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Alimentary System > Jaundice and Chronic Liver Disease > Flashcards

Jaundice and Chronic Liver Disease Flashcards

1
Q

Describe the synthetic function of the liver.

A
  • Clotting factor
  • Bile acids
  • Carbohydrates
  • Proteins e.g. albumin
  • Lipids e.g. cholesterol, TG
  • Hormones e.g. angiotensinogen, IGF
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2
Q

Describe the detoxification function of the liver.

A
  • Breaks down ammonia to form urea
  • Drugs
  • Bilirubin metabolism
  • Breakdown of insulin and hormones
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3
Q

Describe the immune function of the liver.

A
  • Cleanses the blood

- Neutralises and destroys all drugs and toxins

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4
Q

Describe the storage function of the liver.

A
  • Glycogen
  • Vitamins A, D, B12 and K
  • Copper and iron
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5
Q

List the substances investigated in a liver function test.

A
  • Bilirubin
  • Aminotransferases (AST, ALT)
  • Alkaline phosphatase
  • Gamma GT
  • Albumin
  • Prothrombin time
  • Creatinine
  • Platelet count
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6
Q

How does the liver metabolise bilirubin?

A
  • Bilirubin initially bound to albumin (conjugated, fat soluble)
  • Liver helps to solubilise it (unconjugated) so it can be excreted
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7
Q

List causes of elevated bilrubin.

A

Pre-hepatic: haemolysis.

Hepatic: parenchymal damage.

Post-hepatic: obstruction.

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8
Q

What are aminotransferases and what do they indicated?

A
  • Enzymes in hepatocytes

- Indicate damage and inflammation

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9
Q

What does the AST/ALT ratio indicate? What are the normal and abnormal levels?

A

Indicates alcoholic liver disease.

Normal = 0.8.
Abnormal = 2 or higher.
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10
Q

What is alkaline phosphatase and what does it indicate?

A
  • Enzyme in bile ducts (also bone, placenta and intestines)

- Elevated in obstruction or hepatic infiltration

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11
Q

What is gamma GT and what does it indicate?

A
  • Non-specific liver enzyme

- Elevated in alcohol use, drugs e.g. NSAIDs

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12
Q

What can low albumin indicate?

A
  • Chronic liver disease
  • Kidney disorders
  • Malnutrition
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13
Q

What symptoms can occur due to low albumin?

A
  • Balances oncotic forces

- Low albumin –> oedema and ascites

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14
Q

What does prothrombin time indicate and when is it used clinically?

A
  • Degree of liver dysfunction

- Used to stage LD, decide who gets a transplant

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15
Q

What does creatinine indicate and when is it used clinically?

A
  • Essentially kidney function
  • `Determines survival
  • Critical for transplant assessment
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16
Q

How does platelet count relate to the liver and what is it an indirect marker of?

A
  • Liver is a source of thrombopoietin
  • Cirrhotic patients have thrombocytopenia due to hypersplenism
  • Thus, thrombocytopenia = cirrhosis
  • Indirect marker for portal hypertension
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17
Q

Describe what is meant by decompensated liver disease.

A

Acute deterioration in liver function in a patient with cirrhosis, who has one of the following symptoms;

  • Jaundice
  • Ascites
  • Variceal bleeding
  • Hepatic encephalopathy
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18
Q

Describe what is meant by compensated liver disease.

A

The liver is scarred but still able to perform most its basic functions at some level. Patient will have ALL of the following symptoms;

  • Jaundice
  • Ascites
  • Variceal bleeding
  • Hepatic encephalopathy
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19
Q

Define ‘jaundice’.
At what bilibrubin level is it detectable?
What is the differential diagnosis?

A

Definition: yellowing of the skin, sclerae, and other tissues caused by excess circulating bilirubin.

Detectable when bilirubin is >34umol/L.

Different diagnosis: carotenaemia.

20
Q

Describe the specific pathology of pre-hepatic jaundice.

A 
Problem in RBCs, blood
-->
Increased quantity of bilirubin (haemolysis)
Impaired transport
-->
Rise in unconjugated bilirubin
No bilirubin in kidneys/urine
21
Q

What would likely be found in the history taking of a patient with pre-hepatic jaundice.

A
  • History of anaemia (fatigue, SOB, chest pain)
22
Q

What would likely be found on examination of a patient with pre-hepatic jaundice.

A
  • Pallor

- Splenomegaly

23
Q

Describe the specific pathology of hepatic jaundice.

A 
Problem in liver
-->
Defective uptake of bilirubin
Defective conjugation
Defective excretion
--> 
(Same as post-hepatic jaundice)
Rise in conjugated bilirubin
Bilirubin in urine (will appear darker)
24
Q

What would likely be found in the history taking of a patient with hepatic jaundice.

A
  • Risk factors for liver disease (IVDU)

- Signs of decompensation (ascites, variceal bleeding, hepatic encephalopathy)

25
Q

What would likely be found on examination of a patient with hepatic jaundice.

A
  • Spider naevi, gynaecomastia
  • Ascites
  • Asterixis
    (- High colour urine, normal stool)
26
Q

Describe the specific pathology of hepatic jaundice.

A 
Problem in gut, kidneys
--> 
Defective transport of bilirubin by biliary ducts
--> 
(Same as hepatic jaundice)
Rise in conjugated bilirubin
Bilirubin in urine (will appear darker)
27
Q

What would likely be found in the history taking of a patient with post-hepatic jaundice.

A
  • Abdominal pain

- Cholestasis (pruritus, pale stools, high colour urine)

28
Q

What would likely be found on examination of a patient with post-hepatic jaundice.

A
  • Palpable gall bladder (Courvoisier’s sign)
29
Q

What are the investigations for chronic liver disease?

A
  • Liver screen (most important)
  • USS
  • ERCP/MRCP
30
Q

What is ERCP?

A

Endoscopy to examine pancreas and bile ducts.

31
Q

What is MRCP?

A

MRI to examine pancreas and bile ducts.

32
Q

ERCP vs. MRCP - which is better?

A

ERCP has no radiation and fewer complications but MRCP is used most for diagnosis.

33
Q

What conditions is therapeutic ERCP used for?

A
  • Dilated biliary tree (due to stones, tumour)
  • Acute gallstone pancreatitis
  • Stenting of biliary tract obstruction
  • Post-operative biliary complications
34
Q

Name some complications of ERCP.

A
  • Due to sedation

Procedure related;

  • Pancreatitis
  • Cholangitis
  • Sphincterotomy (bleeding, perforation)
35
Q

Name two other imaging modalities used in chronic liver disease.

A
  • Percutaneous Transhepatic Cholangiogram (PTC): when ERCP is not possible
  • Endoscopic ultrasounds (EUS): staging, fine needle aspirate of tumour/cysts
36
Q

Define ‘chronic liver disease’.

A

Liver disease that persists >6 months.

37
Q

List the causes of cirrhosis.

A
  • Alcohol
  • Autoimmune
  • Haemachromatosis
  • Chronic viral hepatitis
  • NAFLD
  • Drugs
  • CF, alpha-1 antitrypsin deficiency
  • Vascular
38
Q

Describe the diagnosis of ascites.

A

Diagnostic paracentesis;

  • Protein and albumin conc.
  • Cell count
  • SAAG (serum ascites albumin gradient)
39
Q

Describe the two categories of SAAG.

A

> 1.1g/dL = high albumin gradient.

<1.1g/dL = low.

40
Q

List causes of a SAAG >1.1g/dL (high albumin gradient).

A
  • Portal hypertension
  • CHF
  • Constrictive pericarditis
  • Budd Chiarri (occlusion of hepatic vein)
  • Myxedema (advanced hypothyroidism)
  • Massive liver metastases
41
Q

List causes of a SAAG <1.1g/dL (low albumin gradient).

A
  • Malignancy
  • TB
  • Chylous (lipid-rich) ascites
  • Pancreatic
  • Biliary ascites
  • Nephrotic syndrome
  • Peritonitis
42
Q

List the treatment options of ascites.

A
  • Diuretics
  • Large volume paracentesis
  • TIPShunt
  • Aquaretics (diuretic with no electrolyte loss)
  • Liver transplant
43
Q

Describe the management of vatical haemorrhage.

A
  • Resuscitate patient
  • Good IV access
  • Blood transfusion as required
  • Emergency endoscopy
  • Endoscopic band ligation
  • TIPShunt for rebleeding after banding
44
Q

List the precipitants of hepatic encephalopathy.

A
  • GI bleed
  • Infection
  • Constipation
  • Dehydration
  • Medication esp. sedation
45
Q

Describe the treatment of hepatic encephalopathy.

A
  • Treat underlying cause (laxatives, broad spectrum antibiotics)
  • Repeated admissions with HE is an indicator for transplant
46
Q

Describe the presentation of hepatocellular carcinoma.

A
  • Decompensation of liver disease
  • Abdominal mass
  • Abdominal pain
  • Weight loss
  • Bleeding from tumour
47
Q

Describe the investigation of hepatocellular carcinoma.

A

Tumour marker: AFP

Radiology: USS, CT, MRI

Biopsy is rare

Alimentary System (43 decks)

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