9. Liver and Biliary System Flashcards
Pre-Hepatic Jaundice
Excessive amount of bilirubin is presented to the liver due to excessive haemolysis
Elevated unconj. BR in serum
Liver Jaundice
Impaired cellular uptake, defective conj, or abnormal secretion by the liver cell.
Both unconj and conj bilirubin may be elevated in serum
Biliary Jaundice
Impaired excretion due to mechanical obstruction to flow
Elevated conj. BR in serum
Signs of portal HTN
Oesophageal varices --> coffee ground vomiting Splenomegaly Caput medusae Ascites Hemorrhoids
Signs of liver cell failure
Asterixis Bruising Clubbing Dupuytren’s contracture Erythema (palmar) Fetor hepaticus Gynaecomastia Have portal hypertension (see left) Itching (Pruritis) Jaundice Spider naevi + testicular atrophy
A 26 y/o male returns from holiday in India. He has had diarrhoea after eating at a seafood restaurant on his last night. He is feverish and nauseous. You notice that the whites of his eyes are yellow.
A. Hepatitis A B. Hepatitis B C. Hepatitis C D. Hepatitis D E. Hepatitis E
A. Hepatitis A
A 64 y/o male with thalassaemia is investigated under the two-week wait for jaundice and weight loss. His blood tests show a raised αFP. Which chronic infection is he most likely to have?
A. Hepatitis A B. Hepatitis B C. Hepatitis C D. Hepatitis D E. Hepatitis E
C. Hepatitis C
aFP- raised in liver cancer, for which Hep C chronicity is a risk factor
A 32 y/o male returns from holiday in Thailand, feeling ‘under the weather’ with RUQ pain, fevers and nausea. He is jaundiced. He reveals he has used IV drugs and had unprotected sex with a stranger while on holiday. Which test is most likely to give the correct diagnosis?
A. Liver function tests B. HIV serology C. Hepatitis B serology D. Hepatitis C PCR E. CXR
C. Hepatitis B serology
A 43 y/o confused man is brought to A&E by police after being found wandering the streets. He is disorientated and unable to give a clear history. You notice the a brownish-yellow ring around in his eyes. What is he likely to have?
A. Alcohol intoxication B. Wilson’s disease C. Opiate overdose D. Haemochromatosis E. Hypoglycaemia
B. Wilson’s disease
72 y/o man with cirrhosis presents to A&E with diffuse abdominal pain and fever. He is nauseous and has vomited. His abdomen is distended and there is shifting dullness on examination. Which investigation would be most urgent?
A. Paracentesis B. Stool sample MC&S C. Abdominal USS D. LFTs E. Blood cultures
A. Paracentesis
Although it’s important to diagnose the underlying condition, this is suggestive of bacterial peritonitis (secondary to cirrhosis) which much be treated quickly as a priority.
Hep A: Transmission Incubation Period Areas of high risk Risk factors Chronic?
Faecal-oral 2 weeks Africa/Asia Poor hygiene Rare
Hep B: Transmission Incubation Period Areas of high risk Risk factors Chronic?
Bodily fluids 4-12 weeks Africa Health workers Likely in children, 5% adults
5% of people with chronic Hep B have Hep D too.
Hep C: Transmission Incubation Period Areas of high risk Risk factors Chronic?
Bodily fluids 2 weeks -6 months Eastern Mediterranean Injecting drugs Yes, 60-80%
Hep D: Transmission Incubation Period Areas of high risk Risk factors Chronic?
Bodily fluids 4-12 weeks Africa ONLY co-infects with Hep B Rare
Hep E: Transmission Incubation Period Areas of high risk Risk factors Chronic?
Faecal-oral 5-6 weeks Poor water supply Immunocompromised patients Pregnancy Rare
Viral Hepatitis: Symptoms and Signs
Fever + Jaundice (+ High AST/ALT)
Other symptoms likely:
- Reduced appetite (anorexia),
- Nausea and vomiting, lasting for a few days
- Abdominal pain
- Itching (without skin lesions), skin rash
- Joint pain
- Dark urine and pale stools
- Tender hepatomegaly
Viral Hepatitis: Investigations
Liver function tests (first line) - indicate whether the jaundice is a liver or biliary cause
FBC
U+Es
Antibodies (diagnostic)
NAAT - Nucleic Acid Amplification Test can indicate viral load- useful to measure treatment response.
Hepatitis B Serology Interpretation
Anti-HBc IgM: Acute
Anti-HBc IgG: resolved acute, or chronic ongoing
HBsAg: Acute/Chronic ongoing infection
Anti-HBs (surface): Resolved acute, prior vaccination (after infection has passed)
Viral Hepatitis: Management
A: supportive care
B: supportive care for acute, antivirals +peginterferon for chronic.
C: supportive care for acute, antivirals for chronic.
Liver transplant if worsening.
Prognosis and complications of Viral Hepatitis
A: nearly all resolve by 6 months
B: viral suppression in 90% of chronic cases
C: mortality at 79% at 10 years for chronic cases.
One complication apart from chronicity is fulminant liver failure - very rare but requires an emergency transplant.
NASH - Non-Alcoholic Steatohepatitis/FLD
Aetiology, RF and Epidemiology
Aetiology: insulin resistance –> increased triglycerides –> steatosis–> inflammation –> steatohepatitis.
Risk factors: T2DM, metabolic syndrome, some medications. WITHOUT significant alcohol use.
Epi: 20-40% of the Western world are likely to have this to an extent.
NASH: Signs and Symptoms
Metabolic syndrome WITHOUT alcohol use
RUQ Pain
Hepatosplenomegaly
Usually no jaundice (not serious enough)/fever
NASH: Investigations
Liver function tests
- AST:ALT ratio will be <1
- (NB ALD: >2)
- GGT <96.5 (above = fibrosis/ALD)
FBC
Metabolic panel (NA, K, U&Es, serum glucose - comorbid T2DM in up to 50%) and lipid profile
Hepatic US (every 6 months ?progression to cirrhosis)
(No Dx test - clinical)