Rob Grogan rjg17icacuk Year 4 BSc Anaesthesia amp Crit Care Disclaimer amp sponsor MedED does not represent the ICSM Faculty or Student Union This lecture series has been designed and produced by students We have made every effort to ensure that the information contained is ID: 933384
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Slide1
Liver and Biliary Disease
Rob Grogan rjg17@ic.ac.uk Year 4 BSc Anaesthesia & Crit Care
Slide2Disclaimer & sponsor “
MedED does not represent the ICSM Faculty or Student Union. This lecture series has been designed and produced by students. We have made every effort to ensure that the information contained is accurate and in line with Learning Objectives featured on SOFIA, however, this guide should not be used to replace formal ICSM teaching and educational materials.”
Slide3Conditions
Definition, aetiology, epidemiology, symptoms, signs, investigations
+ Management, complications and prognosis
Gallstones
(Biliary colic, cholecystitis, acute cholangitis)
✓
✓
Alcoholic hepatitis
✓
✓
NASH
✓
✓
Viral hepatitis (see infections 2)
✓
✓
Autoimmune hepatitis
✓
Cirrhosis
✓
✓
Liver failure
✓
✓
Neoplasms (HCC, cholangiocarcinoma and pancreatic cancer)
✓
PSC/PBS
✓
Liver cysts/abscess (see slides)
✓
Wilson’s disease (see slides)
✓
Haemochromatosis (see slides)
✓
Slide4Learning everything for all conditions
Differentiate conditions based on presentation + common managements
Slide5SBA 1
A 39 year old female attends her GP for a routine check-up. She is obese and has type II diabetes, and been taking metformin and simvastatin for around 2 years. She complains of mild fatigue but has otherwise been well. She says she drinks around 8 units of alcohol per week. On examination there are no signs of chronic liver disease.
Investigations
Albumin 38 g/L (35-51)
ALT 178 IU/L (<40)
AST 154 U/L (<40)
ALP 57 U/L (35-51)
GGT 19 U/L (11-42)
Bilirubin 12
umol
/L (<17)
What is the most likely diagnosis?
Drug-induced hepatitis
Non-alcoholic steatohepatitis
Alcoholic hepatitis
Viral hepatitis
Cirrhosis
Slide6SBA 2
A 21 year old male student in London was well until 4 days ago when he developed diarrhoea, vomiting and RUQ pain. Yesterday morning, his flatmates noticed that his eyes had turned yellow. He has not lost any weight in the past few months and his stools are brown. LFTs revealed high transaminases, and a viral screen was ordered.
Viral screen
Anti-
HepA
IgM/IgG Negative
Hep C Virus RNA Undetectable
HBsAg (
HepB
surface antigen) Positive
Anti-
HBcAg
IgM Positive
Anti-
HBcAg
IgG Negative
Anti-HBsAg IgG Negative
Given the diagnosis, what is the most likely
prognosis for this patient?
Full recovery
Carrier status
Chronic hepatitis
Cirrhosis
Hepatocellular carcinoma
Slide7SBA 3
A 59 year old man with a history of long-standing alcoholism and previous episodes of hepatic encephalopathy presents to ED with altered mental status, fever and worsening abdominal distension and tenderness. An ascitic tap shows neutrophil concentration of 345 cells/mm3
Given the most likely diagnosis, how would you manage this patient?
Reassure and discharge
IM chlordiazepoxide and IV rifaximin
Large volume paracentesis
IV Cefotaxime and oral lactulose
IV vancomycin and IV albumin
Slide8Jaundice
Increased bilirubin concentration in the blood
Liver
Unconjugated bilirubin
– albumin
Unconjugated bilirubin
Conjugated bilirubin
UDPGT
uridine-
diphosphoglucuronic
glucuronosyltransferase
Conjugated bilirubin in bile
Biliary system
Duodenum
Haeme
Unconjugated bilirubin
and iron
Spleen
Urobilinogen
Stercobilinogen
Slide9Jaundice
Pre-hepatic
Haemolysis/Gilbert’s
Hepatocellular
Hepatitis
Cirrhosis
Liver mass
Haemochromatosis
Post-hepatic
Gallstone
Pancreatic cancer/(bile duct cancer)
PSC/PBS
Drugs
Bilirubin
↑
(unconjugated)
↑
(mainly conjugated)
↑
(conjugated)
Slide10Jaundice
Pre-hepatic
Haemolysis/Gilbert’s
Dark urine
(
conj
bilirubin)
Dark urine
(
conj
bilirubin)
+
pale stools
(lack of stercobilin)
+
pruritus
(bile salts)
Post-hepatic
Gallstone
Pancreatic cancer/(bile duct cancer)
PSC/PBS
Drugs
Normal urine
Hepatocellular
Hepatitis
Cirrhosis
Liver mass
Haemochromatosis
Slide11Jaundice- raised bilirubin
Pre-hepatic
Haemolysis/Gilbert’s
Hepatocellular
Hepatitis
Cirrhosis
Liver mass
Haemochromatosis
Raised bilirubin only
Raised ALP/GGT
Hepatocyte damage
Bile duct damage
Raised AST/ALT
Post-hepatic
Gallstone
Pancreatic cancer/(bile duct cancer)
PSC/PBS
Drugs
Slide12Hepatitis
Alcoholic
NASH
Viruses
Autoimmune
Inflammation of the liver
Causes?
Drugs
RUQ pain, jaundice, hepatomegaly, joint pain, nausea, fatigue, dark urine
Acute or chronic (<6 months)
Raised AST and ALT
Acute hepatitis
C
hronic hepatitis
Cirrhosis
Recovery
Liver failure
Slide13Alcoholic liver disease
Steatosis (fatty)
Alcoholic Hepatiti
s
(inflammation)
Completely reversible
Reversible
, especially if mild Irreversible
After few days of heavy drinking
No symptoms
After
long term alcohol use
, rarely after
binge
Nausea, anorexia, weight loss, hepatomegaly
Severe:
fever, jaundice, tachycardia, tender hepatomegaly, bruising, encephalopathy, ascites
Cirrhosis
Come to later
Damage mediated by consumption of NAD+ which promotes fatty infiltration
inflammation
Alcoholic hepatitis
InvestigationsFBC: macrocytic anaemia
LFTs: AST/ALT ratio >2,
↑bilirubin, -/↑ALP,
↑GGT
, ↓ albumin
Clotting:
↑ prothrombin time sensitive marker of significant liver damage
Imaging: hepatic USS
Liver biopsy (diagnostic, rarely needed) and histology: ballooning,
Mallory bodies indicates hepatitis
Management
Alcohol abstinence
+ withdrawal management (diazepam)
Nutrition (enteral preferred, calories
and vitamins)
Weight loss/stop smoking
Steroids in severe alcoholic hepatitis
Alcohol then to
ast
Slide15Non-alcoholic fatty liver disease (NAFLD)
Steatosis (fatty)
Steatohepatitis
(NASH)
(inflammation)
Fatty liver in those who do not consume alcohol in amounts generally considered harmful to the liver
RFs:
Obesity
(truncal),
insulin resistance/diabetes
,
hyperlipidaemia
, hypertension, metabolic syndrome, short bowel syndrome, TPN.
Signs of insulin resistance (polyuria, polydipsia, acanthosis nigricans)
Ix
LFTs: AST:ALT elevated <1, GGT/ALP may also be elevated. Check glucose
Mx
Diet and exercise; controlling RFs (e.g., statins for
hypercholesterolaemia
, good blood sugar control for diabetics with metformin/thiazolidinediones)
Cirrhosis
Completely reversible
Reversible
, especially if mild Irreversible
Slide16SBA 1
A 39 year old female attends her GP for a routine check-up. She is obese and has type II diabetes, and been taking metformin and simvastatin for around 2 years. She complains of mild fatigue but has otherwise been well. She says she drinks around
8 units of alcohol per week. On examination there are no signs of chronic liver disease.
Investigations
Albumin 38 g/L (35-51)
ALT 178 IU/L (<40)
AST 154 U/L (<40)
ALP 57 U/L (35-51)
GGT 19 U/L (11-42)
Bilirubin 12
umol
/L (<17)
What is the most likely diagnosis?
Drug-induced hepatitis
Non-alcoholic steatohepatitis
Alcoholic hepatitis
Viral hepatitis
Cirrhosis
Slide17Viral hepatitis A and hepatitis E
Hepatitis A&E –
Acute
F
ae
co
-oral spread (sex/contaminated water)
Management –
Supportive. Avoid alcohol/excess paracetamol
Viral hepatitis
See infections 2 for Mx
Serology- Hep A Hep E
IgM- Now
IgG- Gone
Slide19Viral hepatitis B, C and D
Hepatitis B&C – Acute or chronic C
most commonly becomes chronic
B usually stays acute (80-90%)
As can be chronic, risk of cirrhosis/HCC (hep C)
Hep D Coinfection/superinfection of hep B.
Increases risk of liver failure for hep B
Management
Hep B: Acute
supportive Chronic antiviral
(e.g., peginterferon-a-2a OR tenofovir)
Hep C: Acute antiviral Chronic antiviral
(e.g., sofosbuvir, ledipasvir)
Slide20Viral hepatitis
Serology- Hep B
Slide21Serology- Hep B
Anti-HBs antibody from vaccine OR cleared infection
HBeAg
represents degree of replication and thus infectivity, HBV DNA shows viral load
Slide22Serology- Hep D (firstly, confirm Hep B, then:
Serology- Hep C
HDV IgG
Slide23SBA 2
A 21 year old male student in London was well until 4 days ago when he developed diarrhoea, vomiting and RUQ pain. Yesterday morning, his flatmates noticed that his eyes had turned yellow. He has not lost any weight in the past few months and his stools are brown. LFTs revealed high transaminases, and a viral screen was ordered.
Viral screen
Anti-
HepA
IgM/IgG Negative
Hep C Virus RNA Undetectable
HBsAg (
HepB
surface antigen) Positive
Anti-
HBcAg
IgM Positive
Anti-
HBcAg
IgG Negative
Anti-HBsAg IgG Negative
Given the diagnosis, what is the most likely
prognosis for this patient?
Full recovery
Carrier status
Chronic hepatitis
Cirrhosis
Hepatocellular carcinoma
Slide24Viral hepatitis
Key features
Mx
A + E
Acute
F
ae
co
-oral
spread (
oro
-anal sex; dirty water)
E can be chronic in immunocompromised
E can be severe in pregnancy (
liver failure)
Supportive for A & E
Avoid alcohol
Antiviral (ribavirin) for immunocompromised with hep E
BAcute or chronicMost adults clear it (full recovery); 10% become carriers; 10% get chronic hep BChildren more likely to be carriers/chronicSexually transmitted; IVDU; vertical
Acute:
supportive (most will clear)
Chronic:
Peginterferon-a-2a
C
Acute
or
c
hronic
Most adults develop chronic
hepatits
(80%), only 30% clear it
. Usually asymptomatic infection.
HCCBlood product spread (IVDU/transfusion)Acute: Antivirals (do not wait for natural clearance)Chronic: Antivirals
(see notes for choice)DSuperinfection of B- requires
HbSAg to infect cellsPeginterferon-a AND tenofovir
Slide25Hepatitis- distinguishing features
Alcoholic
NASH
Viral
Drug
AI
Hx
Long term
alcohol misuse
(but can be after binge)
Insulin resistance, diabetes, obesity, lack of XS alcohol
A&E: travel to endemic area/
faeco
-oral (contaminated water)
B: Unprotected sex/MSM/verticalC: blood products (IVDU needle sharing)FEVERMany drugs, important one is paracetamol (
acute liver failure)
Others: NSAIDs, GCs, isoniazid,
fluclox, erythromycinOther AI disease (T1DM, hashimoto’s, coeliac) F>MIxAST:ALT >2↑GGTAST:ALT <1AST/ALT (in 1000s)Viral serologyAST/ALT (in 1000s)Serum paracetamol concentrationAST/ALTANA, ASMA (Biopsy: interface hepatitis + plasma cells)Mx
Alcohol abstinence, nutrition, (steroids)
Diet + exercise + RF control
See viral hepatitis table
Paracetemol
overdose- N-acetyl cysteine
Not required for year 3
Slide26Haemochromatosis
Definition: condition leading to abnormal iron deposition in certain organs
(liver
,
pancreas
, skin, pituitary, heart, joints)
Primary haemochromatosis
Hereditary- autosomal recessive.
Cannot stop iron absorption from GI tract
Secondary haemochromatosis
Iron overload e.g., multiple transfusions,
Clinical features:
75% asymptomatic.
Key symptoms are hepatomegaly,
diabetes mellitus onset
,
bronze skin
, arthralgia, male impotence
M experience before F
May progress to cirrhosis and HCC
Investigations:
1
st-
Transferrin saturation (raised) and serum ferritin (raised,
non-specific as acute phase protein
)
Gene typing of HFE
Liver biopsy (gold standard)
Hereditary (AR) or multiple transfusions
Bronze skin
Onset of diabetes
Arthralgia, heart disease
Slide27Wilson’s disease
Definition: Impaired copper
excretion, copper accumulates in liver and brain
Clinical features:
Hepatitis + dementia + parkinsonism in young person
Hepatosplenomegaly,
abdo
pain, jaundice, ascites, portal HTN
Kayser-Fleischer rings
Epidemiology:
Autosomal recessive genetic disorder. Age of onset 5-35 years
Investigations
1
st-
LFTs (raised transaminases/bilirubin), 24-hr urinary copper, slit lamp examination
↓ serum ceruloplasmin (copper transport protein), ↑ serum free copper and urinary copper excretion
Genetic testing/liver biopsy and measurement of copper content (gold standard)
Slide28Cirrhosis
AetiologyAlcohol misuse, viral hepatitis (B/C), autoimmune hepatitis, haemochromatosis, NASH, chronic biliary disease
(Macronodular- viral Micronodular- alcoholic)
Normal liver replaced with
fibrosis
and
nodules
of regenerating hepatocytes
Can be stable or decompensated (liver failure)
Slide29Stigmata of chronic liver disease
Slide30Portal hypertension
↑ pressure in portal vein due to cirrhosis (of any cause)
Blood flows from portal to systemic circulation (
porto
-systemic
anastamosis
)
Lower
eosophagus
Anal canal
Umbilicus
Splenorenal
This leads to:
Distended veins (varices)
Ascites
Splenomegaly
Slide31Signs of portal hypertension
Slide32Cirrhosis
ManagementTreat cause + avoid hepatotoxic drugs (alcohol, sedative, opiates, NSAIDs etc.)
Monitor risk of complications (MELD score, 6-monthly USS, endoscopy upon diagnosis and every 3 years)
Manage complications:
Encephalopathy
Treat precipitating event (GI bleed, infection etc.) + short term protein restriction
Oral l
actulose, phosphate enema
Avoid sedatives
Slide33Encephalopathy
Key RFs:
GI bleed, infection
Slide34Cirrhosis
ManagementTreat cause + avoid hepatotoxic drugs (alcohol, sedative, opiates, NSAIDs etc.)
Monitor risk of complications (MELD score, 6-monthly USS, endoscopy upon diagnosis and every 3 years)
Manage complications:
Encephalopathy
Treat precipitating event (GI bleed, infection etc.) + short term protein restriction
Oral l
actulose, phosphate enema
Avoid sedatives
Ascites
Sodium restriction ±
Diuretics (
fures+spir
) ±
Large volume paracentesis
Spontaneous bacterial peritonitis*
Abx (cefuroxime+
metronidazole)
*(>
250 neutrophils per mm
3
ascitic fluid)
E.Coli
Varices
Primary prophylaxis
Non-selective
β
-blocker (if small), EVL (if big)
Ruptured (
haematemesis)
ABCDE, IV fluids/blood (when Hb<7g/dL)
Terlipressin
+ Abx
EVL (after resuscitation, when
haemody
stable)
Secondary prophylaxis
Non-selective
β
-blocker (to replace
terlipressin
after 2-5 days)
TIPS procedure (EVL +
β
-blocker fails to prevent)
*uncontrollable bleeding use balloon tamponade/metal mesh stent
Slide35SBA 3
A 59 year old man with a history of long-standing alcoholism and previous episodes of hepatic encephalopathy presents to ED with altered mental status
, fever
and
worsening abdominal distension and tenderness
. An ascitic tap shows neutrophil concentration of
345 cells/mm3
Given the most likely diagnosis, how would you manage this patient?
Reassure and discharge
IM chlordiazepoxide and IV rifaximin
Large volume paracentesis
IV Cefotaxime and oral lactulose
IV vancomycin and IV albumin
Slide36Liver failure
Definition: severe liver dysfunction leading to jaundice, encephalopathy and coagulopathyAcute: paracetamol overdose
(transaminitis +++) (50% of ALF)/ viral hepatitis
Acute-on-chronic
: acute
decompensation
in patients with chronic liver disease
Ix
Identify cause (viral serology, paracetamol levels, etc.)
Mx
See acute med for paracetamol overdose
Treat complications
Liver transplant
Slide37Liver abscesses/cyst
Pyogenic abscess
S. Aureus (kids), E. Coli (adults)
60% related to biliary disease
e.g., gallstones, strictures
Amoebic abscess
Entamoeba histolytica
infection (
faeco
-oral spread)
Amoebic dysentery (profuse bloody diarrhoea)
Hydatid cyst
Tapeworm
Echinococcus granulosis
infection
Can be massive. Sheep-rearing countries
Definition:
Liver infection
walled off collection pus/cyst fluid
Hx:
Fever, malaise, weight loss, RUQ pain (
shoulder pain), jaundice. Foreign travel.
Ex:
Jaunice, tender hepatomegaly, dullness to percussion/↓ breath sounds at right
lung base
Ix
: Bloods (FBC- mild anaemia,
leukocytosis
,
eosinophilia for hydatid cyst
Stool microscopy: For
Entamoeba histolytica
or
Echinococcus granulosis
Aspiration and culture of abscess: pyogenic (most polymicrobial), amoebic (anchovy sauce with necrotic hepatocytes/trophozoites)
TB
Extrapulmonary manifestation!
Slide38Slide39SBA 4
A 38 year old lady attends the A&E department with jaundice, itchy skin and dark urine for the last few days. On examination, there were no signs of liver disease, but scratch marks on her arms. Her past medical history includes a benign breast lump which was removed 3 years ago, and a UTI treated one week ago at the GP. She has only ever drunk 14 units of alcohol per week and smokes 15 cigarettes per week.
Investigations
Albumin 38 g/L (35-51)
ALT 65 IU/L (<40)
AST 55 U/L (<40)
ALP 1024 U/L (35-51)
GGT 59 U/L (11-42)
Bilirubin 245
umol
/L (<17)
What is the most likely diagnosis?
Alcoholic hepatitis
Pancreatic cancer
Drug induced cholestasis
Choledocholithiasis
Acute cholangitis
Slide40SBA 5
A 35-year-old obese woman with a history of gallstones presents to the emergency department with severe, constant right upper quadrant (RUQ) pain for around 16 hours. She has been vomiting and still feels nauseous. O/E the tympanic temperature was 39.8°C, murphy’s sign was positive, but no evidence of jaundice.
FBC
WBC 22 x 10^9/L (4-11)
LFTs
No significant abnormalities
Given the likely diagnosis, how would you initially manage this patient?
Oral paracetamol and fluids
Nil by mouth and urgent laparoscopic cholecystectomy
Nil by mouth and urgent ERCP
Clear fluids only, IM diclofenac, IV fluids and antibiotics
Clear fluids only, IM diclofenac, IV fluids and antibiotics and percutaneous cholecystostomy
Slide41SBA 6
A 43-year-old man with a history of mild ulcerative colitis is noted to have markedly elevated serum alkaline phosphatase, slightly elevated aminotransferases, and normal bilirubin on routine laboratory testing. He complains of fatigue and upper abdominal pain.
Which investigative finding fits the likely diagnosis?
Presence of antimitochondrial antibodies
Presence of anti-smooth muscle antibodies
Beads on a string appearance on MRCP
Raised CA19-9 tumour marker
Presence of
antihepatitis
B surface antigen antibody (anti-HBsAg)
Slide42Jaundice- raised bilirubin
Pre-hepatic
Haemolysis/Gilbert’s
Hepatocellular
Hepatitis
Cirrhosis
Liver mass
Haemochromatosis
Normal LFTs
Raised ALP/GGT
Hepatocyte damage
Bile duct damage
Raised AST/ALT
Post-hepatic
Gallstone
Pancreatic cancer/(bile duct cancer)
PSC/PBS
Drugs
Slide43SBA 4
A 38 year old lady attends the A&E department with jaundice, itchy skin and dark urine for the last few days. On examination, there were no signs of liver disease
, but scratch marks on her arms. Her past medical history includes a benign breast lump which was removed 3 years ago, and a
UTI treated one week
ago at the GP. She has only ever drunk
14 units of alcohol per week
and smokes
15 cigarettes per week
.
Investigations
Albumin 38 g/L (35-51)
ALT 65 IU/L (<40)
AST 55 U/L (<40)
ALP 1024 U/L (35-51)
GGT 59 U/L (11-42)
Bilirubin 245
umol
/L (<17)
What is the most likely diagnosis?Alcoholic hepatitisPancreatic cancer
Drug induced cholestasis
Choledocholithiasis
Acute cholangitis
Slide44Post-hepatic jaundice
Diagnosis
Typical features
Pathogenesis
Gallstones
Hx biliary colic or cholecystitis
Small gallstones get through the cystic duct into biliary tree
Cholangitis
Charcot’s triad:
Pain, fever, jaundice
Ascending infection of bile ducts by
E. Coli
in stagnant bile
Pancreatic cancer
Painless jaundice + palpable gall bladder (Courvoisier’s)Tumour (usually in) head of pancreas occludes distal bile ductBile duct cancer (aka cholangiocarcinoma)Gradual onset obstructive pattern
Direct occlusion by disease
PBC/PSC
PBC: Hx of AI condition
PSC: Hx of UCChronic inflammation of bile ducts
Slide45Gallstones- easy
Gallstone in gallbladder=
Cholelithiasis
Cholelithiasis + pain=
Biliary colic
Cholelithiasis + inflammation ±secondary infection=
Acute cholecystitis
No jaundice
!
Not obstructing biliary flow*
Ix
USS liver and biliary tree
Slide46Gallstones- easy
Gallstone in gallbladder=
Cholelithiasis
Cholelithiasis + pain=
Biliary colic
Cholelithiasis + inflammation ±secondary infection=
Acute cholecystitis
Mx
Incidental finding… no Mx
Analgesia + elective lap chole
Initial:
Clear fluids only. Analgesics, fluid resus,
broad IV Abx if infection.
Definitive: Lap chole
(within 1 week if uncomplicated)
Slide47Gallstones- easy
Gallstone in CBD=
Choledocholithiasis
Choledocholithiasis + infection=
Ascending cholangitis
May be jaundice/raised
ALP/GGT
Obstruction to biliary flow
Choledocholithiasis + pain=
Biliary colic
Ix
:
USS liver and biliary tree
ERCP if suspect acute cholangitis
Gallstones- easy
Gallstone in CBD=Choledocholithiasis
Choledocholithiasis + infection=
Ascending cholangitis
Choledocholithiasis + pain=
Biliary colic
Mx
(Analgesia) + ERCP
+ lap chole
Slide49Endoscopic Retrograde Cholangio
-Pancreatography (ERCP)
Slide50Gallstones- easy
Gallstone in CBD=Choledocholithiasis
Choledocholithiasis + infection=
Ascending cholangitis
Choledocholithiasis + pain=
Biliary colic
Mx
(Analgesia) + ERCP
+ lap chole
Initial:
Clear fluids only.
Analgesics, fluid
resus, broad IV Abx
+ ERCP
Lap chole
Slide51Gallstones- all in 1 slide
Symptomatic cholelithiasis
Choledocholithiasis
Acute cholecystitis
Acute cholangitis
Sx
RUQ pain
Jaundice
Fever
X/✓
(post-prandial)
X
X
✓
X/
✓
X
✓
(Murphy’s +ve)X (NOTE!)
✓
✓
✓
✓
Bloods WCC
LFTs
-
-
-
-/slightly ↑
↑
-/slightly ↑
↑
↑
Take cultures
Imaging(diagnostic)US: stones in GB (acoustic shadow)
US: stones in CBD +/-dilated CBDUS: stones in GB + GB wall thickening + GB lumen dilation(USS)ERCP if charcot’s triadInitial managementIF SYMPTOMATIC
AnalgesiaAnalgesia+ERCP (regardless of symptoms)
Clear fluids only. Analgesics, fluid resus, broad IV Abx if infection.
Clear fluids only. Analgesics, fluid
resus, broad IV Abx +
ERCP Definitive managementElective lap chole
Elective lap choleEarly lap chole within a week of onset. Otherwise, delayed to let inflammation settle.Elective lap chole
ComplicationsBiliary colic, acute cholecysitis
, choledocholithiasisObstructive jaundice, acute cholangitis, pancreatitisGallbladder empyema, porcelain gallbladder, risk of GB cancer, gallstone ileus
Bile duct perforation/bile peritonitis/sepsis
Charcot’s triad
Slide52Gallstones
Pigment stones (5%)
Calcium bilirubinate
HAEMOLYSIS!
(liver fluke)
Risk factors: 5 Fs
Fair
Fat
Fertile (1 or more kids)
Female
Forty
+OCC, Crohn’s
Mixed stones (80%)
Cholesterol stones (10%)
>50% cholesterol
Slide53SBA 5
A 35-year-old obese woman with a history of gallstones presents to the emergency department with severe, constant right upper quadrant (RUQ)
pain for around 16 hours. She has been vomiting and still feels nauseous
. O/E the tympanic temperature was
39.8°C
,
murphy’s sign was positive
, but
no evidence of jaundice.
FBC
WBC 22 x 10^9/L (4-11)
LFTs
No significant abnormalities
Given the likely diagnosis, how would you initially manage this patient?
Oral paracetamol and fluids
Nil by mouth and urgent laparoscopic cholecystectomy
Nil by mouth and urgent ERCP
Clear fluids only, IM diclofenac, IV fluids and antibiotics Clear fluids only, IM diclofenac, IV fluids and antibiotics and percutaneous cholecystostomy
Slide54PBC and PSC
Both inflammatory conditions of the bile ducts causing cholestasis
Primary biliary cirrhosis
Intrahepatic ducts only
F>M
Histology- ‘florid duct lesion’
Assoc. with
Sjorgen’s
, RA
Raised
antimitochondrial antibodies
usually diagnostic
Cirrhosis, HCC,
granulomas
Primary sclerosing cholangitis
Intra and extra-hepatic ducts
M>F
Histology- ‘
concentric onion skin fibrosis
’
Assoc. with
ulcerative colitis
Diagnose with MRCP (
beaded appearance
)- segmental fibrosis with saccular dilation
Many antibodies including
pANCA
may be raised
Complications include
cirrhosis
, HCC,
cholangiocarcinoma
PBC- “b
i
liary”-
intrahepaticPSC- “scleros
ing” – intra- and
extra- hepatic
Slide55Pancreatic cancer
Pancreatic cancer- painless jaundice,
palpable gallbladder*
Mostly adenocarcinoma from exocrine tissue- 75% in
head
of pancreas
RFs: Smoking, obesity, TD2M, chronic pancreatitis
S+S. Commonly
delayed
presentation due to non-specific signs (malaise, weight loss,
abdo
pain). Jaundice is later sign.
Hepatomegaly if hepatic metastasis
Ix
1st- Can do USS but
pancreatic protocol CT
more sensitive and
shows
the extent of local or distant spread
Gold standard- biopsy (via ERCP/EUS)
Tumour marker: CA19-9
Slide56Malignant liver tumours
Primary tumoursHepatocellular carcinoma (90%)
Cholangiocarcinoma
SECONDARY TUMOURS
(most common)
Metastasised commonly from bowel, breast,
eosophagus
, stomach, pancreas
Slide57Hepatocellular carcinoma (aka hepatoma)
Primary malignancy of hepatocytes usually in cirrhotic liver
RF: hep C, hep B, alcoholic liver disease, AIH, haemochromatosis, NAFLD, aflatoxin, PBC. Smoking, obesity
S+S: Malaise, weight loss, anorexia, (RUQ pain). Jaundice, ascites (due to chronic liver disease) cachexia, hepatomegaly
Ix
LFTs, viral serology
Tumour marker: AFP
6 monthly
USS
for those at high risk of HCC/ 2
wk
wait if liver mass
Liver CT to confirm
Liver biopsy (gold standard)
Slide58Bile duct cancer (cholangiocarcinoma)
Usually adenocarcinomas of bile duct epithelium
RFs:
PSC
, worm infections and cirrhosis
Can arise from intra-, extra-hepatic ducts or the gallbladder
S+S and
Ix
same as pancreatic cancer
-these diseases are distinguished by imaging/histology
Pancreatic cancer more common
Ix
1st- Abdo USS (dilated intrahepatic ducts, mass lesion)
Gold standard- biopsy (using ERCP)
Slide59Before reviewing last SBA….
Took me: 21hrs
Takes you: 30 seconds
Feedback
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Even if viewing slides later!
tinyurl.com/
robliver
Slide60SBA 6
A 43-year-old man with a history of mild ulcerative colitis is noted to have markedly elevated serum alkaline phosphatase
, slightly elevated aminotransferases, and normal bilirubin on routine laboratory testing. He complains of fatigue and upper abdominal pain.
Which investigative finding fits the likely diagnosis?
Presence of antimitochondrial antibodies
Presence of anti-smooth muscle antibodies
Beads on a string appearance on MRCP
Raised CA19-9 tumour marker
Presence of
antihepatitis
B surface antigen antibody (anti-HBsAg)
Slide61Slide62Thank you
tinyurl.com/
robliver
Questions to:
Rob Grogan
rjg17@ic.ac.uk