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Year 2- Alimentary > Jaundice & Chronic Liver Disease > Flashcards

Jaundice & Chronic Liver Disease Flashcards

1
Q

What are the synthetic functions of the liver?

A

Production of:
- Clotting Factors
- Bile Acids
- Albumin
- Hormones
- Carb metabolism
- Lipid metabolism

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2
Q

How does the liver metabolise carbs and lipids?

A

Its where gluconeogenesis, glycogenolysis and glycogenesis occur.

Its also where cholesterol, lipoproteins and Triglycerides are synthesised

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3
Q

What hormones are produced in the liver?

A

Angiotensinogen
Insulin-like growth factor

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4
Q

What roles does the liver play in detoxification?

A

Converts ammonia -> Urea
Detoxifies drugs
Metabolises Bilirubin
Breakdown of insulin & other hormones

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5
Q

How is the liver involved in the immune system?

A
  • Combats infection
  • Clears blood of particles & infectious microorganism
  • Neutralizes drugs/toxins absorbed from the gut
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6
Q

What is stored in the liver?

A

Glycogen
Vitamin A, D, B12, K
Copper & Iron
Fat

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7
Q

What are the parts of a liver function tesT?

A

Serum Bilirubin
Aminotransferases
- ALT = Alanine aminotransferase
- AST = Aspartate aminotransferase
Alkaline Phosphotase (ALP)
Gamma Gt
Albumin
Prothrombin time (time for blood to clot)
Creatinine
platelet Count

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8
Q

What are the reasons for a raised bilirubin and what does this result in?

A

Anything causing:
- Haemolysis = pre-hepatic
- Parenchymal damage in live = Hepatic
- Obstruction in biliary system = Post-hepatic

Raised Bilirubin causes Jaundice

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9
Q

What do raised aminotransferases tell us?

A

theres been some sort of parenchymal injury.
A high AST/ALT ratio points to alcoholic liver disease

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10
Q

What is alkaline phosphatase?

A

ALP is an enzyme of the bile ducts

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11
Q

When is ALP elevated?

A

On biliary obstruction or fatty liver infiltration.

Its also present in bone, placenta and intestines so just an isolated rise in ALP might not mean liver disease

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12
Q

When is Gamma GT elevated?

A

Recent alcohol use & NSAIDs trigger Gamma GT elevation

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13
Q

What liver function test do we use to tell if a raised ALP is liver related?

A

Raised Gamma GT often comes with the raised ALP

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14
Q

What liver function tests tell us about the synthetic function of the liver?

A

Albumin
Prothrombin time

As the liver produces albumin and many essential clotting factors

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15
Q

When would albumin levels be low?

A

Any chronic liver disease lowering liver output
Kidney Disorders causing albumin to be lost in the urine
Malnutrition

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16
Q

What is creatinine level and when is it important to LFTs?

A

Basically a measure of kidney function.
It determines how likely you are to survive liver disease and so who gets a transplant

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17
Q

Why is the platelet count included in LFTs?

A

Thrombopoietin is produced in the liver
So in cirrhotic subjects the platelet count can be really low.

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18
Q

Define Jaundice?

A

Yellowing of the skin, sclerae and other tissues due to excess circulating bilirubin
(can be mistaken for carotenemia)

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19
Q

In what type of jaundice will the urine be discoloured (bright yellow)?

A

Hepatic and post hepatic.
Pre-hepatic jaundice will still have normal coloured urine because the excess bilirubin has not been conjugated and so cannot be excreted out the kidneys

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20
Q

What could cause pre-hepatic jaundice?

A

Increase RBC breakdown (haemolysis)
Impaired transport to Liver

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21
Q

What could cause hepatic jaundice?

A
  • Defective Bilirubin uptake
  • Defective Conjugation
  • Defective Excretion
22
Q

How would we determine pre-hepatic jaundice from a histry/exam?

A
  • A history of anaemia (fatigue, dyspnoea, chest pain). Indicates increased haemolysis
  • Acholuric Jaundice (i.e. jaundice without yellow urine)
  • Pallor
  • Splenomegaly (explains increased haemolysis)
23
Q

What clues would hepatic jaundice give on a history/exam?

A

Sinces its hepatic its due to liver disease:
- Any risk factors for liver disease e.g. IVDU etc
- Decompensation (loss of liver function). = ascites, variceal bleed, encephalopathy
- Asterixis (Flapping Tremor)
- Spider Naevi
- Gynaecomastia

24
Q

What would give away post-hepatic jaundice on a history/exam?

A
  • Abdominal pain
  • Cholestasis (pruritis, pale stools, very coloured urine)
  • A palpable gall bladder
25
Q

What investigations are there for a case of jaundice?

A

Run a liver Screen
Ultrasound
MRCP (MR Cholangeopancreatography)

26
Q

Whats the most common therapy for biliary obstructions?

A

Endoscopic Retrograde Cholangiopancreatography.
Allows you to see and repair issues such as:
- Spotting & Removing stones
- Biopsy +/- stenting tumours
- Stenting biliary tract obstructions
- Dealing with any post-op biliary complications

27
Q

How do we deal with gallstones by ERCP?

A

Shockwaves to break up the stone (lithotripsy)
Or
Cut open the sphincter to gain access and pull out the stones (Sphincterotomy)

28
Q

What are the complications of an ERCP?

A

Sedation problems
Pancreatitis/Cholangitis
Bleeding or Perforation from sphincterotomy

29
Q

What alternatives are there to an ERCP for treating biliary obstructions?

A

Percutaneous Transhepatic Cholangioagram (PTC)
Endoscopic ultrasound

30
Q

What are the advantages of an endoscopic ultrasound

A

Can get much further up the bile duct to:
- Characterize pancreatic masses
- Stage tumors
- Fine needle aspirate tumors or cysts

31
Q

What is a chronic liver disease/

A

Liver disease persisting for more than 6 months. E.g:
- Chronic Hepatitis
- Chronic Cholestasis
- Fibrosis & Cirrhosis
- Liver Tumours
- Steatosis
…and lots more

32
Q

What is cirrhosis?

A

Advanced fibrotic scarring of the liver.
Scar tissue replaces the parenchyma so the liver doesn’t work and inputted stuff like bilirubin, portal blood etc builds up

33
Q

Whats the difference between compensated chronic liver disease vs decompensated?

A

Compensated = No symptoms from chronic liver disease
Decompensated = Symptoms due to the liver damage (E.g. Ascites, variceal bleeding, hepatic encephalopathy)

34
Q

What are the presentations of Cirrhosis?

A

Compensated cirrhosis:
- Screening tests show abnormal LFTs

Decompensated Cirrhosis:
- Ascites
- Variceal Bleeding
- Hepatic Encephalopathy

Hepatocellular Carcinoma

35
Q

What is Hepatic Encephalopathy?

A

Confusion brought on by ammonia crossing the blood brain barrier.
Its often due to liver damage, which usually breaks ammonia down to urea and excretes it in urine.
In severe liver failure it occurs on its own, but when the liver is less damaged it will occur when something precipitates a rise in ammonia for the liver to process.

36
Q

How is Hepatic Encephalopathy graded?

A

From 1-4
(1= mild confusion)
(4= Coma)

37
Q

What other symptoms can come with Hepatic Encephalopathy?

A

Asterixis (flapping tremor)
Foetor Hepaticus (dead breath)

38
Q

What are the common precipitant problems of hepatic encephalopathy?

A

Dehydration
Meds
Infection
GI bleeds (blood in gut -> extra ammonia absorbed)
Constipation (Faeces sitting in gut gives off ammonia -> more ammonia absorbed)

39
Q

How do we treat Hepatic Encephalopathy?

A
  • Treat the underlying cause
  • Repeated admissions with Hepatic Encephalopathy indicate a need for liver Tx
  • Supportive care (ITU care, airway support, NG tube for meds etc)
40
Q

What conditions are associated with Hepatocellular Carcinoma?

A

Chronic Hep B/C and Cirrhosis.

41
Q

How do we screen for Hepatocellular Carcinoma?

A

Anyone with known liver cirrhosis gets surveyed regularly wit?h tests for AFP tumor markers

42
Q

How do we diagnose a Hepatocellular Carcinoma

A

US/CT/MRI
Rarely a liver biopsy

43
Q

How do we treat a Hepatocellular Carcinoma?

A

Curatively:
- Hepatic Resection
- Liver Tx

Palliative:
- Chemo
- Local Ablative Treatments (alcohol injection or radiofrequency ablation)
- Hormonal therapies (Tamoxifen)
- Targeted Therapy (Sorafenib - Tyrosine Kinase Inhibitor)

44
Q

Define Ascites and how to detect it?

A

Excess fluid in peritoneal cavity

  • On exam see dullness in flanks and shifting dullness
  • Swelling
  • US to confirm
45
Q

What other symptoms can come ascites?

A
  • Spider naevi, palmar erythema, abdominal veins, fetor hepaticus – Suggests Liver Failure
  • Umbilical Nodule – Suggests malignant ascites
  • Raised JVP – Suggests cardio disease e.g. Heart Failure
  • Flank haematoma (haemorrhagic ascites)
46
Q

How would you investigate a case of ascites?

A

Diagnostic Paracentesis to check:
- Protein & Albumin Conc.
- Cell Count
- Serum Ascites Albumin Gradient (SAAG) (Diagnoses split between high SAAG and low SAAG ascites)

47
Q

How do you treat ascites?

A
  • Diuretics
  • Large volume Paracentesis
  • TIPS (Transjugular Intrahepatic Portosystemic Shunt) - 2nd line treatment if portal hypertension
  • Failing that Liver Tx
48
Q

Define Varices?

A

Swelling of veins at porto-systemic anastomoses due to portal hypertension

49
Q

What are the locations of varices?

A
  • Skin around Umbilicus
  • Oesophageal & Gastric
  • Rectal
  • Posterior Abdominal Wall
  • Stomal
50
Q

How do we manage varices of the porto-systemic nastomoses?

A

Bleeding is a medical emergency
- Resus including Blood Transfusion if necessary
- Terlipressin (a vasoconstrictor) controls haemorrhage
- Sengstaken-Blakemore tube for uncontrolled bleeding

  • Emergency Endoscopy & Endoscopic Band Ligation
  • TIPS if bleeding again after banding
51
Q

What is a Sengstaken-Blakemore tube?

A

A tube inserted down the oesophagus to suck up hemorrhage from oesophageal varices

Year 2- Alimentary (37 decks)

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