Jaundice and Chronic Liver Disease Flashcards
What does the liver synthesize?
Clotting factors Bile acids Glycogen Albumin Cholesterol, lipoproteins and TG Hormones (angiotensinogen, insulin like growth factor)
What does the liver store?
Glycogen
Vitamins (A, D, B12 & K)
Cu & Fe
What happens during the conjugation of bilirubin?
Solubilization
Initially it is bound to albumin (insoluble - unconjugated)
Liver makes it soluble (conjugated)
What are some liver function tests?
Bilirubin
Aminotransferases
Alkaline Phosphatase (raised in cholestasis, hepatitis, cirrhosis)
Albumin
Gamma GT (GGT - raised in liver injury / cholestasis)
Prothrombin time
What aminotransferases are measured? What can they point to?
AST & ALT (both enzymes present in hepatocytes)
High AST:ALT can indicate ALD
They suggest parenchymal involvement
What does elevated alkaline phosphatase indicate?
Obstruction or liver infiltration
Is elevated during pregnancy
What does low albumin suggest?
CLD
Important test for synthetic function of the liver
What is a prothrombin time test? What’s it useful for?
Tests whether thrombins are forming well
Important bc can stage the degree of liver disease, can help decide who needs transplant
What effect does liver cirrhosis have on the spleen?
Cirrhosis can cause splenomegaly because of portal hypertension
Clinical signs of liver failure?
Jaundice
Ascites
Variceal bleeding
Hepatic encephalopathy (confusion / reduced cognitive function)
Classification of jaundice?
Pre-Hepatic (excess bilirubin/haemolysis/impaired transport)
Hepatic (defective uptake/conjugation/excretion of bilirubin)
Post Hepatic (defective transport by biliary ducts)
Signs that jaundice is hepatic in origin?
Risk factors for liver disease in history (IVDU/drugs)
Decompensation (ascites, variceal bleed, encephalopathy)
Asterixis (liver flap)
Signs that jaundice is post-hepatic in origin?
Abdominal pain
pruritis/pale stool/dark urine
Palpable gall bladder
Investigations for suspected liver failure?
Hep B/C serology LFTs (AST/ALT/Albumin) Bloods Ferritin/transferrin Alpha 1 antitrypsin USS abdomen
Advantages of abdomen ultrasound? What can be seen?
Locate site of obstruction
Tells whether there is portal hypertension
Can detect masses in some cases
Cheap, no radiation
Procedure of ERCP vs MRCP?
ERCP uses an endoscope to visualize the bile ducts
MRCP uses an MRI machine to view the ducts
How is ERCP used therapeutically?
Can be used to stent the biliary tract
Removal of gallstones in CBD
What is choledocholithiasis?
Gallstones in the bile duct
What are some complications of ERCP?
Sedation issues (cardio/resp)
Pancreatitis
Cholangitis
Bleeding/Perforation
What is a Percutaneous Transhepatic Cholangiogram? When is it used?
PTC is an investigation that examines obstruction in the liver/bile duct. There is a dye injected into the liver and then x-rays are taken
It is used for more proximal obstructions/when ERCp isn’t possible due to obstruction etc.
When is an endoscopic ultrasound usually performed?
Characterizing pancreatic masses
Tumour staging
Aspirations/biopsy assisting
Causes of liver cirrhosis?
Alcohol (#1 cause) Autoimmune disease (Hep/PBC) Haemochromatosis Hepatitis (B&C) NAFLD Drugs (MTX, amiodarone) CF, Alpha1 antitrypsin deficiency Vascular problems (portal hypert.) Sarcoidosis/etc.
Types of chronic liver disease? Differences in presentation?
Compensated and decompensated
Decompensated should show more obvious signs, compensated may require testing to be detected
Presentation of cirrhosis?
Ascites Portal hypertension Variceal bleeding Splenomegaly Hepatic encephalopathy
What are spider naevi due to?
Lack of testosterone metabolism in the liver - gets converted to estrogen
Red dots on skin and even feminization of patients
Management of new-onset ascites?
Diagnostic paracentesis (drain fluid & test)
Tests done after diagnostic paracentesis of ascites?
Protein and albumin
Cell count
SAAG (serum-ascites albumin gradient)
If SAAG testing of ascites fluid shows gradient of >1.1 g/dl what are possible causes of ascites?
Portal hypertension
Or malignancy/heart failure causing portal hypertension
If SAAG testing of ascites is <1.1 g/dl what may be causes of the ascites?
Malignancy TB Chylous ascites Pancreatic causes Biliary ascites Nephrotic syndrome
Treatment options for ascites?
Diuretics Large volume paracentesis TIPS Aquaretics Liver transplant
Cause of varicies?
Locations where they can occur?
Portal hypertension
Skin - caput medusa
Rectal
Oesophageal & gastric
Stomal
What are varicies?
Swollen or enlarged veins
Immediate management of varicieal bleeding?
Resuscitate patient - stop bleeding. Done via beta blocker to reduce portal hypertension & endoscopic band ligation if needed
Blood transfusion if needed
Endoscopy once patient is stable
Treatment of varicies?
Endoscopic band ligation
Band the vein to close it, if band falls off band again until vein scarred enough so it won’t rupture again
What is hepatic encephalopathy? Non-cognitive signs?
Confusion due to liver disease
Liver flap is an early sign
Risk factors for hepatocellular carcinoma?
Cirrhosis
Chronic Hep B & C
Presentation of hepatocellular carcinoma?
Decompensation of liver disease
Abdominal mass/pain
Weight loss
Bleeding from tumour
Treatment options for hepatocellular carcinoma?
Hepatic resection
Liver transplant
Chemotherapy
Local ablation
Hormonal therapy (tamoxifen)
