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Year 2 > Cirrhosis and Liver fibrosis > Flashcards

Cirrhosis and Liver fibrosis Flashcards

1
Q

Histologically, how can we see irreversible liver damage

A

Loss of normal hepatic architecture with bridging fibrosis and nodular regeneration

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2
Q

Main causes of irreversible liver damage

A
  1. Chronic alcohol abuse
  2. Non-alcoholic fatty liver disease
  3. Hep B + D
  4. Hep C
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3
Q

What is Wilson’s disease

A

Copper build up in the body - causes liver disease

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4
Q

What diseases can cause liver damage

A
  1. Autoimmune hep
  2. Alpha-antitryspin deficiency
  3. Hereditary haemochromatosis
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5
Q

Risk factors for liver damage

A

Alcohol use

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6
Q

How does liver injury result in irreversible liver damage

A
  1. Chronic injury causes inflammation, matrix deposition, necrosis and angiogenesis -> fibrosis
  2. Liver injury causes necrosis + apoptosis releasing cell contents and ROS
  3. Activates hepatic stellate cells + kupffer cells
  4. Kupffer cells phagocytose necrotic and apoptotic cells + secrete inflammatory mediators
  5. Increased myofibroblasts leads to progressive collagen matrix deposition resulting in fibrosis and scar accumulation in the liver
  6. Severe reduction liver function
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7
Q

Name two inflammatory mediators

A

TGF-beta

PDGF

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8
Q

Role of TGF-beta

A

Transdifferentiation of stellate cells to myofibroblasts

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9
Q

Role of PDGF

A

Stimulates myofibroblast proliferation

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10
Q

What happens to the liver if fibrosis is eliminated

A

Liver can recover

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11
Q

In cirrhosis, can regression occur

A

Yes

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12
Q

What are characteristic features of cirrhosis

A

Regenerating nodules separated by fibrous septa + loss of lobular architecture within nodules

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13
Q

What two types of cirrhosis are there

A

Micro nodular

Macro nodular

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14
Q

What is micro nodular cirrhosis

A

Regenerating nodules are less than 3mm in size

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15
Q

What is micro nodular cirrhosis caused by

A

Alcohol + biliary treat disease

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16
Q

What is macro nodular cirrhosis

A

Nodules are of varying size and normal acini may be seen within the larger nodules

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17
Q

What is macro nodular cirrhosis caused by

A

Chronic viral hepatitis

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18
Q

Clinical presentation of cirrhosis

A
  1. Leuconychia
  2. Clubbing
  3. Palmar erythema
  4. Dupuytren’s contracture
  5. Spider nave
  6. Xanthelasma
  7. Hepatomegaly
  8. Bruising
  9. Ankle swelling + oedema
  10. Abdominal pain due to ascites
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19
Q

What is Xanthelasma

A

Yellow fat deposits under the skin usually around the eyelids

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20
Q

What is leuconychia

A

White discolourations on nails due to hypoalbuminaemia

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21
Q

How is cirrhosis diagnosed

A
  1. Ascites, encephalopathy
  2. HIGH bilirubin
  3. LOW albumin
  4. LONG PTT (1-3 and added up to give score)
  5. Liver biopsy (main way - confirms diagnosis + severity)
  6. Raised AST and ALT
  7. Low Na
  8. Raised serum creatine
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22
Q

What child-pugs classification is gives best prognosis

A

<7

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23
Q

What child-pughs classification is a sign of BAD prognosis

A

> 10

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24
Q

What is the risk at >8

A

Risk of vatical bleeding

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25
Q

Presence of alpha-fetoprotein indicates what

A

HEPATOCELLULAR CARCINOMA

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26
Q

How does an Ultrasound help in cirrhosis diagnosis

A
  1. Shows change in size + shape of the liver - hepatomegaly
  2. Shows modularity of liver and distortion of arterial vascular architecture

HEPATOCELLULAR CARCINOMA

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27
Q

What can a CT show for cirrhosis

A
  1. Hepatosplenomegaly

2. HEPATOCELLULAR CARCINOMA

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28
Q

What can an MRI show for cirrhosis

A

Detects tumours

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29
Q

What can an endoscopy show for cirrhosis

A

Detection of varies and portal hypertensive gastropathy

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30
Q

Complications of cirrhossi

A
  1. Fall in clotting factors
  2. Encephalopathy + confusion
  3. Hypoalbuminaemia (oedema)
  4. Portal hypertension
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31
Q

How is cirrhosis treated

A
  1. Good nutrition
  2. Alcohol absintence
  3. 6 month ultrasound screening for early development of hepatocellular carcinoma
  4. Treat underlying cause
  5. Hep A and B vaccination
  6. reduce salt intake
32
Q

Why should we avoid NSAIDs in treating cirrhosis

A

Can precipitate gastro-intestinal bleeding or renal impairment

33
Q

What forms the portal veins

A

Union of superior mesenteric and splenic veins

34
Q

normal pressure of portal veins

A

5-8mmHg

35
Q

Main pre-hepatic cause of portal hypertension

A

Portal vein thrombosis

36
Q

Main intra-hepatic cause of portal hypertension

A
  1. CIRRHOSIS
  2. Schistosomiasis
  3. Sarcoidosis
37
Q

Main post-hepatic cause of portal hypertension

A
  1. RHF
  2. Constrictive Pericarditis
  3. IVC obstruction
38
Q

How does portal hypertension cocur

A

Liver injury + fibrogenesis the contraction of myofibroblasts contributes to increased resistance to blood flow

39
Q

How is portal hypertension initially compensated

A

Splanchnic vasodilatation from portal hypertension causes drop in BP/ increased CO and formation of collaterals between portal and systemic systems

40
Q

Where are collaterals forms

A
  1. Gastro-oesophageal junction
  2. Rectum
  3. Left renal vein
  4. Diaphragm
  5. Retroperitoneum
41
Q

What happens to the microvasculature of the gut during portal hypertension

A

Becomes congested

Causes hypertensive gastropathies and colopathies

42
Q

Symptoms of portal hypertension

A

Often asymptomatic

43
Q

Clinical sign of portal hypertension

A

Splenomegaly

44
Q

How does chronic liver disease clinically present in conjunction with portal hypertension

A
  1. Haematemesis and Malena from ruptured gastro-oesophageal varice OR portal hypertensive gastropathy
  2. Clubbing
  3. Palmar erythema
  4. Dupuytren’s contracture
  5. Spider Naevi
45
Q

What will most patients with cirrhosis develop over the next 10 years

A

Gastro-oesophageal varices

46
Q

How many of those with gastro-oesophageal varies will bleed

A

1/3

47
Q

When will bleeding occur in gastro-oesophageal varices

A

Those with large varies or those with red signs at endoscopy and severe liver disease

48
Q

How is bleeding from portal hypertension maanged

A
  1. Resuscitate until haemodynamically stable
  2. Blood transfusion if anaemic
  3. Correct clotting abnormalities
49
Q

Why is vasopressin given during portal hypertension

A

Cause vasoconstriction

50
Q

What vasopressin do we give for portal hypertension

A

IV TERLIPRESSIN (SOMATOSTATIN if contraindicated IHD)

51
Q

What antibiotic is given to people with is given to treat infection and why in portal hypertension

A

CEPHALOSPORIN

52
Q

Why is cephalosporin given in portal hypertension

A

Reduce early rebleeding and mortality

53
Q

What is vatical banding

A

Band is put around avarice using an endoscope (after a few days, banded vary degenerate and falls off)

54
Q

What other surgical methods are there for treating portal hypertension

A
  1. Ballon tamponade to reduce bleeding by placing pressure on avarice if banding fails
  2. Transjugular intrahepatic portoclavical shunt
55
Q

When is TIPS done

A

When bleeding can’t be controlled whether acutely or following rebreeding (shunts between systemic and portal system to reduce portal vein pressure)

56
Q

How is portal hypertension prevented

A

Non-selective B-blocker (PROPRANOLOL) - reduces portal pressure

VARICEAL BANDING repeatedly

Liver transplant

57
Q

What is Primary Biliary Cirrhosis

A

Chronic disorder with progressive destruction of small bile ducts = cirrhosis

58
Q

What people does primary biliary cirrhosis effect

A

Women aged 40-50

59
Q

What gender does primary biliary cirrhosis effect

A

Females

60
Q

Risk factors for primary biliary cirrhosis

A
  1. Positive family history
  2. Many UTIs
  3. Smoking
  4. Past pregnancy
  5. Other autoimmune disease
  6. Use of nail polish
61
Q

Pathophysiology of primary biliary cirrhosis

A

Interlobar bile ducts are DAMAGED by chronic autoimmune inflammation resulting in cholestasis which may lead to fibrosis, cirrhosis and portal hypertension

62
Q

What is cholestasis

A

Bile can’t flow from the liver to the duodenum (caused by a gallstone usually)

63
Q

What is found in all patients’ blood with primary biliary cirrhosis

A

Anti-mitochondrial antibodies

64
Q

Clinical presentation of patients with primary biliary cirrhosis

A
  1. Hepatomegaly
  2. Raised serum alkaline phosphate
  3. AMA
  4. Pruritus (itching)
  5. Lethargy and fatigue accompanying itching
  6. Eventually jaundice due to hepatomegaly
  7. Pigmented xanthelasma
65
Q

What is pigmented xanthelasma

A

Yellow fat deposits under the skin usually around the eyelids

66
Q

Complications of primary biliary cirrhosis

A

Cirrhosis
Osteoporosis
Malabsorption of fat-soluble vitamins due to cholestasis
Decreased bilirubin in gut lumen = osteomalacia and coagulopathy

67
Q

What is osetomalacia

A

Softening of the bone due to a loss of phosphates and calcium

68
Q

Differential diagnosis of Primary biliary cirrhosis

A
  1. Autoimmune cholangitis

Extahepatic biliary obstruction

69
Q

How is extra hepatic biliary obstruction excluded

A

Ultrasound

70
Q

Blood test for primary biliary cirrhosis

A
  1. Increased alkaline phosphate
  2. Raised serum cholesterol
  3. AMAs
  4. Raised IgM
71
Q

What can an ultrasound show for primary biliary cirrhosis

A

Diffuse altering in liver architecture + excludes extra hepatic cholestasis

72
Q

How can a liver biopsy help in diagnosis of primary biliary cirrhosis

A
  1. Portal tract infiltrate
  2. Granulomas (40% have them)
  3. Damage to and loss of small bile ducts + ductur=lar proliferation
  4. Portal tract fibrosis and eventually cirrhosis
73
Q

How is primary biliary cirrhosis treated

A
  1. URSODEOXYCHOLIC ACID
  2. BISPHOSPHONATES
  3. Supplements of vit A,D,E,K
74
Q

Why is URSODEOXYCHOLIX ACID given

A

Improves bilirubin and aminotransferase

75
Q

Why are bisphosphonates given

A

Osteoporosis

76
Q

How is pruritus treated

A

COLESTYRAMINE

NALOXONE and NALTREXONE

77
Q

Problem with COLESTYRAMINE

A

Unpalatable

Year 2 (155 decks)

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