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Phase 4 - Katherine > Liver > Flashcards

Liver Flashcards

1
Q

ALT/AST which is more specific for liver damage?

A

ALT

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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

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3
Q

What are ALP and GGT elevated in

A

cholestasis

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4
Q

What is associated with cholestasis and malignant hepatocellular damage + marker of bone turnover

A

ALP

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5
Q

What is sensitive to alcohol ingestion

A

GGT

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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)

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7
Q

Gene in hereditary haemochromatosis?

A

HFE
AR

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8
Q

Mech in Heerditary haemochromatosis

A

Increased intestinal absorption of iron leading to accumulation in tissues

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9
Q

Sx of hereditary haemochromatosis

A

Early: fatigue, weakness, arthralgia, erectile dysfunction

Late: skin bronzing, diabetes, cirrhosis (liver signs), impotence, cardiac arrhythmia

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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

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11
Q

Why is serum ferritin not very specific

A

low specificity as acute phase protein. other things can make it go up

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12
Q

Mx of hereditary haemochromatosis

A

Venesection/phlebotomy 4-500ml weekly

monitor ferritin

low iron diet

liver transplant - when decompensated

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13
Q

Wilson genetics

A

AR
ATP7B gene

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14
Q

Mech in wilson - where is copper deposited?

A

Disorder of biliary excretion of copper

liver , basal ganglia

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15
Q

Name 3 Ix in wilsons

A

copper studies - low, urinary copper ^^^

slit lamp - kayser fletcher

liver biopsy

MRI - BASAL GANGLIA

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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

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17
Q

2 organs affected in A1AT deficiency

A

Lung
Dyspnoea, wheezing, cough i.e. COPD (lung bases commonly)

Liver
Hepatitis, cirrhosis (HCC), fibrosis

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18
Q

Ix in A1AT

A

Serum A1AT (low) -> phenotyping required

CXR and LuFT

LFT and biopsy

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19
Q

Mx of A1AT ? what do you monitor?

A

Avoid smoking / alcohol

Mx of COPD

Monitor LFTs , treat cirrhosis, screen for HCC

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20
Q

4 characteristics of liver failure

A

Hepatic encephalopathy
Jaundice
Abnormal bleeding
Ascites

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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

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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.

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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

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24
Q

drug for paracetamol OD

A

n-acetylcysteine

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25
Q

Mx of high amonia

A

lactulose + neomycin

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26
Q

mx of raised ICP

A

mannitol

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27
Q

Mx of ascites

A

restrict fluid - low salt
diuretics

Drain and Human Albumin Solution

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28
Q

What are ascites

A

collection of fluid in peritoneal cavity

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29
Q

Most common cause of ascites? Name 2 others

A

75% - cirrhosis
(decreased albumin + portal hypertension)

Malignancy - GI / Ovarian (meigs)

Heart failure

Nephrotic

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30
Q

Ix in ascites, name 3

A

Abdo USS

CXR (HF / pleural effusion)

LFT

Shifting dullness

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31
Q

triad OE in spontaneous bacterial peritonitis

Who gets it?

A

guarding, rebound tenderness, pain on palpation

It is bacterial peritonitis secondary to ascites in people with liver cirrhosis

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32
Q

Name 3 Ix in spontaneous bacterial peritonitis

A

FBC - *leuocytosis

LFT, *U+E (renal impairment), blood cultures

*Diagnostic paracentesis - for culture and amylase

Imaging - upright AXR and CXR

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33
Q

Name 1 organism commonly causing spontaneous bacterial peritonitis and mx

A

E.coli, enterococci

IV ceftriaxone

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34
Q

In end stage liver failure 40% develop hepatorenal syndrome … general mx

2 types

Long term Mx

A

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

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35
Q

What happens in advanced/decompensated cirrhosis

A

oedema, ascites, bruising, poor memory, bleeding varices

Decompensated = caput medusae, hepatic encephalopathy, ascites

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36
Q

Name 3 cutaneous signs of cirrhosis

What is cirrhosis?

A

NECROSIS –> FIBROSIS –> NODULAR FORMATION

FLAPS
(finger clubbing, leukonychia, asterixis, palmar erythema, spider naevi, scratch (pruritus), jaundice, dupuytren’s

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37
Q

Name 3 causes of portal HTN

A

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

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38
Q

General Mx of cirrhosis? what 2 conditions do you monitor for?

A

Adequate nutrition and alcohol abstinence, exercise for muscle wasting

Oesophageal varices and HCC

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39
Q

Ix for portal HTN
Name 3

A

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)

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40
Q

Mx of portal HTN

A

Reduce portal venous pressure
-BBs, TIPS (Transjugular Intrahepatic Portosystemic Shunt)

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41
Q

Primary prevention of varicies in portal HTN AND prevention of vatical bleeding once you have them

A

propranolol

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42
Q

Key Ix in varicies

A

endoscopy (early)

[clotting, group, cross match]

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43
Q

Mx in varicies

A

terlipressin

oesophageal -> band ligation

gastric -> endoscopic injection of N-butyl-2cyanoacretate

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44
Q

What if mx of varicies doesnt work

A

Minnesota tube then —> Transjugular Intrahepatic Portosystemic Shunt

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45
Q

what causes Sudden RUQ pain + rapidly developing ascites
[+ hepatomegaly + jaundice + renal involvement (50%)]

Key Ix?

A

budd-chiari syndrome
[occlusion of the hepatic veins]

doppler ultrasound

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46
Q

Mx of budd-chiari

A

Treat asicites - eg TIPS

If due to chronic inferior vena cava thrombosis -> warfarin

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47
Q

Usual cause of liver Ca

A

only 10% primary

Rest are from stomach, colon, lung, breast

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48
Q

Usual cause of primary HCC

A

Hep c

[HC causes HCC]

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49
Q

What is screened in high risk of HCC Eg. HBV ± cirrhosis and HCV/alcoholic cirrhosis

A

USS

AFP

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50
Q

name 2 methods of liver Ca prevention

A

HBV vaccine,
reduced alcohol,
screen those with cirrhosis

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51
Q

Name 3 causes of fatty liver

A

metabolic syndrome
PCOS
alcohol
HBV/HCV

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52
Q

Dx Ix in fatty liver

A

Biopsy: cells swollen with fat

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53
Q

mx fatty liver

A

no alcohol
wt loss + exercise
mx of cause

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54
Q

What is higher in steatohepatitis - AST or ALT

A

ALT

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55
Q

Name 2 things on histology of hepatitis ? chronic?

A

Lobular disarray
Inflammatory cell infiltrate
xone 3 necrosis
bile duct proliferation

chronic = lymphoid follicles at portal tract - classical

56
Q

hep A
incubation?
spread?

A

2-6 weeks
feaco oral

57
Q

Hep A Ix

A

HAV IgM - acute
HAV IgG - lasts years

LFT (AST:ALT <1)

58
Q

Hep A Mx ?
For itch?

A

fluids, antiemetics, rest, avoid alcohol

cholestyramine

59
Q

What dissolves gall stones

A

ursodeoxycholic acid

60
Q

Hep B spread
Incubation?

A

Parenteral - blood or body fluid
Vertical:
Horizontal: sexual

60-90 days

61
Q

What is HBsAg
HBsAb

A

HBsAg - found at current infection (may be produced as vaccine)

HBsAb indicates immunity post infection/vaccine

62
Q

Ix in Hep B ? Name 2 things you’d screen for

A

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
Q

3 methods of prevention for Hep B

A

Blood screening, safe sex, vaccination

64
Q

Complications of HBV

A

Fulminant hepatic failureRelapse
Cirrhosis
HCC
Concurrent HCV/HIV (increases progression to cirrhos

65
Q

HCV spread?
Incubation ?

A

Blood

6 weeks

66
Q

Most common sx of HCV

A

85% aSx -> more likely to develop chronic

67
Q

Name 3 Ix in HCV

A

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
Q

What screening in HCV infection

A

HCC - USS

AFP

69
Q

Mx HCV

A

24 weeks weekly SC pegylated interferon alpha

+ daily oral ribavarin (for 6M)

70
Q

2 types of AI hepatitis

A

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
Q

3 Ix in AI hepatitis

A

Liver biopsy

LFT

Raised IgG

Serum protein electrophoresis

FBC + blood film

72
Q

Mx AI hepatitis ?
monitor what?
vaccination?

A

Prednisolone + azathioprine

6M USS + AFP, liver biopsies,

Hep A/B vaccination

73
Q

Liver abscess- name 3 Ix?

A

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
Q

Mx of liver abscess

What if pyogenic?
amoebic?

A

ABX ± drainage + fluids + pain relief

pyogenic - IV ceftriaxone + metronidazole

Amoebic - metronidazole

75
Q

Causes of acute pancreatitis

A

GETSMASHED
gallstones, alcohol, trauma, steroids, mumps, AI, scorpions, hyperlipidaemia/hypothermia/hypercalcaemia, ERCP, drugs

76
Q

what happens in acute pancreatitis

A

Acute inflammation of pancreas releasing exocrine (secrete via ducts) enzymes causing autodigestion of organ.

77
Q

Usual cause of acute pancreatitis

A

Gallstones block bile duct -> back pressure in main pancreatic duct -> periductal necrosis

78
Q

Name 3 clinical signs of acute pancreatitis

A

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
Q

Main test for pancreatitis ?

Key Ix for prognosis?

?gallstones?

name 2 imaging

A

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
Q

Key DDx for acute pancreatitis

A

ruptured / dissecting aortic aneurysm

81
Q

Score for pancreatitis severity? 3 parts of it

A

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
Q

Mx of acute pancreatitis

A

Pain relief
(pethidine or buprenorphine ± IV benzodiazepines

IV fluids

Nil by mouth

Repeat glasgow + obs

83
Q

Name 2 acute and 2 chronic comps of acute pancreatitis

A

Early:
Pulm oedema
Shock
DIC
renal dysfunction
Haemorrhage

Late:
Necrosis
abscess
pulm oedema
cyst - 4wks after

84
Q

Presentation of chronic pancreatitis

A

alcohol…

Epigastric pain relieved while sitting forward

N+V

Exocrine dysfunction: malabsorption, wt loss, diarrhoea, steatorrhoea

Endocrine dysfunction: diabetes mellitus

85
Q

Mx of chronic pancreatitis

A

Pain relief

replace enzymes

Low fat diet, alcohol advice

86
Q

What type are 90% of pancreatic Ca

A

infiltrating ductal adenocarcinoma

87
Q

Gene in endocrine pancreatic Ca ?

A

MEN1 (AD familial cancer syndrome)

88
Q

Who gets gallstones

A

Fair, fat, fertile, female and forty

89
Q

Dx for gallstones ? other Ix?
when do people get jaundiced?

A

USS is 90-95% sensitive for stones

Urinalysis, CXR, ECG for exclusion

Jaundice if stone moves to CBD

90
Q

Differentiate gallstones causing…
biliary colic
Acute cholecystitis
Ascending cholangitis
Pancreatitis

A

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
Q

What is a +ve murphy’s

A

2 fingers, breathe in, halts inspiration, negative on other side

92
Q

Seen on USS of acute cholecystitis

A

thickened GB wall (>3mm) + fluid or air in the GB, CBD diameter >6mm

93
Q

3 Ix for acute cholecystitis

A

Murphys
USS
ERCP
LFT
Bloods

94
Q

Managing gallstones, colic, and acute cholecystitis

Non vs surgiclal

A

NBM
Pain relief - opiods
Iv fluids
(Consider IV Ceftriaxone)

Surgical
Laparoscopic cholecystectomy

95
Q

Reynolds pentad of ascending cholangitis (infection of bile duct)

A

RUQ + fever/chills + jaundice + altered mental state + hypotension/tachycardia

[JAH RastaFari]

96
Q

Name 3 Ix in ascending cholangitis

A

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
Q

Mx of ascending cholangitis
(Medical emergency)

A

O2 + IV fluids + BC + IVABX ?metronidazole + ceftriaxone

Emergency biliary drainage if AKI, shock, DIC etc

98
Q

Name 3 comps of ascending cholangitis

A

Septic shock
AKI
All other system dysfunction
Liver abscess
Liver failure

99
Q

What happens in Primary sclerosing cholangitis

A

Chronic inflammation + fibrosis of intra + extrahepatic bile ducts leading to multifocal biliary strictures

100
Q

Ix in Primary sclerosing cholangitis

A

bloods - LFT, bilirubin, bile

Igs
-p-ANCA

Imaging
MRCP / USS
-Bead sign

Biopsy

101
Q

Seen on biopsy of Primary sclerosing cholangitis

A

periductal onion skin fibrosis

102
Q

What nutritional supplement for cholestatic disorders?

A

Vit ADEK

103
Q

Main mx of
Primary sclerosing cholangitis? for itch?
Prevent progression?

A

treat strictures with balloon dilation

colestyramine

ursodeoxycholic acid + avoid alcohol

104
Q

What is primary biliary cirrhosis?
Condition closely related to?

A

progressive AI disease causing destuction of small interlobular bile ducts

sjorgrens

[SS - Small ducts, Sjorgrens]

105
Q

Key Ix in PBC ? Name 2 other

A

***Biopsy - granulomatous

AMA - antimitochondrial antibody

TFT - associated

USS

MRCP - rule out PSC

FBC - raised ESR

LFT - raised ALK phos

106
Q

Mx of PBC

A

Ursodeoxycholic acid slows disease progression

Other than that they’re pretty fucked and might wants transplant if it gets repeal bad

107
Q

What promotes cholestasis - so avoid in many of these conditions

A

oestrogen

COCP

108
Q

Seen on bloods with cholestasis

A

elevated serum bilirubin, elevated alkaline phosphatase (>3x), raised GGT

Low albumin in chronic

109
Q

Differentiate PSC / PBC

A

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
Q

Liverfailure key worry with hypoK and HypoMg

A

Torsade du pointes

111
Q

Name 2 signs that mean decompensated liver failure

A

Liver failure
encephalopathy
ascites
asterixes

Hepatorenal syndrome

112
Q

Liver blood supply

A

80% hepatic portal vein
20% hepatic artery

113
Q

When is portal hypertension

A

> 5mmHg (<10 is severe)

114
Q

What does NO do in kidney due to liver failure

A

causes constriction -> hepatorenal syndrome

[Dilation everywhere else in body]

115
Q

Which blood tests most specific for liver problems

A

albumin - low levels indicate failure of synthesis by liver

bilirubin - Rises

PT - raised

116
Q

what do you look for in ascitic tap

A

polymorphs - sign of spontaneous bacterial peritonitis

117
Q

ALT
AST
ALP

A

ALT - Liver [L]
AST - more Systemic [S]
ALP - bile duct / cholesttasis [Pipes]

118
Q

Isolated ALP rise

A

bony mets, vit D deficiency , fracture, renal osteodystrophy

119
Q

Urine / stool in pre inta post hepatic ?

A

pre - normal

liver - dark urine
post - dark urine and pale stools

120
Q

HbeAg
HbeAb

A

Sign of active replication

Sign of current clearning of infection [Dissapears after full beating of infection]

121
Q

IgM
IgG

A

M - infection at the Moment
G - after Gone

122
Q

Abdo Xray

A

Big cuddly Spanish Giants
Bones, Calcium, Soft tissue, Gas

123
Q

Key worry in Crohns / UC

A

Uc - toxic megacolon
Crohns - Small bowel obstruction

124
Q

How is Hep B spread?

A

Commonest is vertical transmission.

Other: needle, transfusion, sexual

125
Q

Explain the structure of the hep B virus and how this relates to testing for active/previous hep B?

A

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
Q

What is the treatment of hepB?

A

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
Q

A patient presents with:

jaundice

pale stools/dark urine

painful splenomegaly

itch

A

ACUTE HEPATITIS

conjugated bilirubinaemia.

128
Q

How is hepC transmitted?

A

parenteral - usually IVDU

129
Q

diagnosis of hepC

A

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
Q

tumour marker for HCC

A

AFP

131
Q

Treatment of hepC

A

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
Q

hepatitis histology

A

mallory bodies
swollen hepatocytes
steatosis

133
Q

alcoholic hepatitis presentation
treatment

A

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
Q

Non invasive liver screen

A

genetic disorders

FBC/clotting

LFTs

HepB antigen

EBV/CMV

ANA/anti-smooth muscle

135
Q

reblead in vatical bleed post OGD

A

TIPS

Phase 4 - Katherine (26 decks)

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