Hepatology Flashcards
Liver functions
Protein synthesis (albumin and clotting factors)
Glucose and fat metabolism
Detoxification and excretion of drugs and hormones (bilirubin and ammonia)
Immunity
Liver injury - Types
Acute - Outcomes are liver failure or recovery
Chronic - Outcomes are Cirrhosis, liver failure (varices, hepatoma) or recovery
Liver injury - Acute
Viral (A,B)
Drug
Alcohol
Vascular
Liver injury - Chronic
Viral (B,C)
Alcohol
Autoimmune
Metabolic (Iron, copper)
Liver injury - Acute presentation
Jaundice Nausea Loss of appetite Hypoglycaemia Liver pain (inflamed) Malaise
Liver injury - Chronic
Peripheral oedema Ascites (swollen abdo) Malaise Weight loss (catabolism) Hepatomegaly Easy bruising Jaundice
Serum liver function tests
Bilirubin Albumin Serum liver enzymes (ALT, ALS) ALP (Alkaline phosphatase) GGT (Gamma-glutamyl transpeptidase)
Jaundice
Unconjugated - Pre-hepatic (Gilberts, haemolysis)
Conjugated - Hepatic - hepatitis, viral, drugs, alcohol, ischaemia, neoplasm
Conjugated - Post-hepatic - Gallstone, ischaemia, inflam
Pre-hepatic
Normal urine
Normal stools
No itching
Normal LFTs
Hepatic/post hepatic
Dark urine
Pale stools
Itching
Abnormal LFTs
Jaundice - Related symptoms
Dark urine Pale stools Itching Biliary pain Abdo swelling Wt loss
Jaundice - History
Alcohol
Drugs
Potential hepatitis contact - Irregular sex, exotic trave, certain foods
Jaundice - Tests
Serum albumin, bilirubin
Liver enzymes (Hepatocellular) - Raised AST/ALT,
Liver enzymes (Cholestatic) - Alkaline phosphatase, GGT
CT abdo
US liver
MRCP/ERCP
Gallstones
Commonly form in gallbladder
Majority are cholesterol-based
Gallstones - Presentation
Gallbladder - biliary pain, cholecystitis, obstructive jaundice
Bile duct - Biliary pain, obstructive jaundice, cholangitis, pancreatitis
Gall stones - Management
Gallbladder - Laparoscopic cholecystectomy
Bile duct - ERCP
Can cause drug-induced liver injury
TB drugs (RIPE)
Flucloxacillin
Augmentin
Paracetamol overdose (worse when combined with alcohol)
Drug-induced liver injury (DILI)
Hepatocellular
Cholestatic
Mixed
Treatment for paracetamol-induced hepatic failure
N-acetylcysteine
Chronic liver disease
Inflam Scarring Fibrosis Jaundice Ascites Varices Wasting Spider naevi (more than 5 is pathological)
Ascites - Causes
Chronic liver disease Portal vein thrombosis Hepatoma Neoplasia Pancreatitis Cardiac causes Sample the ascites fluid to diagnose
Ascites - Pathogenesis
Activated RAAS
Low serum albumin (reduced oncotic pressure)
Ascites - Management
Diuretics - Spironaloctone +/- furosemide
Fluid and salt restriction
TIPS (Trans-jugular intrahepatic portosystemic shunt) -offloads pressure of portal hptn
Raised AST
Cirrhosis
Alcohol
USS showing liver with a nodular outline indicates
Cirrhosis
Alcoholic liver disease
Main cause of liver death in UK
Varices - Treatment
Gastroscopy
Terlipressin - Causes Splanchnic vasoconstriction
Portal hptn - Causes
Cirrhosis
Fibrosis
Portal vein thrombosis
Portal hptn - Consequences
Varices
Splenomegaly
Alcoholic liver disease - Treatment
Lorazepam
Transplant
Liver patients are vulnerable to infecction
Impaired reticuloendothelial function
Spontaneous bacterial peritonitis
Commonest serious infection in cirrhosis
Diagnosis based on neutrophils in ascitic fluid (gram neg - use blood cultures)
Prophylactic antibiotics
Liver transplant
Ascites - Diagnosis
Diagnostic tap - Cloudy, raised WBC
Coma in patients with chronic liver disease
Hepatic encephalopathy - simple bedside tests - basic maths, drawing, writing etc
Treatment - Lactulose
Liver dysfunction - Consequences
Malnutrition Impaired coag Thrombocytopenia Hypoglycemia Gynaecomastia
Drug prescribing in liver disease
Analgesia - sensitive to opiates (lower doses preferred), paracetamol is safest option Sedation - benzodiazipines (lorazepam) Diuretics ACEi Aminoglycosides - Gentamicin
Chronic liver disease - Investigations
Viral serology - Hep B surface antigen, Hep C surface antibody
Immunology - Autoantibodies, Ig
Biochem - Iron, copper, lipids, glucose, alpha-1 antitrypsin
Radiology - USS/CT/MRI
Hepatitis - Differential diagnoses
Viral - a,b,c
Drug-induced
Autoimmune
Alcoholic
Iron studies
Ferritin
Iron
Hepatitis - Diagnosis
Biopsy
Autoimmune hepatitis - Treatment
Steroids (Prednisolone) - AST and bilirubin normalise with steroids
Autoimmune liver diseases
Primary biliary cholangitis/cirrhosis (PBC) - IgM, Antimitochondrial AutoAb
Primary sclerosing cholangitis (PSC) - Variable Ig, Antineutrophil cytoplasmic AutoAb
Autoimmune hepatitis (AIH) - IgG, Antinuclear AutoAb
PBC
Presentation - Itching, Fatigue, Dry eyes, Joint pains, Variceal bleeding
Raised Alk phos and GGT
Treatment - Ursodeoxycholic acid (reduces inflam)
Treatment of cholestatic itch
Antihistamines
Treatment of fatigue
Modafinil
PSC
Leads to strictures (areas of narrowing) + gallstones
Presentation - Itching, pain, jaundice
Raised Alk phos and GGT
Treatment - Ursodeoxycholic acid, liver transplant
Hemochromatosis
Raised ferritin
Liver biopsy
Doppler USS - Fatty liver
Fibroscan - indicates extent of liver fibrosis
Fibroscan
Indicates extent of liver fibrosis
Haemachromatosis
Genetic disorder - mutations in HFE gene (C2827, H63D), autosomal recessive
Uncontrolled intestinal iron absorption with deposition in liver, heart and pancreas
Diagnosis - Raised ferritin, HFE genotyping, liver biopsy
Cirrhosis can present
Alpha 1 antitrypsin deficiency
Z allele of alpha 1 antitrypsin gene
Homozygous
Results in inability to export alpha 1-antitrypsin from liver
Can lead to liver disease (protein retention in liver) or emphysema (protein deficiency in blood)
Hepatocellular carcinoma
Primary liver tumour Mostly occurs when cirrhosis is present Highest risk for Hep B/C, hemochromatosis Lowest risk for alcoholics, autoimmune Treatment - Transplant, resection
NAFL (Non-alcoholic fatty liver)
ALT elevated usually
Obesity, diabetes are RFs
Hepatic vein occlusion
Thrombosis is the main cause
Ascites
Treatment - Anticoag, TIPS, liver transplant
Hepatitis
Inflmmation of liver
Acute - within 6 months
Chronic - beyond 6 months
Acute hep
Malaise, myalgia, GI upset, abdo pain RUQ, jaundice, pale stools, dark urine
Signs - Tender hepatomegaly, jaundice, ascites, encephalopathy
Bloods - Raised ALT/AST, raised bilirubin
Causes - Viral (ABCDE, human herpes viruses - HSV,Ebv), Non-viral (TB), Non infection - drugs, alcohol, etc
Chronic hep
Signs - Clubbin, palmar erythema (red palm), spider naevi
ALT/AST can be normal
Compensated - normal liver disease
Decompensated - Coagulopathy, jaundice, low albumin, ascites, encephalopathy
Complications - HCC, portal hptn
Causes - Viral hep, non viral - drugs alochol etc
HepA
Faeco-oral transmission - person to person, ingesting contaminated food/water
RFs - Travel, sexual contact, injecting drug abuse
Symptoms - Abdo pain, jaundice
Abnormal LFTs - Albumin, bilirubin
Diagnosis - AntiHAV IgM/G Ab
Management - Transplant
Tends to be cute
Once it’s gone, it’s gone and doesn’t relapse
HepE
Contaminated food and water
Undercooked meat products
Pigs
Can cause chronic infections in immunocompromised patients
Diagnosis - HEV RNA (Serum/stool sample), AntiHEV IgM /G Ab
Treatment - Ribavirin
Hep B/D
Commonest hep is B
Blood borne virus - contaminated blood, bodily fluids, sexual contacts, injecting drug use, mother to child
Diagnosis - Anti HB core IgM/G, HepB surface antigen
Treatment - Pegylated interferon alpha 2a, SE (lots) - myalgia, flu like symptoms. Oral nucleotide analogues
Antenatal screening - Pregnant mothers
HepD
Can only get it if Hep B
Blood/bodily fluids
Treatment - Hep B treatment
Test - Hep D antibody, HDV RNA
HepC
Majority of patients are chronic
Drug injecting abuse, sexual transmission, contaminated needle treatments
Test - Gold standard is HCV RNA (PCR) because it indicates current exposure, HCV antibody (indicates exposure but not if currently infected)
Treatment - Sofosbuvir (first line), DAAs (directly acting antivirals) - NS5A, NS5B
Prevention - needle exchanges
