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Phase 2 Quick > Liver > Flashcards

Liver Flashcards

1
Q

What is Jaundice?

A

↑ Serum bilirubin
(visible at >35umol/L)

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1
Q

Ix Jaundice

A
  1. Dark urine, pale stools, itching?
  2. Look for symptoms
    Biliary pain, rigors, abdomen swelling, weight loss
  3. Past history
    Biliary disease, malignancy, HF, blood products, autoimmune disease
  4. Drugs history
    If started drugs/herbs recently
  5. Social history
    Alcohol?
    Family history?
    Potential hepatitis contact? - Irregular sex, IVDU, exotic travel, certain foods

–
Liver enzymes - if high AST/ALT suggests liver disease
Biliary obstruction

Imaging - CT, MRCP, ERCP

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2
Q

Types of Jaundice
Describe

A

1. Pre-hepatic - XS breakdown of Hb (∴ ↑ unconjugated bilirubin)

2. Hepatic - hepatocytes fail to take up, metabolise or excrete bilirubin

3. Post-hepatic - Obstruction in biliary system

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3
Q

Unconjugated or conjugated bilirubin?
What’s the stool & urine look like?

in Pre-hepatic Jaundice

A

↑Unconjugated bilirubin
Normal stool and urine

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4
Q

Unconjugated or conjugated bilirubin?
What’s the stool & urine look like?

in Hepatic Jaundice

A

↑Unconjugated and conjugated bilirubin
Dark urine
Normal/pale stools

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5
Q

Unconjugated or conjugated bilirubin?
What’s the stool & urine look like?

in Post-hepatic Jaundice

A

↑Conjugated bilirubin
Dark urine
Pale stools

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6
Q

Causes of Pre-hepatic jaundice

A

More haemolysis
e.g. malaria, sickle cell anaemia, foetal Hb in newborns

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7
Q

Causes of Hepatic Jaundice

A

Viral hepatitis, drugs, alcohol, cirrhosis

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8
Q

Causes of Post-hepatic jaundice

A

Gallstones
Pancreatitis - head of pancreas blocks CBD

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9
Q

Describe urine, stools, itching and Liver tests in Pre-hepatic Jaundice

A
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10
Q

Describe urine, stools, itching and Liver tests in Hepatic/Post-hepatic Jaundice

A
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11
Q

What is fulminant hepatic failure?

A

Clinical syndrome
Results from massive necrosis of liver cells
∴ severe impairment of liver function

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12
Q

What is compensated liver failure?

A

When liver can still function effectively
No/Few noticeable clinical symptoms

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13
Q

Causes Liver Failure

A

Infections - Viral Hep (B, C, CMV), yellow fever, leptospirosis
Drugs - Paracetamol ovedose, halothane, isoniazid
Toxins - carbon tetrachloride, amanita phalloide mushroom
Vascular - Budd-Chiari

–
OTHER - Alcohol, Non-alcoholic steatohepatitis
Immune - autoimmune hepatitis, 1° biliary cholangitis, sclerosing cholangitis
Metabolic - haemochromatosis, Wilson’s, alpha-1-antitrypsin deficiency

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14
Q

History for Liver Failure

A
  1. Dark urine, pale stools, itching?
  2. Look for symptoms
    Biliary pain, rigors, abdomen swelling, weight loss
  3. Past history
    Biliary disease, malignancy, HF, blood products, autoimmune disease
  4. Drugs history
    If started drugs/herbs recently
  5. Social history
    Alcohol?
    Family history?
    Potential hepatitis contact? - Irregular sex, IVDU, exotic travel, certain foods
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15
Q

Ix Liver Failure

A

Viral serology - Hep B surface Ag, hep C Ab, EBV, CMV etc

Immunology - Autoantibodies (ANA, AMA, ASMA, coeliac Abs) & immunoglobulins

Bloods - LFTs, FBC, U&E, clotting (↑PT/INR), glucose

Iron/Copper studies

Alpha-1-antitrypsin level

USS/CT/MRI/Doppler flow studies of portal vein

Microscopy - blood/urine culture, if neutrophils > 250/mm3 could be spontaneous bacterial peritonitis

IF ascites, peritoneal tap w/ microscopy & culture

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16
Q

Tx Liver Failure

A

TREAT CAUSE!

Conservative - analgesia, fluids
–
Protect airway! - intubate
Also, NG tube (avoid aspiration) & remove blood from stomach

Urinary/Central vein catheters to assess fluid state

LIVER TRANSPLANT!!!
–
TREAT COMPS!

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17
Q

Describe the progression of Acute and Chronic Liver Failure

A
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18
Q

Comps Liver Failure
& How would you treat?

A

Seizures - phenytoin
Encephalopathy - lactulose
Ascites - diuretics
Cerebral oedema - mannitol
Sepsis - Abx
Hypoglycaemia - dextrose
Bleeding - VitK + blood

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19
Q

What is decompensated liver disease?
How does it present?
List some causes

A

When liver is so damaged, cannot function adequately
Presents with overt clinical complications - jaundice, ascites, variceal haemorrhage
AKA chronic liver failure

Causes : infection, portal vein thrombosis, surgery

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20
Q

What is leukonychia?

A

White discolouration on nails (due to hypoalbuminaemia)

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21
Q

What is Xanthelasma?

A

Yellow fat deposits under skin
Around eyelids usually

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22
Q

Causes Portal HTN

A

Pre-hepatic - due to blockage of portal vein before liver
Portal vein thrombosis

Intra-Hepatic - distortion of hepatic architecture
Cirrhosis
Schistosomiasis
Sarcoidosis
Congenital hepatic fibrosis

Post-Hepatic - venous blockage outside of liver
RHF
Constrictive pericarditis
IVC obstruction
Budd-Chiari

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23
Q

Pathophysiology of Portal HTN

A

After liver injury and fibrogenesis (e.g. bc of cirrhosis), contraction of activated myofibroblasts occurs
(Mediated by endothelin, NO + prostaglandins)
∴ ↑ resistance to blood flow

∴ PORTAL HTN
∴ splanchnic vasodilation
∴ ↓ BP
To compensate, ↑cardiac output
Also, ↑salt+water retention to ↑blood vol

∴↑Hyperdynamic circulation (↑portal flow)

∴ formation of collateral vessels! between portal + systemic systems

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24
Q

Signs / Symptoms Portal HTN

A

Usually asymptomatic!

High SAAG?
Ascites
Splenomegaly
Formation of collateral vessels ∴ variceal bleeding!
Hepatic encephalopathy - bc toxins in general circulation

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25
Q

Tx Portal HTN

A

General : Alcohol abstinence, good nutrition

To manage ascites : Fluid restriction, low-salt diet

Manage variceal bleeding
Surgery - reroute blood flow (Portosystemic shunting)
Liver transplant

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26
Q

What are the 3 key histological characteristics of Cirrhosis?

A
  1. Loss of normal hepatic architecture
  2. Nodular regeneration
  3. Bridging fibrosis
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27
Q

Causes Cirrhosis

A

COMMON :
Chronic alcohol abuse
Non-alcoholic fatty liver
Hep B +/- D
Hep C

Less common :
1° biliary cirrhosis
Autoimmune hepatitis - presents w ↑ALT
Hereditary haemochromatosis
Wilson’s
Alpha-1-antitrypsin deficiency
Drugs e.g. amiodarone, methotrexate

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28
Q

RF Cirrhosis

A

Chronic alcohol abuse
Obesity
T2DM
Hep B +/- C

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29
Q

Signs / Symptoms Cirrhosis

A

Compensated - asymptomatic obvs
General, non-specific e.g. malaise

Decompensated -
Jaundice!
Pruritus
Abdo pain - bc of ascites
Bruising
White discolouration on nail - Leukonychia
Clubbing
Xanthelasma
Palmar erythema
Dupuytren’s contractures
Ascites
Oedema

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30
Q

Why do oesophageal varices form?

A

PORTAL HYPERTENSION
Cirrhosis
Thrombosis
Schistosomiasis

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31
Q

Signs / Symptoms Varices

A

Only symptomatic if they rupture + bleed!

Haematemesis
Melaena
Rectal bleeding
Bloody stool
Pallor
Light-headedness
LoC if severe
Signs of chronic liver damage (+ splenomegaly, ascites)

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32
Q

Ix Varices

A

UPPER GI ENDOSCOPY

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33
Q

Tx Oesophageal varices

A

Urgent endoscopy!

Fluid resus - bleeding can be huge

Blood transfusion if very anaemic

BB - reduce CO ∴ ↓ Portal pressure
Nitrate - cause vasodilation ∴ ↓ Portal pressure
Terlipressin (ADH analogue) - ↓ Portal pressure

Correct clotting abnormalities - VitK and platelet transfusion

GS!! ENDOSCOPIC THERAPY - band ligation or scleropathy

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34
Q

Prophylaxis Oesophageal Varices

A

Trans-jugular intrahepatic portoclaval shunt (TIPS)
Propanolol

Don’t drink alcohol
Healthy diet + weight
Reduce risk of hepatitis - no sharing of needles or unprotected sex

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35
Q

Gallstones RF

A

5 Fs
Fat
Fair
Female
Fertile
Forty

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36
Q

Signs / Symptoms Gallstones

A

Asymptomatic!

Can be temporary - stone could dislodge from cystic duct!
Severe colicky RUQ pain
May radiate to epigastric or back
Triggered by meals (esp fatty meals)
Lasts 30 mins - 8 hours
N+V

Can present with comps

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37
Q

Why does eating fatty meals trigger RUQ pain with gallstones?

A

Bc when eating fatty foods, cholecystokinin (CCK) is secreted from duodenum

CCK triggers gallbladder contractions
∴ causes biliary colic (RUQ pain)

∴ Patient advised to avoid fatty foods!!

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38
Q

↑ Bilirubin presents as?

A

Jaundice

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39
Q

What does ↑Bilirubin indicate?

A

Bilirubin = waste product of haemoglobin breakdown!

∴ indicates : Blockage in bile excretion pathway (cholestatic jaundice)
Esp with Pale stools + dark urine

& XS bilirubin breakdown (pre-hepatic jaundice)

& Breakdown in bilirubin metabolism (hepatocellular jaundice)

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40
Q

What is ALP associated with?

A

Liver
Biliary system
Bones
Placenta (∴pregnant women may have ↑ALP)

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41
Q

What does ↑ALP indicate?

A

OBSTRUCTION of biliary system (esp with RUQ pain +/- Jaundice)

ALSO : 1° biliary cirrhosis, liver/bone malignancy, Paget’s

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42
Q

AST & ALT are enzymes produced in the ?
And therefore … ?

A

Liver
∴ markers of hepatocellular injury

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43
Q

What would you expect AST/ALT and ALP levels to be like in Gallstones?

A

(↑) AST/ALT
↑↑ALP

= OBSTRUCTIVE PICTURE

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44
Q

What would you expect AST/ALT and ALP levels to be like in a Hepatitic Picture?

A

↑↑ AST/ALT
(↑) ALP

= HEPATOCELLULAR INJURY
i.e. problem within liver

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45
Q

Ix Gallstones

A

LFTs - ↑ALP
(Bilirubin and ALT is usually normal)

FBC, CRP - look for inflammatory response (which suggests cholecystitis)

Amylase - Check for pancreatitis

GS - US!
Duct dilation, stones, gallbladder wall thickness
CT would not provide results so don’t say that at all in exams

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46
Q

Limitations of US to diagnose gallstones

A

If ↑weight/obese
Gas obstructs view
Discomfort of Px

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47
Q

Tx Gallstones

A

NSAIDs/Analgesia Cholecystectomy (usually laparascopic)

48
Q

What is acute cholecystis?

A

When gallstone blocks cystic duct or GB neck

49
Q

Pathophysiology Acute cholecystitis

A

When CCK signals (after fatty meal), gallbladder walls contract
Causes gallstones to get lodged in cystic duct
∴ BILE STASIS

Chemical irritant
∴ can stimulate mucosa in wall to stimulate inflammatory responses + mucus release
∴ inflammation

∴ Pressure builds up + distention of gallbladder causes symptoms

50
Q

Signs / Symptoms Acute cholecystitis

A

RUQ pain - may radiate to right arm
Muscle guarding, tenderness
Murphy’s sign
N+V
Fever, fatigue (inflammation)

51
Q

What is Murphy’s sign?

A

Tenderness that is worse upon inspiration

52
Q

Ix Acute Cholecystitis

A

Abdo US - stones, thick GB walls, fluid around GB, shrunken GB

FBC - ↑WBC (∴not biliary colic bc = inflammation)

LFTs - to exclude liver/bile duct pathology

53
Q

Tx Acute Cholecystitis

A

Laparoscopic Cholecystomy
Conservative before surgery - aggressive analgesia, IV fluids, IV abx

54
Q

Comps Acute Cholecystitis

A

Peritonitis
Bc bacteria can start to grow (e.g. E.Coli) & invade GB wall

55
Q

What is Ascending Cholangitis?

A

Inflammation of biliary tree

56
Q

Pathophysiology of Ascending Cholangitis

A

Normally bacteria cannot travel up common bile duct bc flow of bile + pancreatic juices
BUT if obstruction occurs = bile stasis
∴ becomes infected and inflamed

57
Q

Causes Ascending Cholangitis

A

> Infection of biliary tree -
Most commonly bc 2° to CBD obstruction (gallstones)

> Benign biliary structures -
Following biliary surgery, malignancy, chronic pancreatitis

> 1° sclerosing cholangitis

58
Q

Signs / Symptoms Ascending Cholangitis

A

Charcot’s triad / Reynold’s pentad
Rigors

59
Q

What is Charcot’s triad?

A
  1. Jaundice
  2. Fever
  3. RUQ pain
60
Q

What is Reynold’s pentad?

A
  1. Jaundice
  2. Fever
  3. RUQ pain
  4. Shock - hypotension, tachycardia
  5. Confusion
61
Q

Ix Ascending Cholangitis

A

US abdo +/- ERCP

> FBC - ↑WBC, ↑ESR/CRP, ↑bilirubin, ↑ALP
(Bilirubin v high if bile duct obstruction)

> Blood cultures - to see which bacteria

> MRCP - to locate stones

> LFTs

> CT

62
Q

What is ERCP?

A

Endoscopic Retrograde Cholangiopancreatography

(Biliary tree contrast XR)

63
Q

What is MRCP?

A

Basically more detailed US

64
Q

Tx Ascending Cholangitis

A

NBM
Treat sepsis - IV Abx, aggressive fluid resus

ERCP & stenting - clear blockage

Shockwave lithotripsy first! if fails, then laparoscopic cholecystectomy

65
Q

Causes Acute Pancreatitis

A

I GET SMASHED

Idiopathic

Gallstones
Ethanol (alcohol!)
Trauma

Steroids
Mumps/Malignancy
Autoimmune e.g. SLE
Scorpion stings
Hyperglycaemia/Hypertriglyridaemia
ERCP
Drugs/Meds

66
Q

Signs / Symptoms Acute Pancreatitis

A

Sudden, epigastric pain radiating to back
Relieved by sitting forwards

N+V
Cullen’s sign
Grey Turner’s sign
Tachycardia
Abdo guarding & tenderness
Distention
Anorexia
Hyperdynamic instability
Fever, chills

67
Q

Pathophysiology of Acute Pancreatitis
(Alcohol, Gallstones)

A

Alcohol - directly toxic to pancreatic cells ∴ causes inflammation !
Also - creates pancreatic juice to become thick + viscous which obstructs pancreatic duct
∴ ↑ Pressure
∴ ducts distend
INFLAMMATION
–
Gallstones - become lodged in sphincter of Oddi
∴ blocks release of pancreatic juices into duodenum
∴ causes INFLAMMATION

68
Q

Ix Acute pancreatitis

A

↑ Serum amylase
↑ Serum lipase - more sens than amylase
Urinalysis - ↑urine amylase
Routine bloods, ↑CRP

Abdo US/CT/MRI/XR
XR - no psoas shadow
CT - shows inflammation
–
If lipase:amylase >2 - suggest alcohol cause
If ↑ALT >150 - suggests gallstones

69
Q

Tx Acute pancreatitis

A

NG Tube
NBM - ↓pancreatic stimulation
Analgesics
Treat gallstones if present - ERCP/Cholecystectomy
Tx Comps

MONITOR CAREFULLY!

70
Q

Monitoring Acute Pancreatitis
Why?

A

Bc repeated acute pancreatitis can cause chronic pancreatitis??

Carefully & regularly
Hourly pulse, BP, urine output
Daily FBC, U&E, glucose amylase

71
Q

Comps Acute Pancreatitis
Early and Late

A

Early - Shock, Renal failure, Sepsis

Late - Pancreatic necrosis, Thrombosis in splenic arteries (causes bowel necrosis)

72
Q

What is the scoring system for Pancreatitis?

A

APACHE 2
&
GLASGOW scoring system
PaO2 < 8kPa
Age > 55
Neutrophils (WBC >15)
Calcium < 2
uRea > 16
Enzymes (LDH >600 or AST/ALT >200)
Albumin < 32
Sugar (glucose > 10)

0 or 1 - mild pancreatitis
2 - moderate pancreatitis
3 or more - severe pancreatitis

73
Q

Is chronic pancreatitis reversible or irreversible?

A

Usually irreversible

74
Q

Signs / Symptoms Chronic Pancreatitis

A

Similar to acute but less intense + longer lasting

Epigastric pain - through back, worsens after alcohol, better when leaving forward, might be related to eating

N+V
Steathorroea
Weight loss (malabsorption)
Insulin dependent DM

75
Q

Causes Chronic Pancreatitis

A

Repeated bouts of acute
Alcohol abuse
Cystic tumours - main cause in children
Tumours
Pancreatic trauma - knife wounds

76
Q

What is chronic pancreatitis?

A

Healthy pancreatic tissue replaced by misshapen ducts, calcium deposits and fibrosis

77
Q

Ix Acute Pancreatitis

A

Abdo CT/US/XR
ERCP, MRCP

Bloods - serum amylase/lipase
Might be raised if enough healthy cells to produce
OR might be low bc no healthy cells
Faecal elastase

78
Q

Tx Chronic Pancreatitis

A

Lifestyle management - STOP alcohol!
Also, healthy diet, more exercise

Pain control - analgesia

Replace pancreatic enzymes + PPI
Give nutritional supplements

ERCP/Surgery as required - pancreatectomy for unremitting for unremitting pain/weight loss

Insulin

79
Q

Comps Chronic Pancreatitis

A

DM
Biliary obstruction
Local arterial aneurysm
Gastric varices

80
Q

Symptoms of Acute Hepatitis

A

Can be asymptomatic
General malaise
Myalgia
Abdo pain
GI upset
Jaundice
Tender hepatomegaly
↑AST, ↑ALT, ↑Bilirubin

81
Q

Signs / Symptoms Chronic Hepatitis

A

Can be Asx / Non-specific symptoms
+ Chronic Liver Disease
LFTs can be normal

82
Q

Hepatitis A big stuff

A

ACUTE
RNA virus
MC acute viral hepatitis

83
Q

Transmission of Hep A

A

Faeco-Oral
Contaminated food or water e.g. shellfish
Overcrowding / Poor sanitation facilitate spread

84
Q

RF Hep A

A

Shellfish
Travellers
Food handlers

85
Q

Where is Hep A found?

A

Africa & S. America

86
Q

How long is the incubation period of Hep A?

A

Short incubation period (15-50 days)
Mean = 28 days

87
Q

Immunity after infection?
Hep A

A

100% Immunity after infection

88
Q

Presentation Hepatitis A

A

Usually symptomatic in adults

PRE-ICTERIC - constitutional Sx + abdo pain
ICTERIC (days to 1week later) - Jaundice! + hepatosplenomegaly

89
Q

Serology Hep A

A

First, anti-HAV IgM (non-spec)
Then, replaced by longer lasting HAV-IgM

90
Q

Ix Hep A

A

Antibody tests - HAV Abs

Liver biochemistry:
Prodromal - normal serum bilirubin, ↑serum AST/ALT
Icteric - ↑Bilirubin (reflects jaundice)

Bloods :
FBC - ↓WBC
↑ESR

91
Q

Tx Hep A

A

Supportive - anti-emetics, rest

92
Q

Monitoring Hep A

A

Monitor Liver function (INR, albumin, bilirubin)
Monitoring of close contacts

93
Q

1° Prevention Hep A

A

Hep A vaccine
6-12 months after first
e.g. travellers, MSMs, IDU

94
Q

Comps Hep A

A

Fulminant Hepatic failure
Acute liver failure

95
Q

Hepatitis E Big stuff

A

RNA virus
ACUTE
Can be chronic in immunosuppressed
MC in older men

96
Q

Where is Hepatitis E common?

A

Hep E > Hep A IN THE UK

97
Q

↑Mortality in?
Hep E

A

Pregnancy

98
Q

Transmission Hep E

A

Faeco-Oral route
Water or food borne
Undercooked pork!

99
Q

Presentation Hep E

A

> 95% cases asymptomatic
Usually self-limiting

100
Q

Which Hepatitis are faeco-oral transmitted?

A

A & E
fAEco-oral

101
Q

Mortality Hep E

A

Acute-on-chronic - ↑Mortality

102
Q

What increases risk of chronic infection with Hep E?

A

Immunosuppressed
- transplant recipients, HIV Px
- rapid progression to cirrhosis & fibrosis

103
Q

Ix Hep E

A

Serology - HEV Abs
Nucleic acid amplification test

104
Q

What types of Hepatitis virus are notifiable?

A

ALL TYPES OF VIRAL HEP

105
Q

What is Acute Liver Failure?

A

Coagulopathy (INR>1.5) and encephalopathy in an otherwise healthy liver

If only HE, then acute liver injury - not failure

106
Q

Types of Drug induced Liver injury

A

Hepatocellular
Cholestatic
Mixed

107
Q

Value for Hepatocellular DILI

A

ALT > 2 x normal
or
ALT/ALP > 5

108
Q

Value for Cholestatic DILI

A

ALP > 2x normal
or ratio < 2

109
Q

Value for Mixed DILI

A

Ratio > 2
but < 5

110
Q

DILI onset?

A

Usually between 1 - 12 weeks!
Not less than 1 week usually
Can be several weeks after stopping

111
Q

DILI - causes

A

ABX !! - fluclocacillin, TB drugs !
CNS drugs - chlorpromazepine, cabamazepin, valproate
Immunosuppresants
Analgesics/MSK - diclofenac
GI drugs - PPI

112
Q

What drugs are not rlly involved in DILI?

A

NSAIDs other than Diclofenac
BB
HRT
ACEi
Thiazides
CCBs

113
Q

Paracetamol drug name

A

Acetaminophen

114
Q

Paracetamol Overdose Pathophysiology

A

95% of paracetamol :
Undergoes glucuronidation -> Paracetamol conjugate forms -

115
Q

Tx Paracetamol Overdose

A

N Acetyl Cysteine (NAC)

Supportive - correst coag defects, electrolytes, renal failure, hypoglycaemia, encephalopathy

116
Q

What clinical indicators are there that an accidental paracetamol overdose is severe?

A

Late presentation! - NAC less effective after 24 hours

Acidosis
Prothrombin time > 70 seconds
Serum creatinine > 300 micromol/L

Consider liver transplant!!!!

117
Q
A

Phase 2 Quick (18 decks)

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