61 - Investigations of the liver and pancreas

Question 1

SER in liver responsible for

Answer 1

bilirubin conjugation + drug detox

Question 2

Lysosomes in liver responsible for

Answer 2

intracellular scavengers (copper, ferritin)

Question 3

Storage of ions and vitamins in liver - which ones?

Answer 3

Iron

A, D, E and B12 storage and metabolism

Question 4

Whats are LFTs?

Answer 4

Alk. phos
ALT (alanine aminotransferase)
Bilirubin
Albumin

Total protein
GGT (y-glutamyl transferase)

Question 5

Available other liver function tests?

Answer 5

Production of metabolites
Clearance of endogenous substances
Clearance of exogenous substances
Imaging, biopsy

Question 6

Hepatocyte damage will release what

Answer 6

Aminotransferases: Alanine/ALT, Aspartate/AST, found intracellularly and only released by cell damage.

ALT is more specific for liver than AST, as AST is found in muscle and RBC too.

Tumour markers - a-fetoprotein is present in primary hepatocellular carcinoma.

Question 7

Biliary tract damage would cause

Answer 7

Impaired excretory function -> increased conjugated bilirubin

Increased synthesis of enzymes by cells lining the bile canaliculi - ALP, yGT

Question 8

Biliary tract damage - ALP

Answer 8

alk. phos
Elevated due to increased production by cells lining the bile canaliculi and overflow into blood

Due to: cholectasis (intra + extrahepatic), infiltrative diseases, tumours, cirrhosis

Made in liver, bone, intestine, placenta

Question 9

Biliary tract damage - gamma glutamyltransferase

Answer 9

Can support a liver source of raised ALP

Elevated due to structural dmg

Question 10

Biochemical markers of fibrosis

Answer 10

Imaging, biopsy and predictive scores

Novel markers: ELF Score
PIIINP
TIMP-1
Hyaluronic acid

Question 11

Bilirubin

Answer 11

Excretory capacity of the liver and free flow of bile

Measured as total, uncojugated, conjugated

Jaundice at serum bilirubin >40-50 umol/l

Question 12

Unconjugated bilirubin

Answer 12

Pre-hepatic and hepatic

Question 13

Conjugated bilirubin

Answer 13

Post-hepatic (obstructive) and hepatic

Question 14

Bilirubin metabolism

Answer 14

slide 21

Question 15

Pre-hepatic aetiology for hyperbilirubinaemia

Answer 15

Haemolysis e.g. Rh incompatibility

Ineffective EPO e.g. spherocytosis

Question 16

Post hepatic (obstructive) aetiology for hyperbilirubinaemia

Answer 16

Gallstones
Biliary stricture
Cancer e.g. cholangiocarcinoma, head of pancreas
Cholangitis

Question 17

Unconjugated bilirubin aetiology for hyperbilirubinaemia

Answer 17

pre-microsomal
microsomal
inherited disorders of conjugation e.g. Gilberts, Crigler-Najjar

Question 18

Conjugated bilirubin aetiology for hyperbilirubinaemia

Answer 18

Post-microsomal/impaired excretion
Intrahepatic obstruction
Inherited disorders of excretion e.g. Dubin-johnson, Rotor

Question 19

Gilbert’s is due to… what is name of other disease affected in similar way

Answer 19

Decreased activity of UDP glucuronyl transferase

Crigler-Najjar

Question 20

Dubin-Johnson and ROTOR is due to….

Answer 20

Reduced ability to excrete bilirubin glucuronide

Question 21

Blood tests in the differential diagnosis of jaundice

Answer 21

AST/ALT high & normal ALP = hepatitis

AST/ALT normal & elevated ALP = obstructive jaundice

Question 22

Urine tests in the differential diagnosis of jaundice - prehepatic

Answer 22

Prehepatic: unconjugated bilirubin - no urinary bilirubin

Question 23

Urine tests in the differential diagnosis of jaundice - hepatic

Answer 23

Hepatocellular

Variable based on obstruction due to disease or inflammatory oedema

Question 24

Urine tests in the differential diagnosis of jaundice - post-hepatic

Answer 24

Obstruction

Dark urine and pale stools

Question 25

Specific tests for Wilson's disease

Answer 25

Caeruloplasmin, urine copper, plasma copper, liver biopsy

Question 26

Specific test for hepatocellular cancer

Answer 26

AFP

Question 27

Systemic effects of liver disease

Answer 27

``` Jaundice Oestrogen excess Bruising Pigmentation Clubbing Dependent oedema Ascites Encephalopathy Osteomalacia/porosis ```

Question 28

Oestrogen excess

Answer 28

Gynaecomastia Spider naevi Liver palms Testicular atrophy

Question 29

Endocrine secretions of pancreas

Answer 29

Islets of langerhans Insulin, glucagon Pancreatic polypeptide

Question 30

Exocrine secretions of pancreas

Answer 30

Bicarb | Digestive enzymes: trypsin, chymotrypsin & elastase, carboxypeptidases, amylase, lipase

Question 31

Acute pancreatitis - aetiology

Answer 31

Acute necrotising liquefaction Aetiology: gallstones, -OH, drugs, hypertiglyceridaemia, trauma, infectious, rare tumours, autoimmune, scorpion toxins

Question 32

Acute pancreatitis - symptoms

Answer 32

Severe epigastric pain Sudden onset Radiating to back

Question 33

Acute pancreatitis - biochemical features

Answer 33

``` Uraemia Hypoalbuminaemia Hypocalcaemia Hyperglycaemia Metabolic acidosis Abnormal LFTs ```

Question 34

Acute pancreatitis - diagnosis

Answer 34

Amylase or lipase Imaging Clinical history

Question 35

Chronic pancreatitis - presentation

Answer 35

Ab pain Malabsorption Impaired glucose tolerance Alcohol often an important factor

Question 36

Chronic pancreatitis - diagnosis and management

Answer 36

Imaging Pancreatic function test Misc: vit D, Ca, FBC, LFTs, glucose, lipids

Question 37

Direct tests for pancreas

Answer 37

Intubation to collect aspirates in duodenum | Secretin, CCK, Lundh tests

Question 38

Indirect tests for pancreas

Answer 38

Pancreatic enzyme analysis in stools (elastase) Trypsinogen (IRT) measured in blood in CF screening Pancreolauryl & NBT-PABA tests