Jaundice and chronic liver disease Flashcards
What are the synthetic functions of the liver? Try and give some examples
clotting factors carbohydrates bile acids proteins - albumin lipids - cholesterol hormones - angiotensin, thrombopoetin
What are the detoxification functions of the liver?
drugs, urea from ammonium, insulin and hormone breakdown and bilirubin metabolism
What are the immune functions of the liver?
combat infection, neutralise and destroy toxins and clear the blood of bacteria
What substances does the liver store?
clotting factors, glycogen, iron and copper, vitamins eg B12, K, A, D
What is bilirubin initially bound to?
albumin
What 3 ways can bilirubin be elevated?
pre-hepatic - haemolysis
hepatic - parenchymal damage
post hepatic - obstructive eg bile ducts, duodeunum
Where are aminotransferase enzymes present?
in hepatocytes
Is ALT or AST ore specific?
ALT
What can a AST/ALT ratio give an indication of?
alcoholic liver disease
parenchymal involvement and damage
Where is alkaline phosphatase found?
bile ducts
What is alkaline phosphatase raised with?
obstruction or liver infiltration
Where is alkaline phosphatase also present and give an example of when it may be raised without bile duct involvement
placenta, bone marrow and intestines
pregnancy
What is Gamma GT? What is it raised with?
non specific enzyme used in conjunction with alkaline phosphatase to confirm liver involvement
alcohol and drug use eg NSAIDS
What is albumin an important test for?
synthetic function as produced by the liver
What can low levels of albumin suggest?
chronic liver disease, malnutrition and kidney disorders
What prothrombin time measure?
time taken for the blood to clot - tells of liver dysfunction and clotting factors
What is prothrombin time used for?
to calculate a score to decide the stage of liver disease and transplantation lists
What is creatine test important for?
determining survival from liver disease and critical for transplantation assessment
Why does cirrhosis lead to splenomegaly?
due to portal hypertension and the spleen chewing up the platelets
What are the 4 main symptoms of liver dysfunction?
jaundice, ascites, variceal bleeding and hepatic encephalopathy
What is jaundice?
Yellowing of the skin, tissues and SCLERAE due to excess circulating bilirubin
What plasma level is jaundice detectable at?
> 34 micromol/L
What is the differential diagnosis for jaundice and what is the key difference between them?
carotenemia
no yellowing of the sclerae
What are pre hepatic causes of jaundice?
increased bilirubin and impaired transport
What are hepatic causes of jaundice?
defective bilirubin uptake, conjugation and excretion
What are post hepatic causes of jaundice?
defective bilirubin transport by biliary ducts
What are the symptoms and signs of pre hepatic jaundice?
history of anaemia eg fatigue, dyspnoea, chest pain
acholuric jaundice - excessive unconjugated bilirubin
pallor, splenomegaly
What are the symptoms and signs of hepatic jaundice?
risk factors of liver disease (IVDU)
decompensation - ascites, encephalopathy and variceal bleeding
CLD signs - spider naevi, gynaecomastia
ascites and asterixis
What is asterixis?
flapping tremor
What are the symptoms and signs of post hepatic jaundice?
abdominal pain eg gallstones
cholestasis, pale stool, pruirits, high colour urine
palpable gallbladder - malignancy
What is a liver screen?
hepatitis B and C serology, serum immunoglobulins, ferritin, fasting glucose etc
What can an ultrasound look for and confirm in a patient with jaundice?
extra or intra hepatic
location and cause of obstruction
portal hypertension, stage disease
What is the differences between ERCP and MRCP?
ERCP can take biopsy and stent but uses sedation and radiation and dyes. only image bile ducts.
MRCP can be claustrophobic
What are some complications of ERCP?
sedation related - CVS, resp
procedure related - pancreatitis, cholangitis and with sphincterotomy can lead to bleeding and perforation
When is PTC used?
when ERCP not possible due to previous surgery or duodenal obstruction
hilar stenting
What are the disadvantages of PTC?
Invasive and risk liver bleed due to puncturing
What is possible to do with an EUS?
biopsy, aspirate, stage tumours of pancreas
What are some chronic liver diseases?
chronic hepatitis, tumours, chronic cholestasis, steatosis, fibrosis and cirrhosis
What are some causes of liver cirrhosis?
alcohol, autoimmune, chronic viral hepatitis, NFLD, drugs, CF, unknown and sarcoidosis
What are the 3 autoimmune diseases which cause cirrhosis?
PBC, PSC and autoimmune heaptitis
What are the pathological changes to the liver during cirrhosis?
injury - smaller, fibrosed and scarred
blocks nutrient entry so the pressure rises and blood has to bypass channels
How does compensated cirrhosis present?
usually picked up by a screening test and abnormal LFTs
How does decompensated cirrhosis present?
ascites, variceal bleeding, hepatic encephalopathy
How else can cirrhosis present?
hepatocellular carcinoma
What is the use of ultrasound with ascites?
detect shifting dullness and fluid
What clinical signs are important to look for with ascites?
spider naevi, gynaecomastia, palmar erythema and abdominal veins
What is fetor hepaticus?
characteristic breath smell, foul in portal hypertension
What can ascites do to JVP?
Raise
What test MUST be done on any patient presenting with ascites?
diagnostic paracentesis
What does diagnostic paracentesis look for?
protein and albumin, cell count, SAAG
What can SAAG tell us?
check if it is related liver (>1.1g)
How is ascites treated?
diuretics, large volume aspiration and TIPs
What are varices?
Due to portal hypertension at porto-systemic anastomoses - enlarged veins
Where can varices be found?
skin, oesophagus, rectal, stomal and posterior abdominal wall
What are the management options for varices?
resuscitate patient, blood transfusion and emergency endoscopy
band ligation by endoscope
What is hepatic encephalopathy?
Confusion due to liver disease
What is the cause of hepatic encephalopathy?
metabolites to the brain and cross the blood brain barrier as they are not being metabolised in the liver
What clinical conditions are common to be found in someone with hepatic encephalopathy?
GI bleed, infection, dehydration
What are the clinical signs of hepatic encephalopathy?
flapping tremor - foetor hepaticus
How is hepatic encephalopathy treated?
broad spectrum antibiotics, fluids, laxatives, transplant
How does someone with hepatocellular carcinoma present?
mass, decompensated liver disease, pain, weight loss, bleeding
How Is hepatocellular carcinoma diagnosed? - marker and scans
AFP
US, CT, MRI
List 4 ways to treat hepatocellular carcinoma
liver resection
chemotherapy
radiofrequency ablation
liver transplantation
