Hepatology

Question 1

LFTs measure what

Answer 1

Serum bilirubin(elevation means liver injury)
Aminotransferases(elevation means hepatocellular damage,hepatitic)
Alkaline phosphatase (elevation means infiltrative liver disease)
Gamma glutamyl transferase(elevation means cholestatic or obstructive)
Albumin

Question 2

Aim of investigation in suspected liver disease

Answer 2

. Detect hepatic abnormality
. Measure severity of liver disease
. Detect pattern of LFT abnormality:whether hepatitic or obstructive
. Identify specific cause
. Investigate possible complication

Question 3

Drugs that increase gamma glutamyl transferase

Answer 3

Barbiturates
Carbamezepine
Ethanol
Rifampicin

Question 4

What is hepatic encephalopathy

Answer 4

Is a neuropsychiatric syndrome caused by liver disease, apathy ,inability to concentrate,delirium, disoriented,drowsiness,slurring of speech,coma

Question 5

Pathophysiology of hepatic encephalopathy

Answer 5

Due to disturbance of brain function provoked by circulating neurotoxins that are normally metabolised by the liver.

Question 6

DD of hepatic encephalopathy

Answer 6

. Intracranial bleed
. Drug or alcohol intoxication
. Delirium tremens or alc withdrawal
. Wernickes encephalopathy
. Primary psychiatric disorders
. Hypoglycemia
. Neurological Wilson’s disease
. Post ictal state

Question 7

Factors precipitating hepatic encephalopathy

Answer 7

.drugs(sedatives,antideps)
.dehrydration
.portosystemic shunting
.infection
.hypokalemia
. constipation
.increased protein load(gi bleed)

Question 8

Management of hepatic encephalopathy

Answer 8

. Lactulose(15-30 ml 3 times daily)
Produces osmotic laxative effect,reduces pH of colonic contenthereby limiting colonic ammonia absorption and promotes incorporation of nitrogen into bacteria
. Rifaximin(400mg 3 times daily)
Antibiotic,reduces bacterial content of bowel

Question 9

Pathophysiology of cirrhosis

Answer 9

Following liver injury,stellate cells in the space of Disse are activated by cytokines produced by kupffer cells and hepatocytes. This transforms the stellate cell into a myifibriblast like cell,capable of producing collagen,pro inflammatory cytokines and tissue fibrosis
Hepatocyte loss
Distortion of normal liver architecture
Disrupts hepatic vasculature
Portosystemic shunts

Question 10

Causes of cirrhosis

Answer 10

. Alcohol
. Chronic virla hepatitis (B or C)
. Non alc fatty liver disease
. Immune
Primary sclerosing cholangitis
. Biliary
Primary biliary cholangitis
Secondary biliary sclerosis
Cystic fibrosis
. Genetic
Haemochromatosis
Wilson’s disease
Alpha 1 antitrypsin deficiency
. Chronic venous outflow obstruction(sinusoidal obstruction syndrome,budd-chiari)

Question 11

Clinical feature of cirrhosis

Answer 11

. Hepatomegaly
. Jaundice
. Ascites
. Circulatory changes(spider telengiectasia almar erythema,cyanosis)
. Endocrine changes(loss of libido,gynecomastia,testicular atrophy,impotence, amenorrhea)
. Haemorrhagic tendencies(bruises,purpura,epistaxis)
. Portal hypertension(splenomegaly,collateral vessels,variceal bleeding)
. Hepatic encephalopathy
. Others (pigmentation,dupuytrens contracture,clubbing)

Question 12

Features of chronic liver failure

Answer 12

. Worsening liver function
Prolonged prothrombin time
Low albumin
. Jaundice
. Portal hypertension
. Variceal bleeding
. Hepatic encephalopathy
. Ascites

Question 13

Child Pugh classification of prognosis of cirrhosis

Answer 13

Encephalopathy
Bilirubin
Albumin
PTT
ascites

Question 14

What is portal hypertension

Answer 14

Normal heptic venous pressure gradient (difference between wedged hepatic venous pressure and free hepatic venous pressure) is 5-6 mm hg. Clinically significant portal hypertension is present when gradient exceeds 10 mm hg and risk of variceal bleeding increases beyond 12 mm hg

Question 15

Classification of portal hypertension

Answer 15

. Pre hepatic pre sinusoidal
Portal vein thrombosis
Abdominal trauma during surgery
. Intrahepatic presinusoidal
Schistosomiasis
Sarcoidosis
Congenital hepatic fibrosis
. Sinusoidal
Cirrhosis
Polycystic liver disease
Metastatic malignant disease
. Intra hepatic post sinusoidal
Veno occlusive disease
. Post hepatic post sinusoidal
Budd chiari syndrome

Question 16

Complications of portal hypertension

Answer 16

. Variceal bleeding
.congestive gastropathy
. Hypersplenism
.ascites
. Iron deficiency anemia
. Renal failure
. Hepatic encephalopathy

Question 17

Emergency management of variceal bleeding

Answer 17

. IV fluids( to replace extracellular volume)
. Vasopressors,terlipressin(to reduce portal pressure,acute bleeding and risk of re bleeding)
. Prophylactic antibiotics,cephalosporin(to reduce incidence of spontaneous bacterial peritonitis)
. Emergency endoscopy(to confirm varices)
. Variceal band ligation( to stop bleeding)
. Proton pump inhibitor( to prevent peptic ulcer)
. Phosphate enema or lactulose(to prevent hepatic encephalopathy

Question 18

Markers of hep B

Answer 18

. Hep B surface antigen(HBsAg)
Active infection
. Hep B core antigen( HBcAg)
. Hep B e antigen(HBeAg)
Indicator of viral replication