Lecture 23 Jaundice and Chronic Liver Disease Flashcards
What are the synthetic functions of the liver
- Clotting factors
- Bile acids
- Carbohydrates
- Gluconeogenesis, Glycogenolysis, Glycogenesis
- Proteins
- Albumin synthesis,
- Lipids
- Cholesterol synthesis, Lipoprotein and TG synthesis
- Hormones
- Angiotensinogen, insulin like growth factor
What are the detoxification functions of the liver
- Urea production from ammonia
- Detoxification of drugs
- Bilirubin metabolism
- Breakdown of insulin and hormones
What are the immune functions of the liver
- Combating infections
- Clearing the blood of particles and infections, including bacteria
- Neutralizing and destroying all drugs and toxins
What are the storage functions of the liver
- Stores glycogen
- Stores Vitamin A, D, B12 and K
- Stores copper and iron
What is involved in a liver function test
Bilirubin ALT ALP Gamma GT Albumin PT Creatinine Platelet count
What is bilirubin bound to when it is unconjugated
Albumin
When is bilirubin elevated
• Pre-hepatic:
• Hepatic:
•Post hepatic:
Haemolysis
Parenchymal damage
Obstructive
What does elevated ALT suggest
Parenchymal involvement
What does elevated ALP suggest
Enzyme present in bile ducts so elevation suggests obstruction or liver infiltration. Also present in bone, placenta and intestines
When is Gamma T elevated
Elevated with alcohol use
Useful to confirm liver source of ALP
Why is PT useful
- Tells degree of liver dysfunction
- Used to calculate scores to decide stage of liver disease, who needs a liver transplant and who gets a liver transplant
- a blood test that measures the time it takes for the liquid portion (plasma) of your blood to clot.
What is the purpose of measuring creatinine
Kidney Functions
Determines survival for liver disease
Why is measuring platelet count important
- Liver is an important source of thrombopoietin
- Cirrhosis results in splenomegaly
- Platelets low in cirrhotic subjects as a result of hypersplenism
- Indirect marker of portal hypertension
What are the symptoms when the liver stops working
Jaundice
Features if Pre-hepatic Jaundice
Increased quantity of bilirubin (Haemolysis)
Impaired transport
Pallor
Splenomegaly
Features of Hepatic Jaundice
Defective uptake of bilirubin Defective conjugation Defective excretion Stigmata of CLD (spider naevi, gynaecomastia) Ascites Asterixis
Features of Post-hepatic Jaundice
Defective transport of bilirubin by biliary ducts
Palpable gall bladder
Investigations for Jaundice
• Hepatitis B & C serology • Autoantibody profile, serum immunoglobulins • Caeruloplasmin and copper • Ferritin and transferrin saturation • Alpha 1 anti trypsin • Fasting glucose and lipid profile Ultrasound CT/MRI scan ERCP
Definition of chronic liver disease
- Liver disease that persists beyond 6 months
- Chronic hepatitis
- Chronic cholestasis
- Fibrosis and Cirrhosis
- Others e.g. steatosis
- Liver tumours
Clinical presentation of Cirrhosis
• Ascites
• Variceal bleeding
• Hepatic encephalopathy
Shifting dullness
Clinical features of ascites
Spiders, palmar erythema, abdominal veins, fetor hepaticus
Umbilical nodule
JVP elevation
Flank haematoma
Diagnosis of ascites
Diagnostic paracentesis
Protein & albumin concentration
Cell count and differential
SAAG
Treatment Options for ascites
- Diuretics
- Large volume paracentesis
- TIPS
- Aquaretics
- Liver transplantation
What causes varices
Portal hypertension
Management of varices
- Resuscitate patient
- Good IV access
- Blood transfusion as required
- Emergency endoscopy
- Endoscopic band ligation
- Add Terlipressin for control
- Sengstaken-Blakemore tube for uncontrolled bleeding
- TIPSS for rebleeding after banding
Define Hepatic Encephalopathy
- Confusion due to liver disease
* Graded 1-4
What are the precipitants of Hepatic Encephalopathy
GI bleed, infection, constipation, dehydration, medication esp. sedation
What are signs of Hepatic Encephalopathy
asterixis and foetor hepaticus (odour of alcohol)
Treatment of Hepatic Encephalopathy
- Laxatives – phosphate enemas and lactulose
* Neomycin, Rifaximin-broad spectrum non absorbed antibiotic
Hepatcellular carcinoma occurs in association with what virus
Hep B and C
Presentation of Hepatocellular carcinoma
- Decompensation of liver disease
- Abdominal mass
- Abdominal pain
- Weight loss
- Bleeding from tumour
Diagnosis of Hepatocellular Carcinoma
- Tumour markers: AFP
- Radiological tests
- Ultrasound
- CT scan
- MRI
- Liver biopsy done very rarely
Treatment for Hepatocellular carcinoma
- Hepatic resection
- Liver transplantation
- Chemotherapy
- Locally delivered: TACE (Transcatheter arterial chemo-embolization)
- Systemic chemotherapy
- Locally ablative treatments
- Alcohol injection
- Radiofrequency ablation
- Sorafenib (Tyrosinase kinase inhibitor)
- Hormonal therapy: Tamoxifen
