CSIM liver Flashcards
commonest cause of liver disease?
NAFLD in 20-30% of population
commonest cause of liver death?
alcohol related liver disease - 84%
risk factors for NAFLD?
obesity diabetes metabolic syndrome male age
stages of ARLD?
normal - > steatosis - > steatohepatitis - > fibrosis/ cirrhosis
steatosis = infiltration of fat in the liver steatohepatitis = fat in the liver with inflammation
commonest presentation of liver disease?
incidental
- abnormal LFTs
- hepatosplenomegaly
- screening for antibodies / autoantibodies
- raised MCV, abnormal clotting, low platlets
why dry eyes / mouth in liver disease?
primary biliary cirrhosis
how much alcohol is 1 unit?
10ml
definition of a binge?
> 10u / sesh
raised ALP and GGT indicates what?
cholestasis
malignancy
alcohol
raised ALT and AST indicates what?
hepatocyte damage
if 1.5-3 x raised think ALD / NAFLD
if >3x raised think viral, autoimmune or drug induced
which anti bodies are present in autoimmune hepatitis?
anti-nuclear antibodies and anti smooth muscle
what does a transferrin saturation <45% rule out?
haemochromotosis
first line imaging in liver disease?
US
what is done when ct is performed?
IV constrast
best imaging for focal lesions?
MRI
indications for liver biopsy?
chronic liver disease for diagnosis and staging
focal lesions
transplantaion
risk associated with liver biopsy?
bleeding
what procedure to remove gall stones?
ERCP
features of metabolic syndrome?
DM hypertension high cholesterol -high LDLs and triglycerides fatty liver central obesity
effect of metabolic syndrome on urate?
increased urate due to renal damage (hypertension)
effect on MCV in alcohol excess?
raised
what does a bright liver indicate on US?
NAFLD
effect on FBC in cirrhosis
decreased platelets due to portal hypertension
significance of AST:ALT ratio?
normally in liver disease AST is LOWER than ALT
in ALD the AST:ALT ratio is > 2:1
why wouldnt you do a liver transplant if cancer is >5cm?
probably already spread
some reasons for liver transplant?
resistant ascites
encephalopathy
cancer < 5cm
uncontrollable varacele bleeds
pancreatic cancer risk is increased with obesity t or f?
true
what is the final common pathway in all liver disease?
activation of hepatic stellate cells causes fibrosis
what are the 4 key sings of a decompensated liver disease?
asterixsis - hepatic flap
encephalopathy
ascites
jaundice
why do you always do a tap in ascites?
check for spontaneous bacterial peritonitis
what does asterixis look like?
asymmetrical FLAP
causes of raised ferritin?
haemochromotosis
ALD
alcohol excess
obesity - raised triglycerides and a fatty liver
would you transplant a liver in an alcoholic?
wait 6 months from their last drink for 2 reasons:
- make sure they are committed to sobriety
- in this time some livers can repair sufficently to not need a new liver
most common sites of varicele bleeding?
oesophageal
rectal
gastric
what drug can be given as prophylaxis for varicele bleeding?
b-blockers
tx for varacele bleed?
banding is first line
if this fails can put in a shunt which decreases pressure in portal vein by moving blood to the hepatic vein
Mx of ascites?
conservative- reduced fluid (<1.5l/day) and salt intake
medical - diuretics - spironalactone / furosemide
surgical - therapeutic paracentesis (draining)
what might the fluid from an ascitic tap be bloody?
clipped a vessel
HCC - about 30% of bloody ascites is due to cancer
what must be given when draining fluid from abdomen?
fluids
what type of pathogen is most common in SBP?
gram neg. bacilli (e. coli, klebsiella etc.)
what secondary prophylaxis is given after SBP?
life long ciprafloxacin
what is hepatorenal syndrome?
renal failure in those with healthy kidneys due to liver disease
what are the types of HRS?
type 1 - rapidly progressive. often associated with acute renal failure
type 2 - slower course. associated with refractory ascites
what is the tx for HRS?
transplant
4 precipitating factors for hepatic enceph?
GI bleeding
infection
renal deterioration
constipation
tx for hepatic enceph?
regular lactulose +/- phosphate enemas
rifaximin
how does rifaximin treat enceph.?
non absorbable abx: reduce gut bacteria so less ammonia produced
where does blood from the liver drain?
hepatic vein
what is the commonest cause of liver cancer?
cirrhosis
why are we cautious of mass biopsy in liver cancer?
risk seeding the tumour
how does liver cancer change the blood supply to the liver?
draws blood from the hepatic artery
most common site for liver cancer metastasis
lung
what are the most common causes for secondary liver cancer?
pancreas
lung
colon
breast
which viruses commonly lead to hepatocellular carcinoma
hep b and c
most common type of cancer in the liver?
secondary from other sites
how can liver cancer lead to Budd- chiari syndrome?
tumour blocks hepatic vein
what change in LFTs is seen in HCC?
raised ALP and GGT
other than LFTs what is raised in HCC?
AFP (alpha fenoprotein) - released by tumour cells
erythropoitin
ILGF
PTHrP - also released by tumour cells
what is fulminant liver failure?
acute liver failure
definition of acute liver failure?
syndrome of liver dysfunction, coagulopathy, hepatic encephalopathy in the absence of pre existing liver disease
diagnosis of ALF?
increased PT by 4-6 seconds (INR >1.5 AND development of hepatic enceph. in the absence of liver disease in a time frame of less than 6 months
top 3 causes of ALF in the west?
paracetamol
indeterminate
idosyncratic drug reaction
how does paracetamol cause liver damage?
the major route for metabolism is safe but saturable
when taken in excess the other route of metabolism is used which produces the hepatotoxic metabolite NAPQI
whats the antidote for paracetamol ?
NAC - N- acetylecysteine
best if given within 10 hours
Ix in ALF?
ammonia ABG Lactate U&Es FBC coag - prothrombin time LFTs viral serology toxicology auto-antibodies
differentials for massive transaminases?
Viral- hep A-E, EBV, CMV, HSV, PMV
vascular- hypotension, congestion , hepatic artery thrombosis
drugs / toxins - loads
auto-immune
rare causes - wilsons
most common cause of raised transaminases in hospital?
ischaemic hepatitis
how does liver failure lead to HE?
3 things occur:
- cerebral vasomotor dysfunction
- oedema secondary to ammonia toxicity
- inflammation due to SIRS
how does increased ammonia lead to encephalopathy?
impaired urea synthesis therefore increased ammonia
the brain an act as an alternative ammonia detox pathway: astrocytes take it in and convert it to glutamine
when there is too much ammonia the astrocytes swell
how does HE match up with GCS?
grade I - GCS 14 - 15
grade II - GCS 11 - 13
grade III - GCS 8 - 11 (stupor / pre coma)
grade IV - GCS <8 (coma)
how should HE grade III and IV be managed?
airway protection and monitoring
what is HE grade IV at high risk of?
uncal herniation (transtentorial downwards)
how to mx raised ICP?
increase serum osmolality :
- hypertonic saline
- mannitol
reduce temp.
how to manage the raised PT in ALF?
dont correct unless bleeding as that masks to LF
what LFT picture would you expect in bone cancer?
raised ALP
normal GGT
what is PBC?
primary biliary cirrhosis - autoimmune disease of the small bile duct
immune injury -> inflammation / repair -> fibrosis / cirrhosis
how is PBC diagnosed?
raised ALP
AMA
histology
2/3 is probable
3/3 is definitive
only definitive diagnosis is with a biopsy although this is rarely done
what is PSC?
RARE disease: primary sclerosing cholangitis - autoimmune disease of the large ducts
an MRI can be used to visualise what kind of autoimmune liver disease?
PSC, the ballooning of the large vessels is visable
what condition does raised ALP and +ve AMA suggest?
PBC
who does PBC affect?
90% are women
often older
symptoms of PBC?
often asymptomatic
FATIGUE
ITCHINESS
dry eyes / mouth
poor memory
younger patients can present with advanced liver disease
what imaging is always done when the ALP is raised and why?
USS to rule out stone / cancer
Tx to slow PBC progression?
UDCA -usodeoxycholic acid (bile acid)
fibrates
TRANSPLANT
Tx for symptom relief in PBC?
stop itching:
rifampicin
cholestyramine
sertraline
anti histamines DO NOT WORK
no treatment for fatigue
which two thing should be specifically monitored in PBC?
OP
cirrhosis
+ve ANA, ASMA and IgG indicate what condition?
autoimmune hepatitis
who does autoimmune hepatitis effect
more common in women
ANY AGE
presentation of autoimmune hepatitis?
asymptomatic
feeling crap: fatigue, anorexia, joint pains
acute hepatitis
1/3 of people have cirrhosis when they present
in which autoimmune liver disease do you always biopsy and why?
autoimmune hepatitis;
confirm diagnosis
staging
principle of tx for Autoimmune hepatitis?
immunosuppression with steroids
aim for normalisation of ALT and IgG
what bloods tests are classically abnormal in PSC?
ANCA +ve (NOT VERY SENSITIVE)
ALP raised
who is PSC typically seen in?
old men
what happens in PSC?
inflammation and fibrosis of the intra- and extrahepatic bile ducts
there are multifocal bile duct strictures
what is closely linked with PSC?
IBD
presentation of PSC?
asymptomatic symptoms aren't as common as in PBC: - fatigue - RUQ pain - itch
jaundice / complications of cirrhosis are not as common as in PBC
what is the general difference in the use of MRIs and CTs in liver disease?
CTs for finding cancers
MRIs for identifying bile duct disease
what does an MRCP look like an PSC?
string of beads: multi-focal, short annular strictures
when there is a cholestatic blood profile, what is the first line investigation? and what next if thats not diagnostic? then what?
USS + check AMA
MRCP
biopsy
mx of PSC?
can treat the dominant stricture (surgery)
no real treatment
what is screened for in PSC?
IBD with a colonoscopy
cirrhosis
which two auto immune conditions CANNOT overlap
PBC and PSC
raised IgA in liver disease suggests what?
alcohol
NAFLD
raised IgM in liver disease suggests what?
PBC
all the Ms- they have the AMA too
autoimmune hepatitis raises which Ig?
IgG
who is at risk of a chronic hep E infection?
immunosuppressed
when can HEV be detected in the stool?
~3 wks post exposure
most common acute hepatitis infection in the UK?
HEV
what is the main factor that determine whether HBV is chronic in a patient?
when they acquire the virus
90% of babies that get it vertically / perinatally have chronic infection compared to ~5% of adults
HBsAg positive means…
HBV infection
HBeAg positive tells you what?
high level of HBV replication – usually high HBV DNA
in practice this is used as a surrogate for measuring DNA level
Anti-HBs Ab positive means…
past infection or vaccination
Anti-HBeAb is present when?
inactive HBV or the reactivation phase
in what phase of infection do liver complications arise?
immune clearance and reactivation
definition of chronic hepatitis
> 6 months liver inflammation
complications of HBV?
cirrhosis
cancer
varicies
transmission of HBV?
blood borne
peri natal -mother to child in birth
sexually
if you are HBeAg positive what does that mean?
high level of HBV replication
it is a surregate marker for HBV DNA levels
which phases of HBV infection do you need to treat and why?
immune clearance
re-activation
these cause cirrhosis
surveillance in HBV?
USS
alpha- fenoprotein AFP
how common is chronic infection in HCV?
50-80% common
how is HCV transmitted?
blood and body fluids(rare)
90% IV drug users in UK
important times to screen for hep C?
IV or intranasal drug use
any elevation of ALT
transplant before ‘91
effect of drinking when you have HCV?
raises risk of cirrhosis
what test can rule our haemochromotosis in the case of raised ferritin levels?
transferrin sat <45% rules it out
