Jaundice and chronic liver disease (not done)

Question 1

What are the basic functions of the liver?

Answer 1

Synthesis

Detoxification

Immunity

Storage

Question 2

What does the liver synthesize?

Answer 2

Clotting factors

Bile acids

Metabollites (carbs, lipids, proteins)

Hormones - Angiotensinogen, Insulin-like growth factor

Question 3

What important protein is synthesized in the liver. Why is it relavent to GI?

Answer 3

Albumin

Low levels of albumin can indicate pathology of the liver and kidneys

Question 4

What are the detoxification functions of the liver?

Answer 4

Turning ammonia into urea

Detoxification of drugs

Billirubin metabolism

Breakdown of insulin and other hormones

Question 5

Highlight the immune functions of the liver

Answer 5

• Combating infections
• Clearing the blood of particles and infections, including bacteria
• Neutralizing and destroying all drugs and toxins

Question 6

What does the liver store?

Answer 6

Glycogen

Vitamins A, D, B12 & K

Copper

Iron

Question 7

What are the different liver function tests?

Answer 7

Billirubin

Aminotransferases

Alkaline phosphotase

Gamma GT

Albumin

Prothrombin time

Creatinine

Platelet count

Question 8

What is bilirubin?

Answer 8

By-product of Haeme metabolism

Produced in the spleen from old RBC’s

Question 9

What is the purpose of Bilirubin testing?

Answer 9

Elevated as a result of:

• Pre-hepatic: Haemolysis
• Hepatic: Parenchymal damage
• Post hepatic: Obstructive

Question 10

What are aminotransferases?

Answer 10

Enzymes that are present in hepatocytes

AST and ALT are both types of aminotransferase

Question 11

What is the purpose of aminotransferase testing?

Answer 11

The ratio of AST:ALT can indicate Alcoholic liver disease (ALD)

Can suggest parenchymal involvement

Question 12

What is alkaline phosphotase?

Answer 12

Enzyme present in bile ducts (+ bone, placenta and intestines)

Question 13

What is the purpose of alkaline phosphotase testing?

Answer 13

Elevated with obstruction or liver infiltration

Question 14

What is Gamma GT and why do we test for it?

Answer 14

Non specific liver enzyme

Levels are elevated by alcohol usage (also by NSAID usage)

Useful to confirm liver source of Alkaline phosphotase (ALP)

Question 15

Why do we test for albumin levels?

Answer 15

Low levels suggest chronic liver disease

Can be low in kidney disorders and malnutrition

Question 16

Why do we test the prothrombin time?

Answer 16

Extremely important test fo liver function as it shows the degree of liver dysfunction

For this reason, it is used to decide the stage of liver disease, who needs/gets a liver transplant

Question 17

Why do we test for creatinine?

Answer 17

Determines survival chances from liver disease

Critical assessment for who needs a liver transplant

(technically shows kidney function not liver)

Question 18

Why do we test for platelet count?

Answer 18

Platelet count is low in cirrhotic subjects as a result of hypersplenism

Indirect marker of portal hypertension

Question 19

What are the symptoms of a failing liver?

Answer 19

• Jaundice
• Ascites
• Variceal bleeding
• Hepatic encephalopathy

Question 20

What is jaundice?

Answer 20

Yellowing of the skin, sclerae, and other tissues caused by excess circulating bilirubin

Question 21

How much bilirubin is needed for jaundice to be detectable?

Answer 21

Detectable when total plasma bilirubin levels exceed 34 µmol/L

Question 22

What is a differential diagnosis for jaundice?

Answer 22

Carotenemia

(increased beta-carotene levels in the blood due to diet)

Question 23

What is the intermediate between Haeme and Bilirubin?

Answer 23

Biliverdin

Question 24

What is the difference between Pre-hepatic, hepatic and post hepatic bilirubin?

Answer 24

Pre-hepatic - Bilirubin is unconjugated and is complexed with albumin (in blood)

Hepatic - Bilirubin conjugates with glucuronic acid

Post-hepatic - Conjugated bilirubin in bloodstream

Question 25

Increased quantity of bilirubin (jaundice) that is PRE-hepatic indicates what?

Answer 25

Increased quantity of bilirubin - as a result of Haemolysis

or

Impaired transport

Question 26

What does increased hepatic levels of bilirubin indicate?

Answer 26

Defective uptake of bilirubin

Defective conjugation

Defective excretion

Question 27

Increased post hepatic levels of bilirubin is an indicator of what?

Answer 27

Defective transport of bilirubin by the biliary ducts

Question 28

What features on a history would indicate pre-hepatic jaundice?

Answer 28

H/o Anaemia

Acholuric jaundice (inherited condition)

Question 29

What features on a history would indicate hepatic jaundice?

Answer 29

Risk factors for liver disease (IVDU, drug intake)

Decompensation (ascites, variceal bleed,encephalopathy)

Question 30

What features on a history would indicate post-hepatic jaundice?

Answer 30

Abdominal pain

Cholestasis (Pruritus, pale stools, high coloured urine)

Question 31

What clues on clinical examination would indicate pre-hepatic jaundice?

Answer 31

Pallor

Splenomegaly

Question 32

What clues on clinical examination would indicated hepatic jaundice?

Answer 32

Stigmata of CLD (spider naevi, gynaecomastia)

Ascites

Asterixis (liver flap)

Question 33

What features on clinical examination would indicate post-hepatic jaundice?

Answer 33

Palpable gall bladder (Courvoisier’s sign)

Question 34

What investigations would you do for jaundice?

Answer 34

Abdominal US scan

Liver screen:

• Hepatitis B & C serology
• Autoantibody profile, serum immunoglobulins
• Caeruloplasmin and copper
• Ferritin and transferrin saturation
• Alpha 1 anti trypsin
• Fasting glucose and lipid profile

Question 35

Why is an abdominal ultrasound scan useful for jaundice?

Answer 35

• Differentiates extrahepatic and intrahepatic obstruction
• Delineates site of obstruction
• Delineates cause of obstruction
• Documents evidence of portal hypertension
• Preliminary staging of extent of disease e.g. cancer spread