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MBChB - Y2 - Systems - Gastrointestinal > Jaundice and Chronic Liver Disease > Flashcards

Jaundice and Chronic Liver Disease Flashcards

1
Q

What are some of the fuctions of the liver?

A

•Clotting factors

•Bile acids

•Carbohydrates

•Gluconeogenesis, Glycogenolysis, Glycogenesis

•Proteins

•Albumin synthesis,

•Lipids

•Cholesterol synthesis, Lipoprotein and TG synthesis

•Hormones

•Angiotensinogen, insulin like growth factor

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2
Q

What detoxification functions does the liver have?

A
  • Urea production from ammonia
  • Detoxification of drugs
  • Bilirubin metabolism
  • Breakdown of insulin and hormones
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3
Q

What is the immune function of the liver?

A
  • Combating infections
  • Clearing the blood of particles and infections, including bacteria
  • Neutralizing and destroying all drugs and toxins
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4
Q

What is the storage function of the liver?

A

Stores glycogen

Stores vitamin A,D, B12 and K

Stores copper and iron

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5
Q

What is measured in liver function tests?

A

Bilirubin

Aminotransferases

Alkaline phosphatases

Gamma GT

Albumin

Prothrombin time

Creatinine

Platelet count

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6
Q

How is bilirubin formed?

A
  • By product of haeme metabolism
  • Generated by senescent RBC’s in spleen
  • Initially bound to albumin (unconjugated)
  • Liver helps to solubilise it (conjugated)
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7
Q

What can cause elevated bilirubin?

A

Pre-hepatic (haemolysis)

Hepatic (Cholestasis, intrahepatic bile duct obstruction)

Post hepatic causes (Cholelithiasis, disease of gallbladder, extra hepatic bile duct bostruction)

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8
Q

How can aminotransferases be used to indicate ALD?

(alcoholic liver disease)

A

AST/ALT ratio if 2:1 can point towards LAD especially if Gamma GT is elevated.

In liver cell injury aspartate transaminase is elevated a little bit and ALT is elevated a lot

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9
Q
A
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10
Q

When is alkaline phosphatase elevated?

A

•Elevated with obstruction or liver infiltration

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11
Q

Where else is alkaline phosphatase present?

A

bone, placenta and intestines

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12
Q

What is Gamma GT and when is it elevated?

A
  • Non specific liver enzyme
  • Elevated with alcohol use
  • Useful to confirm liver source of ALP (alkaline phosphatase)
  • Drugs like NSAID’s can raise levels
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13
Q

What do low albumin levels indicate?

A
  • Important test for synthetic function of liver
  • Low levels suggest chronic liver disease
  • Can be low in kidney disorders and malnutrition
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14
Q

What does prothrombin time tell you?

Prothrombin time tells you how long it takes for blood to clot

A
  • Extremely important test for liver function
  • Tells degree of liver dysfunction
  • Used to calculate scores to decide stage of liver disease, who needs a liver transplant and who gets a liver transplant
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15
Q

What does creatinine tell you?

A

Essentially kidney function

Determines the survival from liver disease

Critical assessment for need for transplant

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16
Q

What hormone is produced by the liver and is responsible for stimulating platelet production?

A

Thrombopoetin

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17
Q

What is the effect of cirrhosis on the spleen?

A

Splenomegaly

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18
Q

Why do platelets become low in cirrhosis?

A

Low in cirrhotic subjects as a result of hypersplenism

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19
Q

What is platelet count a measure of?

A

Indirect marker of portal hypertension

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20
Q

What are the generic symptoms for when the liver stops working?

A

Jaundice

Ascites

Variceal bleeding

Hepatic encephalopathy

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21
Q

When is jaundice detectable?

A

When total plasma bilirubin levels exceed 34 micromoles per litre

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22
Q

What are the general causes of pre hepatic jaundice?

A

Increased quantity of bilirubin (Haemolysis)

Impaired transport

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23
Q

What are the generalised hepatic causes of jaundice?

A

Defective uptake of bilirubin

Defective conjugation

Defective excretion

24
Q

What are the generalised causes of post hepatic jaundice?

A

Defective transport of bilirubin by the biliary ducts

25
Q

What are the clues on history for pre - hepatic jaundice?

A

History of anaemia (fatigue, dyspnoea, chest pain)

Acholuric jaundice (Jaundice in which the circulating blood has excessive amounts of unconjugated bilirubin and no bile pigments)

Medical examination:

Pallor

Splenomegaly

26
Q

What are the clues for hepatic jaundice?

A

Risk factors for liver disease (IVDU, drug intake)

Decompensation (ascites, variceal bleed, encephalopathy)

Medical examination: Stigmata of CLD (spider naevi, gynaecomastia)

Ascites

Asterixis (flapping tremor)

27
Q

What are clues for post hepatic jaundice?

A

Abdominal pain

Cholestasis (pruritus, pale stools , high coloured urine)

Clinical examination: Palpable gall bladder

28
Q

What are investigations for jaundice?

A

Liver screen

  • Hepatitis B & C serology
  • Autoantibody profile, serum immunoglobulins
  • Caeruloplasmin and copper
  • Ferritin and transferrin saturation
  • Alpha 1 anti trypsin
  • Fasting glucose and lipid profile
29
Q

Why is ultrasound the most important investigation of the abdomen?

A

Differentiates extrahepatic and intrahepatic obstruction

Delineates site of obstruction and cause of obstruction

Documents evidence of portal hypertension

Preliminary staging of extent of disease e.g. cancer spread

30
Q

What are the key differences between MRCP and ERCP?

A
31
Q

What are complications of ERCP?

A

Sedation related - respiratory

- cardiovascular

Procedure related

•Pancreatitis

•Cholangitis

•Sphincterotomy

  • Bleeding
  • Perforation
32
Q

What is PTC?

A

Percutaneous transhepatic cholangiogram

Contrast solution is injected into the bile duct in the liver, after which x - rays are taken

33
Q

When is percutaneous transhepatic cholangiogram used?

A

•ERCP not possible due to
duodenal obstruction
or previous surgery

•Hilar stenting

Disadvantage: more invasive than ERCP

34
Q

What is Endoscopic ultrasound used for?

A
  • Characterising pancreatic masses
  • Staging of tumours
  • Fine needle aspirate (FNA) of tumours and cysts
  • Excluding biliary microcalculi
35
Q

What is the definition of chronic liver disease?

A
  • Liver disease that persists beyond 6 months
  • Chronic hepatitis
  • Chronic cholestasis
  • Fibrosis and Cirrhosis
  • Others e.g. steatosis
  • Liver tumours
36
Q

What are the causes of cirrhosis?

A
  • Alcohol
  • Autoimmune – autoimmmune hepatitis, PBC (Primary Biliary cholangitis), PSC (Primary Sclerosing Cholangitis)
  • Haemochromatosis (a hereditary disorder in which iron salts are deposited in the tissues, leading to liver damage, diabetes mellitus, and bronze discoloration of the skin.)
  • Chronic Viral hepatitis: B & C
  • Non-alcoholic fatty liver disease (NAFLD)
  • Drugs (MTX, amiodarone)
  • Cystic fibrosis, a1 antitryptin deficiency, Wilsons disease,
  • Vascular problems (Portal hypertension + liver disease)
  • Cryptogenic
  • Others: sarcoidosis, amyloid, schistosomiasis
37
Q

What is the clinical presentation of cirrhosis?

A

•Compensated chronic liver disease

  • Routinely detected on screening tests
  • Abnormality of liver function tests

•Decompensated chronic liver disease

  • Ascites
  • Variceal bleeding
  • Hepatic encephalopathy

•Hepatocellular carcinoma

38
Q

What are clinical features of ascites?

A

Dullness in flanks and shifting dullness

Can be confirmed by U/S

Corroborating evidence:

Spiders, palmar erythema, abdominal veins, fetor hepaticus

Umbilical nodule

JVP elevation

Flank haematoma

39
Q

What investigation is essential when ascites is present?

A

Paracentesis

•Studies needed on initial evaluation

Protein & albumin concentration

Cell count and differential

SAAG (serum-ascites albumin gradient)

40
Q

What does SAAG stand for?

A

Serum albumin vs Ascites albumin

41
Q

What does an SAAG of over 1.1 indicate?

A

Portal hypertension and suggests a nonperitoneal cause of ascites

(increased hydrostatic pressure within the blood vessels of the hepatic portal system, which in turn forces water into the peritoneal cavity but leaves proteins such as albumin within the vasculature.)

Chronic heart failure

Constrictive pericarditis

Myxederma

Cirrhosis

Portal vein thrombosis

42
Q

What does SAAG less than 1.1 indicate?

A

Indicates nonportal hypertension and suggests a peritoneal cause of ascites. Cause of ascites is not associated with increased portal pressure.

Malignancy

Tuberculosis

Chylous ascites

Pancreatitis

Infections

43
Q

What are the treatment options for ascites?

A

Diuretics

Large volume paracentesis

TIPS (transjugular, intrahepatic, portosystemic shunt)

Aquaretics (An aquaretic is a class of drug that is used to promote aquaresis, the excretion of water without electrolyte loss)

Liver transplantation

44
Q

What are varices a result of?

A

Portal hypertension

45
Q

Where are the porto-systemic anastamoses?

A

Skin - caput medusa

Oesophageal and gastric

Rectal

Posterior abdominal wall

Stomal

46
Q

What is the treatment of varices?

A
  • Resuscitate patient
  • Good IV access
  • Blood transfusion as required
  • Emergency endoscopy
  • Endoscopic band ligation
  • Add Terlipressin for control
  • Sengstaken-Blakemore tube for uncontrolled bleeding
  • TIPSS for rebleeding after banding
47
Q

Define hepatic encephalopathy

A

Confusion due to liver disease

48
Q

What are the precipitants of Hepatic encephalopathy?

A

GI bleed, infection, constipation, dehydration, medication especially sedation

49
Q

What are other signs of hepatic encephalopathy?

A

Flap and foetot hepaticus

50
Q

How do you treat hepatic encephalopathy?

A

By treating the underlying cause

Laxitives

51
Q

When does hepatocellular carcinoma often occur?

A

In the background of cirrhosis

In association with chronic hepatitis B and C

52
Q

What is the presentation of Hepatocellular carcinoma?

A

Decompensation of liver disease

Abdominal mass

Abdominal pain

Wight loss

Bleeding from the tumour

53
Q

How is the diagnosis of hepatocellular carcinoma made?

A

AFP - alpha fetoprotein

Radiological tests:

  • Ultrasound
  • CT scan
  • MRI

Liver biopsy is very rare

54
Q

What is the treatment for hepatocellular carcinoma?

A
55
Q
A

MBChB - Y2 - Systems - Gastrointestinal (38 decks)

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