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(J2) GI II Test 2 > General Features of Liver Disease > Flashcards

General Features of Liver Disease Flashcards

1
Q

What are the components of a portal triad?

A
  • hepatic artery
  • portal vein
  • bile duct

–not hepatic vein–

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2
Q

What are reversible signs of liver damage?

A
  • fat accumulation (steatosis)
  • elevated bilirubin (cholestasis)
  • swelling
  • clumping of intermediate fillaments -> Mallory hyaline
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3
Q

What are signs of irreversible liver damage?

A
  • coagulative necrosis; begining as confluent necrosis (zone 3, around central vein) -> bridging necrosis (connects central vein to portal triads) -> pan-acinar necrosis (multiple adjacent acini)
  • apoptosis; eosinophilic cytoplasm, condensation (pyknosis) and fragmentation (karyorrhexis) of chromatin
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4
Q

How does the liver repair itself following damage?

What does this look like in chronic liver disease?

A
  • stellate cell activation replace lost parenchma with fibrous scar tissue
  • surviving hepatocytes divide to regenerate lost parenchyma

In chronic liver disease this process occurs repeatedly overtime and areas of regenerating hepatocytes will become surrounded by fibrous septae -> regenerative nodules, this is cirrhosis

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5
Q

What is liver failure?

How does it present?

A

loss of 80-90% of liver function

presentation varies with acute or chronic setting but both include:

  • hepatic encephalopathy -> asterixis
  • coagulation abnormalities
  • N/V
  • elevated bilirubin -> jaundice/icterus & itching
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6
Q

What are causes of liver failure?

A

ABCDE

  • A: Acetominophen, HAV, Autoimmune
  • B: HBV
  • C: HCV
  • D: Drugs/toxins (aflatoxin), HDV
  • E: HEV, esoteric (rare; Wilson’s disease and Budd-Chiari)
  • F: Fatty, microvesicular (microvesicular steatosis; pregnancy, valproate, tetracycline, Reye syndrome)
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7
Q

What is acute liver failure?

(appearance)

A

occurs within 6 months (26 weeks) of injury

caused by massive hepatic destruction

  • shrunken liver
  • massive necrosis w/ or w/o regeneration/scaring (depends on timing)
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8
Q

How does acute liver failure present?

A
  • elevated ammonia -> hepatic encephalopathy -> asterixis
  • decreased coagulation factors (elevated PR/INR) -> coagulation abnormalities
  • N/V
  • elevated bilirubin -> jaundice/icterus & itching
  • elevated AST/ALT (hepatocyte damage)
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9
Q

What are the main causes of acute liver failure?

A
  • acetominophen (50%)
  • autoimmune hepatitis
  • drugs/toxins (aflatoxin and aminita mushroom)
  • acute HAV and HBV infections
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10
Q

How is acute liver failure treated?

A
  • supportive (fluids, circulation, and respiration)
  • control bleeding
  • lactulose for ammonia
  • prophylactic ABX
  • liver transplant
  • N-acetylcysteine (in acetominophen OD)
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11
Q

What are complications of acute liver failure?

What are the main causes of death?

A

Complications:

  • GI bleeding
  • coagulopathy
  • multi-organ failure (heart, lung, and kidneys)
  • coma

Cause of death:

  • cerebral edema
  • sepsis
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12
Q

What is an unusual presentation of acute liver failure?

What causes are associated with it?

A

acute liver failure w/o obvious cell death/necrosis

caused by widespread hepatocyte dysfunction rather than loss:

-diffuse microvesicular steatosis of fatty liver of pregnancy

-idiosyncratic drug reactions (valproate and tetracycline)

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13
Q

What is chronic liver failure?

(appearance)

A

progressive loss of liver function due to chronic liver disease

often associated with cirrhosis

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14
Q

How does cirrhosis/chronic liver failure present?

A

often masked early by prexisiting liver disease -> asymptomatic

signs of acute liver failure + portal hypertension + hyperestroginemia (men only)

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15
Q

Why does men with cirrhosis/chronic liver failure have hyperestrogenemia?

How does this present?

A

impaired metabolism of estrogen due to impaired liver function

Presentation:

  • palmar erythema
  • spider angiomata
  • hypogonadism
  • gyenicomastia
  • infertility
  • erectile dysfunction
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16
Q

What are the main causes of chronic liver failure?

A
  • chronic HBV and HCV
  • alcoholic liver disease
  • non-alcoholic fatty liver disease (NAFLD)
17
Q

How is cirrhoisis/chronic liver failure treated?

A
  • treatment of underlying condition
  • control of symptoms
  • monitor for HCC
  • liver transplant
18
Q

What are complications of cirrhosis/chronic liver failure?

A
  • HCC
  • GI bleeding
  • coagulopathy
  • hepatorenal syndrome

-ascites

-sepsis (spontaneous bacterial peritonitis)

19
Q

What are prognostic tools for cirrhosis/chronic liver disease?

A

MELD (model for end-stage liver disease):

  • calculated using bilirubin, creatinine, and INR (CMP + INR)
  • high score = worse prognosis
  • score of >14 indicates transplant

Child-Turcotte-Pugh Score:

  • uses bilirubin, albumin (CMP), PT/INR, and exam findings
  • A (well compensated), B (partially decompensated), and C (decompensated)
20
Q

What is portal hypertension?

A

increased resistance of blood flow in the portal vein

21
Q

What are the causes of portal hypertension?

A

Pre-hepatic:

-thrombosis

Intrahepatic:

  • cirrhosis (**most common**)
  • schistosomiasis (**second most common**)
  • malignancy

Post-hepatic:

  • Budd-Chiari syndrome/hepatic vein obstruction
  • right sided heart failure
22
Q

What is the presentation of portal hypertension?

A
  • ascites
  • portosystemic shunts: esophageal varicies, caput medusae, hemorrhoids
  • congestive splenomegaly
  • hepatic encephalopathy
23
Q

What is ascites?

A

Accumulation of fluid in the peritoneal cavity

Clinically detectable as a fluid wave at 500mL

24
Q

What causes ascites?

A
  • mainly caused by portal HTN secondary to cirrhosis (80%)
  • non-portal HTN related: malignancy, pancreatitis, infection, hypoalbuminemia
25
Q

How is ascites diagnosed and treated?

What tests should be run on ascitic fluid?

A

Diagnosis:

  • abdominal US; can detect ascites and identify certain causes (Budd-Chiari)
  • abdominal paracentesis

Treatment:

  • abdominal paracentesis to remove fluid (therapeutic)
  • treat cause of ascites once identified

Testing of ascitic fluid:

  • cell count -> PMNs >250 = infection
  • albumin/total protein; used in SAAG
  • culture and Gram stain -> identifies possible bacteria
26
Q

What complications are associated with ascites?

(describe it)

A

primary (spontaneous) bacterial peritonitis

  • ascitic fluid PMN >250
  • infection by single organism (typically E. coli or Klebsiella pneumoniae)
27
Q

What is helpful in differentiating causes of ascites?

A

SAAG (serum-ascites albumin gradient):

  • SAAG = serum albumin - ascites albumin
  • >1.1 inidcates portal HTN/liver
  • <1.1 indicates non-liver cause
28
Q

What complications are associated with portosystemic shunts?

A

-life threatening variceal bleeding

29
Q

What complications are associated with congestive splenomegaly?

A

-thrombocytopenia

30
Q

What is hepatic encephalopathy?

How is is graded?

A

AMS in the pressence of liver disease

  • failure to eliminate gut neurotoxins in the liver
  • accumulation of ammonia

Presentation:

  • AMS
  • asterixis
  • behavioral changes

Graded 1-4:

  • 1 = mild/subtle confusion (ask orientation questions)
  • 2 = drowsiness
  • 3 = stupor
  • 4 = coma

(J2) GI II Test 2 (12 decks)

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