1. Hepatobiliary Disease
Michael Watts

2. Functions Blood sugar Homeostasis Bile formation
Plasma protein production (albumin, fibrogen, globulin)
Urea synthesis (ammonia)
Lipid metabolism
Storage (copper, iron, vit B12)

3. Portal System
2/3 Portal Vein
1/3 Hepatic artery
Exit via Hepatic vein

4. PRE- HEPATIC
HEPATIC
POST- HEPATIC

5. Causes of Jaundice Pre-Hepatic Hepatocellular Post Hepatic
Haemolysis (sickle cell, thalassemia, SLE, transfusion, haemolytic disease of the newborn)
Hepatocellular liver damage (drugs, sepsis, pregnancy, TB)
Hepatitis (viral, alcohol, non-alcoholic steatohepatitis, PBC)
Cirrhosis
Structural disorder of bile duct
Cholelithiasis
Pancreatic Ca, Pancreatitis
Congenital atresia of bile duct
Bile duct obstruction (cholangiocarcinoma/stricture)
Primary sclerosing cholangitis

6. Clinical Picture Pre Hepatic Hepatocellular Post Hepatic
Serum Bilirubin ↑
(unconjugated) ↑↑
(mixed)
(conjugated)
Urinary Urobilinogen -
Urinary Bilirubin
ALP
ALT
AST
↑/-
ALT/AST- found in hepatocytes therefore raised in their death. AST:ALT >2:1 = Alcohol liver disease AST:ALT <1 = Viral
ALP- found in mitochondria of bile duct, amongst many other parts of the body. Raised in cholestasis, bone disease and pregnancy
Gamma GT- Elevated in chronic alcohol use, but also in bile duct disease, metastasis and some drugs
Clotting – Raised INR
Glucose - Hypoglycaemia

7. Hepatocellular causes
Defective uptake ie Gilberts syndrome (glucoronyltransferase deficiency) and Crigler Najjar (very rare) = unconjugated hyperbilirubinaemia or low blood supply ( heart failure or TIPSS)
Abnormal conjugation (drugs ie rifampicin, partial glucoronyltransferase deficiency)
Hepatitis, drugs, alcohol, cirrhosis, haemochromatosis, wilsons, Budd-Chiari = conjugated hyperbilirubinaemia

8. Acute Hepatitis
Alcohol Viral Medicines (paracetamol, halothane) Autoimmunity

9. Viral Hepatitis

10. Hepatitis A Most commonly occuring worldwide
Spread by faeco-oral route and by ingestion of contaminated food (shellfish)
Jaundice, anorexia and distaste for cigarettes
2 weeks later: Jaundice (pale stools, dark urine) and recovery, if not = hospital admission
Recovery takes 3-6 weeks
Raised ALT and AST prior to Jaundice
No specific treatment, Prognosis good
Travel vaccine

11. Hepatitis B Another worldwide virus with many carriers
Vertical and horizontal transmission
IVDU,MSM, close contact and toothbrushes!
Inner core surrounded by an enveloped surface protein
cAb = previous infection sAg = infected Anti-HBc IgM is diagnostic
Symptoms similar to HAV, cleared by immune system (sometimes more severe)
Extrahepatic immune complex mediated Arteritis and glomerulonephritis can occur
Tx symptomatic and monitor viral markers. Antivirals where markers persist
Vaccination for those high risk in UK
10% develop chronic hepatitis  20% develop cirrhosis and HCC

12. Hepatitis C Rarer in UK but prevelant in Africa (egypt)
Blood transmission (IVDU = v high risk!)
Limited role in sexual transmission due to low rate in those at risk
Asymptomatic, most diagnosed years later at health check. Can have extrahepatic manifestations.
Diagnosis by exclusion of others. Anti-HCV present at 8 weeks
Tx with Interferon to prevent chronic illness
90% of asymptomatics develop chronic hepatitis, 20-30% develop cirrhosis

13. Hepatitis D
Unable to replicate by itself, needs presence of HBV therefore seen in similar high risk groups
Can be present as a Coinfection (Anti-HDV +Anti-HBV) or superinfection (acute flare up of previous HBV infection)
Chronic disease less common but if develops chance of cirrhosis higher

14. Hepatitis E Similar picture to HAV Contaminated water
Fulminant hepatic failure mortality 1-2% rises to 20% in pregnant women

15. Alcoholic (fatty) Liver Disease
Men > Women
25-50% Immediate mortality
Risk factors: Consumption, female, genetics, obesity, concomitant disease (Haemochromatosis)
Management: Abstinence, withdrawal control (Librium, Pabrinex) Diet, Ascites (Spironolactone, loop, drain) Encephalopathy (lactulose) Variceal bleed
Long term: AA, Variceal / HCC surveillance

16. Autoimmune Hepatitis Acute Women > Men Raised ALT
Anti-Smooth muscle Antibody
IgG
Tx: Steroids

17. Post hepatic Obstruction or impaired excretion of bilirubin
cholestasis

18. Cholestasis
Causes: Gallstones, pancreatitis, pancreas Ca, Cholangiocarcinoma, PBC, PSC, atresia
Signs and symptoms: Jaundice, dark urine, pale stools, pruritis, ?fever, ?pain
Tests: Raised ALP (GGT) > ALT, raised bilirubin, raised WCC, CRP, Liver Screen, MRCP
Mx: Gallstones (ERCP vs Lap Chole) Cholecystitis ( IV fluids and Abx )

19. Primary Biliary Sclerosis
Cholestasis caused by chronic autoimmune granulomatous inflammation of the bile ducts = fibrosis, cirrhosis and portal hypertension
Women > Men
Raised ALP
AMA positive
IgM
Ursodeoxycholic acid (ursodiol) improves cholestasis

20. Primary Sclerosing Cholangitis
Progressive cholestasis with bile duct inflammation and strictures
Pruritis and fatigue
Men > Women
Increases risk of hepatobiliary cancers so yearly colonoscopy and USS, concider lap chole
Raised ALP
AMA negative but ANA, SMA may be positive
Liver transplant necessary in end-stage disease

21. Couvoursiers law
If there is a palpable gallbladder with painless jaundice, the cause is not gallstones

22. Charcots triad = cholangitis
Jaundice
Fever
RUQ
If no jaundice = acute cholecystitis
If no jaundice and fever = biliary colic

23. Neonatal Jaundice Unconjugated hyperbilirubinaemia can be normal
Caused by short lifespan of foetal RBC and low activity of liver in first few days. Extrahepatic circulation of bilirubin from breastfeeding (breast milk jaundice), blood group incapabilities
Test by serum bilirubin and blood grouping of mother and infant
If excessive rise, can cause death or kernicterus
Tx blue light or transfusion

24. History Smoking, Alcohol, Drugs Foreign Travel
PMH/FH of autoimmune disease
FH of liver disease / alcohol misuse
High risk behaviour (IVDU)

25. Signs and symptoms
CONFUSION AND LETHARGY

26. Investigations
FBC ( Hb = bleeding?, WCC = infected/inflammation? Platelets = low? )
U&E’s (renal dysfunction)
LFT’s ( inflammation vs function )
Inflammation = ALT > ALP
If AST >1000 probably viral hepatitis
GGT = alcohol
Function = Low albumin High bilirubin
Virus serology