Jaundice and chronic liver disease

Question 1

what are the synthetic functions of the liver ?

Answer 1

clotting factors
bile acids
carbs - glucneogenesis
lipids - cholesterol
hormones - angiotensinogen

Question 2

what are the detoxification functions of the liver ?

Answer 2

urea from ammonia
drug detox
bilirubin metabolism
breakdown insulin and hormones

Question 3

what is the storage function of the liver ?

Answer 3

glycogen
vitamins A, D, B12, K
copper and iron

Question 4

what is bilirubin ?

Answer 4

a by-product of haeme metabolism in the spleen

Question 5

what can cause elevated bilirubin levels ?

Answer 5

pre-hepatic - haemolysis
hepatic - parenchymal damage
post hepatic - obstruction

Question 6

what are aminotransferase (ALT, AST) and what can abnormal levels indicate ?

Answer 6

enzymes present in hepatocytes

abnormal levels suggest parenchymal involvement

Question 7

what is alkaline phosphatase (ALP) and what can abnormal levels indicate ?

Answer 7

enzymes present in bile duct
elevated levels can indicate obstruction or liver infiltration
also present in bone, placenta and intestines

Question 8

what is gamma GT and what can abnormal levels indicate ?

Answer 8

non-specific liver enzyme
elevated in alcohol use or when using NSAIDs
confirms liver source of ALP

Question 9

what is albumin and what can abnormal levels indicate ?

Answer 9

blood protein, indicates synthetic ability of liver
low levels suggestive of chronic liver disease
can be low in kidney disorders or malnutrition

Question 10

what is prothrombin time and why is it important ?

Answer 10

clotting factor test
very important in telling degree on liver dysfunction
stages liver disease

Question 11

what is creatinine and why is it important ?

Answer 11

essentially kidney function test

determines survival for liver disease and determines need for transplant

Question 12

why is platelet count relevant to liver disease ?

Answer 12

liver produces thrombopoietin
cirrhosis causes splenomegaly which causes low platelet count
indirect marker of portal hypertension

Question 13

what are symptoms of liver disease ?

Answer 13

jaundice
ascites
variceal bleeding
hepatic encephalopathy

Question 14

what is jaundice ?

Answer 14

yellowing of the skin caused by excess circulating bilirubin

differential diagnosis is carotenemia

Question 15

what are the causes, clues on history and clues on exam of pre-hepatic jaundice ?

Answer 15

causes - increased bilirubin (haemolysis), impaired transport
history - anaemia, acholuric jaundice
exam - pallor, splenomegaly

Question 16

what are the causes, clues on history and clues on exam of hepatic jaundice ?

Answer 16

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)

Question 17

what are the causes, clues on history and clues on exam of post-hepatic jaundice ?

Answer 17

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)

Question 18

what is the most important investigation for jaundice ?

Answer 18

ultrasound scan

Question 19

what is ERCP ?

Answer 19

endoscopic retrograde cholangiopacreatography
radiation emitting test
can cause complications
can be therapeutic

Question 20

what is MRCP ?

Answer 20

magnetic resonance cholangiography
no radiation
non-therapeutic

Question 21

what is PTC ?

Answer 21

percutaneous transhepatic cholangiogram
used when ERCP not possible due to obstruction
can be used for hilar stenting
more invasive

Question 22

what is EUS ?

Answer 22

endoscopic ultrasound
used for pancreatic masses, tumour staging
FNA of tumours/cysts
excluding biliary microcaliculi

Question 23

what is liver cirrhosis ?

Answer 23

replacement of normal liver tissue by scar tissue

result of chronic liver disease

Question 24

how does cirrhosis present ?

Answer 24

compensated - abnormal LTFs, routinely picked up
decompensated - ascites, vatical bleeding, hepatic encephalopathy
hepatocellular carcinoma

Question 25

what is ascites, what are its clinical features and how is it diagnosed ?

Answer 25

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

Question 26

how is ascites treated ?

Answer 26

diuretics
large volume paracentesis
TIPS - transjugular intrahepatic portosystemic shunt
aquaretics
liver transplant

Question 27

what are varices, what causes them and where do they occur ?

Answer 27

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

Question 28

how are varices managed ?

Answer 28

band ligation
terlipressin
sengstaken-blakemore tube for continuous bleeding
TIPS for rebreeding after ligation

emergency endoscopy, transfusion and resus

Question 29

what is hepatic encephalopathy and what precipitates it ?

Answer 29

confusion caused by liver disease
precipitated by GI bleed, infection, constipation, dehydration, sedatives
treatment aimed at underlying cause

Question 30

what are causes of hepatocellular carcinoma ?

Answer 30

occurs in the background of cirrhosis

associated with Hep B, C infection

Question 31

how does hepatocellular carcinoma present ?

Answer 31

decompensated liver disease
abdominal mass
abdominal pain
weight loss
bleeding

Question 32

how is hepatocellular carcinoma diagnosed ?

Answer 32

tumour marker - AFP
radiologically - USS, CT, MRI
rarely biopsy

Question 33

how is hepatocellular carcinoma treated ?

Answer 33

resection
transplantation
chemotherapy
ablative treatments
sorafenib - tyrosine kinase inhibitor
tamoxifen - hormone therapy