Jaundice and Chronic Liver Disease

Question 1

what is the synthetic function of the liver?

what does it produce?

Answer 1

bile salts, bile acids, bilirubin
carbohydrates
clotting factors
protein - albumin
lipids - cholesterol, lipoprotein and triglycerides
hormones - angiotensin and insulin like growth factor

Question 2

what vitamins does the liver store?

Answer 2

vitamin A, D, B12 and K

copper and iron

Question 3

what is billirubin elevated as a result of?

Answer 3

pre hepatic haemolysis
hepatic parenchymal damage
post hepatic obstruction

Question 4

where is alkaline phosphate found?

Answer 4

present in the bile ducts

Question 5

Alkaline phosphate can be elevated as a result of?

Answer 5

obstruction of biliary system or liver infiltration

Question 6

when is Gamma GT elevated?

Answer 6

when their is history of alcohol consumption

Question 7

other than alcohol, what can gamma GT also be raised due to?

Answer 7

drugs such as NSAIDS

Question 8

does low or high levels of albumin indicate liver disease?

Answer 8

low levels

Question 9

why is prothrombin time included in liver function tests?

Answer 9

all clotting factors are produced from the liver

it is also a good measurement of the extent of liver dysfunction

Question 10

what tests is a critical assessment for need for transplant?

Answer 10

creatine

Question 11

what information does a platelet count give you in regards to liver disease and why is it carried out?

Answer 11

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

Question 12

what are the signs of decompensated liver disease?

Answer 12

jaundice
ascites
hepatic encephalopathy
variceal bleeding 
infection

Question 13

jaundice is detectable when bilirubin reaches what levels?

Answer 13

> 34umol/l

Question 14

what is a differential diagnosis of jaundice and what can differentiate the two?

Answer 14

carotenemia

in carotenemia you don’t get yellowing of the sclera

Question 15

what are the signs which suggest that the jaundice is pre hepatic?

Answer 15

anaemia
aucholoric jaundice - pale coloured urine
pallor
splenomegaly

Question 16

what are the signs that suggests that the jaundice is hepatic?

Answer 16

ascites, vatical bleeding and encephalopathy

Question 17

what signs suggest that the jaundice is post hepatic?

Answer 17

abdominal pain
cholestasis (pale stool, dark urine, pruritus)
palpable gallbladder

Question 18

what are the main investigations for chronic liver diseases?

Answer 18

ultrasound / endoscopic USS
ERCP/MRCP
percutaneous transhepatic cholangiogram (PTC)

Question 19

what are the complications of ERCP?

Answer 19

respiratory and CV risks with sedation
pancreatitis
cholangitis, sphincterotomy

Question 20

what is defined as chronic liver disease?

Answer 20

liver disease persistent for > 6 months

Question 21

ascites can be detected and confirmed on ultrasound when there is a minimum of what volume of fluid?

Answer 21

100cc/100ml

Question 22

what is defined as low and high albumin/protein ascites?

Answer 22

high >1.1g/dl

low <1.1g/dl

Question 23

what is the difference in the causes of ascites depending on the albumin content?

Answer 23

albumin >1.1g/dl caused by portal hypertension

albumin <1.1g/dl cause is not portal hypertension related

Question 24

what are the treatments for ascites?

Answer 24

diuretics 
large volume paracentesis (drainage)
TIPS - transjugular intrahepatic portosystemic shunt
aquaretic 
liver transplant

Question 25

where are the different portosystemic anastomoses ?

Answer 25

skin (caputmedusae)
oesophageal
rectal
posterior abdominal wall
stomal

Question 26

what are the treatments for vatical haemorrhage?

Answer 26

endoscopic band ligation + terlipressin for bleeding control
sengstaken blakemore tube for controlled bleeding
TIPS to prevent re-bleeding after banding

Question 27

hepatocellular carcinoma is associated with what type(s) of hepatitis?

Answer 27

hep B and C

Question 28

what is the presentation of hepatocellular carcinoma?

Answer 28

decompensated liver disease i.e. ascites, variceal haemorrhage, encephalopathy
abdominal mall
abdominal pain
weight loss 
bleeding from tumour

Question 29

what investigations are used in the diagnosis of hepatocellular carcinoma?

Answer 29

tumour marker - AFP
USS
CT
MRI 
Liver biopsy

Question 30

what is the treatment for hepatocellular carcinoma?

Answer 30

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

Question 31

what can precipitate encephalopathy?

Answer 31

GI bleed
infection
dehydration 
constipation
medication i.e. sedatives

Question 32

how do you treat encephalopathy?

Answer 32

treat the underlying cause i.e.
if infection = antibiotics
if constipation = laxatives (lactulose), enema, aquatics
if dehydration = iv fluids

Question 33

what is acholuric jaundice?

Answer 33

jaundice with pale urine

causes pale urine due to conjugated bilirubin - it is insoluble so isn’t secreted in the urine

Question 34

what are the causes of ascites with an albumin content of 1 g/dl?

Answer 34

non portal hypertensive related;
pancreatitis 
malignancy 
biliary ascites
tuberculosis 
nephrotic syndrome
chylous ascites 
seositis

Question 35

what are the causes of ascites with an albumin content of 2.1 g/dl?

Answer 35

portal hypertensive related i.e.
congestive heart failure
constrictive pericarditis 
masive liver metastasis
budd chiarri
myxedema

Question 36

what are the advantages of carrying out an endoscopic ultrasound scan for suspected LD?

Answer 36

staging of tumours
fine needle aspiration (FNA) of cysts or tumours
excluding biliary microcalculi

Question 37

why might a percutaneous transhepatic cholangiogram (PTC) be carried out?

Answer 37

ERCP not possible due to previous surgery or duodenal obstruction

Question 38

what is the disadvantage of percutaneous transhepatic cholangiogram?

Answer 38

more invasive than ERCP

it is used instead of ERCP

Question 39

what is the most useful investigation for LD and why?

Answer 39

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

Question 40

how does hepatic encephalopathy occur due to CLD?

Answer 40

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

Question 41

what are other features might you find which confirms ascites caused by liver failure? (apart from fluid thrill and shifting dullness)

Answer 41

spider naevi 
gynaecomastia 
palmar erythema
umbilical nodule
elevated JVP
flank haematoma
abdominal veins (caput medusae)
fetor hepaticus

Question 42

what are the causes of liver cirrhosis?

Answer 42

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

Question 43

What drugs can cause liver cirrhosis?

Answer 43

MTX (anti metabolites)

amiadorone

Question 44

what is the clinical presentation of hepatic cirrhosis?

Answer 44

compensated liver disease (abnormal LFT’s)

decompensated liver disease (ascites, vatical haemorrhage, encephalopathy)

Question 45

what does cirrhosis put you at risk of?

Answer 45

hepatocellular carcinoma