Conceptual constructs of liver disease Flashcards
Name some LFTs
ALT
AST
Albumen
Globulin
Alkaline phosphatase
Bilirubin
GGT
What scoring system is used for liver cirrhosis?
Child-Pugh score
Classified A-C
A = good prognosis
C = poor prognosis
Where is bile made (microscopically)?
between 2 hepatocytes in the canaliculus
What is a fibroscan?
non-invasive way of stratifying extent of scar tissue
What does ALT stand for?
alanine aminotransferase
What does AST stand for?
asparte aminotransferase
What happens to albumen in cirrhosis?
it decreases
What does it mean if ALT or AST is raised?
enzymes that originate in hepatocytes
raised = something is damaging liver cells
Solubility of unconjugated and conjugated bilirubin
unconjugated = insoluble
conjugated = soluble
What is intrahepatic cholestasis?
something is going wrong with making bile between hepatocytes
Define cholestasis
alteration in flow of bile
What LFT is raised in cholestasis?
alkaline phosphatase
What does it mean if both alkaline phosphatase and GGT are raised?
HPB origin
What does it mean if alkaline phosphatase is raised by GGT is normal?
raised alk phos from somewhere else
What is GGT?
gamma glutamyl transferase
How does acute liver injury occur?
normal liver has an acute insult
LFTs in acute liver injury
high ALT
INR >1.5
jaundice (high bilirubin)
high ammonia (encephalopathy)
What can interruption to bile flow be caused by?
large duct obstruction (extrahepatic cholestasis)
failure of liver cells to make bile at level of canaliculus (intrahepatic cholestasis)
Describe the patterns of liver injury (hepatic vs cholestatic)
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]
What is DILI?
drug-induced liver injury
Signs of chronic liver disease
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
What are the likely causes if ALT >1000 IU/L?
ischaemia - eg. syncope can cause episodic reduced perfusion to liver
drug-induced (prescribed + non-prescribed)
viral hepatitis
acute biliary obstruction
Non-liver causes of raised ALT
haemolysis
myositis/myopathy
strenuous exercise
sepsis
Causes of raised ALT (but <500IU/L)
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
What screening tool can be used to assess alcohol excess?
AUDIT C
Which viral hepatitis can cause chronic infection?
B + C
Autoimmune hepatitis antibody
anti-smooth muscle antibody
anti LKM
anti LCA
p-ANCA
ANA
Test results for Wilson’s disease
low total copper
low caeruloplasmin
What investigations should be done in NAFLD?
BMI
fasting glucose
HbA1C
urate
fasting lipids
Who is at risk of Hep C?
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
Who is at risk of Hep B?
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
Most likely cause of isolated raised bilirubin
Gilbert’s syndrome
normal LFTs
no bilirubin in urine
normal stool colour
exclude haemolysis (FBC, LDH, haptoglobin, reticulocyte)
What is urine and stool like in hepatic and post-hepatic jaundice?
dark urine
pale stools
Extrahepatic cholestasis causes
stones
cancer
primary sclerosing cholangitis
Main symptoms of intrahepatic cholestasis
fatigue
pruritis
Intrahepatic cholestasis causes
primary biliary cholangitis
small duct PSC
amyloid - renal disease
lymphomas
granulomatous disease
immunodeficiencies (panhypogammaglobulinaemia)
cholestasis of sepsis
heart failure
What antibody is present in primary biliary cholangitis?
antimitochondrial antibody
