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Alimentary > Jaundice and chronic liver disease > Flashcards

Jaundice and chronic liver disease Flashcards

1
Q

What is jaundice (what is the differential diagnosis)?

A
  • Yellowing of the skin, sclerae, and other tissues caused by excess circulating bilirubin.
    • Detectable when total plasma bilirubin levels exceed 34 µmol/L
    • Differential diagnosis is carotenemia
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2
Q

What are the causes of cirrhosis?

A
  • Alcohol (90%)
    • Autoimmune: Autoimmune hepatitis, PBC (primary biliary cholangitis), PSC (primary sclerosing cholangitis)
    • Haemochromatosis
    • Chronic viral hepatitis: B and C
    • Non-alcohol fatty liver disease (NAFLD)
    • Drugs (MTX, amiodarone)
    • Cystic fibrosis, α1 antitrypsin, Wilsons disease
    • Vascular problems (portal hypertension +/- liver disease)
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3
Q

What is the presentation of cirrhosis?

A 
- Compensated chronic liver disease
		○ Abnormality of liver function tests
		○ Routinely detected on screening tests
	- Decompensated chronic liver disease
		○ Ascites
		○ Variceal bleeding
		○ Hepatic encephalopathy
	- Hepatocellular carcinoma
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4
Q

What are the clinical features of ascites?

A
  • Physical exam reveals dullness in flanks and shifting dullness
    • Can be confirmed by ultrasound
    • Spider nevi
    • Palmer erythema
    • Abdominal veins
    • Factor hepaticus
    • Umbilical nodule
    • JVP elevation
    • Flank haematoma
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5
Q

What is the treatment of ascites?

A
  • Diuretics
    • Large volume paracentesis
    • TIPS
    • Aquaretic
    • Liver transplantation
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6
Q

How do you manage a patient in a medical emergency with ascites?

A
  • Resuscitate patient
    • Good IV access
    • Blood transfusion as required
    • Emergency endoscopy
    • Endoscopic band ligation
    • Add Terlipressin for control
    • Sengstaken-Blakemore tube for uncontrolled bleeding
    • TIPSS for rebleeding after bleeding
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7
Q

Why do patients with hepatic encephalopathy present with confusion?

A

• Liver disease
- If the liver stops working all the metabolites go to the brain and they can immediately go into a coma (which, if treated, will immediately get better)

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8
Q

What are the causes of hepatic encephalopathy?

A
  • GI bleed
    • Infection
    • Constipation
    • Dehydration
    • Medication (especially sedation)
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9
Q

What is the treatment of hepatic encephalopathy?

A
  • Treat underlying cause
    • Laxatives: phosphate enemas and lactulose
    • Neomycin, Rifaximin-broad spectrum non absorbed antibiotic
    • Repeated admission with hepatic encephalopathy is an indicator for a liver transplant
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10
Q

What is the background of Hepatocellular carcinoma?

A
  • Commonest cause of liver cancer
    • Occurs in the background of cirrhosis
    • Occurs in association with chronic hepatitis B and C
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11
Q

What does a liver screen look for?

A
  • Hepatitis B and C serology
    • Autoantibody profile, serum immunoglobulins
    • Caeruloplasmin and copper
    • Ferritin and transferrin saturation
    • Alpha 1 and anti-trypsin
    • Fasting glucose and lipid profile
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12
Q

What does an ultrasound do?

A
  • Differentiates extrahepatic and intrahepatic obstruction
    • Delineates site of obstruction
    • Delineates cause of obstruction
    • Documents evidence of portal hypertension
    • Primary staging of extent of disease e.g. cancer spread
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13
Q

What are the advantages and disadvantages of ultrasound?

A
  • Cheap
    • No radiation
    • Portable, widely available
    • Good for gallstones
    • High specificity
    • Lower sensitivity
    • Examines organs as well as biliary system
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14
Q

What are the advantage and disadvantages of CT/MRI?

A
  • Expensive
    • Radiation (only for CT scan)
    • Requires CT / MRI scanner
    • Better for pancreas
    • High specificity
    • High sensitivity
    • Examines organs (and biliary system)
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15
Q

What is ERCP used for?

A

Fixing

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16
Q

What are the advantages and disadvantages of ERCP?

A
  • Radiation
    • Sedation
    • Complications 5%: respiratory, cardiovascular, pancreatitis, cholangitis, sphincterotomy (bleeding, perforation)
    • Failure rate 10%
    • Only images ducts
    • Therapeutic option: dilated biliary tree (+/- visible stones and/or tumour), acute gallstone pancreatitis, stenting of biliary obstruction, post-operative biliary complications
17
Q

What is MRCP used for

A

Diagnosing

18
Q

Explain percutaneous transhepatic cholangiogram (PTC)

A
  • Uses: ERCP not possible due to duodenal obstruction or previous surgery, Hilar stenting
    • More invasive than ERCP
19
Q

Explain Endoscopic ultrasound

A
  • Characterising pancreatic masses
    • Staging tumours
    • Fine needle aspirate (FNA) of tumours and cysts
    • Excluding biliary micro calculi
20
Q

What are the three classifications of jaundice?

A
  • Pre-hepatic
  • Hepatic
  • Post-hepatic
21
Q

Explain pre-hepatic jaundice

A
  • Increased quantity of bilirubin (haemolysis)
    • Impaired transport
    • History of anaemia
    • Acholuric jaundice
22
Q

Explain hepatic jaundice

A
  • Defective uptake of bilirubin
    • Defective conjugation
    • Defective excretion
    • Risk factor for liver disease (IVDU, drug intake)
    • Decompensation (ascites, variceal bleed, encephalopathy)
    • Examination: Stigmata of CLD (spider naevi, gynecomastia), ascites, asterixis
23
Q

Explain post-hepatic jaundice

A
  • Defective transport of bilirubin by the biliary ducts
    • Abdominal pain
    • Cholestasis (purities, pale stool, high coloured urine)
    • Palpable gall bladder (Courvoisier’s sign)
24
Q

What are the routine tests done when a patient has ascites?

A
  • Cell count
  • Protein
  • Albumin
25
Q

What are the optional tests done when a patient presents with ascites?

A
  • Culture
  • Glucose
  • LDH
  • Amylase
  • Gram stain
26
Q

What are the unusual blood tests done when a patient has ascites?

A
  • TB culture
  • Cytology
  • Triglyceride
  • Bilirubin
27
Q

What are the unhelpful tests for a patient with ascites?

A
  • pH
  • Lactate
  • Cholesterol
  • Fibronectin
  • ADA
  • CEA
28
Q

If the SAAG (serum-ascites albumin gradient) is greater than 1.1g/dl, what could the cause of this be?

A 
○ >1.1g/dl portal HTN related
	§ Portal hypertension
	§ CHF
	§ Constrictive pericarditis
	§ Budd Chiarri
	§ Myxoedema 
	§ Massive liver metastases
29
Q

If the SAAG is less than 1.1g/dl, what could the cause of it be?

A 
○ <1.1g/dl nonportal HTN causes 
	§ Malignancy
	§ Tuberculosis
	§ Chylous ascites 
	§ Pancreatic
	§ Biliary ascites 
	§ Nephrotic syndrome 
	§ Serositis
30
Q

What are the tests for hepatocellular carcinoma

A 
• Tumour markers: AFP
	• Radiological tests
	- Ultrasound
	- CT scan 
	- MRI
	• Liver biopsies can be done very rarely
31
Q

Explain biliruben

A
  • By product of haeme metabolism
    • Generated by senescent RBC’s in spleen
    • Initially bound to albumin (unconjugated)
    • Liver helps to solubilise it (conjugated)
    • Elevated as a result of :
      • Pre-hepatic: Haemolysis
      • Hepatic: Parenchymal damage
      • Post hepatic: Obstructive
32
Q

Explain Aminotransferase

A
  • Enzymes present in hepatocytes
    • ALT more specific than AST
    • AST/ALT ratio can point towards ALD
    • Suggests parenchymal involvement
33
Q

What does it mean if Bilirubin and Aminotransferase are raised?

A

Raised Bilirubin and aminotransferase mean that there is liver damage or failure

34
Q

Explain alkaline phosphate

A
  • Enzyme present in bile ducts
    • Elevated with obstruction or liver infiltration
    • Also present in bone, placenta and intestines
35
Q

Explain Gamma GT

A
  • Non specific liver enzyme
    • Elevated with alcohol use
    • Useful to confirm liver source of ALP
    • Drugs like NSAID’s can raise levels
36
Q

Explain albumin

A
  • Important test for synthetic function of liver
    • Low levels suggest chronic liver disease
    • Can be low in kidney disorders and malnutrition
37
Q

Explain prothromine time

A
  • Extremely important test for liver function
    • Tells degree of liver dysfunction
    • Used to calculate scores to decide stage of liver disease, who needs a liver transplant and who gets a liver transplant
38
Q

Explain creatin

A
  • Essentially kidney function
    • Determines survival from liver disease
    • Critical assessment for need for transplant
39
Q

Explain platelet count

A
  • Liver is an important source of thrombopoietin
    • Cirrhosis results in splenomegaly
    • Platelets low in cirrhotic subjects as a result of hypersplenism
    • Indirect marker of portal hypertension

Alimentary (25 decks)

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