Liver Flashcards
What is the most severe form of liver fibrosis?
cirrhosis
How does acute liver injury commonly present?
malaise
nausea
anorexia
jaundice
How does chronic liver injury commonly present?
ascites
oedema
haematemesis (varices)
malaise
anorexia
wasting
easy brushing
itching
hepatomegaly
abnormal LFTs
What are LFTs?
liver function tests
What is included in an LFT?
serum bilirubin, albumin, prothrombin, liver enzymes
What is haematemesis?
vomiting blood
What are varices?
dilated veins in the oesophagus usually due to liver cirrhosis
(basically haemorrhoids of the throat)
What is jaundice?
raised serum bilirubin
What are the categories of jaundice?
unconjugated:
- pre-hepatic
conjugated/ cholestatic:
- hepatic
- post hepatic
What are the causes of pre-hepatic jaundice?
haemolysis
Gilbert’s syndrome
What are the causes of hepatic jaundice?
hepatitis (viral, drugs, alcohol, immune)
ischaemia
neoplasm
congestion (CCF)
What are the causes of post-hepatic jaundice?
gallstones
malignancy
ischaemia
inflammation
How do the symptoms of pre-hepatic and cholestatic (hepatic + post-hepatic) differ?
pre-hepatic: normal urine, normal stool, no itching, normal LFTs
cholestatic: dark urine, maybe pale stool, may be itchy, abnormal LFTs
What tests of used to diagnose jaundice?
High AST/ALT suggests liver disease
dilated intrahepatic bile duct on ultrasound indicates biliary obstruction
CT, MRCP, ERCP used to confirm diagnosis
What is the makeup of a gallstone?
70% cholesterol
30% pigment +/- calcium
What are the risk factors of gallstones?
FFFF:
female
forty
fat
fertile
How does the presentation of gallstones differ depending on whether it is present in the gallbladder or the bile duct?
gallbladder- biliary pain, cholecystitis, maybe obstructive jaundice, no cholangitis, no pancreatitis
bile duct- biliary pain, no cholecystitis, obstructive jaundice, cholangitis, pancreatitis
What is cholangitis?
inflammation of the bile duct
What is cholecystitis?
inflammation of the gallbladder
How are gallbladder stones managed?
- laparoscopic cholecystectomy
- bile acid dissolution therapy (< 1/3 success)
How are bile duct stones managed?
- ERCP with sphincterotomy and removal/ crushing/ stent placement
- surgery for large stones
What is DILI?
drug-induced liver injury
What are the types of DILI?
hepatocellular
cholestatic
mixed
Describe the onset of DILI
usually 1-12 weeks of starting medication
Which drugs cause the highest numbers of DILI?
antibiotics
What is the management of paracetamol induced hepatic failure (overdose)?
NAC- N acetyle Cysteine
100% effective in preventing liver damage when administered within 8 hours
What factors indicate a severe case of paracetamol overdose?
late presentation (NAC less effective)
acidosis (pH<7.3)
prothrombin time > 70 sec
serum creatinine > 300 umol/L
What is the management of a paracetamol overdose with late presentation?
emergency liver transplant or 80% mortality
What is ascites?
collection of fluid in the abdomen
What are the causes of ascites?
chronic liver disease (most)
neoplasia
pancreatitis
cardiac causes
What is the management of ascites?
fluid and salt restriction
diuretics (spironolactone +/- furosemide)
large volume paracentesis and albumin
trans-jugular intrahepatic portosystemic shunt (TIPS)
What is ALD?
alcoholic liver disease
What is the main cause of liver death in the UK?
alcoholic liver disease (ALD)
What is the prognosis for alcoholic liver disease?
poor outcome- 25% will survive 10 years
What are the causes of portal hypertension?
cirrhosis
fibrosis
portal vein thrombosis
What can result from portal hypertension?
varices
splenomegaly
What causes renal failure in liver disease?
- drugs (diuretics, NSAIDS, ACR inhibitors, aminoglycosides)
- infection
- GI bleeding
- myoglobinuria
- renal tract obstruction
What are the bedside tests for encephalopathy?
serial 7’s
WORLD backwards
animal counting in 1 minute
draw a 5 point star
number connection test
What is encephalopathy?
any disease of the brain that alters brain function or structure
What are the causes of hepatitis?
viral (A, B, C, CMV, EBV)
drug-induced
autoimmune
alcoholic
What is cholestatic itch?
itching sensation caused by any liver disease
How is cholestatic itch treated?
cholestyramine helps in ~50% cases
rifampicin effective but can cause liver disease
opiate agonists
UV light, plasmapheresis, liver transplant
What is PBC in terms of the liver?
primary biliary cirrhosis
What is the difference between acute and chronic liver failure?
acute is when you have a sudden occurrence of liver failure in an otherwise healthy liver, chronic is a decompensation of chronic liver disease
Oestrogen regulation is one of the functions of the liver. What are the signs of an issue with this process?
gynecomastia in men (large breasts)
Detoxification is one of the functions of the liver. What are the signs of an issue with this process?
hepatic encephalopathy
Carbohydrate metabolism is one of the functions of the liver. What are the signs of an issue with this process?
hypoglycaemia
Albumin production is one of the functions of the liver. What are the signs of an issue with this process?
oedema
ascites
leukonychia (white nails)
Clotting factor production is one of the functions of the liver. What are the signs of an issue with this process?
easy bruising, easy bleeding
Bilirubin regulation is one of the functions of the liver. What are the signs of an issue with this process?
jaundice
pruritus (itchy skin)
Immunity is one of the functions of the liver. What are the signs of an issue with this process?
spontaneous bacterial infections
What are the signs and symptoms of liver failure?
ACUTE:
- malaise
- nausea
- anorexia
- jaundice/ pruritus
CHRONIC: acute symptoms PLUS:
- ascites/ oedema
- gynaecomastia
- Dupuytren’s contracture
- clubbing/ leaukonychia
- palmar erythema
- xanthelasma
- spider naevi/ caput medusae
- hepatoplenomagaly
- bleeding/ easy bruising
What are the causes of acute liver failure?
paracetamol DILI
alcohol
viral hepatitis
drugs
vascular
obstruction
congestion
What are the causes of chronic liver failure?
alcohol
viral hepatitis
autoimmune (PBC/ PSC)
metabolic (HH, WD, A1At def)
neoplasm
NAFLD/ AFLD
What are the causes of chronic liver failure?
alcohol
viral hepatitis
autoimmune (PBC/ PSC)
metabolic (HH, WD, A1At def)
neoplasm
NAFLD/ AFLD
What are the potential complications of liver failure?
hepatorenal syndrome
bleeding
sepsis
ascites
hypoglycaemia
encephalopathy
seizures
cerebral oedema
What is liver cirrhosis?
fibrosis of the liver caused by long term damage
What are the most common causes of liver cirrhosis?
alcohol abuse (AFLD)
hepatitis B and C
fatty liver disease, HH, WD
What is the most common cause of cirrhosis in the developed world?
alcohol abuse
What is the most common cause of cirrhosis in the undeveloped world?
hepatitis B and C
What us the definitive diagnostic test for liver cirrhosis?
liver biopsy
What can a patient with liver cirrhosis manage their condition themselves?
fluids
analgesia
alcohol abstinence
good nutrition
What is the medical management of liver cirrhosis?
only definitive treatment is liver transplant, but can treat complications of liver failure:
- ascites- diuretics and restrict sodium
- cerebral oedema- mannitol to decrease ICP
- bleeding- vitamin K (clotting factor production) or FFP if actively bleeding
- encephalopathy- lactulose (decrease ammonia), antibiotics and enemas (stop flora making NH3)
- hypoglycaemia - dextrose
Why does liver cirrhosis cause hypoglycaemia?
glycogenolysis not happening
What type of drug is spironolactone?
diuretic
What are the most common complications of liver cirrhosis?
ascites
portal hypertension
varices
Why can liver cirrhosis cause ascites?
- hypoalbuminaemia- reduces plasma oncotic pressure
- portal hypertension- increases hydrostatic pressure
- renal water retention
How does ascites present?
shifting dullness
weight gain
abdo distension
signs of liver disease
respiratory distress (pleural effusion)
How is ascites managed?
1st line- salt restriction
then consider diuretics (furosemide/ spironolactone)
What are the complications of ascites?
infection of ascitic fluid
