jaundice and chronic liver disease Flashcards
function of heart
pumps blood
allows blood to slosh about in its chambers
function of liver compared to heart
doesnt pump blood
allows blood to slosh about in its sinusoids
AND A WHOLE LOT MORE
whats the synthetic function of the liver?
Clotting factors
Bile acids
Carbohydrates
Gluconeogenesis, Glycogenolysis, Glycogenesis
Proteins
Albumin synthesis,
Lipids
Cholesterol synthesis, Lipoprotein and TG synthesis
Hormones
Angiotensinogen, insulin like growth factor
what is detoxification
physiological or medicinal removal of toxic substances from a living organism, including the human body, which is mainly carried out by the liver
what happens during detoxification?
Urea production from ammonia
Detoxification of drugs
Bilirubin metabolism
Breakdown of insulin and hormones
what is the immune function of the liver?
Combating infections
Clearing the blood of particles and infections, including bacteria
Neutralizing and destroying all drugs and toxins
what is the storage function of the liver?
Stores glycogen
Stores Vitamin A, D, B12 and K
Stores copper and iron
how is bilirubin a liver function test?
Elevated as a result of :
Pre-hepatic: Haemolysis
Hepatic: Parenchymal damage
Post hepatic: Obstructive
how is aminotransferases a liver function test?
Enzymes present in hepatocytes
ALT more specific than AST
AST/ALT ratio can point towards ALD
Suggests parenchymal involvement
how is alkaline phosphatase a liver function test?
Enzyme present in bile ducts
Elevated with obstruction or liver infiltration
Also present in bone, placenta and intestines
how is gamma GT a liver function test
Non specific liver enzyme
Elevated with alcohol use
Useful to confirm liver source of ALP
Drugs like NSAID’s can raise levels
how is albumin a liver function test
Important test for synthetic function of liver
Low levels suggest chronic liver disease
Can be low in kidney disorders and malnutrition
how is prothrombin time a liver function test
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
how is creatinine a liver function test
Essentially kidney function
Determines survival from liver disease
Critical assessment for need for transplant
how is platelet count a liver function test?
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
what are the symptos of a liver stopping to work?
Jaundice
Ascites
Variceal bleeding
Hepatic encephalopathy
what is jaundice?
Yellowing of the skin, sclerae, and other tissues caused by excess circulating bilirubin.
when is jaunduce detectable?
Detectable when total plasma bilirubin levels exceed 34 µmol/L
what is the differential diagnosis of jaundice?
carotenemia
what are the classifications of jaundice?
pre hepatic
hepatic
post hepatic
what happens in pre hepatic?
increased quantity of bilirubin
impaired transport
what happens in hepatic
defective uptake of bilirubin
defective conjugation
defective excretion
what happens in post hepatic
defective transport of bilirubin by the biliary ducts
what are clues on history pre hepatic?
history of anaemia
acholuric jaundice
what are clues on history hepatic
Risk factors for liver disease (IVDU, drug intake)
Decompensation (ascites, variceal bleed,encephalopathy)
what are the clues on history post hepatic?
Abdominal pain
Cholestasis (Pruritus, pale stools, high coloured urine)
clues on examination pre hepatic
Pallor
Splenomegaly
whatare the clues on examination hepatic
Stigmata of CLD (spider naevi, gynaecomastia)
Ascites
Asterixis
what are the clues on examination post hepatic
Palpable gall bladder
what are the investigations for jaundice
Liver screen Hepatitis B & C serology Autoantibody profile, serum immunoglobulins Caeruloplasmin and copper Ferritin and transferrin saturation Alpha 1 anti trypsin Fasting glucose and lipid profile
Most important test is Ultrasound of the abdomen
why is ultrassound of the abdomen so good?
Differentiates extrahepatic and intrahepatic obstruction
Delineates site of obstruction
Delineates cause of obstruction
Documents evidence of portal hypertension
Preliminary staging of extent of disease e.g. cancer spread
diiference between MRCP and ERCP
MRCP No radiation No complications 5% claustrophobia Can image outwith the ducts
ERCP Radiation Sedation Complications (5%) Failure rate (10%) Only images ducts Therapeutic option
therapeutic ercp
Dilated biliary tree ± visible stones
± tumour
Acute gallstone pancreatitis
Stenting of biliary tract obstruction
Post-operative biliary complications
complications of ERCP
Sedation related - respiratory - cardiovascular Procedure related Pancreatitis Cholangitis Sphincterotomy Bleeding Perforation
uses of percutaneous transhepatic cholangiogram
ERCP not possible due to
duodenal obstruction
or previous surgery
Hilar stenting
disadvantages of PTC
more invasive than ERCP
function of endoscopic ultrasound
Characterising pancreatic masses
Staging of tumours
Fine needle aspirate (FNA) of tumours and cysts
Excluding biliary microcalculi
definition of chronic liver disease
Liver disease that persists beyond 6 months
give examples of a chronic liver disease?
Chronic hepatitis Chronic cholestasis Fibrosis and Cirrhosis Others e.g. steatosis Liver tumours
clinical presentation of cirrhosis
Compensated chronic liver disease Routinely detected on screening tests Abnormality of liver function tests Decompensated chronic liver disease Ascites Variceal bleeding Hepatic encephalopathy Hepatocellular carcinoma
evidence of ascites?
Physical exam reveals dullness in flanks and shifting dullness (approx 1500cc).
Can be confirmed by U/S which can detect up to 100cc.
Corroborating evidence:
Spiders, palmar erythema, abdominal veins, fetor hepaticus
Umbilical nodule
JVP elevation
Flank haematoma
what are routine checks for ascitic fluid analysis?
cell count
protein
albumin
treatment options for ascites
Diuretics Large volume paracentesis TIPS Aquaretics Liver transplantation
what causes varices?
portal hypertension
management of varices
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 banding
what is Hepatic encephalopathy
Hepatic encephalopathy is a syndrome observed in patients with cirrhosis. Hepatic encephalopathy is defined as a spectrum of neuropsychiatric abnormalities in patients with liver dysfunction, after exclusion of brain disease
whats the commonest cause of liver cancer?
Hepatocellular carcinoma
Hepatocellular carcinoma occurs in the background of
cirrhosis
what is Hepatocellular carcinoma associated with
chronic hep b and c
presentation of Hepatocellular carcinoma
Decompensation of liver disease Abdominal mass Abdominal pain Weight loss Bleeding from tumour
diagnosis of Hepatocellular carcinoma
Tumour markers: AFP Radiological tests Ultrasound CT scan MRI Liver biopsy done very rarely
what is the treatment of Hepatocellular carcinoma
Hepatic resection Liver transplantation Chemotherapy Locally delivered: TACE (Transcatheter arterial chemo-embolization) Systemic chemotherapy Locally ablative treatments Alcohol injection Radiofrequency ablation Sorafenib (Tyrosinase kinase inhibitor) Hormonal therapy: Tamoxifen
