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Phase 2a Revision > Liver > Flashcards

Liver Flashcards

1
Q

Alcoholic liver Disease

A

Due to effects of long - term excess alcohol consumption,

- Recommended amount = 14 units per week - no more than 5 units per day

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2
Q

Alcohol Liver Disease Progression

A

I. Alcohol related fatty liver Build -up of fat in liver

  1. Alcoholic hepatitis = Inflammation in liver sites
  2. Cirrhosis = Liver made of scar tissue
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3
Q

Signs of Liver Disease

A
  • Jaundice
  • Hepatomegaly
  • Spider Naevi
  • Ascites
  • Palmar Erythema
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4
Q

Alcoholic Liver Disease Investigations

A 
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

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5
Q

Alcoholic Liver Disease Management & Complications

A
  • Stop drinking
  • Detoxication
  • Nutrition with vitamins
  • Steroids
  • Liver transplant

→ Spontaneous Bacterial Peritonitis

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6
Q

Alcohol withdrawal symptoms

A

6 -12 hrs = tremor, sweating

12 - 24 hrs = hallucinations

24 - 48 hrs = seizures

48 - 72 hrs = delirium tremens

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7
Q

Alcohol withdrawal management

A
  • Chlordiazepoxide [benzodiazepine] - 1st

- Intravenous high- dose B vitamins with thiamine

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8
Q

Non Alcoholic Fatty Liver Disease

A

Fat deposit in liver cells which can progress to hepatitis & cirrhosis

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9
Q

stages of NAFLD

A
  1. NAFLD
  2. Non- Alcoholic Steatohepatitis
  3. Fibrosis
  4. Cirrhosis
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10
Q

NAFLD risk factors

A
  • obesity
  • poor diet
  • T2 DM
  • High cholesterol
  • Smoking
  • High BP
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11
Q

NAFLD investigations

A
  • Liver ultrasound - can diagnose fatty liver (hepatic steatosis)
  • Enhanced liver Fibrosis blood test - 1st Line
  • NAFLD Fibrosis score
  • Fibroscan
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12
Q

NAFLD management

A
  • Weight loss
  • Stop smoking
  • No alcohol
  • Control diabetes, BP & cholesterol

patients with Liver fibrosis → refer & treat with Vit. E & Pioglitazone

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13
Q

Hep. C

A
  • RNA virus

- spread by blood & body fluids

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14
Q

Hep. C Testing & symptoms

A
  • Hep. C antibody
  • Hep. C RNA testing

-> Asymptomatic, RUQ pain, fever, nausea

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15
Q

Hep. C management

A
  • Antiviral treatment with Direct acting antivirals (DAAs) - Ribavirin
    monitor with alpha fetoprotein
  • Stop smoking & alcohol
  • Notify Public health
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16
Q

Hep. A + Diagnosis

A
  • RNA virus
  • Transmitted via Faecal-oral route usually by contaminated water /food.
  • > LFT = high ALT & AST
  • > Serology = anti-HaV IgM
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17
Q

Hep. A Signs & complications

A
  • Nausea
  • Vomiting
  • Anorexia
  • Jaundice

→ It can cause cholestasis (slowing of bile flow through biliary system)
with dark urine , Pale stools , hepatomegaly.

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18
Q

Hep. A management

A
  • Resolves without treatment in 1-3months
  • Analgesia (avoid paracetamol & alcohol)
  • Vaccination
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19
Q

Hep. B

A
  • DNA virus

- Transmitted by direct contact with blood/ bodily fluids -> parental transmission

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20
Q

Hep. B Investigations

A
  • Screen for HBcAg (past infection) & HBsAg (active infection)
  • If + ve, test HBeAg & viral load
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21
Q

Hep. B management & signs

A

Don’t worry about it!

  • > Acute hepatitis
  • > Fulminant hepatitis
  • > Chronic hepatitis
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22
Q

Hep.D

A
  • RNA virus
  • Only survives in patients who have Hep. B infection
  • It attaches to HBsAg to survive
  • Diagnosis: detect IgM antibody
  • No treatment
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23
Q

Hep. E

A
  • RNA virus
  • Transmitted by faecal oral, mainly water- borne
  • No treatment , detect IgM
  • Progressed to cirrhosis in immunocompromised
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24
Q

Autoimmune Hep.

A
  • 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

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25
Q

Autoimmune Hep. Investigations

A

Liver biopsy

Raised transaminases (ALT & AST)

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26
Q

Autoimmune Hep. Tx

A
  • High dose steroids [prednisolone or Cyclosporin] → Gold

- Immunosuppressants [azathioprine] → 1st Line

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27
Q

Liver Cirrhosis

A
  • 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
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28
Q

Common cause of Liver Cirrhosis

A

→ Alcohol abuse
→ Non alcoholic fatty liver disease
→ Hep. B
→ Hep. C

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29
Q

Signs of Liver cirrhosis

A

→ Jaundice
→ Hepatomegaly & Splenomegaly
→ spider naevi
→ Palmas Erythema

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30
Q

Liver Cirrhosis investigations

A
  • Enhanced Liver Fibrosis
  • Liver biopsy
  • Albumin drops
  • Prothrombin time increases
  • Hyponatraemia
  • Utrasound
  • Fibroscan
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31
Q

Liver Cirrhosis management

A

→ Utrasound & alpha-fetoprotein every 6 months for hepatocellular carcinoma
→ Endoscopy
→ High protein, low sodium diet
→ Liver transplant

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32
Q

Liver Cirrhosis Complications

A
  • Malnutrition
  • Portal Hypertension
  • Varices & Variceal bleeding
  • Ascites
  • Hepatic encephalopathy
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33
Q

Portal hypertension

A

Liver cirrhosis increases the resistance of blood flow in the liver, this increases back - Pressure into the portal system

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34
Q

Portal vein anatomy

A

comes from Superior mesenteric vein & Splenic vein → delivers blood to liver

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35
Q

Portal varices

A

Back- pressure causes vessels in the portal system anastomoses with systemic venous system to be swollen & tortuous → varices

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36
Q

Where do portal varices occur?

A

→ Gastro - oesophageal junction
→ Ileocareal junction
→ rectum
→ Anterior abdominal wall Via the umbilical vein (caput medusae)

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37
Q

Portal hypertension treatment

A

Propranolol → acts as a non- selective beta - blocker

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38
Q

Portal varices management

A
  • Elastic band ligation
  • Injection of scIerosant
  • Transjugular Intra - hepatic Portosystemic Shunt (TIPS)
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39
Q

Bleeding Oesophageal Varices

A

Resus:
→ Vasopressin analogues [Terlipressin]
→ Correct coagulopathy with vit.k & Fresh frozen plasma

→ Give prophylactic broad spectrum antibiotics
→ Elastic band ligation of varices

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40
Q

Ascites

A

Fluid in the Peritoneal cavity

Increased pressure in the portal system causes fluid to leak out of the capillaries into peritoneal cavity.

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41
Q

Ascites & link to Renin- angiotensin system

A
  • 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

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42
Q

Ascites management

A
  • low sodium diet
  • Anti - aldosterone diuretics [Spironolactone]
  • Paracentesis (ascitic drain)
  • Prophylactic antibiotics [ Ciprofloxacin] against Spontaneous bacterial peritonitis
43
Q

Hepatic Encephalopathy Pathophysiology

A
  • 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
44
Q

Hepatic encephalopathy symptoms

A
  • Altered mood & behaviour, Sleep disturbance, dyspraxia
  • Drowsiness, Confusion, Slurring speech
  • Restlessness, Asterixis
  • Coma
45
Q

Hepatic Encephalopathy Management

A

→ Lactulose (to help nitrogenous waste loss)
→ IV Mannitol
→ Vit. K

46
Q

Cholecystitis

A

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
47
Q

Cholecystitis Symptoms

A

→ Pain in Right Upper Quadrant → radiate to Right shoulder

→ Murphy’s sign (gallbladder pain on inspiration when palpated)
→ Nausea & vomiting
→ Fever
→ Tachycardia & Tachypnoea

48
Q

Cholecystitis Investigations

A

→ Abdominal Ultrasound scan

  • Thickened gallbladder wall
  • Stones in gallbladder
  • Fluid in gallbladder

→ Magnetic Resonance Cholangiopancreatography (MRCP)

49
Q

Cholecystitis Management

A
  • Nil by mouth
  • IV fluids
  • Antibiotic

→Endoscopic Retrograde Cholangio -pancreatography

→ Cholecystectomy

50
Q

Ascending cholangitis

A

= 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
51
Q

Ascending cholangitis Symptoms

A

CHARCOT ‘S TRIAD :

  • Right upper quadrant pain
  • Fever
  • Jaundice (high bilirubin)
52
Q

Ascending cholangitis Management

A 
→ Nil by mouth
→ IV Fluids
→ Blood cultures
→ IV antibiotics
→ ICU/ HDU
53
Q

Ascending Cholangitis Investigations

A
  • Abdo. Ultrasound scan
  • CT scan
  • MRCP
  • Endoscopic ultrasound
  • ERCP
54
Q

What is the opening of the common bile duct called?

A

Sphincter of Oddi

55
Q

Primary Sclerosing Cholangitis

A

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
56
Q

Primary Sclerosing Cholangitis Risk factors

A
  • Male
  • Age 30-40
  • Ulcerative Colitis
  • Family history
57
Q

Primary Sclerosing Cholangitis Presentation

A
  • Jaundice
  • Right upper quandrant Pain
  • pruritus
  • Fatigue
  • Hepatomegaly
58
Q

Primary Sclerosing Cholangitis Investigations

A
  • Magnetic Resonance Cholangiopancreatography (MRCP)
  • Liver Function Tests - deranged
    → shows cholestatic pic., alkaline phosphatase
    → Rise in bilirubin
  • Autoantibodies
59
Q

Primary Sclerosing Cholangitis Complications

A
  • Acute bacterial cholangitis

- Cholangiocarcinoma

60
Q

Primary Sclerosing Cholangitis Management

A
  • Liver transplant
  • ERCP for stent
  • Colestyramine (bile acid)
  • Sertraline for pruritus
61
Q

Pancreatitis

A

Inflammation of the pancreas.

Acute = Rapid onset of inflammation & Symptoms.

Chronic = long- term inflammation & symptoms with a progressive deterioration in Pancreas

62
Q

Pancreatitis Causes

A 
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]
63
Q

Pancreatitis Symptoms + Signs

A
  • Severe epigastric pain radiates to back
  • Vomiting

→ Cullen’s sign (periumbilical region)
→ Grey Turner Sign (left flank)

64
Q

Pancreatitis Investigations

A

(Glasgow score)

  • Serum Amylase - raised
  • C-reactive protein
  • Ultrasound (check for gallstones)
  • CT abdomen
65
Q

Management of Acute Pancreatitis

A
  • IV Fluids
  • Resus
  • Analgesia
  • Nil by mouth
  • Antibiotic
66
Q

Management of Chronic Pancreatitis

A
  • Abstinence from alcohol & smoking
  • Analgesia
  • Replacement Pancreatic enzymes
  • Insulin regimes
67
Q

Complication of Acute Pancreatitis

A
  • Acute renal failure
  • Sepsis
  • Pancreatic Abscess
68
Q

Alpha 1 Antitrypsin Deficiency

A

Condition caused by an abnormality in the gene for a protease inhibitor called Alpha -1 - Antitrypsin.

  • Autosomal recessive
69
Q

Alpha 1 A Pathophysiology

A
  • 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

70
Q

Alpha 1 A Diagnosis

A
  • low serum Alpha - 1 - Antitrypsin
  • Liver biopsy & acid - Schiff - Positive staining globules
  • Genetic resting
  • CT thorax
71
Q

Alpha -1 A Management

A
  • Stop smoking
  • Symptomatic management
  • Replacement Alpha-1- A
  • Organ transplant
72
Q

Acute Live Failure Symptoms

A
  • Malaise
  • Nausea
  • Anorexia
  • Jaundice / Pruritis
73
Q

Chronic liver failure Symptoms

A
  • Ascites/ Oedema
  • Malaise
  • Spider Naevi
  • Palmar Erythema
  • Clubbing
  • Bleeding
74
Q

Acute Liver failure causes

A
  • Paracetamol Drug- Induced - Liver - Injury
  • Alcohol
  • viral hepatitis
  • Drugs
  • Obstruction
75
Q

Chronic liver failure Causes

A
  • Alcohol
  • viral hepatitis
  • Autoimmune
  • Neoplastic
  • NAFLD / AFLD
76
Q

Liver Cirrhosis Investigation

A
  • Prothrombin time
77
Q

Bleeding varices
Investigations
Symptoms
Treatment

A

Ix : Upper Gl endoscopy

Symptoms = Melaena, Haematemesis (coffee ground vomit)

Tx = Endoscopic therapy & band ligation, Fluid resus, Terlipressin (ADH analogue) or Ocreotide, Balloon Tamponade

78
Q

Haemochromatosis

A

Dysregulated dietary iron absorption & increased iron release from macrophages.

  • Autosomal recessive
79
Q

Haemochromatosis Pathophysiology & Symptoms

A

Iron accumulates in liver, joints, Pancreas, heart, skin & gonads

Symptoms = Slate Grey Skin or brownish bronze

80
Q

Haemochromatosis Investigations

A

Liver biopsy

Iron - Bloods, LFTs

81
Q

Haemochromatosis Treatment

A

1st Line = Venesection

2nd Line = Chelation

Gold= Liver transplant

82
Q

Wilson’s Disease

A

Too much copper builds up in liver & CNS.

  • Autosomal recessive
83
Q

Wilson’s Disease Pathophysiology & symptoms

A

Cu2+ accumulates in liver, basal ganglia & cornea

Symptoms - Kayser-Fleischer ring, Parkinsonian, Depression

84
Q

Wilson’s Disease Investigations

A

Gold= Liver biopsy

1st line = 24 hr urine Copper & blood caeruloplasmin

85
Q

Wilson’s Disease Treatment

A
  • Penicillamine (copper chelation)

- Liver transplant

86
Q

Hepatocellular Carcinoma
Presentation
Investigations
Treatment

A

Presentation= Weight loss, fatigue, dark Stools & Pale urine

Investigations = LFTs, Clotting studies, CT, MRI, Ultrasound with biopsy

Treatment = Partial hepatectomy, Chemotherapy

87
Q

Biliary colic
Symptoms
Investigations
Treatment

A

Temporary blockade of cystic duct by gallstones.

Symptoms = RUQ Pain after fatty meals

Investigations = FBC, CRP, LFTs

Treatment = Analgesia & Cholecystectomy

88
Q

Primary Biliary Cirrhosis

Presentation
Investigation
Treatment

A

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

89
Q

Peritonitis
Symptoms
Investigations
Treatment

A

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

90
Q

Jaundice + treatment

A

Skin turning yellow due to high bilirubin levels.

Treatment = lots of fluid / rest, Stop alcohol

91
Q

3 main types of Jaundice & causes

A

Pre- hepatic = Pernicious Ihaemolytic anaemia

Intrahepatic = Hepatitis & Cirrhosis

Post - hepatic = Obstructive e.g. gallstones

92
Q

How are 3 types of Jaundice characterised?

A

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

93
Q

What are the Symptoms of the 3 types of jaundice?

A

Pre - hepatic = Pallor , fatigue , Exertional Dyspnoea

Hepatic = Anorexia , fatigue , Nausea , Abdo. Pain

Post - hepatic = Pale stools , Dark urine , Pruritus , Steatorrhoea , RUQ pain

94
Q 
Pancreatic cancer
Who?
Symptoms
Investigations
Management
A

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.

95
Q

Cholelithiasis

A

Stones form in the gallbladder.

Form from concen. bile in the bile duct & are mostly cholesterol.

96
Q

Gall stone Anatomy

A
  • 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.
97
Q

Gallstones Risks

A

F = Fat

F = Fair

F = Female

F = Forty

98
Q

Gallstones Symptoms

A
  • Biliary colic - colicky or RUQ epigastric pain, triggered by fatty meals.
  • Acute cholecystitis
  • Acute cholangitis
  • Obstructive jaundice
  • Pancreatitis
99
Q

Gallstones Diagnosis

A
  • 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
100
Q

Gallstones Treatment

A
  • Cholecystectomy

- IV Fluids & Co- amoxiclav (cholecystitis)

101
Q

Primary Biliary Cholangitis

Sx:

Ix:

Tx:

A

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

102
Q

Paracetamol Overdose Management

A

N-acetyl-cysteine + Activated charcoal within 1hr of ingestion

103
Q

Cholecystitis Risks

A 
Fat 
Female
Forty
Flatulent
Fertile

Phase 2a Revision (9 decks)

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