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4TH YEAR > CSIM liver > Flashcards

CSIM liver Flashcards

1
Q

commonest cause of liver disease?

A

NAFLD in 20-30% of population

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2
Q

commonest cause of liver death?

A

alcohol related liver disease - 84%

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3
Q

risk factors for NAFLD?

A 
obesity
diabetes
metabolic syndrome
male
age
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4
Q

stages of ARLD?

A

normal - > steatosis - > steatohepatitis - > fibrosis/ cirrhosis

steatosis = infiltration of fat in the liver
steatohepatitis = fat in the liver with inflammation
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5
Q

commonest presentation of liver disease?

A

incidental

  • abnormal LFTs
  • hepatosplenomegaly
  • screening for antibodies / autoantibodies
  • raised MCV, abnormal clotting, low platlets
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6
Q

why dry eyes / mouth in liver disease?

A

primary biliary cirrhosis

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7
Q

how much alcohol is 1 unit?

A

10ml

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8
Q

definition of a binge?

A

> 10u / sesh

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9
Q

raised ALP and GGT indicates what?

A

cholestasis
malignancy
alcohol

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10
Q

raised ALT and AST indicates what?

A

hepatocyte damage
if 1.5-3 x raised think ALD / NAFLD
if >3x raised think viral, autoimmune or drug induced

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11
Q

which anti bodies are present in autoimmune hepatitis?

A

anti-nuclear antibodies and anti smooth muscle

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12
Q

what does a transferrin saturation <45% rule out?

A

haemochromotosis

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13
Q

first line imaging in liver disease?

A

US

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14
Q

what is done when ct is performed?

A

IV constrast

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15
Q

best imaging for focal lesions?

A

MRI

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16
Q

indications for liver biopsy?

A

chronic liver disease for diagnosis and staging
focal lesions
transplantaion

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17
Q

risk associated with liver biopsy?

A

bleeding

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18
Q

what procedure to remove gall stones?

A

ERCP

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19
Q

features of metabolic syndrome?

A 
DM
hypertension
high cholesterol -high LDLs and triglycerides
fatty liver 
central obesity
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20
Q

effect of metabolic syndrome on urate?

A

increased urate due to renal damage (hypertension)

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21
Q

effect on MCV in alcohol excess?

A

raised

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22
Q

what does a bright liver indicate on US?

A

NAFLD

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23
Q

effect on FBC in cirrhosis

A

decreased platelets due to portal hypertension

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24
Q

significance of AST:ALT ratio?

A

normally in liver disease AST is LOWER than ALT

in ALD the AST:ALT ratio is > 2:1

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25
Q

why wouldnt you do a liver transplant if cancer is >5cm?

A

probably already spread

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26
Q

some reasons for liver transplant?

A

resistant ascites
encephalopathy
cancer < 5cm
uncontrollable varacele bleeds

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27
Q

pancreatic cancer risk is increased with obesity t or f?

A

true

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28
Q

what is the final common pathway in all liver disease?

A

activation of hepatic stellate cells causes fibrosis

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29
Q

what are the 4 key sings of a decompensated liver disease?

A

asterixsis - hepatic flap
encephalopathy
ascites
jaundice

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30
Q

why do you always do a tap in ascites?

A

check for spontaneous bacterial peritonitis

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31
Q

what does asterixis look like?

A

asymmetrical FLAP

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32
Q

causes of raised ferritin?

A

haemochromotosis
ALD
alcohol excess
obesity - raised triglycerides and a fatty liver

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33
Q

would you transplant a liver in an alcoholic?

A

wait 6 months from their last drink for 2 reasons:

  1. make sure they are committed to sobriety
  2. in this time some livers can repair sufficently to not need a new liver
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34
Q

most common sites of varicele bleeding?

A

oesophageal
rectal
gastric

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35
Q

what drug can be given as prophylaxis for varicele bleeding?

A

b-blockers

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36
Q

tx for varacele bleed?

A

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

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37
Q

Mx of ascites?

A

conservative- reduced fluid (<1.5l/day) and salt intake
medical - diuretics - spironalactone / furosemide
surgical - therapeutic paracentesis (draining)

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38
Q

what might the fluid from an ascitic tap be bloody?

A

clipped a vessel

HCC - about 30% of bloody ascites is due to cancer

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39
Q

what must be given when draining fluid from abdomen?

A

fluids

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40
Q

what type of pathogen is most common in SBP?

A

gram neg. bacilli (e. coli, klebsiella etc.)

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41
Q

what secondary prophylaxis is given after SBP?

A

life long ciprafloxacin

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42
Q

what is hepatorenal syndrome?

A

renal failure in those with healthy kidneys due to liver disease

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43
Q

what are the types of HRS?

A

type 1 - rapidly progressive. often associated with acute renal failure
type 2 - slower course. associated with refractory ascites

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44
Q

what is the tx for HRS?

A

transplant

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45
Q

4 precipitating factors for hepatic enceph?

A

GI bleeding
infection
renal deterioration
constipation

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46
Q

tx for hepatic enceph?

A

regular lactulose +/- phosphate enemas

rifaximin

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47
Q

how does rifaximin treat enceph.?

A

non absorbable abx: reduce gut bacteria so less ammonia produced

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48
Q

where does blood from the liver drain?

A

hepatic vein

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49
Q

what is the commonest cause of liver cancer?

A

cirrhosis

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50
Q

why are we cautious of mass biopsy in liver cancer?

A

risk seeding the tumour

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51
Q

how does liver cancer change the blood supply to the liver?

A

draws blood from the hepatic artery

52
Q

most common site for liver cancer metastasis

A

lung

53
Q

what are the most common causes for secondary liver cancer?

A

pancreas
lung
colon
breast

54
Q

which viruses commonly lead to hepatocellular carcinoma

A

hep b and c

55
Q

most common type of cancer in the liver?

A

secondary from other sites

56
Q

how can liver cancer lead to Budd- chiari syndrome?

A

tumour blocks hepatic vein

57
Q

what change in LFTs is seen in HCC?

A

raised ALP and GGT

58
Q

other than LFTs what is raised in HCC?

A

AFP (alpha fenoprotein) - released by tumour cells
erythropoitin
ILGF
PTHrP - also released by tumour cells

59
Q

what is fulminant liver failure?

A

acute liver failure

60
Q

definition of acute liver failure?

A

syndrome of liver dysfunction, coagulopathy, hepatic encephalopathy in the absence of pre existing liver disease

61
Q

diagnosis of ALF?

A 
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
62
Q

top 3 causes of ALF in the west?

A

paracetamol
indeterminate
idosyncratic drug reaction

63
Q

how does paracetamol cause liver damage?

A

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

64
Q

whats the antidote for paracetamol ?

A

NAC - N- acetylecysteine

best if given within 10 hours

65
Q

Ix in ALF?

A 
ammonia
ABG
Lactate
U&amp;Es
FBC
coag - prothrombin time
LFTs
viral serology
toxicology
auto-antibodies
66
Q

differentials for massive transaminases?

A

Viral- hep A-E, EBV, CMV, HSV, PMV

vascular- hypotension, congestion , hepatic artery thrombosis

drugs / toxins - loads

auto-immune

rare causes - wilsons

67
Q

most common cause of raised transaminases in hospital?

A

ischaemic hepatitis

68
Q

how does liver failure lead to HE?

A

3 things occur:

  1. cerebral vasomotor dysfunction
  2. oedema secondary to ammonia toxicity
  3. inflammation due to SIRS
69
Q

how does increased ammonia lead to encephalopathy?

A

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

70
Q

how does HE match up with GCS?

A

grade I - GCS 14 - 15
grade II - GCS 11 - 13

grade III - GCS 8 - 11 (stupor / pre coma)
grade IV - GCS <8 (coma)

71
Q

how should HE grade III and IV be managed?

A

airway protection and monitoring

72
Q

what is HE grade IV at high risk of?

A

uncal herniation (transtentorial downwards)

73
Q

how to mx raised ICP?

A

increase serum osmolality :

  • hypertonic saline
  • mannitol

reduce temp.

74
Q

how to manage the raised PT in ALF?

A

dont correct unless bleeding as that masks to LF

75
Q

what LFT picture would you expect in bone cancer?

A

raised ALP

normal GGT

76
Q

what is PBC?

A

primary biliary cirrhosis - autoimmune disease of the small bile duct

immune injury -> inflammation / repair -> fibrosis / cirrhosis

77
Q

how is PBC diagnosed?

A

raised ALP
AMA
histology

2/3 is probable
3/3 is definitive
only definitive diagnosis is with a biopsy although this is rarely done

78
Q

what is PSC?

A

RARE disease: primary sclerosing cholangitis - autoimmune disease of the large ducts

79
Q

an MRI can be used to visualise what kind of autoimmune liver disease?

A

PSC, the ballooning of the large vessels is visable

80
Q

what condition does raised ALP and +ve AMA suggest?

A

PBC

81
Q

who does PBC affect?

A

90% are women

often older

82
Q

symptoms of PBC?

A

often asymptomatic

FATIGUE
ITCHINESS

dry eyes / mouth
poor memory
younger patients can present with advanced liver disease

83
Q

what imaging is always done when the ALP is raised and why?

A

USS to rule out stone / cancer

84
Q

Tx to slow PBC progression?

A

UDCA -usodeoxycholic acid (bile acid)
fibrates
TRANSPLANT

85
Q

Tx for symptom relief in PBC?

A

stop itching:
rifampicin
cholestyramine
sertraline

anti histamines DO NOT WORK

no treatment for fatigue

86
Q

which two thing should be specifically monitored in PBC?

A

OP

cirrhosis

87
Q

+ve ANA, ASMA and IgG indicate what condition?

A

autoimmune hepatitis

88
Q

who does autoimmune hepatitis effect

A

more common in women

ANY AGE

89
Q

presentation of autoimmune hepatitis?

A

asymptomatic
feeling crap: fatigue, anorexia, joint pains
acute hepatitis
1/3 of people have cirrhosis when they present

90
Q

in which autoimmune liver disease do you always biopsy and why?

A

autoimmune hepatitis;
confirm diagnosis
staging

91
Q

principle of tx for Autoimmune hepatitis?

A

immunosuppression with steroids

aim for normalisation of ALT and IgG

92
Q

what bloods tests are classically abnormal in PSC?

A

ANCA +ve (NOT VERY SENSITIVE)

ALP raised

93
Q

who is PSC typically seen in?

A

old men

94
Q

what happens in PSC?

A

inflammation and fibrosis of the intra- and extrahepatic bile ducts
there are multifocal bile duct strictures

95
Q

what is closely linked with PSC?

A

IBD

96
Q

presentation of PSC?

A 
asymptomatic
symptoms aren't as common as in PBC:
- fatigue
- RUQ pain
- itch

jaundice / complications of cirrhosis are not as common as in PBC

97
Q

what is the general difference in the use of MRIs and CTs in liver disease?

A

CTs for finding cancers

MRIs for identifying bile duct disease

98
Q

what does an MRCP look like an PSC?

A

string of beads: multi-focal, short annular strictures

99
Q

when there is a cholestatic blood profile, what is the first line investigation? and what next if thats not diagnostic? then what?

A

USS + check AMA
MRCP
biopsy

100
Q

mx of PSC?

A

can treat the dominant stricture (surgery)

no real treatment

101
Q

what is screened for in PSC?

A

IBD with a colonoscopy

cirrhosis

102
Q

which two auto immune conditions CANNOT overlap

A

PBC and PSC

103
Q

raised IgA in liver disease suggests what?

A

alcohol

NAFLD

104
Q

raised IgM in liver disease suggests what?

A

PBC

all the Ms- they have the AMA too

105
Q

autoimmune hepatitis raises which Ig?

A

IgG

106
Q

who is at risk of a chronic hep E infection?

A

immunosuppressed

107
Q

when can HEV be detected in the stool?

A

~3 wks post exposure

108
Q

most common acute hepatitis infection in the UK?

A

HEV

109
Q

what is the main factor that determine whether HBV is chronic in a patient?

A

when they acquire the virus

90% of babies that get it vertically / perinatally have chronic infection compared to ~5% of adults

110
Q

HBsAg positive means…

A

HBV infection

111
Q

HBeAg positive tells you what?

A

high level of HBV replication – usually high HBV DNA

in practice this is used as a surrogate for measuring DNA level

112
Q

Anti-HBs Ab positive means…

A

past infection or vaccination

113
Q

Anti-HBeAb is present when?

A

inactive HBV or the reactivation phase

114
Q

in what phase of infection do liver complications arise?

A

immune clearance and reactivation

115
Q

definition of chronic hepatitis

A

> 6 months liver inflammation

116
Q

complications of HBV?

A

cirrhosis
cancer
varicies

117
Q

transmission of HBV?

A

blood borne
peri natal -mother to child in birth
sexually

118
Q

if you are HBeAg positive what does that mean?

A

high level of HBV replication

it is a surregate marker for HBV DNA levels

119
Q

which phases of HBV infection do you need to treat and why?

A

immune clearance
re-activation

these cause cirrhosis

120
Q

surveillance in HBV?

A

USS

alpha- fenoprotein AFP

121
Q

how common is chronic infection in HCV?

A

50-80% common

122
Q

how is HCV transmitted?

A

blood and body fluids(rare)

90% IV drug users in UK

123
Q

important times to screen for hep C?

A

IV or intranasal drug use
any elevation of ALT
transplant before ‘91

124
Q

effect of drinking when you have HCV?

A

raises risk of cirrhosis

125
Q

what test can rule our haemochromotosis in the case of raised ferritin levels?

A

transferrin sat <45% rules it out

4TH YEAR (12 decks)

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