Jaundice and Chronic Liver Disease Flashcards
what does the liver synthesise?
> clotting factors >bile acids > carbohydrates > proteins > lipids > hormones
in what way is liver involved in detoxification?
> produces urea from ammonia
detoxifies drugs
metabolises bilirubin
breaks down insulin and hormones
what does the liver store?
> glycogen
vitamin A, D, B12 AND k
copper
iron
what is bilirubin generated by
> senescent RBC’s in spleen
why may bilirubin levels be elevated?
> haemolysis
parenchymal damage
obstruction
what is bilirubin initially bound to?
albumin
what are amino transferases?
enzymes present in hepatocytes
where is alkaline phosphatase present?
> bile ducts
bone
placenta
intestines
with what is alkaline phosphatase elevated?
obstruction or liver infiltration
what can elevate gamma GT levels?
> alcohol use
> NSAID’s
what does albumin test for?
synthetic function of the liver
what do low albumin levels suggest?
> chronic liver disease
kidney disorders
malnutrition
what does prothrombin time test tell you?
the degree of liver dysfunction
what tests are carried out to assess transplant need?
> prothrombin time
creatinine
what is platelet count an indirect marker for?
portal hypertension
why would platelet count by low in cirrhotic patients?
cirrhosis results in splenomegaly and platelet counts are low due to hypersplenism
what are general symptoms of liver failure?
> jaundice
ascites
variceal bleeding
hepatic encephalopathy
define jaundice
yellowing of the skin, sclerae and other tissues due to excess circulating bilirubin
at what total plasma bilirubin level is jaundice detectable?
levels exceeding 34 umol/L
what is the differential diagnosis for jaundice?
carotenemia
what could cause pre-hepatic jaundice?
> Increased quantity of bilirubin (Haemolysis)
> Impaired transport
what are the reasons for hepatic jaundice?
> Defective uptake of bilirubin
Defective conjugation
Defective excretion
what classification of jaundice is caused by defective transport of bilirubin by the biliary ducts?
post hepatic jaundice
what would be the history of prehepatic jaundice?
> anaemia (fatigue, dyspnoea, chest pain)
> acholuric jaundice
what would you expect to find in a history of someone who has hepatic jaundice?
> liver disease risk factors (drugs)
> decompensation (ascites, variceal bleed, encephalopathy)
what would you expect to see in a history of someone with posthepatic jaundice?
> abdominal pain
> cholectasis
what would you see in clinical examination in prehepatic jaundice?
> pallor
> splenomegaly
what would you see in clinical examination in hepatic jaundice?
> spider naevi, gynaecomastia
ascites
asterixis
what sort of jaundice would you feel a palpable gallbladder?
post hepatic jaundice
what investigations would be carried out in jaundice?
> liver screen
> ultrasound of the abdomen
what does a liver screen test?
> hepatitis b and c serology > serum immunoglobulins > copper levels > ferritin and transferritin saturation > alpha antitrypsin > fasting glucose and lipid profile
why is ultrasound of the abdomen the most important test in jaundice?
> differentiates extrahepatic and intrahepatic obstruction
delineates site of obstruction
delineates cause of obstruction
documents evidence of portal hypertension
preliminary staging of disease extent
why would a MRCP be better than a ERCP?
> no radiation
no complication risk
can image outwith the ducts
when is therapeutic ERCP used?
> dilated biliary tree (visible stones, tumour)
acute gallstone pancreatitis
stenting biliary obstruction
post-operative biliary complications
what complications are associated with ERCP?
> pancreatitis
cholangitis
shpincterotomy (bleeding, perforation)
when is percutaneous transhepatic cholangiogram carried out?
for hilar stenting when ERCP is not possible due to duodenal obstruction or previous surgery
what is the disadvantage of using percutaneous transhepatic cholangiogram instead of ERCP?
it is more invasive
what is endoscopic ultrasound used for?
> characterising pancreatic masses
staging tumours
fine needle aspirate of tumours and cysts
excluding biliary microcalculi
define chronic liver disease
liver disease that persists beyond 6 months
name some things that can cause liver cirrhosis
> alcohol > autoimmune disease > haemochromatosis > NAFLD > Drugs > cystic fibrosis > vascular problems
what pathological changes occur in the liver due to cirrhosis?
the injury to the liver causes the sinusoids to become blocked, pressure increases in them and blood cannot flow. bypass channels are created to go around them.
hepatocytes apoptose and fibrosis healing occurs.
how may compensated cirrhosis present?
> abnormality in liver function tests and routinely detected in screening
how may decompensated cirrhosis present?
> ascites
variceal bleeding
hepatic encephalopathy
what are the clinical features of ascites?
> shifting dullness
corroborating evidence (spider neavi, palmar erythema, abdominal veins, fetor hepaticus, umbilical nodule, jvp elevation, flank hematoma)
what should all patients who have new onset ascites have?
diagnostic paracentesis:
> protein and albumin concentration
> cell count
> SAAG serum ascites albumin gradient
in what conditions would SAAG levels be low?
> malignancy
exudative
tuberculosis
what is optional to analyse in ascetic fluid?
> culture > glucose > LD > amylase > gram stain
in what conditions would SAAG levels be high?
> portal hypertension
constrictive pericarditis
mass liver metastasis
what are the treatment options for ascites?
> diuretics > large volume parcentesis > TIPS (shunt) > aquaretics > liver transplantation
what causes varices?
portal hypertension
where are varices found?
at porto-systemic anastomoses: > skin > oesophagus/gastric > rectal > posterior abdominal wall > stomal
what is the management of varices?
> resuscitation > blood transfusion > emergency endoscopy > endoscopic band ligation > sengstaken-blakemore tube for uncontrolled bleeding
what is hepatic encephalopathy?
confusion due to liver disease
how is hepatic encephalopathy graded?
from 1-4
what can hepatic encephalopathy precipitate from?
> GI bleed > infection > constipation > dehydration > sedation (medication)
what are the signs of hepatic encephalopathy?
> confusion
flap tremor
asterixis
foetor hepaticus
how do you manage hepatic encephalopathy?
> treat underlying cause
laxatives
broad spectrum non-absorbed antibiotics: neomycin, rifaximin
repeated admission=transplant
how does hepatocellular carcinoma present?
> abdominal mass > abdominal pain > weight loss > bleeding > decompensation of liver disease
how do you diagnose hepatocellular carcinoma?
> tumour markers: AFP
ultrasound, ct, mri
(liver biopsy rarely done)
what is the treatment for hepatocellular carcinoma?
> hepatic resection > liver transplantation > chemotherapy > local ablative treatment (alcohol injection, radiofrequent ablation) > sorafenib > hormonal therapy ( tamoxifen)
