Jaundice and Chronic Liver Disease: Investigations, Treatment and Management Flashcards
When the Liver stops working what is the main symptoms that occur
Jaundice
Ascities
Variceal Bleeding
Hepatic encephalopathy
What is the cause of jaundice
Excess circulating bilirubin (exceed 34 µmol/L)
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
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
What is the cause of pre hepatic jaundice
Increased quantity of bilirubin - heamolysis
Impaired transport
What is the cause of hepatic jaundice
Defective uptake of bilirubin
Defective conjugation
Defective excretion
What is the cause of post hepatic jaundice
Defective transport of bilirubin by the biliary ducts
What classification of jaundice acholuric jaundice
Prehepatic due to excessive circulation of unconjugated bile and no bile pigments in the blood
What are the specific symptoms of pre hepatic jaundice
History of anaemia:
Dysnopea
Chest pain
Fatigue
Pallor
Splenomegaly
IVDU and drug intake have the highest risk factor for what kind of Jaundice
Hepatic jaundice
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
What is the symptoms of post hepatic jaundice
Abdominal pain Pruritus pale stools (normal colour if before liver) High coloured urine Palpable gallbladder
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
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)
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
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
What is the disadvantages of ERCP
Radiation
Sedation
Complications (5%)
Failure rate (10%)
Only images ducts
Define MRCP
is a special type of magnetic resonance imaging (MRI) exam that produces detailed images of the hepatobiliary and pancreatic systems
What is the advantages and disadvantages to MRCP
Noninvassive procedure
No radiation
No complications
Can image outwith the ducts
clautraphobia - 5%
Only offer diagnosis
What is ERCP used to treat
Dilated biliary tree (due to visible stones or tumour)
Chlodocholithiasis - Acute gallstone pancreatitis
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
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
