Liver Flashcards
What are the common causes of acute liver injury?
viral (A, B, EBV)
drugs
alcohol
vascular
obstruction
congestion
What are the common causes of chronic liver injury?
alcohol
viral (B, C)
autoimmune
metabolic (iron, copper)
congestion
obstruction
What are the presentations of acute liver injury?
malaise, nausea, anorexia, jaundice
rarer: confusion, bleeding, liver pain
What are the presentations of chronic liver injury?
ascites, oedema, haematemesis (vomiting blood), malaise, anorexia, wasting, easy bruising, itching, hepatomegaly, abnormal LFTs
rarer: jaundice, confusion
What is measured in Liver Function Tests?
serum bilirubin
albumin
prothrombin time
Serum liver enzymes: (give no index of liver function)
alkaline phosphatase
gamma-GT
transaminases (AST, ALT)
What are the signs of cholestatic jaundice?
dark urine
pale stools
itching
abnormal LFTs
What is the significance of very high AST/ALT levels in the blood?
Suggestive of liver disease
What are the 3 types of gallstones?
Intrahepatic bile duct stones (hepatolithiasis)
- contain mainly brown pigment and cholesterol stones
Gallbladder stones (cholecystolithias)
- contain cholesterol (or black pigment) stones
Extrahepatic bile duct stones (choledocholithiasis)
- primary sontes mainly brown pigment stones, whereas secondary stones mainly cholesterol stones
How are gallstones managed?
Gallbladder stones:
- Laparoscopic cholecystectomy
- Bile acid dissolution therapy (<1/3 success)
Bile duct stones:
- ERCP (Endoscopic retrograde cholangiopancreatography) with sphincterotomy and removal (basket or balloon), crushing (mechanical, laser..), stent placement
- surgery (large stones)
What are the key presentations of gallbladder and bile duct stones?
Gallbladder:
Biliary pain, cholecystitis, sometimes obstructive jaundice
Bile duct:
Biliary pain, Obstructive jaundice, Cholangitis (inflammation of bile duct system) , Pancreatitis
What are the types of Drug-induced liver injury?
- Hepatocellular (ALT >2 ULN, ALT/Alk Phos ≥ 5)
diclofenac, disulfiram, isoniazid, lamotrigine - Cholestatic (Alk Phos >2 ULN or ALT/Alk phos ≤ 2)
amoxicillin-clavulanate, cephalosporins, flucloxacillin, penicillin, sulfonamide, terbinafine - Mixed (ALT/Alk phos between 2 and 5)
carbamazepine, lamotrigine, phenytoin, sulfonamides
Which drugs most commonly cause DILI?
Antibiotics (32-45%) - augmentin, flucloxacillin, penicillin, erythromycin
CNS Drugs (15%) - chlorpromazine, carbamazepine, valproate
Immunosuppressants (5%)
Analgesics/musculoskeletal (5-17%) - diclofenac
GI Drugs (10%) - PPIs
Dietary supplements (10%)
Multiple drugs (20%)
How is paracetamol induced liver failure treated?
N-acetyl cysteine (NAC)
+ supportive treatment to correct coagulation defects, fluid/electrolyte imbalances, renal failure, hypoglycaemia, encephalopathy
What are the indicators of severe paracetamol-induced liver failure?
late presentation (NAC less effective >24hrs)
acidosis (pH<7.3)
prothrombin time >70 sec
serum creatinine ≥ 300umol/l
80% mortality if no liver transplant
What are the causes of ascites?
- Chronic liver disease (most) - hepatoma, TB, +/- portal vein thrombosis
- Neoplasia
- Pancreatitis, cardiac causes
What is the pathophysiology of ascites?
increased intrahepatic resistance
↓
Systemic vasodilation -> Portal hypertension
↓ ↓
↓ ascites <– low serum albumin
Secretion of:
- Renin-angiotensin
- Noradrenaline
- Vasopression
↓
Fluid retention
What is the management for ascites?
- Fluid and salt restriction
- Diuretics (spironolactone +/- furosemide (helps to maintain normal potassium))
- large-volume paracentesis + albumin
- trans-jugular intrahepatic portsystemic shunt (TIPS)
What is the effect of alcohol on the liver?
It changes the way that hepatocytes metabolise and produce fat.
Fat accumulation within hepatocytes is termed steatosis which can be large droplet (macrovesicular) or small droplet (microvesicular).
What are the risk factors for Alcoholic hepatitis?
Female
Drinking pattern, binge
Quantity consumed
Obesity
HCV
Genetics
What are the stages of progression to Alcoholic hepatitis?
Normal
↓ (90% of heavy drinkers)
Steatosis
↓ (20-40%)
Alcoholic steatohepatitis/fibrosis
↓ (8-20%)
Cirrhosis → (3-10%) Hepatocellular carcinoma
↓ (70%)
Alcoholic hepatitis
What is portal hypertension?
High blood pressure in the portal system as a result of increased hepatic resistance and increased splanchnic blood flow.
What are the causes of portal hypertension?
cirrhosis, fibrosis, portal vein thrombosis
What are possible consequences of portal hypertension?
Varices (oesophageal, gastric…)
Splenomegaly
What is the Lille score used for?
To assess the patient response to a liver transplant
Scores >0.45 predict a 6-month survival of 25%. Scores <0.45 predict a 6-month survival of 85%