Hepatology/Liver Flashcards
What is spontaneous bacterial peritonitis commonly a secondary complication of?
Large-volume ascites.
What is the gold standard for the diagnosis of liver cirrhosis?
A biopsy
What is a limitation of using a biopsy for the diagnosis of liver cirrhosis?
It is quite invasive.
Child-Pugh classes of hepatic impairment
TBC
Encephalopathy
TBC
Enecephaltitis
TBC
What is hepatic steatosis also known as?
Fatty liver disease
What is hepatic steatosis (fatty liver disease)?
An increased build-up of fat in the liver impairing its function.
What is cirrhosis of the liver?
Cirrhosis is late-stage scarring (fibrosis) of the liver.
How does end-stage cirrhosis affect LFTs?
LFTs may not be elevated in end-stage cirrhosis as the liver does not have the capacity to release the liver enzymes.
Viral encephalitis
TBC
Autoimmune encephalitis
TBC
Where is ALT found in high concentrations?
ALT is found in high concentrations within hepatocytes
In what 3 organs is ALP particularly concentrated?
- Liver
- Bile Duct
- Bone tissues
What is cholestasis?
Any condition in which the flow of bile from the liver stops or slows.
If a patient has a rise in ALP, what is it important to review?
If there is a rise in ALP, it important to review the level of GGT.
What can a raised GGT be suggestive of (either in isolation or with raised ALP)?
Raised GGT can be suggestive of biliary epithelial damage and bile flow obstruction. It can also be raised in response to alcohol and drugs such as phenytoin.
What are the 3 major organs of the biliary system?
- Liver
- Gall bladder
- Bile ducts
How can ALP and GGT be interpreted together?
A markedly raised ALP with a raised GGT is highly suggestive of cholestasis.
How should an isolated rise in ALP be interpreted?
Raised ALP without raised GGT may suggest non-hepatobiliary pathology such as bone breakdown
What are 4 causes of an isolated raise in ALP?
- Bony metastases or primary bone tumours (e.g. sarcoma)
- Vitamin D deficiency
- Recent bone fractures
- Renal osteodystrophy
What is an isolated rise in bilirubin suggestive of?
A pre-hepatic cause of jaundice such as Gilbert’s Syndrome or haemolysis.
What are the liver’s 4 main synthetic functions?
- Conjugation and elimination of bilirubin
- Synthesis of albumin
- Synthesis of clotting factors
- Gluconeogenesis
What is gluconeogenesis?
Formation of glucose from sources other than carbohydrates (such as fats and proteins) occurring mostly in the liver.
What are 4 measures of the liver’s synthetic function?
- Serum bilirubin
- Serum albumin
- Prothrombin time (PT)
- Serum blood glucose
What are 3 reasons albumin levels may fall?
- Liver disease causing decreased albumin production (e.g. cirrhosis).
- Inflammation temporarily reducing albumin production
- Excessive albumin loss due to protein-losing enteropathies or nephrotic syndrome.
What does an AST/ALT ratio where ALT>AST suggest?
ALT > AST is associated with chronic liver disease
What does an AST/ALT ratio where AST>ALT suggest?
AST > ALT is associated with cirrhosis and acute alcoholic hepatitis
What 4 LFT changes usually occur in acute hepatocellular damage?
- ALT: Pronounced rise
- ALP: Normal or slight rise
- GGT: Normal or slight rise
- Bilirubin: Slight or pronounced rise
What 4 LFT changes usually occur in chronic hepatocellular damage?
- ALT: Normal or slight rise
- ALP: Normal or slight rise
- GGT: Normal or slight rise
- Bilirubin: Normal or slight rise
What 4 LFT changes usually occur in acute cholestasis?
- ALT: Normal or slight rise
- ALP: Pronounced rise
- GGT: Pronounced rise
- Bilirubin: Pronounced rise
What are 3 common causes of acute hepatocellular injury?
- Poisoning (for example paracetamol overdose)
- Infection (Hepatitis A, B or C)
- Liver ischaemia
What are 4 common causes of chronic hepatocellular injury?
- Alcoholic fatty liver disease
- Non-alcoholic fatty liver disease
- Chronic infection (Hepatitis A, B or C)
- Primary biliary cirrhosis
What occurs to ALT in hepatocellular injury?
It enters the bloodstream.
What is ALT a useful marker of?
Hepatocellular injury.
What often causes ALP levels to rise?
ALP is often raised in cholestasis.
What is ALP a useful marker of?
ALP is a useful indirect marker of cholestasis.
What is gall bladder sludging?
When bile remains in the gallbladder for too long, mixing with cholesterol and calcium salts, forming a sludge
What is adenomyomatosis?
Adenomyomatosis is a benign condition characterised by hyperplastic changes of unknown cause involving the wall of the gallbladder.
What is hepatomegaly?
Enlargement of the liver
What is cholecystitis?
A condition characterised by the inflammation of gallbladder
What is primary biliary cirrhosis?
An auto-immune disease that causes progressive destruction of the bile ducts.
What are 7 factors to consider for drug therapy relating to the liver ?
- LFTs – INR, ALT, ALP, AST, GGT, bilirubin, albumin and pattern of change
- SIGNS AND SYMPTOMS OF LIVER DISEASE – eg. ascites, oesophageal varices, jaundice, encephalopathy
- CAUSE OF LIVER IMPAIRMENT – chronic (eg. alcoholic liver disease) or acute (eg. drug induced)
- CREATININE – ensure no hepato-renal syndrome/renal impairment if using medications which are renally cleared
- PHARMACOKINETICS – favourable characteristics in liver impairment are renal excretion, short half-life, low protein binding, no high first-pass metabolism, no active metabolites and no enterohepatic recirculation
- PHARMACODYNAMICS – avoid or use with caution any medications with side effects which might worsen signs/symptoms of liver disease (eg. blood thinning, oesophageal reflux, fluid retention, sedation/CNS activity, constipation, hepatotoxic)
- HEPATOTOXICITY – consider current drug causes, hold/suspend any non-essential medications which may cause severe/fatal hepatotoxicity
How is albumin produced?
Albumin is a protein synthesised by the liver
What is the role of albumin in the bloodstream?
Albumin enters your bloodstream and helps keep fluid from leaking out of your blood vessels into other tissues. It also carries hormones, vitamins and enzymes throughout the body.
What are the 3 main functions of albumin?
- Maintenance of appropriate osmotic pressure
- Binding and transport of various substances in the blood such as hormones and drugs
- Neutralisation of free radicals
What are free radicals?
Highly reactive and unstable molecules in the body produced as a byproduct of normal metabolism.
What are 4 conditions which you should check for if a patient has low albumin?
- Malnutrition
- Liver disease
- Kidney disease
- Inflammatory disease
What are 4 conditions which you should check for if a patient has high albumin?
- Acute infections
- Burns
- Stress from surgery
- Heart attack
