GI - liver Flashcards
what is a sign of encephalopathy
cock wrists back and patients have a flap
what causes encephalopathy
high levels of ammonia in blood due to decreased metabolism of it as…
- nutrient rich blood not directed to liver due to portosystemic shunts
or
- hepatocytes not efficient at breaking down ammonia
what is the treatment of encephalopathy
lactulose
non-absorbable ABs e.g. Rifaximin
maintain nutrition
transplant
what colour does collagen stain in space of disse in fibrosis
blue
how does cirrhosis cause hepatorenal syndrome
Portal hypertension - liver thinks there is reduced BF - releases NO (vasodilator) - kidneys release renin - aldosterone causes vasoconstriction in the kidney
what does the liver store
Vit A D B12 and iron
glycogen
what zone is closest to the central vein
Z1
what zone is nearest to the portal space
Z3
what is happening:
shifting dullness
dark on US
ascites
what is the treatment of ascites
tap - check for SBP decrease salt spironolactone paracentesis TIPSS Transplant no NSAIDS
how can variceal bleeding be prevented
beta blockers
ligation
what is the treatment of variceal bleeding
sclerotherapy
balloon tamponade (temporary)
TIPSS
what qualifies acute liver disease
rapid development of hepatic dysfunction without prior liver disease (<6 months)
s/s liver disease
lethargy/arthralgia jaundice RUQ pain itch nausea hypoglycaemia
what is the treatment for an itch associated with liver disease
sodium bicarbonate bath
orseodeoxycholic acid
cholestryamine
what is the treatment for liver disease
no alcohol no high fat food increase calories fluids bed rest (3/12)
what drugs cause acute liver disease
paracetamol methotrexate flucloxacillin co-amoxiclav statins ALCOHOL
what viruses cause acute liver disease
Hep A B C D E
CMV
EBV
toxoplasmosis
what is fulminant hepatic failure
jaundice and encephalopathy in a patient with a previously normal liver in <2 weeks
what inflammation in seen in acute liver inflammation
neutrophils
list come causes of FHF
paracetamol overdose fulminant viral drugs HBV Non-A-E hepatitis
AFLP mushrooms malignancy wilsons budd chairi hep A
what is the treatment for FHF
inotropes fluids renal replacement management of raised ICP transplant increase calories
how is simple steatosis diagnosed
US
how is steatohepatitis (fat+inflammation) diagnosed
biopsy
what is the histology of NAFLD
maladaptation to oxidative stress
what happens after excess fat accumulation in NAFLD
intrahepatic oxidative stress
lipid peroxidation
TNF alpha
cytokine cascade - stellate cells produce collagen in response
how is a cirrhotic liver described
liver small shrunken and hard
leathery
craggy
nodular - nodules seen on surface
what defines liver cirrhosis
bands of fibrosis separating regenerative nodules of hepatocytes
what is the treatment of NAFLD
lose weight
exercise
what are some causes of liver cirrhosis
alcohol HBV/HCV iron overload autoimmune gallstones NASH PBC/PSC wilsons A1ATD Budd Chairi
what are some complications of liver cirrhosis
ascites liver failure encephalopathy variceal bleeding osteoporosis osteomalacia
what is the treatment of liver cirrhosis
treat underlying cause avoid salt small frequent meals vit B (thiamine) and D supplement
what is the cause of pre-hepatic portal hypertension
portal vein thrombosis/occlusion
what is the cause of intra-hepatic portal hypertension
distortion of architecture
what are some s/s compensated liver cirrhosis
spider naevi gynaecomastia palmar erythema clubbing hepato/splenomegaly jaundice
what are some s/s decompensated liver cirrhosis
jaundice acute liver failure ascites encephalopathy bruising/purpura infection/insult/SIRS
why does liver cirrhosis predispose to HCC
cells constantly dying and regenerating - increased chance of mutation
increased oxidative stress to cell DNA due to chronic inflammation
what is cardiac cirrhosis
liver cirrhosis secondary to RSHF
most commonly - incompetent tricuspid valve causes back flow of blood to liver so liver can’t drain blood
what is caput medusa
result of portal hypertension umbilical vein (ligamentum hepes) comes back into use to divert blood from portal to systemic system
what causes ascites
low albumin levels
high portal pressure
- large hydrostatic pressure of capillaries and low osmotic drive of capillaries
what is secondary aldosteronism
liver unable to breakdown excess aldosterone
low albumin causes low plasma volume which activates renin production from kidneys which produces aldosteronism
why would renal vasodilators be prescribed in liver cirrhosis
to conter act hormone vasoconstrictors - endothelin, aldosterone, angiotensin II - to maintain kidney function
what is affected first in liver disease - phase 1 or 2 of metabolism
1
what is phase 1 of liver metabolism
biotransformation
what is phase 2 of liver metabolism
conjugation
what is N-acetyl-p-benzoquinomine
highly reactive intermediate formed from metabolism of paracetamol
how is N-acetyl-p-benzoquinomine removed by liver
glutathione
why does liver failure increase your risk of paracetamol overdose
glutathione stores are reduced so metabolism is a normal rate but not enough enzyme to remove N-acetyl-p-benzoquinomine
what is Hy’s rule
if ALT/AST > 5 times normal limit
Bilirubin > 3mg/dl
drug is causing liver disease
does autoimmune hepatitis affect women or men more
women
what are 2 genetic predisposing factors to autoimmune hepatitis and which is more severe
HLA-DR3: early onset and severe
HLA-DR4: late onset and less severe
what kind of LFTs does autoimmune hepatitis show
hepatic
what are some s/s of autoimmune hepatitis
fatigue weight loss RUQ pain hepato/splenomegaly jaundice elevated PT, AST/ALT anorexia nausea
what is the treatment of autoimmune hepatitis
prednisolone
azathioprine/mercaptopurine
transplant
what is the histology of autoimmune hepatitis
chronic hepatitis with marked piecemeal necrosis and lobular involvement and interface hepatitis
numerous plasma cells
who does T1AIH affect
adults, typically women>40
what are some blood markers of T1AIH
ASMA +
ANA +
increased IgG
who does T2AIH affect
children/young adults
what blood markers are seen in T2AIH
LKMI +
anti-LC1 +
what is less easily treated and more likely to progress to cirrhosis - T1 or T2
T2
what blood markers are seen in T3AIH
ASLA +
liver-pancrease antigen +
what are some common triggers of AIH
virus
toxin
drug
what is PBC
primary biliary cirrhosis
bile ducts within the liver are damaged by chronic AI granulomatous inflammation
(immune reaction against PDH)
who does PBC typically affect
middle aged women fat forty female fertile
what are some s/s of PBC
fatigue itch without rash xanthelasma xanthomata jaundice hyperlipidaemia
what blood markers are raised in PBC
AMA +
raised IgM
how is PBC diagnosed
2/3 of
cholestatic LFTs
liver biopsy
AMA+
what is the treatment of PBC
urseodeoxycholic acid
transplant
what is seen in the histology of PBC
granulomas
bile duct loss/inflammation
chronic portal inflammation
what are some s/s PSC
maybe itch and rigors
does PSC affect men or women more
men
what kind of jaundice does PSC show
post hepatic
is PSC associated with UC or Crohn’s
UC
what is PSC
progressive fibrosis and obliteration of biliary tracts - bile duct inflammation and strictures - intra and extra hepatic ducts
how is PSC diagnosied
ERCP/MRCP
biopsy
what blood markers are raised in PSC
p-ANCA +
AMA -
is PSC or PBC more likely to cause cholangiocarcinoma/CRC
PSC
what is seen in the histology of PSC
periductal onion skinning fibrosis
beading of bile ducts
what would ALP do in PSC
raised
true/false
AIH is a relapsing and remitting disease
true
true/false
AIH can be drug induced and also induced by protein supplements/bulking
true
what is primary haemochromatosis
increased iron absorption due to an AR condition affecting the HFE gene
is haemochromatosis worse in men or women
men - no errections
true/false
haemochromatosis is worse in homozygotes
true
what can secondary haemochromatosis be caused by
iron overload in diet / iron transfusions /therapy
what is haemochromatosis
iron deposited in portal connective tissue of liver which stimulates fibrosis
what does haemochromatosis predispose to
HCC cirrhosis pancreatic failure diabetes heart failure impotence
what is the treatment for haemochromatosis
venesection/phlebotomy
what are some investigations for haemochromatosis
LFTs
increased serum ferritin
liver MRI
liver biopsy
how does haemochromatosis cause “bronzed diabetic”
darkened skin
hyperglycaemia
how is the presence of iron in hepatocytes confirmed
perl’s stain
what is the name of the genetic disorder in which there is a loss of function/low levels of caeruloplasmin - copper binding drug
wilsons
what kind of inheritance is wilsons
autosomal recessive
what happens as a result of copper deposition in the eyes
keiser-fleshier rings
what happens as a result of copper deposition in the liver
cirrhosis
chronic hepatitis
sub fulminant hepatic failure
what happens as a result of copper deposition in the brain
chorea-athertoid movements
depression/mania/labile emotions/personality change/changed libido/personality change
neurodegeneration
what gene is involved in wilsons
ATP7B
what is the treatment of wilsons
copper chelating drugs e.g. penicillamine
what is seen in the blood of someone with wilsons
serum copper
low caeruloplasmin
what is budd chairi
thrombosis of hepatic veins - blood can’t drain from liver which causes cirrhosis
what are some causes of budd chairi
pregnancy oral contraceptive HCC TB tumour compressing hepatic vein protein S or C deficiency
what are some s/s of budd chairi
jaundice
tender hepatomegaly
ascites (chronic)
how is budd chairi diagnosed
Doppler US of hepatic veins
what is the treatment for budd chairi
recanalisation
TIPSS
what is the inheritance of A1ATD
autosomal recessive
what is seen in the histology of A1ATD
cytoplasmic globules of unsecreted protein in liver cells
where can methotrexate cause damage
liver
lungs
what chemical that is a product of alcohol metabolism is responsible for liver cell injury in alcoholic liver disease
acetaldehyde
what is the main pathology of ALD
increased peripheral release of fatty acids and increased synthesis of fatty acids and triglycerides within hepatocytes
what cells lay down collagen and where do they do so
fibroblasts - in the space of disse
what are the stages between fatty liver and cirrhosis
fatty liver
hepatitis
fibrosis
cirrhosis
how does a fatty liver appear
fatty vacuoles appear clear in hepatocytes
how does hepatitis - fibrosis appear
nodular/hepatocyte necrosis
neutrophils
mallory bodies
describe alcohol cirrhosis
micro nodular cirrhosis with abundant white scarring
what are some things alcoholic cirrhosis predisposes to
portal HT varices ascites malnutrition HCC
what are some s/s of alcoholic liver disease
hepatomegaly fever leukocytosis thrombocytopenia jaundice etc
what is the treatment of alcoholic hepatitis
fluids
blood transfusion
steroids in ST
is alcoholic liver disease reversible
yes - if cessation of drinking
but not fibrosis and further
what viral cause of hepatitis is associated with glandular fever
EBV
what 2 enzymes are important in alcohol metabolism
alcohol dehydrogenase
aldehyde dehydrogenase
true/false
ketone bodies from alcohol are toxic
true
what is the minimum price per unit alcohol
50p
what is the weekly recommended intake of alcohol for men and women
14 units
spread evening over 3+ days
what is Wernicke-Korsakoff’s syndrome
Vitamin B1 deficiency (thiamine) as a result of chronic alcoholism
- encephalopathy and loss of nerves
what is the route of spread of Hep A
faecal oral
can hep A be chronic
no - usually resolves after 3 months
is there a hep A vaccine
yes
what is seen in the blood of Hep A
Hep A IgM
how is Hep A tested
clotted blood for serology - gold top
how does Hep A virus cause damage
directly cytopathic
what are some s/s Hep A
fever malaise N and V jaundice RUQ pain hepatomegaly clay coloured stool dark urine headache
what do the LFTs/bilirubin show for Hep A
raised LFTs
raised Bilirubin
what is hep A associated with
poor hygiene
over crowding
how long after chronic liver disease does cirrhosis occur
20 years
how long after chronic liver disease does cancer occur
30 years
how is Hep B transmitted
mother to child
blood
sex
needles
does hep B have a long incubation period
yes
can Hep B be chronic
yes but more likely to be acute
unless child infected at birth then more likely to develop to chronic
how does hep B cause damage
damage to anti-viral host immune response - autoimmune
can hep B have a spontaneous cure
yes
what is the most common type of hepatitis infection
B
what are some risk factors for hepatitis
HBV + mother
SE asian / african / eastern european
MSM
multiple sex partners
is there a Hep B vaccine
is there prophylactic post exposure treatment
yes
yes = vaccine + Hep B Ig
what is the treatment for chronic Hep B infection
Peginterferon +/- antivirals e.g. entecavir, tenofovir, adefovir
is hep B DNA or RNA
DNA
if a patient already has cirrhosis how often should they have an ultrasound
every 6 months
can Hep B predispose to HCC
yes
what are the LFTs / bilirubin like in Hep B
raised
when is HBsAg seen
all Hep B infected individuals
patient is infected and infectious
if someone is HBsAg+ but asymptomatic what are they classed as
carrier
when is HBeAg present
highly infectious individuals
when is Hep B DNA present
high titre in highly infectious
what blood marker is used to predict the risk of chronic liver disease in hep b
Hep B DNA
as HBV DNA increases the risk of HCC increases
true/false
true
what blood marker indicates low infectivity in hep B
Anti-HBe Ab
when is HB IgM seen and what does it progress to after a while
recently infected individuals
—> IgG after while of infection
if someone has Anti-HBs + Anti-HBc marker what do we know
they are immune from natural infection
if someone has Anti-HBs marker what do we know
they are immune from vaccine or natural infection
how is Hep C spread
blood
sex (more so blood)
what are some indications that you might consider Hep C
recent tattoo in foreign country
blood transfusion
pakistani/indian
is there a hep C vaccine
no
what is the treatment for hep C
peginterferon
ribavirin
what hepatitis virus is associated with herpes simplex virus
hep C
is hep C DNA or RNA
RNA
is hep C more likely to resolve or become chronic
chronic
C for chronic
true/false
Hep C disease waxes and wanes
true
if a person was Hep C Ab positive what can we tell
they have had Hep C infection
either past or active
if a person was hep C DNA positive what can we tell
active infection
what other blood marker is seen in Hep C
Hep C IgM
what are some side effects of peginterferon (interferon alpha)
flu like symptoms
thyroid disease
autoimmune disease
psychiatric disease
do you give antivirals in acute Hep B/C infection
no
when are antivirals e.g. adefovir contraindicated
HCC
what other measures are taken when someone is infected with Hep B/C
HCC screening reduce alcohol vaccination against influenza/pneumococcal if cirrhotic notify PH immunisation of contacts monitor for encephalopathy/resolution
what hepatitis only occurs when Hep B is also present
hep D
what is the treatment for Hep B and D co infection
peg interferon alpha
liver transplant
what is the transmission of Hep E
faecal oral
zoonosis (pigs deer rabbits)
person to person e.g. immunocompromised
is there a Hep E vaccine
no
what is more common Hep E or Hep A
Hep E
what Hep virus is associated with tropical / holidays etc
Hep E
