Liver Flashcards
Name 8 causes of prehepatic jaundice
Congenital
- Haemolysis:
→ enzyme defect: G6PD deficiency,
→ RBC membrane defects: hereditary spherocytosis, elliptocytosis
→ RBC hb defects : sickle cell anaemia, thalassemia
Acquired
- medication: rifampicin, probenecid, ribavirin, protease inhibitors
- autoimmune haemolytic anaemia,
- haemolytic transfusion reaction
- increased bilirubin production: massive blood transfusion, superficial and internal hematoma resorption
- ineffective erythropoiesis: pernicious anemia, sideroblastic anaemia
Name 8 causes of intrahepatic jaundice
Non obstructive
Infective
- viral hepatitis (hepatitis a-e, CMV, yellow fever) (also bacterial, sepsis)
Non-infective
- Impaired bilirubin conjugation (unconjugated hyperbilirubinemia): Gilbert syndrome, crigler - najjar syndrome
- hepato cellular injury ( mixed unconjugated conjugated hyperbilirubinemia ):
→ liver disease (alcoholic hepatitis, nonalcoholic steatohepatitis, cirrhosis, congestive hepatopathy,
→ metabolic ( Wilson disease, haemochromatosis, alpha 1 antitrypsin deficiency)
→ autoimmune hepatitis
→ drug toxicity ( paracetamol, estrogen, macrolide, arsenic, herbal) - impaired hepatic excretion of bilirubin (conjugated): dubin - Johnson syndrome, rotor syndrome
Obstructive
- intrahepatic cholestasis (conjugated):
→ intrahepatic biliary tract d/o (primary biliary cholangitis, PSC, post-op),
→ infiltrative disease (TB, sarcoidosis, amyloidosis, lymphoma),
→ intrahepatic cholestasis of pregnancy, TPN,
→ infectious eg malaria,
→ intrahepatic gallstones,
→ cancer
What type of hyperbilirubinaemia will be present in prehepatic jaundice
Unconjugated
What type of hyperbilirubinaemia will be present in intrahepatic jaundice
- Unconjugated: impaired bilirubin conjugation eg Gilbert syndrome
- mixed: hepatocellular injury eg viral hepatitis, liver disease, drug toxicity
- conjugated: impaired hepatic excretion of bilirubin (dubin-johnson syndrome), intrahepatic cholestasis
Name 7 causes of post hepatic jaundice
Obstructive
Intraluminal
- Choledocholithiasis in CBD
Intra-mural
- bile duct strictures
- primary sclerosing cholangitis.
- malformation of biliary tract
Extra-mural
- tumours eg head of pancreas cancer
- lymph nodes
- chronic pancreatitis
What type of hyperbilirubinaemia will be present in post hepatic jaundice
Conjugated
What test for Wilson’s disease
Ceruloplasmin (low)
Treatment severe malaria at primary clinic?
Stabilise. Give one of the following then transfer ASAP:
- IM artesunate 2,4 mg/kg stat or
- IM quinine 20 mg salt/kg stat (divided into 10 mg/kg diluted to concentration 60 - 100 mg/ml administered in each thigh)
Treatment severe malaria in hospital?
- Stabilise patient and admit to intensive care
- iv arsenate for all (alternative = quinine)
→ weigh > 20 kg: 2.4 mg/kg at 0, 12 and 24 hours then daily until can tolerate oral treatment
Name 4 side effects artesunate
Very safe and tolerable.
- common: gi disturbance, dizzy
- Haem: neutropenia, reduced reticulocyte count, anaemia, eosinophilia
- raised AST
- delayed haemolysis after a week of treatment: follow-up well
Name 4 side effects quinine
Narrow therapeutic window.
- hypoglycaemia must common
- cinchonism: mild hearing impairment and visual disturb, tinnitus, headache, nausea,
- hypotension, heart block, ventricular arrhythmia
- convulsions
Management uncomplicated malaria? Caused by P falciparum, p malaria, P Knowlesi
- Artemether lumefantrine (act coartem ): dose according to weight. Adults > 35 kg four tablets stat followed by 4 tabs after 8 hours, then 4 twice daily on the following 2 days (total = 24 tabs)
> 85kg = 5 days treatment. - or oral quinine plus doxycycline/clindamycin only if above contraindicated or unavailable
How should coartem be administered
With fat containing food to aid absorption
Name 5 side effects artemether-lumefantrine
- Sleep disturbances, headaches, dizzy, fatigue
- palpitations
- abdominal pain, anorexic
- cough, asthma
- arthralgia, myalgia
Management for malaria caused by P ovale, P vivax?
Artemether - lumefantrine followed by primaquine
Name 5 organisms that cause malaria
Treat with coartem:
- plasmodium falciparum, (most common)
- p malaria,
- P Knowlesi
Coartem + primaquine
- p ovale
- P vivaX
Lab diagnosis of malaria? (2)
- Blood malaria antigen rapid diagnostic test (rdt) and
- microscopy of thick and thin blood smears
→ high levels parasite = >4% = severe malaria
Differential diagnosis malaria? (5)
- Influenza
- viral hepatitis
- meningitis/ encephalitis
- EBV also cause splenomegaly
- typhoid fever (salmonella)
Name 8 complications malaria
- Severe haemolytic anaemia and /or bone marrow dysfunction
- hypoglycaemia (monitor every 6 hours in severe anaemia)
- cerebral malaria
- renal failure, early complication due to hypovolaemia, sequestration of parasitised red cells in renal vasculature, intravascular haemolysis, haemoglobinUria
- respiratory distress: ARDS
- hepatic dysfunction
- bleeding: thrombocytopenia
- splenic rupture in P vivaX
Name 10 signs chronic liver disease
- head: hepatic fetor on breath, jaundice
- chest: gynaecomastia, breast atrophy in women
- hands: clubbing , asterixis, leuconychia (hypoalbuminaemia), palmar erythema, terry nails
- skin: purpura (purple), excoriation marks, spider naevi
- Abdomen: caput medusae (flows out from umbilicus. Flow below umbilicus up = IVC obstruction)
- limbs: muscle wasting
Define portal hypertension
Hepatic venous Pressure gradient between portal and hepatic vein > 5 mmHg
Clinically significant when 10 or more
Bleeding risk at 12 or more
Name 10 causes portal hypertension
Pre-hepatic
- portal/splenic vein thrombosis
- splenomegaly
- av fistula
- sarcoidosis
Hepatic
- cirrhosis! (Alcohol, chronic hepatitis, biliary atresia, primary biliary cirrhosis)
- schistosomiasis
- hepatitis
Post-hepatic
- IvC / hepatic vein obstruction
- right heart failure
- constrictive pericarditis
- budd-chiari syndrome OH (Obstruction Hepatic vein)
Name 8 signs portal ht
- Oesophageal varices → UGI bleed, haematemesis
- melena (gastric varices)
- haemorrhoids or anorectal varices
- congestive splenomegaly with signs hypersplenism (thrombocytopenia → spontaneous bleeding, easy brusing)
- Transudative ascites, oedema
- Caput medusae (paraumbilical vein enlargement
- general: fatigue, anorexia, nausea vomiting, jaundice, pruritis)
- symptoms encephalopathy: disturbance sleep-wake cycle, intellectual function deteriorate, memory loss, inability to communicate, personality change, inappropriate behaviour
Management portal ht? (4)
- B blockers to reduce varices bleed risk - propanol.
- terlipressin injections (vasopressin) for bleeds
- nitrates (reduce portal pressure by selective venodilation in splanchnic circulation)
- shunts eg tips (transjugular intrahepatic portosystemic shunt) to decrease portal venous pressure
- endoscopic variceal ligation
Name complications portal ht (5)
- Portocaval anastomosis: oesophageal varies, kaput medusae, gastric varies, haemorrhoids → bleeds!
- thrombocytopenia due to congestive splenomenaly (hypersplenism)
- hepatic encephalopathy!
- hepatorenal syndrome
- sepsis: spontaneous bacterial peritonitis.
- congestive gastropathy
- ascites
- iron deficiency anaemia
Treatment hepatic encephalopathy?
- Correct hypoK
- Lactulose to lower ph, form ammonium to prevent increased ammonia, eliminate nitrogen producing bacteria from colon
Imaging diagnosis portal ht? (2)
- Ultrasound: cavernous transformation of portal vein, vein dilated > 13 MM , increased blood flow via portosystemic anastomoses using duplex
- Abdo ct: portal vein thrombosis
- measure pressure with balloon catheter inserted using transjugular route
- endoscopy etc for varices
Malaria prophylaxis?
Doxycycline oral 100mg daily from 2 days prior to going to area until 4 weeks after.
Contraindicated in pregnancy
Approach to hepatomegaly?
MIAMI
Malignancy = massive craggy (rough)
- metastatic
- primary HCC
- myeloproliferative disease eg myelofibrosis, lukemia
- lymphoproliferative eg lymphoma
Infection = mild hepatomegaly
- viral: hepatitis HIV
- parasitic: hydatid disease (echinococcus), malaria, schistosomiasis, amoebic abscess
- bacterial; infections mononucleosis (glandular fever),
Autoimmune
Metabolic = moderate
- Haemochromatosis
- fatty liver secondary to dm, obesity, toxins
- storage disorders: Gaucher’s disease
Infiltrating / inherited/idiopathic
- amyloidosis, granuloma (sarcoid)
- porphyria
Other
- hepatic congestion: RHF (massive pulsatile), budd-chiari syndrome
- haematological: sickle cell disease, haemolytic anaemia
- toxins: alcoholic liver disease with fatty infiltration = massive
- local: early cirrhosis = firm, irregular, biliary obstruction = mild
Define cirrhosis
Irreversible diffuse fibrosis of the liver
What will as ascitic fluid show in Tb peritonitis (3)
- Low saag
- lymphocytosis
- high ADA, positive culture, positive acid fast bacilli smear
What will as ascitic fluid show in disseminated malignancy (3)
- Low saag
- high LDH
- lymphocytosis if lymphoma
How is acute liver failure diagnosed? (3)
- Severe acute liver injury ( increased transaminases) with encephalopathy +
- impaired synthetic function (inr 1,5 or more)
- in pt without cirrhosis or pre-existing liver disease
Worsening pt or bilirubin with improving transaminases, platelets often low
Define hepatomegaly
> 13 cm
Name causes liver cirrhosis (7)
HEPATIC
- hereditary: haemochromatosis, Wilson’s disease, porphyria’s, glycogen storage disorder, hereditary fructose intolerance, hereditary haemorrhagic telangiectasia / oster-weber-rendu synd
- enzyme deficiency: Alpha 1 antitrypsin
- PBC /psc
- alcoholic liver disease!
- toxins: aflatoxin (aspergillus), medications, chemicals (ccl4 ), pesticides
- inflammation (hepatitis): chronic viral hepatitis b, d esp C!, autoimmune hepatitis, parasitic infections (schistosomiasis, malaria) , Nash = non-alcoholic fatty liver disease!
- cryptogenic cirrhosis / congestion of hepatic vein ( Budd - chiari, congestive cardiac cirrhosis)/ Ca
Lab diagnosis alcoholic liver disease? (2)
- GGT high
- AST > alt
Gold standard diagnosis liver cirrhosis?
Biopsy
Score for cirrhosis severity?
Child-pugh score for prognosis 1 year survival.
Child’s ABCDEs: albumin, bilirubin, coagulation (inr), distended abdo (ascites), encephalopathy
Also MELD score for 3 month mortality and to prioritise patients needing transplant
Biochemical findings liver cirrhosis? (3)
- albumin low <3,5
- bilirubin high > 2
- Inr high >1,7
Name 7 complications cirrhosis
VARIcES
- varices
- ascites / anaemia
- renal fail ( hepatorenal syndrome)
- infection
- coagulopathy
- encephalopathy
- sepsis
Triad of hepatopulmonary syndrome?
- Liver disease
- Increased alveolar - arterial gradient while breathing room air
- evidence intrapulmonary vascular abnormalities
Management coagulopathy in acute liver failure? (3)
- Vitamin K 10 mg iv slow bolus
- if bleeding / going for surgery/procedure: FFP 4u
- it platelets <50 + bleeding / surgery: platelets 6 U.
Paracetamol poisoning antidote?
N-acetyl cysteine
Also works for most drugs/toxins causing acute liver failure
Label picture 9
See picture 10
Which hepatitis viruses only cause acute hepatitis
Hepatitis A and E. The vowels!
Consonants (b, C,D) also chronic
Which LFTs high in biliary obstruction
Alp! ( GGT also raised, ast/alt slightly raised )
Which LFTs high in hepatitis
Ast/alt
Which LFTs high in alcoholic liver disease
GGT
AST > alt
Best screen for acute hepatitis B infection?
Hepatitis B core IgM antibody
Most likely cause of ascites if fluid clear/straw colour/light green
Cirrhosis
Most likely cause of ascites if fluid bloody
Malignancy
Most likely cause of ascites if fluid cloudy
Infection
Most likely cause of ascites if fluid milky white
Chylous - lymphatic obstruction
Name 5 tests that should be ordered for ascitic fluid
- Total albumin (plus serum albumin) and protein
- amylase (pancreatic ascites )
- neutrophil count (bacterial peritonitis)
- cytology
- microscopy und culture
Name 3 most common causes liver cirrhosis
- Chronic viral hepatitis
- prolonged excessive alcohol consumption
- non alcoholic fatty liver disease
Name 6 features chronic liver failure
- Worsening synthetic liver function: prolonged pt, low albumin
- jaundice
- PHT
- variceal bleeding
- hepatic encephalopathy
- ascites: spontaneous bacterial peritonitis, hepatorenal failure
Name 3 common features alcoholic cirrhosis
- Florid spider telangiectasia
- Gynaeccomastia
- parotid enlargement
Name functions of the liver (5)
- Carbohydrate, amino acid, lipid, drug, toxin metabolism
- clotting factor production
- bilirubin metabolism and bile production
- storage of vitamins and minerals: A, D, b12, K, folate
- Immune regulation:
Most common cause portal hypertension?
Schistosomiasis
How is hepatitis A spread
Faecal - oral
How is hepatitis A diagnosed
Anti-hav IgM
How is hepatitis B spread
Blood
Name the 5 phases of chronic hepatitis B and the associated lab results
- Immune - tolerant phase: hbsag +, hbeag+, Viral load highest so very infections
- immune reactive hbeag positive phase: hbsag +, hbeag+, Viral load high, alt high, moderate/severe necroinflammation on histology. Weeks to years.
- inactive carrier: hbsag +, anti- HBe antibody +,
- hbeag negative phase: hbsag +, anti- HBe antibody +, fluctuating viral load, moderate/ severe necroinflammation
- HBSag negative phase: anti- HBe antibody +,
Serology in acute hepatitis? (3)
- HBsAg +
- anti-hbc IGm +
- anti-hbc IgG +
- anti- HBs -
Hepatitis B Serology post-infection?
- HBsAg -
- anti-hbc IGm -
- anti-hbc IgG +
- anti- HBs + / -
Hepatitis B serology immunisation?
- HBsAg -
- anti-hbc IGm -
- anti-hbc IgG -
- anti- HBs +
Treatment malaria in pregnancy?
Quinine
