357: Approach to the Patient with Liver Disease Flashcards
Review: Characteristics of the liver
Largest organ of the body
Weight: 1-1.5kg, 1.5-2.5% of lean body mass
Receives dual blood supply: 20% from hepatic artery, 80% from portal vein
Special cell types found in the liver
- Kupffer cells (member of reticuloendothelial system)
2. Stellate cells (Ito or fat-storing)
Review: Zones of the liver based on function
Zone 1: Both arterial and portal venous blood entering the acinus from the portal areas
Zone 3: Flowing through the sinusoids to the terminal hepatic veins
Zone 2: Intervening hepatocytes
Blood flow in portal areas
Zone 1 to Zone 3
Bile flow in portal areas
Zone 3 to Zone 1
Lie within the sinusoidal vascular space and represent the largest group of fixed macrophages in the body
Kupffer cells
Located in the space of Disse; produce collagen and matrix when activated
Stellate cells
Most common liver “function” tests
- Serum bilirubin - measure of hepatic conjugation and excretion
- Serum albumin - measures of protein synthesis
- Prothrombin time - measures of protein synthesis
Basic classification of causes of liver diseases
- Hepatocellular diseases (viral hepatitis, alcoholic liver disease)
- Cholestatic (obstructive) (gallstone or malignant obstruction, primary biliary cirrhosis, some drug-induced liver disease)
- Mixed (cholestatic forms of viral hepatitis, many drug-induced liver diseases)
Goals in evaluation of liver disease
- Establish the etiologic diagnosis
- Estimate disease severity (grading) - e.g. active or inactive; mild, moderate, or severe
- Establish the disease stage (staging) - e.g. early or late; precirrhotic, cirrhotic or end-stage
Most common and most characteristic symptom of liver disease
FATIGUE
*after activity or exercise, intermittent, variable in severity
T or F: Poor appetite with weight loss are more frequent in ACUTE liver disease and rare in CHRONIC disease except in cirrhosis
True
ITCHING in acute liver disease
- Early in obstructive jaundice
- Later in hepatocellular disease (acute hepatitis)
- Preceding onset of jaundice in chronic liver diseases
- Once cirrhosis develops
Hallmark symptom of liver disease;
Most reliable marker of severity
JAUNDICE
Bilirubin level where jaundice is rarely detectable
<43 umol/L (2.5mg/dL)
What does lightening of color of stools and steatorrhea indicate?
Severe cholestasis
Symptom which usually indicates indirect (unconjugated) hyperbilirubinemia and typical of hemolytic anemia, Gilbert’s syndrome and Crigler-Najjar syndrome
Jaundice WITHOUT dark urine
Major risk factors for liver disease sought in clinical history
- Alcohol use
- Medication use (herbal, birth control pills, OTC drugs)
- Personal habits
- Sexual activity (# of lifetime sexual partners, Men: MSM)
- Travel
- Exposure to jaundiced or other high-risk persons
- Injection drug use
- Recent surgery
- Remote or recent blood transfusion
- Occupation
- Accidental exposure to blood or needlestick
- Familial history of liver disease
T or F: Sexual exposure is a common mode of spread of both Hepatitis B and Hepatitis C.
False
Sexual exposure RARE in Hep C
Transmission is more common among HIV-co-infected mothers and linked to prolonged and difficult labor and delivery, early rupture of membranes and internal fetal monitoring.
Hepatitis B or Hepatitis C?
Hepatitis C
Injection drug use is now the single most common risk factor for: Hepatitis B or Hepatitis C?
Hepatitis C
Traveling to developing area of the world, exposure to persons with jaundice, and exposure to young children in day-care centers are risk factors for:
Hepatitis A or Hepatitis E?
Hepatitis A
One of the more common causes of jaundice in Asia and Africa but uncommon in developed nations:
Hepatitis A, Hepatitis B, Hepatitis C or Hepatitis E?
Hepatitis E
Trivia: What does autochthonous means?
Non-travel-related
