GI problems Three: The liver Flashcards
What are the patterns of liver disease?
- Hepatocellular
- Cholestasis
- Mixed patterns
If AST, ALT elevated but then GGT but not ALP are elevated what does this suggest?
- Hepatocellular disease but not strictly with some cholestasis involved.
What does low albumin suggest?
Decreases synthesis suggesting chronic disease perhaps cirrhosis.
What happens to PT in acute liver disease?
Elevated in ACUTE because clotting factors are not synthesised
Indicator for liver failure.
Why do spider nivea develop?
Portal hypertension
What are risk factors for metabolic syndrome? What can it lead to?
BMI
Lipids
Diabetes
Hypertension
Gout
Fatty liver
If GGT goes up alone what does this suggest?
- Usually indicates steatosis (Fatty or NAFLD) i.e fat deposits into liver cells
What if GGT and ALP increases?
Cholestasis i.e obstruction to biliary drainage
What happens if AST and ALT are raised?
Think of hepatitis i.e hepatocellular damage
What are causes of hepatitis? / hepatocellular damage?
- Viral hepatitis
- Alcoholic hepatitis (Acute vol. toxicity)
- Non-alcoholic heaptitis (Related to NAFLD)
Less commonly
- Autoimmune hepatitis
- Ischeamic hepatitis
- Heamochromatosis (iron metabolism)
- Drugs/herbal remedies
How can liver tumours present?
- Cholestasis
- Mixed pattern
What are the common primary and secondary liver tumours?
Primary: Hepatocellular carcinoma (dont see in absence of chronic liver disease)
Secondary: Liver mets
Whats seens on LFTS in liver cirrhosis?
- Decreased albumin
- Normal prothrombin
- Raised liver enzymes
What are some complications of liver cirrhosis?
- Portal hypertension
= Enlarged spleen
= Thrombocytopeania (decreased platelets)
What are the patterns of alcoholic liver disease?
- Can become hepatitis or steatosis
- Abstinence can revert these changes.
- Note abstinence can change hepatitis to steatosis.
- Steatosis and hepatitis can progress to cirrhosis.
Whats the pathophysiology of NAFLD? What can reverse it?
Healthy liver:
- Multi-hit hypothesis i.e insulin resistance, obesity, diabetes, hyperlipideamia can lead to lipid droplet deposition in the liver. (steatosis) this can then become inflamed and turn to liver fibrosis / cirrhosis.
Reversible: Adiponectin or antioxidants
How are alcoholic and non-alocholic FLD diagnosed?
Based on history
Which hepatitis virus are fecal-oral transmission and which are blood/body fluid?
A&E acute infection and fecal-oral route.
B,C,D are body fluids. Can cause liver cirrhosis
How can EBV and CMV lead to liver issues?
- Diagnosed on blood film, looking for atypical lymphocytes.
These can cause viral hepatitis.
How can auto-immune hepatitis be diagnosed?
- Chronic autoimmune disease
- Autoantibodies attack liver, inflammation and damage. Can screen for common autoantibodies and do liver biopsy
When does ischeamic hepatitis occur and what happens?
Select presentation of extreme blood loss
= Cardiogenic, severe sepsis, hepatic art. clot, dehydration or blood loss.
Transaminases in the 1000s
Recovery is rapid with good perfusion to support.
i.e liver becomes inflamed if ischeamic.
Whats happening in heamochromatosis? How do you diagnose?
- Autosomal recessive.
- Low hepcidin -> Increased iron absorption which deposits in liver = hepatitis.
Diagnosis: Ferritin (can raise in inflam anyways) and iron saturation
When can drugs cause liver hepatitis?
- Paracetamol overdose. (antidote is N-acetylcystiene)
BUT many drugs can affect LFTs and present as;
= Cholestasis
= Mixed
= Predominantly hepatitis though
Whats a risk factor for hepatocellular carcinoma?
Chronic hepatitis B with or without cirrhosis
If ALTs and ASTs are in thousands which are the likely causes?
- Viral
- Ischemia
- Paracetomal
If AST>2xALT what is likely?
Alcoholic hepatitis because normally ALT>AST
No known reason why
What does jaundice indicate?
Obstruction proportional to bilirubin
Decompensation because of liver disease.
If albumin is low what does it suggest?
Cirrhosis
What does platelet count mean for the liver?
Portal hypertension which is suggested with cirrhosis.
What is the use of ultrasound?
- Examine gall bladder for stones and biliary obstructions
- Liver can look echogenic i.e steatosis or slightly nodular (cirrhosis but later stage)
- Portal hypertension / dilation = cirrhosis
What can be done as part of the liver work up?
- LFTs
- Ultrasound
- Hep A serology, Hep B serology, Hep C serology
- Iron studies
- Autoantibodies
How do you diagnose alcoholic hepatitis and whats the plan?
- Significant alcohol history
- AST/ALT reversal 2:1
- Low albumin with clinical signs of chronic liver disease
Plan:
- Abstinence (small amounts of alcohol can cause decompensation)
- Lose weight
- Long term control of diabetes and dyslipidaemia
What can portal hypertension lead to?
- Splenomeagly
- Ascities
What is portal hypertension or ascites linked to?
Liver cirrhosis
What does it suggest when a Pt has low albumin, ascites, thrombocytopenia, jaundice?
Low albumin: Poor synthesis function i.e b/c cirrhosis
Ascites - Portal hypertension
Thrombocytopeania = Hypersplenism (portal hypertension)
Jaundice = Hepatic inflammation and necrosis
How do you treat portal hypertension?
- Diuretics
- Protein supplements to improve nutrition and albumin
- Symptom releief
What can happen when people with advance cirrhosis get sick?
They can decompensate: Esp. if dehydrated (from sepsis)
Acute on chronic i.e PT time + Inflamed + LFTs + albumin (mixed picture)
- Hepatic encephalopathy (actue liver failure)
- Hepatic flap
How do treat acute on chronic liver failure?
- IV antibiotics for infection
- IV fluids for dehydration from infection
- Lactulose and fleet enema for hepatic encephalopathy
- NG feeding to maintain nutrition
If advanced liver disease decompensates what can happen?
They might not be able to recompesnate
-> Increased portal hypertension which can result in vericoele bleeding (emergency)
-> Ascites is also a risk factor for spontaneous bacterial peritonitis (Cirrhosis = impaired gut barrier)
