Biliary Tract and Liver diseases Flashcards
What is liver cirrhosis?
Scarred shrunken liver microscopically as a result of chronic liver disease
What is liver cirrhosis defined as histologically?
Presence of fibrous collagenous bands between nodules of hepatocytes
What are the commonest causes of liver cirrhosis?
Alcohol
Obesity
Heb B + C
Acute causes of chronic liver disease?
Drugs Alcohol Virus - Hep A,B,E, COVID Vascular - Hepatic vein thrombosis (Budd chiari) Ischaemic liver disease Wilson's disease
Chronic causes of liver disease
Alcohol Fatty liver disease AI disease - Hepatitis, primary biliary cirrhosis Primary sclerosis cholangitis Virus - Hep B+C Haemochromatosis of Wilson's disease A1AT deficiency
what are the four stages of liver damage?
Normal
Fatty
Fibrosis
Cirrhosis
What are the main symptoms of liver failure?
Jaundice (failure to clear bilirubin)
Coagulopathy (failure to produce clotting factors)
Hypoalbuminaemia (failure to produce protein)
Encephalopathy (Failure to get rid of toxins)
Ascites
How are varices treated?
Endoscopic banding
Beta blockers
TIPSS (Trans intrahepatic portosystemic shunt)
Surgery (Venous shunts)
How is bilirubin metabolised?
Unconjuguated bilirubin arises from heme breakdown in RBC
Then transported bound to albumin to liver -> conjugation by UDP glucuronyl transferase to bilirubin glucuronide.
Excreted via bile ducts to bowel -> converted to bacteria to be excreted in faeces as stercobilin or reabsorbed back into bood and excreted in urine as urobilin
What are the main causes of jaundice?
Prehepatic (raised unconjuguated bilirubin) -> Haemolysis or Gilberts syndrome
Intrahepatic
Post hepatic
How can chronic liver disease cause low platelets?
Chronic liver disease causes portal hypertension
This pushes more blood into spleen
Spleen traps and reduces number of platelets
What are some signs that suggest chronic liver disease?
Spider naevi
Gynaecomastia
Ascities
What is ascites?
Leakage of fluid out of portal blood vessels into peritoneal cavity
What is portal hypertension?
Liver becomes inflamed, damaged or cirrhotic
Blood cannot enter and backs up into portal mesenteric system causing increased pressure
What is intrahepatic jaundice?
The liver cannot clear bile
What is hepatocellular jaundice and what liver markers are raised?
Inflammation of hepatocytes
Raised ALT/AST
What are some causes of hepatocellular jaundice?
Viruses Fat Alcohol Drugs Ischaemia Inherited conditions
What is cholestatic jaundice and what liver markers are raised?
Inflammation of cholangiocytes
Raised ALP/GGT
What are some causes of cholestatic jaundice?
Primary biliary cirrhosis
Primary sclerosing cholangitis
Drugs
Sarcoidosis
What cells line bile ducts?
Cholangiocytes
What are the causes of post hepatic jaundice?
Stones Strictures (Primary Sclerosing Cholangitis) Worms Pancreatic Ca Gall bladder Ca Cholangiocarcinoma
What is primary sclerosing cholangitis strongly associated with (80%)?
Ulcerative colitis
High ALT and AST could be caused by abnormal what?
Hepatocytes
High ALP and GGT could be caused by abnormal what?
Cholangiocytes
What would a high ALT suggest?
Viral, drug or ischaemic cause
What should you consider with an isolated raised ALP (with normal GGT and transaminases)?
Bone cause
Check ALP isoenzymes, bone profile, vit D, pregnancy
What could an isolated raised bilirubin suggest?
Gilbert’s syndrome
What would a full liver screen include?
Virus screen - Hep A,B,C,E
AI
Inherited causes - Wilsons, A1AT deficiency, Haemochromatosis
USS liver
What is Wilson’s disease?
Failure to excrete copper - builds up in liver causing inflammation and cirrhosis
Inherited condition
Portal hypertension can cause hepatorenal failure. What is this?
Kidney failure secondary to liver failure
due to reduced blood flow to kidneys
The causes of jaundice can be categorised into which three areas?
Pre-hepatic
Intra-hepatic
Post-hepatic
What are the two causes of pre-hepatic jaundice?
Haemolysis - excessive RBC breakdown
Gilbert’s - UDP glucuronyl transferase deficiency
What does intrahepatic jaundice mean?
Inside liver
Hepatocytes cannot conjugate bilirubin so cannot be removed
What does post hepatic jaundice mean?
Bilirubin has been conjugated but cannot be removed
What clotting factors does the liver produce?
10
9
7
2
What is primary sclerosing cholangitis?
Progressive course of cholestasis with inflammation and fibrosis of intrahepatic and extra hepatic bile ducts
Causes duct narrowing
What two cancers are patients with PSC at an increased risk of?
Bowel Ca due to UC
Cholangiocarcinoma
What two enzymes do hepatocytes produce?
ALT
AST
Alcohol causes AST to be more raised that what?
ALT
What non-invasive investigation can be done to assess for fibrosis?
Fibroscan
What is the greatest cause of needing a liver transplant in the UK?
Paracetamol overdose