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Alimentary system > Jaundice and chronic liver disease > Flashcards

Jaundice and chronic liver disease Flashcards

1
Q

What are the functions of the liver?

A
  • Synthesis
  • Detoxification
  • Immune function
  • Storage
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2
Q

What are the synthetic functions of the liver?

A

Clotting factors
Bile acids
Carbohydrates - Gluconeogenesis, Glycogenolysis, Glycogenesis
Proteins - Albumin synthesis
Lipids - Cholesterol synthesis, Lipoprotein and TG synthesis
Hormones - Angiotensinogen, insulin like growth factor

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3
Q

What does the liver detoxify?

A
  • Urea production from ammonia
  • Detoxification of drugs
  • Bilirubin metabolism
  • Breakdown of insulin and hormones
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4
Q

What is stored in the liver?

A
  • Stores glycogen
  • Stores Vitamin A, D, B12 and K
  • Stores copper and iron
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5
Q

What do liver functions test assess?

A
  • Bilirubin
  • Aminotransferases e.g. AST/ALT
  • Alkaline phosphatase
  • Gamma GT
  • Albumin
  • Prothrombin time
  • Creatinine
  • Platelet count
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6
Q

What is bilirubin?

A

Breakdown product of haemoglobin

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7
Q

What are the 3 types of jaundice?

A
  • Pre-hepatic: Haemolysis
  • Hepatic: Parenchymal damage
  • Post hepatic: Obstructive
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8
Q

What are the clinical significances of aminotransferases in LFTs?

A
  • Enzymes present in hepatocytes – biomarkers of liver damage
  • Aspartate transaminase (AST)
  • Alanine transaminase (ALT)
  • ALT more specific than AST
  • AST/ALT ratio can point towards ALD
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9
Q

Name two clinically important aminotransferases

A
  • Aspartate transaminase (AST)

* Alanine transaminase (ALT)

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10
Q

What enzyme is elevated in obstruction or liver infiltration?

A

Alkaline phosphatase, normally found in bile duct, bone, placenta and intestines

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11
Q

What enzyme is elevated following excessive alcohol intake or NSAID use?

A

gamma-glutamyl transferase

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12
Q

What causes increased gamma GT?

A

Excessive alcohol

NSAIDs

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13
Q

Why is albumin checked in LFTs?

A

Important test for synthetic function of liver

Low levels suggest chronic liver disease

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14
Q

Why is creatine checked in LFTs if its a kidney enzyme?

A
  • Essentially kidney function
  • Determines survival from liver disease
  • Critical assessment for need for transplant
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15
Q

What is the effect on platelet counts in those with splenomegaly/cirrhosis?

A

Platelet levels decreased, indirect marker of portal hypertension

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16
Q

What does low platelet count act as a indirect marker of?

A

Portal hypertension

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17
Q

What are signs of liver disease/liver failure?

A
  • Jaundice
  • Ascites
  • Variceal bleeding
  • Hepatic encephalopathy
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18
Q

What are normal blood levels of bilirubin?

A

Total bilirubin: 0.1 to 1.2 mg/dL (1.71 to 20.5 µmol/L)

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19
Q

What level of bilirubin in the blood indicates jaundice?

A

Detectable when total plasma bilirubin levels exceed 34 µmol/L

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20
Q

What can be confused with jaundice?

A

Carotenaemia

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21
Q

What causes pre-hepatic jaundice?

A

o Increased quantity of bilirubin (Haemolysis)

o Impaired transport

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22
Q

What causes hepatic jaundice?

A

o Defective uptake of bilirubin
o Defective conjugation
o Defective excretion

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23
Q

What causes post-hepatic jaundice?

A

o Defective transport of bilirubin by the biliary ducts

24
Q

What are some clinical signs associated with pre-hepatic jaundice that can be obtained from history?

A

History of anaemia (fatigue, dyspnoea, chest pain)

Acholuric jaundice

25
Q

What are some clinical signs associated with hepatic jaundice that can be obtained from history?

A

Risk factors for liver disease (IVDU, drug intake)

Decompensation (ascites, variceal bleed,encephalopathy)

26
Q

What are some clinical signs associated with post-hepatic jaundice that can be obtained from history?

A

Abdominal pain

Cholestasis (Pruritus, pale stools, high coloured urine)

27
Q

What are some clinical signs associated with pre-hepatic jaundice that can be obtained from examination?

A

Pallor

Splenomegaly

28
Q

What are some clinical signs associated with hepatic jaundice that can be obtained from examination?

A

Stigmata of CLD (spider naevi, gynaecomastia)
Ascites
Asterixis (flapping tremor)

29
Q

What are some clinical signs associated with post-hepatic jaundice that can be obtained from examination?

A

Palpable gall bladder (Courvoisier’s sign)

30
Q

What does ERCP stand for?

A

Endoscopic retrograde cholangiopancreatography (ERCP)

31
Q

What is ERCP?

A

Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that combines the use of endoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or pancreatic ductal systems. Through the endoscope, the physician can see the inside of the stomach and duodenum, and inject a contrast medium into the ducts in the biliary tree and pancreas so they can be seen on radiographs.

32
Q

What is MRCP?

A

Magnetic resonance cholangiopancreatography (MRCP) is a medical imaging technique that uses magnetic resonance imaging to visualize the biliary and pancreatic ducts in a non-invasive manner. This procedure can be used to determine if gallstones are lodged in any of the ducts surrounding the gallbladder

33
Q

What is a papilla?

A

Papillas are small rounded protuberances in the bosy, like a nipple, with some examples being the major and mino duodenal papillas, which allow the emptying of bile into the duodenum

34
Q

What is the other term for common bile duct obstruction?

A

Choledocholithiasis

35
Q

How is choledocholithiasis treated?

A

cholecystectomy
ERCP
sphincterotomy

36
Q

What are some complications of ERCP?

A 
Sedation related - Respiratory, Cardiovascular
Procedure related
-	Pancreatitis
-	Cholangitis
-	Sphincterotomy: bleeding, perforation
37
Q

What are some mechanisms of imaging used for identifying diseases of the biliary tract?

A

Magnetic resonance cholangiopancreatography (MRCP)
Endoscopic retrograde cholangiopancreatography (ERCP)
Percutaneous transhepatic cholangiography (PTC)

38
Q

List some chronic liver diseases

A
  • Chronic hepatitis
  • Chronic cholestasis
  • Fibrosis and Cirrhosis
  • Others e.g. steatosis
  • Liver tumours
39
Q

What can cause cirrhosis?

A
  • Alcohol
  • Autoimmune – autoimmmune hepatitis, PBC (Primary Biliary cholangitis), PSC (Primary Sclerosing Cholangitis)
  • Haemochromatosis
  • Chronic Viral hepatitis: B & C
  • Non-alcoholic fatty liver disease (NAFLD)
  • Drugs (MTX, amiodarone)
  • Cystic fibrosis, a1antitryptin deficiency, Wilsons disease,
  • Vascular problems (Portal hypertension + liver disease)
  • Cryptogenic
  • Others: sarcoidosis, amyloid, schistosomiasis
40
Q

How can people present with cirrhosis?

A 
Abnormal LFTs on screening tests
Ascites
Variceal bleeding
Hepatic encephalopathy
Hepatocellular carcinoma
41
Q

How much fluid theoretically would be in the peritoneal cavity to be classified as ascites?

A

> 25ml

42
Q

How much fluid is required to be in the peritoneal cavity to allow ultrasound to confirm the presence of ascites?

A

> 100ml

43
Q

Shifting dullness is caused by how much fluid in the peritoneal cavity?

A

1500ml

44
Q

What are some clinical signs associated with ascites?

A 
Spiders naevi
Palmar erythema
Abdominal veins
Fetor hepaticus
Umbilical nodule
JVP elevation
Flank haematoma
45
Q

How can we tell is ascites is caused by portal hypertension or not?

A
  • > 1.1g/dl portal hypertension related (97% accuracy)
  • < 1.1g/dl non-portal hypertension causes (97% acc)

Protein & albumin concentration

46
Q

What is used to find the cause of ascites?

A

The serum-ascites albumin gradient or gap (SAAG) is a calculation used in medicine to help determine the cause of ascites

SAAG = (serum albumin) − (albumin level of ascitic fluid)

47
Q

What are some treatment options for ascites?

A
  • Diuretics
  • Large volume paracentesis
  • TIPS (transjugular intrahepatic portosystemic shunt)
  • Aquaretics - class of drug that is used to promote aquaresis, the excretion of water without electrolyte loss
  • Liver transplantation
48
Q

At which porto-systemic anastomoses can varices develop?

A
  • Skin – Caput medusa
  • Oesophageal & Gastric
  • Rectal
  • Posterior abdominal wall
  • Stomal
49
Q

How do you treat vatical haemorrhages?

A
  • Resuscitate patient
  • Good IV access
  • Blood transfusion as required
  • Emergency endoscopy
  • Endoscopic band ligation
  • Add Terlipressin for control of blood pressure
  • Sengstaken-Blakemore tube for uncontrolled bleeding
  • TIPSS for rebleeding after banding
50
Q

What is hepatic encephalopathy?

A
  • A neuropsychiatric condition developing as a consequence of liver disease, which develops within 2 weeks of a patient with a normal liver, or in patients with an acute exacerbation of underlying liver disease
  • Confusion due to liver disease
  • Graded 1-4
  • Grade 4 –emeergency liver transplant
51
Q

What can cause hepatic encephalopathy?

A 
GI bleed
Infection
Constipation
Dehydration
Medication esp. sedation
52
Q

What clinical signs are seen in those with hepatic encephalopathy?

A

Asterixis (flapping tremor)

Foetor hepaticus

53
Q

How do you treat hepatic encephalopathy?

A

Treat underlying cause:

  • constipation: laxatives
  • infection: antibiotics
  • GI bleed: as varices
  • dehydration: rehydration therapy, IV fluids
  • medication: removal
54
Q

What infections are linked to hepatocarcinoma?

A

Hepatitis B and C

55
Q

What are some biomarkers for hepatocarcinoma?

A

AFP (alpha feto-protein)

56
Q

How can we deliver chemotherapy locally to hepatocarcinoma?

A

TACE (Transcatheter arterial chemo-embolization)

57
Q

What are some local ablative treatments for hepatocarcinoma?

A
  • Alcohol injection

* Radiofrequency ablation

Alimentary system (32 decks)

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