Jaundice and Chronic Liver Disease/Hepato-Biliary Pathology Flashcards
What are the three classes of jaundice?
Pre-hepatic
Hepatic
Post Hepatic
What is the cause of jaundice?
Increase in circulating bilirubin due to altered metabolism
What part of haemoglobin is converted to bilirubin?
Haem part
What is involved in the pre-hepatic phase?
Breakdown of haemoglobin -> haem and globin, haem is converted to bilirubin
What is involved in the hepatic phase?
Uptake and conjugation of bilirubin by the hepatocytes and excretion of the conjugated bilirubin into the biliary system
What is involved in the post-hepatic phase?
Transport of conjugated bilirubin in the biliary system , breakdown in the intestine and reabsorption
What is cholestasis?
Accumulation of bile within the hepatocytes or bile canaliculi due to viral hepatitis, alcoholic hepatitis, liver failure or drugs
What are the types of hepatic jaundice?
Predictable - dose related
Unpredictable - not dose related
What causes hepatic jaundice?
Intra-hepatic bile duct obstruction Due to: Primary biliary cholangitis Primary sclerosing cholangitis Tumours of the liver
What is primary biliary cholangitis?
An organ specific auto-immune disease causing granulomatous inflammation involving the bile ducts, loss of intra-hepatic bile ducts and progression to cirrhosis
What can be detected in serum for diagnosis of primary biliary cholangitis?
Anti-mitochondrial auto-antibodies
Raised alkaline phosphatase
What is primary sclerosing cholangitis?
Chronic inflammation and fibrous obliteration of the bile ducts causing loss of intra-hepatic bile ducts and progression to cirrhosis
Primary sclerosing cholangitis is associated with an increased risk of what?
Cholangiocarcinoma
What is the cause of post-hepatic jaundice?
Gallstones and diseases of the gall bladder causing extra hepatic obstruction
What is acute cholecystitis?
Acute inflammation of the gall bladder
What is caused by acute cholecystitis?
Empyema leading to the perforation of the gall bladder, biliary peritonitis and eventual progression to chronic inflammation in which pus is formed in the gall bladder
What is chronic cholecystitis?
Chronic inflammation and fibrosis of the gall bladder
What are the causes of common bile duct obstruction?
Gallstones
Bile duct tumours
Benign strictures
External compression due to tumours
What are the effects of common bile duct obstruction?
Jaundice
No bile excreted into duodenum
Infection of bile proximal to the obstruction
Secondary biliary cirrhosis if obstruction is prolonged
What can cause an elevation in circulating bilirubin?
Haemolysis
Parenchymal Damage
Obstruction
How are amino transferases used to determine liver function?
ALT and AST can indicate liver injury but are not specific to it, if AST levels > ALT levels alcoholic liver disease is indicated
May also indicate parenchymal involvement
What is alkaline phosphatase and how is it used to determine liver function?
An enzyme present in the bile ducts which becomes elevated during obstruction or liver infiltration
However it is non-specific as it is also present in bone disease, placenta and the intestines
What is gamma-GT and how is it used to determine liver function?
A non-specific liver enzyme which is elevated with alcohol consumption and some drugs
Can be useful to confirm a liver source of ALP
If alkaline phosphatase and gamma-GT levels are moth raised then liver disease is indicated
How is albumin useful in detecting liver disease?
Important test for synthetic function of the liver
Low levels suggest chronic liver disease, kidney disorders or malnutrition
How is prothrombin time useful in detecting liver disease?
Important test for liver function, tells the extent and prognosis of liver function
Test of the clotting factors so if abnormal significant disease is indicated
How is creatinine a useful test in the diagnosis of liver disease?
Creatinine tests kidney function, since kidney and liver function are closely related it helps to determine the prognosis of liver disease
How is a platelet count a useful test in the diagnosis of liver disease?
Liver is an important source of thrombopoeitin, poor liver function will reduce bone marrow activity, also cirrhosis can result in splenomegaly - hypersplenism results in low platelets
Give 5 things which would be tested for in the blood in investigation of liver disease
Immunoglobulins - IgA, IgG, IgM Autoantibodies - AMA, ASMA, ANA Caeruloplasmin copper Ferritin Alpha-1-antitrypsin Hepatitis serology Epstein Barr Virus Cytomegalovirus Leptospira Alphafoetoprotein Fatty liver disease - fasting glucose or lipid profile
What are the typical presentations of liver failure?
Jaundice
Ascites
Variceal bleeding
Hepatic encephalopathy
When would a liver biopsy be indicated?
In unknown parenchymal disease or if an unknown focal liver lesion
If the aetiology of disease is known but more information is required on inflammation, fibrosis or cirrhosis
What imaging investigations might be done in suspected liver failure?
Ultrasound of liver and biliary tree CT of abdomen MRI of abdomen ERCP Endoscopic ultrasound MRCP
Give the causes of acute liver injury
Hepatitis Viral Hepatitis - A, B, C or E Viruses Alcohol Drugs Bile duct obstruction
What happens to the liver in viral hepatitis?
Live inflammation, cell damage and death
What kinds of viral hepatitis might resolve and return to normal without treatment?
A or E
What kinds of viral hepatitis can cause liver failure due to liver damage caused by severe hepatitis?
A, B or E
What kinds of viral hepatitis can progress to chronic hepatitis and cirrhosis?
B or C
What is alcoholic hepatitis?
Inflammatory response of the liver to alcohol causing acute inflammation, liver cell death and liver failure
What can alcoholic hepatitis progress to?
Cirrhosis
What are the causes of hepatic cirrhosis?
Alcohol Hepatitis B or C Autoimmune hepatitis Primary biliary cholangitis Primary haemachromatosis Wilson's disease Obesity/diabetes mellitus Idiopathic
What is hepatic cirrhosis
A diffuse process involving the whole liver causing loss of normal liver structure which is replaced by nodules of hepatocytes and fibrous tissue
Give the complications of hepatic cirrhosis
Liver failure caused by altered liver function
Portal hypertension causing haemorrhage risk
Increased risk of hepatocellular carcinoma
What are the histological types of liver tumours?
Hepatocellular carcinoma
Cholangiocarcinoma
Metastatic tumours also commonly occur in the liver
How does hepatocellular carcinoma usually develop and what cells does it affect?
Generally develops with cirrhosis
Malignant tumour of the hepatocytes
What is cholangiocarcinoma?
A malignant tumour of the bile duct epithelium
What are the common liver disorders?
Jaundice Liver failure Intrahepatic bile duct obstruction Cirrhosis Tumours
What are the causes of cholestasis?
Viral hepatitis
Alcoholic hepatitis
Liver failure
Drugs
What are the causes of intra-hepatic bile duct obstruction?
Primary biliary cholangitis
Primary sclerosing cholangitis
Tumours
How might gall stones present?
Asymptomatic Dyspeptic symptoms Biliary colic Acute cholecystitis Empyema Perforation Jaundice Gallstone ileus
What investigations would be done if suspecting gallstones?
MRCP EUS CT Amylase and lipase WCC
What would be done if diagnosis of gallstones had been confirmed as therapeutic management?
PTC or ERCP
What is the best surgical procedure for removal of gallstones?
Laparoscopic cholecystectomy
What is choledocholithiasis?
Presence of at least one gall stone in the common bile duct
How might choledocholithiasis present?
Post-cholecystectomy pain
Obstructive jaundice
Acute pancreatitis
Ascending cholangitis
What is the management for choledocholithiasis?
Laparoscopic CBD exploration
ERCP
Transhepatic stone retrieval
What are the risk factors for cholangiocarcinoma?
Increasing age Primary sclerosing cholangitis Congenital cystic disease Biliary enteric drainage Thorotrast (old contrast agent) Hepatolithiasis Carcinogen exposure
What are the histological types of ampullary tumours?
Adenoma
Adenocarcinoma
What is the treatment for ampullary tumours?
Endoscopic excision
Trans-duodenal excision
Pancreatico-duodenectomy
