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Phase 2a Revision > Liver > Flashcards

Liver Flashcards

1
Q

what is liver failure

A

when the liver loses the ability to regenerate and repair

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2
Q

what symptoms occur in liver failure

A
  • hepatic encephalopathy
  • abnormal bleeding
  • ascites
  • jaundice
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3
Q

what are the 3 classifications of liver failure

A
  • Fulminant hepatic failure
  • Late-onset hepatic failure
  • Chronic decompensated hepatic failure
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4
Q

How is Fulminant hepatic failure defined

A

when failure takes place within 8wks of the onset of the underlying illness

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5
Q

How is Late-onset hepatic failure defined

A

when there has been a gap of 8-26wks between failure and onset of underlying illness

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6
Q

How is Chronic decompensated hepatic failure defined

A

when the latent period is >6mths

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7
Q

what are the 7 broad categories of causes of hepatic failure

A
  • toxins
  • infection
  • metabolism
  • pregnancy
  • neoplastic
  • vascular
  • other
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8
Q

what toxins commonly cause liver failure

A
  • paracetamol
  • chronic alcohol use
  • illicit drugs
  • poisening
  • drug toxicity (eg. methotrexate)
  • Reye’s syndrome
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9
Q

infective causes of hepatic failure

A
  • Viral Hepatitis
  • Adenovirus
  • EBV
  • Cytomegalovirus
  • viral haemorrhagic fevers
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10
Q

neoplastic causes of hepatic failure

A
  • hepatocellular carcinoma

- metastatic carcinoma

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11
Q

metabolic causes of hepatic failure

A
  • wilson’s disease

- alpha-1-antitrypsin deficiency

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12
Q

how can pregnancy cause hepatic failure

A

acute fatty liver of pregnancy

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13
Q

vascular causes of hepatic failure

A
  • ischaemia
  • veno-occlusive disease
  • budd-chiari syndrome
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14
Q

other causes of hepatic failure

A

autoimmune liver disease

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15
Q

what is hepatic encephalopathy

A

a spectrum of neuropsychiatric abnormalities in patients with liver failure after exclusion of other known brain disease

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16
Q

what are the two types of hepatic encephalopathy

A
  • covert

- overt

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17
Q

what is covert hepatic encephalopathy

A

a subclinical, less severe manifestation

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18
Q

what are the common causes of hepatic encephalopathy

A
  • AKI
  • electrolyte imbalance
  • GI bleed
  • infection
  • constipation
  • sedative drugs (eg. opiates/BZs)
  • diuretics
  • high protein intake
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19
Q

what Ix can be used to assess the severity of hepatic encephalopathy

A

psychometric testing

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20
Q

which criteria is used to grade the severity of hepatic encephalopathy

A

west haven criteria

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21
Q

Symptoms of Grade 1 hepatic encephalopathy

A
  • trivial lack of awareness
  • euphoria/anxiety
  • shortened attention span
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22
Q

symptoms of Grade 2 hepatic encephalopathy

A
  • lethargy / apathy
  • minimal disorientation for time and place
  • subtle personality change
  • inappropriate behaviour
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23
Q

symptoms of grade 3 hepatic encephalopathy

A
  • somnolence to semi-stupor
  • responsive to verbal stimuli
  • confusion
  • gross disorientation
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24
Q

symptoms of grade 4 hepatic encephalopathy

A

coma

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25
Q

what other Ix is done for hepatic encephalopathy

A
  • arterial/serum ammonia levels
  • EEG
  • MRI/CT
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26
Q

differential diagnosis for hepatic encephalopathy

A
  • Intracranial lesions
  • infection
  • metabolic
  • toxic
  • drugs
  • post-seizure
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27
Q

Mx for hepatic encephalopathy

A
  • Abx (typically given empirically)

- lactulose/lactitol (converts ammonia to an non-absorbable ammonium)

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28
Q

what is the recommended prevention for hepatic encephalopathy

A

Rifaximin

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29
Q

what is ascites

A

an excessive accumulation of fluid in the abdominal cavity

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30
Q

what is diuretic-resistant ascites

A

ascites that isn’t affected by dietary sodium restriction therefore requires intensive diuretic tx for at least 1wk

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31
Q

what in diuretic-intractable ascites

A

ascites that isn’t affected by therapy due to the development of diuretic-induced complications that preclude the use of an effective diuretic dose

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32
Q

what are the possible causes of ascites

A
  • cirrhosis
  • malignancy
  • HF
  • nephrotic syndrome
  • protein-losing enteropathy
  • TB
  • pancreatitis
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33
Q

presenting symptoms of ascites

A
  • abdominal distention
  • weight gain
  • discomfort
  • nausea/appetite suppression
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34
Q

what is the best Ix to assess ascites

A

US

35
Q

Tx for ascites

A
  • salt-restricted diet
  • diuretics (best = spironolactone)
  • midodrine (vasopressor)
  • paracentesis
36
Q

how do vasopressors help tx ascites

A

results in an increase MAP and urine sodium excretion and decreases in plasma renin and aldosterone

37
Q

what causes jaundice

A

increased bilirubin level

38
Q

what is the normal bilirubin level

A

3-20 umol/L

39
Q

what bilirubin level is jaundice seen in

A

> 35umol/L

40
Q

what are the causes of jaundice split into

A
  • pre-hepatic
  • hepatocellcular
  • cholestasis
41
Q

how is bilirubin produced

A

the breakdown of haemoglobin in the reticuloendothelial system

42
Q

what are the common pre-hepatic causes of Jaundice

A
  • Gilbert’s syndrome
  • Haemolytic anaemia
  • thalassaemia
  • trauma
  • Crigler-Nijjar syndrome
43
Q

what are the common hepatocellulcar causes of jaundice

A
  • viral hepatitis (Hep A&B)
  • alcoholic hepatitis
  • autoimmune hepatitis
  • drug-induced hepatitis
  • decompensated cirrhosis
44
Q

what are the types of cholestasis

A
  • intrahepatic

- extrahepatic

45
Q

causes of intrahepatic cholestasis

A
  • primary biliary cholangitis
  • drugs
  • primary sclerosing cholangitis
  • dubin-johnson syndrome
  • Rotor’s syndrome
46
Q

causes of extrahepatic cholestasis

A
  • bile duct strictures
  • common duct stone
  • CA of the head of the pancreas
  • tumour of the ampulla of Vater
  • Pancreatitis
  • Gallbladder CA
47
Q

differential diagnosis for hepatic failure

A
  • structural lesions
  • cerebral infection
  • drug/alcohol intoxication
  • delirium tremens
  • wernicke’s encephalopathy
  • hypoglycaemia
48
Q

what may an FBC show in hepatic failure

A
  • iron-deficiency anaemia
  • thombocytopenia

raised MCV

49
Q

Main Mx of hepatic failure

A

liver transplant

50
Q

tx for raised ICP

A

mannitol

51
Q

what are the three steps of alcoholic liver disease

A

1) alcohol related fatty liver
2) alcoholic hepatitis
3) cirrhosis

52
Q

what is the recommended alcohol limit

A

14 units/wk

53
Q

What does CAGE stand for

A

C- cut down
A - anger
G - guilty
E - eye opener

54
Q

what is the audit questionnaire

A

Alcohol Use Disorders Identification Test

55
Q

what is the purpose of the audit questionnaire

A

designed by WHO to screen people for harmful alcohol use

56
Q

What are the signs of Liver disease

A
  • jaundice
  • hepatomegaly
  • spider naevi
  • palmar erythema
  • gynaecomastia
  • bruising
  • ascites
  • caput medusae
  • asterixis (“flapping tremor”)
57
Q

what will LFTs show in liver disease

A
  • elevated ALT & AST
  • very elevated gamma-GT
  • low albumin
  • elevated bilirubin (IN CIRRHOSIS)
58
Q

what will the clotting factors show in liver disease

A

elevated prothrombin time

59
Q

Will U&Es be normal in liver disease

A

maybe, but may be deranged in hepatorenal syndrome

60
Q

other than bloods what other Ix can be used for liver disease

A
  • US (can be used to visualise the fatty changes)
  • fibroscan
  • endoscopy
  • CT
  • MRI
  • biopsy
61
Q

general management principals with alcoholic liver disease

A
  • stop drinking
  • detoxication regime
  • nutritional support (*Thiamine)
  • steriods
  • tx complications
  • referral for transplant
62
Q

what symptoms are seen in alcohol withdrawal and when

A
  • 6-12hrs : tremor, sweating, headache, craving, anxiety
  • 12-24hrs : hallucinations
  • 24-48hrs : seizures
  • 24-72hrs : delerium tremens
63
Q

what receptor does alcohol stimulate in the brain

A

GABA

64
Q

what receptor does alcohol inhibit in the brain

A

glutamate (aka NMDA)

65
Q

what is the effect of GABA stimulation

A

relaxes the brain

66
Q

what is the effect of glutamate inhibition

A

further inhibitory effect of the electrical activity of the brain

67
Q

what is the brain chemistry that is seen in chronic alcohol user going cold turkey

A

GABA system being up-regulated and the glutamate system being down-regulated to balanced

Therefore, when alcohol is removed GABA under-functions and glutamate over-functions resulting in extreme excitability of the brain with excessive adrenergic activity

68
Q

what medication is used to tx the effects of alcohol withdrawal

A

Chlordiazepoxide

69
Q

What is used to prevent Wernicke-Korsakoff Syndrome

A

IV high-dose B vitamins

Pabrinex

70
Q

what causes Wernicke-Korsakoff Syndrome

A

Thiamine (Vit B1) deficiency

71
Q

What are the main symptoms wernicke’s encephalopathy

A
  • confusion
  • oculomotor disturbances
  • ataxiaq
72
Q

What are the main features of Korsakoffs syndrome

A
  • memory impairment (retro & anterograde)

- behavioural changes

73
Q

what are the possible complications of cirrhosis

A
  • malnutrition
  • portal hypertension
  • varices
  • ascites
  • spontaneous bacterial peritonitis
  • hepatorenal syndrome
  • hepatic encephalopathy
  • hepatocellular CA
74
Q

management of malnutrition in cirrhosis pts

A
  • regular meals
  • low Na diet (minimise fluid retention)
  • high protein & high calorie diet
  • avoid alcohol
75
Q

management of portal HTN in cirrhosis pts

A
  • propanolol
76
Q

where can varices form

A
  • gastro-oesophageal junction
  • ileocaecal junction
  • rectum
  • anterior abdo wall (caput medusae)
77
Q

Mx of varices

A
  • control portal HTN

- ligation

78
Q

management of bleeding varices

A
  • resuscitation
    - vasopressin analogues(terlipressin)
    - correct coagulopathy (Vit K)
    - prohphylatic broad spec abx
  • urgent endoscopy
79
Q

Mx of ascites

A
  • low Na diet
  • anti-aldosterone iuretics (spironolactone)
  • paracentesis
  • prohphylatic abx
80
Q

what is spontaneous bacterial peritonitis (SBP)

A
  • infection developing in the ascitic fluid or peritoneal lining without any clear cause
81
Q

what are the most common causes of spontaneous bacterial peritonitis (SBP)

A
  • e.coli
  • Klebsiella pnuemoniae
  • gram positive cocci
82
Q

Mx of spontaneous bacterial peritonitis (SBP)

A
  • ascitic culture (prior to abx)

- IV cephalosporin (eg. cefotaxime)

83
Q

what is hepatorenal syndrome

A

when portal HTN causes dilation in the portal vascular system reducing blood volume in in other areas (eg. kidneys).

Hypotension in the kidneys leads to activiation in the renin-angiotensin system = constriction, causing starvation to the kidney

84
Q

what is the prognosis of hepatorenal syndrome

A

fatal within a week unless liver transplant performed

Phase 2a Revision (13 decks)

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