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Systems: Alimentary AB > Jaundice and Chronic Liver Disease > Flashcards

Jaundice and Chronic Liver Disease Flashcards

1
Q

What does the liver synthesise?

A
  • Clotting factors
  • Bile acids
  • Carbohydrates
  • Proteins
  • Lipids
  • Hormones
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2
Q

What relating to carbohydrates takes place in the liver?

A
  • Gluconeogenesis
  • Glycogenolysis
  • Glycogenesis
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3
Q

What protein is synthesised in the liver?

A

Albumin

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4
Q

What lipids are synthesised in the liver?

A
  • Cholesterol
  • Lipoproteins
  • TG
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5
Q

What hormones are synthesised in the liver?

A
  • Angiotensinogen

- Insulin like growth factor

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6
Q

What are the detoxification functions of the liver?

A
  • Urea production
  • Detoxification of drugs
  • Bilirubin metabolism
  • Breakdown of insulin and hormones
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7
Q

What is the immune function of the liver?

A
  • Combating infections
  • Clearing the blood of particles and infections including bacteria
  • Neutralising and destroying all drugs and toxins
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8
Q

What is the storage function of the liver?

A
  • Stores glycogen
  • Stores vitamin A, D,B12, K
  • Stores copper and iron
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9
Q

What is bilirubin a by product of?

A

Haeme metabolism

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10
Q

What generates bilirubin?

A

Senescent RBCs in the spleen

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11
Q

Describe the conjugation of bilirubin.

A
  • Unconjugated: initially bound to albumin

- Conjugated: liver helps to solubilise it

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12
Q

What can cause pre-hepatic elevate bilirubin?

A

Haemolysis

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13
Q

What can cause hepatic elevated bilirubin?

A

Parenchymal damage

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14
Q

What can cause post hepatic elevated bilirubin?

A

Obstruction

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15
Q

What are aminotranferases?

A

Enzymes present in hepatocytes

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16
Q

Which aminotransferase is more specific?

A

ALT

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17
Q

What can the AST/ALT ratio point towards?

A

ALD

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18
Q

What can the ST/ALT ration point towards?

A

Parenchymal involvement

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19
Q

What is alkaline phosphatase?

A

Enzyme present in bile ducts

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20
Q

What may elevated alkaline phosphatase suggest?

A
  • Obstruction

- Liver infiltration

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21
Q

Other than the bile ducts, where is alkaline phosphatase also present?

A
  • Bone
  • Placenta
  • Intestines
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22
Q

What is gamma GT?

A

Non-specific liver enzyme

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23
Q

When is gamma GT elevated?

A

Alcohol use

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24
Q

What is gamma GT useful for?

A

Confirm liver source of ALP

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25
Q

What can elevate gamma CT other than alcohol?

A

Drugs like NSAIDs

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26
Q

What is albumin an important test for?

A

Synthetic function of the liver

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27
Q

What can low levels of albumin suggest?

A
  • Chronic liver disease
  • Kidney disorders
  • Malnutrition
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28
Q

What is an extremely important test for liver function?

A

Prothrombin time

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29
Q

What does the prothrombin time indicate?

A

Degree of liver dysfunction

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30
Q

What is prothrombin time used to calculate?

A

Scores to decide stage of liver disease, who needs a liver transplant and who gets a liver transplant

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31
Q

What is creatinine essentially?

A

Kidney function

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32
Q

What does creatinine determine?

A

Survival from liver disease

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33
Q

What is creatinine testing essential in?

A

Critical assessment for need for transplant

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34
Q

What is an important source of thrombopoietin?

A

Liver

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35
Q

What can splenomegaly be a result of?

A

Cirrhosis

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36
Q

Why are platelets low in cirrhotic subjects?

A

As a result of hypersplenism

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37
Q

What is the platelet count an indirect marker of?

A

Portal hypertension

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38
Q

What are 4 symptoms of liver failure?

A
  • Jaundice
  • Ascites
  • Variceal bleeding
  • Hepatic encephalopathy
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39
Q

Jaundice

A

Yellowing of the skin sclerae and other tissues caused by excess circulating bilirubin

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40
Q

When is jaundice detectable?

A

When total plasma bilirubin levels exceed 34umol/l

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41
Q

What is the differential diagnosis for jaundice?

A

Carotenemia

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42
Q

Describe the life of bilirubin.

A

-RBC release heme
-Heme acted on by heme oxygenase to form biliverdin
-Biliverdin acted on by biliverdin reductase to form bilirubin
-Bilirubin acted on by UGT to for bilirubin diglucuronide
Bilirubin diglucuronide excreted in stool or enter enterohepatic recirculation

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43
Q

What are the 3 classifications of jaundice?

A
  • Pre hepatic: unconjugated
  • Hepatic: conjugated
  • Post hepatic: conjugated
44
Q

What does human waste look like in pre hepatic jaundice?

A

Normal coloured urine

45
Q

What does human waste look like in hepatic jaundice?

A

-Very yellow urine

46
Q

What does human waste look like in post hepatic jaundice?

A
  • Very yellow urine

- Pale stools

47
Q

What is the pathology behind pre hepatic jaundice?

A
  • Increased quantity of bilirubin (haemolysis)

- Impaired transport

48
Q

What is the pathology behind hepatic jaundice?

A
  • Defective uptake of bilirubin
  • Defective conjugation
  • Defective excretion
49
Q

What is the pathology behind post hepatic jaundice?

A

Defective transport of bilirubin by the biliary ducts

50
Q

What are the clues in the history of patients with pre hepatic jaundice?

A
  • History of anaemia (fatigue, dyspnoea, chest pain)

- Acholuric jaundice

51
Q

What are the clues in the history of patients with hepatic jaundice?

A
  • Risk factors for liver disease (IVDU, drug intake)

- Decompensation (ascites, varieal bleed, encephalopathy)

52
Q

What are the clues in the history of patients with post hepatic jaundice?

A
  • Abdominal pain

- Cholestasis (pruritus, pale stools, high coloured urine)

53
Q

What are the clues on clinical examination of someone with pre hepatic jaundice?

A
  • Pallor

- Splenomegaly

54
Q

What are the clues on clinical examination of hepatic jaundice?

A
  • Stigmata of CLD (spider naevi, gynaecomastia)
  • Ascites
  • Aterixis
55
Q

What are the clues on clinical examination of someone with post hepatic jaundice?

A

Palpable gall bladder (Courvoiser’s sign)

56
Q

What are the investigations carried out for a patient who is jaundiced?

A
  • Liver screen
  • Abdominal ultrasound
  • CT/MRI
  • ERCP
  • MRCP
57
Q

What is included in a liver screen?

A
  • Hepatitis B and C serology
  • Autoantibody profile, serum immunoglobulins
  • Caeruloplasmin and copper
  • Ferritin and transferrin saturation
  • Alpha 1 anti-trypsin
  • Fasting glucose and lipid profile
58
Q

Why is an abdominal ultrasound the most important test?

A
  • Differentiates extrahepatic and intrahepatic obstruction
  • Delineates site of obstruction
  • Delineates cause of obstruction
  • Documents evidence of portal hypertension
  • Preliminary staging of extent of disease e.g cancer spread
59
Q

What are the features of an ultrasound scan?

A
  • Cheap
  • No radiation
  • Portable, widely available
  • Good for gallstones
  • High specificity
  • Lower sensitivity
  • Examines organs as well as biliary system
60
Q

What are the feature of a CT/MRI scan?

A
  • Expensive
  • Radiation (CT only)
  • Requires CT/MRI scanner
  • Better for pancreas
  • High specificity
  • High sensitivity
  • Examines organs and biliary system
61
Q

What are the features of MRCP?

A
  • No radiation
  • No complications
  • 5% claustrophobic
  • Can image outwith the ducts
62
Q

What are the features of ERCP?

A
  • Radiation
  • Sedation
  • Complications
  • Failure
  • Only image ducts
  • Therapeutic option
63
Q

What can therapeutic ERCP be used for?

A
  • Dilated biliary tree with visible stones or tumour
  • Acute gallstone pancreatitis
  • Stenting of biliary tract obstruction
  • Post operative biliary complications
64
Q

What sedation related complications can arise from ERCP?

A
  • Respiratory

- Cardiovascular

65
Q

What procedure related complications can arise from ERCO?

A
  • Pancreatitis
  • Cholangitis
  • Sphincterotomy (bleeding/perforation)
66
Q

When is percutaneous transhepatic cholangiogram used?

A
  • ERCP not possible due to duodenal obstruction or previous surgery
  • Hilar stenting
67
Q

What is a disadvantage of percutaneous transhepatic cholangiogram?

A

More invasive than ERCP

68
Q

What is possible to collect using endoscopic ultrasound?

A

Biopsy

69
Q

What is endoscopic ultrasound used for?

A
  • Characterising pancreatic masses
  • Staging tumours
  • Fine needle aspiration of tumours and cysts
  • Excluding biliary microcalculi
70
Q

Chronic liver disease

A

Liver disease that persist beyond 6 months

71
Q

Give examples of liver diseases which are chronic.

A
  • Chronic hepatitis
  • Chronic cholestasis
  • Fibrosis and cirrhosis
  • Others like steatosis
  • Liver tumours
72
Q

What is the main cause of cirrhosis?

A

Alcohol

73
Q

Other than alcohol, what else can cause cirrhosis?

A
  • Autoimmune
  • Hemochromatosis
  • Chronic viral hepatitis
  • NAFLD
  • Drugs
  • Cystic fibrosis, a1 anti-trypsin deficiency, Wilson’s disease
  • Vascular problems
  • Cryptogenic
  • Other
74
Q

What are the pathological changes which take place with cirrhosis?

A
  • Infiltrating lymphocytes
  • Extracellular matric proteins
  • Apoptotic hepatocytes
  • Activated Kupffer cells
  • Sinusoid lumen with increased resistance to blood flow
75
Q

What is the clinical presentation of cirrhosis?

A
  • Compensated chronic liver disease picked up by screening test or abnormal LFTs
  • Decompensated chronic liver disease presents with ascites, variceal bleeding and hepatic encephalopathy
  • Hepatocellular carcinoma
76
Q

What is found on physical examination of ascite?

A

Dullness in flanks and shifting dullness

77
Q

How can ascites be confirmed?

A

Ultrasound

78
Q

What is the corroborating evidence for ascites?

A
  • Spider naevi
  • Palmar erythema
  • Abdominal veins
  • Fetor hepaticus
  • Umbilical nodule
  • JVP elevation
  • Flank haematoma
79
Q

What should all patients with new onset ascites have?

A

Diagnostic paracentesis

80
Q

What initial investigations are required for ascites?

A
  • Protein and albumin concentration
  • Cell count and differential
  • SAAG
81
Q

What is routinely done as part of ascetic fluid analysis?

A
  • Cell count
  • Protein
  • Albumin
82
Q

What is optionally done as part of ascetic fluid analysis?

A
  • Culture
  • Glucose
  • LDH
  • Amylase
  • Gram stain
83
Q

What can be done but is unusual as part of ascetic fluid analysis?

A
  • TB culture
  • Cytology
  • Triglyceride
  • Bilirubin
84
Q

What is unhelpful in ascetic fluid analysis?

A
  • pH
  • Lactate
  • Cholesterol
  • Fibronectin
  • ADA
  • CEA
85
Q

SAAG

A

Serum ascites albumin gradient

86
Q

What does a SAAG of >1.1g/dl point to?

A
  • Portal hypertension
  • CHF
  • Constrictive pericarditis
  • Budd Chiarri
  • Myxedema
  • Massive liver metastases
87
Q

What does a SAAG of<1.1g/dl point to?

A
  • Malignancy
  • Tuberculosis
  • Chylous ascites
  • Pancreatic
  • Biliary ascites
  • Nephrotic syndrome
  • Serositis
88
Q

What are the treatment options for ascites?

A
  • Diuretics
  • Large volume paracentesis
  • TIPS
  • Aquaretics
  • Liver transplantation
89
Q

What are varices due to?

A

Portal hypertension

90
Q

Where can varices occur?

A
  • Skin
  • Oesophageal and gastric
  • Rectal
  • Posterior abdominal wall
  • Stomal
91
Q

What is the immediate management for varices?

A
  • Resuscitate patient
  • Good IV access
  • Blood transfusion as required
  • emergency endoscopy
92
Q

Why are varices treated as medical emergencies?

A

Prone to rupture

93
Q

How are varices treated?

A
  • Endoscopic band ligation
  • Add Terlipressin for control
  • Sengstaken-Blakemore tube for uncontrolled bleeding
  • TIPSS for rebleeding after banding
94
Q

Hepatic encephalopathy

A

Confusion due to liver disease

95
Q

How is hepatic encephalopathy graded?

A

1-4

96
Q

What are the precipitants fro hepatic encephalopathy?

A
  • GI bleed
  • Infection
  • constipation
  • Dehydration
  • Medication
  • Sedation
97
Q

How is hepatic encephalopathy reversed?

A

Treat underlying cause

98
Q

What is the treatment usually fro hepatic encephalopathy?

A
  • Laxatives (phosphate enemas and lactulose)

- Broad spectrum non absorbed antibiotic such as neomycin or rifaximin

99
Q

What is repeated admissions with hepatic encephalopathy an indicator for?

A

Liver transplant

100
Q

What does hepatocellular carcinoma occur in the background of?

A

Cirrhosis

101
Q

What does hepatocellular carcinoma associated with?

A

Chronic hepatitis B and C

102
Q

What is the presentation of hepatocellular carcinoma?

A
  • Decompensation of liver disease
  • Abdominal mass
  • Abdominal pain
  • Weight loss
  • Bleeding from tumour
103
Q

How is hepatocellular carcinoma diagnosed?

A
  • Tumour markers: AFP
  • Ultrasound
  • CT
  • MRI
  • Liver biopsy (rare)
104
Q

What are the treatment options for hepatocellular carcinoma?

A
  • Hepatic resection
  • Liver transplantation
  • Chemotherapy
  • Locally ablative treatments
  • Sorafenib (tyrosinase kinase inhibitor)
  • Hormonal therapy (tamoxifen)
105
Q

What chemotherapy can be used with hepatocellular carcinoma?

A
  • Locally delivered TACE: trans catheter arterial chemo-embolization
  • Systemic chemotherapy
106
Q

What locally ablative treatments are there for hepatocellular carcinoma?

A
  • Alcohol injection

- Radiofrequency ablation

Systems: Alimentary AB (37 decks)

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