Hepatobiliary Flashcards
what are some non-specific and some specific symptoms of liver disease
fatigue, weight loss, anorexia
jaundice, pruritis, bleeding varices, ascites, edema, encephalopathy
risk factors for NAFLD
obesity, t2dm, metabolic sd, sedantary lifestyle, age, male
clinical course of ARLD
fatty liver, fatty liver + fibrosis, cirrhosis
what are the different complications of cirrhosis?
liver failure, portal hypotension, hcc
what are some signs of portal hypertension
varices, ascites, SBP
what are some signs of liver failure
jaundice, coagulopathy, encephalopathy
why is it important to ask about occupation in liver disease
ALD, toxins viral hepatitis/healthcare
what might u need to ask someone with liver failure if he looks athletic
anabolic steroids
what are some family history questions related to liver disease
haemochromatosis, wilsons disease
what is pruritis a sign of?
bile duct blockaged - cholestasis
what does abdo pain, fevers, rigors suggest in hepatobiliary context
cholangitis, biliary colic
what liver disease causes pigmentation?
PBC, haemochromatosis
what alt/ast levels are seen in ald/nafld and viral/drug/autoimmune hepatitis?
ald/nafld - 1.5-3x
viral drug autoimmune - >3x
what level of bilirubin is clinical jaundice
> 30 micromol/L
what coagulation factors does the liver make
10 9 7 2
what autoantibodies suggest autoimmune hepatitis, PBC or PSC
autoimmune hepatitis -> ANA and ASMA
PBC - AMA
PSC - pANCA
which Ig is raised in NALFD and ARLD
IgA
what is raised IgM assoc with
PBC
what Ig is raised in autoimmune hepatitis
IgG
what does a low ferritin indicative of in live disease
rules out haemochromatosis
what is liver biopsy indicated in liver disease
chronic liver disease - diagnosis and staging
focal lesions
post transplant; in rejection
how is liver disease staging done
either biopsy, or if non-invasively using blood tests and imaging
what is the score used to assess prognosis of liver failure
child-pugh score
what are the things scored in the child pugh score
pour another beer at eleven
PT ascites bilirubin Albuin encephalopathy
autoantibodies associated with autoimmune hepatibiliary conditions?
AMA - PBC
ANA/ASMA - AI hepatitis
ANCA - PSC
Immunogobulins associated with hepatobiliary conditions?
IgA - alcohol/nafld
IgM - PBC
IgG - AI hepatitis
who commonly get PBC
middle aged/older females
what is PBC?
autoimmune damage to intrahepatic bile ducts
what is the clinical course of PBC
immune insult -> bile duct damage -> inflammation -> fibrosis/cirrhosis
symptoms of PBC
asymptomatic fatigue itching dry eyes/mouth poor memory advanced liver disease symptoms
LFT signs of PBC
raised Alk phos
what autoantibody is PBC assoc with
AMA
what are 3 diagnostic criteria for PBC
raised alk phos
AMA
liver biopsy
treatment for PBC
uresodeoxycholic acid
treat itch with cholestyramine
what is autoimmune hepatitis
autoimmune condition causing liver cell death
what are 2 types of AI hepatitis
type 1 - more common, can affect any age
type 2 - less common, more commonly in young adults
symptoms of AI hepatitis
asymptomatic
fatigue, anorexia, nausea, joint pains
acute hepatitis or cirrhosis
signs of AI hepatitis
raised ALT, raised IgG, ANA and ASMA, raised bilirubin
what is PSC
primary sclerosing cholangitis
inflammation and fibrosis of intra and extra hepatic bile ducts - strictures and obstruction
symptoms of PSC
asymptomatic
itching, fatigue, ruq pain, weight loss, cholangitis, jaundice, liver failure
steatorrhea, fat malabsorption
portal hypertension
signs of PSC
raised ANCA and ALP
what imaging modality is best for PSC
MRCP
what 2 types of PSC can u get
large and small duct
what is required for diagnosis of small duct psc
liver biopsy
difference between hyperacute liver failure, acute liver failure and subacute liver failure
hyperacute - within 7 days
acute - 1 week to 1 month
subacute: 1 - 3 months
cerebral edema uncommon in subacute
most common causes of hyperacute liver failure, acute liver failure and subacute liver failure
hyperacute: paracetamol OD
acute: viral hepatitis
subacute: seronegative hepatitis
how does paracetamol overdose happen
major metabolic pathway is saturable, minor pathway results in toxic metabolite
treatment for paracetamol OD
n-acetyl cysteine
what drugs causes a higher risk of paracetamol OD
antiepileptics, rifampicin
what is a crucial prognostic marker in paracetamol OD
lactate
signs of paracetamol OD
hyperacute liver failure signs
reduces GCS, raised bilirubin, raised alt, acidosis
what serum level of paracetamol do you treat with n-acetylcysteine
over 100 mg/L
what causes hepatic encephalopathy
possibly due to ammonia toxicity, causing raised levels of glutamine and osmotic swelling of brain cells: cerebral edema
definition of acute liver failure
rapid, live dysfunction, coagulopathy, hepatic encephalopathy in the absence of pre-existing liver disease
3 criteria for formal diagnosis of acute liver failure
increased PT by 4-6 secs
hepatic encephalopathy
without preexisting cirrhosis and illness of less than 6 months
4 broad categories of causes of massively raised transaminases
vascular
viral
drugs/toxins
genetic/congenital
vascular causes of massively raised transaminases
budd chiari sd - clots in hepatic vein
hepatic artery thrombosis
ischaemic hepatitis
viral causes of massively raised transaminases
hepatitis ABCDE
CMV, EBV, PMV, HSV
drugs/toxins causes of massively raised transaminases
NSAIDs, paracetamol, salicylates, statins, antibirals, antibiotics, mdma, cocaine
congential/genetic causes of massively raised transaminases
wilsons, autoimmune hepatitis
causes of cirrhosis by acquired, autoimmune and genetic
acquired - alcoholic, nafld, viral hepatitis
autoimmune - pbc, psc, AIH
genetic - wilsons, haemochromatosis
what characterises liver cirrhosis?
abnormal nodular architecture separated by fibrotic tissue
consequences of cirrhosis
portal hypertension ascites HE varices +/- bleeding coagulopathy SBP hepatorenal syndrome HCC
describe why portal hypertension happens
fibrotic changes in liver causes increased resistance, followed by increased splanchnic vasodilation which causes increases flow. both of which combine to cause increase portal pressure.
consequences of portal hypertension
systemic arterial hypotension, triggering neurohormonal systems to retain fluid
ascites
varices due to collateral build up
complication of ascites
SBP
how is SBP defined?
> 250 pmn/ microlitre
what is the serum ascite albumin gradient in SBP
high SAAG >11g/L
why is SAAG high in ascites
increased hydrostatic pressure forcing fluid out, increasing albumin concentration
what causes hepatorenal syndrome
arterial hypoperfusion, causing renal artery constriction and decreased renal function.
what is portosystemic encephalopathy?
encephalopathy due to chronic liver failure. caused by build up of gut derived toxins.
signs and symptoms of portosystemic encephalopathy
reduced GCS confusion irritability change in personality/mood/intellect sleep disturbance nausea, vomiting hyperreflexia and increased tone
hyperreflexia and increased tone is always observed in portosystemic encephalopathy - T or F
true
causes of portosystemic encephalopathy
drugs, infection, bleeding, constipation, electrolyte disturbance
what is fetor hepaticus
sweet breath smelled in portosystemic encephalopathy
how to diagnose portosystemic encephalopathy
clinical diagnosis on a background of liver failure supported by biochemistry
describe the progression and stages of cirrhosis
compensated, with portalhypertension, with varices
with bleeding varices, jaundice or HE,
any further decompensating event leading to sepsis or death
what causes of typical of micronodular and macronodular cirrhosis?
micronodular - ald, biliary tract problems
macro - viral chronic hepatitis
symptoms and signs of cirrhosis
jaundice, peripheral edema, muscle wasting, malnourished, ascites, SBP oesophageal varices
biochemical picture of cirrhosis
raised alt/ast raised billirub increased PT low albumin raised ferritin and TSAT
how is HCC usually diagnosed?
CT/MRI and then maybe biopsy
biggest risk factor of HCC
cirrhosis, secondary to HBV
what does a low caeruloplasmin level suggest?
wilson’s disease
what is AFP associated with?
HCC
what kind of presentation would prompt you to do a ca19-9 level?
jaundice, abdominal pain, itching, fever, weight loss, change in color of stool and urine, LFTs with obstructive picture
what investigation is diagnostic for autoimmune hepatitis?
combination of histological evidence with presence of specific auto antibodies, and raised biochemical markers
what evidence is required for diagnosis of PSC?
significantly raised ALP
imaging evidence of biliary strictures
+/- histological evidence
what imaging modality is best used in diagnosing PSC?
MRCP
is PBC intrahepatic or extrahepatic?
intrahepatic
is PSC intrahepatic or extrahepatic?
extrahepatic
what is the diagnostic investigation for alcoholic related liver disease
deranged LFTs
liver biopsy
what is the staging score used in alcohol liver disease?
glasgow alcohol hepatitis score
4 factors in deciding type of acute liver failure (hyperacute, acute, subacute), what are they for each type?
encephalopathy
cerebral edema
PT
bilirubin
which viral hepatitis more commonly cause acute liver failure?
hep A and hep B
top 5 most common causes of acute liver failure
paracetamol OD seronegative (indeterminate) hepatitis drug reaction hepatitis A or B viral ischaemic hepatitis
what is ischaemic hepatitis?
liver failure due to lack of perfusion
investigations required in acute liver failure
everything
bloods - esp LFTs, U&Es, coagulation, viral markers, paracetamol levels, auto antibodies, caeruloplasmin, ferritin, glucose, amylase, lactate
imaging - USS, CT
biopsy
