liver Flashcards
ACUTE liver failure is liver failure without _______, with _________pathy and _______ _______pathy, within ___ weeks of onset
without chronic liver dis, coagulopathy, hepatic encephalopathy, 28
what is the most common cause of acute liver injury?
drugs eg alcohol, paracetamol, antidepressants, cocaine, ecstasy
4 infective causes of acute liver injury?
hep a, hep b, cmv, ebv, malaria, yellow fever
why is there systemic multi-organ failure in acute liver failure?
The hepatocytes die by necrosis. This means that the liver cannot clear the toxins anymore, so there is an inflammatory response around the body.The systemic inflammatory response causes vasodilation and hypo perfusion, which injures the rest of the organs through ischaemia
some symptoms of acute liver failure?
asterixis, flapping tremour, fatigue, jaundice, malaise, bleeding, bruising, haptatic encephalopathy, ruq pain, hypoglycaemia, pear drops smell (fetor hepaticus)
what would high ALT mean?
hepatocyte damage
what would high AST mean?
alcohol
what would high ALP mean?
bile duct pathology - if GGT is also raised
bone pathology - if everything else is normal
what would high GGT mean?
bile duct, obstruction, alcohol, phenytoin
what would the clottting profile look like in acute liver failure?
low albumin
high inr
high prothrombin time
what
what imaging would you use in liver failure?
ultrasound to see liver size
doppler to see hepatic and portal veins
two supplements you would want to give in acute liver failure?
thiamine and folate
what can you give for seizures in acute liver failure
phenytoin
5 aetiologies of chronic liver dis?
alcohol inf (hep b/c) alpha 1 antitrypsin def wilsons autoimmune cholangitis ischaemia drug
5 pathophysiological/histological features of chronic liver disease?
steatosis bands of cirrhosis/fibrosis regenerative nodulues hepatitis balooned hepatocytes irreversible remodelling
5 signs of chronic liver dis?
sarcopenia coagulopathy ascites hepatomegaly jaundice caput medusa spider naevi palmar erythema asterixis
5 symptoms of chronic liver failure?
haematemesis fatigue itching bruising anorexia confusion
what abnormal lfts are typical of chronic liver failure?
high bilirubin
low albumin
high pt
how do you assess the amount of fibrosis in the liver?
transient elastography
what is gold standard for chronic liver disease?
liver biopsy (but is rarely done cos spenny)
what does fbc in chronic liver dis show?
thrombocytopenia
how to treat hepatic encephalopathy?
laxatives
how to treat ascites?
aldosterone antagonist or paracentesis
how to treat spontaneous bacterial peritonitis?
abx
albumin solution
cholecystitis vs cholangitis?
cholecystitis = inflam of the gallbladder (usually because it is blocked at the neck by a stone) cholangitis = inflam of the billiary tree tubes - gallstones, ercp, cholangiosarcoma
3 aetiologies of gall stones?
too much cholesterol
poor bladder emptying
rbc turnover
simply, what’s in a gallstone?
cholesterol and bile salts
what is billiary colic?
intermittent pain caused by temporary obstruction
what is acalculous cholecystitis?
inflammation of the gallbladder not caused by a stone
where is the pain in gallbladder pathology?
ruq
symptoms of biliary colic?
intermittent ruq/epigastric pain
worse after eating
nausea
symptoms of acute cholecystitis?
severe constant ruq pain
worse on inspiration
referred to shoulder c3,4, 5 if severe
murphys sign
symptoms of ascending cholangitis?
ruq pain
jaundice, dark urine, itching, coagulopathy
rigors
fever
how can you treat cholecystitis?
ercp to remove stones
remove the gallbladder if stones are reoccuring
drain the gallbladder
4 pathophysiological effects of alcohol on the liver?
uses up NAD and creates NADH
NADH decreases gluconeogenesis and increases fatty acid oxidation
free radicals produced
activates kupffer ells which release TNFa and ROS
oxidative stress leads to more inflammation
end result of all the inflammation is fibrosis
3 stages of alcoholic liver disease and are they reversible?
- alcohol related fatty liver - reverses in 2 weeks
- alcoholic hepatitis - reverses in 2 months
- cirrhosis - not reversible
presentation of alcoholic fatty liver?
vague or no symptoms
hepatomegaly
5 clinical presentations of hepatitis/cirrhosis?
hepatomegaly jaundice spider naevi caput medusa asterixis clubbing oedema ascites bruising high temp palmar erythema gynaecomastia
what do you see on an fbc in alcoholic liver dis?
increased cell volume (macrocytic anaemia)
what do you see in alcoholic liver disease, on LFT?
raised AST
slightly raised ALT (AST>ALT)
raised GGT
if severe: low albumin, high PT, high bilirubin
3 changes you see on ultrasound, in alcoholic liver dis?
fatty
cirrhosis
ascites
changes in blood vessels
why might you do an endoscopy in liver dis?
to look for oesophageal varices
two screening question systems for alcoholism?
CAGE
AUDIT
management of alcoholic liver disease?
drinking cessation [supported]
high thymine, high protein diet
short period of steroids
transplant
aetiology of pancreatitis? (5)
i - iatrogenic - ERCP is most common iatrogenic cause g - gallstones - most common e - ethanol t - trauma s - scorpion bite m - measles/mumps/mycoplasma a - autoimmune s - steroids h - hypercalcaemia e - ERCP d - drugs eg valproate
aetiology of chronic pancreatitis? (3)
repeated acute
alcohol
CF
tumours
3 enzymes secreted by the pancreas?
amylase, lipase, trypsin
2 pathophysiological effects of pancreatitis?
hyperglycaemia
malabsorption
what is the pain like in pancreatitis?
severe generalised or upper abdo radiating to the back worse after eating relieved by sitting forward
clinical presentations of pancreatitis?
cullens/fox sign grey-turner syndrome abdo distention steatorrhoea nausea/vom diabetes-like/hyperglycaemia weight loss jaundice
some blood tests you might do in pancreatitis?
serum amylase (not specific but 1st line) serum lipase hba1c (esp if chronic) igG4 - if autoimmune suspected LFT - AST suggests alcohol is a cause
what imaging for pancreatitis?
USS
MRCP to look for gallstones
an example of a pancreatic enzyme replacement? what could you give it with?
creon
a PPI
What U&E disturbance is there in cirrhosis?
hyponatraemia
high urea and creatinine
on an USS what would you see in cirrhosis?
nodules corkscrew arteries large portal vein ascites splenomegaly
3 complications of cirrhosis
portal hypertension
varices
ascites
where does the portal vein drain from?
superior mesenteric and splenic veins
3 common places for varices to form?
varices form where the portal circulation meets the systemic circulation, eg:
- gastro oesophageal junction
- ileo caecal junction
- rectum
- umbilical vein (forms caput medusae)
management of stable varices?
- propanolol
- elastic band ligation
- TIPSS: shunt blood from portal –> systemic circ , if refractory to other treatments
management of bleeding varices?
fluids
elastic band ligation/schlerotherapy/blakemore tube
-vasopressin analgue eg terlepressin to vasoconstrict
clotting factors and vit K
abx for peritonitis
what is ascites?
accumulation of fluid in the peritoneal cavity
non liver causes of ascites? (3)
peritonitis
water retention
cardiac failure
in portal hypertension, _____ is low, so the ________ releases _______ which worsens ascites
renal perfusion / kidney/ renin
transudative vs exudative ascites & some causes of each?
transudative: low protein in the exudate (below 25); caused by portal htn, malnutrition, fluid retention
exudative: high protein - malignancy and pregnancy
what does the SAAG (serum albumin ascites gradient) tell you?
if it is more than 11, it is transudative ascites, eg caused by portal hypertension
what hormone increases gallbladder contraction?
CCK in response to fatty food
what LFT result is the best indicator of liver function in chronic disease?
albumin
what is gilbert’s syndrome?
gGT deficiency, high bilirubin, jaundice, other LFTs normal, autosomal recessive
raised bilirubin and jaundice but normal LFTs suggests..
gilbert’s
haemolytic anaemia
if the urine is dark and the stools are pale the cause is most likely..
post hepatic obstruction
how does haemolytic anaemia affect jaundice/stools/urine?
there is yellow skin but the pathology is not with the production of bile (so stools not pale) or excretion of it, so the stools and urine are normal
in biliary obstruction, are there high levels of conjugated or unconjugated bilirubin?
conjugated bilirubin is high
unconj and hb are normal
which bacteria is associated with bloody diarrhoea, haemolysis, uraemia and anaemia?
ecoli 0157 h7
which bacteria is associated with RLQ pain and pork?
yersinia
some signs/symptoms of acute hepatitis?
malaise lethargy myalgia gi upset jaundice pale stools, dark urine tender hepatomegaly
what hepatitis cannot be chronic?
A
who gets hep D?
only when infected with hep B
mode of transmission of hep A?
faecal oral
what is significant about hep B?
bad if neonates get it, they develop a chronic infection
it is the only DNA virus, all the others are RNA
presents with jaundice
which hepatitis causes neurological symptoms?
E
which hepatitis has 2 phases of mild symptoms? what are those symptoms?
hep A
1 - mild - malaise/abdo pain
2 - jaundice
3 causes of dysentery?
dysentery = watery diarrhoea cholera e coli clostridium perfringens staph aureus giardia crypto bacillus cereus
what blood test results would you see in c diff infection?
high crp
high wbc
low albumin
5 reasons why you would culture diarrhoea?
hypovolaemia dehydration for more than a week blood or mucus over 70 preg immunocomp ibd public health
What is haaemachromotosis?
too much iron in the body, due to mutations in HFE protein, iron is deposited around the body resulting in organ damage
how is haemachromotosis inherited?
autosomal recessive
clinical presentation of haemachromotosis? (5)
bronze patches on skin tiredness arthritis hair loss erectile dysfunction amenorrhoea poor cognition/mood
haematinics in haemachromotosis?
ferritin raised (not v specific) transferrin raised (this is more specific)
what do you use to see iron in heart and liver in haemachromotosis?
mri
treatment for haemachromotosis?
venesection weakly, to remove the iron
3 complications of haemachromotosis?
t1 diabetes cirrhosis hypothyroidism hypogonadism cardiomyopathy chondrocalcinosis
what is wilsons disease?
too much copper
due to a mutation in the copper binding protein ATP7B (which removes copper from the liver)
how is wilsons disease inherited?
autosomal recessive
5 complications/presentations of wilsons disease?
liver cirrhosis neuro problems eg concentration, dystonia, incoordination, parkinsonism haemolytic anaemia kidney dysfunction / acidosis osteopenia rings in eyes
where is copper deposited in the brain to cause parkinsonism, how does the presentation differ to parkinsons?
basal ganglia
wilsons = symmetrical (parkinsons is not)
what protein carries copper in serum, how specific is the test? what could you also test?
caeruloplasmin not specific, low in cancer and inflam 24hr urine copper serum copper - low. free serum copper - high gold standard = liver biopsy
management of wilsons disease?
copper chelation with penicillamine or trientene
how is alpha 1 antitrypsin deficiency inherited?
autosomal recessive
what two organs does alpha 1 antitrypsin affect?
lung (emphysaema) and liver (cirrhosis)
what is the pathophysiological effect of alpha 1 antitrypsin deficiency?
alpha 1 antitrypsin breaks down neutrophil elastase
without it neutrophil elastase is overractive
damage to connective tissue
–> fibrosis
clinical presentations of liver alpha 1 antitrypsin deficiency?
liver cirrhosis
the emphysaema develops first so they will already have COPD/barrel chested with cough and dyspnoea
what is the test for alpha 1 antitrypsin deficiency?
serum alpha 1 antitrypsin levels liver biopsy - acid schiff pos ct chest genetic testing deranged LFT `
primary vs secondary peritonitis?
primary = spontaneous bacterial peritonitis (e.coli, chlamydia, neisseria) secondary = bile, barium, trauma
what is spotaneous bacterial peritonitis?
infection of the peritoneal fluid
two conditions where transmural bacterial peritonitis could happen?
pancreatitis, ischaemic bowel
what is the pain like in peritonitis?
severe
generalised at first, may be localised if it affects the parietal peritoneum (to shoulder if diaphragm affected)
guarding
relieved by putting hands on abdo, and stretching out
worsened by moving
when bowel sounds cease in peritonitis, what has happened?
paralytic ileus - bowel movements inhibited by pain
what is a late presentation of peritonitis?
circulatory collapse hippocratic face thready pulse, cold peripheries paralytic ileus still in pain
what investigations to diagnose peritonitis?
supine x ray - see dilated bowel
erect x ray - see subdiaphragmatic gas
ascitic tap
blood culture
what differentials should you exclude in peritonitis and how?
preg -hcg
pancreatitis - aylase
mi - ecg / troponin
lactate, crp and wcc will also be raised
Management of peritonitis?
abx
fluid
peritoneal lavage
analgaesia
what are the two most common primary liver cancers?
- hepatocellular carcinoma
2. cholangiocarcinoma (of the bile duct)
what are liver hemangiomas?
benign, asymptomatic tumours of blood vessels/birthmark
what is focal nodular hyperplasia & some important features?
nodule of scar tissue in liver
benign, no malignant potential
more in women, associated with oestrogen
a major risk factor for hepatocellular carcinoma?
cirrhosis
which may have been caused by hep B/C, alcohol, faty liver dis, HBV ..
3 risk factors for cholangiosarcoma?
primary sclerosing cholangitis
IBD
Hep B
parasites
what is the presentation of cholangiosarcoma?
painless jaundice
some presentations of hepatocellular carcinoma?
generally late / asymptomatic weight loss ruq pain enlarged, irregular liver n/v jaundice bruit over liver
a tumour marker for hepatocellular carcinoma?
alpha fetoprotein
a tumour marker for cholangiocarcinoma?
CA19-9
best imaging / investigation for cholangiosarcoma?
ERCP
A drug that can be used in late stage liver cancers?
kinase inhibitors eg sorafenib
what type of cancer is pancreatic cancer?
adenocarcinoma
where is the most common location in the pancreas for pancreatic cancer to develop?
in the head of the pancreas
what kind of jaundice does pancreatic cancer cause & why? what are the symptoms of this?
obstructive jaundice, because as the tumour grows it blocks the pancreatic duct
painless
pale stools and dark urine
4 presentations of pancreatic cancer?
obstructive painless jaundice with pale urine and dark stools
itching
weight loss
upper abdo/back pain
mass
new or worsening diabetes
n/v
courveissers - painless obstructive jaundice + palpable gallbladder means gallstones are unlikely
troussea sign – migratory thrombophlebitis - blood clots that make lumps under the skin = pancreatic malignancy
what investigations could you do in ?pancreatic cancer?
CA19-9 - raised but not specific
CT T.A.P
M/ERCP - to stent the bile duct and also take a biopsy
Surgery for pancreatic cancer?
pancreatectomy
whipples
ercp for symptomatic management
ERCP vs MRCP?
ERCP = endoscopic retrograde cholangiopancreatography
MRCP = magnetic resonance cholangiopancreatography
ERCP is more invasive but better diagnostically
what does a hernia feel like (to the patient)?
soft lump
aching
pulling/dragging sensation
what is an incarcerated hernia? what can happen as a result?
becomes irreducible and a portion of bowel is stuck through the hole
obstruction –> vomiting, pain, constipation
strangulation –> necrosis
what sort of hernias do not need to be managed?
those with a wide neck - there is a lower risk of strangulation/herniation
what are the two kinds of inguinal hernias?
direct - through the posterior wall of the inguinal canal. caused by heavy lifting. do not reduce when you press the inguinal ring. wide neck, usually unproblematic
indirect - through the deep inguinal ring into the inguinal canal. congenital. can strangulate. reduce when you press the inguinal ring
where is a femoral hernia?
at the top of the thigh
abdominal contents move through the femoral ring into the femoral canal
small neck - complications
who gets umbilical hernias?
neonates and old people
in neonates they resolve by themselves
in old people is because of weakening of the abs
where is a spigelian hernia?
between the rectus abdominus and linear semilunaris
who gets obturator hernias?
old women – due to pelvic floor damage
formed by herniation through the obturator foramen at the base of the pelvis
what hernias can present as dyspepsia/nausea?
hiatus hernias – due to herniation of stomach into diaphragm
what hernias present with lower groin or thigh pain and a positive howship-rhomberg sign on internal rotation of the hip?
obturator hernias
what hernias present with non specific abdo pain and commonly cause complications?
spigelian hernias (between the rectus abdominus and linear semilunaris)
how do you get hepatitic encephalopathy?
ammonia - usually metabolised by liver
if liver not working ammonia crosses BBB
ammonia –> glutamate
also draws water in –> cerebral oedema
why do you get gynaecomastia in liver dis?
the liver is involved in oestrogen regulation
what is leukonychia?
white nails
due to low protein (albumin)
which can indicate liveer failure
two examples of autoimmune liver conditions?
primary biliary cholangitis - esp females
primary scherosing cholangitis
if someone with liver failure was actively bleeding what blood product would you give them?
fresh frozen plasma
what is the treatment for hep C?
ribavirin
what is the treatment for hep b?
first line is pegylated interferon alpha 2a
second line is tenofovir
what happens in paracetamol overdose?
glucoronidation and sulphation pathways are overwhelmed –> produce NAPQI by a CYP
NAPQI is fine if it is added to glutathione, then it can be excreted
in overdose you run out of glutathione –> NAPQI is toxic
presentation of paracetamol overdose?
n/v
ruq pain
anorexia
treatment of paracetamol overdose?
n-acetylcysteine
activated charcoal, if presents within an hour
what is steatosis?
harmless build up of fat in the liver cells
can go on to develop steatohepatitis, which is what can cause fibrosis/cirrhosis
what is wernicke-korsakoff encephalopathy?
liver associated
ataxia, confusion, nystagmus, memory impairment
treat with iv thymine / vit b1
what is budd-chiari syndrome and what does it cause?
occlusion of liver veins –> portal hypertension
what does TIPSS stand for?
transjugular intrahepatic portal systemic shunt
what is the most common bacteria in spontaneous bacterial peritonitis & what would be the treatment?
e.coli
cefotaxime
where is the ampulla of vater?
between the pancreatic duct and the common bile duct
what is the pathophysiology of primary sclerosing cholangitis?
fibrosis and strictures of the bile ducts
= reduced flow of bile
= bile backs up into liver – hepatitis – cirrhosis
what is the epidemiology of primary sclerosing cholangitis?
male
30-40
strong association with ulcerative colitis
presentation of PSC?
jaundice chronic RUQ pain fatigue itching hepatomegaly signs of cirrhosis
investigations for PSC? 3
LFT - ALP high, bilirubin may be high, others increase as condition progresses
autoantibodies eg ANA, pANCA, anti-cardiolipin - don’t confirm anything but suggest autoimmune cause
MRCP - gold standard
in gilberts syndrome, what are the urine and stools like?
even though there is jaundice, the urine and stools are normal, as this is prehepatic jaundice
in pre hepatic jaundice, the urine is _____ and the stools are _____
normal
normal
in intrahepatic jaundice, the urine is ____ and the stools are ____
urine = dark stools = normal
in post hepatic jaundice, the urine is ____ and the stools are _____
dark urine
pale stools
what is the pathophysiology of primary billiary cirrhosis?
autoimmune attack of bile ducts
= build up of bile, cholesterol and bilirubin as they cannot get to intestines
– put into blood instead
what is the epidemiology of primary biliary cirrhosis?
women
autoimmune esp coeliac, hypothyroid
rheum eg RA, Sjogrens
what is the presentation of PBC?
itch jaundice pale stool abdo pain fatigue xanthoma/xanthelasma (cholesterol deposits)
what is the test for PBC?
LFT - ALP raised first anti-mitochondrial antibodies ANA - not sensitive or specific ESR IgM raised
what is the treatment for PBC and PSC?
Ursodeoxycholic acid reduces the intestinal absorption of cholesterol
Colestyramine is a bile acid sequestrate
liver transplant
consider immunosupression
what is the best investigation to confirm ascending cholangitis?
contrast enhanced dynamic CT
what is the treatment for autoimmune hepatitis?
prednisolone - 1st line
+ azathiopurine
what is first line treatment for alcohol withdrawal?
chlordiazepoxide
what is the most common cause of liver cirrhosis?
alcohol
what is the name of the rings in the eyes in wilsons disease?
kayser-fletcher rings
which 2 hepatitises have faecal-oral transmission?
A and E
what is Murphys sign and what does it show?
pain on inspiration when you palpate the right subcostal area
= cholecystitis
cullens and grey turners signs indicate ____
acute pancreatitis
what is Charcot’s (liver) triad?
fever + rigors
jaundice
RUQ pain
typical of ascending cholangitis
marker for testicular seminoma?
ALP
Marker for choriocarcinoma?
hCG
choriocarcinoma = cells left behind from pregnancy become cancerous v rare
or a v rare type of testicular cancer
what is testicular teratoma like at biopsy?
lots of different cells
mallory bodies are associated with?
alcoholic liver damage
if the serum ascites-albumin gradient is low what is the cause?
low gradient = exudative
eg inflam, infection
what is the difference between the transmission of hep B and hep C?
B = sex
C = needles
why is there decreased immunity in chronic liver disease?
liver does protein synthesis so poor liver function = decreased clotting factors, complement, opsonisation etc
bowel wall may be more permeable
liver regulates immune response
