1
Q
Give 4 functions of the liver
A
- Glucose and fat metabolism
- Detoxification and excretion
- Protein synthesis (e.g. albumin, clotting factos)
- Bile production
2
Q
Name 3 things that liver function tests measure
A
- Serum bilirubin
- Serum albumin
- Pro-thrombin time
3
Q
Name an enzyme that increases in the serum in cholestatic liver disease (duct and obstructive disease)
A
Alkaline phosphate
4
Q
What enzymes increase in the serum in hepatocellular liver disease?
A
Transaminases - e.g. AST and ALT
5
Q
What tests give no index of liver function and why?
A
Liver enzymes - alkaline phosphate, GGT, AST, ALT
Released by damaged cells
6
Q
Define jaundice
A
Raised serum bilirubin
7
Q
Name the 3 broad categories of jaundice
A
- Pre-hepatic
- Hepatic
- Post-hepatic
8
Q
Give 2 causes of pre-hepatic jaundice
A
Excess bilirubin production
- Haemolytic anaemia
- Gilberts disease
9
Q
Give 4 causes of hepatic jaundice
A
- Liver disease
- Hepatitis - viral, drug, immune, alcohol
- Ischaemia
- Neoplasm - HCC, mets
- Congestions - CCF
10
Q
Give 3 causes of post-hepatic jaundice
A
Duct obstruction
- Gallstones
- Stricture - Malignancy, ischaemia, inflammatory
- Blocked stent
11
Q
What colour is the urine and stools in pre-hepatic jaundice?
A
Both are normal
No itching and the LFTs are normal
12
Q
What colour is the urine and stools in someone with cholestatic jaundice (hepatic and post hepatic)?
A
Dark urine
Pale stools
Ithching
LFTs are abnormal
13
Q
What can cause raised unconjugated bilirubin?
A
A pre-hepatic problem (haemolysis, hypersplenism)
14
Q
What can cause raised conjugated bilirubin?
A
Indicated cholestatic problem [liver disease (hepatic) or bile duct obstruction (post hepatic)]
15
Q
Give 3 symptoms of jaundice
A
- Biliary pain
- Rigors - indicate an obstructive cause
- Abdomen swelling
- Weight loss
16
Q
Why are liver patients vulnerable to infection?
A
- Impaired reticuloendothelial function
- Reduced opsonic activity
- Leucocyte function
- Permeable gut wall
17
Q
Give 3 causes of Gallstones
A
- Obesity and rapid weight loss
- DM
- Contraceptive pill
- Liver cirrhosis
18
Q
Give 4 risk factors for gallstones
A
- Female
- Fat
- Fertile
- Smoking
19
Q
Name 2 types of gallstones
A
- Cholesterol (70%)
2. Pigment (30%)
20
Q
Describe the pathophysiology of cholesterol gallstones
A
Excess cholesterol/lack of bile salts –> cholesterol crystals –> gallstone formation, precipitated by reduced gallbladder motility
21
Q
Describe the pathophysiology of pigment gallstones
A
Excess bilirubin –> polymers and calcium bilirubinate –> stones
22
Q
Give 4 symptoms of gallstones
A
Most are asymptomatic
- Biliary colic (sudden RUQ pain radiating to the back +/- nausea/vomiting)
- Acute cholecystitis (gallbladder distension –> inflammation, necrosis, ischaemia)
- Obstructive jaundice
- Cholangitis
- Pancreatitis
23
Q
How can gallstones be removed from the gallbladder?
A
Laparoscopic cholecystectomy
ERCP with removal or destruction (mechanical lithotripsy) or stent placement
Bile acid dissolution therapy (for people not suitable for surgery)
24
Q
What is liver failure?
A
When the liver has lost the ability to regenerate to repair, so that decompensation occurs
25
Name 3 types of liver failure
1. Acute = sudden failure in previously healthy liver
2. Chronic = liver failure on the background cirrhosis
3. Fulminant = massive necrosis of liver cells --> severe liver function impairment
26
Give 5 causes of acute liver disease
1. Viral hepatitis
2. Drug induced hepatitis
3. Alcohol induced hepatitis
4. Vascular - Budd-CHiari
5. Obstruction
27
Give 2 possible outcomes of acute liver disease
1. Recovery
| 2. Liver failure
28
Give 5 causes of chronic liver disease
1. Alcohol
2. NAFLD
3. Viral hepatitis (B,C,E)
4. Autoimmune diseases
5. Metabolic
6. Vascular - Budd-Chairi
29
Give 2 possible outcomes of chronic liver disease
1. Cirrhosis
| 2. Liver failure
30
Give 5 signs of acute liver failure
1. Jaundice
2. Fetor hepaticus (smells like pears)
3. Coagulopathy
4. Asterixis - liver flap
5. Malaise
6. Lethargy
7. Encephalopathy
31
Give 5 signs of chronic liver disease
1. Ascites
2. Oedema
3. Bruising
4. Clubbing
5. Depuytren's contracture
6. Palmar erythema
7. Spider naevi
32
What investigations are conducted on someone on with liver failure?
Blood tests - FBCs, U+Es, LFTs, clotting factors, glucose
Imaging - EEG, USS, CXR, doppler USS
Microbiology - blood and urine culture and ascitic tap
33
What do the blood tests show in someone with liver failure?
```
Raised bilirubin
Low glucose
High AST and ALT
Low levels of coagulation factors
Raised prothrombin time
High ammonia levels
```
34
Describe the treatment for liver failure
1. Nutrition
2. Supplements
3. Treat complications
- Raised intracranial pressure = mannitol
- PPI = reduce GI bleeds
- Vit K, platelets, blood, FFP = coagulopthy
4. Liver transplant
35
Give 4 complications of of liver failure
1. Hepatic encephalopathy
2. Abnormal bleeding
3. Jaundice
4. Ascites
36
What drugs should be avoided in liver failure?
Constipators
Oral hypoglycaemics
Warfarin has enhanced effects
Opiates
37
Describe the pathophysiology of paracetamol poisoning
Intermediate metabolite (NAPQI) causes cellular necrosis, builds up when conjugation pathway is saturated
38
What is the treatment for paracetamol poisoning?
N-acetyl cysteine (NAC) converts reactive intermediate to stable metabolite
39
What give someone a poor prognosis following a paracetamol overdose?
1. Late presentation (NAC less effective >24hrs)
2. Acidosis
3. High prothrombin time
4. High serum creatinine
Liver transplant considered
40
What is cirrhosis?
Scarring of liver = irreversible
A chronic disease of the liver resulting from necrosis of liver cells followed by fibrosis (scarring)
The end result is impairment of hepatocyte function and distortion of liver architecture
41
Give 3 causes of cirrhosis
1. Alcohol
2. Chronic Hep B and V
3. Non alcoholic fatty liver disease
4. Genetic - Wilsons, A1ATD, HH, CF
5. Autoimmune - AH, PBC, PSC
6. Drugs - methotrexate, amiodarone, methyldopa
7. Neoplasm
42
Give 4 signs of cirrhosis
1. Hypoalbuminaemia
2. Clubbing
3. Terry's nails
4. Palmar erythema
5. Spider naevi
6. Hepatosplenomegaly
7. Ankle oedema
8. Loss of body hair
9. Ascites
43
What investigations are done in someone with cirrhosis?
1. FBC = decreased albumin, increased prothrombin time, low WCC and platelets
2. LFTs = raised bilirubin, AST, ALT, ALP, GGT
3. Imaging - USS, MRI = lesion, hepatomegaly, portal vein problems
4. Ascitic tap = indicates SBP
5. Liver biopsy = confirms clinical diagnosis
44
What is the treatment for liver cirrhosis?
1. Good nutrition and alcohol abstinence
2. Cholestryramine for pruritus
3. Treat underlying cause
4. Fluid and salt restriction for ascetics --> spironolactone, furosemide
5. Consider for liver transplant
6. Screen for HCC
45
Give 4 complications of cirrhosis
1. Decompensation
2. SBP
3. Portal hypertension
4. Increased risk of HCC
46
Approximately what percentage of blood flow to the liver is provided by the portal vein?
75%
47
Give 3 causes of portal hypertension
1. Pre-hepatic = portal vein thrombosis
2. Hepatic = cirrhosis, schistosomiasis, sarcoidosis
3. Post-hepatic = Budd-Chiari, RHF, constrictive pericarditis
48
Give 3 signs of portal hypertension
1. Ascites
2. Splenomegaly
3. Varices
49
Why can portal hypertension lead to varices?
Obstruction to portal blood flow
| Blood is diverted into collaterals and so causes varices
50
What are the potential consequences of varices?
If they rupture --> haemorrhage
51
What is the primary treatment for varices?
Endoscopic therapy - banding
| And Beta blocker
52
Describe the pathophysiology of hepatic encephalopathy
Ammonia accumulates and crosses the BBB causing cerebral oedema
53
Name 4 sequelae's of hepatic encephalopathy
SAVE
1. Splenomegaly
2. Ascites
3. Varices
4. Encephalopathy
54
What is ascites?
Chronic accumulation of fluid in the peritoneal cavity that leads to abdominal distension
55
Give 4 causes of ascites and an example for each
1. Local inflammation - peritonitis
2. Leaky vessels - imbalance between hydrostatic and oncotic pressures
3. Low flow - cirrhosis, thrombosis, cardiac failure
4. Low protein - hypoalbuminaemia
56
Describe the pathophysiology of ascites
1. Increased intra-hepatic resistance leads to portal hypertension --> ascites
2. Systemic vasodilation leads to secretion of RAAS, NAd and ADH --> fluid retention
3. Low serum albumin also leads to ascites
Transudate = blockage of venous drainage
Exudate = inflammation
57
Give 3 signs of ascites
1. Distension
2. Dyspnoea
3. Shifting dullness on percussion
4. Signs of liver failure
58
What investigations might you do in someone who you suspect has ascites?
1. USS
| 2 Ascitic tap
59
Describe the treatment for ascites
1. Restrict sodium and fluids
2. Diuretics - spirolactone
3. Paracentesis
4. Albumin replacement
60
Describe the effects of alcoholic liver disease
1. Fatty liver --> hepatitis --> cirrhosis and fibrosis
2. GIT --> gastritis, varices, peptic ulcers, pancreatitis , carcinoma
3. CNS --> Degreased memory and cognition, wernicke's encephalopathy
4. Folate deficiency --> anaemia
5. Reproduction --> testicular atrophy, reduced testosterone/progesterone
6. Heart --> dilated cardiomyoapthy, arrhythmias
61
What might be seen histologically that indicates a diagnosis of alcoholic liver disease?
Neutrophils and fat accumulation within hepatocytes
62
What type of anaemia do you associate with alcoholic liver disease?
Macrocytic anaemia
63
What blood test might show that someone has alcoholic liver disease?
Serum GGT will be elevated
64
What distinctive feature is often seen on biopsy in people suffering form alcoholic liver disease?
Mallory bodies
65
What are the CAGE questions?
1. Cut down?
2. Annoyed at criticism?
3. Guilty about drinking?
4. Eyeopener?
66
How do you treat alcoholic liver disease?
```
Alcohol management
1 = public health interventions
2 = early alcohol use screening
3 = Pharmacoloigal - disulfiram, acamprosate calcium
4 = Psychosocial - CBT, group support
```
67
How does alcoholic hepatitis present?
```
Jaundice
Anorexia
Nausea
Fever
Encephalopathy
Cirrhosis
Hepatomegaly
```
68
How long does hepatitis persist for to be deemed chronic?
6 months
69
Give 4 types of hepatitis?
1. Viral - A,B,C,D,E
2. Drug induced
3. Alcohol induced
4. Autoimmune
70
Give 3 infective causes of acute hepatitis
1. Hepatitis A-E infections
2. EBV
3. CMV
71
Give 3 non-infective causes of acute and chronic hepatitis
1. Alcohol
2. Drugs
3. Toxins
4. Autoimmune
72
Give 3 symptoms of acute hepatitis
1. General malaise
2. Myalgia
3. GI upset
4. Abdominal pain
5. Raised AST, ALT
6. +/- jaundice
73
What are the potential complications of chronic hepatitis?
Uncontrolled inflammation --> fibrosis --> cirrhosis --> HCC
74
If HAV a RNA or DNA virus?
RNA virus - PicoRNAvirus
75
How is HAV transmitted?
Faeco-oral transmission - contaminated food/water, shellfish
76
Who could be at risk of HAV infection?
Travellers and food handlers
77
Is HAV acute or chronic?
Acute
| 100% immunity after infection
78
How might you diagnose someone with HAV infection?
Viral serology - initially anti-HAV IgM and then anti-HAV IgG
AST and ALT rise 3-5 weeks after infection
79
Describe the management of HAV infection
1. Supportive
2. Monitor liver function to ensure no fulminant hepatic failure
3. Manage close contacts
80
What is the primary prevention of HAV?
Vaccination
81
Is HBV a RNA or DNA virus?
DNA virus
| Replicates in hepatocytes
82
How is HBV transmitted?
Blood borne transmission - IVDU, needle-stick, sexual, vertical
Highly infectious
83
Describe the natural history of HBC in 4 phases
1. Immune tolerance phase: unimpeded viral replication --> high HBV DNA levels.
2. Immune clearance phase: the immune system ‘wakes up’ = liver inflammation and high ALT
3. Inactive HBV carrier phase: HBV DNA levels are low = ALT levels are normal, no liver inflammation
4. Reactivation phase: ALT and HBV DNA levels are intermittent and inflammation is seen on the liver --> fibrosis
84
What HBV protein triggers the initial immune response?
The core proteins
85
How might you diagnose someone with HBV?
Viral serology = HBV surface antigen can be detected from 6w-3m, anti-HBV core IgM after 3 months, AST elevation
86
Describe the management of HBV infection
1. Supportive
2. Monitor liver function
3. Manage contacts
4. Follow up at 6 months to see if HBV surface antigens has clears
87
How would you know if someone had acute or chronic HBV infection?
Follow up appointment at 6 months to see if HBV surface Ag has cleared
Still present = chronic hepatitis
88
What are the potential consequences of chronic HBV infection?
1. Cirrhosis
2. HCC
3. Decompensated cirrhosis
89
How can HBV infection be prevented?
Vaccination - injecting a small amount of inactivated HbsAg
90
Describe 2 treatment options for HBV infection
1. Alpha interferon - boosts immune system
| 2. Antivirals - tenofovir, inhibits viral replications
91
Give 3 side effects of alpha interferon treatment for HBV
1. Myalgia
2. Malaise
3. Lethargy
4. Thyroiditis
5. Mental health problems
92
Give 2 HBV specific symptoms
Arthralgia
| Urticaria (hives)
93
If HCV a RNA or DNA virus?
RNA virus - flavivirus
94
How is HCV transmitted?
Blood borne
95
Give 4 risk factors for developing HBV/HCV infection
1. IVDU
2. People who have required blood products - blood transfusion
3. Needle stick injuries
4. Unprotected sex
5. Vertical transmission
96
How might you diagnose someone with current HCV infection?
Viral serology - HCV RNA tells you if the infection is still present
97
Describe the treatment for HCV
Direct acting antivirals are currently in use
| Weakly interferon injections
98
What percentage of people with acute HCV infection will progress onto chronic infection?
Approximately 70%
99
What percentage of people with acute HBV infection will progress onto chronic infection?
Approximately 5%
100
How can HCV infection be prevented?
1. Screen blood products
2. Lifestyle modification
3. Needle exchange
No vaccination, and previous infection doesn't confer immunity
101
Is HDV a RNA or DNA virus?
Incomplete RNA virus
| Needs Hep B for assembly
102
How is HDV transmitted?
Blood borne transmission - particularly IVDU
103
Is HEV a RNA or DNA virus?
Small RNA virus
104
How is HEV transmitted?
Faeco-oral transmission
105
Is HEV acute or chronic?
Usually acute but there is a risk of chronic disease in the immunocompromised
106
How might you diagnose someone with HEV infection?
Viral serology - initially anti-HEV IgM and then anti HEV IgG
107
Describe the primary prevention of HEV
Good food hygiene
| Vaccine is in development
108
What types of viral hepatitis are capable of causing choric infection?
Hepatitis B (+/- D), C and E in the immunosuppressed
109
What is non alcoholic steatoheptitis (NASH)?
An advanced form of non-alcoholic fatty liver disease
110
Give 3 causes of non-alcoholic fatty liver disease
1. T2DM
2. Obesity
3. Hypertension
4. Hyperlipidaemia
111
How do you manage NAFLD?
Lose weight
| Control HTN, DM and lipids
112
What is Budd-Chiari syndrome?
Hepatic vein occlusion --> ischaemia and hepatocyte damage --> liver failure or insidious cirrhosis
113
Name 3 metabolic disorders that can cause liver disease
1. Haemochromatosis - iron overload
2. Alpha 1 anti-trypsin deficiency
3. Wilson's disease - disorder of copper metabolism
114
90% of people with haemochromatosis have a mutation in which gene?
HFE
115
Haemochromatosis is a genetic disorder, how is it inherited?
Autosomal recessive inheritance
116
Describe the pathophysiology of haemochromatosis
Uncontrolled intestinal iron absorption --> deposition of iron in liver, heart, pancreas, joins, skin --> fibrosis and functional organ failure
117
Give 4 signs of haemochromatosis
1. Hepatomegaly
2. Cardiomegaly
3. DM
4. Hyperpigmentation of skin
5. Lethargy
6. Osteoporosis
118
How might you diagnose someone with haemochromatosis?
1. Raised ferritin
2. HFE genotyping
3. Liver biopsy
119
What histological stain can be used for haemochromatosis?
Perl's stain
120
What is the treatment for haemochromatosis?
1. Iron removal - venesection
2. Monitor DM
3. Low iron diet
4. Screening for HFE
121
Give 2 complications of haemochromatosis?
Liver cirrhosis --> failure/cancer
| DM due to pancreatic depositions
122
How is alpha 1 anti-trypsin deficiency inherited?
Autosomal recessive mutation in serine protease inhibitor gene
123
Describe the pathophysiology of alpha 1 anti-trypsin deficiency?
No protease inhibitor --> lung elastase/liver destruction (cirrhosis)
124
How does Alpha 1 anti-trypsin deficiency present?
Liver disease in the young - cirrhosis, jaundice
| Lung disease in the old (smokers) - emphysema
125
How would you diagnose Alpha 1 anti-trypsin deficiency?
Bloods = decreased serum A1AT
LFT = obstructive disease pattern
Liver biopsy = periodic acid Schiff +ve
126
What is the treatment for Alpha 1 anti-trypsin deficiency?
Smoking cessation
| Liver/lung transplant
127
What is Wilson's disease?
An autosomal recessive disorder of copper metabolism
| Excess deposition of copper in the liver
128
Describe the pathophysiology of Wilson's disease
Impaired incorporation of Cu into caeruloplasmin --> Cu accumulation in liver
129
How does Wilson's disease present?
```
Children = liver disease - hepatitis, cirrhosis, fulminant liver failure
Adults = CNS problems, mood changes, and Kayser-Fleischer rings
```
130
What are Kayser-Fleischer rings?
Cu in iris and cornea --> bronze ring
131
What CNS changes are seen in a patient with Wilson's disease?
```
Tremor
Dysarthria
Dyskinesia
Ataxia
Parkinsonism
Dementia
Depression
```
132
What is the treatment for Wilson's disease?
Lifetime treatment with penicillamine (chelating agent)
Low Cu diet - no liver, nuts, chocolate, mushrooms, shellfish
Liver transplant
133
Describe the pathophysiology of autoimmune hepatitis
Abnormal T cell function and autoantibodies vs hepatocyte surface antigens
134
What people are more likely to present with autoimmune hepatitis?
Young (10-30) and middle aged (>40) women
135
How does autoimmune hepatitis present?
```
Fatigue, fever, malaise
Hepatitis
Hepatosplenomegaly
Amenorrhoea
Polyarthritis
Pleurisy
Lung infiltrates
Glomuleronephritis
```
136
What diseases are associated with autoimmune hepatitis?
```
Autoimmune thyroiditis
DM
Pernicious anaemia
PSC
UC
```
137
What results would you see from the investigations of someone who you suspect has autoimmune hepatitis?
Raised LFTs - increased bilirubin, AST, ALT, ALP
Hypersplenism = low WCC and platelets
Autoantibodies = +ve anti-nuclear antibody
Liver biopsy = mononuclear infiltrate
138
How is autoimmune hepatitis treated?
Prednisolone - immunosuppression
| Liver transplant
139
What is primary biliary cirrhosis?
An autoimmune disease where intra-hepatic bile ducts are destructed by chronic granulomatous inflammation --> cholestatis (bile in liver) --> cirrhosis, fibrosis, portal hypertension
140
Describe 2 features of the epidemiology of primary biliary cirrhosis
1. Females > males
| 2. Familial - 10 fold risk increase
141
Give 3 disease associated with primary biliary cirrhosis
1. Thyroiditis
2. RA
3. Coeliac disease
4. Lung disease
Other autoimmune diseases
142
Give 3 symptoms of primary biliary cirrhosis
1. Pruritis
2. Fatigue
3. Heptosplenomeglay
4. Obstructive jaundice
5. Cirrhosis and coagulopathy
143
What would investigations show in someone with biliary cirrhosis?
Bloods = elevated LFTS (ALP), increased bilirubin, raised IgM decreased albumin and clotting factors
Positive anti-mitochondrial antibody = diagnostic
Liver biopsy = epithelial disruption and lymphocyte infiltration
144
What is the treatment for primary biliary cirrhosis?
Ursodeoxycholic acid - improves bilirubin and aminotransferase levels
Cholestyramine - for pruritis
ADEK vitamins
Liver transplant
145
What is Primary sclerosing cholangitis?
Autoimmune inflammation and narrowing of intra and extra hepatic bile ducts
146
Describe the pathophysiology of primary sclerosis cholangitis
Inflammation of the bile duct --> stricture and hardening --> progressive obliterating fibrosis of bile duct branches --> cirrhosis --> liver failure
147
Give 3 causes of primary sclerosis cholangitis
1. Primary = unknown causes
2. Infection
3. Thrombosis
4. Iatrogenic trauma
148
Give 3 symptoms of primary sclerosis cholangitis
1. Pruritus
2. Charcot's triad = fever with chills, RUQ pain, obstructive jaundice
3. Cirrhosis
4. Liver failure
5. Fatigue
149
What would the investigations show in someone with primary sclerosis cholangitis?
Bloods = elevated ALP, bilirubin and Ig, AMA negative
Imaging = ERCP and MRCP
Liver biopsy = fibrous and obliterative cholangitis
150
What is the treatment for primary sclerosis cholangitis?
Cholestyramine for pruritus
ADEK vitamins
Liver transplant
151
What complications might occur due to primary sclerosis cholangitis?
Increased risk of bile duct, gallbladder, liver and colon cancer
152
What is ascending cholangitis?
Obstruction of biliary tract causing bacterial infection
| Regarded as a medical emergency
153
Give 3 causes of ascending cholangitis?
Gallstone
Primary infection (Klebsiella, E. coli)
Strictures following surgery
Pancreases head malignancy
154
Name the triad that describes the 3 common symptoms of ascending cholangitis
Charcot's triad
1. Fever
2. RUQ pain
3. Jaundice
155
What other symptoms can present with Charcot's triad with ascending cholangitis?
Reynolds pentad
- Charcot's triad
- Hypotension
- Confusion/altered mental state
156
What investigations might you do in someone who you suspect might have ascending cholangitis?
1. USS
2. Blood tests - LFTS
3. CT - excludes carcinoma
4. ERCP - definitive investigation
157
Describe the management of ascending cholangitis
```
Fluid resuscitation
Treat infection with broad spectrum antibiotics (cefotaxime, metronidazole)
ERCP to clear obstruction
Stenting
Laparoscopic cholecystectomy
```
158
What is the difference between ascending cholangitis and acute cholecystitis?
A patient with acute cholecystitis would not have signs of jaundice
159
What is the main difference between biliary colic and acute cholecystitis?
Acute cholecystitis has an inflammatory component
160
What complications can occur due to acute ascending cholangitis?
```
Sepsis
Biliary colic
Acute cholecystitis
Empyema
Carcinoma
Pancreatitis
```
161
Are most liver cancers primary or secondary?
Secondary - metastasised to the liver
162
Where have most secondary liver cancers arisen form?
1. GI tract
2. Breast
3. Bronchus
4. Uterus (women)
163
Describe the aetiology of HCC
1. Cirrhosis
2. HBV/HCV
3. Alcohol
4. Haemochromatosis
164
Give 5 symptoms of HCC
1. Weight loss
2. Anorexia
3. Fever
4. Malaise
5. Ascites
6. RUQ pain
165
What investigations might you do on someone who you suspect has HCC?
1. Blood - serum AFP may be raised
2. US or CT to identify lesions
3. MRI
4. Biopsy = diagnostic
166
Describe the treatment for HCC
1. Surgical resection of solitary tumours
2. Liver transplant
3. Percutaneous ablation
4. Prevention = Hep B vaccination
167
What is cholangiocarcinoma?
Cancer of the biliary tree
168
Give 3 causes of cholangiocarcinoma
1. Flukes (parasitic worms)
2. Primary sclerosing cholangitis
3. HBV and HCV
4. DM
169
Give 4 symptoms of cholangiocarcinoma
1. Fever
2. Abdominal pain
3. Ascites
4. Early jaundice
5. Malaise
6. Fatigue
170
What investigations might you do in someone who you think has cholangiocarcinoma?
Raised bilirubin and alkaline phosphate
Contrast MRI
ERCP for biopsy
171
What is the management for cholangiocarcinoma?
Most are inoperable
| Complete resection/stent = symptom relief
172
What is peritonitis?
Inflammation of the peritoneal lining
173
Name causes of peritonitis
1. Primary = spontaneous bacterial peritonitis, ascites, immunocompromised
2. Secondary = Bowel perforation, abdomen organ inflammation, TB, bowel ischaemia
174
Give 3 symptoms of peritonitis
1. Abdominal pain and tenderness
2. Nausea
3. Chills
4. Rigors
5. Fever
175
Give 3 signs of peritonitis on an abdomen examination
1. Guarding
2. Rebound
3. Rigidity
4. Silent abdomen
176
What investigations might you do in someone who you suspect could have peritonitis?
1. Blood tests: raised WCC, platelets, CRP, amylase, reduced blood count
2. CXR: look for air under the diaphragm
3. Abdominal x-ray: look for bowel obstruction
4. CT: can show inflammation, ischaemia or cancer
5. ECG: epigastric pain could be related to the heart
6. B-HCG: a hormone secreted by pregnant ladies
177
What is the management for peritonitis?
1. ABC
2. Treat the underlying cause
3. Surgical repair of abdomen
4. Anti-inflammatories
178
Give 5 potential complications of peritonitis
1. Hypovolaemia
2. Kidney failure
3. Systemic sepsis
4. Paralytic ileus
5. Pulmonary atelectasis (lung collapse)
6. Portal pyaemia (pus in portal vein)
179
What is the commonest serious infection in those with cirrhosis?
Spontaneous bacterial peritonitis
180
Name a bacteria that can cause spontaneous bacterial peritonitis
1. E. coli
| 2. S. pneumoniae
181
How can spontaneous bacterial peritonitis be diagnosed
By looking for the presence of neutrophils in ascitic fluid
182
Describe the treatment for spontaneous bacterial peritonitis
Cefotaxime and metronidazole
183
What investigation is it important to do in someone with chronic liver disease and ascites? Explain why it is important
Ascitic tap to rule out spontaneous bacterial peritonitis
184
You do an ascitic in someone with ascites. The neutrophil count comes back as - Neutrophils > 250/mm3. What is the likely cause of the raised neutrophils?
Spontaneous bacterial peritonitis
185
What is acute pancreatitis?
An inflammatory process with release of inflammatory cytokines (TNF alpha, IL-6) and pancreatic enzymes (trypsin, lipase)
186
Describe the pathophysiology of acute pancreatitis
Self-perpetuating exocrine enzyme mediated auto-digestion of organ
Acinar cell injury --> inflammatory response --> multiple organ damage
Oedema + fluid shift --> hypovolaemia --> EC fluid is stuck in gut/peritoneum
187
Give 5 causes of pancreatitis
```
I GET SMASHED – remember
Idiopathic
Gallstones (60%)
Ethanol = alcohol (30%)
Trauma
Steroids
Mumps
Autoimmune
Scorpion venom
Hyperlipidaemia/hypothermia/high Ca
ERCP (endoscopic retrograde cholangiopancreatography)
Drugs (furosemide, corticosteroid, NSAIDs, ACEi)
```
188
Give 4 symptoms of acute pancreatitis
1. Severe epigastric pain that radiates to the back
2. Anorexia
3. Nausea, vomiting
4. Signs of septic shock - fever, dehydration, hypotension, tachycardia
5. Necrotising - umbilical (Cullens sign) vs flank (Grey Turners sign)
189
What investigations are done on someone you think has acute pancreatitis?
Raised serum amylase and lipase
Erect CXR
Contrast CT
MRI
190
Name a scoring system that can be used as a prognostic tool in acute pancreatitis
Glasgow and ranson
191
What 8 points make up the Glasgow and ranson scoring system?
1. Hypoxia = PaO2 < 8kPa
2. Age > 55 years
3. Neutrophilia > 15x10^9
4. Hypocalaemia < 2mmol/L
5. Hyperuricaemia > 15mmol/L
6. Elevated enzymes
7. Hypoalbuminaemia < 32g/L
8. Hyperglycaemia - serum glucose > 15mmol/L
192
Describe the treatment for acute pancreatitis
1. Analgesia
2. Catheterise and ABC approach for shock patients
3. Drainage of oedematous fluid collections
4. Antibiotics
5. Nutrition - NJ tube feeding
193
Give 2 potential complications of acute pancreatitis
1. Systemic inflammatory response syndrome
2. Multiple organ dysfunction
3. Pancreatic necrosis
194
Why is morphine contraindicated in acute pancreatitis?
Morphine increases sphincter of Oddi pressure and so aggravates pancreatitis
195
What is chronic pancreatitis?
Chronic inflammation of the pancreas leads to irreversible damage
- Progressive loss of exocrine pancreatic tissue which is replaced by fibrosis
196
Describe the pathogenesis of chronic pancreatitis
Pancreatic duct obstruction leads to activation of pancreatic enzymes --> necrosis --> fibrosis
197
Name 3 causes of chronic pacnreatitis
1. Excess alcohol
2. CKD
3. Idiopathic
4. Recurrent acute pancreatitis
5. Genetic - CF, HH, Hereditary pancreatitis
198
Describe how alcohol can cause chronic pancreatitis
Alcohol --> proteins precipitate in the ductal structure of the pancreas (obstruction) --> pancreatic fibrosis
199
Give 5 symptoms of chronic pancreatitis
1. Severe epigastric pain that radiate through to the back
2. Weight loss
3. Nausea, vomiting
4. Steatorrhea (lack of lipase)
5. Exocrine/endocrine dysfunction
200
A sign of chronic pancreatitis is exocrine dysfunction, what can be consequence of this?
1. Malabsorption
2. Weight loss
3. Diarrhoea
4. Steatorrhoea
201
A sign of chronic pancreatitis is endocrine dysfunction, what can be consequence of this?
DM
202
What immunoglobulin might be elevated in someone with autoimmune chronic pancreatitis?
IgG4
203
How is autoimmune chronic pancreatitis treated?
Steroids
204
What is the treatment for chronic pancreatitis?
Alcohol cessation
Analgesia (NSAIDs, tramadol)
Pancreatic enzyme (creon) and vitamin replacement
If DM = insulin
Surgery - local resection, for unremitting pain
205
Why can pancreatitis cause malabsorption?
Pancreatitis result in pancreatic insufficiency and so lack of pancreatic digestive enzymes
Defective intra-luminal digestion leads to malabsorption
206
What 2 enzymes, if raised, suggest pancreatitis?
LDH (lactate dehydrogenase) and AST
207
Give 3 complications of chronic pancreatitis
1. Diabetes
2. Pseudocyst
3. Biliary obstruction --> obstructive jaundice, cancer
208
Name a drug that can cause drug induced liver injury
1. Co-amoxiclav
2. Flucloxacillin
3. Erythromycin
4. TB drugs
209
Give 5 causes of diarrhoea infection
1. Traveller's diarrhoea
2. Viral - (rotavirus/norovirus)
3. Bacterial (E. coli)
4. parasites (helminths, protozoa)
5. Nosocomial (C. diff)
210
Give 5 causes of non-diarrhoeal infection
1. Gastritis/peptic ulcer disease (H. pylori)
2. Acute cholecystitis
3. Peritonitis
4. Thyphois/paratyphoid
5. Amoebic liver abscess
211
Give 3 ways in which diarrhoea can be prevented
1. Access to clean water
2. Good sanitation
3. Hand hygiene
212
What is the diagnostic criteria for travellers diarrhoea?
> 3 unformed stools per dat and a least one of:
- abdominal pain
- cramps
- nausea
- vomiting
Occurs within 2 weeks (usually 3 days) of arrival in a new country
213
Give 3 casues of traveller's diarrhoea
1. Enterotoxigenic E. coli
2. Norovirus
3. Giardia
214
Describe the pathophysiology of traveller's diarrhoea
Heat labile ETEC modifies Gs and it is in a permanent 'locked on' state
Adenylate cyclase is activated and there is increased production of cAMP
Leads to increased secretion of Cl- into the intestinal lumen, H2O follows down as osmotic gradient --> diarrhoea
215
Which type of E. coli can cause bloody diarrhoea and has a shiga like toxin?
Enterohaemorrhagic E.coli (EHEC)
216
What does EIEC stand for?
Enteroinvasive E. coli
217
What type of E. coli is responsible for causing large volumes of watery diarrhoea?
Enteropathogenic E.coli (EPEC)
218
What does EAEC stand for?
Enteroaggregative E. coli --> infantile diarrhoea
219
What does DAEC stand for?
Diffusely adherent E. coli
220
What is the leading cause of diarrhoea illness in young children?
Rotavirus
| There is a vaccine = rotary
221
Name a helminth responsible for diarrhoea infection?
Schistosomiasis
| Strongyloides
222
Give 5 symptoms of helminth infection
1. Fever
2. Eosinophilia
3. Diarrhoea
4. Cough
5. Wheeze
223
Why is c. diff infectious?
Spore forming bacteria (gram positive)
224
Give 5 risk factors for c.diff infection
1. Increasing age
2. Comordities
3. Antibiotic use
4. PPI
5. Long hospital admission
6. NG tube feeding and GI surgery
7. Immunocompromised - HIV, anti-caner drugs
225
Name 5 antibiotics that can cause c. diff infection
1. Ciprofloxacin (quinolones)
2. Co-amoxiclav (penicillins)
3. Clindamycin
4. Cephlosporins
5. Carbapenems
RULE OF C's
226
Describe the treatment for c. diff infection
Metronidazole and vancomycin (PO)
Rifampicin/rifaximin
Stool transplant
227
What can helicobacter pylori infections cause?
H. pylori produces urease --> ammonia --> damage to gastric mucosa --> neutrophil recruitment and inflammation
Causing gastritis, peptic ulcer disease, gastric cancer
228
Describe H. pylori
A gram negative bacilli with a flagellum
229
Describe the treatment for H. pylori infection
Triple therapy = 2 antibiotics and 1 PPI
| Omeprazole, clarithomyocine and amoxicillin
230
Define biliary colic
Pain associated with the temporary obstruction of the cystic or common bile duct
