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HEPATO-BILIARY
SYSTEM DR.SRINATH.CHANDRAMANI
ANATOMY
PHYSIOLOGY
SYMPTOMATOLOGY
INVESTIGATIONS
INDIVIDUAL DISEASES
HEPATOBILIARY SYSTEM
INDIVIDUAL DISEASES
VIRAL HEPATITIS
AUTOIMMUNE HEPATITIS
DRUG INDUCED HEPATITIS
ALCOHOLIC HEPATITIS
CIRRHOSIS + COMPLICATIONS
LIVER TRANSPLANTATION
GALLSTONES + PANCRAETITIS
Anatomy The right and the Left lobe are independent with regard to :
1. Portal blood supply
2. Arterial blood supply
3. Bile drainage.
Basic liver architecture :
Hepatocytes, which constitute two-thirds of the mass of the
liver.
Kupffer cells (members of the reticuloendothelial system),
Stellate (Ito or fat-storing) cells,
endothelial cells and blood vessels,
bile ductular cells, and
supporting structures.
Functional classification Based on drainage by major hepatic vein, Liver is
Functionally divided into 4 Sectors / 8 Segments
Caudate lobe is anatomically distinct having no
drainage by either of the 3 major hepatic veins. By
segment classification, It is classified as Segment 1.
Significance of above classification :
Interpretation of Radiological data
Planning of liver resection procedures.
PHYSIOLOGY Organ with a high metabolic rate and rich blood supply.
Dual Blood supply :
1. Hepatic artery 20% supply - Oxygen rich
2. Portal Vein - 80% supply - Nutrition rich
Portal Zones :
Blood flows from zone 1 to zone 3 of the acinus and drains
into the hepatic veins (central veins).
Secreted bile flows in the opposite direction, in a counter
current pattern from zone 2 to zone 1.
The sinusoids are lined by unique endothelial cells that have
prominent fenestrae of variable size, allowing the free flow
of plasma but not cellular elements.
The plasma is thus in direct contact with hepatocytes in the
subendothelial space of Disse.
Functions Hepatocytes perform numerous and vital roles in maintaining
homeostasis and health. These include :
synthesis of most essential serum proteins viz. albumin, carrier
proteins, coagulation factors, many hormonal and growth
factors.
production of bile and its carriers (bile acids, cholesterol,
lecithin, phospholipids),
regulation of nutrients (glucose, glycogen, lipids, cholesterol,
amino acids),
metabolism and conjugation of lipophilic compounds (bilirubin, anions, cations, drugs) for excretion in the bile or
urine.
Symptomatology
Jaundice
Parotid enlargement
Fetor hepaticus
Spider naevi
Gynaecomastia
Abdominal pain
Ascitis
Caput medusa
Dupeytrens contracture
Paper money skin
Pruritis
Testicular atrophy
High coloured urine
Pedal edema
Altered
sensorium/convulsion
Peticheia/ echymosis
Etiology & Approach Acute ( < 6 months ) Chronic ( > 6 months )
Infective Infective
Trauma Toxin/Drug induced
Vascular Genetic/enzyme deficiency
Toxin/Drug induced Glycogen storage disorders
Autoimmune Neoplasms
Physical obstruction Obstruction
Recurrent Jaundice
Hemolysis
Intermittent obstruction
Autoimmune hepatitis
Drug induced hepatitis
BRIC benign recurrent intrahepatic cholestasis
Liver Function Test
S.Bilurubin
Transaminases AST / ALT
Alkaline phosphatase / GGTP
S.Proteins / A:G ratio
Prothrombin time
Alpha-fetoprotein
TEST 1 1. Nucleotidase activity is increased in
(A) Bone disease
(B) Prostate cancer
(C) Chronic renal failure
(D) Cholestatic disorders
2. Which does not contribute to serum alkaline
phosphatase
(A) Liver
(B) Osteoblasts
(C) Renal tubular cells
(D) Neutrophils
3. Ratio of AST/ALT>1 present in
(A) Non-alcoholic steatohepatitis
(B) Alcoholic hepatitis
(C) Wilson's disease
(D) All of the above
TEST 1
4. A 50 year old lady presented with history of pain upper abdomen, nausea and decreased appetite for 5 days. She had undergone cholecystectomy 2 year ago. Her bilirubin was 10 mg/dl, SGOT 900 IU SGPT 700 IU/I and serum alkaline phosphatase was 280 IU/I. What is the most likely
diagnosis?
(A) Acute pancreatitis
(B) Acute cholangitis
(C) Acute viral hepatitis
(D) Posterior penetration of peptic ulcer
5. Patients with coagulation abnormality due To liver disease Are likely to have
(A) Prolonged bleeding time
(B) Prolonged prothrombin time
(C) Thrombocytosis
(D) Short partial thromboplastin time
6. All are haemoglobin except
(A) Bilirubin (B) Biliverdin
(C) Hemosiderin (D) Lipofuscin
7. Chances of developing kernicterus appears to be significant when serum level of
unconjugated bilirubin reaches
(A) 50 mg% (B) 20 mg%
(C) 10 mg% (D) 5 mg%
TEST 1 8. Gilbert's syndrome all are true, except
(A) Conjugated hyperbilirubinemia
(B) Fasting hypoglycaemia
(C) Normal liver histology
(D) Liver enzymes normal
9. Conjugated hyperbilirubinemia is seen in
(A) Gilberts syndrome
(B) Criggler Najjar type-I
(C) Criggler Najjar type-II
(D) Dubin Johnsons syndrome
10. The test used to diagnose Dubin Johnson syndrome is
(A) Serum transminases
(B) Bromsulphalein test (BSP)
(C) Hippurate test peptidase
(D) Gamma glutamyl transferase level
Viral Hepatitis Hepatotrophic virus.
Classification based on Route of
transmission.
Clinical Features :
- Prodromal phase
- Clinical phase
- Recovery phase
Extraintestinal manifestations.
General info All viruses are RNA viruses except Hepatitis B which
is a DNA virus.
Pathological injury occurs due to :
Direct injury
Immune mediated
Incubation period :
Start with B(+D) , C, E and A and substract 10 from
60 days.
B(+D) 60 days , C 50 days, E 40 days and A 30 days.
General Info
The typical morphologic lesions of all types of viral hepatitis
consist of :
panlobular infiltration with mononuclear cells,
hepatic cell necrosis,
hyperplasia of Kupffer cells,
variable degrees of cholestasis.
Hepatic cell regeneration is present, as evidenced by
numerous mitotic figures, Multinucleated cells, and rosetteor pseudoacinar formation.
Liver cell damage consists of hepatic cell degeneration and
necrosis, cell dropout, ballooning of cells, and acidophilic
degeneration of hepatocytes (forming so-called Councilman
or apoptotic bodies).
Lipofuschin is a wear and tear pigment.
Waterborne Hepatitis
Parameter Hepatitis A Hepatitis E
Epidemiology
Mode of transmission
Incubation period
Clinical peculiarity
Diagnosis
Treatment
Prognosis
Blood borne Hepatitis Parameter Hepatitis B Hepatits C
Epidemiology
Mode of
transmission
Mother to child
Needle stick injury
Incubation period
Clinical peculiarity
Diagnosis
Treatment
Prognosis
Serum markers for Hepatitis B
HBsAg
Anti-HBs antibody
HBcAg
Anti- HBcAb
HBeAg
Anti Hbe antibody
HBV DNA by PCR
Hepatitis B Plus D
Co-Infection Superinfection Both together HBV precedes
HDV infection
IgM HBc positive IgM HBc negative
No change in chronicity 6 fold increase in
chronicity
No change in cirrhosis Hastened progression
to cirrhosis
Increase risk of HCC Greater risk of HCC
Autoimmune hepatitis Autoimmune hepatitis is characterised by :
Female predominance 2nd decade / post menopausal.
Hyperglobulinemia
Positive circulating auto anti-bodies
Association with HLA-DR3 and HLA-DR4.
Prominence of extrahepatic features of autoimmunity
Secondary conditions have to be excluded viz.
virus,drugs,alcohol,etc.
Good response to immunosuppressive therapy. In general,
responders have :
Florid clinical picture
High antibody titer/ hyper globulinemia
Higher SGPT
Active Liver histology.
Classification is based on circulating antibody type.
may have a 6-month mortality of as high as 40%.
AUTOIMMUNE HEPATITIS
TYPE 1 TYPE 2 TYPE 3
ANTIBODY ANA ANTI-LKM ANTI-LsAg
EPIDEMIOLOG
Y
2-3RD DECADE
F >> M
4-5TH DECADE
F>M
5-6TH DECADE
M>F
CLINICAL
COURSE
ACUTE,
FLORID
CHRONIC,
INDOLENT
UNDERLYING
MALIGNANCY
TREATMENT IV STEROIDS,
PLASMAPHERE
SIS
ORAL
STEROIDS
UNDERLYING
MALIGNANCY
PROGNOSIS GOOD MODERATE POOR
Drug induced Hepatitis
Mode of Hepatic Injury
In general, two major types of chemical hepatotoxicity have been recognized :
(1) direct toxic type and
(2) idiosyncratic type.
Drug induced Hepatitis is classified based on the clinical and labaratory pattern.
Patterns of hepatotoxicity Hepatitis
Anesthetic : Halothane
Anticonvulsant : Phenytoin, carbamazepine
Antihypertensive : Methyldopa, captopril, enalapril
Antibiotic : Isoniazid, rifampin, nitrofurantoin
Diuretic : Chlorothiazide
Antidepressant : Iproniazid, amitriptyline, imipramine, trazodone,
venlafaxine
Anti-inflammatory : Ibuprofen, indomethacin, diclofenac
Antifungal : Ketoconazole, fluconazole, itraconazole
Antiviral : Zidovudine, didanosine, nevirapine
Calcium channel blocker :Nifedipine, verapamil, diltiazem
Mixed hepatitis/cholestatic
Immunosuppressive : Azathioprine
Lipid lowering : Nicotinic acid, lovastatin and other statins
Antibiotic : Amoxclav, trimethoprim-sulfamethoxazole
Antifungal : Terbinafine
Patterns of Hepatotoxicity Cholestasis
Anabolic steroid : Methyl testosterone
Antibiotic : Erythromycin, nitrofurantoin, rifampin, amoxclav, oxacillin
Oral contraceptive : Norethynodrel with mestranol
Anticonvulsant : Carbamazepine
Calcium channel blocker : Nifedipine, verapamil
Fatty liver
Antibiotic : Tetracycline
Anticonvulsant : Sodium valproate
Antiarrhythmic : Amiodarone
Antiviral : NRTI, Protease inhibitors.
Oncotherapeutic : methotrexate
Patterns of hepatotoxicity Toxic (necrosis)
Hydrocarbon Carbon tetrachloride
Metal : Yellow phosphorus
Mushroom : Amanita phalloides
Analgesic : Acetaminophen
Granulomas
Anti-inflammatory : Phenylbutazone
Antibiotic : Sulfonamides
Xanthine oxidase inhibitor : Allopurinol
Antiarrhythmic : Quinidine, diltiazem
Anticonvulsant : Carbamazepine
Vascular injury
Veno-occlusive/Portal vein thrombosis : Cytotoxic / Irradiation
Sex hormones
Neoplastic
Focal adenoma : sex hormones
Hepatocellular carcinoma : Danazol, Anobolic hormones
Management Diagnosis : is mainly based on history. Correlation with clinical
manifestation and above mentioned clinical picture helps. Anti-Histone Antibody is important marker.
Treatment : is largely supportive, except in acetaminophen
hepatotoxicity.
Withdrawal of the suspected agent is indicated at the first
sign of an adverse reaction.
Liver transplantation maybe curative in fulminant cases.
Glucocorticoids for drug hepatotoxicity with allergic features,
silibinin for hepatotoxic mushroom poisoning, and
ursodeoxycholic acid for cholestatic drug hepatotoxicity
have never been shown to be effective and are not recommended.
Misc Hepatitis
Reyes syndrome
Characterised by vacuolisation of liver
and renal tubules.
Increases Transaminases, Prothrombin
time and ammonia
hypoglycaemia and metabolic alkalosis.
Characterised by lack of jaundice.
Misc Hepatitis Budd-Chiari syndrome : Extremely rare disorder.
Thrombosis of Hepatic vein.
Etiology : Hypercoagulable states , Malignancy,
Myeloproliferative state.
Clinical features depend on extent and rate of
venous obstruction.
Hepatomegaly and Ascitis present in nearly 100%.
Varices in >50%.
Angiography diagnostic. CT preferred mode. Search
for underlying cause.
Medically lifelong anticoagulation . Surgical stenting.
SOS Liver transplant.
Prognosis is poor. Death wihin 3 years if untreated.
Misc Hepatitis Liver abscesses : Most common Amoeba
vs Pyogenic.
Intense RHypochondriac pain,
septicaemia. Intercostal tenderness.
USG, FNAC,CT is diagnostic.
Multiple sites is Pyogenic, Single lesion is
amoebic.
Metronidazole for 2 weeks. Antibiotics SOS.
Drainage SOS.
Prognosis excellent. Rupture and sub
phrenic abscess are complication.
Summary of chronic hepatitis
Etiology Age/gender Association Diagnosis
Hep B & D All/males
Orient, African,
Drug users,
Homosexuals,
Immunosupressed
HBsAg,HBVDNA
HEP C All/equal
Blood transfusion
Drug users,
Hemodialysis
Anti-HCV Ab
HCV RNA by PCR
Autoimmune 14-25 yrs/
Females
Multisystem
involvement
ANA, ASMA,
Anti-LKM, LsAg
Drug induced 3rd-5th decade
females Drug history
Anti histone,
drug levels
Wilson 10-30 yrs/
equal
Family history,
Hemolysis
KF ring,biopsy
Neurological
symptom.
Cu,Cerupl. level
TEST 2
11. True about hepatitis A include
(A) Spreads by faco-oral route
(B) Incubation period is 45-180 days
(C) Predisposes to cirrhosis
(D) lgG anti-HIV antibodied used for diagnosis
12. The marker of Hepatitis B in the window
period is
(A) HBsAG (B) Anti HBsAG
(C) Anti HBC (D) HBcAg
TEST 2 13. Two laboratory technicians from a District hospital were tested
Australia Antigen positive. True about the further steps is.....
(A) Discard all the blood samples collected by them.
(B) Do not allow them to work in the laboratory.
(C) test the if they are Anti-HBC (IgM) positive
(D) Retest them for Australia antigen after 6 months
14. Antigen which does not appear in blood in Hepatitis B is....
(A) HBc Ag
(B) HBe Ag
(C) HBs Ag
(D) None of the above
15. Acute liver injury associated with hepatitis B virus is due to
(A) Direct cytopathic effect of the virus
(B) Sensitized cytotoxic T-cells
(C) Immune-complex mediated tissue damage
(D) Vasculitis
TEST 2
16. Extrahepatic manifestation of Hepatitis-B are
(A) Aplastic anemia
(B) Cryoglobulinemia
(C) Peptic ulcer
(D) Gallstones
17. The likelihood of becoming an HbsAg carrier
after acute HBV infection is high in....
(A) Neonates
(B) Chronic hemodialysis patients
(C) Persons with Down's syndrome
(D) Persons with HIV infection
(E) All of the above
TEST 2 18. A person screened for blood donation, which of the following
serology is safe for blood donation?
(A) Anti HBsAg positive
(B) HBsAg positive
(C) Anti HBc positive and anti HBSAg positive
(D) HBeAg positive
19. The disease associated with hepatitis C virus is...
(A) Leprosy (B) Lichen planus
(C) Psoriasis (D) Vitiligo
20. Which of the following drugs is known to cause granuloma in the
liver?
(A) Allopurinol
(B) Nifedipine
(C) Tetracycline
(D) Methyl testosterone
Alcoholic Liver Disease
Cirrhosis
Etiological classification of cirrhosis :
(1) alcoholic;
(2) cryptogenic and posthepatitic;
(3) biliary;
(4) cardiac; and
(5) metabolic, inherited, and drug-
related.
(6) NAFLD / NASH
Biliary Cirrhosis Primary biliary cirrhosis :
auto- immune
AMA, Lipoprotein X
CREST syndrome,
Ursodeoxycholic acid
Cholestyramine
Liver transplant with excellent results.
Secondary biliary cirrhosis
Better prognosis
6-12 months
surgical correction is the cure.
NAFD/NASH/NON-ALCOHOLIC
CIRRHOSIS
MORE IN FEMALES
ASSOCIATION WITH PANCREATIC
INSUFFICIENCY / DM/OBESITY
HAS BECOME THE COMMONEST
CAUSE OF CRYPTOGENIC CIRRHOSIS
Complications of Cirrhosis
Variceal bleeding
Hepatic Encephalopathy
Spontaneous Bacterial Peritonitis
Coagulopathy
Hepato-renal syndrome
Hepato-Pulmonary syndrome
CHILD PUGH Grading of Liver disease
PORTAL CIRCULATION
Adult portal circulation Portal blood flow : 1000 1200ml/min
Portal pressure : normally 7mm of Hg.
Various sites of porto-systemic shunts/collaterals exist in the body.
Normally 100% of portal venous blood can be recovered from the
hepatic veins.
Collateral circulation comes into play in 2 situations :
1. INTRA HEPATIC PORTAL VEIN OBSTRUCTION :
The site of obstruction is within the liver. Commonest example being
cirrhosis.
Both physical as well as myo-proliferative factors are involved in portal
vein obstruction.
In such cases barely 13% blood flows through the hepatic vein, rest is
shunted.
Blood ultimately reaches Superior vena cava through the Azygous
system.
Typically the collaterals are abdominal shunts as discussed below.
Few collaterals to pulmonary veins described but rare.
2. EXTRA HEPATIC PORTAL VEIN
OBSTRUCTION :
The block lies outside the liver and hence
collaterals develop to bypass the block
and enter the liver as close to the porta
hepatis as possible.
Lumbar collaterals may be large.
The volume of shunt may be smaller than
intra hepatic obstruction.
SITES OF PORTO-SYSTEMIC ANASTOMOSIS : (Refer Figure)
SITE PORTAL VEIN SYSTEMIC VEIN CLINICAL OUTCOME
1. Cardia Stomach a. Left Gastric Esophageal Gastro-esophageal
b. Posterior Gastric Diagphramatic & Fundic varices c. Short Gastric Intercostal/Azygous
2. Anus Sup. Hemorrhoidal Middle & Inferior Rectal varices
Vein Hemorrhoidal Vein
3. Falciform ligament Paraumbilical Umbilical circulatn Caput Medusa
Vein of fetus
4. Abdominal organ Veins of Sappey Diapragmatic Prominent veins
Lumbar vein
5. Renal Splenic vein Left Renal vein Not known
Porto-systemic Anastomosis
Hepatic Encephalopathy
Cause
Precipitating Factors
Daignosis
Clinical Grading
Management
Spontaneous Bacterial Peritonitis
Difference from secondary
bacterial peritonitis
Mixed anaerobic flora
Presentation
Diagnosis
Treatment
Prophylaxis
Hepato-renal Syndrome Diagnostic criteria
S.Creatinine > 1.5 mg/dl / GFR < 40ml/min
Failure to improve with volume expansion
Avid Sodium retention < 20mmol
Hyponatremia
Rule out Volume loss/Nephrotoxic Drugs
Anatomically normal kidneys.
No Hematuria/Proteinuria
Vasopressin.
Liver transplant.
Hepato-pulmonary syndrome
Orthodeoxia
Concept of Pa-aO2 gap.
Prognosis
Orthoptic Liver transplant Indications for liver transplantation are :
In children Biliary atresia, Neonatal hepatitis, Antitrypsin
deficiency , Inherited disorders of metabolism, Wilsons disease, Glycogen storage disorders.
In adults, Primary biliary cirrhosis, Viral hepatitis, drug/toxin
induced hepatitis and end stage liver disease.
Contraindications for liver transplantation :
Absolute : HIV, Malignancy
Relative : Age > 70, Renal failure, immunosuppression
Types of donor organ
Cadaver donor transplant : demand >>> supply.
Unpredictable. Hence always done in emergency. Transport issues.
Can be split into potential 2 (1 adult + 1 child) rarely.
Living-donor transplantation : can reduce waiting time and cold-ischemia time.
done under elective, rather than emergency,
circumstances;
and may be lifesaving in recipients who cannot afford to
wait for a cadaver donor.
Success measured as 1-year survival has improved from_30% to_85% today.
Pancreatitis Pancreatitis is the inflammation of the pancreas.
Phyiology : Pancreas is a exocrine gland as well as an endocrine
gland.
Pancreas have a large functional reserve so as to maintain normal
function till >90% is destroyed. Even sensitive tests (Secretin stimulation)
detect only when >60% damage has occurred. Moreover the
symptoms of disease are very vague and non-specific.
Epidemiology : Pancreatic insufficiency is found in 0.4-5% of autopsy
studies.
However true incidence and prevalence is very difficult due to above
mentioned reasons.
Incidence increases with age i.e. > 15% have some problem > 65
years.
Common in the male gender, however this is changing and closely
matches alco
Pancreatitis is of two types depending on
the duration viz.
Acute pancreatitis < 2 weeks
Chronic pancreatitis > 6 weeks
more often months
Etiology : remember the following acronym:
A - Alcohol
Anatomic pancreatic division, Annular pancreas
Auto-immune Sjogrens syndrome
B - Bile stones / Gallstones
Biliary duct strictures
C - Carcinoma
Cholestrol - Hypertriglyceridemia
Connective tissue disorder - TTP
D - Drugs Anti-HIV , Valproate, Sulfonamides
E - ERCP
Others - Post surgery
Trauma
Renal failure
Infections Coxsackie, Mumps
Hyperamylasemia
Test 3 21. Most common presenting symptom in primary biliary cirrhosis is...
(A) Jaundice
(B) Pruritis
(C)Splenomegaly
(D)Gastrointestinal bleeding
22. Which of the following statements are Correct of cirrhosis EXCEPT
(A) Antimitochondrial antibodies positive in primary biliary cirrhosis.
(B) In late stage of PSC treatment is liver transplantation.
(C) In advanced stages major blood supply is through hepatic vein.
(D) Elevated lipoprotein-X in PBC.
23. Which one of the following is not a feature of liver histology in non-
cirrhotic portal fibrosis (NCPF)?
(A) Fibrosis in and around the portal tracts.
(B) Thrombosis of the medium and small portal vein branches.
(C) Non-specific inflammatory cell infiltrates in the portal tracts.
(D) Bridging fibrosis
Test 3 24. A 20 year old boy presented with severe hematemesis. On
examination there was no hepatomegaly, mild splenomegaly
present. On endoscopy esophageal varices were
seen. What is the most probable diagnosis?
(A) Cirrhosis liver
(B) Budd Chiari syndrome
(C) Non cirhotic portal fibrosis
(D) Veno occlusive disease
25. Which of the following statements is incorrect with regard to
heptorenal syndrome in a patient with wlicirrosis?
(A) The creatinine clearance is > 40 ml/min
(B) The urinary sodium is less than 10 mol/L
(C) The urine osmolality is lower than the plasmaosmolality.
(D) There is poor response to volume expansion.
Test 3 27.. All of the following drugs are used in hepatic encephalopathy,
except....
(A) Mannitol (B) Metronidazole
(C) Lactulose (D) Phenoharbitone
28. Which of the following is false regarding non-alcoholic fatty liver
(A) Seen in diabetic
(B) Clofibrate is used in treatment.
(C)Commonest cause of cryptogenic cirrhosis
(D) Associated with transaminitis
29. Reye's syndrome is characterized by all except ....
(A) Viral infection is seen.
(B) Present as deep jaundice
(C) Cerebral edema
(D) Microvesicular fatty infiltration
Test 3 30. What is the line of management of a case of moderate to severe
hepatic insufficiency with portal hypertension, according to the modified
Pugh's classification?
(A) Sclerotherapy
(B) Orthotopic liver transplantation
(C) Shunt Surgery
(D) Conservative
31. In hereditary spherocytosis, the gall bladder shows....
(A)Mixed stones
(B)Cholesterol stones
(C)Pigment stones
(D)All of the above
32. Acalculous cholecystitis can be seen in all the following conditions
except
(A) Enteric fever
(B) Dengue haemorrhagic fever
(C) Leptospirosis
(D) Malaria
Test 3 33. A patient presents with jaundice, right upper quadrant pain
chills with high fever, hypotension and mental confusion. The
most likely diagnosis is...
(A) Gallstone pancreatitis
(B) Hepatitis
(C) Acute suppurative cholangitis
(D) Amoebic liver abscess
34. Hemoblia is characterised by all except
(A) Jaundice (B) Biliary colic
(C) Malena (D) Fever
35. Serum amylase usually becomes elevated in acute
pancreatitis after
(A) 1/2 hrs. (B) 4-6 hrs.
(C) 24-48 hrs. (D) 48-72 hrs.
Test 3 36. Serum amylase level is raised in all except
(A) Acute pancreatitis
(B) Perforation of stomach
(C) Strangulated small intestine
(D) Acute appendicitis
37. Serum amylase is raised in
(A) Rubella (B) Measles
(C) Mumps (D) Chicken pox
38.. The following can be associated with acute pancreatitis
EXCEPT
(A) Hyperparathyroidism
(B) Hyperthyroidism
(C) Hypercalcemia
(D) Hypertriglceridemia
Test 3 39. Which one of the following types of pancreatitis has the best prognosis?
(A) Gall stone pancreatitis
(B) Alcoholic pancreatitis
(C) Idiopathic pancreatitis
(D) Traumatic pancreatitis
40. How much of the acinar pancreas must be destroyed to result in steatorrhoea
(A) 10% (B) 30%
(C) 60% (D) 90%