Lecture 23 Jaundice and Chronic Liver Disease

Question 1

What are the synthetic functions of the liver

Answer 1

• Clotting factors
• Bile acids
• Carbohydrates
• Gluconeogenesis, Glycogenolysis, Glycogenesis
• Proteins
• Albumin synthesis,
• Lipids
• Cholesterol synthesis, Lipoprotein and TG synthesis
• Hormones
• Angiotensinogen, insulin like growth factor

Question 2

What are the detoxification functions of the liver

Answer 2

• Urea production from ammonia
• Detoxification of drugs
• Bilirubin metabolism
• Breakdown of insulin and hormones

Question 3

What are the immune functions of the liver

Answer 3

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

Question 4

What are the storage functions of the liver

Answer 4

• Stores glycogen
• Stores Vitamin A, D, B12 and K
• Stores copper and iron

Question 5

What is involved in a liver function test

Answer 5

Bilirubin
ALT
ALP
Gamma GT
Albumin
PT
Creatinine 
Platelet count

Question 6

What is bilirubin bound to when it is unconjugated

Answer 6

Albumin

Question 7

When is bilirubin elevated
• Pre-hepatic:
• Hepatic:
•Post hepatic:

Answer 7

Haemolysis
Parenchymal damage
Obstructive

Question 8

What does elevated ALT suggest

Answer 8

Parenchymal involvement

Question 9

What does elevated ALP suggest

Answer 9

Enzyme present in bile ducts so elevation suggests obstruction or liver infiltration. Also present in bone, placenta and intestines

Question 10

When is Gamma T elevated

Answer 10

Elevated with alcohol use

Useful to confirm liver source of ALP

Question 11

Why is PT useful

Answer 11

• 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.

Question 12

What is the purpose of measuring creatinine

Answer 12

Kidney Functions

Determines survival for liver disease

Question 13

Why is measuring platelet count important

Answer 13

• 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

Question 14

What are the symptoms when the liver stops working

Answer 14

Jaundice

Question 15

Features if Pre-hepatic Jaundice

Answer 15

 Increased quantity of bilirubin (Haemolysis)
 Impaired transport
 Pallor
 Splenomegaly

Question 16

Features of Hepatic Jaundice

Answer 16

	Defective uptake of bilirubin
	Defective conjugation	
	Defective excretion
	Stigmata of CLD (spider naevi, gynaecomastia)
	Ascites
	Asterixis

Question 17

Features of Post-hepatic Jaundice

Answer 17

Defective transport of bilirubin by biliary ducts

Palpable gall bladder

Question 18

Investigations for Jaundice

Answer 18

•	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

Question 19

Definition of chronic liver disease

Answer 19

• Liver disease that persists beyond 6 months
• Chronic hepatitis
• Chronic cholestasis
• Fibrosis and Cirrhosis
• Others e.g. steatosis
• Liver tumours

Question 20

Clinical presentation of Cirrhosis

Answer 20

• Ascites
• Variceal bleeding
• Hepatic encephalopathy
Shifting dullness

Question 21

Clinical features of ascites

Answer 21

Spiders, palmar erythema, abdominal veins, fetor hepaticus
Umbilical nodule
JVP elevation
Flank haematoma

Question 22

Diagnosis of ascites

Answer 22

Diagnostic paracentesis
Protein & albumin concentration
Cell count and differential
SAAG

Question 23

Treatment Options for ascites

Answer 23

• Diuretics
• Large volume paracentesis
• TIPS
• Aquaretics
• Liver transplantation

Question 24

What causes varices

Answer 24

Portal hypertension

Question 25

Management of varices

Answer 25

• 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

Question 26

Define Hepatic Encephalopathy

Answer 26

• Confusion due to liver disease

* Graded 1-4

Question 27

What are the precipitants of Hepatic Encephalopathy

Answer 27

GI bleed, infection, constipation, dehydration, medication esp. sedation

Question 28

What are signs of Hepatic Encephalopathy

Answer 28

asterixis and foetor hepaticus (odour of alcohol)

Question 29

Treatment of Hepatic Encephalopathy

Answer 29

• Laxatives – phosphate enemas and lactulose

* Neomycin, Rifaximin-broad spectrum non absorbed antibiotic

Question 30

Hepatcellular carcinoma occurs in association with what virus

Answer 30

Hep B and C

Question 31

Presentation of Hepatocellular carcinoma

Answer 31

• Decompensation of liver disease
• Abdominal mass
• Abdominal pain
• Weight loss
• Bleeding from tumour

Question 32

Diagnosis of Hepatocellular Carcinoma

Answer 32

• Tumour markers: AFP
• Radiological tests
• Ultrasound
• CT scan
• MRI
• Liver biopsy done very rarely

Question 33

Treatment for Hepatocellular carcinoma

Answer 33

• 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