Liver & Biliary Overview Flashcards

Question

What would a clotting screen show in someone with chronic alcohol consumption?

Answer 1

* clotting screen is a functional assessment that tells you how well the liver is working * the liver makes **clotting factors**, so ***clotting time increases*** when the ***liver is damaged*** * **_increased prothrombin time_** is a sensitive marker of **significant liver damage**

Answer 2

* **_hepatic ultrasound scan_** is performed * liver biopsy is diagnostic, but rarely needed the presence of **_Mallory bodies_** indicates **hepatitis** * these are damaged intermediate filaments within the hepatocytes there may also be **_ballooning degeneration_** of hepatocytes * this is a form of liver parenchymal cell death

Answer 3

* **alcohol abstinence** * **_diazepam_** may be given in hospital to manage alcohol withdrawal * this prevents **withdrawal symptoms** and **seizures** * **nutrition** * enteral preferred - calories and vitamins - alcoholics are often malnourished * weight loss / smoking cessation * **_steroids_** are given in **_severe alcoholic hepatitis_**

Answer 4

* the presence of a **fatty liver** in those who **_do not consume alcohol_** in amounts generally considered harmful to the liver * **steatosis** is completely reversible * this progresses to **steatohepatitis (NASH)**, which involves **inflammation** * this is reversible, especially if it is mild * this progresses to **cirrhosis**, which is irreversible

Answer 5

* **obesity (truncal)** * **insulin resistance / type II diabetes** * hyperlipidaemia * hypertension * metabolic syndrome * short bowel syndrome * total parenteral nutrition (TPN)

Answer 6

* they may have signs of **insulin resistance** * polyuria * polydipsia * acanthosis nigricans

Answer 7

* LFTs * **AST : ALT ratio \< 1** * GGT / ALP may also be raised * **blood glucose** to check for diabetes / how well controlled it is

Answer 8

* diet and exercise * controlling risk factors * statins for hypercholesterolaemia * good blood sugar control in diabetes * metformin for diabetics

Answer 9

* **steatosis** involves **_fatty accumulation_** in the liver * a liver can remain fatty without disturbing liver function * by various mechanisms and insults to the liver, steatosis can progress to **non-alcoholic steatohepatitis (NASH)** * NASH involves steatosis combined with **_inflammation_** and sometimes **_fibrosis_**

Answer 10

* usually **no noticeable symptoms** and is only detected during routine blood tests or unrelated abdominal imaging * may have some symptoms related to liver dysfunction * fatigue * malaise * dull RUQ abdominal discomfort

Answer 11

* hep A & E usually cause **_acute hepatitis_**, which very rarely progresses to chronic hepatitis * *when you think of A&E - think of ACUTE problems* * hepatitis A&E can become **chronic** in **_immunosuppressed individuals_** * **hepatitis E** can cause **_severe liver failure_** in **_pregnant women_**

Answer 12

* they are spread via the **_fAEco-oral route_** * this is via contaminated water or sex * management is **supportive** as this infection is acute and will regress on its own * **_paracetamol_** and **_alcohol_** should be avoided

Answer 13

* **IgM** tells you that the **_infection is acute_** * they currently have the infection * **IgG** tells you that they **have had the infection**, but have **_now cleared it_** * IgM = now* * IgG = gone*

Answer 14

* Hep B & C can be **acute or chronic** * **Hep _C**_ most commonly becomes _****C**_hronic** * **Hep B** usually stays **acute** (80-90% cases) * as they can become chronic, there is a risk of **cirrhosis / hepatocellular carcinoma** * this risk is greater with Hep C infection as it is more likely to become chronic

Answer 15

* Hep D is a **_coinfection / superinfection of Hep B_** * it can only occur if someone is already infected with Hep B * Hep D infection **increases the risk of _liver failure_** in someone with Hep B infection

Answer 16

* it **_does not require treatment_** as the infection is cleared naturally in 90% cases * if Hep B persists for **\> 6 months** then **antiviral treatment** is required

Answer 17

* antiviral treatment ***suppresses HBV DNA replication*** * it is **_NOT curative_**, so drug withdrawal leads to **relapse** * if the liver is working well (i.e. no decompensated cirrhosis) then **_peginterferon-a-2a_** is given * if the liver is functioining poorly (i.e. decompensated cirrhosis), then give **_tenofovir_** or **_entecavir_**

Answer 18

peginterferon-a-2a **_AND_** tenofovir/entecavir

Answer 19

* this needs to be treated with antivirals as infection is likely to become chronic * treat with **_sofosbuvir_** or **_ledipasvir_**

Answer 20

***_Surface antigen:_*** * HBsAg is on the **outside** of the molecule * if HBsAg is present, there is a **_current active Hep B infection_** ***_Core antigen:_*** * HBcAg is in the **middle** of the virus and is **not detectable in the blood** * this is not useful in telling whether there is a current active infection

Answer 21

***_Surface antibody:_*** * HBsAb tells you that the person has **_cleared_ a Hep B infection** * they had the infection in the past, but do not have it currently * OR they have been **_vaccinated_** against Hep B ***_Core antibody:_*** * this is only derived from **natural infection** * if **_IgM_** is present, there is an **_acute infection_** * if **_IgG_** is present, this person may have a **_chronic infection_**

Answer 22

HBeAg represents **degree of replication**, and thus **_infectivity_**

Answer 23

* most adults clear this infection * 10% become carriers and 10% develop chronic infection * children are more likely to become **carriers / chronic infection** * this can be transmitted: * **sexually** * **IVDU / blood products** * **vertical transmission**

Answer 24

* **_blood product spread_** * IVDU / transfusion * 80% of adults develop chronic hepatitis, which increases risk of hepatocellular carcinoma * infection is usually asymptomatic

Answer 25

***_Hep A & E:_*** * travel to endemic area / faeco-oral (contaminated water) ***_Hep B:_*** * unprotected sex / MSM * vertical transmission ***_Hep C_******_:_*** * blood products - IVDU sharing needles * **_FEVER_** in all of these infections **_AST / ALT will be in 1000s_**

Answer 26

* **paracetamol overdose** leading to **_acute liver failure_** * AST / ALT will be in 1000s * need to measure **serum paracetamol concentration** * treatment is **N-acetyl-cysteine**

Answer 27

* some drugs will affect the **hepatocytes** themselves * paracetamol * NSAIDs * rifampicin * erythromycin * some drugs **induce cholestasis** by paralysing the bile duct * oral contraceptive pill * co-amoxiclav * nitrofurantoin

Answer 28

* prevalence is highest in **_young females_** and people with **_other autoimmune diseases_** * e.g. type 1 diabetes * hashimoto's thyroiditis * coeliac disease * it is a chronic disease that can lead to **cirrhosis** and **liver failure** if left untreated

Answer 29

autoimmune liver screen * this is an autoantibody test that identifies some important antibodies responsible for autoimmune liver disease * ANA (antinuclear antibody) * ASMA (anti-smooth muscle antibody) * AMA (antimitochondrial antibody)

Answer 30

condition leading to **_abnormal iron deposition_** in certain organs * skin * **liver** * **pancreas** * heart * pituitary gland * joints * the levels of iron build-up in the organs over many years, leading to unpleasant symptoms

Answer 31

***_Primary haemochromatosis:_*** * hereditary - it is autosomal recessive * there is an **_inability to stop iron being absorbed_** from the GI tract, leading to its accumulation in affected organs ***_Secondary haemochromatosis:_*** * this is due to **_iron overload_** * e.g. having multiple transfusions

Answer 32

* a defect in the **_HFE gene_** means that **transferrin binds poorly to its receptor** * this causes the liver to **_reduce hepcidin production_** * hepcidin usually **inhibits ferroportin** (enterocyte iron transporter) * with reduced hepcidin production, **_ferroportin activity_** in the enterocytes in **_unregulated_** * **more iron is transported across the enterocytes**, leading to **_iron accumulation_** and damage to affected organs

Answer 33

* 75% of cases are asymptomatic * hepatomegaly * **diabetes mellitus onset** * **bronze skin** * arthralgia * male impotence / testicular atrophy

Answer 34

* females have an additional method of **excreting iron** through **_menstruation_** * this is not possible in males, so **iron accumulates more quickly**

Answer 35

* first line investigation is **_transferrin saturation_** and **_serum ferritin_** * transferrin saturation will be raised * serum ferritin will be raised (this is non-specific as it is an acute phase protein) * **gene typing of HFE** * gold standard is **_liver biopsy_** to see iron deposits

Answer 36

* **_impaired copper excretion_** leads to **copper accumulation** in the **_liver_** and **_brain_** * it is an autosomal recessive genetic disorder * age of onset is **5 - 35 years**

Answer 37

* characterised by **hepatitis + dementia + parkinsonism** in a **young person** * hepatosplenomegaly * abdominal pain * jaundice * ascites * portal hypertension * **Kayser-Fleischer rings**

Answer 38

* 1^st line investigation is LFTs + bloods + 24-hour urinary copper * raised transaminases & bilirubin * **reduced serum ceruloplasmin (copper transport protein)** * **increased serum free copper** * **increased urinary copper excretion** * slit lamp examination * gold standard is genetic testing / liver biopsy and measurement of copper content

Answer 39

* normal liver is replaced by **_fibrosis_** and **_nodules_** of **regenerating hepatocytes** * it can be **stable** or **_decompensated_** (liver failure) * the liver still functions when it is cirrhotic, but cirrhosis can eventually lead to liver failure, which can be life-threatening * there is also increased risk of HCC

Answer 40

* alcohol misuse * viral hepatitis (B / C) * autoimmune hepatitis * haemochromatosis * NASH * chronic biliary disease * ***viral hepatitis*** leads to **_macronodular cirrhosis_** (nodules \> 3mm) * ***chronic alcohol abuse*** leads to a **_micronodular cirrhosis_** (nodules \< 3mm)

Answer 41

* clubbing * spider naevi * Dupuytren's contracture * palmar erythema * gynaecomastia * increased bruising * a patient can be clincally well with hepatitis or cirrhosis, with signs of chronic stable liver disease

Answer 42

* blood from the spleen (**_splenic vein_**) and bowels (**_inferior_** and **_superior mesenteric veins_**) travels through the liver via the **portal vein** * this blood is full of **ingested toxins / pathogens** * the blood passes through the liver to be **detoxified** and then becomes part of the **systemic circulation** via the **inferior vena cava**

Answer 43

* an **_increased pressure in the portal vein_** due to cirrhosis (of any cause) * it occurs due to a **blockage in the liver** (e.g. due to cirrhosis) leads to a **_backlog of blood_** into the portal system * this raises pressure within the portal vein

Answer 44

* blood in the portal vein **has not yet been processed** by the liver * it transfers into the systemic circulation at sites of **_porto-systemic anastomoses_** * lower oesophagus * anal canal * umbilicus * splenorenal * this **increases the pressure** in the **systemic circulation** at the porto-systemic anastomosis points

Answer 45

* distended veins (varices) - **_caput medusa_** * due to increased pressure as a result of porto-systemic anastomoses * **_ascites_** * blood is backing up into the veins and leaking out into the abdomen * **_splenomegaly_** * the spleen isn't being drained properly via the splenic vein, so it becomes engorged in blood * **_oesophageal varices_**

Answer 46

* treat cause + **_avoid hepatotoxic drugs_** * alcohol * NSAIDs * sedatives * opiates * monitor the **risk of complications** * MELD score * 6-monthly USS * endoscopy upon diagnosis and every 3 years following

Answer 47

* the liver functions to **remove gut products** from the blood * these arrive via the **portal vein**, and are removed before the blood returns to systemic circulation * in decompensated cirrhosis, the **hepatocytes are damaged** and **_less functional_** and there is **scar tissue** in the liver * the liver is **less effective at removing gut products** from the blood, so they make their way into the **systemic circulation** (**_intrahepatic shunting_**) * some blood from the gut **bypasses the liver** due to raised portal pressure at the sites of **_porto-systemic anastomoses_** * gut products in systemic circulation then impact on **_neurotransmission in the brain_**, causing encephalopathy * in this case, it is caused by **ammonia**

Answer 48

***_GI bleeding:_*** * bleeding into the gut acts as a **"protein meal"** * blood is broken down into **ammonia**, which causes encephalopathy * the same effect would be seen in a **_high protein diet_** ***_Other causes:_*** * infection * constipation * zinc deficiency * benzodiazepines

Answer 49

* treat precipitating event + **_short term protein restriction_** * managing GI bleed, infection, etc. * **_oral lactulose_**, phosphate enema * this reduces ammonia production by gut bacteria * **avoid sedatives**

Answer 50

* need to avoid fluid stasis in the abdomen as it could become infected * **sodium restriction** * diuretics - **furosemide + spironolactone** * **large volume paracentesis** * this is different to "ascitic tap" which is diagnostic paracentesis * this involves a needle into the abdomen to remove fluid

Answer 51

* this is the development of a **bacterial infection** in the peritoneum * it occurs when the **_ascitic fluid_** (i.e. an increased volume of peritoneal fluid) **becomes infected** **_without an apparent source_** * it is diagnosed using **paracentesis** (needle aspiration of ascitic fluid) * SBP is diagnosed when **neutrophil count** of the aspirate is **_\> 250 cells per mm³_** in the absence of another reason for this

Answer 52

* antibiotic treatment with **_cefurotaxime + metronidazole_**

Answer 53

* varices are **_abnormally dilated vessels_** (usually veins) that are at **risk of rupture** * primary prophylaxis is in place to **_prevent rupture_** of varices * if ***small varices*** then give **_non-selective beta-blocker_** * if ***large varices*** then **_EVL_** (esophageal variceal ligation)

Answer 54

* start with ABCDE approach then **_IV fluids and/or blood_** * need to replace blood when **_Hb \< 7 g/dL_** or patient could bleed to death * fluids will replace volume, but not clotting factors * then give **_terlipressin + antibiotics_** * terlipressin reduces blood flow to the gut, which reduces pressure on the portal system * **_EVL_** is performed after resuscitation when the patient is **haemodynamically stable** * this involves placing bands over the varices to stop bleeding

Answer 55

* give **_non-selective beta-blocker_** to replace terlipressin after 2-5 days * if EVL + beta-blocker fails to prevent rupture, then TIPS procedure is performed * this involves connecting the portal vein to the hepatic vein in the liver to reduce pressure in the portal system

Answer 56

severe liver dysfunction leading to **_jaundice_**, **_encephalopathy_** and **_coagulopathy_** ***_Acute:_*** * encephalopathy occurs **1-4 weeks** after onset of jaundice * it is hyperacute if \< 7 days after onset of jaundice * seen in **_paracetamol overdose_** and **_viral hepatitis_** * associated with transaminitis (very high AST / ALT) ***_Subacute:_*** * encephalopathy develops **4-12 weeks** after onset of jaundice

Answer 57

* this is **acute decompensation** in a patient who already has chronic liver disease

Answer 58

* ***cholelithiasis*** refers to a **_gallstone in the gallbladder_** * ***biliary colic*** refers to presence of **_cholelithiasis + pain_** * the stone in the gallbladder moves into the **cystic duct** and **_obstructs the flow of bile_** moving into the common bile duct * the **gallbladder contracts vigorously against the stone**, which causes pain * this is worse after a **fatty meal** as this stimulates the gallbladder to contract (release of bile helps emulsification of fats)

Answer 59

* acute cholecystitis refers to **_cholelithiasis + inflammation_ with or without infection** * there is **_no jaundice_** in acute cholecystis * the stone is within the gallbladder or cystic duct and is **not obstructing the flow of bile**

Answer 60

USS of the liver and biliary tree

Answer 61

* no treatment for cholelithiasis as it is an incidental finding * biliary colic is treated with **analgesia + elective lap chole** * acute cholecystitis is initially treated: * clear fluids only (to prevent gallbaldder from contracting) * analgesics * fluid resuscitation * broad spectrum IV abx if infection then treated with **lap chole within 1 week** if uncomplicated * if fever and high WCC persists, they could have an abscess * perform delayed cholecystectomy after few weeks/months

Answer 62

* choledocholelithiasis refers to a **gallstone in the _common bile duct_** * if there is **choledocholelithiasis + pain** then this is **_biliary colic_** * this term means presence of pain due to gallstones

Answer 63

* an infection can develop **behind the blocked common bile duct** where there is **stagnant bile** * this is **_ascending cholangitis_** (infection of bile duct) * this is usually due to E. coli * the patient may be **_jaundiced_** with **_raised ALP / GGT_** as there is an obstruction to biliary flow * if the stone comes down the CBD to block the **pancreatic duct** then this can cause **_pancreatitis_**

Answer 64

* ultrasound of liver and biliary tree * ERCP if ascending cholangitis is suspected

Answer 65

* for both **_analgesia + ERCP + lap chole_** * in cholelithiasis, you do not remove the gallbladder if there is no pain * in choledocholelithiasis, remove the gallbladder even if there is no pain * the stone in the CBD will go on to cause complications, including pancreatitis and ascending cholangitis

Answer 66

**_Charcot's triad_** * pain * fever * jaundice

Answer 67

* initial treatment involves: * clear fluids only * analgesics * fluid resuscitation * broad IV antibiotics * ERCP to drain pus from common bile duct, then remove stones * delayed lap chole will be performed at a later date

Answer 68

* Fair * Fat * Female * Forty * Fertile (1 or more children)

Answer 69

**Murphy's sign** * press hand into the RUQ when patient is breathing in * they will stop breathing as it hurts so much when the gallbladder presses into the hand

Answer 70

* ***primary biliary cirrhosis*** affects **_intrahepatic ducts_** only * remember "b**_i_**liary" - **_i_**ntrahepatic * ***primary sclerosing cholangitis*** affects both **_intrahepatic and extrahepatic ducts_** * remember "scl**_e_**ros**_i_**ng" - **_e_**xtra- and **_i_**ntra- hepatic * they are both **inflammatory conditions of the bile ducts** that cause **_cholestasis_**

Answer 71

* only affects **_intrahepatic ducts_** * more common in **females** * autoimmune condition in which the intrahepatic bile ducts are **slowly destroyed** * this leads to a **build-up of bile** and **other toxins in the liver** (**_cholestasis_**)

Answer 72

* it is associated with other **autoimmune conditions** including **_Sjorgen's syndrome_** and **_rheumatoid arthritis_** * raised **_antimitochondrial antibodies_** are usually diagnostic * a **_"florid duct lesion"_** will be present on histology * this is a granulomatous destruction of bile ducts

Answer 73

* cirrhosis * hepatocellular carcinoma * **_granuloma_** * aggregation of macrophages that occurs due to chronic inflammation

Answer 74

a long-term progressive disease of the liver and bile ducts characterised by **_inflammation and scarring of the bile ducts_** that usually allow bile to drain from the liver * affects both **_intra- and extra- hepatic ducts_** * affects **_males_** more than females

Answer 75

* associated with **_ulcerative colitis_** * complications include cirrhosis, hepatocellular carcinoma and **cholangiocarcinoma**

Answer 76

* it is diagnosed with **_MRCP_** * this shows a **_beaded appearance_** - ***segmental fibrosis with saccular dilation*** * histology will show **_"concentric onion skin fibrosis"_** * many antibodies, including **_pANCA_**, may be raised

Answer 77

* **_p_**ancreatic cancer presents with ****_p_**ainless jaundice** and a ****_p_**alpable gallbladder** * pancreatic cancers are mostly **adenocarcinomas** from exocrine tissue * 75% are found in the **head of the pancreas**

Answer 78

* smoking * obesity * type 2 diabetes mellitus * chronic pancreatitis

Answer 79

* it commonly has a **_delayed presentation_** due to **non-specific signs** * malaise * weight loss * abdominal pain * **_post-hepatic jaundice_** is a later sign * if the tumour in the head of the pancreas **obstructs the bile duct**, this leads to **painless jaundice** and a **palpable gallbladder** * **metastasis** can lead to **_hepatomegaly_**

Answer 80

* 1^st line can be **USS** but **_pancreatic protocol CT_** is ***more sensitive*** and shows the extent of ***local or distant spread*** * gold standard is **_biopsy_** via ERCP / EUS * **_CA19-9 tumour marker_** will be raised

Answer 81

***_Primary tumours:_*** * these originate in the liver * 90% are **hepatocellular carcinomas** * these occur in people who have had cirrhosis for a long time * **cholangiocarcinomas** are cancer of the bile ducts ***_Secondary tumours (most common):_*** * these are liver tumours that have **_metastasised from elsewhere_** * common sites are: * **bowel** * **breast** * **oesophagus** * **stomach** * **pancreas**

Answer 82

* this is a **primary malignancy** of hepatocytes that usually occurs in a **_cirrhotic liver_** * hepatitis B and C infection * alcoholic liver disease * autoimmune hepatitis * haemochromatosis * NAFLD * aflatoxin * PBC / PSC * smoking * obesity

Answer 83

* malaise * anorexia * weight loss * RUQ pain * jaundice * ascites (due to chronic liver disease) * cachexia * hepatomegaly

Answer 84

* **LFTs** and **viral serology** are first line * tumour marker is **_AFP_** * those at high risk of HCC have a **_6-monthly USS_** * if a liver mass is found, they are referred via 2ww pathway * **_liver CT_** to confirm the mass * gold standard is **_liver biopsy_**

Answer 85

* they are usually **adenomas of the bile duct epithelium** * can arise from **_intra-_** or **_extra-hepatic ducts_** or the **_gallbladder_**

Answer 86

* PSC * worm infections * cirrhosis

Answer 87

* signs and symptoms are the same as pancreatic cancer * pancreatic cancer is more common * they are distinguished by imaging / histology

Answer 88

* first line is abdominal USS * this shows dilated intrahepatic ducts and mass lesion * gold standard is biopsy using ERCP

Liver & Biliary Overview Flashcards

(118 cards)