--- module: 048-01 language: en chapter: 48 title: "Liver, Biliary Tract, and Pancreatic Disease" module_title: "Foundations" source_sha256: ed13b8f0b9081eb71864bc32f5dcc5ef87b6d1dba723fdb0eacde59735fa2efd --- # Liver, biliary tract, and pancreatic disease ## Orientation and liver tests ### Portal blood brings nutrients, toxins, microbial products ### Hepatocytes synthesise, detoxify, make urea and bile ### Symptoms subtle until reserve is exhausted ### Aminotransferases mark membrane injury, not function ### Alkaline phosphatase: cholestasis, also bone ### Albumin reflects weeks, altered by many factors ### Prothrombin time changes rapidly with synthetic failure ## Pattern and investigation ### Hepatocellular pattern: aminotransferases dominate ### Cholestatic pattern: phosphatase and bilirubin ### Very high values: ischaemia, paracetamol, hepatitis #### Degree does not reliably predict outcome ### Ultrasound: ducts, gallbladder, texture, vessels, ascites ## Jaundice ### Unconjugated: haemolysis, ineffective erythropoiesis ### Conjugated bilirubin is water soluble, darkens urine ### Pale stool and pruritus: less bile reaches gut ### Painful febrile jaundice: ascending cholangitis ### Painless progressive jaundice: malignant obstruction ### Urgent if coagulopathy, confusion, hypoglycaemia ## Acute hepatitis and liver failure ### Viral, drug, toxic, immune, ischaemic, metabolic causes ### Precise exposure timeline including herbal products #### Dose and timing crucial in paracetamol poisoning ### Failure: new injury, coagulopathy, encephalopathy ### Cerebral oedema, hypoglycaemia, infection, collapse ### Repeat glucose, stop toxins, avoid sedation ### Early discussion with a transplant centre ### N-acetylcysteine replenishes glutathione ## Chronic liver disease and cirrhosis ### Nodules and scar raise intrahepatic resistance #### Function falls ### Compensated disease may be silent ### Decompensation: ascites, bleeding, encephalopathy ### Alcohol: steatosis to hepatitis to cirrhosis #### Abstinence support is central ### Metabolic steatotic disease: insulin resistance #### Fibrosis stage predicts liver outcomes ### Hepatitis B integrates, cancer without cirrhosis ### Hepatitis C cured, advanced fibrosis still monitored ## Portal hypertension and ascites ### Collaterals, splenomegaly, ascites ### Varices may bleed catastrophically #### Beta blockade or banding for prevention ### Acute bleeding: restrained resuscitation #### Vasoactives, antibiotics, endoscopic control #### Shunt if bleeding persists or high risk ### Ascites: portal pressure, vasodilation, sodium retention ### Diagnostic paracentesis for new or worsening ascites ### Peritonitis may lack local tenderness #### Prompt antibiotics, albumin in selected patients ### Recurrent ascites: sodium, diuretics, drainage #### Albumin replacement with large volumes ## Encephalopathy and hepatorenal dysfunction ### Altered attention, sleep, behaviour, consciousness ### Lactulose promotes colonic ammonia disposal #### Titrate to regular soft stool ### Rifaximin reduces recurrence ### Ammonia level neither confirms nor excludes ### Kidney injury: volume, sepsis, nephrotoxins first ### Hepatorenal: renal vasoconstriction amid vasodilation #### Albumin plus vasoconstrictor bridges to transplant ## Liver cancer and transplantation ### Cirrhosis and hepatitis B raise carcinoma risk ### Surveillance finds tumours for curative therapy ### Alpha-fetoprotein supports, not diagnostic alone ### Transplant replaces function, removes portal hypertension #### Lifelong immune suppression and surveillance ## Gallstones and biliary disease ### Supersaturated bile and gallbladder stasis ### Biliary pain: transient cystic-duct obstruction ### Cholecystitis: prolonged pain, fever, tenderness #### Ultrasound first, early cholecystectomy ### Common-duct stone: jaundice or pancreatitis ### Cholangitis is infected obstruction #### Fluids, antibiotics, urgent drainage ## Pancreatitis and pancreatic cancer ### Acute: premature enzyme activation #### Gallstones and alcohol are common causes ### Severity: organ failure, not enzyme height ### Analgesia, titrated fluids, enteral nutrition ### Prophylactic antibiotics do not treat sterile necrosis ### Chronic: irreversible fibrosis #### Exocrine failure, diabetes, cancer risk #### Enzymes with meals, vitamins, diabetes care ### Cancer presents late, often painless jaundice #### Imaging establishes resectability #### Surgery with systemic therapy: main chance of cure