 going towards the central vein.
Going from 1-3, the hepatocytes get progressively less blood and become increasingly susceptible to toxins.
5
Q
Give two methods of hepatocyte cell death.
A
- Apoptosis
- Necrosis
6
Q
Give six reasons why patients with chronic liver disease may become acutely ill.
A
- Constipation
- Drugs
- GI bleed
- Infection
- Metabolite disturbances (Hypo… Na/K/glycaemia)
- Alcohol withdrawal
7
Q
Give four reasons why liver patients are vulnerable to infection.
A
- Impaired reticulo-endothelial function
- Reduced opsonic activity
- Leukocyte function
- Permeable gut wall
8
Q
Give five sites of infection that liver patients are vulnerable to.
A
- Spontaneous bacterial peritonitis
- Septicaemia
- Pneumonia
- Skin
- Urinary tract
9
Q
What is the most common serious infection which occurs in liver cirrhosis?
A
Spontaneous bacterial peritonitis
10
Q
Give six drugs which should not be prescribed to liver patients without careful consideration.
A
- Sedatives
- Analgesics
- NSAIDs
- Diuretics
- ACE inhibitors
- Aminoglycosides
11
Q
Give three reasons why patients with liver disease might go into a coma.
A
- Hepatic encephalopathy
- Hyponatraemia/hypoglycaemia
- Intracranial event
12
Q
Describe hepatic encephalopathy.
A
A decline in brain function that occurs due to the liver not being able to metabolise ammonia, causing it to build up in the brain.
13
Q
Give three reasons why coagulopathy occurs in liver disease.
A
- Impaired coagulation factor synthesis
- Vitamin K deficiency (cholestasis)
- Thrombocytopenia
14
Q
Give three endocrine changes which occur in liver disease.
A
- Gynaecomastia
- Impotence
- Amenorrhoea
15
Q
How is malnutrition in liver disease treated?
A
Naso-gastric feeding
16
Q
How is variceal bleeding in liver disease treated?
A
- Endoscoping banding
- Propranolol
- Terlipressin
17
Q
How is encephalopathy in liver disease treated?
A
- Lactulose
- Rifaximin (antibiotic)
18
Q
How are infections in liver disease treated?
A
Antibiotics
19
Q
Which analgesics can and can’t be prescribed in liver disease?
A
- Sensitive to opiates
- NSAIDs cause renal failure
- Paracetamol safest
20
Q
Which sedations can be used in patients with liver disease?
A
Short-acting benzodiazepines
21
Q
Which antihypertensives must be avoided in liver disease?
A
ACE inhibitors
22
Q
Describe the onset of drug-induced liver injury.
A
Usually occurs within 1-2 weeks of starting the drug, and may occur several weeks after stopping.
23
Q
Give seven types of drugs which can cause drug induced liver injury.
A
- Antibiotics
- CNS drugs
- Immunosuppressants
- Analgesics/musculoskeletal
- Gastrointestinal drugs
- Dietary supplements
- Alternative herbal therapies
24
Q
What percentage of acute liver failure is drug induced liver injury responsible for?
A
> 65%
25
What percentage of acute hepatitis is drug induced liver injury responsible for?
30%
26
What three serum measurements would you take in suspected liver disease?
- Bilirubin
- Albumin
- Prothrombin time
27
Which two cholestatic liver enzymes can give an indication about liver/bile health?
- Alkaline phosphatase
| - gamma-GT
28
Which two hepatocellular enzymes are raised in liver injury?
- Aspartate aminotransferase (AST)
| - Alanine aminotransferase (ALT)
29
What are the two main outcomes of acute liver injury?
- Liver failure
| - Recovery
30
What are the three possible outcomes of chronic liver injury?
- Recovery
- Liver failure
- Cirrhosis (which leads to liver failure)
31
Give six causes of acute liver injury.
- Viral (A, B, EBV)
- Drugs
- Alcohol
- Vascular
- Obstruction
- Congestion (HF)
32
Give four causes of chronic liver injury.
- Alcohol
- Viral (B, C)
- Autoimmune
- Metabolic (iron, copper)
33
Give four common presenting features of acute liver injury.
- Malaise
- Nausea
- Anorexia
- Jaundice
34
Give four rarer presentations of acute liver injury.
- Confusion
- Bleeding
- Liver pain
- Hypoglycaemia
35
What are the common presentations in chronic liver injury?
- Ascites
- Oedema
- Haematemesis (varices)
- Malaise
- Anorexia
- Wasting
- Easy bruising
- Itching
- Hepatomegaly
- Abnormal LFTs
36
Give two rarer presentations of chronic liver injury.
- Jaundice
| - Confusion
37
Describe the current trend in pancreatic carcinoma in the UK.
Incidence is rising
38
Which gender is pancreatic carcinoma more common in?
Males
39
What age is pancreatic carcinoma more common in?
>60 years
40
What is the genetic element of pancreatic carcinoma?
95% have mutations in KRAS2 gene
41
Give seven risk factors for pancreatic carcinoma.
- Smoking
- Alcohol
- Carcinogens
- Diabetes mellitus
- Chronic pancreatitis
- Increased waist circumference
- Possibly high fat and red/processed meat diet
42
What type of cancer are most pancreatic carcinomas?
Ductal adenocarcinomas
43
What percentage of pancreatic carcinoma occurs in the head?
60%
44
What percentage of pancreatic carcinoma occurs in the body?
25%
45
What percentage of pancreatic carcinoma occurs in the tail?
15%
46
In which areas of the pancreas does carcinoma give a better prognosis?
- Ampulla of Vater
| - Pancreatic islet cells
47
When does pancreatic carcinoma metastasize?
Early
48
When does pancreatic carcinoma present?
Late
49
What is the usual presenting feature of pancreatic carcinoma of the head?
Painless obstructive jaundice
50
What is the usual presenting feature of pancreatic carcinoma of the body/tail?
Epigastric pain which radiates to the back and is relieved on sitting forward.
51
Give four general presentations of pancreatic carcinoma.
- Anorexia
- Weight loss
- Diabetes
- Acute pancreatitis
52
Give five rare features of pancreatic carcinoma.
- Thrombophlebitis migrans (arm vein becomes swollen and red, then a leg vein)
- Raised calcium
- Marantic endocarditis (nonbacterial)
- Portal hypertension
- Nephrosis
53
Give seven signs of pancreatic carcinoma.
- Jaundice
- Palpable gall bladder
- Epigastric mass
- Hepatomegaly
- Splenomegaly
- Lymphadenopathy
- Ascites
54
What would blood tests show in pancreatic carcinoma?
Cholestatic jaundice
55
Give three potential features of an USS/CT in pancreatic carcinoma.
- Pancreatic mass
- Dilated biliary tree
- Hepatic metastases
56
What surgery may be carried out in pancreatic carcinoma?
Pancreatoduodenectomy (Whipple’s procedure)
57
Why is surgery rarely used in pancreatic cancer?
It is only effective if there are no metastases, and most present with metastatic disease.
58
When is a laparoscopic excision easiest to perform in pancreatic cancer?
When the carcinoma is in the tail.
59
When would chemotherapy be used in pancreatic cancer?
Post-op
60
What may be done for palliation of jaundice/anorexia in pancreatic carcinoma?
Endoscopic or percutaneous stent
61
What can be given to control pain in pancreatic carcinoma?
- Opiates
| - Radiotherapy
62
What is the mean survival in pancreatic carcinoma?
<6months
63
What is the 5 year survival rate in pancreatic carcinoma?
3%
64
What is acute pancreatitis?
Self-perpetuating pancreatic inflammation by enzyme-mediated autodigestion.
65
Give 12 causes of acute pancreatitis.
GETSMASHED
- Gallstones
- Ethanol
- Trauma
- Steroids
- Mumps
- Autoimmune
- Scorpion venom
- Hyperlipidaemia, hypothermia, hypercalcaemia
- ERCP and emboli
- Drugs
Also pregnancy and neoplasia
66
What happens to the blood volume in acute pancreatitis?
There is hypovolaemia.
67
Briefly describe the pathophysiology behind acute pancreatitis and hypovolaemia.
- There is oedema and fluid shifting, and extracellular fluid gets trapped in the gut, peritoneum, and retroperitoneum.
68
Describe the progression of acute pancreatitis.
Progression may be rapid from mild oedema to necrotising pancreatitis.
69
What percentage of pancreatitis patients progress to necrotising pancreatitis?
20%
70
Describe the symptoms of acute pancreatitis.
- Gradual or sudden severe epigastric/central abdominal pain
- Pain radiates to back
- Sitting forward may relieve pain
- Prominent vomiting
71
Give the signs of acute pancreatitis.
- Tachycardia
- Fever
- Jaundice
- Shock
- Ileus
- Rigid abdomen +/- local or general tenderness
- Periumbilical bruising (Cullen’s sign)
- Flank bruising (Grey Turner’s sign)
72
Why does bruising occur in acute pancreatitis?
Due to blood vessel autodigestion and retroperitoneal haemorrhage.
73
How is the degree of elevation of serum amylase relate to acute pancreatitis?
It is not related to disease severity
74
Give three conditions which may cause a lesser rise in serum amylase in acute pancreatitis.
- Cholecystitis
- Mesenteric infarction
- GI perforation
75
Give a condition which may increase levels of serum amylase in acute pancreatitis.
Renal failure
76
How is serum lipase used to investigate chronic pancreatitis?
It is more sensitive than amylase and is specific for pancreatitis.
77
Why is an ABG carried out in acute pancreatitis?
To monitor oxygenation and acid-base.
78
What X rays should be carried out in acute pancreatitis?
- AXR
| - Erect CXR
79
What may the AXR show in acute pancreatitis?
No psoas shadow
80
Why is a CT scan used in acute pancreatitis?
To assess severity and complications
81
When would an USS be used in acute pancreatitis?
If there is gallstones
82
When would an ERCP be used in acute pancreatitis?
If LFTs decline
83
What does CRP suggest about acute pancreatitis if it is high for a long time?
It is a predictor of severe disease
84
Give the 8 Glasgow criteria for predicting severe disease in acute pancreatitis.
PANCREAS
- PaCO2 <8KPa
- Age >55yrs
- Neutrophilia >15x10^9/L
- Calcium <2mmol/L
- Renal function (urea >16mmol/L)
- Enzymes (high liver enzymes)
- Albumin <32g/L
- Sugar >10mmol/L
85
Give the principles of management of acute pancreatitis.
- Nil by mouth (may need NG tube)
- IV fluids
- Analgesia (pethidine, morphine)
- Monitoring
- ERCP and gallstone removal if progressive
86
Give seven early complications of acute pancreatitis.
- Shock
- ARDS
- Renal failure
- DIC
- Sepsis
- Hypocalcaemia
- Hyperglycaemia
87
Give seven late complications of acute pancreatitis.
- Pancreatic necrosis
- Pseudocyst
- Abscesses
- Bleeding
- Thrombosis
- Fistulae
- Recurrent oedematous pancreatitis
88
What is chronic pancreatitis?
A chronic inflammatory process of the pancreas, leading to irreversible loss of pancreatic function.
89
Describe the pathogenesis of chronic pancreatitis.
- Chronic inflammation in the pancreas leads to replacement of functional pancreatic tissue by fibrous scar tissue
- There are dilated ducts and areas of calcification
90
Describe the progression of chronic pancreatitis, in terms of endocrine and exocrine function.
Loss of exocrine tissue predominates early, whereas endocrine tissue is typically spared until late disease.
91
What is the main cause of chronic pancreatitis?
Alcohol
92
Give six rare causes of chronic pancreatitis.
- Familial
- Cystic fibrosis
- Haemochromatosis
- Pancreatic duct obstruction (stones/tumour)
- Increased parathyroid hormone
- Congenital
93
Describe the clinical presentation (signs/symptoms) of chronic pancreatitis.
- Epigastric pain which ‘bores’ through to the back
- Pain relieved by sitting forward or hot water bottle on epigastrum or back
- Bloating
- Steatorrhoea
- Weight loss
- Brittle diabetes
- Symptoms relapse and worsen
94
What investigations should be carried out in chronic pancreatitis?
- Ultrasound +/- CT
- MRCP + ERCP
- AXR
- Blood glucose
- Breath tests
95
What feature on an ultrasound/CT is diagnostic of chronic pancreatitis?
Pancreatic calcifications
96
What may be seen on an AXR in chronic pancreatitis?
Speckled calcification
97
What may the blood glucose tests show in chronic pancreatitis?
Hyperglycaemia
98
How is chronic pancreatitis treated?
- Analgesia (coeliac-plexus block)
- Lipase
- Potentially insulin
- Dietary changes
- Pancreatectomy/pancreaticojejunostomy
99
What dietary changes should be made in chronic pancreatitis?
- No alcohol
- Low fat
- Medium-chain triglycerides may be tried
100
Give three reasons why surgery may be carried out in chronic pancreatitis.
- Unremitting pain
- Narcotic abuse
- Weight loss
101
Give seven complications of chronic pancreatitis.
- Pseudocyst
- Diabetes
- Biliary obstruction
- Local arterial aneurysm
- Splenic vein thrombosis
- Gastric varices
- Pancreatic carcinoma
102
What is a hernia?
The protrusion of a viscus or part of a viscus through a defect of the walls of its containing cavity into an abnormal position.
103
What does ‘irreducible’ mean, in relation to hernias?
Cannot be pushed back into proper place.
104
What does ‘incarceration’ mean, in relation to hernias?
Contents of the hernial sac are stuck inside by adhesions.
105
What does ‘obstructed’ mean, in relation to hernias?
Bowel contents cannot pass through.
106
When is a hernia described as ‘strangulated’?
If ischaemia occurs
107
What is a herniotomy?
Ligation and excision of the hernia.
108
What is a herniorrhaphy?
Repair of the defect
109
Give seven risk factors for inguinal hernias.
- Male
- Chronic cough
- Constipation
- Urinary obstruction
- Heavy lifting
- Ascites
- Past abdominal surgery
110
Describe an indirect inguinal hernia.
The hernia passes through the deep inguinal ring and out of the superficial inguinal ring.
111
Where is an indirect inguinal hernia in relation to the epigastric vessels?
Hernial is lateral to the vessels.
112
What percentage of inguinal hernias are direct and indirect?
- Direct = 20%
| - Indirect = 80%
113
Out of direct and indirect inguinal hernias, which are more likely to strangulate?
Indirect
114
Do direct or indirect inguinal hernias reduce more easily?
Direct
115
What is a direct inguinal hernia?
The hernia pushes out directly through the posterior wall of the inguinal canal.
116
Where is a direct hernia in relation to the epigastric vessels?
The hernia is medial to the vessels.
117
What pre-op advice is given to patients with hernias?
- Lose weight (if overweight)
| - Stop smoking
118
Give two surgical techniques that can be used to repair inguinal hernias.
- Mesh technique (polypropylene mesh reinforces posterior wall)
- Laparoscopic repair
119
Describe a femoral hernia.
Bowel enters the femoral canal.
120
How does a femoral hernia present?
Mass in the upper medial thigh or above the inguinal ligament.
121
Which gender are femoral hernias more common in?
Women
122
Which age are femoral hernias more common in?
Middle age/elderly
123
What method of treatment is recommended for femoral hernias?
Surgical
124
What is the likelihood of a femoral hernia being irreducible or strangulating?
High for both
125
Where does a paraumbilical hernia occur?
Just above or below umbilicus.
126
Give two risk factors for paraumbilical hernias.
- Obesity
| - Ascites
127
What does surgery for paraumbilical hernias involve?
Repair of rectus sheath
128
What can herniate through the defect in paraumbilical hernias?
Omentum or bowel
129
What is an epigastric hernia?
Hernia which passes through the linea alba above the umbilicus.
130
What causes incisional hernias?
Breakdown of muscle closure after surgery.
131
What age are hiatus hernias more common in?
Over 50yrs
132
Give the typical patient demographic for hiatus hernias.
Obese women
133
How can hiatus hernias present?
Symptomatic GORD (50%)
134
What is the best diagnostic test for hiatus hernias?
Barium swallow
135
Give three treatment options for hiatus hernias.
- Weight loss
- Treat reflux
- Surgery
136
Why is an upper GI endoscopy sometimes used in a hiatus hernia?
To visualise the mucosa
137
Give two indications for surgery in hiatus hernia.
- Intractable symptoms
| - Complications
138
Why should rolling hiatus hernias always be prepared?
They should be prepared prophylactically as they may strangulate, which requires emergency surgery.
139
What are the relative incidences of hiatus hernias?
```
Sliding = 80%
Rolling = 20%
```
140
Describe a sliding hiatus hernia.
Gasto-oesophageal junction slides up into chest.
141
Describe a rolling hiatus hernia.
Gasto-oesophageal junction remains in abdomen but a bulge of stomach herniates into the chest alongside the oesophagus.
142
In which type of hiatus hernia is GORS more likely to occur?
Sliding
143
Why does GORD occur in sliding hiatus hernia?
Lower oesophageal sphincter becomes less competent.
144
Give a side effect of N-acetylcysteine.
Rash
145
Describe the acid-base balance of the blood in liver disease.
Likely to have metabolic acidosis
146
What autoantibody may be associated with, but not specific to, primary sclerosing cholangitis?
ANCA
147
How is oestrogen linked to bile secretion?
Oestrogen inhibits bile secretion, leading to cholestasis.
148
Describe hepatorenal syndrome.
In late stage liver failure the RAAS system is activated due to splanchnic vasodilation.
This causes vasoconstriction of the renal vasculature, so blood is diverted away from the renal cortex.
Therefore glomerular filtration rate is reduced, leading to ‘functional’ renal failure.
149
Describe hepatic pulmonary syndrome.
Hypoxaemia in end stage liver failure due to intrapulmonary vascular dilation.
150
How is a gallstone ileus treated?
Laparotomy (don’t need to remove gallbladder)
151
Why should the gallbladder always be removed in gallstones?
50-60% will recur
152
Why does dehydration occur in jaundice?
Osmotic effects of bile salts
153
Give three mechanisms of acinar cell injury which lead to acute pancreatitis.
- Duct obstruction (impaired blood flow and necrosis)
- Direct injury
- Defective intracellular transport (intracellular activation of enzymes)
154
Give three conditions that cause rigors.
- Lobar pneumonia
- Cholangiitis
- Pyelonephritis
155
What is the cut off for serum amylase and lipase levels to diagnose pancreatitis?
>3x upper limit of normal
