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%