Hepatology - medicine Flashcards
What are the general clinical signs of liver disease?
vague, non-specific
Inappetence
Lethargy
Weight loss
Vomiting
PUPD
What specific signs of liver disease are there?
Icterus
Coagulopathy
Ascites
Hepatic encephalopathy
What is prehepatic jaundice?
Accelerated haemolysis
eg. IMHA
What is hepatic jaundice?
Liver cells arent working properly to clear bilirubin from the blood
What is post hepatic jaundice?
disease of biliary system eg. Inflammation or blockage
Why do ascites form during liver disease?
Liver is main site of albumin production
Controls oncotic pressure - if reduced then fluid leaks out of capillaries
What skin pathology can arise due to liver disease?
Hepatocutaneous syndrome - thickened cracked paw pads
What are the hepatocellular enzymes in small animals?
ALT
AST
What are the cholestatic enzymes?
ALP
GGT
What can cause elevated hepatic enzymes?
Primary disease - toxins, infections, immune mediated
Secondary disease - systemic inflammation, vacuolar hepatic change, hypoxaemia, endocrinopathies
What does the magnitude of the liver enzyme elevations tell us about the disease?
NOT prognostic
Often low with secondary hepatopathy
Can be anything with primary hepatopathy
May fluctuate
What are 3 tests that are evidence of hepatic dysfunction?
Elevated bile acids/ammonia - bile acid stimulation test
Hyperbilirubinaemia
Coagulation derangement - PT/APPT
What are two infectious inflammatory causes of hepatocellular disease?
Neutrophilic cholangitis (bacteria)
Leptospirosis
What are two sterile inflammatory causes of hepatocellular disease?
Chronic hepatitis
Lymphocytic cholangitis - immune mediated liver disease in cats
What drug can cause hepatocellular disease?
Phenobarbitone - antiepileptic drugs
What are some common causes of cholestatic disease?
Pancreatitis
Neutrophilic/lymphocytic cholangitis
Biliary rupture/obstruction
Gall bladder mucocoele
Lipidosis
Neoplasm compressing biliary tree
What can cause a small liver?
Portovascular disease
Chronic hepatopathy
What can cause a large liver?
Acute hepatic insult
Vacuolar change
Neoplastic or inflammatory disease
What does the gall bladder look like on ultrasound?
Cut kiwi
What minimally invasive diagnostics can you do for liver disease?
Abdominal effusion analysis
Specific infectious disease testing - lepto, FIP
What should you do before hepatic sampling?
Check platelets, PT, aPTT first for clotting function
Know blood type for if haemorrhages
Give preventative vitamin K maybe
When should you FNA in liver disease?
When you suspect:
Diffuse infiltrative hepatic disease
Diffuse metabolic disease
Focal hepatic pathology
When should you biopsy liver disease?
When you suspect:
Inflammatory disease
Neoplastic disease
What are the different techniques for biopsy/surgery for hepatic sampling?
Ultrasound guided percutaneous needle - tru-cut
Laparoscopy
Laparotomy - complete surgery
What are the practicalities of tru-cut percutaneous needle biopsy?
Is a referral level procedure
Need a lack of ascites
What are the complications of hepatic sampling?
Haemorrhage
Ascites
Clinical deterioration
May be unnecessary/non diagnostic
What is the term for getting a sample of bile from the liver/gall bladder?
Cholecystocentesis
When should you do a cholecystocentesis?
If suspect bacterial biliary infection - so can do bile cytology/culture
To rule this out in other cases eg. hepatic lipidosis
What are the contraindications for cholecystocentesis?
Biliary obstruction
Gall bladder wall pathology/mucocoele
When is surgery indicated for liver disease?
If there is abdominal free fluid
Hepatic mass lesion
Gall bladder compromise
Gall bladder mucocoele
Obstructive biliary disease
How is liver disease in cats different?
Enzyme elevations variable
Short enzyme half lives
Often have non-specific signs
Usually have comorbidities
What is an immune mediated liver disease in cats?
Lymphocytic cholangitis
What treatment is preferable for a congenital portosystemic shunt?
Surgical correction - improves QOL long term
Stabilise medically first
What is the medical therapy for hepatic encephalopathy? What is used to reduce ammonia levels?
Diet modification - less animal protein, more plant protein, feed cottage cheese
Lactulose - converts ammonia to ammonium ion so it is trapped in colon
What is the general therapeutic treatment of liver disease?
Diet modification - restrict copper
Antioxidants
Anti-inflammatory/immunosuppressives
Choleretics - improve bile flow
What are the main antioxidant drugs?
N-acetyl-cystine - IV
Milk thistle extracts/isolates - oral
S-Adenosyl-L-methionine (SAMe)
Vitamin E
What is a choleretic drug?
Ursodeoxycholic acid (UDCA) - synthetically derived bile acid which reduces bile viscosity so increases bile flow
What two liver diseases do you use antimicrobials in?
Neutrophilic cholangitis
Bacterial cholangiohepatitis
What antimicrobials do you use for liver disease?
Ideally culture and sensitivity
Amoxicillin clavulanate if not
What is portal hypertension?
Increased resistance to blood flow through the liver
What are the consequences of portal hypertension?
Secondary shunting
GI wall oedema (splanchnic bed)
Ascites
How do you treat portal hypertension?
Treat cause
Blood pressure reduction drugs:
Spironolactone - aldosterone antagonist which limits fluid accumulation
Sodium restriction
What liver related disease are bedlingtons predisposed to?
Copper associated chronic hepatitis
What is the decoppering therapy for dogs with copper associated chronic hepatitis?
Chelator - D-penicillamine
Dietary copper restriction
Zinc supplements - not alongside chelators though
How long does de-coppering take?
6-9 months
What is the most important management aspect of feline hepatic lipidosis?
Nutritional support - tube feeding to stop fat mobilistation
What is the treatment for feline hepatic lipidosis?
Tube feeding - 40-60 kcal/kg/day
Antioxidants - SAMe, vit E
UDCA - choleretic
Supportive - fluids, antiemetic, opioids
What liver condition can be caused by very bad dental disease?
Reactive hepatopathy
