Jaundice and chronic liver disease Flashcards
what are the synthetic functions of the liver ?
clotting factors bile acids carbs - glucneogenesis lipids - cholesterol hormones - angiotensinogen
what are the detoxification functions of the liver ?
urea from ammonia
drug detox
bilirubin metabolism
breakdown insulin and hormones
what is the storage function of the liver ?
glycogen
vitamins A, D, B12, K
copper and iron
what is bilirubin ?
a by-product of haeme metabolism in the spleen
what can cause elevated bilirubin levels ?
pre-hepatic - haemolysis
hepatic - parenchymal damage
post hepatic - obstruction
what are aminotransferase (ALT, AST) and what can abnormal levels indicate ?
enzymes present in hepatocytes
abnormal levels suggest parenchymal involvement
what is alkaline phosphatase (ALP) and what can abnormal levels indicate ?
enzymes present in bile duct
elevated levels can indicate obstruction or liver infiltration
also present in bone, placenta and intestines
what is gamma GT and what can abnormal levels indicate ?
non-specific liver enzyme
elevated in alcohol use or when using NSAIDs
confirms liver source of ALP
what is albumin and what can abnormal levels indicate ?
blood protein, indicates synthetic ability of liver
low levels suggestive of chronic liver disease
can be low in kidney disorders or malnutrition
what is prothrombin time and why is it important ?
clotting factor test
very important in telling degree on liver dysfunction
stages liver disease
what is creatinine and why is it important ?
essentially kidney function test
determines survival for liver disease and determines need for transplant
why is platelet count relevant to liver disease ?
liver produces thrombopoietin
cirrhosis causes splenomegaly which causes low platelet count
indirect marker of portal hypertension
what are symptoms of liver disease ?
jaundice
ascites
variceal bleeding
hepatic encephalopathy
what is jaundice ?
yellowing of the skin caused by excess circulating bilirubin
differential diagnosis is carotenemia
what are the causes, clues on history and clues on exam of pre-hepatic jaundice ?
causes - increased bilirubin (haemolysis), impaired transport
history - anaemia, acholuric jaundice
exam - pallor, splenomegaly
what are the causes, clues on history and clues on exam of hepatic jaundice ?
causes - defective uptake of bilirubin, defective conjugation, defective excretion
history - risk factors for LD (IVDA, drugs)
exam - signs of CLD (spider naevi, gynaecomastia), ascites, asterixis (flapping tremor)
what are the causes, clues on history and clues on exam of post-hepatic jaundice ?
causes - defective transport of bilirubin down biliary ducts
history - abdominal pain, cholestasis (pruritus, pale stools, high coloured urine)
exam - palpable gall bladder (courvoiser’s sign)
what is the most important investigation for jaundice ?
ultrasound scan
what is ERCP ?
endoscopic retrograde cholangiopacreatography
radiation emitting test
can cause complications
can be therapeutic
what is MRCP ?
magnetic resonance cholangiography
no radiation
non-therapeutic
what is PTC ?
percutaneous transhepatic cholangiogram
used when ERCP not possible due to obstruction
can be used for hilar stenting
more invasive
what is EUS ?
endoscopic ultrasound
used for pancreatic masses, tumour staging
FNA of tumours/cysts
excluding biliary microcaliculi
what is liver cirrhosis ?
replacement of normal liver tissue by scar tissue
result of chronic liver disease
how does cirrhosis present ?
compensated - abnormal LTFs, routinely picked up
decompensated - ascites, vatical bleeding, hepatic encephalopathy
hepatocellular carcinoma
what is ascites, what are its clinical features and how is it diagnosed ?
collection of fluid in peritoneal cavity
features - dullness on flanks, shifting dullness, signs on CLD, umbilical nodule, raise JVP
diagnosed via USS and paracentesis analysis of protein and cell count
how is ascites treated ?
diuretics large volume paracentesis TIPS - transjugular intrahepatic portosystemic shunt aquaretics liver transplant
what are varices, what causes them and where do they occur ?
extremely dilated veins
caused by portal hypertension
occur at anatamoses - skin (caput medusae), oesophageal/gastric, rectal, posterior abdominal wall, stomal
they are a medical emergency
how are varices managed ?
band ligation
terlipressin
sengstaken-blakemore tube for continuous bleeding
TIPS for rebreeding after ligation
emergency endoscopy, transfusion and resus
what is hepatic encephalopathy and what precipitates it ?
confusion caused by liver disease
precipitated by GI bleed, infection, constipation, dehydration, sedatives
treatment aimed at underlying cause
what are causes of hepatocellular carcinoma ?
occurs in the background of cirrhosis
associated with Hep B, C infection
how does hepatocellular carcinoma present ?
decompensated liver disease abdominal mass abdominal pain weight loss bleeding
how is hepatocellular carcinoma diagnosed ?
tumour marker - AFP
radiologically - USS, CT, MRI
rarely biopsy
how is hepatocellular carcinoma treated ?
resection transplantation chemotherapy ablative treatments sorafenib - tyrosine kinase inhibitor tamoxifen - hormone therapy
