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2ND YEAR SYSTEMS: GI > Jaundice and chronic liver disease > Flashcards

Jaundice and chronic liver disease Flashcards

1
Q

Synthetic function of the liver (what it produces) (6)

A

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

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2
Q

what things does the liver help to detoxify in the body

A

drugs
urea production from ammonia
bilirubin metabolism
breaks down insulin and hormones

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3
Q

What role does the liver play in immunity (3)

A

combats infections

clears the blood of particles and infections including bacteria

neutralises and destroys all drugs and toxins

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4
Q

Storage function of the liver?

A

Stores glycogen

Stores Vitamin A, D, B12 and K

Stores Cu and Fe

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5
Q

what is a liver function test

A

tests that determine the health of your liver by measuring the levels of proteins, liver enzymes, and bilirubin in your blood

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6
Q

What is Bilirubin?

A

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

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7
Q

why might Bilirubin levels be elevated? pre hepatic, hepatic and post hepatic

A

Pre-hepatic: Haemolysis

Hepatic: Parenchymal damage

Post hepatic: Obstructive

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8
Q

Testing for aminotransferases: what is it? most specific test?

A

enzymes present in hepatocytes

alanine transaminase (ALT) more specific than aspartate aminotransferase (AST)

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9
Q

The AST/ALT ratio points towards what?

A

ALD - aldosterone levels in the blood

when aldosterone is produced it increases blood pressure

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10
Q

what is alkaline phosphatase? when is it elevated? where is it present

A

enzyme present in bile ducts

elevated with obstruction or liver infiltration

also present in bone, placenta and intestines

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11
Q

Gamma GT: what is it? when is it elevated? How can it’s levels be raised

A

Non specific liver enzyme

Elevated with alcohol use

Useful to confirm liver source of ALP - Alkaline phosphatase

Drugs like NSAID’s can raise levels

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12
Q

Albumin: what is this test important for? What do low levels of albumin suggest? And when might low levels occur?

A

important for testing synthetic function of the liver

low levels suggest chronic liver disease

can be low in kidney disorders and malnutrition too

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13
Q

Prothrombin time - very important! but why?

A

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

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14
Q

What does a creatinine test show?

A

essentially kidney function

determines survival from liver disease

critical assessment for need for transplant

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15
Q

platelet count

A

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

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16
Q

when the liver fails, what type of symptoms are present in a patient (4)

A

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

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17
Q

what is Jaundice? what blood level does it need to exceed to be detectable?

A

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

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18
Q

Jaundice can be classified in 3 groups: pre hepatic, hepatic and post hepatic. Describe each phase when working normally

A

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

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19
Q

Describe how the pre hepatic, hepatic and post hepatic phases are altered with jaundice

A

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

20
Q

What are some clues you get from a patient’s history that indicate which class of jaundice they have?

A

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)

21
Q

clinical examination clues about pre, hepatic and post hepatic jaundice

A

pre - pallor, splenomegaly

hepatic - ascites, signs of Chronic LD (spider naevi, gynaecomastia)
liver flap = asterixis

post hepatic - palpable gall bladder

22
Q

Investigations: liver screening (6)

A

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

23
Q

What is the most important test for liver disease? why?

A

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

24
Q

Differences between ERCP and MRCP?

A

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

25
Q

how can ERCP be used therapeutically

A

dilated biliary tree - may see visible stones or tumour

acute gallstone pancreatitis

stenting of biliary tract obstruction

post-operative biliary complications

26
Q

What is choledocholithiasis

A

presence of gallstones in common bile duct

27
Q

what are some complications with ERCP

A

Sedation related:- respiratory or cardiovascular

Procedure related:-
Pancreatitis
Cholangitis

Sphincterotomy -Bleeding or perforation

28
Q

what is percutaneous transhepatic cholangiogram used

A

when ERCP isn’t possible due to duodenal obstruction or previous surgery

for hilar stenting

29
Q

what is endocsopic ultrasound used for?

A

Characterising pancreatic masses

Staging of tumours

Fine needle aspirate (FNA) of tumours and cysts

Excluding biliary microcalculi

30
Q

What is chronic liver disease defined as?

A

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
31
Q

Clinical features of ascites

A

dullness in flank area and shifting dullness

Spider naevi, palmar erythema, abdominal veins, fetor hepaticus

Umbilical nodule
JVP elevation
Flank haematoma - bleeding outwith vessels

32
Q

what should all patients with new- onset ascites have done?

A

diagnostic paracentesis - a needle is inserted into the peritoneal cavity and ascitic fluid is removed for testing

33
Q

what tests are done to examine ascites fluid?

A

Protein & albumin concentration

Cell count

SAAG (serum-ascites albumin gradient)

34
Q

SAAG - serum ascites albumin gradient result of >1.1 g/dl means what? (6)

A

Portal hypertension

Congestive heart failure

Constrictive pericarditis

Budd Chiari - blood flowing into liver has trouble flowing out

Myxedema - severe hypothyroidism

Massive liver metastases

35
Q

SAAG - serum ascites albumin gradient result of <1.1 g/dl means what?

A

Malignancy

Tuberculosis

Chylous ascites - lymph fluid in peritoneal cavity

Pancreatic

Biliary ascites

Nephrotic syndrome

Serositis - inflammation of serous membrane

36
Q

Treatment options for ascites (5)

A

Diuretics

Large volume paracentesis

TIPS - Transjugular intrahepatic portosystemic shunt - reduce portal hypertension

Aquaretics - promotes excretion of H20 without loss of electrolytes

Liver transplantation

37
Q

What are varices caused by? what types can you get?

A

due to portal hypertension

can get them:-
on skin - caput medusa
oesophageal and gastric
rectal
post. abdominal wall
stomal
38
Q

Management of varices (4)

A

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

39
Q

When would a Sengstaken-Blakemore tube be used?

A

management of oesophageal varices

40
Q

what is hepatic encephalopathy

A

Confusion due to liver disease

It is graded 1-4

41
Q

how is hepatic encephalopathy treated

A

medications to treat infections, medications or procedures to control bleeding eg.

laxatives

neomycin, rifaximin-broad spectrum non absrobed antibiotic

42
Q

other underlying causes related to hepatic encephalopathy

A

GI bleed, infection, constipation, dehydration, medication esp. sedation

43
Q

Hepatocellular carcinoma

A

commonest cause of liver cancer

occurs in background of cirrhosis or in association with chronic hep B+C

44
Q

Presentation of hepatocellular carcinoma (5)

A

Decompensation of liver disease - can no longer tolerate it

Abdominal mass

Abdominal pain

Weight loss

Bleeding from tumour

45
Q

Diagnosis of hepatocellullar carcinoma

A

Tumour markers: AFP - alpha-fetoprotein

radiology - CT, ultrasound, MRI

liver biopsy - rarely done

46
Q

Treatment of hepatocellular carcinoma

A

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

2ND YEAR SYSTEMS: GI (38 decks)

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