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302- metabolic and renal > intro to herpetology > Flashcards

intro to herpetology Flashcards

1
Q

how long is acute liver disease?

A
  • 6 weeks
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2
Q

howling is subacute liver disease?

A

6-26 weeks

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3
Q

how long is chronic liver disease?

A

> 26 weeks

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4
Q

what are causes of acute liver disease?

A
  • drugs
  • viral hepatitis A,B,C,E
  • autoimmune hepatitis
  • wilsons disease
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5
Q

what are causes of subacute liver disease?

A

drugs
viral hepatitis ABC
autoimmune hepatitis
wilsons disease

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6
Q

what are causes of chronic liver disease?

A 
viral hepatitis B and C 
alcohol
non alcoholic fatty liver disease 
haemochromatosis 
A1 antitripsin deficiency
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7
Q

what are the different liver enzymes?

A
  • Aspartate aminotransferase (AST) (40 iu/l)
  • Alanine aminotransferase (ALT) (40 iu/l)
  • Alkaline phosphatase (ALP) (200 iu/l)
  • Gamma GT (50 iu/l)
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8
Q

what are the different liver function tests?

A
  • Bilirubin (17µmol/l)
  • liver enzymes- AST,ALT,ALP, gammaGT
  • Albumin (40 gm/l)
  • prothrombin time
  • INR <1.1 OR 2-3 on warfarin
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9
Q

what is the next step if liver function tests are abnormal?

A 
do a liver screen: 
1. hepatitis serology 
2. ANA,SMA,LKM autoimmune hepatitis 
3. AMA for primary billiard cholangitis 
4. alpha1 antitripsin 
copper, caeruloplasmin (wilsons disease)
5. ferritin (haemochromatosis)
6. ultrasound
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10
Q

what are the tests for autoimmune hepatitis?

A

ANA- antinuclear antibody
SMA- anti smooth muscle antibody
LKM- antiliver kidney microsomal antibody

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11
Q

What can different liver function tests show?

A

Liver enzymes are used to distinguish between hepato-cellular damage and cholestatic damage.
Bilirubin albumin and INR are used to assess liver synthetic function.

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12
Q

Can the ALT/AST ratio show?

A

ALT > AST is seen in chronic liver disease

AST > ALT is seen in cirrhosis and acute alcoholic hepatitis

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13
Q

What is the difference between hepatic and cholestatic liver function tests?

A

A greater than 10-fold increase in ALT and a less than 3-fold increase in ALP suggests a predominantly hepatocellular injury

A less than 10-fold increase in ALT and a more than 3-fold increase in ALP suggests cholestasis
It is possible to have a mixed picture involving hepatocellular injury and cholestasis

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14
Q

What is cholestasis?

A

A reduction of stoppage in viral flu disorders of the liver bile duct and pancreas can cause the cholestasis

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15
Q

What is liver cirrhosis?

A

scarring of the liver caused by long-term liver damage. The scar tissue prevents the liver working properly

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16
Q

what is the recommended dose of paracetamol?

A

4gms/day

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17
Q

what is the toxic dose of paracetamol?

A

> 15 grams

18
Q

what is the mechanism for paracetamol (acetomenaphin) toxicity?

A

normally paracetamol is metabolised into non-toxic metabolites by glutathione
in an overdose the glutathione is overwhelmed and a toxic metabolite NAPQI which causes liver necrosis accumulates

19
Q

what is the antidote to paracetamol overdose?

A

N-acetlycystine NAC- this replenishes the glutathione stores

you can also give activated charcoal <4hrs after ingestion to help with any GI issues that may develop

20
Q

when should you give NAC for paracetamol overdose?

A
  • if given with 16 hrs then liver failure is rare

- some benefit can be achieved even if given up to 36 hrs

21
Q

what is compensated liver cirrhosis?

A

there are enough healthy cells to make up for the damaged ones, but minor complications like hemorrhoids can still occur.

22
Q

why do you get haemorrhoids with compensated liver cirrhosis?

A

can get internal haemorrhoids above the pectinate line as these are supplied by the superior rectal vein which is part off the portal system

these are not usually painful, but they are prone to bleeding

23
Q

what is decompensated liver cirrhosis?

A

when healthy cells can no longer keep up with the workload, causing major complications;

  • hepatic encephalopathy
  • ascites
  • esophageal and gastric variceal hemorrhage
24
Q

what is hepatic encephalopathy?

A

is the occurrence of confusion, altered level of consciousness, and coma as a result of liver failure; mainly its inability to metabolize ammonia to urea.

can also see asterexisis- liver flap on examination

It may ultimately lead to death

25
Q

what is the treatment for hepatic encephalopathy?

A

lactulose- to decrease absoption of of ammonia

rifaximin - to kill bowel flora that produce ammonia

reduce protein intake to reduce ammonia

26
Q

what is the pathophysiology of hepatic encephalopathy?

A
  • ammonia and other toxic metabolites are not metabolised by the liver accumulate

they are detoxified by astrocytes in the CNS which causes glutamine accumulation

this results in osmotic stress and swelling in the CNS

27
Q

what are symptoms of paracetamol overdose?

A
  • present with nausea
    vomiting
    RUQP
    confusion
  • jaundice and liver failure can develop over 3-4 days
  • they also have very high liver enzymes and prothrombin time
28
Q

what are precipitating causes of hepatic encephalopathy?

A 
constipation 
diuretics 
infection 
sedatives 
GI bleeding
29
Q

what is the effect of cirrhosis on oestrogen metabolism?

A
  • impaired metabolism causing…
  • amenorrhea and irregular menstural bleeding in women

-gyneacomastia and low libido in males

30
Q

what can blood test show in liver cirrhosis?

A
  • thrombocytopenia (esp if have splenomegaly)
  • anaemia
  • leukopenia
  • elevated liver enzymes
  • albumin decreased
  • INR and prothrombin time increased
  • bilirubin is increased in decompensated cirrhosis
31
Q

how can you manage ascites?

A
  • sodium restriction to <2g a day
  • treat with diuretics such as furosemide and spironolactone
  • do large volume paracentesis and give albumin afterwards
32
Q

why is albumin given after large volume paracentesis?

A

Supplementing 5 g of albumin per each liter over 5 L of ascitic fluid removed decreases complications of paracentesis, such as electrolyte imbalances and increases in serum creatinine levels secondary to large shifts of intravascular volume

33
Q

what to do if you get recurrent paracentesis?

A
  • do recurrent large volumes of paracentesis
  • Transjugular intrahepatic portosystemic shunt - allows you to bring blood from the bowels to the heart by avoiding the liver
    • Consider liver transplant
  • Long-term drains
34
Q

what is the treatment for oesophageal bleeding?

A
  • IV telipressin (vasopressin agonist) which reduces oesophageal BP
  • IV antibiotics
  • endoscopy in theatre with variceal banding
  • balloon tamponade- if too much bleeding
  • non selective beta blocker for secondary prophylaxis
35
Q

what is a complication of ascites?

A

spontaneous bacterial peritonitis often caused by

  • ecoli
  • klebsiella pneumoniae
  • streptococcus pneuomniae
36
Q

why can you get hepatorenal syndrome?

A
  • portal hypertension causes arterial and capillary vasodilation
  • this leads to reduction in systemic vascular resistance which can damage the kidneys
37
Q

what is non alcoholic fatty liver disease?

A
  • like alcoholic liver disease but in the absence of alcohol
  • associated with;
  • T2DM,obesity, hypertension and elevated triglycerides
38
Q

what are indications for liver transplant in paracetamol overdose?

A

•pH<7.3 after fluid resuscitation or

  • Arterial lactate > 3.5 mmol at 4 hours or
  • Arterial lactate > 3.0mmol/l at 12 hours or

• PT > 100 seconds (INR > 6.5)
Serum creatinine > 300 mmol/l (3.4 mg/dl)
Grade 3 or 4 encephalopathy

39
Q

what are indications for non paracetamol overdose liver transplant?

A

• Prothrombin time greater than 100 seconds (INR> 6.5) (irrespective of grade of encephalopathy) or any three of the following

  1. Age less than 11 years or greater than
    40 years 2. Etiology of non-A/non-B hepatitis,
    halothane hepatitis, or idiosyncratic drug
    reactions
  2. Duration of jaundice of more than 7 days
    before onset of encephalopathy 4. Prothrombin time greater than 50 seconds
    (INR> 3.5) 5. Serum bilirubin
40
Q

what are indications for liver transplant in liver cirrhosis?

A
  • Ascites/ SBP
  • Variceal bleeding
  • Hepatic encephalopathy
  • Hepatocellular cancer
41
Q

what is the prognostic score used to prioritise liver transplant in cirrhosis?

A

child pugh score

302- metabolic and renal (8 decks)

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