Jaundice and Chronic Liver Disease: Investigations, Treatment and Management Flashcards by Sarah Anderson

When the Liver stops working what is the main symptoms that occur

Jaundice
Ascities
Variceal Bleeding
Hepatic encephalopathy

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What is the cause of jaundice

Excess circulating bilirubin (exceed 34 µmol/L)

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What is the overall symptoms of jaundice

Yellowing of the skin, sclerae (white outer layers or the eye ball)
and other tissues

and high yellow coloured urine

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What is the three classification of jaundice

Pre-hepatic - Unconjugated bilirubin before the liver

Hepatic - conjugated bilirubin in the liver

Post Hepatic - conjugated bilirubin after the liver

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What is the cause of pre hepatic jaundice

Increased quantity of bilirubin - heamolysis

Impaired transport

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What is the cause of hepatic jaundice

Defective uptake of bilirubin
Defective conjugation
Defective excretion

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What is the cause of post hepatic jaundice

Defective transport of bilirubin by the biliary ducts

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What classification of jaundice acholuric jaundice

Prehepatic due to excessive circulation of unconjugated bile and no bile pigments in the blood

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What are the specific symptoms of pre hepatic jaundice

History of anaemia:
Dysnopea
Chest pain
Fatigue

Pallor
Splenomegaly

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IVDU and drug intake have the highest risk factor for what kind of Jaundice

Hepatic jaundice

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What is the symptoms of hepatic jaundice

Ascites - accumulation of fluid in peritoneal cavity

Variceal bleed - dilated blood vessels

encephalopathy

Spider naevi,

Gynaecomastia (moobs)

Asterixis - flapping tremor

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What is the symptoms of post hepatic jaundice

Abdominal pain
Pruritus
pale stools (normal colour if before liver)
High coloured urine
Palpable gallbladder

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What is testes for in Liver screen investigations to check the health of your liver

Hepatitis B & C serology

Autoantibody profile,

serum immunoglobulins

Caeruloplasmin and copper (cooper storage)

Ferritin and transferrin saturation (iron storage)

Alpha 1 anti trypsin

Fasting glucose and lipid profile

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What is the different imaging investigation used in the diagnosis of liver disease and jaundice

Ultrasound of abdomen

CT/MRI scan

Endoscopic retrograde cholangiopancreatography (ERCP)

Magnetic resonance cholangiopancreatography (MRCP)

Percutaneous Transhepatic Cholangiogram

Endoscopic Ultrasound (EUS)

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Why is ultrasound of the abdomen the most important investigation

Differentiates extrahepatic and intrahepatic obstruction

finds the cause and extent of obstruction

Documents evidence of portal hypertension

Preliminary staging of extent of disease e.g. cancer spread

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What is Endoscopic retrograde cholangiopancreatography (ERCP)

Technique that combines the use of endoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or pancreatic ductal systems.

Offer therapeutic option as well as imaging

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What is the disadvantages of ERCP

Radiation
Sedation

Complications (5%)

Failure rate (10%)

Only images ducts

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Define MRCP

is a special type of magnetic resonance imaging (MRI) exam that produces detailed images of the hepatobiliary and pancreatic systems

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What is the advantages and disadvantages to MRCP

Noninvassive procedure
No radiation
No complications
Can image outwith the ducts

clautraphobia - 5%
Only offer diagnosis

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What is ERCP used to treat

Dilated biliary tree (due to visible stones or tumour)

Chlodocholithiasis - Acute gallstone pancreatitis

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How does ERCP perform therapeutic

Sphincterotomy
(An operation to cut the muscle between the common bile duct and the pancreatic duct. The operation uses a catheter and a wire to remove gallstones or other blockages)

stenting of biliary duct obstruction

stone retrieval basket

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What is the complication of ERCP

Pancreatitis

Cholangitis - infection of the bile duct

Bleeding

Perforation

Sedation complications leading to respiratory and cardiovascular problems

What happens in the PCT imaging

Done under local anesthesia by a radiologist
thin needle is inserted through the skin (percutaneous) and through the liver (transhepatic) into a bile duct

more invasive than ERCP so used when ERCP cant be carried out due to obstruction or previous surgery
or to perform Hilar stenting

What is the functions of Endoscopic ultrasound

Characterising pancreatic masses

Staging of tumours

Fine needle aspirate (FNA) of tumours cysts, small stones (but not biliary microcalculi)

Define chronic liver disease

Liver disease persisting beyond 6 months - cirrhosis

What is the aetiologies of Cirrhosis

``` Alcohol Autoimmune Heamocrhomatosis Chronic Viral Hepatitis B, C Non- Alcoholic Fatty Liver Disease Drugs Cystic fibrosis Vascular problems - portal hypertension Cryptogenic ```

What is the pathology of cirrhosis

Chronic liver injury occurs causing infiltrating lymphocytes this causes fibrosis as extracellular matrix proteins gather blocking the sinusoids of the liver therefore increasing resistance to blood flow so liver cant receive nutrients or oxygen from the blood Cirrhosis occurs as a diffuse process involving whole liver as hepatocytes death is replaced by nodules of hepatocytes that are separated by the broad band of fibrous tissue leading to loss of normal liver structure

What further complications arise from chronic liver disease

Ascites Variceal bleeding Hepatic encephalopathy Hepatocellular carcinoma (liver cancer)

What is ascites

accumulation of fluid in the peritoneal cavity - swollen abdomen

What is found on physical examination of someone with ascites

Shifting dullness Dulness in flanks Spiders naevia Palmar Erythema, Abdominal veins Fetor hepaticus - Umbilical nodule JVP elevation Flank haematoma

How does fetor hepaticas occur

also known as breath of the dead or hepatic foetor, is a condition seen in portal hypertension where portosystemic shunting allows thiols to pass directly into the lungs

Spider naevi sis caused by what hormone imbalance

Increased oestrogen levels in the blood

How is acitites diagnosed

Diagnostic paracentesiss -needle is inserted into the peritoneal cavity and ascitic fluid is removed

What is investigated in diagnostic paracentesis

Protein & albumin concentration Cell count and differential SAAG (serum-ascites albumin gradient)

What is the treatment options of Ascites

Diuretics Large volume paracentesis TIPS Aquaretics (drug that promotes excretion of water without electrolyte loss) Liver transplantation

What happens in a TIPS procedure

Transjugular intrahepatic portosystemic shunt is an artificial channel within the liver that establishes communication between the inflow portal vein and the outflow hepatic vein therefore decreasing portal hypertension

What causes variceal haemorrhage

Portal hypertension small blood vessels cant handle alot of pressure there for burst as a consequence

Where are varicel bleeds most likely to occur then

Portosystemic anastomoses: ``` Skin Oesophageal Rectal Posterior abdominal wall Stomal ```

What is caput medusa

varices appearing on the skin

What is the management of Varcies

Emergency endoscopy: Endoscopic band ligation - tying ligate lightly around blood vessel to stop bleeding If re- bleeding after endoscopy - TIPS Terlipressin - vasoactive drug used in the management of low blood pressure helps control vacies Sengstaken-Blakemore tube (medical device inserted through the nose or mouth for management of hemorrhage due to esophageal varices)

Define hepatic encephalopathy

Confusion due to liver disease | increased ammonium in the blood going to the brain

What are precipitants that with liver disease lead to hepatic encephalopathy

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

What is the management of hepatic encephalopathy

Treat underlying cause Constipation: Laxatives – phosphate enemas and lactulose Infection: Neomycin, Rifaximin-broad spectrum non absorbed antibiotic

What is repeated addmission with Hepatic encephalopathy an indicator of

Liver transplant

What is additional symptoms with hepatic encephalopathy

Flapping tremor – asterixis foetor hepaticus - dead breath

What is the aetiology Hepatocellular carcinoma (liver cancer)

Cirrhosis | Chronic Hepatitis B and C

What is the symptoms Hepatocellular carcinoma

Liver disease Abdominal mass Abdominal pain Weight loss Bleeding from tumour

What Image investigations are used for the diagnosis of hepatocellual carcinoma

Ultrasound CT scan MRI (liver biopsy rarely done)

What is the tumour marker for hepatocellular carcinoma

AFP

What is the treatment options for hepatocellualr carcinoma

Hepatic resection Liver transplantation Chemotherapy Locally ablative Sorafenib (Tyrosinase kinase inhibitor) Hormonal therapy: Tamoxifen

What is the two forms of chemotherapy in the treatment of hepatocellualr carcinoma

Locally delivered: TACE (Transcatheter arterial chemo-embolization) Systemic chemotherapy

What are the two forms of ablative therapy treatment in herpatocellular carcinoma

Alcohol injection Radiofrequency ablation

How can hepatic resection occur

Chop off one half of the liver due to the individual blood supply of the liver lobes