1
Q
List the types of Jaundice
A
- Pre-hepatic
- Liver jaundice
- Biliary Jaundice
2
Q
What is pre-hepatic jaundice
A
Excessive amount of bilirubin presented to the liver due to excessive haemolysis
3
Q
How is pre-hepatic jaundice detected in the serum
A
elevated unconjugated bilirubin in the serum
4
Q
What hepatic jaundice
A
Impaired cellular uptake, defective conjugation or abnormal secretion of bilirubin by the liver cell
5
Q
How is hepatic jaundice detected in the serum
A
Both conjugated and unconjugated bilirubin may be elevated in the serum
6
Q
What is biliary jaundice
A
impaired excretion due to mechanical obstruction to bile flow
7
Q
How is biliary jaundice detected in the serum
A
Elevated conjugated bilirubin in the serum
8
Q
What are the effects of portal HTN
A
- oesophageal varices
- splenomegaly
- caput medusae
- ascites
- haemorrhoids
9
Q
What are the effects of liver cell failure
A
ABCDEFGHIJ 1. Asterixis (flapping tremor) 2. Bruising 3. Clubbing 4. Dupuytren's contracture 5. Erythema 6. Fetor hepaticus (ketones and ammonia in the breath smells like freshly mown hay) 7. Gynaecomastia 8. Have portal hypertension 9. Itching 10. Jaundice spider naevi + testicular atrophy
10
Q
What is hepatitis
A
inflammation of the liver
11
Q
Which hepatitis viruses are transmitted through the faecal-oral root
A
Hepatitis A + E
12
Q
Which hepatitis virus is transmitted by body fluids
A
Hepatitis B, C + D
13
Q
What is the incubation period of a pathogen
A
the period between exposure to an infection and the appearance of the first symptoms.
14
Q
State the incubation period, areas of high risk and risk factors for hepatitis A
A
- 2 weeks
- Africa/Asia
- poor hygiene
15
Q
State the incubation period, areas of high risk and risk factors for hepatitis B
A
- 4-12 weeks
- Africa
- If you are a health worker
16
Q
State the incubation period, areas of high risk and risk factors for hepatitis C
A
- 2 weeks to 6 months
- Eastern Mediterranean
- Injecting drugs
17
Q
State the incubation period, areas of high risk and risk factors for hepatitis D
A
- 4-12 weeks
- Africa
- only co-infects with Hep B
18
Q
State the incubation period, areas of high risk and risk factors for hepatitis E
A
- 5-6 weeks
- Poor water supply
- Immunocompromised patients
and pregnant patients
19
Q
Which 2 types of hepatitis’ are likely to be co-infected
A
Hep B + D
20
Q
A patient has Hep D, which other infection do they have
A
Hep B
21
Q
Which hepatitis is likely to be chronic in children
A
Hep B
22
Q
Can Hep B be chronic
A
Likely in children
5% of adults
23
Q
Which type of hepatitis is the most likely to be chronic
A
Hep C
24
Q
Which types of hepatitis is mainly acute
A
Hep A, D + E
25
Viral hepatitis: what is the generic triad
1. Fever
2. Jaundice
3. Raised AST/ALT
26
Which type of hepatitis is mainly asymptomatic
Hep C (in 80% of patients)
27
What is the first line investigation if you suspect viral hepatitis
Liver function tests
28
What is the gold standard (diagnostic) tool is you suspect viral hepatitis
Antibodies
29
What is the list of investigation you do if viral hepatitis is suspected
1. Liver function test (first line)
2. FBC
3. U+Es
4. Antibodies (diagnostic)
30
What is used to measure treatment response in viral hepatitis
NAAT (Nucleic Acid Amplification Test)
| Test can indicate treatment response
31
What does HBsAg suggest
Hep B infection
| acute and chronic
32
What immunoglobulin is produced first in Hep B
anti-HBc IgM
33
Which immunoglobulin shows you are either cured or vaccinated against Hep B
anti-HBs IgG
34
Which immunoglobulin is produced first in any infection
IgM
35
Which immunoglobulin provides immunity in the long run and has a long life span
IgG
36
Which antigen shows you have an active infection of Hep B
HBsAg
37
What is present on Hep B serology of someone who has chronic HBV infection
HBsAg
| IgG anti-HBcAg
38
What is present on Hep B serology of someone who has an acute HBV infection
HBsAg
| IgM anti-HBcAg
39
What is present on Hep B serology of someone who has resolved HBV infection
IgG anti-HBsAg
| IgG anti-HBcAg
40
What is NASH
Non-alcoholic steatohepatitis
41
What is the aetiology of NASH
Insulin resistance leading to increased triglycerides
which leads to steatosis (fatty changes, organ retention of lipid) which leads to inflammation then finally steatohepatitis
42
What is the triad for NASH
1. RUQ pain
2. Metabolic syndrome without alcohol use
3. hepatsplenomegaly
43
What is the investigations for NASH
1. LFT's (more ALT produced so AST:ALT ratio is less than 1)
2. metabolic panel and lipid profile
3. abdominal USS
4. liver biopsy
44
What is the treatment for NASH
1. correction of lipid and glucose profiles
| 2. improving diet and exercise
45
What is the triad for alcoholic liver disease
1. RUQ
2. Associated with heavy alcohol use
3. hepatosplenomegaly
46
What are the investigations for alcoholic liver disease
1. LFT's (higher AST: high ALT) ratio of more than 2
increased GGT
2. FBC (increased neutrophils and decreased platelets)
3. U + E's
4. Vitamin screening
5. hepatic ultrasound
47
What is the treatment for alcoholic liver disease
1. Support with alcohol abstinence
2. Treat metabolic and lipid profile
3. Steroids
4. Nutritional support
5. Liver transplant in liver failure
48
What are the symptoms for cirrhosis
1. abdominal distention
2. pruritis (itchy skin)
3. coffee ground vomit
49
What are the clinical signs fro cirrhosis
1. asterixies
2. dupeytren's contracture
3. jaundice
4. ascites
50
What are the investigations (+ findings) liver cirrhosis
```
1. LFT's
low albumin
PT pro-longed
2. Electrolytes, U+E's
Na may be low due to ascites
3. US/CT/MRI
atrophy/fibrotic nodules
```
51
A 26 y/o male returns from holiday in India. He has had diarrhoea after eating at a seafood restaurant on his last night. He is feverish and nauseous. You notice that the whites of his eyes are yellow.
```
A. Hepatitis A
B. Hepatitis B
C. Hepatitis C
D. Hepatitis D
E. Hepatitis E
```
A. Hepatitis A
52
A 64 y/o male with thalassaemia is investigated under the two-week wait for jaundice and weight loss. His blood tests show a raised αFP. Which chronic infection is he most likely to have?
```
A. Hepatitis A
B. Hepatitis B
C. Hepatitis C
D. Hepatitis D
E. Hepatitis E
```
C. Hepatitis C
| aFP is a marker for hepatic carcinoma
53
A 32 y/o male returns from holiday in Thailand, feeling ‘under the weather’ with RUQ pain, fevers and nausea. He is jaundiced. He reveals he has used IV drugs and had unprotected sex with a stranger while on holiday. Which test is most likely to give the correct diagnosis?
```
A. Liver function tests
B. HIV serology
C. Hepatitis B serology
D. Hepatitis C PCR
E. CXR
```
C. Hepatitis B serology
54
A 43 y/o confused man is brought to A&E by police after being found wandering the streets. He is disorientated and unable to give a clear history. You notice the following in his eyes (Kayser-Fleischer rings). What is he likely to have?
```
A. Alcohol intoxication
B. Wilson’s disease
C. Opiate overdose
D. Haemochromatosis
E. Hypoglycaemia
```
B. Wilson’s disease
55
72 y/o man with cirrhosis presents to A&E with diffuse abdominal pain and fever. He is nauseous and has vomited. His abdomen is distended and there is shifting dullness on examination. Which investigation would be most urgent?
```
A. Paracentesis
B. Stool sample MC&S
C. Abdominal USS
D. LFTs
E. Blood cultures
```
A. Paracentesis
56
What is the aetiology of gall stones
often found in
1. fat
2. fair
3. fertile
4. females
5. above forty
6. often with a FHx
57
What are the symptoms of gall stones
```
1. RUQ pain
radiate to shoulder and back
post prandial (after meals)
colicky
2. Nausea
```
58
What are the signs of gall stones
1. Murphy's sign: positive sign is when hannd is place in RUQ and patient is asked to breath in, when they do, the pain is worse
2. Boas sign: pain radiates to the scapula
59
What is the first line investigation for gall stones
LFTs
60
What is the gold standard investigation for gall stones
abdominal ultrasound
61
What is the management for gall stones in the gall bladder (cholelithiasis)
cholecystectomy
62
What is the management for gall stones in the common bile duct (choledocholithiasis)
ERCP
63
What are the complications of gallstones
1. ascending cholangitis
| 2. acute cholecystitis
64
What is ascending cholangitis
Gall stones in the bile duct
leading to bile stasis
the bacteria from the gut moves into the bile ducts
65
What is acute cholecystitis
gall stones in the gall bladder
| leading to bile stasis, inflammation and bacteria build up
66
What are the sign and symptoms of acute cholecystitis
```
1. constant RUQ pain
may radiate to R right scapula (Boas sign)
2. fever
3. nausea + vomiting
4. rebound tenderness
5. positive Murphys sign
```
67
What are the signs and symptoms of ascending cholangitis
```
1. Charcot's triad
fever
RUQ pain
jaundice
If septic: reynold's pentad
Charcot's triad + hypotension and confusion
```
68
What is primary biliary cirrhosis
An autoimmune condition resulting in damage to (and destruction of) the biliary epithelial cells lining the small intrahepatic bile ducts
69
What are the risk factors for primary biliary cirrhosis
1. peak diagnosis ages 55-65 y/o
2. females more likely 10:1
3. other autoimmune diseases
4. hypocholesteraemia
70
What condition is primary biliary cirrhosis likely to paired with
Sjogren's
71
What are the features of Sjogren's syndrome
dry eyes and mouth
72
What are the signs and symptoms od primary biliary cirrhosis
1. Pruritis (itching of the skin)
2. fatigue
3. Sjogren's
4. hyperpigmentation
5. lesions such as xanthomas
73
What is the gold standard investigation for primary biliary cirrhosis
1. AMA (mitochondrial antibodies)
74
What are the investigations for primary biliary cirrhosis
1. LFTs
2. ASA - diagnostic
3. Abdomenal US - so that obstructive duct lesion MUST be excluded
75
What is primary sclerosing cholangitis
its the inflammation and fibrosis of the intra-hepatic and extra-hepatic bile ducts, resultng in diffuse multi-focal stricture formation
76
What are the risk factors for primary sclerosing cholangitis
male gender
| IBD
77
What are the signs and symptoms of primary sclerosing cholangitits
1. RUQ pain
2. prutitis
3. fatigue
78
What are the investigations for primary sclerosing cholangitis
```
1. LFTs - first line
GGT elevated
2. MRCP - diagnostic
beading
3. AMA antibodies
should be negative
```
79
What is the gold standard investigation for primary sclerosing cholangitis
MRCP
80
What is pancreatic cancer
technically pancreatic ductal adenocarcinoma
81
What are the investigations for pancreatic cancer
1. LFT's
2. USS
3. CT (if suspicious)
82
A 41 y/o female presents with a history of colicky, right sided abdominal pain. She states the pain is worse after eating fish and chips and Indian takeaways. On examination her abdomen is soft and non-tender. Which is the best investigation to confirm her diagnosis?
```
A. Abdominal X-ray
B. ERCP
C. Liver biopsy
D. USS of biliary tree
E. CT-KUB
```
D. USS of biliary tree
83
A 41 y/o female presents to A&E with a history of severe, continuous, RUQ pain. She feels feverish and complains of an occasional pain in her right shoulder. On examination she displays RUQ tenderness and a positive Murphy’s sign. What is the most likely diagnosis?
```
A. Biliary colic
B. Ascending cholangitis
C. Acute cholecystitis
D. Primary biliary cirrhosis
E. Cholangiocarcinoma
```
C. Acute cholecystitis
84
While waiting to be admitted, her RUQ pain becomes worse and she starts shaking uncontrollably. You notice she now looks jaundiced. What is the most likely diagnosis?
```
A. Biliary colic
B. Ascending cholangitis
C. Acute cholecystitis
D. Primary biliary cirrhosis
E. Cholangiocarcinoma
```
B. Ascending cholangitis
85
A 35 y/o man presents with a two week history of jaundice and RUQ pain. He is taking mesalazine for a “bowel condition”. What is the most likely cause of his jaundice?
```
A. Autoimmune hepatitis
B. Haemochromatosis
C. Primary sclerosing cholangitis
D. Primary biliary cirrhosis
E. Drug side effect
```
C. Primary sclerosing cholangitis
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