Jaundice and chronic liver disease Flashcards
What are the roles of the liver?
Synthesis
Detoxification
Immune function
Storage funtion
What does the liver synthesise?
Clotting factors Bile acids Carbohydrates Proteins Lipids Hormones
How is the liver involved in detoxification?
Urea production from ammonia
Detoxification of drugs
Bilirubin metabolism
Breakdown of insulin and hormones
What is the immune role of the liver?
Combating infections
Clearing blood pf particles and infections
Neutralising and destroying all drugs and toxicities
What does the liver store?
Glycogen
Vit A, D, B12, K
Copper and iron
What is bilirubin?
Byproduct of ham metabolism generated by old/dying RBCs in the spleen
What is the cycle of bilirubin?
Initially bound to albumin- unconjugated form
Liver then solubilises it to its conjugated form
What can cause elevated bilirubin?
Prehepatic- haemolytic
Hepatic- parenchymal damage
Post hepatic- obstruction
What are aminotransferases?
Enzymes in hepatocytes
Present in parenchyma
What does elevated aminotransferase indicate?
Parenchymal damage
What does a high AST/ALT ratio indicate?
Alcoholic liver disease
What is alkaline phosphatase?
Enzyme of the bile ducts
Not specific to liver
When is alkaline phosphatase raised?
Obstruction of liver infiltration
Where is alkaline phosphatase present?
Liver
Bone
Intestines
Placenta
What is gamma GT?
Non specific liver enzyme
What is gamma GT used for?
To confirm high alkaline ohoshatase levels are due to liver pathology
What is albumin?
Protein produced by liver
What does low albumin indicate?
Chronic liver disease
What does prothrombin time indicate?
Degree of liver damage
What is prothrombin time used to calculate?
Stage of liver disease and priority of transplant patients
What is creatinine used to determine?
Kidney function and survival odds from liver disease
When is the platelet count low?
In cirrhotic patients as a result of hypersplenism
Indirect marker of portal hypertension
What is jaundice?
Yellowing of skin, sclerae and other tissues due to excess circulating bilirubin
What are the 3 forms of jaundice?
Pre hepatic
Hepatic
Post hepatic
What are the causes of pre hepatic jaundice?
Increased bilirubin from haemolytic
Impaired transport to liver
Want are the hepatic causes of jaundice?
Defective uptake of bilirubin- defective conjugation or secretion
What is the post hepatic cause of jaundice?
Defective transport by biliary system
What is the presentation of pre hepatic jaundice?
History of anaemia
Pallor
Splenomegaly
Acholuric jaundice
What is choleric jaundice?
Jaundice caused by excess circulating unconjugated bilirubin
What is the presentation of hepatic jaundice?
Risk factors for liver disease Decompensation Ascites Asterixis Spider navel Gynacomastia
What is the presentation of post hepatic jaundice?
Abdo pain Pruritus Pale stools High coloured urine Palpable gallbladder
What investigations are done for jaundice?
Liver screen
Ultrasound
MRCP
What tests are done in a liver screen for jaundice?
Hep B and C serology Autoantibody profile, serum Its Caeruloplasmin and copper Ferritin and transferrin Alpha1 antitrypsin Fasting glucose and liver profile
What is the purpose of doing an ultrasound for jaundice?
Can see site and cause of obstruction
Cheap, safe and noninvasive
How is jaundice treated?
Via ECRP
What can ECRP treat?
Dilated biliary tree
Acute gallstone pancreatitis
Post op biliary complications
Biliary tract obstruction
How is acute gallstone pancreatitis treated?
Removal via sphincetrectomy or breakdown of stones via ECRP
How is biliary tract obstruction treated?
Stenting
What is chronic liver disease?
Liver disease persisting for over 6 months
What are some examples of chronic liver disease?
Chronic hepatitis Chronic cholestasis Fibrosis and cirrhosis Liver tumours Others...
What is cirrhosis?
Advanced fibrosis replaces functional parenchyma and prevents movement of blood into and out of the liver
What is the presentation of compensated chronic liver disease?
Abnormality of LFTs
What is the presentation of decompensated chronic liver disease?
Ascites
Variceal bleeding
Hepatic encephalopathy
What is hepatic encephalopathy?
Confusion brought on by liver disease
What causes hepatic encephalopathy?
GI bleeds Infecton Constipation Dehydration Medication
What is the presentation of hepatic encephalopathy?
Confusion
Flapping tremor
Foetor hepaticas (bad breath)
What is the treatment of hepatic encephalopathy?
Treat underlying cause
Repeat admissions- indication for liver transplant
What is hepatocellular carcinoma associated with?
Chronic Hep B and C
cirrhosis
How is hepatocellular carcinoma diagnosed?
Tumour marker tests in those with cirrhosis Ultrasound CT MRI Liver biopsy in rare cases
What is the curative treatment for hepatocellilar carcinoma?
Hepatic resection
Transplant
What are the palliative treatments for hepatocellualr carcinoma?
Chemo
Local ablative treatments- alcohol injection, radio frequency ablation
Sorafenib
Hormonal therapy
What is ascites?
Accumulation of fluid in peritoneal cavity
What is found on a physical exam with ascites?
Dullness in flanks and shifting dullness
What is the presentation of ascites?
Spider navel, palmar erythema, abdomen veins, fetter hepaticas
Umbilical nodule
JVP elevation
Flank haematoma
What investigations are carried out for ascites?
Protein and albumin concentration of fluid
Cell count of fluid
Serum ascites albumin gradient
How is ascites treated?
Diuretic
Large volume paracentesis
Liver transplant in serious cases
What are varices?
Abnormally dilated vessel with tortuous course
What is the cause of varices?
Portal hypertension
How are varices treated?
Resusitation- possible blood transfusions
Endoscopic ban ligation
Control bleeding
Where do you get varices?
Oesophagus
Stomach
Rectum
Umbilicus
