Chapter 4- LIVER Flashcards
What is bilirubin?
Product of RBC breakdown, clinical jaundice when bilirubin is >50micromol/L
What makes up the portal triad
Bile duct
Branch of hepatic artery
Branch of portal vein
What’s the name of a liver cell
Hepatocyte
Portal triad leads to what?
Central vein
What primarily supplies the liver with rich blood supply
The portal vein
Symptoms of acute alcoholic hepatitis
Raised WBC
Fever
Deterioration in clotting
Large rise in ALT
What is discrimination function and what does >32 show?
(Prolongation in prothrombin time * 4.2) + (bilirubin/17)
> 32=severe disease
What 5 things are used in the Glasgow alcohol hepatitis score
Age WBC Urea INR Bilirubin
What number signifies a worse prognosis on the Glasgow alcohol hepatitis score?
9 or greater
List 7 other effects of alcohol
Pancreatitis Chronic brain injury Cardiomyopathy Myositis Neuropathy Osteoporosis Social
What does NAFLD stand for
Non alcoholic fatty liver disease
What does NASH stand for
Non alcohol steatohepatitis
What is non alcohol steatohepatitis
Fat plus significant injury
What does the NAFLD fibrosis score take into account?
Age BMI hyperglycaemia Platelet count Albumin AST ALT
What does a NAFLD fibrosis score of
Predictor of absence of significant fibrosis
What does a NAFLD fibrosis score of
Intermediate score
What does a NAFLD fibrosis score of >0.675 predict
Predictor of presence of significant fibrosis
When do NICE recommend bariatric surgery
For BMI >40 or
BMI 35-40 if coexistence condition that may improve with weight loss
Did a study show pioglitazone to be worse than placebo for secondary outcomes of NAFLD in diabetics?
No better but not for primary outcomes
In a study was vitamin E associated with significantly higher rates of improvement in NAFLD in diabetics
YEAH
What concerns do pioglitazone bring up?
Heart failure and bladder cancer
Give 7 signs of chronic liver disease
Jaundice Bruising Spider naevi Dupuytrens contractures Palmer erythema Gynaecomastia Ascites
What’s gynaecomastia
Man boobs
What is the child Pugh score used to assess?
The prognosis of chronic liver disease, mainly cirrhosis
What 5 things are assessed in the child Pugh score
Encephalopathy Ascites Bilirubin Albumin INR
What can Ascites cause
Umbilical hernia
What are the different grades on the child Pugh score
A
B
C
Is bed rest good for Ascites?
No it’s unhelpful
List ways you can manage Ascites
Salt restriction- beware antibiotics and pre prepared foods Diuretics Paracentesis TIPSS Alfa pump Pleurx Transplant
Which two diuretics are used for management of Ascites
Spironolactone
Furosemide
How do you treat oesophageal varices?
Glypressin injection
Which antibiotic is best studied for treating infection with Ascites
Ciproxin 500mg BD
Varices are classified by what and give two examples
Their location
Esophageal
Gastric
Esophageal varices are graded by what?
Their size
A- small straight
B- enlarged, tortuous, occupies less than 1/3 of lumen
C- large, coil-shaped, occupies more than 1/3 of lumen
Name three surgical techniques for helping variceal haemorrhage
Endoscopic scleropathy
Endoscopic variceal band ligation
Ballooning
What does SBP stand for
Spontaneous bacterial peritonitis
What are the features of spontaneous bacterial peritonitis
Mild fever Ascites Deteriorating renal function Encephalopathy Deteriorating liver function Asymptomatic
How do you diagnose spontaneous bacterial peritonitis
Ascitic fluid neutrophil count of >250cell/mm^3 or >500white cell/mm^3
Culture into blood culture bottles doubles chance of detecting
Clinical suspicion
How do you treat spontaneous bacterial peritonitis
Tazocin 4.5g TDS IV 5days or ciproxin 750mg BD orally
If no improvement in 48hrs repeat tap (should be >25% reduction in wcc)
Albumin day 1 and 3 reduces renal injury
Paracentesis/transplant
What is hepato-renal syndrome
Functional renal impairment in someone with significant liver disease
How many types of hepato-renal syndrome are there
2
What is type 1 hepato-renal syndrome
Doubling of creatinine over
What’s type 2 hepato-renal syndrome
Doubling of creatinine over >6weeks
Irreversible
How do you manage hepato-renal syndrome
Ensure fluid resuscitated
Stop diuretics (and other nephrotoxins)
Look for SBP (or other infection)
Stop beta-blockers
What Is encephalopathy often associated with
Acute GI bleed or infection
What type of syndrome is encephalopathy?
Neurocognitive syndrome
What’s encephalopathy difficult to differentiate from
Dementia
How many grades are there to encephalopathy
4
What’s the 5 pointed star used to assess
Grading of encephalopathy
How do you assess/grade encephalopathy
5 point star
Stroop test
How can you treat encephalopathy
Avoid sedating drugs Correct electrolytes Treat constipation Seek infection esp. SBP consider intubation Lactulose Night time snack Benzodiazepine antagonists Transplantation
What’s used to treat alcohol withdrawal
Chlordiazepoxide
Do levels of bilirubin increase in liver disease
Yes they do
Increased bilirubin levels can reduce the absorption of highly lipophilic drugs- why?
Because there is reduced bile salt excretion into intestine (which solubilises fats)
In liver disease there is a possible reduction in biliary clearance which can effect what drugs?
Drugs cleared by the biliary system e.g digoxin, may increase clinical effects so monitor
Drugs that undergo enterohepatic recirculation may have reduced exposure in liver patients.. Why? And give an example
Reduced biliary excretion so less chance of enterohepatic circulation, e.g COC
How does increased levels of bilirubin in liver patients affect protein bound drugs give two examples of protein bound drugs
Bilirubin can compete against the drug molecule for the protein binding site thus increasing the amount of ‘free drug’ e.g phenytoin, warfarin
What does AST stand for
Aspartate aminotransferase
What does ALT stand for
Alanine transaminase
What is ALT often termed
Liver specific enzyme
In patients with liver disease do they always have raised transaminase enzymes?
No because there’s a massive reduction in number of functioning hepatocytes which can give a false normal
What does ALP stand for
Alkaline phosphatase
Raised ALP in isolation may be due to what
Other reasons e.g Paget’s disease
What’s cholestasis
Where bile cannot flow from the liver to the duodenum
List four liver enzymes
AST
ALT
ALP
GAMMA-GT
Low levels of albumin can cause what
OEDEMA
What is albumin
One of the proteins produced by the liver, has a long half life of 20-26days
In chronic liver disease are levels of albumin high or low
LOW
Are clotting factors produced by the liver?
Yeh man
How does PT/INR change in acute and chronic liver disease
Increases
Generally decreased albumin and raised PT/INR indicate what?
Reduced synthetic function
How does low albumin affect protein binding?
Decreased albumin= decreased protein binding which can increase amount of free drug in highly protein bound drugs e.g phenytoin
What might hepatic encephalopathy be due to?
Passage of neurotoxins to the brain
How can you reduce the nitrogen load from the gut in hepatic encephalopathy?
Lactulose
Bowel enema
Why do you use antibiotics in hepatic encephalopathy?
To lower the amino acid production by decreasing the concentration of ammonia-forming colonic bacteria
What can develop if wernickes encephaolpathy is left untreated
Korsakoff’s syndrome
What is wernickes Korsakoff’s syndrome
A spectrum of disease resulting from thiamine deficiency, usually related to alcohol abuse
How do you treat wernickes Korsakoff’s syndrome
Thiamine orally plus vitamin B complex or multivitamins which should be given indefinitely
What are the key triad of symptoms present in wernickes Korsakoff’s syndrome
Mental confusion
Ataxia and ophthalmoplegia
Offer oral thiamine to harmful or dependent drinkers if either of what two conditions apply:
They are malnourished
They have decompensated liver disease
What is pruritus?
Severe itching of skin
What solubilises fats?
Bile salts
