Hepatology Flashcards
List the causes for acute (4) + chronic (8) hepatitis
Acute: • Alcohol • Viruses (A–E/non A–E) • Autoimmune • Drug reactions (methyldopa, nitrofurantoin, diclofenac)
Chronic:
SAME 4 PLUS (viruses only B±D, C)
Hyperlipidaemia
Metabolic: Wilsons / a-1 antitrypsin / haemochromatosis
List the Ix for a liver screen (8)
Viral screen Lipids Iron studies (ferritin/transferrin) a-1 antitrypsin AFP Caeruloplasmin (Cu) Immunology – autoAbs Abdo USS
What would the virology tests show for Hep B in:
- the incubation phase?
- active hepatitis
- chronic hepatitis
- natural immunity
- vaccination
- HBsAg +ve / HBeAg +ve / PCR +ve
- all +ve except HBsAg
- same but >6m and LFTs less deranged
- HBsAb +ve / HBsAg –ve; HBeAb +ve / HBeAg –ve; HBcAb +ve / HBcAg –ve
- Same but HBcAb IgG –ve / HBeAb –ve
How does acute viral hepatitis present?
Pre-ictal/prodromal phase:
Non-specific lethargy / malaise / anorexia / N+V
Vague RUQ pain
Ictal phase: Intrahepatic cholestatic jaundice Pale urine/dark stools Pruritis / rash Lymphadenopathy Hepato/splenomegaly
How does acute alcoholic hepatitis present? (6)
Alcoholic after binge RUQ pain Jaundice Systemic upset ± S/o chronic CLD AST:ALT >2
What is the prognosis predictor used in Alcoholic Hepatitis? / what does it consist of (3) / what value suggests severe
Discriminant Function
Severe = DF > 32
Hepatic encephalopathy
PT time
Bilirubin
What other conditions are associated with autoimmune hepatitis? (3)
PSC
PBS
IBD
What would be seen on liver screen Ix in autoimmune hepatitis?
Serology –ve
High autoAb titres (non-specific ANA/ASMA)
High transaminases
Outline the pharmacological management of autoimmune hepatitis (acute/long-term)
Acute:
Prednisolone 30mg OD
TMPT testing before starting Azathioprine
Reduce Pred
Long-term:
Azathio
Bone protection
Cortico (Pred)
How is viral hepatitis managed?
Any acute – supportive / alc avoidance
Chronic – PEG-interferons
List the indications for liver biopsy (5)
List the contraindications (3)
?Chronic hepatitis ?Cirrhosis ?Cancer ?Storage disease Unexplained hepatomegaly
Bleeding probs: Platelets low / PT prolonged Overloaded liver (ascites) Obstructed liver (extrahepatic cholestasis)
List some complications of liver biopsy (2+4)
Abdo/shoulder pain
Minor intraperitoneal bleeding
Haemothorax
Pleurisy
Haemobilia
Biliary peritonitis
List some non-invasive alternatives to liver biopsy (3)
Biomarkers (LFTs, bloods)
Fibroscan (transient elastography)
MR elastography
How long after a paracetamol overdose for
- Symptoms to appear
- LFT to change (+what do they show
- 24hrs initially asymp (may be anorexia/nausea)
- takes 18hrs for LFTs to derange (peaks at 72-96)
Deranged ALT/ALP/INR
What physical features occur with paracetamol liver injury (6)
RUQ pain Hypotension Hypoglycaemia Metab acidosis Pancreatitis Arrhythmias
What can occur in paracetamol overdose if untreated? (2)
Fulminant liver failure Renal failure (acute tubular necrosis)
Outline the management of a paracetamol overdose (6) (ALBILM)
A–E
Lavage / charcoal (<1hr) (if >12g / >150mg/kg kids)
Bloods (4hrs):
LFT/INR / UEs / ABG / Gluc / Salicylate + Para level
IV N-AC
(over guidelines <8hrs; >150mg/kg + time unclear (stat))
Liver team – if deteriorates
Mental health liaison
What are some possible SEs of N-AC (4)
How are they treated
Rash
Oedema (rarely serious)
Hypotension (only stop if true anaphylaxis)
Bronchospasm
IV chloramphenamine
Stop N-AC only if true anaphylaxis (Alternative: oral methionine)
What pt groups is HCC seen more in?
List the causes for HCC (6)
Males > females
China/Sub-saharan
Chronic hepatitis Cirrhosis Metabolic liver disease Anabolic steroids Aspergillus aflatoxin Parasites
What 2 additional features in HCC may differentiate from other liver problems
Abdo mass
Liver bruit
Also: Non-specific (malaise/lethargy/wt loss) RUQ pain s/o CLD/decompensation Hepatomegaly (smooth or hard/irreg) Jaundice (late)
Investigations for ?Liver cancer
Bloods: LFTs / Clotting / Viral serology / AFP USS / CT (find lesions / guide biopsy) Biopsy ERCP (?cholangio) MRI (benign vs malig)
Cholangiocarcinoma:
Causes (2)
Present as (1)
Treatment if presents early/late
Causes:
Parasitic
Primary sclerosing cholangitis
Present as: painless jaundice
Presents early: extended liver resection
Presents late: ERCP stent for palliation