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Dannys Medicine Finals > Hepatology > Flashcards

Hepatology Flashcards

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1
Q

What are the functions of the liver

A 
PUSHDoG
Protein Synthesis
Urea Production (bile) 
Storage (ADEK, B12, Minerals) 
Hormone synthesis
Detoxification
Glucose and fat metabolism
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2
Q

ALCOHOLIC LIVER DISEASE

what is the stepwise progression?

A

Fatty Liver (Steotosis)
Hepatitis (Inflammation)
Cirrhosis (scarred - irreversible)

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3
Q

Signs of Liver Disease?

A 
Caput Medusa (engorged epigastric superficial veins)
Hepatomegaly
Asterixis 
Ascites
Palmar erythema
Spider Naevi (increased oestrogen)

Gynaecomastia (increased oestrogen)
Bruising (decreased clotting factors)
Jaundice

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4
Q

What is the Child Pugh Score and what are the 5 measurements?

A

Used assess the prognosis of chronic liver disease

1) Encephalopathy
2) Ascites
3) Bilirubin
4) Albumin
5) Prothrombin time prolonged by

Can get either 1,2,3 for each measurement

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5
Q

The AST/ALT ratio can be used to determine the likely cause of LFT derangement

What can the ratio tell us?

A

ALT > AST is associated with chronic liver disease

AST > ALT is associated with cirrhosis and acute alcoholic hepatitis

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6
Q

Common causes of chronic hepatocellular injury include:

A

Alcoholic fatty liver disease
Non-alcoholic fatty liver disease
Chronic infection (Hepatitis B or C)
Primary biliary cirrhosis

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7
Q

Less common causes of chronic hepatocellular injury include:

A

Alpha-1 antitrypsin deficiency
Wilson’s disease
Haemochromatosis

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8
Q

Causes of an isolated rise in bilirubin include:

A

Gilbert’s syndrome: the most common cause.

Haemolysis

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9
Q

Causes of an isolated rise in ALP include:

A

Bony metastases or primary bone tumours (e.g. sarcoma)
Vitamin D deficiency
Recent bone fractures
Renal osteodystrophy

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10
Q

The combination of the colour of urine and stools can give an indication as to the cause of jaundice:

What are they?

A

Normal urine + normal stools = pre-hepatic cause

Dark urine + normal stools = hepatic cause

Dark urine + pale stools = post-hepatic cause (obstructive)

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11
Q

Causes of unconjugated hyperbilirubinaemia include:

A

Haemolysis (e.g. haemolytic anaemia)
Impaired hepatic uptake (e.g. drugs, congestive cardiac failure)
Impaired conjugation (e.g. Gilbert’s syndrome)

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12
Q

Causes of conjugated hyperbilirubinaemia include:

A

Hepatocellular injury

Cholestasis

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13
Q

ALCOHOLIC LIVER DISEASE

Signs shown on blood investigations?

A

FBC - increased MCV

LFT - increased ALT, AST and particularly gGT
AST/ALT ratio >2

Decreased Albumin
Increased Bilirubin
Increased Prothrombin time

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14
Q

ALCOHOLIC LIVER DISEASE

Acute Management?

A 
Steroids 
Vitamin Replenishment (Thiamine)
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15
Q

Gold standard Imaging for diagnosing cirrhosis?

A

Liver biopsy

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16
Q

Signs of Alcohol withdrawal after:

6-12hrs?
12-24hrs?
24-48hrs?
72hrs?

A

6-12hrs - sweating, anxiety, tremor
12-24hrs- hallucinations
24-48hrs- seizures
72hrs- delirium tremens

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17
Q

Treatment of alcohol withdrawal?

A

Chlordiazepoxide

IV Pabrinex

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18
Q

Wernickes Encephalopathy triad?

A

Opthalmaparesis + Nystagmus
Confusion
Ataxia

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19
Q

Korsakoffs syndrome triad?

A

Psychosis
Confabulation
Amnesia (anterograde/ retrograde)

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20
Q

ACUTE LIVER FAILURE

Signs?

A

Coagulopathy INR >1.5

Hepatic encephalopathy

Transaminitis (deranged LFTs) + Hyperbilirubinaemia

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21
Q

ACUTE LIVER FAILURE

Main causes in europe and worldwide?

A

Europe - drug induced

Worldwide - Viral (Hep A,B,E)

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22
Q

ACUTE LIVER FAILURE

first line imaging?

A

Ultrasound

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23
Q

ACUTE LIVER FAILURE

What does hyperammonaemia increase the risk of?

A

Cerebral Oedema

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24
Q

What is difference between ALF and ALI?

A

ALI has no hepatic encephalopathy

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25
ACUTE LIVER FAILURE Who should receive emergency liver transplant?
Primary causes of ALF only
26
ACUTE LIVER FAILURE What features should be investigated for?
Features of chronic liver disease as it could be first presentation of decompensated cirrhosis
27
How is HE tested?
normally clinical, however arterial ammonia and EEG can be completed
28
Treatment of HE?
1st - Lactulose (excretion of ammonia) + Rifaximin (reduce no of bacteria in gut producing ammonia)
29
What is normal ICP?
7-15mmHg
30
Ascites Treatment?
``` Aldosterone antagonists and loop diuretics Reduce salt intake Drain if tense (paracentesis) Prophylactic Abx (ciprofloxacin or norfloxacin) ```
31
What prophylactic Abx can be given for Ascites?
Ciprofloxacin/ Norfloxacin
32
Treatment of raised ICP?
Head elevation to 30 degrees MANNITOL and Hypertonic SALINE Removal of CSF
33
Features of raised ICP?
``` Headache. Blurred vision. Confusion. High blood pressure. Shallow breathing. Vomiting. Changes in your behaviour. Weakness or problems with moving or talking. ```
34
What is Cushings Reflex?
The Cushing reflex is a physiological nervous system response to acute elevations of intracranial pressure (ICP)
35
What is Cushings Triad?
Bradycardia Widening pulse pressure (Increasing systolic and decreasing diastolic) Irregular breathing
36
How does Fibrosis cause portal hypertension?
Fibrosis causes increased resistance in vessels leading into the liver = portal hypertension (portal vein)
37
Most common causes of liver cirrhosis?
ALD NAFLD Hep B Hep C
38
Markers of synthetic function of the liver?
* Prothrombin time * Albumin Bilirubin blood glucose
39
What should be measured every 6 months for people with liver cirrhosis?
Alpha fetoprotein tumour marker for Hepatocellular carcinoma + ULTRASOUND!
40
First line investigation in NAFLD/ Cirrhosis
Enhanced Liver Fibrosis (blood test)
41
What does enhanced liver fibrosis blood test involve?
Measures 3 direct biomarkers of fibrosis 1) HA 2) PIIINP 3) TIMP and then combines them to produce a result
42
What are the possible results from ELF test?
<7.7 mild/ no fibrosis > 7.7 -9.8 = moderate fibrosis >9.9 = severe fibrosis
43
What may be found on US in a cirrhotic liver?
1) Nodules 2) Corkscrew appearance to arteries due to increased blood flow 3) Enlarged portal vein with reduced flow 4) Ascites 5) splenomegaly
44
what is transient elastography?
Fibroscan - measures stiffness of the liver
45
who should be screened for using Fibroscan?
people with hepatitis C virus infection men who drink over 50 units of alcohol per week and women who drink over 35 units of alcohol per week and have done so for several months people diagnosed with alcohol-related liver disease
46
What should be carried out for patients with a new diagnosis of cirrhosis
upper endoscopy to check for varices
47
How should a cirrhotic patient change their diet
Low sodium high protein meals every 2/3 hours - high calorie
48
What is MELD score?
Uses a combination of a patient's bilirubin, creatinine, and (INR) to predict survival in patients with cirrhosis
49
Treatment of stable varices?
Beta blockers (propanolol) endoscopic variceal band ligation performed at two-weekly intervals until all varices have been eradicated. for medium to large varices
50
What is given alongside endoscopic variceal band ligation?
Proton pump inhibitor cover is given to prevent EVL-induced ulceration
51
What is the treatment of a bleeding variceal
1) Vasopressin analogues (Terlipressin) 2) Correct clotting (Vit K and FFP) 3) Prophylactic Abx (Quinolones - ciprofloxacin) 4) ENDOSCOPY - elastic band ligation or previously sclerotherapy
52
Last line treatment of variceal haemorrhage
TIPS - make connection between hepatic and portal vein to relieve pressure on portal system
53
Complication of TIPS?
Exacerbation of hepatic encephalopathy
54
Likely causative organisms for Spontaneous Bacterial Peritonitis and the treatment?
E.coli Klebsiella IV Cefotaxime
55
What is Hepatorenal syndrome and how is it caused?
1) Portal hypertension causing dilation of portal vessels and blood pooling 2) This causes hypotension in kidneys which activates RAAS 3) Vasoconstriction due to RAAS and low circulatory volume results in lack of blood to kidneys 4) lack of blood to kidneys results in rapidly deteriorating kidney function
56
Common associations with NAFLD?
OBESITY type 2 diabetes Sudden weight loss/ starvation
57
Stepwise development of NAFLD?
1) Steatosis 2) Steatohepatitis (NASH) 3) Fibrosis 4) Cirrhosis
58
Features of NAFLD?
usually asymptomatic hepatomegaly ALT is typically greater than AST increased echogenicity on ultrasound
59
Investigations of NAFLD?
1st - ELF test 2nd - NAFLD fibrosis score 3rd - Fibroscan
60
What will NAFLD with advanced fibrosis be recommended
Liver biopsy to stage disease
61
What is PBC?
Primary Biliary Cholangitis which is the autoimmune inflammation of small bile ducts
62
Which ducts are inflamed in PBC?
Intralobular ducts / Canals of Hering
63
Clinical features of PBC
PRURITIS FATIGUE ``` Jaundice - pale stools Hyperpigmentation RUQ pain (10%) Clubbing / Hepatosplenomegaly XANTHOMA/ XANTHELASMA (increased cholesterol) ```
64
What do PBC patients have a high risk of
HCC - 20 fold increase in risk
65
Treatment of Pruritis?
Cholestyramine
66
What age and gender is typical of PBC
middle aged females
67
Diagnostic investigations of PBC?
1) Anti - mitochondrial antibodies (AMA) found in 98% of patients 2) Increased serum IgM / ESR 3) Liver biopsy to stage
68
Management of PBC?
Ursodeoxycholic acid Replenish Fat soluble vitamins
69
What is involved in ongoing research for treatment of NAFLD?
gastric banding and insulin-sensitising drugs (e.g. metformin, pioglitazone)
70
process of cirrhosis to varices?
cirrhosis → portal hypertension → ascites, variceal haemorrhage
71
when should liver transplant in PBC be considered
If bilirubin over 100
72
how do bile acids, cholesterol and bilirubin end up in the blood
They are normally excreted via bile ducts into intestines. Obstruction to this outflow means chemicals build up in the blood
73
What symptoms/signs do bile acids, cholesterol and bilirubin cause
Bile acids - itching Cholesterol - Xanthoma, Xanthelasma, CV disease Bilirubin - jaundice
74
How do you get Steatorrhoea from biliary obstruction
less bile acids in gut so more fat malabsorption
75
How do you get pale stools from biliary obstruction
Less bilirubin reached the gut which darkens stools
76
PRIMARY SCLEROSING CHOLANGITIS What is it?
when intra and extra hepatic ducts become strictured and fibrotic
77
PRIMARY SCLEROSING CHOLANGITIS Risk factors?
Ulcerative colitis (70 of PSC pts have both) male aged 30-40
78
PRIMARY SCLEROSING CHOLANGITIS Likely autoantibodies?
pANCA (94%) ANA (70%) aCL (63%)
79
PRIMARY SCLEROSING CHOLANGITIS Presentation?
``` Jaundice RUQ pain Pruritis Fatigue Hepatomegaly ```
80
PRIMARY SCLEROSING CHOLANGITIS Associations?
``` Cholangiocarcinoma (20%) Colorectal cancer Acute bacterial cholangitis Bone disease Vit ADEK deficiencies ```
81
PRIMARY SCLEROSING CHOLANGITIS LFT picture?
Cholestatic ^^ALP ^ Bilirubin ^ ALT and AST if hepatitis
82
PRIMARY SCLEROSING CHOLANGITIS Diagnosis?
MRCP shows biliary stricturing MRI bile ducts, liber, pancreas
83
PRIMARY SCLEROSING CHOLANGITIS Management?
Liver transplant ERCP to stent and dilate strictures
84
PRIMARY SCLEROSING CHOLANGITIS treatment of pruritis? What can slow progression of the disease?
Cholestyramine Ursodeoxycholic acid
85
PRIMARY SCLEROSING CHOLANGITIS What should be monitored for?
Cirrhosis and associated cancers (CCA)
86
what is charcots triad?
Fever Jaundice RUQ pain
87
What LFTs show hepatic/ cholestatic picture?
Hepatic = ^^ AST/ALT Cholestatic = ^^ ALP/gGT
88
What does ERCP increase the risk of
Pancreatitis and Cholangitis
89
What is the tumour marker of CCA?
Ca 19.9
90
How are cholangiocarcinomas diagnosed?
Gold standard is ERCP
91
Who typically gets autoimmune hepatitis type 1
Female menopause age characterised by fatigue and liver features
92
Autoantibodies found in Type 1 autoimmune hepatitis?
Anti-nuclear antibodies (ANA) Anti-smooth muscle antibodies (anti-actin) Anti-soluble liver antigen (anti-SLA/LP)
93
Autoantibodies found in Type 2 autoimmune hepatitis?
Anti-liver kidney microsomes-1 (anti-LKM1) | Anti-liver cytosol antigen type 1 (anti-LC1)
94
Diagnosis of autoimmune hepatitis?
Liver biopsy
95
Who typically gets autoimmune hepatitis type 2
patients in their teenage or early twenties present with acute hepatitis with high transaminases and jaundice.
96
Most common types of primary liver cancer?
HCC (80%) CCA (20%)
97
Risk factors of: HCC?
Hepatitis B Alcohol NAFLD Cirrhosis!!!!
98
Risk factors of: CCA?
PSC
99
Symptoms of liver cancer
Non specific liver signs + weight loss + Anorexia CCA -possible jaundice
100
Tumour markers for: HCC CCA
HCC - alpha fetoprotein CCA - Tumour marker Ca 19.9
101
how are HCC and CCA diagnosed
HCC - CT/MRI CCA - ERCP
102
Treatment of liver cancer?
Extremely poor prognosis, possible surgical resection/ ablation Sorafenib - multi kinase inhibitors
103
Treatment of Autoimmune Hepatitis
Prednisolone + Azathioprine
104
Symptoms of biliary colic?
Abrupt RUQ pain after eating + Nausea/ vomiting
105
Who is typical patient of biliary colic
Fat fair fertile females in forties
106
Acute Cholecystitis symptoms?
Persistent RUQ pain that radiates to back/shoulder pyrexia/ fever Murphys sign!
107
Why does biliary colic happen?
occur due to ↑ cholesterol, ↓ bile salts and biliary stasis the pain occurs due to the gallbladder contracting against a stone lodged in the cystic duct
108
Investigations and treatment of biliary colic?
Ultrasound Elective laparoscopic cholecystectomy
109
How may jaundice occur after cholecysectomy
Gall stones in common bile duct in 15% therefore would present with obstructive jaundice
110
Notable risk factors of biliary colic?
Crohns Diabetes COCP rapid weight loss (weight reduction surgery)
111
what does Acute Cholecystitis occur secondary to
Gallstones in 90% of cases
112
How would LFTs show in Acute Cholecystitis
Usually Normal
113
Signs of Acute Cholecystitis
RUQ pain (radiate to right shoulder) fever N/V Murphys Sign
114
Acute Cholecystitis investigation choice?
Ultrasound 1st line cholescintigraphy (HIDA scan) if dx still unsure
115
Treatment of Acute Cholecystitis?
IV Abx and Elective Laparoscopic Cholecystectomy within 1 week
116
What is ascending cholangitis
bacterial infection (typically E. coli) of the biliary tree. The most common predisposing factor is gallstones.
117
Ascending Cholangitis management?
intravenous antibiotics endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction
118
Ascending Cholangitis Features?
Charcot's Triad Fever 90% RUQ pain 70% Jaundice 60% AND Hypotension Confusion (the additional 2 factors in addition to the 3 above make Reynolds' pentad)
119
What is Reynolds Pentad
Fever RUQ pain Jaundice HYPOTENSION CONFUSION Diagnosis of Septic Ascending Cholangitis
120
What is Courvoisier sign
Palpable mass in RUQ
121
HAEMOCHROMATOSIS What is it?
Autosomal recessive iron storage disorder resulting in widespread iron deposits in tissues
122
HAEMOCHROMATOSIS what gene is affected?
HFE protein on chromosome 6
123
HAEMOCHROMATOSIS at what age does it typically present
After 40 and later in females due to menstruation
124
HAEMOCHROMATOSIS Symptomatic presentation?
Cognitive problems (memory/ mood) Hair loss ED Fatigue joint pain bronze discolouration
125
HAEMOCHROMATOSIS How is it diagnosed?
1) Transferrin saturation and Serum Ferritin | 2) genetic testing
126
HAEMOCHROMATOSIS How did it used to be diagnosed
Used to be diagnosed using Perls Stain + liver biopsy
127
HAEMOCHROMATOSIS potential complications (by organ)
Pancreas - T1DM Liver - Cirrhosis (can lead to HCC) Pituitary/ Gonads (hypotrophic hypogonadism/ infertility) Heart - Cardiomyopathy Hypothyroid Joints - Chondrocalcinosis (pseudogout)
128
HAEMOCHROMATOSIS how is it managed?
Venesection (weekly blood removal) 2nd - Desferrioxamine
129
WILSON'S DISEASE What is it?
Autosomal recessive condition causing excess copper deposits in tissues
130
WILSON'S DISEASE Defective gene?
ATP7B geen on chromosome 13
131
WILSON'S DISEASE Features?
HEPATIC (40%) - chronic hepatitis - cirrhosis NEUROLOGICAL (50%) - spectrum of subtle to dysarthria PSYCHIATRIC (10%) - depression / psychosis KAYSER - FLEISCHER RINGS ASTERIXIS
132
What are Kayser- Fleischer Rings?
green/brown ring in Descemets Corneal Membrane due to copper deposits
133
What happens if copper deposits get into basal ganglia?
Parkinsonism (symmetrical unlike parkinsons)
134
WILSON'S DISEASE Diagnosis?
Decrease in serum Caeruloplasmin / total body copper Increase in 24hr urinary copper excretion
135
How to assess for Kayser Fleischer rings?
Slit lamp exam
136
WILSON'S DISEASE Management?
Copper Chelation 1) Penicillamine 2) Trientine
137
What is A1AT?
Alpha 1 antitrypsin is a protease inhibitor - inhibiting neutrophil elastase which breaks down tissue - therefore a deficiency results in tissue breakdown
138
What happens as a result of Neutrophil elastase levels being high?
Lung - emphysema, COPD, bronchiectasis Liver - cirrhosis
139
What is the defective chromosome in A1AT deficiency?
Chromosome 14
140
Diagnosis of A1AT deficiency?
low serum A1AT liver biopsy CT thorax and spirometry for emphysema and COPD
141
Management of A1AT deficiency?
- Smoking cessation - Symptomatic (COPD e.g. bronchodilators) - End stage liver transplant - Monitor for hepatocellular carcinoma
142
Name of RNA in Hepatitis A? route of transmission?
RNA Picornavirus Faeco-oral
143
Is there a vaccine for Hep A?
Yes - for high risk such as MSM, travellers of prevalent countries
144
Features of Hep A?
``` Flu like prodrome RUQ pain tender hepatomegaly Jaundice , N+V Cholestatic LFTs ```
145
Management of Hep A -
resolves in 1-3 months + Analgesia
146
HEPATITIS B Route of transmission?
Infected bodily fluids + vertical transmission from mother to baby
147
HEPATITIS B name of virus?
DNA Hepadnavirus
148
HEPATITIS B Is there a vaccine?
Immunised at 2,3,4 months old + booster for high risk groups e.g healthcare
149
HEPATITIS B Signs?
Fever Jaundice Elevated transaminases (AST/ALT)
150
HEPATITIS B What % are likely to be chronic infection carriers?
10%
151
HEPATITIS B What viral marker implies active infection?
HbsAg surface antigen
152
HEPATITIS B What viral marker implies highly infective?
E antigen HbeAg is a marker of viral replication (acute phase)
153
HEPATITIS B How to test for past / current infection?
HbcAb (antibody)
154
HEPATITIS B | What does it mean if HbeAg negative but HbeAb positive?
Virus stopped replicating (out of acute phase)
155
HEPATITIS B HbcAb can be measured using IgM and IgG what does IgM HbcAb imply? What does IgG imply?
IgM is acute phase so virus active IgG HbcAb implies past infection of HbsAg is -ve.
156
HEPATITIS B Management?
Antivirals - Pegylated interferon alpha testing for liver cirrhosis / HCC
157
What is name of Hepatitis C virus and is there a vaccine How is it normally transmitted
RNA flavivirus and no vaccine Infected blood
158
What percentage of Hep C patients become chronic f
75%
159
What % of Hep C patients are symptomatic and what are the symptoms
30% get: transient rise in aminotransferases + jaundice Fatigue Arthralgia
160
Management of Hep C?
Direct acting antivirals based on viral genotype Usually combination of Sofasbuvir + Daclatasvir/ Simeprevir (PROTEASE INHIBITORS) successful in 90% of cases
161
How is Hep C screened?
Hep C Antibodies Hep C RNA testing confirms diagnosis and calculates viral load
162
What is Hepatitis D? How is it transmitted?
Single stranded RNA only survives if also infected with Hep B - attaches to Hep B surface antigen Bodily fluids similarly to Hep B
163
Hep E virus and route of transmission?
RNA hepevirus Faeco-oral
164
Hep E normally clears with no treatment after a month but when is it dangerous?
Pregnancy (20% mortality)
165
What is the risk if someone has Hep B and D superinfection
Fulminant hepatitis, cirrhosis
166
What can be found on blood test in pernicious anaemia?
antibodies to intrinsic factor +/- gastric parietal cells Macrocytic anaemia
167
What cancer is there an increased risk of in pernicious anaemia tx of pernicious anaemia?
gastric cancer IM B12 replacement (hydroxocobalamin)
168
What are Sister Mary joseph nodes?
Periumbilical lymphadenopathy
169
Where is Virchows Node?
Left supraclavicular
170
Potential signs on examination in Cholangiocarcinoma?
A palpable mass in the right upper quadrant (Courvoisier sign), periumbilical lymphadenopathy (Sister Mary Joseph nodes) left supraclavicular adenopathy (Virchow node)
171
Budd-Chiari Syndrome (Hepatic Vein Thrombosis) Features? Ix of choice?
Triad of: 1) sudden onset abdominal pain 2) Ascites 3) tender hepatomegaly Ultrasound with Doppler flow studies

Dannys Medicine Finals (9 decks)

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