hepatology Flashcards
name some functions of the liver.
nutrition/metabolic
- stores glycogen
- releases glucose
- absorbs fats, fat soluble vitamins and iron
- manufactures cholesterol
clotting factors
detoxification
- drug excretion (and activation)
- alcohol breakdown
immune function
- Kupfer cells engulf antigens
bile salts
- dissolves dietary fats
bilirubin
manufactures proteins
- albumin
- binding proteins
what risk factors would you ask for in a patient with liver disease?
- Blood transfusions prior to 1990 in the UK
- IVDU
- operations/vaccinations with dubious sterile procedures
- sexual exposure
- medications
- FH of liver disease, diabetes, IBD
- obesity/features of metabolic syndrome
- travel
what are the key features of acute liver injury/disease?
no pre existing liver disease
resolves in six months
- Hep A, E, CMV, EBV
- drug induced liver injury (DILI)
what are the key features of chronic liver disease?
- starts with acute liver disease (often asymptomatic)
- on going effects beyond 6 months
- may lead to cirrhosis and its complications (genetics important)
1) alcohol
2) hep c
3) non alcoholic steatohepatitis (NASH)
4) autoimmune (primary billiard cholangitis, primary sclerosing cholangitis, Autoimmune hepatitis)
when examining a patient for liver disease, what can you do to look for evidence of chronicity?
check for stigmata of chronic liver disease
- spider naevi
- clubbing
- palmar erythema
- ascites
as well as signs of complications of liver disease
give some examples of complications of liver disease
- portal hypertension
- splenomegaly
- hepatic encephalopathy
- jaundice
- ascites
- oedema
- itchy skin
- gynacomastia
- amenorrhoea
what does grade 1 of hepatic encephalopathy consist of?
- psychomotor slowing
- constructional apraxia
- poor memory
- reversed sleep pattern
what does grade 2 of hepatic encephalopathy consist of?
- lethargy
- disorientation
- agitation/ irritability
- asterixis
what does grade 3 hepatic encephalopathy consist of?
drowsiness
what does grade 4 hepatic encephalopathy consist of?
coma
what investigations are done in liver disease?
similar in both acute and chronic liver disease
- thrombocytopenia is a sensitive marker for liver fibrosis
- LFTs will indicate where damage is
(ALT rise= hepatocytes, ALP rise = the ducts)/ If cholestatic change is suspected, USS to asses if ducts are dilated (obstructive jaundice). May be USS findings that suggest cirrhosis also - bilirubin, albumin and prothrombin time/INR are markers of synthetic function and in acute abnormalities, should raise concern
what are the USS features of liver cirrhosis?
- coarse texture
- nodularity
- splenomegaly
- ascites
what are the cholestatic (dilated ducts) causes of liver disease?
- gallstones
- malignancy
what are the cholestatic (non dilated ducts) causes of liver disease?
- alcoholic hepatitis
- cirrhosis (primary billiard cholangitis, primary sclerosing cholangitis)
- drug induced liver injury
what can cause ALT >500?
- viral
- ischaemia
- toxic (paracetamol is common)
- autoimmune
what can cause ALT to be between 100-200?
- NASH
- autoimmune hepatitis
- chronic viral hepatitis
what does the liver screen consist of?
- hepatitis B&C serology (in acute liver disease, consider Hep A and E if ALT rise)
- iron studies (ferritin and transferrin)
- autoantibodies (AMA and SMA) and immunoglobulins
- consider caeuruloplasmin if under 30
- alpha a antitrypsin
- coeliac serology
- TFT, lipids and glucose
what are the commonest causes of cirrhosis?
- Alcoholic liver disease
- NASH
- viral hepatitis (B and C)
what causes of cirrhosis are commoner in women?
- autoimmune hepatitis
- primary billiard cholangitis
what causes of cirrhosis are commoner in men?
- primary sclerosing cholangitis, associated with IBD
- earlier in men = haemachromatosis
what is the treatment of chronic liver disease?
its based on removing the underlying aetiology (stopping drinking, weight loss, antivirals, venesection, etc) to prevent further liver damage and progress to cirrhosis
when should cirrhosis be suspected?
- thrombocytopenia
- clinical stigmata of chronic liver disease
- imaging can be suggestive (splenomegaly, course texture and nodularity)
- presence of varices on endoscopy in a patient with chronicler disease would be diagnostic of cirrhosis
why is it important to screen for varices in patients with cirrhosis?
as primary prophylaxis can decrease the risk of bleeding significantly
what is used to treat ascites in cirrhosis?
spironolactone or, if tense, paracentesis
what can be done if a patient with cirrhosis is at risk of osteoporosis?
DEXA scan
bone density scan
what is a hepatocellular carcinoma?
a type of primary liver tumour that can develop in patients with cirrhosis
patients should be screened using alpha fetoprotein and USS every 6 months for early diagnosis and good prognosis
When should a diagnostic ascitic tap (cell count and MC&S)be done?
in all patients with ascites who are admitted to hospital to look for spontaneous bacterial peritonitis (SBP)
