Jaundice and Chronic Liver Disease Flashcards
1
Q
What is a doctor who deals with the liver called?
A
Hepatologist
2
Q
What are the different categories of liver functions?
A
Synthetic function
Detoxification function
Immune function
Storage function
3
Q
What are synthetic functions of the liver?
A
Clotting factors
Bile acids
Carbohydrates
Proteins
Lipids
Hormones
4
Q
What functions related to carbohydrates is the liver responsible for?
A
Gluconeogenesis
Glycogenolysis
Glycogenesis
5
Q
What is glycogenolysis?
A
Breakdown of glycogen to glucose
6
Q
What is glycogenesis?
A
The formation of glycogen from glucose
7
Q
What is gluconeogenesis?
A
Generation of glucose from non-carbohydrate substances
8
Q
What protein is the liver responsible for making?
A
Albumin
9
Q
What lipids is the liver responsible for making?
A
Cholesterol
Lipoprotein and triacylglyerol
10
Q
What hormones is the liver responsible for making?
A
Angiotensinogen
Insulin like growth factor
11
Q
What are detoxification functions of the liver?
A
Urea production from ammonia
Detoxification of drugs
Bilirubin metabolism
Breakdown of insulin and hormones
12
Q
What are immune functions of the liver?
A
Combating infections
Clearing the blood of particles and infections, including bacteria
Neutralising and destroying all drugs and toxins
13
Q
What are storage functions of the liver?
A
Stores glycogen
Stores vitamin A, D, B12 and K
Stores copper and iron
14
Q
What things do liver function tests measure?
A
Bilirubin
Aminotransferases
Alkaline phophotase
Gamma GT
Albumin
Prothrombin time
Creatinine
Platelet count
15
Q
What is bilirubin a by product of?
A
Haem metabolism
16
Q
What is bilirubin generated by?
A
Senescent RBCs in the spleen
17
Q
What is bilirubin bound to when it is unconjugated?
A
Albumin
18
Q
What does conjugating bilirubin do?
A
Solubilises it
19
Q
What is bilirubin elevated as a result of?
A
Haemolysis (pre-hepatic)
Parenchymal damage (hepatic)
Obstruction (post hepatic)
20
Q
What are aminotransferases?
A
Enzymes present in hepatocytes
21
Q
What are examples of aminotransferases?
A
AST
ALT
22
Q
What can the AST/ALT ratio point towards?
A
Alcoholic liver disease
23
Q
What is alkaline phosphotase?
A
Enzyme present in bile ducts
24
Q
What causes alkaline phosphatase to be elevated?
A
Obstruction or liver infiltration
25
Other than the bile duct, where is alkaline phosphatase present?
Bone
Placenta
Intestines
26
What is Gamma GT?
Non-specific liver enzyme
27
What causes Gamma GT to be elevated?
Alcohol use
28
What drugs can raise Gamma GT levels?
NSAIDs
29
What do low levels of albumin suggest?
Chronic liver disease
30
Other than liver diseases, what else can cause low albumin levels?
Kidney disorders and malnutrition
31
What does prothrombin time tell?
Degree of liver dysfunction
32
What is prothrombin time used to calculate?
Scores to decide stage of liver disease, who needs a liver transplant and who gets a liver transplant
33
How does cirrhosis of the liver affect the spleen?
Causes splenomegaly
34
What is platelet count being low an indirect marker of?
Portal hypertension
35
What is the clinical presentation of the liver not working?
Jaundice
Ascites
Variceal bleeding
Hepatic encephalopathy
36
What is jaundice?
Yellowing of the skin, sclerae and other tissues caused by excess circulating bilirubin
37
When is jaundice detectable?
When total plasma bilirubin levels exceed 34umol/L
38
What are the different classifications of jaundice?
Pre-hepatic
Hepatic
Post-hepatic
39
What can cause pre-hepatic jaundice?
Increased quantity of bilirubin (haemolysis)
Impaired transport
40
What can cause hepatic jaundice?
Defective uptake of bilirubin
Defective conjugation
Defective excretion
41
What can cause post-hepatic jaundice?
Defective transport of bilirubin by the biliary ducts
42
When is bilirubin unconjugated?
Before it arrives in the liver
43
What are clues from the history for pre-hepatic jaundice?
History of anaemic (fatigue, dyspnoea, chest pain)
Acholuric jaundice
44
What are clues from the history for hepatic jaundice?
Risk factors for liver disease (such as IVDU, drug intake)
Decompensation (ascites, variceal bleed, encephalopathy)
45
What are clues from the history for post-hepatic jaundice?
Abdominal pain
Cholestasis (pruritus, pale stools, high coloured urine)
46
What are clues on clinical examination for pre-hepatic jaundice?
Pallor
Splenomegaly
47
What are clues on clinical examination for hepatic jaundice?
Stigmata of CLD (spider naevi, gynaecomastia)
Ascites
Asterixis
48
What are clues on clinical examination for post-hepatic jaundice?
Palpable gallbladder
49
What investigations are done for jaundice?
Liver screen
Ultrasound of abdomen (most important test)
50
What is checked in a liver screen with jaundice?
Hepatitis B and C serology
Autoantibody profile, serum immunoglobulins
Caeruloplasmin and copper
Ferritin and transferrin saturation
Alpha 1 anti-trypsin
Fasting glucose and lipid profile
51
What does an USS for jaundice tell us?
Extrahepatic or intrahepatic cause
Site of obstruction
Cause of obstruction
Documents evidence of portal hypertension
52
What are advantages of US for jaundice?
Cheap
No radiation
Portable, widely available
Good for gallstones
High specificity
Examines organs as well as biliary system
53
What are advantages of CT/MRI for jaundice?
Better for pancreas
High specificity
High sensitivity
Examines organs as well as biliary system
54
What are disadvantages of MRI/CT scan?
Expensive
Requires CT/MRI scanner
Radiation (CT only)
55
What does MRCP stand for?
Magnetic resonance cholangiopancreatography
56
What is Magnetic resonance cholangiopancreatography (MRCP)?
MRI scan that looks at hepatobiliary and pancreatic systems
57
What does ERCP stand for?
Endoscopic retrograde cholangiopancreatography
58
What is a Endoscopic retrograde cholangiopancreatography (ERCP)?
Endoscopic through the mouth to examine the stomach and duodenum
59
What are advantages of MRCP?
No radiation
No complications
60
What are disadvantages of MRCP?
5% claustrophobia
Can image outwidth the ducts
61
What are disadvantages of ERCP?
Radiation
Sedation
Complications
Failure rate
Only images ducts
62
What is an advantage of ERCP?
Therapeutic option
63
How can ERCP be therapeutic?
Stenting of biliary tract obstruction
64
What are some sedation related complications of ERCP?
Respiratory and cardiovascular problems
65
What are some procedure related complications of ERCP?
Pancreatitis
Cholangitis
Sphincterotomy (bleeding, perforation)
66
Other than MRCP and ERCP, USS, MRI and CT what other imaging methods can be used to investigate jaundice?
Percutaneous transhepatic cholangiogram
Endoscopic ultrasound
67
What is Percutaneous transhepatic cholangiogram?
Radiological imaging used to visualise the anatomy of the biliary tract, contrast is injected into biliary track and x-rays are taken
68
When is Percutaneous transhepatic cholangiogram used?
ERCP not possible due to duodenal obstruction or previous surgery
Hilar stenting
69
What is a disadvantage of percutaneous transhepatic cholangiogram?
More invasive than ERCP
70
Why is endoscopic ultrasound used?
Biopsy possible
Characterising pancreatic masses
Staging of tumours
Fine needle aspirate (FNA) of tumours and cysts
71
When is something considered to be a chronic liver disease?
Persists longer than 6 months
72
What are examples of chronic liver disease?
Chronic hepatitis
Chronic cholestasis
Fibrosis and cirrhosis
Liver tumours
73
What is the aetiology of cirrhosis?
Alcohol
Autoimmune
Haemochromatosis
Chronic viral hepatitis (B and C)
NAFLD
Drugs
Cystic fibrosis
Vascular problems (portal hypertension)
Cryptogenic
Others such as sarcoidosis, amyloid, schistosomiasis
74
What are examples of autoimmune causes of cirrhosis?
Autoimmune hepatitis
PBC
PSC
75
What are some pathological changes in the liver with cirrhosis?
Infiltrating lymphocytes
Apoptotic hepatocyte
Activated Kupffer cell
Sinusoid lumen with increased resistance to blood flow
76
What are some clinical features of cirrhosis due to compensated liver disease?
Routinly detected on screening tests
Abnormalities of liver function tests
77
What is compensated cirrhosis?
The liver is coping with the damage and maintaining important functions
78
What is the clinical presentation of decompensated chronic liver disease?
Ascites
Variceal bleeding
Hepatic encephalopathy
79
What are ascites?
Build up of fluid in the peritoneal cavity
80
What are clinical features of ascites?
Physical exam reveals dullness in flanks and shifting dullness
Spider naevi, palmar erthema, abdominal veins, fetor hepaticus
Umbilical nodule
JVP elevation
Flank haematoma
81
What investigation can ascites be confirmed by?
USS
82
What should all patients with new-onset ascites have?
Diagnostic paracentesis
83
What is a diagnostic paracentesis?
Procedure where a needle or catheter is inserted into the peritoneal cavity to obtain ascitic fluid for diagnostic or therapeutic purposes
84
What studies are needed on initial evaluation of ascites?
Protein and albumin concentration
Cell count and differential
SAAG (serum-ascites albumin gradient)
85
What does SAAG stand for?
Serum-ascites albumin gradient
86
What causes a high albumin gradient in ascites?
Portal hypertension
Congestive heart failure
Constrictive pericarditis
Budd Chiarri
Massive liver metstasis
87
What causes a low albumin gradient in ascites?
Malignancy
Tuberculosis
Pancreatic
Biliary ascites
Nephrotic syndrome
88
What level of albumin is considered a high albumin gradient for ascites?
\>1.1g/dL
89
What are treatment options for ascites?
Diuretics
Large volume paracentesis
TIPS
Aquaretics
Liver transplantation
90
What is large volume paracentesis?
Removal of 5L of fluid or more
91
What does TIPS stand for?
Transjugular Intrahepatic Portosystemic Shunt
92
What is a transjugular intrahepatic portosystemic shunt (TIPS)?
Procedure that uses image guidance to connect the portal vein to the hepatic vein in the liver
93
What are aquaretics?
Class of drugs that promote aquaresis (excretion of water without electrolyte loss)
94
What are varices?
Dilated blood vessels
95
What do varices occur due to?
Portal hypertension
96
What is the management of variceal haemorrhage?
Resuscitate patient
Good IV access
Blood transfusion as required
Emergency endoscopy
Endoscopic band ligation
TIPS for rebleeding after banding
97
What is endoscopic band ligation?
Procedure where dilated vein is cut of by a band
98
What is hepatic encephalopathy?
Confusion due to liver disease
99
How is hepatic encephalopathy graded?
1 to 4
100
What are precipitants of hepatic encephalopathy?
GI bleed
Infection
Constipation
Dehydration
Medication especially sedation
101
What is the treatment for hepatic encephalopathy?
Treat underlying cause
Laxatives
Neomycin, rifaximin (broad spectrum of non-absorbed antibiotics)
102
What is repeated admission with hepatic encephalopthy an indicator for?
Liver transplant
103
What histological class is most responsible for liver cancer?
Hepatocellular carcinoma
104
What does hepatocellular carcinoma occur in the background of?
Cirrhosis
105
What does hepatocellular carcinoma occur in association with?
Chronic hepatitis B and C
106
What is the presentation of hepatocellular carcinoma?
Decompensation of liver disease
Abdominal mass
Abdominal pain
Weight loss
Bleeding from tumour
107
What is used to diagnose hepatocellular carcinoma?
Tumour markers (AFP)
Radiological tests (USS, CT scan, MRI scan)
108
What tumour marker is used to diagnosed hepatocellular carcinoma?
AFP
109
What is the treatment for hepatocellular carcinoma?
Hepatic resection
Liver transplantation
Chemotherapy
Locally ablative treatmnts
Sorafenib
Hormonal therapy
110
What are the different ways that chemotherapy can be delivered for hepatocellular carcinoma?
Locally delivered
Systemic chemotherapy
111
What are examples of locally ablative treatments for hepatocellular carcinoma?
Alcohol injection
Radiofrequency ablation
112
What is sorafenib?
Tyrosine kinase inhibitor
