Jaundice and chronic liver disease Flashcards
Synthetic function of the liver (what it produces) (6)
Clotting factors
Bile acids
Carbohydrates
- Gluconeogenesis
- Glycogenolysis
- Glycogenesis
Proteins eg Albumin synthesis
Lipids - Cholesterol synthesis, Lipoprotein and TG synthesis
Hormones eg Angiotensinogen, insulin like growth factor
what things does the liver help to detoxify in the body
drugs
urea production from ammonia
bilirubin metabolism
breaks down insulin and hormones
What role does the liver play in immunity (3)
combats infections
clears the blood of particles and infections including bacteria
neutralises and destroys all drugs and toxins
Storage function of the liver?
Stores glycogen
Stores Vitamin A, D, B12 and K
Stores Cu and Fe
what is a liver function test
tests that determine the health of your liver by measuring the levels of proteins, liver enzymes, and bilirubin in your blood
What is Bilirubin?
a yellowish substance in your blood
Made by product of haeme metabolism - generated by old RBC’s in spleen
Initially bound to albumin (unconjugated)
Liver helps to solubilise it (conjugated)
It should then travel through your liver, gallbladder, and digestive tract before being excreted
why might Bilirubin levels be elevated? pre hepatic, hepatic and post hepatic
Pre-hepatic: Haemolysis
Hepatic: Parenchymal damage
Post hepatic: Obstructive
Testing for aminotransferases: what is it? most specific test?
enzymes present in hepatocytes
alanine transaminase (ALT) more specific than aspartate aminotransferase (AST)
The AST/ALT ratio points towards what?
ALD - aldosterone levels in the blood
when aldosterone is produced it increases blood pressure
what is alkaline phosphatase? when is it elevated? where is it present
enzyme present in bile ducts
elevated with obstruction or liver infiltration
also present in bone, placenta and intestines
Gamma GT: what is it? when is it elevated? How can it’s levels be raised
Non specific liver enzyme
Elevated with alcohol use
Useful to confirm liver source of ALP - Alkaline phosphatase
Drugs like NSAID’s can raise levels
Albumin: what is this test important for? What do low levels of albumin suggest? And when might low levels occur?
important for testing synthetic function of the liver
low levels suggest chronic liver disease
can be low in kidney disorders and malnutrition too
Prothrombin time - very important! but why?
extremely important test for liver function
tells the degree of liver dysfunction
used to calculate scores to decide stage of liver disease and see who needs a transplant and who gets one
What does a creatinine test show?
essentially kidney function
determines survival from liver disease
critical assessment for need for transplant
platelet count
liver is an important source of thrombopoietin
cirrhosis resluts in splenomegaly
platelets low in cirrhotic subjects as a result of hypersplenism - causes rapid and premature destruction of blood cells
indirect marker of portal hypertension
when the liver fails, what type of symptoms are present in a patient (4)
jaundice
ascites - abnormal build up of fluid in abdomen
variceal bleeding - dilated blood vessels in the esophagus or stomach caused by portal hypertension
hepatic encephalopathy - spectrum of neuropsychiatric abnormalities
what is Jaundice? what blood level does it need to exceed to be detectable?
Yellowing of the skin, sclerae (white bit of the eye), and other tissues caused by excess circulating bilirubin
Detectable when total plasma bilirubin levels exceed 34 µmol/L
Differential diagnosis is carotenemia
Jaundice can be classified in 3 groups: pre hepatic, hepatic and post hepatic. Describe each phase when working normally
pre hepatic - increased quantity of unconjugated bilirubin (haemolysis) - complexed with albumin
hepatic - taken into the liver and conjugated - Glucuronic acid dissolves it
post hepatic - conjugated bilirubin leaves the liver and moves into the gut.
From there it is either:- excreted in faeces
moves to kidney and is excreted through urine
moves back to the liver
Describe how the pre hepatic, hepatic and post hepatic phases are altered with jaundice
pre hepatic - impaired transport of bilirubin to the liver
hepatic - defective uptake of bilirubin by the liver, defective conjugation or defective excretion by the liver
post hepatic - defective transport of bilirubin by the biliary ducts
What are some clues you get from a patient’s history that indicate which class of jaundice they have?
pre hepatic - history of anaemia, acholuric jaundice - increased level of conjugated bilirubin in blood
hepatic - risk factors for liver disease like IVDU, drug intake
decompensation meaning the development of ascites, variceal bleed, encephalopathy
post hepatic - abdominal pain, cholestasis (pruritus - itching, pale stools, high coloured urine)
clinical examination clues about pre, hepatic and post hepatic jaundice
pre - pallor, splenomegaly
hepatic - ascites, signs of Chronic LD (spider naevi, gynaecomastia)
liver flap = asterixis
post hepatic - palpable gall bladder
Investigations: liver screening (6)
Hepatitis B & C serology
Autoantibody profile, serum immunoglobulins
Caeruloplasmin and copper
Ferritin and transferrin saturation
Alpha 1 anti trypsin - inherited - liver disease
Fasting glucose and lipid profile
What is the most important test for liver disease? why?
ultrasound of the abdomen
Differentiates extrahepatic and intrahepatic obstruction
Precisely shows site/cause of obstruction
Documents evidence of portal hypertension
Preliminary staging of extent of disease e.g. cancer spread
Differences between ERCP and MRCP?
Both used for imaging the biliary tree and investigating biliary obstruction
Magnetic resonance cholangiopancreatography MRCP - has no radiation or complications, 5% claustrophobia, can image outwith the ducts
ERCP - uses x ray and endoscopy. Radiation used, sedation required, complications 5%, failure 10%, only images the ducts
how can ERCP be used therapeutically
dilated biliary tree - may see visible stones or tumour
acute gallstone pancreatitis
stenting of biliary tract obstruction
post-operative biliary complications
What is choledocholithiasis
presence of gallstones in common bile duct
what are some complications with ERCP
Sedation related:- respiratory or cardiovascular
Procedure related:-
Pancreatitis
Cholangitis
Sphincterotomy -Bleeding or perforation
what is percutaneous transhepatic cholangiogram used
when ERCP isn’t possible due to duodenal obstruction or previous surgery
for hilar stenting
what is endocsopic ultrasound used for?
Characterising pancreatic masses
Staging of tumours
Fine needle aspirate (FNA) of tumours and cysts
Excluding biliary microcalculi
What is chronic liver disease defined as?
Liver disease that persists beyond 6 months
Chronic hepatitis Chronic cholestasis - reduction or stoppage of bile flow Fibrosis and Cirrhosis Others e.g. steatosis Liver tumours
Clinical features of ascites
dullness in flank area and shifting dullness
Spider naevi, palmar erythema, abdominal veins, fetor hepaticus
Umbilical nodule
JVP elevation
Flank haematoma - bleeding outwith vessels
what should all patients with new- onset ascites have done?
diagnostic paracentesis - a needle is inserted into the peritoneal cavity and ascitic fluid is removed for testing
what tests are done to examine ascites fluid?
Protein & albumin concentration
Cell count
SAAG (serum-ascites albumin gradient)
SAAG - serum ascites albumin gradient result of >1.1 g/dl means what? (6)
Portal hypertension
Congestive heart failure
Constrictive pericarditis
Budd Chiari - blood flowing into liver has trouble flowing out
Myxedema - severe hypothyroidism
Massive liver metastases
SAAG - serum ascites albumin gradient result of <1.1 g/dl means what?
Malignancy
Tuberculosis
Chylous ascites - lymph fluid in peritoneal cavity
Pancreatic
Biliary ascites
Nephrotic syndrome
Serositis - inflammation of serous membrane
Treatment options for ascites (5)
Diuretics
Large volume paracentesis
TIPS - Transjugular intrahepatic portosystemic shunt - reduce portal hypertension
Aquaretics - promotes excretion of H20 without loss of electrolytes
Liver transplantation
What are varices caused by? what types can you get?
due to portal hypertension
can get them:- on skin - caput medusa oesophageal and gastric rectal post. abdominal wall stomal
Management of varices (4)
Resuscitate patient
Good IV access
Blood transfusion as required
Emergency endoscopy - endoscopic band ligation - used to control varices and prevent bleeding. Terlipressin used to lower BP
When would a Sengstaken-Blakemore tube be used?
management of oesophageal varices
what is hepatic encephalopathy
Confusion due to liver disease
It is graded 1-4
how is hepatic encephalopathy treated
medications to treat infections, medications or procedures to control bleeding eg.
laxatives
neomycin, rifaximin-broad spectrum non absrobed antibiotic
other underlying causes related to hepatic encephalopathy
GI bleed, infection, constipation, dehydration, medication esp. sedation
Hepatocellular carcinoma
commonest cause of liver cancer
occurs in background of cirrhosis or in association with chronic hep B+C
Presentation of hepatocellular carcinoma (5)
Decompensation of liver disease - can no longer tolerate it
Abdominal mass
Abdominal pain
Weight loss
Bleeding from tumour
Diagnosis of hepatocellullar carcinoma
Tumour markers: AFP - alpha-fetoprotein
radiology - CT, ultrasound, MRI
liver biopsy - rarely done
Treatment of hepatocellular carcinoma
Hepatic resection
Liver transplantation
Chemotherapy:-
- Locally delivered: TACE (Transcatheter arterial chemo-embolization) - blocks hepatic artery to treat
- Systemic chemotherapy
Locally ablative treatments:-
- Alcohol injection
- Radiofrequency ablation
Sorafenib (Tyrosinase kinase inhibitor)
Hormonal therapy: Tamoxifen
