Jaundice and Chronic Liver Disease Flashcards
What are the production functions of the liver?
Producing: Clotting factors Bile acids Glucose control in blood: Glucagon Cholesterol synthesis Lipoprotein and TG synthesis Production of hormones
Which carbohydrate cycles happen in the liver?
glucogenesis
glycogenesis
What is the production of bile acids essential for?
The digestion of fats
Which hormones does the liver produce?
Angiotensin
Insulin like growth factor
What are the detoxification functions of the liver?
Urea production from ammonia
Detoxification of drugs
Bilirubin metabolism
Breakdown of insulin and other hormones
What are the basic LFTs?
Bilirubin Aminotransferases: ALT and AST Alkaline phosphatase Gamma GT Albumin Prothrombin time Creatinine Platelet count
What is bilirubin a by product of?
Haeme metabolism
Where is heme metabolised?
Spleen
Where is haeme taken to?
To the liver
What does liver do to haeme?
Helps to solubilise it
What is a pre-hepatic cause for elevated bilirubin?
Haemolysis (excess RBC)
What is a hepatic cause for elevated bilirubin?
Liver damage (when the problem is actually in the liver)
What is a post-hepatic reason for elevated bilirubin?
Blockage in the hepatic ducts
Where is aminotransferase present?
In hepatocytes
If there is liver damage what will aminotransferase results show?
Elevation of these enzymes
What are the 2 types of aminotransferases?
AST
ALT
Where is alkaline phosphatase?
Cells lining bile ducts
When is alkaline phosphatase level elevated?
When there is obstruction or liver infiltration
In what other organs is alkaline phosphatase present?
Bone
Placenta
What is Gamma GT?
Non-specific liver enzyme
When is gamma GT elevated?
With alcohol abuse
What drugs can raise gamma GT?
NSAID’s
What albumin an important test for?
Liver function
What do low levels of albumin suggest?
Chronic liver disease
Which LFT is used to determine the stage of liver disease and the qualification for liver transplantation?
Prothrombin time
What is platelet count an indirect marker of?
Portal hypertension
What are the 4 main symptoms for liver failure?
Jaundice
Ascites
Variceal bleeding
Hepatic encephalopathy
What is ascites?
Fluid in the abdomen
What is jaundice as a symtpom?
Yellowing of the skin due excess of circulating bilirubin
What is hepatic encephalopathy?
Confusion due to ammonia crossing the blood brain barrier
At what bilirubin levels is jaundice detectable?
When total plasma bilirubin levels exceed 34 umol/L
What is a differential diagnosis for jaundice?
Carotenemia
Which sign determines that is cannot be anything other than jaundice?
Yellowing of the sclera
What are pre-hepatic clues of jaundice on clinical examination?
Pallor
Splenomegaly
History of anaemia
Alcholuric jaundice
What are hepatic clues of jaundice on clinical examination?
Ascites
Asterixis
Risk factors for liver disease
What are post-hepatic clues of jaundice on clinical examination?
Palpable gall bladder
Abdominal pain
Colestasis
What is the first line investigation for jaundice?
USS
What are the pros of an ultrasound scan?
Cheap No radiation Portable and widely available Good for gallstone viewing Examines organs
What are the cons of CT and MRI scans?
Expensive - MRI
Radiation - CT
Requires a scanner
High specificty
What is ERCP?
Endoscopy procedure that travels to the bottom of the bile duct and injects dye
What are some complications of ERCP?
Pancreatitis
What does physical examination with ascites reveal?
Dullness in flanks
And shifting dullness
What is cirrhosis
Repair of liver damage by scar tissue
What are some causes of cirrhosis?
Alcohol Autoimmnue - PBC, PSC Hameochromatosis Chronic viral hepatitis Non-alcoholic fatty liver disease Drug Cystic fibrosis
Why is an USS very good for ascites?
It is good at detecting small amounts of fluid in the abdomen
What are other signs of chronic liver disease?
Ascites Spider Neiva Palmar erythema Abdominal veins Fetor hepaticus Umbilical nodule JVP elevation Flank haematoma
Is all ascites due to liver disease?
No
What procedure should be given to all patients with new-onset ascites?
Diagnostic paracentesis
What is diagnostic paracentesis?
Where a needle is inserted into the abdomen to gain a sample of fluid in the abdominal cavity
What are the treatments for ascites?
Diuretics
Large volume drainage
Aquaretics
Liver transplantation
What does SAAG stand for?
Serum-ascites albumin gradient
What does SAAG >1.1g/dl suggest?
Portal hypertension
CHF
Constrictive pericarditis
Myxedema Massive liver metastases
What does SAAG <1.1 g/dl suggest?
Malignancy Tuberculosis Pancreatic Biliary ascites Nephrotic syndrome Serositis
What are variceal haemorrhages a consequence of?
Portal hypertension
Where are the porto-systemic anastomoses in the body where variceal haemorrhage can occur?
Oesophagus
Umbilicus
Bare area of the liver
Ano-rectal junction
What is the management of variceal haemorrhages?
Resuscitation Good IV access Blood transfusions as required Emergency endoscopy Band ligation
What is hepatic encephalopathy?
Confusion due to liver disease
What causes HE?
Ammonia crossing the blood brain barrier
How is HE graded?
1-4
How is HE treated?
By treating the underlying cause
What is the commonest cause of HE?
Constipation
What does hepatocellular carcinoma occur in the background of?
Cirrhosis
Chronic HBV and HCV
What is the presentation of hepatocellular carcinoma?
Decompensation of liver disease Abdominal mass Abdominal pain Weight loss Bleeding
How is the diagnosis for hepatocellular carcinoma made?
Alpha fetoprotein USS CT RI Liver biopsy - rarely done
What is the treatmet options for hepatocellular carcinoma?
Hepatic resection Liver transplantation Chemotherapy Locally ablative treatments Sorafenib Hormonal therapy
