GI And Liver Flashcards
What is ALP and when is ALP affected
Alkaline phosphatase - Role in dephosphorylating molecules particularly in the bone and biliary tree
…SO…
Increased in biliary tree damage + bone pathology
Not just specific to liver pathology but may be indicative of it
What is GGT and when is GGT affected
Gamma-glutamyl transferase - enzyme which has a role in glutathione synthesis (major antioxidant)… found everywhere in body but mainly the liver
…SO…
It’s increased in Acute liver disease
Shows a hepatic/bony cause for the change
REMEMBER… ALP suggests biliary tree damage
Not just specific to liver pathology but may be indicative of it
Define appendicitis
Inflamed appendix; usually due to luminal obstruction
Surgical emergency
Causes of appendicitis
Faecolith (hard solidified faeces)
Lymphoid hyperplasia (in teens, of peyer’s patches)
Worms
Blockage typically affected with ecoli and as pressure increases inside appendix you get increased risk of rupture (SBP)
Signs and Sx of appendicitis
Umbilical pain which localises to the McBurney’s point
Pyrexia + rebound tenderness & abdo gauging
Rosving’s - palpation of the left iliac fossa causes pain in the RIF).
Obturator sign - pain is worsened by flexing and internally rotating the hip.
Psoas sign - pain is worsened by extending the hip.
Complication of appendicitis
Rupture
Peri-appendiceal abscess
Investigation and Dx of appendicitis
CT Abdo + pelvis - gold standard
Rule out pregnancy in females of child-bearing age assume they are pregnant until proven otherwise - to rule out ectopic pregnancy (presents with right iliac fossa pain)
Tx for appendicitis
Antibiotics
- ensure the abcess is drained before giving ABx (they are walled off bacterial collection therefore systemic ABx aren’t useful; drain and give intra-abscess ABx)
Then appendectomy (laproscopic)
What is AST / ALT
Also useful markers that may help identify liver pathology (like GGT and ALP)
They are found in the liver, heart, kidney muscles
AST:ALT ratio ≈ 1 (so if the ratio is off then may suggest pathology)
> 2:1 ratio suggests alcoholic liver disease (esp with increased GGT)
> 4.5:1 ratio suggests Wilson’s (Copper accumulation) / hyperthyroidism
< 0.9:1 ratio suggests NAFLD
A 19-year-old woman is admitted to hospital having taken an overdose of over 200 paracetamol tablets at home. Despite treatment with n-acetylcysteine she develops jaundice, worsening coagulopathy on her clotting studies and is now confused. She is referred for liver transplant.
What condition does she have..?
Acute liver failure
Pathophysiology of acute liver failure
The rapid decline in hepatic function characterised by jaundice, coagulopathy and hepatic encephalopathy
Coagulopathy: INR > 1.5
Essentially liver loses ability to regenerate and repair -> irreversible damage (i.e. decompensated cirrhosis)
What is fulminant liver failure
Rare syndrome of massive hepatocyte necrosis (histological LH see multi-acinar necrosis too)
Onset………..
Hyperacute: within 7 days
Acute: between 8 and 28 days
Sub-acute: between 29 days and 12 weeks
Main cause of fulminant liver failure
paracetamol overdose - in 70% of cases
What is acute on chronic liver failure
Rapid decline in Px with chronic liver Sx
What is chronic liver failure
Px with progressive Hx of liver disease
Name 3 types of liver function tests we can measure
Bilirubin (conjugated/unconjugated) increases
Albumin decreases
Prothrombin time (PT/INR) increases
These 3 are directly relate to liver damage…v.specific
Remember the enzymes (AST,ALT,GGT,ALP) aren’t as specific as they can be altered by a lot of other things
Name 2 hepatocellular enzymes
Transaminases
AST
ALT
Name a Cholestatic enzyme
Alkaline phosphatase:
ALP
Give 5 causes of acute liver failure
Viral; Hep A, B, E / CMV / EBV
Autoimmune Hep
Drugs; Paracetamol / alcohol / ecstasy
HCC (hepatocellular carcinoma)
Budd-chiari syndrome (post hepatic vein blockage)
Signs and Sx of acute liver failure
Acute presentation of…
Jaundice, coagulopathy and
hepatic encephalopathy - Altered mood, sleep disturbance, inappropriate behaviour
What criteria is used for hepatic encephalopathy
West haven criteria grade 1-4:
1) altered mood / sleep disturbance
2) lethargy / mild confusion / Asterixis
3) marked confusion
4) comatose
Investigation and Dx of acute liver disease
Bloods:
LFTs - (increased bilirubin, decreased albumin, increased PT/INR)
Increased serum AST/ALT decreased glucose
Imaging:
USS to check for budd-chiari syndrome
Microbiology:
Rule out infections; blood culture, urine culture, ascites tap
Tx for acute liver disease
Acute: ABCDE; IV fluids, analgesia
Then treat underlying cause + complications;
Paracetamol overdose; give activated charcoal + N-acetyl cysteine.
ICP - IV MANNITOL
Hepatic encephalopathy - LACTULOSE; Increase NH3 excretion
Ascites - diuretics; spironolactone
Haemorrhage - Vitamin K
Sepsis - SEPSIS 6.
What type of complications are there in acute liver disease?
ICP
Hepatic encephalopathy
Ascites
Haemorrhage
Sepsis