Hepatology Flashcards
Alcoholism
- Liver pathologies causes by alcoholism (3)
- USS finding (fatty liver), biopsy results
- Blood tests
- Withdrawal - symptoms
- Withdrawal - management
- Wernicke’s Encephalopathy - clinical features
- Korsakoff’s syndrome - cause and symptoms
- CAGE questionnaire (4)
- Questionnaire to decide level of alcohol dependence
- Advice if dependent
- Management - mild
- Medication to stop anxiety, insomnia, craving
- Medication causing acetaldehyde build up (N+V, flushing, headache, palpitations if drink)
- How to work out units
- Steatosis (fat in liver cells), hepatitis + cirrhosis
- Echogenicity up + mallory bodies, neutrophil infiltrates
- Macrocytic anaemia, high AST/ALT, very high YGT, high ALP in cirrhosis, high PT
- Tachycardia, HTN, tremor (6-12 hours), hallucination (12-24 hours), seizures (1-2 days), delirium tremens (1-3 days)
- Chlordiazepoxide, vit K, pabrinex (3 vitamins)
Pabrinex contains thiamine (vit B1 - always give if AD), riboflavin (B2), vitamin C - Confusion, ophthalmoplegia, ataxia
- Hypothalamic damage/cerebral atrophy from chronic thiamine deficiency (confabulation, no insight, apathy)
- Do you feel: should Cut down / Annoyed if drinking criticised / Guilty about drinking, ever have Eye opener
- AUDIT questionnaire
- No sudden stopping/NSAIDs/warfarin tell DVLA/work
- CBT +/- acamprostate
- Acamprostate
- Disulfiram
- % x ml / 1000 x no. of days
Cirrhosis
- Definition
- Causes
- Hand signs
- Face/neck signs
- Chest signs
- Abdominal signs
- Blood tests
- Further tests
- Decompensated definition
- Conservative management
- Screening required for
- Cirrhosis scores: severity, compensated mortality/need for transplant
- Hepatocellular degeneration, inflammation, + fibrous tissue thickening
- Alcohol, hepatitis (B/C), genetic (Wilson’s), drugs (methotrexate), autoimmune
- Clubbing, leukonychia, dupuytren’s contracture, palmar erythema, asterixis (flapping tremor if decompensated)
- Jaundice, raised JVP
- Spider naevi, gynacomastia, bruising (abnormal clotting)
- Hepatosplenomegaly, ascites, caput medusae
- AST/ALT/ALP/YGT/bilirubin up, U+E (deranges in HRS), platelets/albumin down, PT up, FBC (MCV high), IgA, cholesterol
- USS liver (nodular surface, corkscrew arteries, corkscrew portal vein), CT, biopsy if needed for extent of damage, MRCP/ERCP
- Cirrhosis with ascites/ bleeding / reduced GCS
- Alcohol abstinence, nutrition (low Na+, high protein)
- Varices development - OGD
- Child-Pugh (5-15), Meld (every 6 months)
Liver function tests (LFTs)
- Hepatic function tests
Aminotransferases (AST, ALT)
- Most specific for liver injury
- ALT - expressed in
- AST - expressed in
- ALP - expressed in
- yGT - expressed in
- Alcoholic liver disease
- Acute viral hepatitis
- Chronic viral hepatitis
- Fatty infiltration of liver
- Ischaemic hepatitis
- Cholestasis - blood results
- Bone - blood results
- Other causes for raised LDH
- Serum albumin, serum bilirubin, PT (INR)
- ALT
- Liver, kidney, muscle
- Liver, heart, skeletal muscle, RBCs
- Liver, bone (raised in growing children), placenta
- Liver, pancreas, renal tubules, intestine
- High AST:ALT is >2:1, high yGT, macrocytosis
- High ALT, maybe high AST, maybe normal bilirubin
- High ALT
- Mildly high AST/ALT
- Very high ALT, high LDH
- High ALP + yGT
- High ALP, normal yGT
- Liver metastases, obstructive jaundice
Jaundice
Causes
- Pre-hepatic
- Intra-hepatic
- Post-hepatic
- Unconjugated
- Conjugated
- Bilirubinuria - found in which types (2), appearance, why
- Urobilinogen - absent in which cause
- History - important points
- Examination
- Blood tests
- Further investigations
- Increased haemolysis e.g. sickle cell, malaria, spherocytosis, thalassaemia
- Hepatocellular damage
- Cholestasis
- Overproduction (haemolysis), impaired hepatic uptake (hepatitis from rifampicin, paracetamol, ischaemia), impaired conjugation (Gilbert’s), physiological neonatal (combination)
- Hepatocellular damage, cholestasis
- Intra and post, conjugated is water soluble, urine dark
- Cholestasis
- Blood transfusions, IVDU, piercings/tattoos, sex, travel, jaundice contacts, FH, alcohol, medication
- Chronic liver disease, hepatic encephalopathy, lymphadenopathy, hepatosplenomegaly, ascites, palpable gall bladder (not gallstones if painless jaundice - Courvoisier)
- FBC, clotting, film, reticulocyte count, Coombs/haptoglobin for haemolysis, malaria, Paul Bunnell (EBV), culture, hepatitis serology
- Ultrasound, then ERCP, or biopsy
Disorders of excretion (cholestasis) - blood tests
Bilirubin
ALP
Copper raised
Cholesterol
(all increased in cholestasis)
Synthetic liver function - which tests
Coagulation - prothrombin time and INR
Liver screen
Albumin
Which clotting factors are produced by the liver?
1,2,5,7,11 and 13
Which tests are done in a liver screen?
Viral hepatitis CMV and EBV Autoantibodies Ig Ferritin Copper
USS of the liver
Acute liver failure
- Definition
- Consequences (2)
- Main causes (3)
- Infectious causes
- Drug sauses
- ‘Other’ causes
- Important questions
- Bloods
- Imaging
- Immediate management
- Monitoring requirement
- Commonest mode of death
- Fulminant hepatic failure - definition
- Complications
- Acute liver injury (reduction in hepatic function <6m due to hepatocellular death) - hyperacute <7d, acute 8-21d, subacute 4-26 weeks
- Increased INR, hepatic encephalopathy
- Infections, drugs, malignancy
- Hepatitis (A, B, E), immunocompromised (EBV, CMV), foreign travel (dengue)
- Paracetamol, cocaine, iron, amoxicillin, rifampicin, isoniazid, phenytoin, valproate
- Autoimmune, Wilson’s, ischaemia, pregnancy related (acute fatty liver / HELLP)
- Recent new medication, travel history, unprotected sex, IVDU
- FBC, U+E, LFT, albumin, coagulation, copper, glucose, ABG, hepatitis screen, toxicology, autoantibodies, culture
- USS, CT, ascitic tap
- ABC, fluid resuscitation, vitamin support, IV N-acetylcysteine if paracetamol, discuss with transplant/ITU
- INR 6 hourly, urine output, creatinine
- Sepsis
- Sudden onset liver failure with hepatic encephalopathy within 2 weeks in a person with no underlying liver pathology
- Cerebral oedema (mannitol, hyperventilate), ascites, bleeding (Vit K, platelets, FFP + blood), infection (ceftriaxone NOT gentamicin), encephalopathy
Hepatic encephalopathy
- Due to build up of
- Precipitating events
- Microbiology (3)
- Imaging (2)
- Bloods
- General acute management
- First line ammonia-focussed management
- Ammonia
- Infection, GI bleed (protein absorption), constipation, dehydration, alcohol binge, TIPS
- Blood cultures, ascitic tap, urine dip
- USS, CT
- FBC, U+E, LFT, coagulation, CRP, ABG (including ammonia), glucose
- ABCDE, fluids, ABX (rifamixin), treat the cause
- Lactulose - thought to promote the excretion of ammonia and increasing the metabolism of ammonia by gut bacteria
Liver tumours
Primary
- Main causes
- Important diagnostic tests (2)
- Symptoms
- Signs
- Hepatocellular carcinoma (HCC) - commonest cause
Cholangiocarcinoma (biliary tree cancer)
- Main risk factor
- Elevated markers
- What symptom comes earlier than in HCC
- Test to do if suspected following USS/CT
- Benign tumours - types (2)
Secondary (commonest)
- Origins in men
- Origins in women
- Hepatocellular carcinoma (75%), cholangiocarcinoma
- Abdominal USS/CT (3 phase), alpha feto protein (HCC)
- Fever, malaise, weight loss, RUQ pain
- Hepatomegaly (hard and irregular if metastases / HCC / cirrhosis), decompensation (e.g. jaundice, ascites)
- Hepatitis B - monitor AFP for HCC recurrence
- Primary sclerosing cholangitis (PSC)
- CA 19-9 (normally pancreas), CEA (normally bowel), CA 125 (normally ovarian)
- Jaundice
- ERCP with biopsy
- Haemangioma (don’t biopsy), adenoma (caused by steroids, COCP, pregnancy)
- Stomach, colon, lung
- Stomach, colon, breast, uterus
Autoimmune hepatitis
- Types (2), autoantibodies present, age
- Other linked autoimmune diseases
- Presentation
- Bloods
- Bloods suggesting hypersplenism
- Invasive test, + result
- Diagnosis
- 1st line management
- 1 (Anti-smooth, ANA - adults <40); 2 (anti-LKM1 - children)
- SLE, UC, GN, haemolysis, DM, PSC, thyroid disease, pernicious anaemia
- Acute hepatitis (e.g. jaundice), autoimmune disease signs (e.g. fever, malaise, urticaria, pleurisy polyarthritis), amennorhoea
- Bilirubin, AST, ALT, ALP, IgG all raised
- Pancytopaenia
- Liver biopsy (mononuclear infiltrate of peri/portal areas, piecemeal necrosis, +/ fibrosis)
- IgG, autoantibodies, histology in absence of viral disease
- Prednisolone, then azathioprine
Primary biliary cholangitis
- Cause and result
- Antibody present
- Typical presentation
- Early blood results
- Late blood results
- Complications
- Management
- Autoimmune distruction of the lobular ducts, can lead to cholestasis and fibrosis/cirrhosis/portal HTN
- Anti-mitochondrial (AMA) - M2 subtype
- Age 50, asymptomatic, maybe lethargy, pruritis, then jaundice much later
- Raised ALP, yGT (mild AST/ALT)
- Raised bilirubin/PTT, low albumin
- Malabsorption of fat-soluble vitamins (A, D, E, K) from cholestasis and low bilirubin in gut lumen leads to osteomalacia, coagulopathy
- Symptoms (colestyramine for pruritis, codeine for diarrhoea), vits A/D/E/K, ursodeoxycholic acid (UDCA)
Primary sclerosing cholangitis
- Definition
- Associated condition
- Autoantibody present
- Associated cancer
- Other bloods
- Diagnostic imaging + findings
- Chronic liver disease leading due to fibrosis and inflammation leading to bile duct scarring, cholestasis and cirrhosis
- IBD
- p-ANCA
- Cholangiocarcinoma
- ALP, bilirubin, gamma globulins, IgM
- MRCP - duct stricture, damage/dilatation ‘beaded’ appearance
Liver disease - peripheral signs
Bruising - poor clotting
Malnourished
Oedema