jaundice and chronic liver disease Flashcards by oli crawford

function of heart

pumps blood

allows blood to slosh about in its chambers

How well did you know this?

Not at all

Perfectly

function of liver compared to heart

doesnt pump blood
allows blood to slosh about in its sinusoids
AND A WHOLE LOT MORE

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

what happens during detoxification?

Urea production from ammonia
Detoxification of drugs
Bilirubin metabolism
Breakdown of insulin and hormones

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

what is the storage function of the liver?

Stores glycogen
Stores Vitamin A, D, B12 and K
Stores copper and iron

How well did you know this?

Not at all

Perfectly

how is bilirubin a liver function test?

Elevated as a result of :
Pre-hepatic: Haemolysis
Hepatic: Parenchymal damage
Post hepatic: Obstructive

How well did you know this?

Not at all

Perfectly

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 well did you know this?

Not at all

Perfectly

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 well did you know this?

Not at all

Perfectly

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 well did you know this?

Not at all

Perfectly

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 well did you know this?

Not at all

Perfectly

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 well did you know this?

Not at all

Perfectly

how is creatinine a liver function test

Essentially kidney function
Determines survival from liver disease
Critical assessment for need for transplant

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

what are the symptos of a liver stopping to work?

Jaundice
Ascites
Variceal bleeding
Hepatic encephalopathy

How well did you know this?

Not at all

Perfectly

what is jaundice?

Yellowing of the skin, sclerae, and other tissues caused by excess circulating bilirubin.

How well did you know this?

Not at all

Perfectly

when is jaunduce detectable?

Detectable when total plasma bilirubin levels exceed 34 µmol/L

How well did you know this?

Not at all

Perfectly

what is the differential diagnosis of jaundice?

carotenemia

How well did you know this?

Not at all

Perfectly

what are the classifications of jaundice?

pre hepatic
hepatic
post hepatic

How well did you know this?

Not at all

Perfectly

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 ```