Jaundice and Chronic Liver Disease Flashcards
what is the synthetic function of the liver?
what does it produce?
bile salts, bile acids, bilirubin
carbohydrates
clotting factors
protein - albumin
lipids - cholesterol, lipoprotein and triglycerides
hormones - angiotensin and insulin like growth factor
what vitamins does the liver store?
vitamin A, D, B12 and K
copper and iron
what is billirubin elevated as a result of?
pre hepatic haemolysis
hepatic parenchymal damage
post hepatic obstruction
where is alkaline phosphate found?
present in the bile ducts
Alkaline phosphate can be elevated as a result of?
obstruction of biliary system or liver infiltration
when is Gamma GT elevated?
when their is history of alcohol consumption
other than alcohol, what can gamma GT also be raised due to?
drugs such as NSAIDS
does low or high levels of albumin indicate liver disease?
low levels
why is prothrombin time included in liver function tests?
all clotting factors are produced from the liver
it is also a good measurement of the extent of liver dysfunction
what tests is a critical assessment for need for transplant?
creatine
what information does a platelet count give you in regards to liver disease and why is it carried out?
the liver produces thrombopoetin which is a regulates production of platelets.
in cirrhosis the liver produces less thrombopoetin = low platelets.
cirrhosis = splenomagely ad the spleen holds on to as many platelets as it can therefore there are less circulating platelets
–> thrombocytopenia is an indicator of CLD
what are the signs of decompensated liver disease?
jaundice ascites hepatic encephalopathy variceal bleeding infection
jaundice is detectable when bilirubin reaches what levels?
> 34umol/l
what is a differential diagnosis of jaundice and what can differentiate the two?
carotenemia
in carotenemia you don’t get yellowing of the sclera
what are the signs which suggest that the jaundice is pre hepatic?
anaemia
aucholoric jaundice - pale coloured urine
pallor
splenomegaly
what are the signs that suggests that the jaundice is hepatic?
ascites, vatical bleeding and encephalopathy
what signs suggest that the jaundice is post hepatic?
abdominal pain
cholestasis (pale stool, dark urine, pruritus)
palpable gallbladder
what are the main investigations for chronic liver diseases?
ultrasound / endoscopic USS
ERCP/MRCP
percutaneous transhepatic cholangiogram (PTC)
what are the complications of ERCP?
respiratory and CV risks with sedation
pancreatitis
cholangitis, sphincterotomy
what is defined as chronic liver disease?
liver disease persistent for > 6 months
ascites can be detected and confirmed on ultrasound when there is a minimum of what volume of fluid?
100cc/100ml
what is defined as low and high albumin/protein ascites?
high >1.1g/dl
low <1.1g/dl
what is the difference in the causes of ascites depending on the albumin content?
albumin >1.1g/dl caused by portal hypertension
albumin <1.1g/dl cause is not portal hypertension related
what are the treatments for ascites?
diuretics large volume paracentesis (drainage) TIPS - transjugular intrahepatic portosystemic shunt aquaretic liver transplant
where are the different portosystemic anastomoses ?
skin (caputmedusae) oesophageal rectal posterior abdominal wall stomal
what are the treatments for vatical haemorrhage?
endoscopic band ligation + terlipressin for bleeding control
sengstaken blakemore tube for controlled bleeding
TIPS to prevent re-bleeding after banding
hepatocellular carcinoma is associated with what type(s) of hepatitis?
hep B and C
what is the presentation of hepatocellular carcinoma?
decompensated liver disease i.e. ascites, variceal haemorrhage, encephalopathy abdominal mall abdominal pain weight loss bleeding from tumour
what investigations are used in the diagnosis of hepatocellular carcinoma?
tumour marker - AFP USS CT MRI Liver biopsy
what is the treatment for hepatocellular carcinoma?
hepatic resection
liver transplant
palliative:
chemotherapy
locally ablative treatments - alcohol injection or radio frequency ablation
sorafenib (tyrosine kinase inhibitor) or tamoxifen (hormone therapy) - last resorts
what can precipitate encephalopathy?
GI bleed infection dehydration constipation medication i.e. sedatives
how do you treat encephalopathy?
treat the underlying cause i.e.
if infection = antibiotics
if constipation = laxatives (lactulose), enema, aquatics
if dehydration = iv fluids
what is acholuric jaundice?
jaundice with pale urine
causes pale urine due to conjugated bilirubin - it is insoluble so isn’t secreted in the urine
what are the causes of ascites with an albumin content of 1 g/dl?
non portal hypertensive related; pancreatitis malignancy biliary ascites tuberculosis nephrotic syndrome chylous ascites seositis
what are the causes of ascites with an albumin content of 2.1 g/dl?
portal hypertensive related i.e. congestive heart failure constrictive pericarditis masive liver metastasis budd chiarri myxedema
what are the advantages of carrying out an endoscopic ultrasound scan for suspected LD?
staging of tumours
fine needle aspiration (FNA) of cysts or tumours
excluding biliary microcalculi
why might a percutaneous transhepatic cholangiogram (PTC) be carried out?
ERCP not possible due to previous surgery or duodenal obstruction
what is the disadvantage of percutaneous transhepatic cholangiogram?
more invasive than ERCP
it is used instead of ERCP
what is the most useful investigation for LD and why?
abdominal USS
- differentiates intrahepatic from extra hepatic obstruction
- identifies site and cause of obstruction
- documents evidence of portal hypertension
- early staging of extent of disease e.g. cancer spread
how does hepatic encephalopathy occur due to CLD?
bacteria in our gut break down proteins and release ammonia.
this ammonia is broken down in urea by the liver
ammonia is toxic to our brains therefore if the liver cannot break it down = encephalopathy
what are other features might you find which confirms ascites caused by liver failure? (apart from fluid thrill and shifting dullness)
spider naevi gynaecomastia palmar erythema umbilical nodule elevated JVP flank haematoma abdominal veins (caput medusae) fetor hepaticus
what are the causes of liver cirrhosis?
alcohol autoimmune (PSC, PBC) drugs i.e. TMX (antimetabolites), amiodarone NAFLD cystic fibrosis vascular problems i.e portal hypertension chronic viral hepatitis B & C haemochromatosis, wilsons disease cryptogenic others: sarcoidosis, amyloidosis
What drugs can cause liver cirrhosis?
MTX (anti metabolites)
amiadorone
what is the clinical presentation of hepatic cirrhosis?
compensated liver disease (abnormal LFT’s)
decompensated liver disease (ascites, vatical haemorrhage, encephalopathy)
what does cirrhosis put you at risk of?
hepatocellular carcinoma
