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Internal Medicine > Liver > Flashcards

Liver Flashcards

1
Q

Name 8 causes of prehepatic jaundice

A

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
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2
Q

Name 8 causes of intrahepatic jaundice

A

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
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3
Q

What type of hyperbilirubinaemia will be present in prehepatic jaundice

A

Unconjugated

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4
Q

What type of hyperbilirubinaemia will be present in intrahepatic jaundice

A
  • 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
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5
Q

Name 7 causes of post hepatic jaundice

A

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
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6
Q

What type of hyperbilirubinaemia will be present in post hepatic jaundice

A

Conjugated

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7
Q

What test for Wilson’s disease

A

Ceruloplasmin (low)

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8
Q

Treatment severe malaria at primary clinic?

A

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)
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9
Q

Treatment severe malaria in hospital?

A
  • 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
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10
Q

Name 4 side effects artesunate

A

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
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11
Q

Name 4 side effects quinine

A

Narrow therapeutic window.

  • hypoglycaemia must common
  • cinchonism: mild hearing impairment and visual disturb, tinnitus, headache, nausea,
  • hypotension, heart block, ventricular arrhythmia
  • convulsions
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12
Q

Management uncomplicated malaria? Caused by P falciparum, p malaria, P Knowlesi

A
  • 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
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13
Q

How should coartem be administered

A

With fat containing food to aid absorption

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14
Q

Name 5 side effects artemether-lumefantrine

A
  • Sleep disturbances, headaches, dizzy, fatigue
  • palpitations
  • abdominal pain, anorexic
  • cough, asthma
  • arthralgia, myalgia
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15
Q

Management for malaria caused by P ovale, P vivax?

A

Artemether - lumefantrine followed by primaquine

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16
Q

Name 5 organisms that cause malaria

A

Treat with coartem:

  • plasmodium falciparum, (most common)
  • p malaria,
  • P Knowlesi

Coartem + primaquine

  • p ovale
  • P vivaX
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17
Q

Lab diagnosis of malaria? (2)

A
  • Blood malaria antigen rapid diagnostic test (rdt) and
  • microscopy of thick and thin blood smears
    → high levels parasite = >4% = severe malaria
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18
Q

Differential diagnosis malaria? (5)

A
  • Influenza
  • viral hepatitis
  • meningitis/ encephalitis
  • EBV also cause splenomegaly
  • typhoid fever (salmonella)
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19
Q

Name 8 complications malaria

A
  • 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
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20
Q

Name 10 signs chronic liver disease

A
  • 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
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21
Q

Define portal hypertension

A

Hepatic venous Pressure gradient between portal and hepatic vein > 5 mmHg
Clinically significant when 10 or more
Bleeding risk at 12 or more

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22
Q

Name 10 causes portal hypertension

A

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)
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23
Q

Name 8 signs portal ht

A
  • 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
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24
Q

Management portal ht? (4)

A
  • 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
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25
Q

Name complications portal ht (5)

A
  • 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
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26
Q

Treatment hepatic encephalopathy?

A
  • Correct hypoK
  • Lactulose to lower ph, form ammonium to prevent increased ammonia, eliminate nitrogen producing bacteria from colon
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27
Q

Imaging diagnosis portal ht? (2)

A
  • 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
28
Q

Malaria prophylaxis?

A

Doxycycline oral 100mg daily from 2 days prior to going to area until 4 weeks after.
Contraindicated in pregnancy

29
Q

Approach to hepatomegaly?

A

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
30
Q

Define cirrhosis

A

Irreversible diffuse fibrosis of the liver

31
Q

What will as ascitic fluid show in Tb peritonitis (3)

A
  • Low saag
  • lymphocytosis
  • high ADA, positive culture, positive acid fast bacilli smear
32
Q

What will as ascitic fluid show in disseminated malignancy (3)

A
  • Low saag
  • high LDH
  • lymphocytosis if lymphoma
33
Q

How is acute liver failure diagnosed? (3)

A
  • 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

34
Q

Define hepatomegaly

A

> 13 cm

35
Q

Name causes liver cirrhosis (7)

A

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
36
Q

Lab diagnosis alcoholic liver disease? (2)

A
  • GGT high
  • AST > alt
37
Q

Gold standard diagnosis liver cirrhosis?

A

Biopsy

38
Q

Score for cirrhosis severity?

A

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

39
Q

Biochemical findings liver cirrhosis? (3)

A
  • albumin low <3,5
  • bilirubin high > 2
  • Inr high >1,7
40
Q

Name 7 complications cirrhosis

A

VARIcES

  • varices
  • ascites / anaemia
  • renal fail ( hepatorenal syndrome)
  • infection
  • coagulopathy
  • encephalopathy
  • sepsis
41
Q

Triad of hepatopulmonary syndrome?

A
  • Liver disease
  • Increased alveolar - arterial gradient while breathing room air
  • evidence intrapulmonary vascular abnormalities
42
Q

Management coagulopathy in acute liver failure? (3)

A
  • Vitamin K 10 mg iv slow bolus
  • if bleeding / going for surgery/procedure: FFP 4u
  • it platelets <50 + bleeding / surgery: platelets 6 U.
43
Q

Paracetamol poisoning antidote?

A

N-acetyl cysteine

Also works for most drugs/toxins causing acute liver failure

44
Q

Label picture 9

A

See picture 10

45
Q

Which hepatitis viruses only cause acute hepatitis

A

Hepatitis A and E. The vowels!

Consonants (b, C,D) also chronic

46
Q

Which LFTs high in biliary obstruction

A

Alp! ( GGT also raised, ast/alt slightly raised )

47
Q

Which LFTs high in hepatitis

A

Ast/alt

48
Q

Which LFTs high in alcoholic liver disease

A

GGT
AST > alt

49
Q

Best screen for acute hepatitis B infection?

A

Hepatitis B core IgM antibody

50
Q

Most likely cause of ascites if fluid clear/straw colour/light green

A

Cirrhosis

51
Q

Most likely cause of ascites if fluid bloody

A

Malignancy

52
Q

Most likely cause of ascites if fluid cloudy

A

Infection

53
Q

Most likely cause of ascites if fluid milky white

A

Chylous - lymphatic obstruction

54
Q

Name 5 tests that should be ordered for ascitic fluid

A
  • Total albumin (plus serum albumin) and protein
  • amylase (pancreatic ascites )
  • neutrophil count (bacterial peritonitis)
  • cytology
  • microscopy und culture
55
Q

Name 3 most common causes liver cirrhosis

A
  • Chronic viral hepatitis
  • prolonged excessive alcohol consumption
  • non alcoholic fatty liver disease
56
Q

Name 6 features chronic liver failure

A
  • Worsening synthetic liver function: prolonged pt, low albumin
  • jaundice
  • PHT
  • variceal bleeding
  • hepatic encephalopathy
  • ascites: spontaneous bacterial peritonitis, hepatorenal failure
57
Q

Name 3 common features alcoholic cirrhosis

A
  • Florid spider telangiectasia
  • Gynaeccomastia
  • parotid enlargement
58
Q

Name functions of the liver (5)

A
  • 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:
59
Q

Most common cause portal hypertension?

A

Schistosomiasis

60
Q

How is hepatitis A spread

A

Faecal - oral

61
Q

How is hepatitis A diagnosed

A

Anti-hav IgM

62
Q

How is hepatitis B spread

A

Blood

63
Q

Name the 5 phases of chronic hepatitis B and the associated lab results

A
  • 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 +,
64
Q

Serology in acute hepatitis? (3)

A
  • HBsAg +
  • anti-hbc IGm +
  • anti-hbc IgG +
  • anti- HBs -
65
Q

Hepatitis B Serology post-infection?

A
  • HBsAg -
  • anti-hbc IGm -
  • anti-hbc IgG +
  • anti- HBs + / -
66
Q

Hepatitis B serology immunisation?

A
  • HBsAg -
  • anti-hbc IGm -
  • anti-hbc IgG -
  • anti- HBs +
67
Q

Treatment malaria in pregnancy?

A

Quinine

Internal Medicine (20 decks)

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