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TCD Metabolic > Jaundice (Abnormal LFTs) > Flashcards

Jaundice (Abnormal LFTs) Flashcards

1
Q

What are the essential functions of the liver? (4)

A

-Stores excess glucose as glycogen
-Produces clotting factors for the clotting cascade
-Metabolism of carbohydrates, fats and proteins
-Destroys or detoxifies harmful endogenous and exogenous substances

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2
Q

Which types of hepatitis are transmitted via blood and bodily fluids?

A

Hepatitis B
Hepatitis C
Hepatitis D

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3
Q

Which types of hepatitis have a faecal-oral route of transmission?

A

Hepatitis A
Hepatitis E

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4
Q

Which type of hepatitis is acute only?

A

Hepatitis A

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5
Q

What type of hepatitis is chronic only?

A

Hepatitis E

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6
Q

What types of hepatitis are both acute and chronic?

A

Hepatitis B
Hepatitis C
Hepatitis D

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7
Q

Which type of hepatitis is rare and usually associated with immunosuppression?

A

Hepatitis E

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8
Q

What features during an examination would alert you to potential development of hepatotoxicity? (6)

A

-Confusion (due to hepatic encephalopathy)
-Liver asterixis (flapping tremor)
-Yellow skin or sclera (jaundice)
-Bruising of skin/bleeding of gums or anywhere else (due to clotting derangement)
-Tenderness in right upper quadrant (due to liver inflammation)
-Hepatomegaly

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9
Q

What are the non-specific symptoms of paracetamol overdose? (2)

A

Nausea/vomiting
Abdominal pain

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10
Q

What signs and symptoms of paracetamol overdose are especially concerning? (4)

A

-Acute confusion (encephalopathy)
-Reduced urine output
-Hypoglycaemia
-Reduced consciousness (GCS)

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11
Q

What medication is given in paracetamol overdose?

A

N-Acetylcysteine - works by acting as a glutathione donor, preventing toxic build up of NAPQI.

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12
Q

How can paracetamol cause liver damage?

A

There are two potential mechanisms of paracetamol metabolism - either higher doses, more of the metabolic reaction is pushed to the second pathway, leading to increased metabolite production. Normally, glutathione deals with this metabolite, but when glutathione stores are depleted, another pathway is generated, which can lead to hepatotoxicity and cell death.

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13
Q

What plasma-paracetamol concentration should be regarded as carrying serious risk of liver damage?

A

Concentrations above the treatment line at the point on the x-axis corresponding to time in hours after ingestion; starting from 100mg/litre and above at 4 hours after ingestion.

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14
Q

What are the four enzyme components of a liver function test?

A

ALT
AST
ALP
GGT

[These enzymes are found normally inside liver cells, but can leak out into blood following liver or biliary injury.]

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15
Q

What are the two non-enzyme components of a liver function test?

A

Albumin
Bilirubin

[These are substances produced or processed/excreted by the liver.]

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16
Q

What are the enzyme components of a liver function test a useful indicator of?

A

The extent and mode of liver injury.

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17
Q

What are the non-enzyme components of a liver function test a useful indicator of?

A

The level of liver function/dysfunction.

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18
Q

What are the main indicators for liver function tests? (3)

A

Diagnosis and monitoring of liver disease
Routine part of recommended monitoring for several forms of medication
As part of routine assessment of acutely presenting patients

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19
Q

What are alanine aminotransferase (ALT) and aspartate aminotransferase (AST)?

A

Enzymes found in hepatocytes and released in large amounts when there is hepatic parenchymal damage; they are also found in the heart, skeletal muscles and blood cells and so may increase after myocardial infarction, rhabdomyolysis and haemolysis.

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20
Q

What is alkaline phosphatase (ALP)?

A

An enzyme found in large amounts in the biliary cells of the liver, as well as bone and placenta. Rises physiologically during periods of growth and pregnancy.

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21
Q

What is γ-glutamyltransferase (GGT)?

A

An enzyme present in the liver, renal tubules, pancreas and intestine; levels in the blood can be raised by biliary disease and by enzyme induction (i.e in prolonged exposure to alcohol and to some drugs).

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22
Q

What is albumin?

A

The predominant serum protein, produced largely by the liver.

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23
Q

What amount of paracetamol ingestion puts a patient at serious risk of toxicity?

A

More than 150mg/kg of paracetamol in any 24 hour period.

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24
Q

What is therapeutic excess?

A

The ingestion of a potentially toxic dose of paracetamol with the intent to treat pain or fever and without self harm intent during its clinical use.

25
Q

What is meant by the term ‘staggered overdose’?

A

Ingestion of a potentially toxic dose of paracetamol over more than one hour, with the possible intention of causing self harm.

26
Q

When does paracetamol toxicity normally peak?

A

48 to 72 hours after ingestion.

27
Q

What are the King’s College Criteria for liver transplant in paracetamol induced acute liver failure? (2)

A

-Arterial pH <7.3 or arterial lactate >3.0 after adequate fluid resuscitation
OR
-All three of following occur within 24 hour period:
Creatinine >300micromol/litre
PT>100 seconds (INR>6.5)
Grade III/IV encephalopathy

28
Q

Why should glucose levels be tested in cases of paracetamol overdose?

A

Hypoglycaemia is common in hepatic necrosis.

29
Q

When should serum paracetamol levels be taken in cases of paracetamol overdose? (3)

A

-4 hours post ingestion
-ASAP if dose is staggered
-ASAP if dose taken more than 4 hours ago

30
Q

Define acute liver failure.

A

Liver injury with the presence of hepatic encephalopathy in a patient without related pre-existing liver disease.

31
Q

What are five potential causes of acute liver failure?

A

-Paracetamol overdose
-Severe acute viral hepatitis
-Acute vascular injury to the liver (especially Budd Chiari syndrome)
-Autoimmune hepatitis
-Direct exposure to toxins

32
Q

What can ALT:AST ratio help assess?

A

Presence of liver fibrosis.

33
Q

What may raised serum alkaline phosphatase (ALP) suggest? (2)

A

-Biliary obstruction
-Bony disease (such as Paget’s disease, fractures or metastatic disease)

34
Q

How can you distinguish between bony and biliary causes of raised serum alkaline phosphatase (ALP)? (2)

A

-Clinical context
-GGT levels (raised in biliary disease but NOT in bony disease)

35
Q

When can serum albumin levels be low? (4)

A

-In poor underlying liver synthetic function in the medically stable patient
-Acute illness (may be precipitous), particularly sepsis
-Extreme malnutrition
-Cases of protein loss from kidneys or bowels

36
Q

What may raised bilirubin levels indicate? (3)

A

-Increased cell breakdown (pre-hepatic jaundice)
-Reduced liver function (hepatic jaundice)
-Biliary obstruction (post-hepatic jaundice)

37
Q

What is Gilbert’s Syndrome?

A

A genetic condition seen in 5% of the population in which an individual has low levels of conjugating enzymes, which causes raised unconjugated bilirubin levels in the presence of otherwise normal LFTs.

38
Q

What are the most common causes of an inflammatory liver process causing an isolated raised ALT level? (4)

A

-Fatty liver related to alcohol
-Viral infection
-Non-alcohol related fatty liver (usually associated with metabolic syndrome)
-Autoimmune liver disease

39
Q

How can units of alcohol consumption be calculated?

A

Units of alcohol = [strength of alcohol (ABV) x volume (ml)] / 1000

40
Q

What MCV may suggest underlying liver cirrhosis?

A

A mildly raised MCV

41
Q

What MCV may be suggestive of hazardous alcohol consumption?

A

A very high MCV, greater than 110fl.

42
Q

When are ALT, ALP and GGT raised respectively?

A

ALT —> typically raised in conditions that damage hepatocytes
ALP and GGT —> tend to be elevated due to conditions that cause cholestasis or cholangitis.

43
Q

When is a liver biopsy indicated? (2)

A

In acute illness where the cause of LFT abnormalities isn’t clear (i.e liver screen is normal) or where there is a need to confirm severity of liver disease.

44
Q

What is fulminant hepatitis?

A

A rare syndrome of rapid (within days or weeks) massive necrosis of the liver, leading to acute liver failure.

45
Q

What symptoms are indicative of acute hepatitis? (3)

A

Feeling generally unwell
Right upper quadrant ache
In severe cases: confusion and drowsiness

46
Q

What signs are indicative of acute hepatitis? (4)

A

Jaundice
Stool/urine discolouration
In severe cases: hypoglycaemia and coagulopathy

47
Q

What signs and symptoms classically indicate fulminant hepatitis?

A

Development of hepatic encephalopathy within 28 days of jaundice (liver failure) in people without previous liver disease.

48
Q

How can liver cirrhosis cause pathology? (2)

A

-Loss of liver function (leading to jaundice, coagulopathy, decreased drug and hormone metabolism, increased susceptibility to infection and sepsis)
-Portal hypertension (may be associated with varices, piles, ascites, encephalopathy and renal failure)

49
Q

What is haemochromatosis?

A

An autosomal recessive genetic condition affecting the HFE gene which causes deficiency of the iron-regulatory hormone hepcidin, resulting in accumulation of iron in tissues.

50
Q

What is the mainstay of treatment for haemochromatosis?

A

Phlebotomy to lower iron levels in the blood.

51
Q

What are the early symptoms of haemochromatosis? (6)

A

-Fatigue
-Weakness
-Arthropathy (joint disease)
-Abdominal pain
-Erectile dysfunction
-Cardiac issues (arrhythmia or cardiomyopathy)

52
Q

What are the late symptoms of haemochromatosis? (3)

A

-Bronzing of skin
-Hepatomegaly/cirrhosis of the liver
-Mood/memory disturbance

53
Q

What is Wilson’s Disease?

A

An autosomal recessive genetic disorder of copper metabolism, causing accumulation and toxicity in the liver.

54
Q

What blood test can indicate Wilson’s Disease?

A

Low serum caeruloplasmin

55
Q

How is Wilson’s Disease managed?

A

Copper chelation agents to remove copper from the body

56
Q

What serum virology results would indicate a past infection of hepatitis B?

A

IgG Hep B core antibody positive
Hep B surface antigen negative

57
Q

How can IgM hep B core antibody distinguish between acute and chronic infection?

A

High levels of IgM hep B core antibody = acute
Low levels of IgM hep B core antibody = chronic

58
Q

What does positive Hep B surface antigen indicate?

A

Either active hep B infection OR a recent vaccination against hep B

59
Q

When is positive Hep B envelope antigen seen?

A

During the acute phase of hepatitis B infection, when the virus is replicating quickly.

(The higher the Hep B E antigen, the more infective the patient is at that time.)

TCD Metabolic (2 decks)

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