Abnormal Liver Function (week 5) Flashcards
What is the most common cause of liver disease?
NAFLD (20-30% of population)
What is the most common cause of liver death?
Alcoholic liver disease (84%)
How does cirrhosis develop from normal liver tissue?
Normal –> initial insult to liver (fat or alcohol) = inflammation Steatosis Steatohepatitis Fibrosis –> Cirrhosis (last stage isn’t reversible)
What are the complications of liver cirrhosis?
Ascites Liver failure Liver cancer Portal HTN (& associated complications) etc.
How can cirrhosis present?
Incidental findings - Abnormal LFTs, hepatosplenomegaly, raised MCV/abnormal clotting/low platelets Non-specific symptoms - Anorexia, weight loss, lethargy Specific symptoms (usually late stage) - Jaundice, pruritus (itchy skin due to cholestasis), bleeding varices, ascites/oedema, hepatic encephalopathy
What does raised alkaline phosphatase and raised gamma GGT indicate?
Indicates Cholestasis, malignancy or alcohol abuse
Alcohol will have raised MCV
What does increased ALT/AST (the transaminases) indicate?
Indicate hepatocellular damage
1.5-3x the upper limit of normal in ALD/NAFLD
> 3x uppler limit of normal in viral, drug induced (paracetamol) and AI hepatitis
At what level of bilirubin do you get clinical jaundice?
> 30 µmol/L
When do you get unconjugated bilirubin?
Gilberts, haemolysis, newborn babies (physiological)
Which clotting factor(s) are tested in Prothrombin Time (PTT) & therfore, which clotting pathway is being measured?
Factor VII.
Extrinsic pathway
Why is PTT relevant in liver screening?
Liver makes clotting factors II, VII, IX & X. This is disrupted in acute liver failure/damage, which causes the PTT to increase (this happens very quickly).
Which autoantibodies do we test for in liver studies? What do they indicate?
ANA (antinuclear Ab) & anti SMA (anti smooth muscle Ab) in AI hepatitis.
AMA (anti mitochondrial Ab) in PBC (95%).
(P Billy Connolly is a lAMA)
pANCA in PSC (50%)
(Private Steve Clark is a P wANCA)
Which immunoglobulins are measured in liver studies? What do they indicate?
Increased IgG - AI hepatitis
Increased IgM - PBC
Increased IgA - Alcoholic liver disease/NAFLD
Which tumour markers are relevant to the hepatobiliary system?
Alpha fetoprotein - HCC
CA19-9 - Cholangiocarcinoma
What is the first line imaging in Hepatobiliary disease? Which others may be helpful?
USS - 1st line
CT, MRI, ERCP
What are the benefits and limitations of USS in hepatobiliary disease?
Good to show obstruction of bile ducts, liver tumour or mass lesion, gallstones and can assess blood flow using doppler function.
Cant assess pancreas well.
What are the benefits and limitations of CT in hepatobiliary disease?
More sensitive than USS. Excellent investigation for focal liver lesions, varices and evidence of portal hypertension (hypervascularisation)
Needs IV contrast - caution in renal impairment
What is the main use of ERCP?
To remove stones or to place stents
What are the indications for liver biopsy?
Chronic liver disease - Diagnosis or staging Focal lesions (guided) Post transplant (rejection)
What is the “gold standard” for liver disease staging?
Liver biopsy
Name 2 scoring systems that can non-invasively assess liver disease
FIB-4 score (Age, ALT, AST and platelet count)
NAFLD fibrosis score
What is the classical findings in primary biliary cirrhosis (PBC)?
AMA +ve
Raised ALP
What is PBC are what are the symptoms?
Granulomatous inflammation around the small intrahepatic bile ducts
Asymptomatic (incidental finding)
Fatigue, itch, dry eyes and mouth
If severe - symptoms of advanced liver disease
What is the diagnostic criteria of PBC?
Abnormal LFTs (cholestatic) = Raised ALP
Positive AMA
Compatible Hx
(2 of above = PBC probable, all 3 = definite PBC)
What is the treatment for PBC and what is the therapeutic aim?
Ursodeoxycholic acid (UDCA) (S/E = weight gain, hair thinning and diarrhoea)
Fibrates
Transplantation
Treat itch - Cholestyramine, Rifampicin or Naltrexone
What is the classical finding in AI hepatitis?
Raised ALT
ANA/ASMA +ve
Raised IgG
What are the main types of AI hepatitis? Which autoantibodies do you find for each?
Type 1 (75% of cases & can affect all ages)
ANA/AMSA
Type 2 (<10% of cases & affects young adults)
LKM-1 or LC
Is AI hepatitis more common in males or females?
Type 1 - F:M = 3:1
Type 2 - F:M = 10:1
How can AI hepatitis present?
Asymptomatic (incidental finding)
Fatigue, anorexia, nausea, joint pains
Acute hepatitis
Complications of cirrhosis
What is the treatment for AI hepatitis? What is the treatment aim/goal?
Immunosuppression - steroids (1st line short term), Azathioprine (1st line long term), Tacrolimus (2nd line)
Transplantation
Aim for normalisation of ALT and IgG
What is the classical findings in primary sclerosing cholangitis (PSC)?
Raised ALP
ANCA +ve
(Private Steve Clark is a wANCA)
What is PSC and what associated diseases does it have?
Inflammation and fibrosis of intra and extra hepatic bile ducts, causing multifocal strictures
60-80% patients have IBD
(Private Steve Clark is a wANCA and a Incredibly Boring Dude)
How does PSC present?
Asymptomatic (incidental finding)
Fatigue, itch, RUQ pain, weight loss
Cholangitis (often not at presentation)
Jaundice and complications of cirrhosis
What is the LFT pattern in PSC?
Shows Cholestasis
- -> Increased bilirubin
- -> Increased ALP (indicated obstruction)
Apart from blood tests, what investigations are useful in PSC? What would they show?
USS - often normal
MRCP - Multi-focal, short annular strictures alternating with normal or dilated segments (beading)
Liver biopsy - early (often non specific), later = ‘Onion skin’ fibrosis
How do you manage PSC?
Look and test for IBD
If strictures causing symptoms (cholangitis, jaundice, pruritus) - ERCP (insert balloons/stents)
Itch - Cholestyramine, Rifampicin or Naltrexone
Screen for malignancy - Cholangiocarcinoma
Summarise PBC - Type of patient, Hallmark LFT/autoantibodies, Symptoms and treatment.
Typical patient - Middle aged women
LFT/Autoantibodies - Raised ALP + AMA +ve
Symptoms - Fatigue, itch, dry eyes & mouth
Treatment - Ursodeoxycholic Acid (UDCA)
P Billy Connolly is a lAMA
Summarise AI hepatitis - Type of patient, Hallmark LFT/autoantibodies, Symptoms and treatment.
Typical patient - Any age or sex
LFT/Autoantibodies - Raised ALT + ANA + ASMA
Symptoms - often asymptomatic
Treatment - Immunosuppression
Summarise PSC - Type of patient, Hallmark LFT/autoantibodies, Symptoms and Management.
Typical patient - Men
LFT/Autoantibodies - Raised ALP + ANCA +ve
Symptoms - Fatigue, itch, RUQ pain, weight loss
Associated with IBD
Management - Screen for cholangiocarcinoma and bowel cancer
Private Steve Clark is a wANCA and an Incredibly Boring Dude
What is AMA associated with?
PBC
What is ANA + ASMA associated with?
AI hepatitis
What is ANCA associated with?
PSC
What is IgA associated with?
Alcohol, NAFLD
What is IgM associated with?
PBC
What is IgG associated with?
AI hepatitis
What are the 2 blood supplies of the liver?
Hepatic artery - Arterial blood from aorta
Portal Vein - Venous blood from the bowel (2/3)
How can we aid prevention of HCC (hepatocellular Carcinoma)?
Primary prevention - HBV vaccine & avoid carcinogens
Secondary prevention - Reduce alcohol and calorie intake, Reduce exposure to Hep C (increase education)
Who do we screen for HCC, how do we do it and how often?
Screen cirrhotic patients
AFP (upper normal limit is 10)
USS - every 6 months - look for liver nodules
If nodule <1cm - scan again in 3 months
If nodule 1-2cm - FNAB looking for HCC
If nodule >2cm - AFP > 400 = HCC (do CT/MRI angiography to stage and confirm HCC)
What are the 4 stages of CT or MRI scan for HCC?
Normal scan
Add contrast - Arterial blood supply (aorta/blood seen in white - white areas in liver = HCC) most important stage
Venous stage
Late venous stage
Which scoring system do we use to assess liver function? what are the 5 parameters?
Child-Pugh score (5 best function - 15 worst)- looks at fitness to undergo a surgical procedure
Encephalopathy, Ascites, Bilirubin, Albumin, PTT