68 - jaundice, 69 enlarged liver

Question 1

Causes of jaundice

Answer 1

Pre-hepatic: haemolytic anaemias, Gilbert’s syndrome, malaria

Hepatic: hepatitis, chronic alcoholism, cirrhosis, hepatic necrosis,

Post-hepatic: pancreatic cancer, pregnancy, pancreatitis, cysts, parasites

Question 2

What is the function of bile acids?

Answer 2

produced by liver to emulsify fats and help excrete bilirubin

Bile Aids absorption of fat soluable vitamins A,D,E and K

Question 3

Lack of bile ->

Answer 3

steatorrhea and vitamin deficiencies. ADEK

Question 4

Risk of what with neonatal jaundice

Answer 4

kernicterus

Question 5

Which type of bilirubin can cross blood brain barrier

Answer 5

unconjugated

Question 6

What can kernicterus -> ?

Answer 6

permanent athetoid cerebral palsy and other neurological problems (and death!)

Question 7

Ix in neonatal jaundice

Answer 7

Full blood count and grouping

Urine culture

Transcutaneous bilirubinometer

Serum bilirubin (always in less than 24 hours)

Direct antiglobulin test (DAT): Also known as the direct Coombs’ test; this test is used to detect antibodies or complement proteins that are bound to the surface of red blood cells. Positive test indicates immune mediated haemolytic anemia.

Indirect screens maternal blood for IgG antibodies.

Question 8

Mx of severe neonatal jaundice

Answer 8

Phototherapy: baby gets a sunlamp. UV light breaks down bilirubin. Check blood levels every 8 hours. Ensure baby is naked.

Treat underlying cause (iv immunoglobulin if blood group incompatibility)

Exchange transfusions: dangerous. Babies blood volume is replaced entirely.

Question 9

Why is physiological jaundice common? How long does it often last?

Answer 9

Due to under compensating hepatic enzymes, shorter life of fetal blood cells and lack of enteric bacteria.

Lasts about two weeks.

Question 10

What is cause of rhesus disease

Answer 10

mother is Rh –ve and foetus is +ve.

Maternal antibodies (IgG) are produced against the Rh group, accumulating with successive pregnancies (very rare in firstborns).

Question 11

Basic prevention of rhesus disease

Answer 11

IM injection of Anti-D for Rh or blood transfusions for ABO (rarely needed)

Question 12

Risk of what with Rhesus in preg?

Answer 12

hydrops fetalis - very poor prognosis

Question 13

What is biliary atresia? when does it present?
What happens?
mx?

Answer 13

Rare malformation of the bile ducts.
Jaundice after 1st week of life

Cirrhosis and portal hypertension develop

Poor prognosis, even with surgical treatment there is high risk of morbidity and mortality. Usually requires liver transplant.

Question 14

Hep A
Transmission?
prognosis?

Answer 14

faecal-oral infection producing mild self-limiting disease. Avoid poorly prepared food.

Most recover after 2/12.

Question 15

Hep B
Transmission?
prognosis?
Complications?

Answer 15

Blood borne.

15% produce antibodies which do not overcome the infection, leading to chronic illness. Of these 65% respond to treatment.

Causes cancer and cirrhosis.

Question 16

Hep C
Transmission?
prognosis?

Answer 16

Blood borne.

Leads to chronic hepatitis and cirrhosis but usually clinically silent for decades. Viral levels may be lowered by treatment.

Question 17

Hepatitis vaccines?

Answer 17

Vaccine available to prevent A, lasts 10 years

B vaccine: 3 injections lasting a lifetime offered to those at risk: MSM, healthcare and sex workers, IVDU, travellers.

No vaccines available for other hepatitis viruses.

Question 18

what is haemochromatosi

Answer 18

AR condition leading to excess iron absorption by small bowel. Iron is deposited through body, damaging organs.

Question 19

triad of haemochromatosis

Answer 19

bronzed skin, diabetes and cirrhosis.

Question 20

Dx of haemochromatosis

Answer 20

transferrin and ferritin testing. Organ biopsy may be necessary.

Question 21

Mx haemochromatosis

Answer 21

chelation therapy (desferrioxamine mesilate) and venesection.

Question 22

What is gilberts? what happens?

Answer 22

Common liver disease producing elevated bile levels in bloodstream and thus jaundice particularly during stress.
Reduced glucuronyltransferase, enzyme responsible for conjugating bilirubin.
Clinically harmless.

Question 23

Name 4 things the liver does

Answer 23

Bile digestion

Drug metabolism (cytochrome p450) and hormone breakdown

Glycogenesis and glycogenolysis. Gluconeogenesis

Protein metabolism: albumin, clotting factors, angiotensinogen

Lipogenesis and cholesterol synthesis

Storage: glycogen, vitamins, monocytes, metals.

Toxin removal

Question 24

Bar liver what causes decrease in Albumin?
AST?
ALT ?
ALP?

Answer 24

Albumin: also decreased in nephrotic syndrome

AST: also indicates cardiac and muscular damage

ALT: usually higher than AST in liver disease. Also indicates muscular damage

ALP: if ratio of ALP raised over AST then the problem may be in the biliary disease. Also raised in Paget’s

Question 25

What does raised GT indicate?

Answer 25

steatohepatitis

-fatty alcohol liver

Question 26

Which LFT is thought to be most sensitive to acute liver damage

Answer 26

PT

Question 27

Hep antibodies 
What doi they mean if positive? 
HBsAg
Anti-HBc
Anti-HBs

If all negative?

Answer 27

HBsAg indicates present infection if positive.

Anti-HBc indicates past and present infection. Takes longer to alter than HBsAg

Anti-HBs indicates immunity to Hep B if positive. Thus, if it is the only positive, indicates vaccination.

IgM anti-HBc indicates acute infection if positive.

Thus, all negative indicates Hep B susceptible.

Question 28

Causes of hepatocellular carcinoma

Answer 28

by alcoholism, chronic hepatitis (infectious or for any other reason), haemochromatosis, alpha1 anti-trypsin defiency

Question 29

Sx of hepatocellular carcinoma

Answer 29

: jaundice, oedema, bleeding and bruising, loss of appetite, weight loss, fatigue, vomiting and nausea.

Question 30

Screening of those at risk of hepatocellular carcinoma includes?

Answer 30

US

Alpha-fetoprotein biomarker and CT with three phase contrast.

Question 31

Mx of hepatocellular Ca

Answer 31

Surgical resection and transplantation. Chemo and radiotherapy usually reserved for palliative treatment or those awaiting a transplant.