Jaundice and Chronic Liver Disease Flashcards
What are some of the fuctions of the liver?
•Clotting factors
•Bile acids
•Carbohydrates
•Gluconeogenesis, Glycogenolysis, Glycogenesis
•Proteins
•Albumin synthesis,
•Lipids
•Cholesterol synthesis, Lipoprotein and TG synthesis
•Hormones
•Angiotensinogen, insulin like growth factor
What detoxification functions does the liver have?
- Urea production from ammonia
- Detoxification of drugs
- Bilirubin metabolism
- Breakdown of insulin and hormones
What is the immune function of the liver?
- Combating infections
- Clearing the blood of particles and infections, including bacteria
- Neutralizing and destroying all drugs and toxins
What is the storage function of the liver?
Stores glycogen
Stores vitamin A,D, B12 and K
Stores copper and iron
What is measured in liver function tests?
Bilirubin
Aminotransferases
Alkaline phosphatases
Gamma GT
Albumin
Prothrombin time
Creatinine
Platelet count
How is bilirubin formed?
- By product of haeme metabolism
- Generated by senescent RBC’s in spleen
- Initially bound to albumin (unconjugated)
- Liver helps to solubilise it (conjugated)
What can cause elevated bilirubin?
Pre-hepatic (haemolysis)
Hepatic (Cholestasis, intrahepatic bile duct obstruction)
Post hepatic causes (Cholelithiasis, disease of gallbladder, extra hepatic bile duct bostruction)
How can aminotransferases be used to indicate ALD?
(alcoholic liver disease)
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
When is alkaline phosphatase elevated?
•Elevated with obstruction or liver infiltration
Where else is alkaline phosphatase present?
bone, placenta and intestines
What is Gamma GT and when is it elevated?
- Non specific liver enzyme
- Elevated with alcohol use
- Useful to confirm liver source of ALP (alkaline phosphatase)
- Drugs like NSAID’s can raise levels
What do low albumin levels indicate?
- Important test for synthetic function of liver
- Low levels suggest chronic liver disease
- Can be low in kidney disorders and malnutrition
What does prothrombin time tell you?
Prothrombin time tells you how long it takes for blood to clot
- 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
What does creatinine tell you?
Essentially kidney function
Determines the survival from liver disease
Critical assessment for need for transplant
What hormone is produced by the liver and is responsible for stimulating platelet production?
Thrombopoetin
What is the effect of cirrhosis on the spleen?
Splenomegaly
Why do platelets become low in cirrhosis?
Low in cirrhotic subjects as a result of hypersplenism
What is platelet count a measure of?
Indirect marker of portal hypertension
What are the generic symptoms for when the liver stops working?
Jaundice
Ascites
Variceal bleeding
Hepatic encephalopathy
When is jaundice detectable?
When total plasma bilirubin levels exceed 34 micromoles per litre
What are the general causes of pre hepatic jaundice?
Increased quantity of bilirubin (Haemolysis)
Impaired transport
What are the generalised hepatic causes of jaundice?
Defective uptake of bilirubin
Defective conjugation
Defective excretion
What are the generalised causes of post hepatic jaundice?
Defective transport of bilirubin by the biliary ducts
What are the clues on history for pre - hepatic jaundice?
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
What are the clues for hepatic jaundice?
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)
What are clues for post hepatic jaundice?
Abdominal pain
Cholestasis (pruritus, pale stools , high coloured urine)
Clinical examination: Palpable gall bladder
What are investigations for jaundice?
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
Why is ultrasound the most important investigation of the abdomen?
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
What are the key differences between MRCP and ERCP?
What are complications of ERCP?
Sedation related - respiratory
- cardiovascular
Procedure related
•Pancreatitis
•Cholangitis
•Sphincterotomy
- Bleeding
- Perforation
What is PTC?
Percutaneous transhepatic cholangiogram
Contrast solution is injected into the bile duct in the liver, after which x - rays are taken
When is percutaneous transhepatic cholangiogram used?
•ERCP not possible due to
duodenal obstruction
or previous surgery
•Hilar stenting
Disadvantage: more invasive than ERCP
What is Endoscopic ultrasound used for?
- Characterising pancreatic masses
- Staging of tumours
- Fine needle aspirate (FNA) of tumours and cysts
- Excluding biliary microcalculi
What is the definition of chronic liver disease?
- Liver disease that persists beyond 6 months
- Chronic hepatitis
- Chronic cholestasis
- Fibrosis and Cirrhosis
- Others e.g. steatosis
- Liver tumours
What are the causes of cirrhosis?
- 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
What is the clinical presentation of cirrhosis?
•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
What are clinical features of ascites?
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
What investigation is essential when ascites is present?
Paracentesis
•Studies needed on initial evaluation
Protein & albumin concentration
Cell count and differential
SAAG (serum-ascites albumin gradient)
What does SAAG stand for?
Serum albumin vs Ascites albumin
What does an SAAG of over 1.1 indicate?
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
What does SAAG less than 1.1 indicate?
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
What are the treatment options for ascites?
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
What are varices a result of?
Portal hypertension
Where are the porto-systemic anastamoses?
Skin - caput medusa
Oesophageal and gastric
Rectal
Posterior abdominal wall
Stomal
What is the treatment of varices?
- 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
Define hepatic encephalopathy
Confusion due to liver disease
What are the precipitants of Hepatic encephalopathy?
GI bleed, infection, constipation, dehydration, medication especially sedation
What are other signs of hepatic encephalopathy?
Flap and foetot hepaticus
How do you treat hepatic encephalopathy?
By treating the underlying cause
Laxitives
When does hepatocellular carcinoma often occur?
In the background of cirrhosis
In association with chronic hepatitis B and C
What is the presentation of Hepatocellular carcinoma?
Decompensation of liver disease
Abdominal mass
Abdominal pain
Wight loss
Bleeding from the tumour
How is the diagnosis of hepatocellular carcinoma made?
AFP - alpha fetoprotein
Radiological tests:
- Ultrasound
- CT scan
- MRI
Liver biopsy is very rare
What is the treatment for hepatocellular carcinoma?
