Liver Flashcards
what functions does the liver haver ?
filtration
protein synthesis
clotting factor
blood sugars
cholesterol etc
what does ALP, ALT and GGT indicate ?
ALP (biliary damage)
ALT (hepatocyte damage)
GGT (general damage)
how do you know if there is a cholestatic problem in the liver ?
ALP and GGT raised more than ALT
how do you know if there is a hepatitis problem with the liver ?
ALT raised more than ALP and GGT
what is viral hepatitis ?
infection of the liver by hepatitis viruses ?
what are the types of hepatitis viruses ?
acute (A,B,E)
chronic (B,C)
how is hep A transmitted and is it rare ?
faecal-oral: poor: poor sanitation,
rare in the UK
how is hep B transmitted ?
BBV
sexually transmitted
MSM (men sex with men)
PWID (person who injects drugs)
children with infected women
how is hep C transmitted ?
BBV: PWID, transfusions, tattoo on developing world
how is hep E transmitted and who is the primary host ?
faecal-oral spread: pigs primary host
how does acute viral hepatitis presented ?
RUQ abdominal pain
nausea/vomiting
jaundice
diarrhoea
arthralgia
how does chronic viral hepatitis present ?
limited symptoms unless advanced disease: ascites, jaundice, encephalopathy
how do you investigate for viral hepatitis ?
deranged LFTs (hepatitic) serology
In hep B what would HBsAg (surface antigen) show ?
evidence of infection
in hep B what does HBeAg (e antigen) show ?
high viral replication
in hep B what does Anti-HBs (surface antibody) show ?
clearance of infection OR immunity in vaccinated
in hep B what does anti-Be (e antibody) show ?
reduced viral replication
in hep B what does Anti-HBc (core antibody) show ?
only seen in previously infected patients
what would be seen in a hep A viral serology test ?
clotted blood for HAV IgM confirms diagnosis
what would be seen in a hep C viral serology test?
HCV IgG indicates exposure to virus at some point
HCV RNA detected by PCR indicates active infection
what would be seen in a hep E viral serology test ?
blood for HEV IgM
how would you manage acute viral hepatitis ?
supportive
avoid alcohol
monster for fulminant hepatic failure
how would you manage chronic hep B?
reduce infectivity and liver inflammation and fibrosis
antiviral therapy – tenofovir and entecavir
how do you manage chronic hep C ?
all patients who will accept treatment.
Protease inhibitors, NS5A inhibitors, polymerase inhibitors. 8-12 weeks of combination DAA treatment - use of 2+ drugs reduces risk of antiviral resistance and treatment failure.
What is NAFLD ?
non-alcoholic fatty liver disease
increased fat in hepatocytes that cannot be attributed to any other cause
what is the most common cause of liver failure?
NAFLD
what are ask factors for NAFLD ?
old age, obesity, diabetes mellitus
how does NAFLD present ?
mostly asymptomatic until they develop cirrhosis
may complain of RUQ pain
how would you investigate for NAFLD ?
ultrasound or abnormal liver function test
how would you manage NASH ?
weight loss
exercise
other experimental treatments
how would you manage NAFLD?
weight loss and exercise
what is the follow up guidelines when managed ?
moniter for complication
cirrhotic screen for hepatocellur carcinoma with twice yearly ultrasound
what is alcoholic liver disease ?
increased peripheral release of fatty acids, and increased synthesis of fatty acids within the liver.
how long can the liver be reversible for alcoholic liver disease ?
6 weeks
when is the liver irreversible for alcoholic liver disease and how long does it take ?
fibrosis - months to years
cirrhosis - years
how does alcoholic liver disease present ?
steatosis - little symptoms, malaise, nausea, incidental finding
hepatitis - RUQ pain, hepatomegaly, fever, jaundice
cirrhosis - jaundice, encephalopathy, ascites
how would you investigate for alcoholic liver disease ?
recent excess alcohol
rearranged hepatitic LFTs- AST:ALT ratio raised
what would the LFT test show for alcoholic liver disease ?
AST:ALT ratio raised
how would you manage alcoholic liver disease ?
stop drinking
screening
what is cirrhosis ?
irreversible liver damage
what are the two types of cirrhosis ?
compensated
decompensated
explain how cirrhosis is caused ?
bands of fibrosis separating regenerative nodules of hepatocytes
what is compensated cirrhosis ?
cirrhosis present, but patient asymptomatic as liver still able to perform some of its function
what is decompensated cirrhosis ?
run out of liver and it cannot perform its function
what causes cirrhosis ?
alcohol
NAFLD
chronic viral hepatitis
haemochromatosis
Wilsons
PBC
PSC
drugs
how does compensated cirrhosis present (7) ?
spider naevi
palmar erythema
clubbing
gynaecomastia
hepatomegaly
splenomegaly
oedema
how does decompensated cirrhosis present (4) ?
jaundice
ascites
encephalopathy
bruising
how do you screen for unhealthy alcohol use ?
CAGE
Feel the need to Cut down. People Annoyed you by criticising your drinking. Ever felt Guilty about drinking. Ever needed an Eye-opener.
how do you investigate for cirrhosis ?
Bloods - deranged LFTs to find the cause
ultrasound
liver biopsy
how do you manage liver cirrhosis ?
depends on the cause
treat the underlying cause
appropriate nutrition
how would you manage ascites ?
spironolactone
what complications does ascites cause and what would you do to treat this ?
spontaneous bacterial peritonitis
urgent antibiotics
ascitic tap
when would you consider for a liver transplant ?
if UKELD score is above 49
what is the UKELD score ?
calculates probability of death
used for consideration of liver transplant
why may liver failure occur ?
development of coagulopathy and encephalopathy
what background often associated with liver failure ?
cirrhosis
what causes liver failure (6) ?
viral hepatitis
alcohol
NAFLD
PBC
PSC
haemochromatosis
how does liver failure present ?
jaundice
hepatic encephalopathy
fetor hepaticus
flap
signs of chronic liver disease
how do you investigate for liver failure ?
FBC
U&Es
LFTs
clotting
glucose
hepatitis serology
look for cause
ultrasound
how would you manage liver failure ?
treat the cause :)
what is PSC ?
autoimmune destruction of large and medium sized bile ducts
who is mostly affected by PSC and what is associated with PSC ?
usually in males
associated with UC
how does PSC present ?
pruritus +/- fatigue,
if advanced: ascending cholangitis, cirrhosis, liver failure.
how would you investigate for PSC?
raised ALP then bilirubin. AMA negative.
Imaging - MRCP and ERCP reveal duct anatomy and drainage.
how would you manage and monitor PSC ?
maintain bile flow
monitor for cholangiocarcinoma and colorectal cancer. Liver transplant for end stage.
what would you give to help improve LFTs in PSC?
ursodeoxycholic
what would you give for pruritus (itch) in PSC ?
colestyramine
what is PBC ?
autoimmune destruction of interlobular bile ducts
who does PBC more commonly affect ?
usually in females
typically around 50 years
how does PBC present ?
often asymptomatic, and diagnosed after incidental raised ALP. Lethargy and pruritus may precede jaundice by years. Jaundice, skin pigmentation, xanthelasma, hepatsplenomegaly.
how would you investigate PBC ?
raised ALP and GGT
mildly raised ALT
AMA positive
how would you manage PBC ?
ursodeoxycholic acid
transplant
what is autoimmune hepatitis ?
autoantibodies directed against hepatocyte surface antigens
who does autoimmune hepatitis affect mostly ?
affects more women than men
twin peaks: 10-30 and over 40
who does type 1 autoimmune hepatitis affect ?
adults
who does type 2 autoimmune hepatitis affect ?
children and young adults
how does autoimmune hepatitis present ?
acute onset of symptoms similar to acute viral hepatitis. Malaise, fatigue, lethargy, nausea, abdominal pain.
Signs - hepatosplenomegaly, jaundice, stigmata of chronic liver disease, splenomegaly.
how would you investigate autoimmune hepatitis ?
raised AST and ALT, elevated IgG
presence of ASMA
liver biopsy - chronic hepatitis with marked piecemeal necrosis and lobular involvement
how would you manage autoimmune hepatitis ?
Immunosuppression - prednisolone and azathioprine.
Prednisolone - start at 30mg daily and taper to 15mg at week 4, then maintain on 5mg until therapy endpoint. Sometimes stopped after 2 years but relapse often occurs.
what is hepatocelllular carcinoma ?
Most common primary liver cancer.
who does hepatocellular carcinoma affect ?
more common In men
what is a major risk factor for hepatocellular carcinoma ?
Most important risk factor is cirrhosis - Hep BV, Hep CV, alcohol, NAFLD, Auto immune Hepatitis.
how does hepatocelluar carcinoma present ?
weight loss and RUQ pain. Can be asymptomatic. Worsening of pre-existing liver disease. Acute liver failure. Signs of cirrhosis, hard enlarged liver.
how would you investigate for hepatoceelluar carcinoma ?
LFTs and other bloods. AFP is an HCC tumour marker
CT scan
Biopsy
how would you manage hepatocellular carcinoma ?
Liver transplant is the best available treatment for single tumours less than 5cm or less than 3 tumours less than 3cm each. Recurrence low.
Resection for small tumours with preserved liver function. Recurrence high.
TransArterial ChemoEmbolisation (TACE) - injection into hepatic artery.
