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Phase 2 > Liver > Flashcards

Liver Flashcards

1
Q

Key presentation of Acute liver failure

A

Jaundice! Malaise, confusion (hepatic encephalopathy!)

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2
Q

Other signs/symptoms of Acute liver failure

A

Fetor hepaticus
Asterix
Bleeding
Hypoglycaemia
Liver pain
Nausea
Anorexia

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3
Q

Ix Acute liver failure

A

Blood tests - INR > 1.5 seconds

Serum LFTs -
in acute, albumin is initially normal
all bilirubin is unconjugated
↑ AST, ↑ ALT

Grading hepatic encephalopathy

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4
Q

What is serum albumin a marker of?

A

Synthetic function
Useful to gauge severity of CHRONIC liver disease

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5
Q

What does Prothrombin time measure?

A

Mark of synthetic function
Due to short half-life, sensitive indicator of acute and chronic

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6
Q

Other than acute and chronic liver failure, what can cause a prolonged prothrombin time? When does this commonly occur?

A

Vitamine K deficiency
In biliary obstruction bc low conc of bile salts = poor absorption of vitamin K

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7
Q

Aminotransferases

A

Contained in hepatocytes
Leak into blood w/ liver cell damage

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8
Q

Other than the liver, where else can aspartate aminotransferase (AST) be found?

A

Heart, muscle, kidney, brain

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9
Q

When else can there be high levels on AST (other than liver failure)?

A

Hepatic necrosis
MI
Muscle injury
Congestive cardiac failure

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10
Q

Other than the liver, where else can alanine aminotransferase (ALT) be found?

A

More specific to the liver

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11
Q

When is there increased levels of ALT?

A

Rise only occurs with liver disease

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12
Q

Other than the liver, where else is Alkaline phosphate found?

A

Bone, intestine, placenta

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13
Q

When is there increased levels of alkaline phosphate?

A

Both intrahepatic and extrahepatic cholestatic disease
Also hepatic infiltrations (e.g. metastases), cirrhosis

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14
Q

What colour is bilirubin?

A

Yellow

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15
Q

Dark urine, pale stool, itching? If yes then,

A

likely to be cholestatic
NOT pre-hepatic

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16
Q

Other Ix for acute liver failure

A

CT abdomen - to see if Budd-Chiari syndrome
CXR
Pregnancy test

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17
Q

Tx acute liver failure

A

Treat underlying cause
Treat complications!

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18
Q

How do you treat encephalopathy in liver failure?

A

Lactulose

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19
Q

How do you treat ascites in liver failure?

A

diuretics e.g. spironolactone

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20
Q

How do you treat cerebral oedema in liver failure?

A

Mannitol

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21
Q

How do you treat bleeding in liver failure?

A

Vitamin K

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22
Q

How do you treat sepsis in liver failure?

A

Abx

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23
Q

How do you treat hypoglycaemia in liver failure?

A

dextrose

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24
Q

DDx for acute liver failure

A

Severe acute hepatitis
Cholestasis
Haemolysis

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25
Q

Causes of acute liver failure

A

Viral A, B, EBV
Drugs
Obstruction
Vascular ischaemia
CHF

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26
Q

RF acute liver failure

A

Alcohol
Age
Poor nutrition
Pregnancy
Chronic hep B

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27
Q

Causes chronic liver failure

A

Viral B, C
Alcohol
Non-Alcoholic steatohepatitis
Autoimmune conditions e.g. Autoimmune hepatitis, 1o biliary cirrhosis, Sclerosing cholangitis
Metabolic conditions e.g. haemochromatosis, Wilson’s syndrome
Vascular conditions e.g. portal hypertension

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28
Q

Key presentation of chronic liver failure

A

Ascites, Haematemesis, Oedema

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29
Q

Other signs/symptoms of chronic liver failure

A

Hepatomegaly!
Fetor hepaticus
Anorexia
Easy bruising
Itching
Jaundice, Confusion (rare)

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30
Q

1st line Ix Chronic liver failure

A

Serum LFTs -
good to gauge severity
falling serum albumin = bad sign

FBC

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31
Q

GS Chronic liver failure

A

Endoscopy
Ultrasound
CT scan/MRI

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32
Q

Other Chronic liver failure

A

Biopsy - if degree of inflammation is needed

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33
Q

Tx Chronic liver failure

A

Lifestyle modification - ↓ alcohol
Antivirals
Liver transplant!

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34
Q

When alcohol enters body, goes to liver and into hepatocytes. What are the 3 pathways it can take?

A
  1. Alcohol dehydrogenase
  2. Cytochrome P4502E1 (CYP2E1)
  3. Peroxisomal catalase
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35
Q

Describe the alcohol dehydrogenase pathway

A

ADH converts alcohol -> acetylaldehyde
∴ NAD+ is converted to NADH and produces ROS

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36
Q

3 stages of alcoholic liver failure

A
  1. Fatty liver
  2. Alcoholic hepatitis
  3. Cirrhosis
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37
Q

Describe fatty liver process

A

↑ Alcohol = ↑ NADH
NADH triggers cells to produce ↑ fatty acids
↓ NAD+ = ↓ fatty acid oxidation

∴ ↑ Fat production
∴ FATTY LIVER

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38
Q

Describe a fatty liver

A

Large, heavy, greasy tender liver
Yellow-ish due to fat deposits

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39
Q

Describe the process of alcoholic hepatitis

A

Acetylaldehyde can bind to compounds in cell and inhibit them
forms acetylaldehyde adducts, body recognises these as foreign
∴ immune response
∴ inflammation

ALSO, ROS causes lots of damage

∴ ALCOHOLIC HEPATITIS

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40
Q

What can you find during Alcoholic hepatitis?

A

MALLORY BODIES! (not specific tho)

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41
Q

Key presentation of Alcoholic liver failure

A

RUQ pain

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42
Q

Other signs/symptoms of alcoholic liver failure

A

Hepatomegaly
Ascites
Jaundice
Nausea
Vomiting
Diarrhoea

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43
Q

1st line Ix alcoholic liver failure

A

LFTs - GGT and ALP ↑↑↑
↑ AST and ALT (AST:ALT, 2:1)

FBC - ↓ Platelets, hypoglycaemia

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44
Q

GS Ix alcoholic liver failure

A

Liver biopsy

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45
Q

Tx alcoholic liver failure

A

Stop drinking alcohol!! Usually enough to treat
If alcoholic hepatitis, corticosteroids can be used

IV thiamine - prevents Wernicke-Korsakoff’s encephalopathy

Liver transplant - if severe

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46
Q

What can occur after alcohol withdrawal?
How would you treat this?

A

12-24 hours after - Delirium tremens
Presents w/ seizures, vomiting, headache, sweating, palpitations
Diazepam

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47
Q

Causes of liver cirrhosis

A

Alcoholic liver disease - common in HICs
NAFLD
Hep B, Hep C - common in LICs

Haemochromatosis
Wilson’s disease
A1AT deficiency

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48
Q

Describe the 2 types of liver cirrhosis

A
  1. Micronodular
    Regenerating nodules < 3mm in size, uniform involvement
    Often caused by alcohol or biliary tract disease
  2. Macronodular
    Varying size of nodules
    Normal acini seen in larger nodules
    Often caused by chronic viral hep
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49
Q

Key presentation of cirrhosis

A

Compensated - Asymptomatic, sometimes presents w weight loss, weakness, fatigue

Decompensated - Jaundice, pruritus, abdominal pain?

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50
Q

Other signs/symptoms of cirrhosis

A

Clubbing
Palmar erythema
Spider naevi
Leukonychia
Dupuytren’s contracture
Oedema
Xanthelasma
Bruising

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51
Q

1st line Ix Cirrhosis

A

LFTs - low albumin, long PT

Liver biochemistry -
↑ AST, ↑ ALT, ↓ Na+, alpha-fetoprotein

Ultrasound/CT - hepatomegaly
If liver is small = severe liver disease

MRI - detects tumours

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52
Q

What does low Na+ indicate with regards to liver disease?

A

SEVERE liver disease

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53
Q

If alpha-fetoprotein is present in liver biochemistry, what does this indicate?

A

Hepatocellular carcinoma

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54
Q

GS Ix cirrhosis

A

Liver biopsy

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55
Q

Describe the Child-Pugh classification

A

< 7 = best, > 10 = sign of bad prognosis
↑ Risk of variceal bleeding if > 8

Ascites, encephalopathy, ↑ bilirubin, ↓ albumin, long PT -> given 1-3 and added up to give score

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56
Q

Tx Cirrhosis

A

Treat underlying cause
↓ Salt intake/good nutrition
6 month ultrasound screening for hepatocellular carcinoma

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57
Q

What Tx should you avoid if you suspect a patient has cirrhosis? Why?

A

NSAIDs and aspirin
May cause GI bleeding/renal impairment

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58
Q

Complications of cirrhosis

A

Coagulopathy - ↓ in clotting factors II, VII, IX, X
Encephalopathy - liver flap and confusion/coma
Portal hypertension

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59
Q

What is NAFLD characterised by?

A

Fat deposited in liver cells which can interfere with function

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60
Q

Epidemiology of NAFLD

A

25% of population
3/4 of all obese people

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61
Q

Causes of NAFLD

A

Fat deposition in liver (insulin resistance)

3 of the following :
Obesity
HTN
DM
Hyperlipidaemia
Hypertriglyceridaemia

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62
Q

Describe the progression of NAFLD

A

Steatosis -> Steatohepatitis -> Fibrosis –> Cirrhosis

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63
Q

Key presentation of NAFLD

A

Usually no symptoms
Liver ache in 10%

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64
Q

Other signs/symptoms of NAFLD

A

Jaundice
Hepatomegaly
Fatigue
Malaise
RUQ pain

65
Q

Ix NAFLD

A

LFT - ↑ ALT, sometimes ↑ AST
Liver ultrasound

GS : Biopsy

66
Q

Tx NAFLD

A

Diet, exercise, avoid alcohol, weight loss if obese
Stop smoking
Control of DM, BP and cholesterol

67
Q

How do you calculate a unit of alcohol?

A

Strength (ABV) x vol (ml) / 1000
= Units

68
Q

Describe pre-hepatic, hepatic and post-hepatic causes of jaundice

A

Pre-hepatic
XS breakdown of Hb ∴ ↑ Uncnojugated bilirubin

Hepatic
Hepatocytes don’t take up, metabolise or excrete bilirubin ∴ ↑ Unconjugated AND conjugated bilirubin

Post-Hepatic
Obstruction in biliary system e.g. gallstones
∴ ↑ Conjugated bilirubin

69
Q

Give some examples of pre-hepatic causes of jaundice

A

Malaria
Sickle cell anaemia
Foetal Hb in newborns

70
Q

Give some examples of hepatic causes of jaundice

A

Viral hepatitis
Drugs
Alcohol
Cirrhosis

71
Q

Give some examples of post-hepatic causes of jaundice

A

Gallstones
Pancreatitis

72
Q

Jaundice key presentation

A

Yellow discolouration of skin, sclera and mucous membranes

73
Q

Tx Jaundice

A

usually no Tx required

74
Q

Describe Hep A virus

A

RNA virus, acute only. Notifiable disease!!
100% immunity after infection

75
Q

Epidemiology Hep A

A

Endemic in Africa and S. America
Most common acute viral hepatitis in world

76
Q

Route of transmission of Hep A
Give examples

A

FAEcal-oral
Ingestion of contaminated food or water, poor sanitation, overcrowding

77
Q

Hepatitis A is a ____virus

A

Pircornavirus

78
Q

When is Hepatitis A maximally infectious?

A

JUST BEFORE onset of jaundice

79
Q

Key presentation of Hep A

A

Prodromal phase (1-2 weeks) -
N+V, fever, malaise (non-specific) + RUQ pain

Icteric phase (~3 months) -
Jaundice, dark urine, pale stools, pruritus

80
Q

Describe the incubation period of Hep A

A

Short
15-50 days (mean = 28 days)

81
Q

Describe the serology of Hep A infection

A

HAV IgM antibodies = active disease
HAV IgG antibodies = recovery or vaccination

82
Q

Draw the graph for Hep A serology please
(How levels vary weeks after infection)

A

Virus in faeces and virus in blood graph
Serum ALT, IgG and IgM HAV

83
Q

Tx Hepatitis A

A

Self-limiting
∴ supportive care e.g. anti-emetics, rest, avoid alcohol etc

Manage close contacts by giving human normal immunoglobulin (HNIG) for Hep A within 14 days!!
Vaccine available!

84
Q

What might be increased in Hep A? Why?

A

Atypical lymphocytes
i.e. v large lymphocytes
Bc of stimulation from antigens

85
Q

Describe Hepatitis E virus

A

RNA virus, acute only! (acc can be chronic in immunosuppressed)
100% immunity after infection

86
Q

Epidemiology Hep E

A

Common in elder men and in Indochina
More common than Hep A in UK
High mortality in pregnancy

87
Q

Mode of transmission Hep E
Give examples

A

FAEcal-oral
Found in undercooked pork!
Spread by contaminated water, rodents, dogs and pigs

88
Q

Key presentation of Hep E

A

> 95% asymptomatic

89
Q

Complication of HEV

A

Fulminant hepatitis (rare but increased risk w pregnancy)

90
Q

Prognosis of HEV

A

Mortality = 1-2%
(10-20% in pregnant)

91
Q

Serology of HEV

A

?
Chronic - HEV RNA

92
Q

Tx HEV

A

Supportive management e.g. rest, avoid alcohol, fluids
Consider ribavirin

93
Q

Describe Hep B

A

DNA virus, acute AND chronic

94
Q

Where can Hep B be found?

A

In semen and saliva

95
Q

Route of transmission HBV
give examples

A

Blood borne
e.g. needles, tattoos, sexual, blood products, IVDU, mother to child, dialysis

96
Q

Key presentation of HBV

A

Prodromal phase (1-2 weeks)
N+V, fever, malaise (non-specific symptoms) + RUQ pain

Icteric phase (few weeks - 6 months)
Jaundice, dark urine, pale stools, pruritus, athralgia

97
Q

Complications of HBV

A

Hepatocellular carcinoma
Fulminant hepatitis
Cirrhosis

98
Q

HBV serology

A

Draw graph

HbSAg
ANTI - HbSAg
ANTI - HbCAg

(Susceptible, immune vaccine, immune natural, acute infection, chronic infection)

(IgM + = active infection)

99
Q

When does HbSAg appear with HBV?

A

During initial infection (1-6 months)

100
Q

Tx HBV

A

Acute - supportive

Chronic -
Pegylated interferon-alpha 2a

& Nucleoside analogues e.g. Oral tenofovir or **oral entecav

101
Q

Epidemiology of HBV

A

Far East, Africa and Mediterranean

102
Q

S/E pegylated interferon alpha 2a

A

Flu-like illness, fever, lethargy, mental issues (anxiety), autoimmune disease, ↓ WBC and platelets

103
Q

How do you take pegylated interferon-alpha 2a?

A

SC weekly

104
Q

How does pegylated interferon-alpha 2a work?

A

Stimulates immune response - immunomodulatory

105
Q

How do you take nucleoside/nucleotide analogues?

A

One tablet a day

106
Q

S/E of nucleoside/nucleotide analogues

A

Minimal side effects

107
Q

Examples of nucleoside/nucleotide analogues

A

Tenofovir
Entecavir

108
Q

What should you monitor with tenofovir?

A

Renal function

109
Q

How do nucleoside/nucleotide analogues work?

A

Inhibits viral replication

110
Q

How does biliary colic present?

A

Majority are asymptomatic !

Sudden, severe, constant epigastric pain
Can radiate to back
worse after eating large fatty meals

111
Q

Ix Biliary colic

A

FBC - ↑ CRP, rule out cholecystitis
LFTs - ↑ ALP
Amylase - rule out pancreatitis

GS : ULTRASOUND
duct dilation, stones, gallbladder wall thickness

112
Q

RF Biliary colic

A

5 Fs
Fat
Forty
Fertile
Fair
Female

113
Q

Tx Biliary Colic

A

NSAIDs, analgesia
Option cholecystectomy - bc gallstones can recur

113
Q

Tx Biliary Colic

A

NSAIDs, analgesia
Option cholecystectomy - bc gallstones can recur

114
Q

Causes Acute pancreatitis

A

I GET SMASHED
Idiopathic

Gall stones
Ethanol (alcohol)
Trauma

Steroids
Mumps/malignancy
Autoimmune
Scorpion stings
Hyperlipidaemia and hypercalcaemia
ERCP
Drugs - azathioprine, metronidazole, tetracycline, furosemide

115
Q

Key presentation Acute pancreatitis

A

Epigastric pain radiating to back
Relieved by sitting forward

Guarding and tenderness
N+V
Fever
Tachycardia
Anorexia
Cullen’s (periumbilical) and Grey Turner’s (flank) sign

116
Q

Ix Acute Pancreatitis

A

Serum amylase ↑
Urinalysis
Serum Lipase
↑ CRP

Abdo ultrasounds, CT, MRI

117
Q

Describe the Glasgow Scoring system

A

PANCREAS
PaO2 < 8kPa
Age > 55
Neutrophils (WBCs > 15)
Calcium < 2
uRea > 16
Enzymes (LDH > 600 or AST/ALT > 200)
Albumin < 32
Sugar (Glucose > 10)

0-1 mild pancreatitis
2 moderate
3+ severe

118
Q

Tx Acute pancreatitis

A

NBM - to decrease pancreatic stimulation
Analgesics
Prophylactic Abx

119
Q

Key presentation chronic pancreatitis

A

Same as acute but longer lasting

Worse after alcohol
Steatorrhoea
Weight loss (malabsorption)
Insulin dependent DM

120
Q

Tx Chronic pancreatitis

A

Alcohol cessation
Pancreatic enzyme supplements w PPI - helps digestion
Insulin
ERCP or surgery if req

121
Q

Key presentation of Acute Cholecystitis

A

RUQ pain - may radiate to right shoulder

Fatigue
Fever
POS Murphy’s sign
Tenderness & guarding

122
Q

Ix Acute Cholecystitis

A

Abdo ultrasound - stones, thick gallbladder walls, fluid around gallbladder

123
Q

What is acute cholecystitis?

A

Acute inflammation of the gallbladder
Usually bc of gallstone

124
Q

Tx Acute cholecystitis

A

Conservative management before surgery (Abx, heavy analgesia, IV fluids)
Cholecystectomy

125
Q

What is acute cholangitis?

A

Acute inflammation and infection of bile duct

126
Q

Cause of acute cholangitis

A

Due to bile duct obstruction

*Gallstones
Trauma
Surgery

127
Q

Key presentation of Acute Cholangitis

A

Charcot’s triad
1. RUQ pain
2. Jaundice
3. Fever + rigors

Reynold’s pentad
Charcot’s triad + confusion + septic shock

128
Q

Ix Acute Cholangitis

A

FBCs - Leukocytosis
LFTs - ↑ ALP and bilirubin
↑ CRP
Blood cultures - identify pathogen

Ultrasound +/- ERCP

129
Q

What is ERCP?

A

Endoscopy Retrograde Cholangiopancreatography

130
Q

Tx Acute Cholangitis

A

Treat Sepsis - Iv Abx, aggressive fluid resus
ERCP and stenting
Cholecystectomy

131
Q

What is Primary Biliary Cholangitis associated with?

A

FEMALE !!! (9:1 ratio)
Autoimmune disease
Rheumatoid conditions (e.g. RA)

132
Q

What is Primary Biliary Cholangitis?

A

When immune system attack small bile ducts within liver
causes obstruction to outflow of bile = cholestasis
∴ fibrosos, cirrhosis + liver failure

133
Q

Key presentation Primary Biliary Cholangitis

A

Fatigue
Pruritus
GI disturbance and abdo pain
Jaundice, pale stools
Xanthoma and xanthelasma
Signs of cirrhosis - ascites, splenomegaly, spider naevi

134
Q

Ix Primary Biliary Cholangitis

A

LFTs - ↑ ALP, ↑ GGT, ↑ bilirubin
AMA (anti-mitochondrial antibodies) - most specific to PBC, ANA

Liver biopsy

135
Q

Tx Primary Biliary Cholangitis

A

Ursodeoxycholic acid - reduce cholestasis
Cholestryamine - ↓ cholesterol absorption

136
Q

What is Primary Sclerosing Cholangitis?

A

When biliary tree is strictured and fibrotic
∴ obstruction of bile out of liver

137
Q

Key presentation Primary Sclerosing Cholangitis

A

Jaundice
Chronic RUQ pain
Pruritus
Fatigue
Hepatomegaly

138
Q

RF Primary Sclerosing Cholangitis

A

Male
FHx
30 - 40 years
UC!!!!!!!!!!

139
Q

Ix Primary Sclerosing Cholangitis

A

LFT
pANCA
ANA
aCL

GS : MRCP!! - may show bile duct lesions or strictures

140
Q

Tx Primary Sclerosing Cholangitis

A

Liver transplant
ERCP - can be used to dilate and stent strictures
Cholestryamine

141
Q

Complications of Primary Sclerosing Cholangitis

A

Acute bacterial cholangitis
Cholangiocarcinoma
Colorectal cancer
Cirrhosis, liver failure

142
Q

Causes of Hepatocellular Carcinoma

A

Viral Hep (B and C)
Alcohol
NAFLD

143
Q

RF Hepatocellular Carcinoma

A

Male !!

144
Q

Presentation Hepatocellular Carcinoma

A

Non-spec symptoms - weight loss, fatigue, N+V

Liver symptoms - jaundice, ascites, hepatic encephalopathy, pruritus

145
Q

Ix Hepatocellular Carcinoma

A

1st line - ABdo ultrasound

GS : ABDO CT !
Serum alpha-fetoprotein = tumour marker for HCC

146
Q

Tx Hepatocellular Carcinoma

A

Liver transplant

147
Q

Cause of Spontaneous bacterial peritonitis

A

Gram -ve = E.coli, Klebsiella spp
Gram +ve = Strep spp

148
Q

Presentation Spontaneous bacterial peritonitis

A

Severe acute abdo pain
Guarding
N+V
Diarrhoea
Fever

149
Q

Ix Spontaneous bacterial peritonitis

A

Ascitic tap
Culture
ESR + CRP

150
Q

Tx Spontaneous bacterial peritonitis

A

ABCDE
IV Abx (cefotaxime)
Paracentesis

151
Q

Complications Spontaneous bacterial peritonitis

A

Septicaemia

152
Q

Tx Paracetamol overdose

A

Acetylcysteine - asap
Activated charcoal !!!

153
Q

Tx Hepatic Encephalopathy

A

1st line - Lactulose
Rifaximin
Liver transplant

154
Q

What are the aminotransferase levels in Gilbert’s syndrome?

A

Normally, normal

155
Q

Define Gilbert’s syndrome

A

Decreased levels of UDPGT which results in impaired conjugation of bilirubin.

156
Q

Presentation of Wernicke-Korsakoff’s encephalopathy

A

Triad of:
1. Confusion
2. Ataxia
3. Nystagmus

157
Q

Tx Ascending cholagitis

A

Abx - IV co-amoxiclav

Phase 2 (24 decks)

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