KM - Liver Disease Flashcards
What do you call the middle of a liver lobule?
Central vein
What is the portal triad?
Hepatic artery
Bile duct
Portal vein
Describe blood flow
Portal vein via sinusoid to central vein
What is the space between the sinusoid and the…?
Space of Disse
Name the numbering system of the lobule
1 is around Portal tract
3 is around the central vein
The portal triad is seen where in the hexagon of a liver lobule?
Each of the six corners
If you think the high bilirubin is due to pre hepatic causes, what do you do?
Fbc and film
If you think the high bilirubin is due to hepatic
Repeat LFTs
What reaction is done to see whether the bilirubin is conjugated or
Van den Bergh reaction
If you think the high bilirubin is due to obstructive cause, what do you do next?
Check alkaline phosphatase as it is high in obstructive causes
How is Gilbert’s inherited? What percentage are carriers?
Recessive, 50% carriers
Probability of a both partners
25%
Why is bilirubin to elevated during fasting in people with Gilbert’s?
Increases
What’s the faulty enzyme ?
UDP glucuronyl transferase
What is most representative of the function of the liver?
Prothrombin time
Why isn’t albumin as representative?
Slow to change in liver disease
What are ALT, AST and GGT?
Enzymes present in certain parts of the liver lobule, leaks out depending on area of liver damage. They are enzymes against certain toxins.
In paracetamol overdose, what is high?
Prothrombin time goes rapidly high
as well as ALT, AST AND GGT but these don’t correlate with any liver disease
When dl you call
If it goes up by more than 1 s per hour
What are the true markers of liver function?
Albumin
Clotting factors
Bilirubin
(Enzymes aren’t really true markers)
What is the typical sign of someone with Gilbert’s?
High bilirubin, everything else normal, bili worsens with fasting
Hepatic causes of high bilirubin
Viral hepatitis
Alcoholic HEP
CIRRHOSIS
Post hepatic causes
Pancreatic cancer
???
Causes of pre hepatic jaundice
Haemolysis
Gilberts
Note
Alk phosph isn’t necessarily high
Causes of hepatitis
Viral
Alcoholic
Autoimmune
How is hep A transmitted?
Fecal-oral
What are the consequences of hep A?
Most people are fine and become immune with IgG memory
But some people die if malnourished
How is hep B transmitted?
Spread by blood, sharing needles
Consequences of hep B
Incubation period of 1 month
Describe what happens after someone gets hep B
Two coats
Surface antigen and core (e) antigen
These antigens are excreted in the blood
Immune system mounts a reaction against both e antigen and surface antigen
What is the difference in the antibodies of someone exposed to Hep B vs someone who has been vaccinated?
Anti-HBs = people who have been vaccinated Anti-HBe = people who have been exposed
Consequences of hep B
People often don’t know they have it as they’re subclinical, so if their immune system doesn’t clear the hep B, they remain infectious for years unless they have treatment!
What is seen on biopsy of an alcoholic liver?
Fatty lobules
Malorie’s hyaline pinky strands of material due to hepatocyte damage
Neutrophils
Cholestasis i.e. bile stains
Alcoholic fatty liver disease biopsy features
Malorie's hyaline Blue collagen around hepatocytes Fibrosis Balloon cells Fatty change Megamitochondria
What is a differential for alcoholic fatty liver hepatitis?
Non alcoholic steatohepatitis (NASH)
Steato = fat
E.g. Due to obesity, diabetes
Treatment for alcoholic fatty liver disease
Stop alcohol
Thiamine
B1
Thiamine deficiency causes
Beri beri
What causes pernicious anaemia?
B12 deficiency
Signs of alcohol use
Spider naevi
Palmar erythema
Gynaecomastia
Dupytren’s contracture
What do these signs signify?
Chronic stable liver disease
What sign might be seen on the abdomen of an alcohol user?
Visible vein on anterior abdominal wall
Why do you seen a visible vein?
Occurs because of pressure in umbilical vein due to portal htn
What can the visible veins result in?
Splenomegaly as they connects to splenic vein
So this is another sign of portal HTN
What does shifting dullness suggest?
Ascites, another marker of portal htn
Signs of portal htn
Splenomegaly
Ascites
Visible veins
What causes portal htn?
Cirrhosis of liver
Why can alcoholics vomit blood?
Visible vein ruptures, so people start vomiting blood
Acute management of oesohageal bleeding
Put an NG tube in with a balloon to put pressure on the bleeding
Senc starkin
If the pt now develops flapping tremor, what does it suggest?
Liver failure
Consequences of liver failure
Clotting factors and albumin fail so bleeding and bruising common
???
Ammonia irritates brain hence encephalopathy
Defining features of cirrhosis
Nodules - regenerating liver cells
Fibrosis
Shunting of blood
Whole liver is involved
Causes of cirrhosis
Fatty liver disease - micronodular Viral hepatitis - B, C, D - macronodular Haemochromatitis Wilson's disease (copper) PBC Primary sclerosis cholangitis
Difference between fatty liver cirrhosis and hepatitis cirrhosis?
Fatty liver - micronodular
Hepatitis - macronodular
What happens after alcoholic liver disease before things get bad?
Chronic stable liver disease
Sites of portal-systemic anastomoses
Oesophagus
Rectal
Umbilical vein
Spleno-renal shunt (artificial)
What does pruritus suggest?
Jaundice caused by OBSTRUCTION
It’s the bile salts that cause the pruritus
What blood results would you see in obstructive jaundice?
High alk phosph and high bilirubin
What is the difference between urobilinogen and stercobilinogen and bilirubin
Bacteria convert bilirubin into stercobilirubin, which is reabsorbed and peed out as urobilinogen and excreted as stercobilinogen via faces
What kind of liver tumour produces bile?
Hepatocellular carcinoma
Mucinous cells in the liver might suggest
Metastasis of pancreatic cancer
Sarcoma features
Spindly
What is Courvoisier’s law?
Palpable gallbladder with jaundice = pancreatic cancer
Why is the gall bladder not palpable with gall stones?
Gallbladder with gallstones becomes fibrotic and is incapable of becoming enlarged
