Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

Phase 2 Quick > Liver > Flashcards

Liver Flashcards

1
Q

What is Jaundice?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

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

in Pre-hepatic Jaundice

A

↑Unconjugated bilirubin
Normal stool and urine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

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

in Post-hepatic Jaundice

A

↑Conjugated bilirubin
Dark urine
Pale stools

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Causes of Pre-hepatic jaundice

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Causes of Hepatic Jaundice

A

Viral hepatitis, drugs, alcohol, cirrhosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Causes of Post-hepatic jaundice

A

Gallstones
Pancreatitis - head of pancreas blocks CBD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

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

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

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

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What is fulminant hepatic failure?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What is compensated liver failure?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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!

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Describe the progression of Acute and Chronic Liver Failure

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What is leukonychia?

A

White discolouration on nails (due to hypoalbuminaemia)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What is Xanthelasma?

A

Yellow fat deposits under skin
Around eyelids usually

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Signs / Symptoms Portal HTN
Usually asymptomatic! High SAAG? Ascites Splenomegaly Formation of collateral vessels ∴ variceal bleeding! Hepatic encephalopathy - bc toxins in general circulation
25
Tx Portal HTN
General : Alcohol abstinence, good nutrition To manage ascites : Fluid restriction, low-salt diet Manage variceal bleeding Surgery - reroute blood flow (Portosystemic shunting) Liver transplant
26
What are the 3 key histological characteristics of Cirrhosis?
1. Loss of normal hepatic architecture 2. Nodular regeneration 3. Bridging fibrosis
27
Causes Cirrhosis
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
28
RF Cirrhosis
Chronic alcohol abuse Obesity T2DM Hep B +/- C
29
Signs / Symptoms Cirrhosis
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
30
Why do oesophageal varices form?
PORTAL HYPERTENSION Cirrhosis Thrombosis Schistosomiasis
31
Signs / Symptoms Varices
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)
32
Ix Varices
UPPER GI ENDOSCOPY
33
Tx Oesophageal varices
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**
34
Prophylaxis Oesophageal Varices
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
35
Gallstones RF
**5 Fs** **F**at **F**air **F**emale **F**ertile **F**orty
36
Signs / Symptoms Gallstones
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
37
Why does eating fatty meals trigger RUQ pain with gallstones?
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!!
38
↑ Bilirubin presents as?
Jaundice
39
What does ↑Bilirubin indicate?
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)
40
What is ALP associated with?
Liver Biliary system Bones Placenta (∴pregnant women may have ↑ALP)
41
What does ↑ALP indicate?
OBSTRUCTION of biliary system (esp with RUQ pain +/- Jaundice) ALSO : 1° biliary cirrhosis, liver/bone malignancy, Paget's
42
AST & ALT are enzymes produced in the ? And therefore ... ?
Liver ∴ markers of hepatocellular injury
43
What would you expect AST/ALT and ALP levels to be like in Gallstones?
(↑) AST/ALT **↑↑**ALP = OBSTRUCTIVE PICTURE
44
What would you expect AST/ALT and ALP levels to be like in a Hepatitic Picture?
**↑↑** AST/ALT (↑) ALP = HEPATOCELLULAR INJURY i.e. problem within liver
45
Ix Gallstones
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
46
Limitations of US to diagnose gallstones
If ↑weight/obese Gas obstructs view Discomfort of Px
47
Tx Gallstones
NSAIDs/Analgesia Cholecystectomy (usually laparascopic)
48
What is acute cholecystis?
When gallstone blocks cystic duct or GB neck
49
Pathophysiology Acute cholecystitis
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
Signs / Symptoms Acute cholecystitis
RUQ pain - may radiate to right arm Muscle guarding, tenderness Murphy's sign N+V Fever, fatigue (inflammation)
51
What is Murphy's sign?
Tenderness that is worse upon inspiration
52
Ix Acute Cholecystitis
**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
Tx Acute Cholecystitis
Laparoscopic Cholecystomy Conservative before surgery - aggressive analgesia, IV fluids, IV abx
54
Comps Acute Cholecystitis
Peritonitis Bc bacteria can start to grow (e.g. E.Coli) & invade GB wall
55
What is Ascending Cholangitis?
Inflammation of biliary tree
56
Pathophysiology of Ascending Cholangitis
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
Causes Ascending Cholangitis
> 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
Signs / Symptoms Ascending Cholangitis
Charcot's triad / Reynold's pentad Rigors
59
What is Charcot's triad?
1. Jaundice 2. Fever 3. RUQ pain
60
What is Reynold's pentad?
1. Jaundice 2. Fever 3. RUQ pain 4. Shock - hypotension, tachycardia 5. Confusion
61
Ix Ascending Cholangitis
**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
What is ERCP?
Endoscopic Retrograde Cholangiopancreatography (Biliary tree contrast XR)
63
What is MRCP?
Basically more detailed US
64
Tx Ascending Cholangitis
NBM Treat sepsis - IV Abx, aggressive fluid resus ERCP & stenting - clear blockage Shockwave lithotripsy first! if fails, then laparoscopic cholecystectomy
65
Causes Acute Pancreatitis
**I GET SMASHED** **I**diopathic **Gallstones** **Ethanol (alcohol!)** **T**rauma **S**teroids **M**umps/Malignancy **A**utoimmune e.g. SLE **S**corpion stings **H**yperglycaemia/**H**ypertriglyridaemia **E**RCP **D**rugs/Meds
66
Signs / Symptoms Acute Pancreatitis
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
Pathophysiology of Acute Pancreatitis (Alcohol, Gallstones)
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
Ix Acute pancreatitis
↑ 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
Tx Acute pancreatitis
NG Tube NBM - ↓pancreatic stimulation Analgesics Treat gallstones if present - ERCP/Cholecystectomy Tx Comps MONITOR CAREFULLY!
70
Monitoring Acute Pancreatitis Why?
Bc repeated acute pancreatitis can cause chronic pancreatitis?? Carefully & regularly Hourly pulse, BP, urine output Daily FBC, U&E, glucose amylase
71
Comps Acute Pancreatitis Early and Late
Early - Shock, Renal failure, Sepsis Late - Pancreatic necrosis, Thrombosis in splenic arteries (causes bowel necrosis)
72
What is the scoring system for Pancreatitis?
APACHE 2 & **GLASGOW scoring system** **P**aO2 < 8kPa **A**ge > 55 **N**eutrophils (WBC >15) **C**alcium < 2 u**R**ea > 16 **E**nzymes (LDH >600 or AST/ALT >200) **A**lbumin < 32 **S**ugar (glucose > 10) 0 or 1 - mild pancreatitis 2 - moderate pancreatitis 3 or more - severe pancreatitis
73
Is chronic pancreatitis reversible or irreversible?
Usually irreversible
74
Signs / Symptoms Chronic Pancreatitis
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
Causes Chronic Pancreatitis
Repeated bouts of acute Alcohol abuse Cystic tumours - main cause in children Tumours Pancreatic trauma - knife wounds
76
What is chronic pancreatitis?
Healthy pancreatic tissue replaced by misshapen ducts, calcium deposits and fibrosis
77
Ix Acute Pancreatitis
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
Tx Chronic Pancreatitis
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
Comps Chronic Pancreatitis
DM Biliary obstruction Local arterial aneurysm Gastric varices
80
Symptoms of Acute Hepatitis
Can be asymptomatic General malaise Myalgia Abdo pain GI upset Jaundice Tender hepatomegaly ↑AST, ↑ALT, ↑Bilirubin
81
Signs / Symptoms Chronic Hepatitis
Can be Asx / Non-specific symptoms + Chronic Liver Disease LFTs can be normal
82
Hepatitis A big stuff
ACUTE RNA virus MC acute viral hepatitis
83
Transmission of Hep A
Faeco-Oral Contaminated food or water e.g. shellfish Overcrowding / Poor sanitation facilitate spread
84
RF Hep A
Shellfish Travellers Food handlers
85
Where is Hep A found?
Africa & S. America
86
How long is the incubation period of Hep A?
Short incubation period (15-50 days) Mean = 28 days
87
Immunity after infection? Hep A
100% Immunity after infection
88
Presentation Hepatitis A
Usually symptomatic in adults PRE-ICTERIC - constitutional Sx + abdo pain ICTERIC (days to 1week later) - Jaundice! + hepatosplenomegaly
89
Serology Hep A
First, anti-HAV IgM (non-spec) Then, replaced by longer lasting HAV-IgM
90
Ix Hep A
Antibody tests - HAV Abs Liver biochemistry: Prodromal - normal serum bilirubin, ↑serum AST/ALT Icteric - ↑Bilirubin (reflects jaundice) Bloods : FBC - ↓WBC ↑ESR
91
Tx Hep A
Supportive - anti-emetics, rest
92
Monitoring Hep A
Monitor Liver function (INR, albumin, bilirubin) Monitoring of close contacts
93
1° Prevention Hep A
Hep A vaccine 6-12 months after first e.g. travellers, MSMs, IDU
94
Comps Hep A
Fulminant Hepatic failure Acute liver failure
95
Hepatitis E Big stuff
RNA virus ACUTE Can be chronic in immunosuppressed MC in older men
96
Where is Hepatitis E common?
Hep E > Hep A IN THE UK
97
↑Mortality in? Hep E
Pregnancy
98
Transmission Hep E
Faeco-Oral route Water or food borne Undercooked pork!
99
Presentation Hep E
> 95% cases asymptomatic Usually self-limiting
100
Which Hepatitis are faeco-oral transmitted?
A & E f**AE**co-oral
101
Mortality Hep E
Acute-on-chronic - ↑Mortality
102
What increases risk of chronic infection with Hep E?
Immunosuppressed - transplant recipients, HIV Px - rapid progression to cirrhosis & fibrosis
103
Ix Hep E
Serology - HEV Abs Nucleic acid amplification test
104
What types of Hepatitis virus are notifiable?
ALL TYPES OF VIRAL HEP
105
What is Acute Liver Failure?
Coagulopathy (INR>1.5) and encephalopathy in an otherwise healthy liver If only HE, then acute liver injury - not failure
106
Types of Drug induced Liver injury
Hepatocellular Cholestatic Mixed
107
Value for Hepatocellular DILI
ALT > 2 x normal or ALT/ALP > 5
108
Value for Cholestatic DILI
ALP > 2x normal or ratio < 2
109
Value for Mixed DILI
Ratio > 2 but < 5
110
DILI onset?
Usually between 1 - 12 weeks! Not less than 1 week usually Can be several weeks after stopping
111
DILI - causes
ABX !! - fluclocacillin, TB drugs ! CNS drugs - chlorpromazepine, cabamazepin, valproate Immunosuppresants Analgesics/MSK - diclofenac GI drugs - PPI
112
What drugs are not rlly involved in DILI?
NSAIDs other than Diclofenac BB HRT ACEi Thiazides CCBs
113
Paracetamol drug name
Acetaminophen
114
Paracetamol Overdose Pathophysiology
95% of paracetamol : Undergoes glucuronidation -> Paracetamol conjugate forms -
115
Tx Paracetamol Overdose
**N Acetyl Cysteine** (NAC) Supportive - correst coag defects, electrolytes, renal failure, hypoglycaemia, encephalopathy
116
What clinical indicators are there that an accidental paracetamol overdose is severe?
Late presentation! - NAC less effective after 24 hours Acidosis Prothrombin time > 70 seconds Serum creatinine > 300 micromol/L Consider liver transplant!!!!
117

Phase 2 Quick (18 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions