Liver Flashcards
1
Q
ALT/AST which is more specific for liver damage?
A
ALT
2
Q
when levels are raised what do these ratios indicate?
AST:ALT = 1
AST:ALT > 2.5
AST:ALT < 1
A
AST:ALT = 1
Ischaemia
AST:ALT > 2.5
Alcoholic hepatitis
AST:ALT < 1
High ALT for hepatocellular damage e.g. paracetamol OD with hepatocellular necrosis, viral hepatitis, ischaemic necrosis, toxic hepatitis
3
Q
What are ALP and GGT elevated in
A
cholestasis
4
Q
What is associated with cholestasis and malignant hepatocellular damage + marker of bone turnover
A
ALP
5
Q
What is sensitive to alcohol ingestion
A
GGT
6
Q
Name 2 inherited causes of liver disease
A
Hereditary haemochromatosis
Deficiency of iron regulatory hormone hepcidin
Wilson’s disease
Hepatolenticular degeneration - accumulation of copper at tissues
Alpha-1 antitrypsin deficiency
Affects liver and lungs (emphysema)
7
Q
Gene in hereditary haemochromatosis?
A
HFE
AR
8
Q
Mech in Heerditary haemochromatosis
A
Increased intestinal absorption of iron leading to accumulation in tissues
9
Q
Sx of hereditary haemochromatosis
A
Early: fatigue, weakness, arthralgia, erectile dysfunction
Late: skin bronzing, diabetes, cirrhosis (liver signs), impotence, cardiac arrhythmia
10
Q
Name 3 Ix in Hereditary haemochromatosis
A
*Iron studies
-Serum ferritin (high) - lots of iron in cells
-Transferrin saturation (>45%) - lots of iron in blood specific
HFE genetic testing
LFTs
MRI - iron overloaded liver
Liver biopsy with Perl’s stain *Liver fibroscan/transient elastography
ECG/ECHO for cardiomyopathy
11
Q
Why is serum ferritin not very specific
A
low specificity as acute phase protein. other things can make it go up
12
Q
Mx of hereditary haemochromatosis
A
Venesection/phlebotomy 4-500ml weekly
monitor ferritin
low iron diet
liver transplant - when decompensated
13
Q
Wilson genetics
A
AR
ATP7B gene
14
Q
Mech in wilson - where is copper deposited?
A
Disorder of biliary excretion of copper
liver , basal ganglia
15
Q
Name 3 Ix in wilsons
A
copper studies - low, urinary copper ^^^
slit lamp - kayser fletcher
liver biopsy
MRI - BASAL GANGLIA
16
Q
name 3 Mx of wilsons
A
Penicillamine
zinc - reduces copper absorption
low copper diet (avoid mushrooms, liver, chocolate, nuts)
Monitor hepatic function, renal function, FBC and clotting
Avoid alcohol and hepatotoxic drugs
17
Q
2 organs affected in A1AT deficiency
A
Lung
Dyspnoea, wheezing, cough i.e. COPD (lung bases commonly)
Liver
Hepatitis, cirrhosis (HCC), fibrosis
18
Q
Ix in A1AT
A
Serum A1AT (low) -> phenotyping required
CXR and LuFT
LFT and biopsy
19
Q
Mx of A1AT ? what do you monitor?
A
Avoid smoking / alcohol
Mx of COPD
Monitor LFTs , treat cirrhosis, screen for HCC
20
Q
4 characteristics of liver failure
A
Hepatic encephalopathy
Jaundice
Abnormal bleeding
Ascites
21
Q
Name 3 DDx of liver failure
A
Paracetamol, alcohol, medications (co-amoxiclav, cipro, doxy, erythro, methotrexate, gold)
Viral hepatitis, EBV, CMV
HCC
Wilson’s A1ATd
Ischaemia, Budd-Chiari
AI liver disease
22
Q
what happens in hepatic encephalopathy
A
In liver failure ammonia builds up in circulation and crosses BBB. Astrocytes clear this turning glutamate to glutamine.
Glutamine excess causes fluid shift to cells -> cerebral oedema.
23
Q
Name 3 signs of chronic liver disease
A
caput medusae
Finger clubbing
Leukonychia
Asterixis (liver flap)
Palmar erythema
Spider naevi/scratch marks
Shifting dullness
Bleeding
24
Q
drug for paracetamol OD
A
n-acetylcysteine
25
Mx of high amonia
lactulose + neomycin
26
mx of raised ICP
mannitol
27
Mx of ascites
restrict fluid - low salt
diuretics
Drain and Human Albumin Solution
28
What are ascites
collection of fluid in peritoneal cavity
29
Most common cause of ascites? Name 2 others
75% - cirrhosis
(decreased albumin + portal hypertension)
Malignancy - GI / Ovarian (meigs)
Heart failure
Nephrotic
30
Ix in ascites, name 3
Abdo USS
CXR (HF / pleural effusion)
LFT
Shifting dullness
31
triad OE in spontaneous bacterial peritonitis
Who gets it?
guarding, rebound tenderness, pain on palpation
It is bacterial peritonitis secondary to ascites in people with liver cirrhosis
32
Name 3 Ix in spontaneous bacterial peritonitis
FBC - *leuocytosis
LFT, *U+E (renal impairment), blood cultures
*Diagnostic paracentesis - for culture and amylase
Imaging - upright AXR and CXR
33
Name 1 organism commonly causing spontaneous bacterial peritonitis and mx
E.coli, enterococci
IV ceftriaxone
34
In end stage liver failure 40% develop hepatorenal syndrome ... general mx
2 types
Long term Mx
Type 1 - rapid - survival ~2 weeks
terlipressin with albumin
Type 2 - last 6 months
TIPS
Admit to HDU
Monitor fluids
Stop nephrotoxic drugs /diuretics
TRANSPLANT
35
What happens in advanced/decompensated cirrhosis
oedema, ascites, bruising, poor memory, bleeding varices
Decompensated = caput medusae, hepatic encephalopathy, ascites
36
Name 3 cutaneous signs of cirrhosis
What is cirrhosis?
NECROSIS --> FIBROSIS --> NODULAR FORMATION
FLAPS
(finger clubbing, leukonychia, asterixis, palmar erythema, spider naevi, scratch (pruritus), jaundice, dupuytren’s
37
Name 3 causes of portal HTN
Pre hepatic
Portal vein thrombosis, splenic vein thrombosis, extrinsic compression e.g. tumour
Hepatic
Cirrhosis, hepatitis, schistosomiasis, granuloma (sarcoid)
Post hepatic
Budd-Chiari, RHF/CHF, constrictive pericarditis
38
General Mx of cirrhosis? what 2 conditions do you monitor for?
Adequate nutrition and alcohol abstinence, exercise for muscle wasting
Oesophageal varices and HCC
39
Ix for portal HTN
Name 3
AUSS for liver/spleen/ascites
Doppler ultrasound - blood flows
Spiral CT for portal vasculature
Endoscopy for oesophageal varices
Portal pressure by hepatic venous pressure gradient (normal < 5, varices > 10)
40
Mx of portal HTN
Reduce portal venous pressure
-BBs, TIPS (Transjugular Intrahepatic Portosystemic Shunt)
41
Primary prevention of varicies in portal HTN AND prevention of vatical bleeding once you have them
propranolol
42
Key Ix in varicies
endoscopy (early)
[clotting, group, cross match]
43
Mx in varicies
terlipressin
oesophageal -> band ligation
gastric -> endoscopic injection of N-butyl-2cyanoacretate
44
What if mx of varicies doesnt work
Minnesota tube then ---> Transjugular Intrahepatic Portosystemic Shunt
45
what causes Sudden RUQ pain + rapidly developing ascites
[+ hepatomegaly + jaundice + renal involvement (50%)]
Key Ix?
budd-chiari syndrome
[occlusion of the hepatic veins]
doppler ultrasound
46
Mx of budd-chiari
Treat asicites - eg TIPS
If due to chronic inferior vena cava thrombosis -> warfarin
47
Usual cause of liver Ca
only 10% primary
Rest are from stomach, colon, lung, breast
48
Usual cause of primary HCC
Hep c
[HC causes HCC]
49
What is screened in high risk of HCC Eg. HBV ± cirrhosis and HCV/alcoholic cirrhosis
USS
AFP
50
name 2 methods of liver Ca prevention
HBV vaccine,
reduced alcohol,
screen those with cirrhosis
51
Name 3 causes of fatty liver
metabolic syndrome
PCOS
alcohol
HBV/HCV
52
Dx Ix in fatty liver
Biopsy: cells swollen with fat
53
mx fatty liver
no alcohol
wt loss + exercise
mx of cause
54
What is higher in steatohepatitis - AST or ALT
ALT
55
Name 2 things on histology of hepatitis ? chronic?
Lobular disarray
Inflammatory cell infiltrate
xone 3 necrosis
bile duct proliferation
chronic = lymphoid follicles at portal tract - classical
56
hep A
incubation?
spread?
2-6 weeks
feaco oral
57
Hep A Ix
HAV IgM - acute
HAV IgG - lasts years
LFT (AST:ALT <1)
58
Hep A Mx ?
For itch?
fluids, antiemetics, rest, avoid alcohol
cholestyramine
59
What dissolves gall stones
ursodeoxycholic acid
60
Hep B spread
Incubation?
Parenteral - blood or body fluid
Vertical:
Horizontal: sexual
60-90 days
61
What is HBsAg
HBsAb
HBsAg - found at current infection (may be produced as vaccine)
HBsAb indicates immunity post infection/vaccine
62
Ix in Hep B ? Name 2 things you'd screen for
PCR HBV (for response to therapy and viral replication)
Viral serology
FBC, LFT, clotting, ferritin, AA screen, caeruloplasmin
Screen for liver cancer (USS AFP) + Hep C + HIV
63
3 methods of prevention for Hep B
Blood screening, safe sex, vaccination
64
Complications of HBV
Fulminant hepatic failureRelapse
Cirrhosis
HCC
Concurrent HCV/HIV (increases progression to cirrhos
65
HCV spread?
Incubation ?
Blood
6 weeks
66
Most common sx of HCV
85% aSx -> more likely to develop chronic
67
Name 3 Ix in HCV
HCV serology
PCR HCV RNA
LFT (AST:ALT < 1) will fluctuate in chronic infection
HIV, HBV testing
Biopsy for degree of inflammation and fibrosis if
68
What screening in HCV infection
HCC - USS
AFP
69
Mx HCV
24 weeks weekly SC pegylated interferon alpha
+ daily oral ribavarin (for 6M)
70
2 types of AI hepatitis
75% Type 1: ANA (anti-nuclear Ab), ASMA (anti-smooth muscle Ab)
Type 2: ALKM-1 (anti-liver-kidney-microsomal), anti-LC-1 (anti-liver-cystolic)
71
3 Ix in AI hepatitis
Liver biopsy
LFT
Raised IgG
Serum protein electrophoresis
FBC + blood film
72
Mx AI hepatitis ?
monitor what?
vaccination?
Prednisolone + azathioprine
6M USS + AFP, liver biopsies,
Hep A/B vaccination
73
Liver abscess- name 3 Ix?
FBC - raised WCC, mild anaemia
Raised ESR
Abnormal LFT
Blood cultures - 50%
Stool microscopy and cultures - cysts or trophozoites of E.histolytica
CXR - right reactive pleural effusion, raised hemidiaphragm
USS/CT liver - show abscess and guide aspiration
Aspiration + culture
74
Mx of liver abscess
What if pyogenic?
amoebic?
ABX ± drainage + fluids + pain relief
pyogenic - IV ceftriaxone + metronidazole
Amoebic - metronidazole
75
Causes of acute pancreatitis
GETSMASHED
gallstones, alcohol, trauma, steroids, mumps, AI, scorpions, hyperlipidaemia/hypothermia/hypercalcaemia, ERCP, drugs
76
what happens in acute pancreatitis
Acute inflammation of pancreas releasing exocrine (secrete via ducts) enzymes causing autodigestion of organ.
77
Usual cause of acute pancreatitis
Gallstones block bile duct -> back pressure in main pancreatic duct -> periductal necrosis
78
Name 3 clinical signs of acute pancreatitis
Cullen’s sign (periumbilical bruising)
Grey Turner’s sign (flank bruising) - retroperitoneal haemorrhage
Epigastric tenderness + rigidity (fluid shift to gut and peritoneum)
Tachycardia, fever, hypoxaemia
Jaundice if cause is gallstones/alcohol
79
Main test for pancreatitis ?
Key Ix for prognosis?
?gallstones?
name 2 imaging
Main - Serum amylase x3 (lipase)
prognosis
FBC (leukocytosis), CRP (>200 = pancreatic necrosis)
gallstones
LFT (AST:ALT > 3), raised bilirubin
Hypocalcaemia, hyperglycaemia, raised urea
Imaging
CXR - exclude perforation, shows ARDS
CT with contrast is diagnostic
USS - swollen pancreas ± gallstones
ERCP
80
Key DDx for acute pancreatitis
ruptured / dissecting aortic aneurysm
81
Score for pancreatitis severity? 3 parts of it
Modified glasgow score - PANCREAS
PaO2 < 8kPa
Age > 55
Neutrophilia: WCC > 15
Calcium <2mmol/L
Renal, urea > 16mmol/L
Enzymes:
AST/ALT>200 units
Albumin <32g/L
Sugar > 10mmol/L
82
Mx of acute pancreatitis
Pain relief
(pethidine or buprenorphine ± IV benzodiazepines
IV fluids
Nil by mouth
Repeat glasgow + obs
83
Name 2 acute and 2 chronic comps of acute pancreatitis
Early:
Pulm oedema
Shock
DIC
renal dysfunction
Haemorrhage
Late:
Necrosis
abscess
pulm oedema
cyst - 4wks after
84
Presentation of chronic pancreatitis
alcohol...
Epigastric pain relieved while sitting forward
N+V
Exocrine dysfunction: malabsorption, wt loss, diarrhoea, steatorrhoea
Endocrine dysfunction: diabetes mellitus
85
Mx of chronic pancreatitis
Pain relief
replace enzymes
Low fat diet, alcohol advice
86
What type are 90% of pancreatic Ca
infiltrating ductal adenocarcinoma
87
Gene in endocrine pancreatic Ca ?
MEN1 (AD familial cancer syndrome)
88
Who gets gallstones
Fair, fat, fertile, female and forty
89
Dx for gallstones ? other Ix?
when do people get jaundiced?
USS is 90-95% sensitive for stones
Urinalysis, CXR, ECG for exclusion
Jaundice if stone moves to CBD
90
Differentiate gallstones causing...
biliary colic
Acute cholecystitis
Ascending cholangitis
Pancreatitis
biliary colic
RUQ pain
Acute cholecystitis
RUQ pain + fever/WCC + positive Murphy's sign
Ascending cholangitis
RUQ pain + fever/WCC + jaundice - Charcot’s triad
Pancreatitis
Jaundice - raised bilirubin, alk phos, GGT
91
What is a +ve murphy's
2 fingers, breathe in, halts inspiration, negative on other side
92
Seen on USS of acute cholecystitis
thickened GB wall (>3mm) + fluid or air in the GB, CBD diameter >6mm
93
3 Ix for acute cholecystitis
Murphys
USS
ERCP
LFT
Bloods
94
Managing gallstones, colic, and acute cholecystitis
Non vs surgiclal
NBM
Pain relief - opiods
Iv fluids
(Consider IV Ceftriaxone)
Surgical
Laparoscopic cholecystectomy
95
Reynolds pentad of ascending cholangitis (infection of bile duct)
RUQ + fever/chills + jaundice + altered mental state + hypotension/tachycardia
[JAH RastaFari]
96
Name 3 Ix in ascending cholangitis
WCC/ESR/CRP, LFT
Worry about sepsis, pancreas and AKI
U+E, amylase, blood cultures
Imaging
KUB XR + AUSS + contrast CT (best method), MRCP (Magnetic resonance cholangiopancreatography)
97
Mx of ascending cholangitis
(Medical emergency)
O2 + IV fluids + BC + IVABX ?metronidazole + ceftriaxone
Emergency biliary drainage if AKI, shock, DIC etc
98
Name 3 comps of ascending cholangitis
Septic shock
AKI
All other system dysfunction
Liver abscess
Liver failure
99
What happens in Primary sclerosing cholangitis
Chronic inflammation + fibrosis of intra + extrahepatic bile ducts leading to multifocal biliary strictures
100
Ix in Primary sclerosing cholangitis
bloods - LFT, bilirubin, bile
Igs
-p-ANCA
Imaging
MRCP / USS
-Bead sign
Biopsy
101
Seen on biopsy of Primary sclerosing cholangitis
periductal onion skin fibrosis
102
What nutritional supplement for cholestatic disorders?
Vit ADEK
103
Main mx of
Primary sclerosing cholangitis? for itch?
Prevent progression?
treat strictures with balloon dilation
colestyramine
ursodeoxycholic acid + avoid alcohol
104
What is primary biliary cirrhosis?
Condition closely related to?
progressive AI disease causing destuction of small interlobular bile ducts
sjorgrens
[SS - Small ducts, Sjorgrens]
105
Key Ix in PBC ? Name 2 other
***Biopsy - granulomatous
AMA - antimitochondrial antibody
TFT - associated
USS
MRCP - rule out PSC
FBC - raised ESR
LFT - raised ALK phos
106
Mx of PBC
Ursodeoxycholic acid slows disease progression
Other than that they're pretty fucked and might wants transplant if it gets repeal bad
107
What promotes cholestasis - so avoid in many of these conditions
oestrogen
COCP
108
Seen on bloods with cholestasis
elevated serum bilirubin, elevated alkaline phosphatase (>3x), raised GGT
Low albumin in chronic
109
Differentiate PSC / PBC
PSC
Linked to IBD + P-ANCA
Male 10-30 [like Dan and his UC]
PBC
Sjorgrens / Thyroid , CREST
AMA
Alk phos raised
Female - 40-60
110
Liverfailure key worry with hypoK and HypoMg
Torsade du pointes
111
Name 2 signs that mean decompensated liver failure
Liver failure
encephalopathy
ascites
asterixes
Hepatorenal syndrome
112
Liver blood supply
80% hepatic portal vein
20% hepatic artery
113
When is portal hypertension
>5mmHg (<10 is severe)
114
What does NO do in kidney due to liver failure
causes constriction -> hepatorenal syndrome
[Dilation everywhere else in body]
115
Which blood tests most specific for liver problems
albumin - low levels indicate failure of synthesis by liver
bilirubin - Rises
PT - raised
116
what do you look for in ascitic tap
polymorphs - sign of spontaneous bacterial peritonitis
117
ALT
AST
ALP
ALT - Liver [L]
AST - more Systemic [S]
ALP - bile duct / cholesttasis [Pipes]
118
Isolated ALP rise
bony mets, vit D deficiency , fracture, renal osteodystrophy
119
Urine / stool in pre inta post hepatic ?
pre - normal
liver - dark urine
post - dark urine and pale stools
120
HbeAg
HbeAb
Sign of active replication
Sign of current clearning of infection [Dissapears after full beating of infection]
121
IgM
IgG
M - infection at the Moment
G - after Gone
122
Abdo Xray
Big cuddly Spanish Giants
Bones, Calcium, Soft tissue, Gas
123
Key worry in Crohns / UC
Uc - toxic megacolon
Crohns - Small bowel obstruction
124
How is Hep B spread?
Commonest is vertical transmission.
Other: needle, transfusion, sexual
125
Explain the structure of the hep B virus and how this relates to testing for active/previous hep B?
The virus is a DNA virus. The DNA is surrounded by core antigen. This is then surrounded by surface antigen. Between these two layers there are floating E antigens.
If a test result is positive for any of surface antigen, E antigen or viral load (this comes from broken off pieces of viral DNA) then the patient HAS GOT HEP B.
If the patient has previously had hepB, they may have surface antiBODY and E antiBODY and core antiBODY.
If a patient has had a hepB vaccine but never had hepB then they will have the surface hepB antibody but nothing else - this is because this antibody is injected as the vaccine but they will not have the other bits as they haven't had previous exposure to the virus.
126
What is the treatment of hepB?
Gold standard = plegylated interferon alpha = weekly injectable for 48 weeks.
other options = oral tenofovir or entecavir.
Difficult to clear the virus as it is a DNA virus.
127
A patient presents with:
jaundice
pale stools/dark urine
painful splenomegaly
itch
ACUTE HEPATITIS
conjugated bilirubinaemia.
128
How is hepC transmitted?
parenteral - usually IVDU
129
diagnosis of hepC
viral serology to look for hepC antibody
PCR - to confirm current infection
They will then undergo a liver fibroscan - looks at the risk of cirrhosis and HCC (if they are higher risk they need AFP surveillance)
130
tumour marker for HCC
AFP
131
Treatment of hepC
AIM IS CURE
They will have a fixed combination of two antiretroviral drugs for 12ish weeks depending on the drug.
Don't know if we need to know the names of these... find in infectious diseases booklet.
132
hepatitis histology
mallory bodies
swollen hepatocytes
steatosis
133
alcoholic hepatitis presentation
treatment
rapid onset jaundice
signs of liver disease
investigation = LFT (^^^AST and GGT), FBC (microcytic anaemia), USS
Poor prognosis = PT time (coagulation)
treatment = stop drinking and steroids if doesn't respond
134
Non invasive liver screen
genetic disorders
FBC/clotting
LFTs
HepB antigen
EBV/CMV
ANA/anti-smooth muscle
135
reblead in vatical bleed post OGD
TIPS
