Conceptual constructs of liver disease

Question 1

Name some LFTs

Answer 1

ALT
AST
Albumen
Globulin
Alkaline phosphatase
Bilirubin
GGT

Question 2

What scoring system is used for liver cirrhosis?

Answer 2

Child-Pugh score
Classified A-C
A = good prognosis
C = poor prognosis

Question 3

Where is bile made (microscopically)?

Answer 3

between 2 hepatocytes in the canaliculus

Question 4

What is a fibroscan?

Answer 4

non-invasive way of stratifying extent of scar tissue

Question 5

What does ALT stand for?

Answer 5

alanine aminotransferase

Question 6

What does AST stand for?

Answer 6

asparte aminotransferase

Question 7

What happens to albumen in cirrhosis?

Answer 7

it decreases

Question 8

What does it mean if ALT or AST is raised?

Answer 8

enzymes that originate in hepatocytes
raised = something is damaging liver cells

Question 9

Solubility of unconjugated and conjugated bilirubin

Answer 9

unconjugated = insoluble
conjugated = soluble

Question 10

What is intrahepatic cholestasis?

Answer 10

something is going wrong with making bile between hepatocytes

Question 11

Define cholestasis

Answer 11

alteration in flow of bile

Question 12

What LFT is raised in cholestasis?

Answer 12

alkaline phosphatase

Question 13

What does it mean if both alkaline phosphatase and GGT are raised?

Answer 13

HPB origin

Question 14

What does it mean if alkaline phosphatase is raised by GGT is normal?

Answer 14

raised alk phos from somewhere else

Question 15

What is GGT?

Answer 15

gamma glutamyl transferase

Question 16

How does acute liver injury occur?

Answer 16

normal liver has an acute insult

Question 17

LFTs in acute liver injury

Answer 17

high ALT
INR >1.5
jaundice (high bilirubin)
high ammonia (encephalopathy)

Question 18

What can interruption to bile flow be caused by?

Answer 18

large duct obstruction (extrahepatic cholestasis)

failure of liver cells to make bile at level of canaliculus (intrahepatic cholestasis)

Question 19

Describe the patterns of liver injury (hepatic vs cholestatic)

Answer 19

hepatic:
- ALT >5x ULN
- Alk phos <2x ULN

cholestatic:
- ALT <2x ULN
- Alk phos >5x ULN

mixed:
- ALT 2-5x ULN
- Alk phos 2-5x ULN

[ULN = upper limit of normal]

Question 20

What is DILI?

Answer 20

drug-induced liver injury

Question 21

Signs of chronic liver disease

Answer 21

jaundice
raised JVP
spider naevi
gynaecomastia
clubbing
palmar erythema
ascites
oesophageal varices
splenomegaly
rectal varices
fetor hepaticus
loss of sexual hair
testicular atrophy
liver flap (asterixis)
bleeding tendency
ankle oedema
anaemia

Question 22

What are the likely causes if ALT >1000 IU/L?

Answer 22

ischaemia - eg. syncope can cause episodic reduced perfusion to liver

drug-induced (prescribed + non-prescribed)

viral hepatitis

acute biliary obstruction

Question 23

Non-liver causes of raised ALT

Answer 23

haemolysis
myositis/myopathy
strenuous exercise
sepsis

Question 24

Causes of raised ALT (but <500IU/L)

Answer 24

alcohol excess
NAFLD
viral hepatitis
metabolic (haemochromatosis, Wilson’s, alpha-1-antitrypsin deficiency)
autoimmune hepatitis
drug-induced liver injury
acute Budd Chiari
acute bile duct obstruction

Question 25

What screening tool can be used to assess alcohol excess?

Answer 25

AUDIT C

Question 26

Which viral hepatitis can cause chronic infection?

Answer 26

B + C

Question 27

Autoimmune hepatitis antibody

Answer 27

anti-smooth muscle antibody anti LKM anti LCA p-ANCA ANA

Question 28

Test results for Wilson's disease

Answer 28

low total copper low caeruloplasmin

Question 29

What investigations should be done in NAFLD?

Answer 29

BMI fasting glucose HbA1C urate fasting lipids

Question 30

Who is at risk of Hep C?

Answer 30

ex and current drug users blood transfusions before 1991 organ/tissue transplant before 1992 lived in area with high levels of Hep C mother has Hep C health workers accidentally exposed tattoo/piercing in place where equipment not sterilised sexual partners, family members and close contacts of those with Hep C

Question 31

Who is at risk of Hep B?

Answer 31

vaginal, anal or oral sex without a condom injecting drugs/sharing needles injured by a needle tattoo/piercing with unsterilised equipment blood transfusion in country that does not check for Hep B can pass to babies during pregnancy/birth from mother

Question 32

Most likely cause of isolated raised bilirubin

Answer 32

Gilbert's syndrome normal LFTs no bilirubin in urine normal stool colour exclude haemolysis (FBC, LDH, haptoglobin, reticulocyte)

Question 33

What is urine and stool like in hepatic and post-hepatic jaundice?

Answer 33

dark urine pale stools

Question 34

Extrahepatic cholestasis causes

Answer 34

stones cancer primary sclerosing cholangitis

Question 35

Main symptoms of intrahepatic cholestasis

Answer 35

fatigue pruritis

Question 36

Intrahepatic cholestasis causes

Answer 36

primary biliary cholangitis small duct PSC amyloid - renal disease lymphomas granulomatous disease immunodeficiencies (panhypogammaglobulinaemia) cholestasis of sepsis heart failure

Question 37

What antibody is present in primary biliary cholangitis?

Answer 37

antimitochondrial antibody