Liver Flashcards
Alcoholic liver Disease
Due to effects of long - term excess alcohol consumption,
- Recommended amount = 14 units per week - no more than 5 units per day
Alcohol Liver Disease Progression
I. Alcohol related fatty liver Build -up of fat in liver
- Alcoholic hepatitis = Inflammation in liver sites
- Cirrhosis = Liver made of scar tissue
Signs of Liver Disease
- Jaundice
- Hepatomegaly
- Spider Naevi
- Ascites
- Palmar Erythema
Alcoholic Liver Disease Investigations
Bloods: FBC = Raised MCV LFTS = high ALT & AST & gamma- GT low albumin High bilirubin in Cirrhosis High PT time
Ultrasound
Endoscopy
CT & MRI Scans
Liver biopsy
Alcoholic Liver Disease Management & Complications
- Stop drinking
- Detoxication
- Nutrition with vitamins
- Steroids
- Liver transplant
→ Spontaneous Bacterial Peritonitis
Alcohol withdrawal symptoms
6 -12 hrs = tremor, sweating
12 - 24 hrs = hallucinations
24 - 48 hrs = seizures
48 - 72 hrs = delirium tremens
Alcohol withdrawal management
- Chlordiazepoxide [benzodiazepine] - 1st
- Intravenous high- dose B vitamins with thiamine
Non Alcoholic Fatty Liver Disease
Fat deposit in liver cells which can progress to hepatitis & cirrhosis
stages of NAFLD
- NAFLD
- Non- Alcoholic Steatohepatitis
- Fibrosis
- Cirrhosis
NAFLD risk factors
- obesity
- poor diet
- T2 DM
- High cholesterol
- Smoking
- High BP
NAFLD investigations
- Liver ultrasound - can diagnose fatty liver (hepatic steatosis)
- Enhanced liver Fibrosis blood test - 1st Line
- NAFLD Fibrosis score
- Fibroscan
NAFLD management
- Weight loss
- Stop smoking
- No alcohol
- Control diabetes, BP & cholesterol
patients with Liver fibrosis → refer & treat with Vit. E & Pioglitazone
Hep. C
- RNA virus
- spread by blood & body fluids
Hep. C Testing & symptoms
- Hep. C antibody
- Hep. C RNA testing
-> Asymptomatic, RUQ pain, fever, nausea
Hep. C management
- Antiviral treatment with Direct acting antivirals (DAAs) - Ribavirin
monitor with alpha fetoprotein - Stop smoking & alcohol
- Notify Public health
Hep. A + Diagnosis
- RNA virus
- Transmitted via Faecal-oral route usually by contaminated water /food.
- > LFT = high ALT & AST
- > Serology = anti-HaV IgM
Hep. A Signs & complications
- Nausea
- Vomiting
- Anorexia
- Jaundice
→ It can cause cholestasis (slowing of bile flow through biliary system)
with dark urine , Pale stools , hepatomegaly.
Hep. A management
- Resolves without treatment in 1-3months
- Analgesia (avoid paracetamol & alcohol)
- Vaccination
Hep. B
- DNA virus
- Transmitted by direct contact with blood/ bodily fluids -> parental transmission
Hep. B Investigations
- Screen for HBcAg (past infection) & HBsAg (active infection)
- If + ve, test HBeAg & viral load
Hep. B management & signs
Don’t worry about it!
- > Acute hepatitis
- > Fulminant hepatitis
- > Chronic hepatitis
Hep.D
- RNA virus
- Only survives in patients who have Hep. B infection
- It attaches to HBsAg to survive
- Diagnosis: detect IgM antibody
- No treatment
Hep. E
- RNA virus
- Transmitted by faecal oral, mainly water- borne
- No treatment , detect IgM
- Progressed to cirrhosis in immunocompromised
Autoimmune Hep.
- genetic disposition & triggered by environmental factors e.g. Viral infection causes a T cell-mediated response against liver cells.
- T - calls then alert to attack liver cells
→ Type 1 occurs in adults
→ Type 2 occurs in Children
Autoimmune Hep. Investigations
Liver biopsy
Raised transaminases (ALT & AST)
Autoimmune Hep. Tx
- High dose steroids [prednisolone or Cyclosporin] → Gold
- Immunosuppressants [azathioprine] → 1st Line
Liver Cirrhosis
- Chronic inflammation & damage to liver cells
- They are replaced with scar tissue (fibrosis) & nodules of scar tissue
- Fibrosis increases resistance in the vessels which causes portal hypertension
Common cause of Liver Cirrhosis
→ Alcohol abuse
→ Non alcoholic fatty liver disease
→ Hep. B
→ Hep. C
Signs of Liver cirrhosis
→ Jaundice
→ Hepatomegaly & Splenomegaly
→ spider naevi
→ Palmas Erythema
Liver Cirrhosis investigations
- Enhanced Liver Fibrosis
- Liver biopsy
- Albumin drops
- Prothrombin time increases
- Hyponatraemia
- Utrasound
- Fibroscan
Liver Cirrhosis management
→ Utrasound & alpha-fetoprotein every 6 months for hepatocellular carcinoma
→ Endoscopy
→ High protein, low sodium diet
→ Liver transplant
Liver Cirrhosis Complications
- Malnutrition
- Portal Hypertension
- Varices & Variceal bleeding
- Ascites
- Hepatic encephalopathy
Portal hypertension
Liver cirrhosis increases the resistance of blood flow in the liver, this increases back - Pressure into the portal system
Portal vein anatomy
comes from Superior mesenteric vein & Splenic vein → delivers blood to liver
Portal varices
Back- pressure causes vessels in the portal system anastomoses with systemic venous system to be swollen & tortuous → varices
Where do portal varices occur?
→ Gastro - oesophageal junction
→ Ileocareal junction
→ rectum
→ Anterior abdominal wall Via the umbilical vein (caput medusae)
Portal hypertension treatment
Propranolol → acts as a non- selective beta - blocker
Portal varices management
- Elastic band ligation
- Injection of scIerosant
- Transjugular Intra - hepatic Portosystemic Shunt (TIPS)
Bleeding Oesophageal Varices
Resus:
→ Vasopressin analogues [Terlipressin]
→ Correct coagulopathy with vit.k & Fresh frozen plasma
→ Give prophylactic broad spectrum antibiotics
→ Elastic band ligation of varices
Ascites
Fluid in the Peritoneal cavity
Increased pressure in the portal system causes fluid to leak out of the capillaries into peritoneal cavity.
Ascites & link to Renin- angiotensin system
- Drop in volume caused by fluid loss
- causes reduction in blood pressure in kidneys
- Juxtaglomerular cells in the afferent arterioles sense low BP
- kidneys secrete renin
- leads to more aldosterone & reabsorption of fluid & sodium in kidneys
Cirrhosis causes transudative → Low protein ascites
Ascites management
- low sodium diet
- Anti - aldosterone diuretics [Spironolactone]
- Paracentesis (ascitic drain)
- Prophylactic antibiotics [ Ciprofloxacin] against Spontaneous bacterial peritonitis
Hepatic Encephalopathy Pathophysiology
- In liver failure, Ammonia accumulates in the circulation.
- Ammonia crosses the blood-brain barrier → cerebral circulation → detoxified by astrocytes → form glutamine through amidation of glutamate
- Excess glutamine disrupts osmotic balance & astrocytes swell to give cerebral oedema
Hepatic encephalopathy symptoms
- Altered mood & behaviour, Sleep disturbance, dyspraxia
- Drowsiness, Confusion, Slurring speech
- Restlessness, Asterixis
- Coma
Hepatic Encephalopathy Management
→ Lactulose (to help nitrogenous waste loss)
→ IV Mannitol
→ Vit. K
Cholecystitis
Inflammation of gallbladder caused by blockage of the cystic duct preventing gallbladder from draining.
- mainly caused by gallstones - trapped in neck of gallbladder / in cystic duct
Cholecystitis Symptoms
→ Pain in Right Upper Quadrant → radiate to Right shoulder
→ Murphy’s sign (gallbladder pain on inspiration when palpated)
→ Nausea & vomiting
→ Fever
→ Tachycardia & Tachypnoea
Cholecystitis Investigations
→ Abdominal Ultrasound scan
- Thickened gallbladder wall
- Stones in gallbladder
- Fluid in gallbladder
→ Magnetic Resonance Cholangiopancreatography (MRCP)
Cholecystitis Management
- Nil by mouth
- IV fluids
- Antibiotic
→Endoscopic Retrograde Cholangio -pancreatography
→ Cholecystectomy
Ascending cholangitis
= Bacteria ascending through biliary tree leading to septicaemia.
Due to:
→ obstruction/ gallstones in common bile duct
→ Infection in ERCP Procedure mainly
- E. Coli
- Klebsiella
- Enterococcus
Ascending cholangitis Symptoms
CHARCOT ‘S TRIAD :
- Right upper quadrant pain
- Fever
- Jaundice (high bilirubin)
Ascending cholangitis Management
→ Nil by mouth → IV Fluids → Blood cultures → IV antibiotics → ICU/ HDU
Ascending Cholangitis Investigations
- Abdo. Ultrasound scan
- CT scan
- MRCP
- Endoscopic ultrasound
- ERCP
What is the opening of the common bile duct called?
Sphincter of Oddi
Primary Sclerosing Cholangitis
Intrahepatic / Extrahepatic duets becomes Strictured & Fibrotic.
- This causes an obstruction to the flow of bile from liver into intestines.
- Maybe due to genetic / Intestinal microbiome
Primary Sclerosing Cholangitis Risk factors
- Male
- Age 30-40
- Ulcerative Colitis
- Family history
Primary Sclerosing Cholangitis Presentation
- Jaundice
- Right upper quandrant Pain
- pruritus
- Fatigue
- Hepatomegaly
Primary Sclerosing Cholangitis Investigations
- Magnetic Resonance Cholangiopancreatography (MRCP)
- Liver Function Tests - deranged
→ shows cholestatic pic., alkaline phosphatase
→ Rise in bilirubin - Autoantibodies
Primary Sclerosing Cholangitis Complications
- Acute bacterial cholangitis
- Cholangiocarcinoma
Primary Sclerosing Cholangitis Management
- Liver transplant
- ERCP for stent
- Colestyramine (bile acid)
- Sertraline for pruritus
Pancreatitis
Inflammation of the pancreas.
Acute = Rapid onset of inflammation & Symptoms.
Chronic = long- term inflammation & symptoms with a progressive deterioration in Pancreas
Pancreatitis Causes
I = Idiopathic G = Gallstones E = Ethanol T = Trauma S = Steroids M = Mumps A = Autoimmune S = Scorpion sting H = Hyperlipidaemia E = ERCP D = Drugs [Furosemide/ Thiazide diuretics & Azathioprine]
Pancreatitis Symptoms + Signs
- Severe epigastric pain radiates to back
- Vomiting
→ Cullen’s sign (periumbilical region)
→ Grey Turner Sign (left flank)
Pancreatitis Investigations
(Glasgow score)
- Serum Amylase - raised
- C-reactive protein
- Ultrasound (check for gallstones)
- CT abdomen
Management of Acute Pancreatitis
- IV Fluids
- Resus
- Analgesia
- Nil by mouth
- Antibiotic
Management of Chronic Pancreatitis
- Abstinence from alcohol & smoking
- Analgesia
- Replacement Pancreatic enzymes
- Insulin regimes
Complication of Acute Pancreatitis
- Acute renal failure
- Sepsis
- Pancreatic Abscess
Alpha 1 Antitrypsin Deficiency
Condition caused by an abnormality in the gene for a protease inhibitor called Alpha -1 - Antitrypsin.
- Autosomal recessive
Alpha 1 A Pathophysiology
- Neutrophils secrete Elastase which digests connective tissues.
- AIpha 1 A made in the liver inhibits neutrophil Elastase
Organs affected are :
> Liver → Liver cirrhosis
> Lungs → Bronchiectasis & emphysema
Alpha 1 A Diagnosis
- low serum Alpha - 1 - Antitrypsin
- Liver biopsy & acid - Schiff - Positive staining globules
- Genetic resting
- CT thorax
Alpha -1 A Management
- Stop smoking
- Symptomatic management
- Replacement Alpha-1- A
- Organ transplant
Acute Live Failure Symptoms
- Malaise
- Nausea
- Anorexia
- Jaundice / Pruritis
Chronic liver failure Symptoms
- Ascites/ Oedema
- Malaise
- Spider Naevi
- Palmar Erythema
- Clubbing
- Bleeding
Acute Liver failure causes
- Paracetamol Drug- Induced - Liver - Injury
- Alcohol
- viral hepatitis
- Drugs
- Obstruction
Chronic liver failure Causes
- Alcohol
- viral hepatitis
- Autoimmune
- Neoplastic
- NAFLD / AFLD
Liver Cirrhosis Investigation
- Prothrombin time
Bleeding varices
Investigations
Symptoms
Treatment
Ix : Upper Gl endoscopy
Symptoms = Melaena, Haematemesis (coffee ground vomit)
Tx = Endoscopic therapy & band ligation, Fluid resus, Terlipressin (ADH analogue) or Ocreotide, Balloon Tamponade
Haemochromatosis
Dysregulated dietary iron absorption & increased iron release from macrophages.
- Autosomal recessive
Haemochromatosis Pathophysiology & Symptoms
Iron accumulates in liver, joints, Pancreas, heart, skin & gonads
Symptoms = Slate Grey Skin or brownish bronze
Haemochromatosis Investigations
Liver biopsy
Iron - Bloods, LFTs
Haemochromatosis Treatment
1st Line = Venesection
2nd Line = Chelation
Gold= Liver transplant
Wilson’s Disease
Too much copper builds up in liver & CNS.
- Autosomal recessive
Wilson’s Disease Pathophysiology & symptoms
Cu2+ accumulates in liver, basal ganglia & cornea
Symptoms - Kayser-Fleischer ring, Parkinsonian, Depression
Wilson’s Disease Investigations
Gold= Liver biopsy
1st line = 24 hr urine Copper & blood caeruloplasmin
Wilson’s Disease Treatment
- Penicillamine (copper chelation)
- Liver transplant
Hepatocellular Carcinoma
Presentation
Investigations
Treatment
Presentation= Weight loss, fatigue, dark Stools & Pale urine
Investigations = LFTs, Clotting studies, CT, MRI, Ultrasound with biopsy
Treatment = Partial hepatectomy, Chemotherapy
Biliary colic
Symptoms
Investigations
Treatment
Temporary blockade of cystic duct by gallstones.
Symptoms = RUQ Pain after fatty meals
Investigations = FBC, CRP, LFTs
Treatment = Analgesia & Cholecystectomy
Primary Biliary Cirrhosis
Presentation
Investigation
Treatment
Progressive autoimmune destruction of liver - biliary free leading to fibrosis then Cirrhosis
Symptoms = Pruritis, Xanthelasma, Raised serum alkaline Phosphatase, Steatorrhoea
Ix = Biopsy, AMA, LFT - GGT & ALP raised
Treatment = Ursodeoxycholic acid - to reduce Cholestasis
Peritonitis
Symptoms
Investigations
Treatment
Inflammation of tissues that line abdominal wall.
Symptoms = Rebound tenderness, central abdo. pain, localised guarding, Rigidity
Investigations = Blood test, Peritoneal fluid analysis, X-ray
Treatment = IV Antibiotics, Surgery
Jaundice + treatment
Skin turning yellow due to high bilirubin levels.
Treatment = lots of fluid / rest, Stop alcohol
3 main types of Jaundice & causes
Pre- hepatic = Pernicious Ihaemolytic anaemia
Intrahepatic = Hepatitis & Cirrhosis
Post - hepatic = Obstructive e.g. gallstones
How are 3 types of Jaundice characterised?
Pre - hepatic = Unconjugated bilirubin - dark brown stool, normal AST & ALT & ALP
Intrahepatic = Unconjugated + Conjugated bilirubin - dark urine, High AST, ALT, ALP
Post - hepatic = Conjugated bilirubin - dark urine, clay stools, high ALP
What are the Symptoms of the 3 types of jaundice?
Pre - hepatic = Pallor , fatigue , Exertional Dyspnoea
Hepatic = Anorexia , fatigue , Nausea , Abdo. Pain
Post - hepatic = Pale stools , Dark urine , Pruritus , Steatorrhoea , RUQ pain
Pancreatic cancer Who? Symptoms Investigations Management
Who = Men, >65, smokers, obese, Chronic Pancreatitis, family history
Symptoms = Epigastric pain [worse at night], Obstructive jaundice, Weight loss, Palpable gallbladder (courvoisier ‘s sign), Trousseau’s sign
Investigations = Bloods & Carbohydrate antigen 19-9 & LFTs
- CT & Endoscopic US , - Biopsy
Management = Surgery (whipple’s procedure)
= Chemo.
Cholelithiasis
Stones form in the gallbladder.
Form from concen. bile in the bile duct & are mostly cholesterol.
Gall stone Anatomy
- Left & Right hepatic duct join to form the Common hepatic duct.
Cystic duct from gallbladder joins the common hepatic duct. - Pancreatic duct joins the common hepatic duct → becomes the ampulla of Vater, which opens into duodenum.
- Sphincter of Oddi surrounds the Ampulla of Vater & controls flow of bile & Pancreatic secretions into duodenum.
Gallstones Risks
F = Fat
F = Fair
F = Female
F = Forty
Gallstones Symptoms
- Biliary colic - colicky or RUQ epigastric pain, triggered by fatty meals.
- Acute cholecystitis
- Acute cholangitis
- Obstructive jaundice
- Pancreatitis
Gallstones Diagnosis
- Liver Function Tests
→ Raised bilirubin (jaundice) with pale stools & dark urine
→ Raised Alkaline Phosphatase
→ Raised Alanine aminotransferase & Aspartat aminotransferase - Ultrasound
- Magnetic Resonance Cholangio-Pancreatography
- Endoscopic Retrograde Cholangio - Pancreatography
Gallstones Treatment
- Cholecystectomy
- IV Fluids & Co- amoxiclav (cholecystitis)
Primary Biliary Cholangitis
Sx:
Ix:
Tx:
Inherited abnorm. of immunoregulation → T lymphocyte mediated attack on bile duct epithelial cells.
Sx: fatigue, itchy skin (dry eyes & mouth), RUQ pain, Hyperpig.
Ix: LFTs, Fibroscan, MRCP
Tx: Ursodeoxycholic (bile acid), Corticosteroid
Paracetamol Overdose Management
N-acetyl-cysteine + Activated charcoal within 1hr of ingestion
Cholecystitis Risks
Fat Female Forty Flatulent Fertile
