LIVER Flashcards
what does the liver do
protein synthesis- albumin, clotting factors
glucose and fat metabolism
detoification and excretion
defence against infection- reticuloendothelial system
timings for acute and chronic liver failure
<6 months is acute
>6 months is chronic
chronic liver damage leads to…
fibrosis. the severest form of this is cirrhosis
is jaundice more associated with acute or chronic liver injury
acute
what are some things tested in a serum liver function test, directly relating to liver damage, and what indicates liver damage
serum bilirubin,- increased
albumin, - increased
prothombin time- decreased
what is jaundice
raised serum bilirubin- conjugated or unconjugated causing yellowing of the skin
what is gallstone made of
cholesterol!!!, bile pigments, phospholipids
risk factors for gallstones
female, fertile, fat
presentation of gallstones
majority= asymptomatic
when symtoms- biliary/ gallstone colic- sudden severe epigastric pain, starting hours after a meal
n+v + sweating
what are some enzymes not specific to liver but an increase shows likely liver damage
ALT
AST
prehepatic causes of jaundice
prehepatic- unconjugated build up. due to increased red blood cell breakdown.
sickle cell anemia
thallasemia
maleria
gilberts syndrome
foetal hb
intrahepatic causes of jaundice
failure of hepatocytes to take up, metabolise or excrete biliruben
viral hepatitis
parenchymal disease
drugs/ alcohol
cirrhosis
post hepatic causes of jaundice
obstruction in biliary system - causes increase in conj
gallstone
pancreatic cancer
when do you see dark urine and pale stool
in intrhepatic/ post hepatic jaundice
pathology of jaunduce
haemoglobin breaks to haem and globin
haem- haem oxygenase- bilidervin
bilidervin reductionase- unconj bilirubin
conj in liver
what is acute liver failure
liver loses regeneration/ repair ability- irreversibly damaged
causes of acute liver failure
viral- hep a, b, ebv
drugs- paracetamol/ alcohol
metaolic- wilsons
presentation of acute liver failure
jaundice, coagulopathy, hepatic encephalopathy
nausea, anorexia
investigations for acute liver failure
bloods- LFT- high bilirubin, low albumin, high prothrombin time
imaging- ultrasound
treatmbt for acute liver faulure
manage it- itu, anaglesia, treat underlying cause
only real treatment is liver transplant
treat complicationsc
complications of liver failure and how to treat
- increased intracranial pressure- iv mannitol (treat swelling around brain)
- hepatic encephalopathy- lactolose
- ascites- diuretics
- haemorrhage- vit k
- sepsis- sepsis 6
what is chronic liver failure
progressive liver disease over 6+ months due to repeated liver insults
causes of chronic liver failure
alcohol
non alcoholic steatohepatitis
viral- hep B and C
autoimmune
risk factors for chronic liver disease
alcohol
obesity
t2dm
drugs
stages of chronic liver disease
hepatitis- fibrosis- cirrhosis (irreversible, end stage. can be compensated or decomensated with jaundice, coagulopathy)
presentation of chronic liver failure
ascites
portal htn
oesophageal varicies
caput medusae (swollen veins around belly button)
spider naveus
easy bruising
itching
investigation for chronic liver failure
gs- liver biopsy- needed to determine extent of cld (fibrosis vs cirrhosis)
LFT
imaging- ultrasound
treatment for chronic liver failure
lifestyle mod
decompensated- consider liver transplant
manage complication
what score asses the prpognosis of chronic liver failure
child pugh score
what is cirrhosis
chronic inflammation and damage to liver cells
functional cells replaced by scar tissue (fibrosis)
nodules of scar tissue form within the liver- causes portal hypertension
causes of liver cirrhosis
alcoholic related liver disease
non alcholic fatty liver disease
HEP B AND C
other causes is wilsons disease, alpha-antitrypsin deficiency
presentation fo cirrhosis
ascites
jaundice
hepatomegaly
splenomegaly
spider naevi
bruising
investigations for cirrhosis
DIAGNOSTIC- liver biopsy
lft- low albumin, high inr
ultrasound/ ct- hepatomegaly
treatment of cirrhosis
liver transplant
alcohol abstinence
treat complication
screen for hepatocellular carcinoma every 6 month
acute vs chronic hepatitis
acute- less than 6 months
chronic- >6months
hepatitis presentation
- fever
- malaise
- nausea + v
- hepatomegaky
- ruq pain/ abdominal pain
- jaundice- usually after a while, dark urine and pale stool
increases ast/alt
causes of hepatitis
infectious:
- hepaptitis abcde
- herpes- ebv, cmv
- influenza
- tuberculosis
non infectious:
- drugs
- alcohol
- non alcoholic fatty liver disease
- pregnancy
- autoimmune hepatitis
- metabolic causes- wilsons
chronic hepatitis presentation, what is compensatedd and decompensated and main complication
usually asymptomatic but may have signs of chronic liver disease like slubbing, spider naevi
compensated- liver function maintained
decopensated- coagulopathy (high inr), jaundice, low albumin, ascites
main comp is hepatocellular carcinoma, portal hyeprtension
hep a- what is it, a/c? hows it spread, rf
ssrna
Always acute
feacal oraly- through contaminated food and water, shellfish!
Its common in travellers! Especially to africa or india, incubation period of 2-4 weeks!, its the most common worldwide but rarer in the uk
Rf to it is travellers, homeless people, overcrowding, msm, ivdu , cld
hep a- vaccine? investigation? treatment? immunity
is a vaccine but not routinely offered- only to those travvelling, icdu msm
invest- mainly serology-HAVIGM/ IGG, ALSO LFT
self limiting- supportive care
recovery= 100% immunity
hep b-what is it, a/c? hows it spread, rf
dna virus
acute and chronic
spread through blood and bodily fluid- verticle transmission, hroizontal transmission, sex, ivdu, sharing needles
Rf is those with sex or ivdu, dialysis pt, healthcare worker
hep b- vaccine? investigation? treatment? complication, prevention
routine vaccine in uk!!
invest- serology (look at HbSag, anti HbAsg, anti C ab)
treatment is pehylated inteferon alpha 2
complication isHCC
prevention- screening blood products, antenatal screenig, vaccinate babies and healtcare workers
hep c- what is it, a/c?, spread?, investigaiton, treatment and prevention, immunity?
Ssrna
Acute and chronic
Spread through blood- sex, needles
Diagnosis made on SEROLOGY- HCV RNA= CURRENT!!
Can get a recurrent infection
Treatment- direct acting antiviral - oral ribavirin
Prevention_ screen bloods, barrier contraception, sterolse medical equiptment
hep d- about, diagnosis, treatment and complication
You can only get this if youve already gotten hep B
Ss rna though
You can either get a concurrent infection where you get infected at the same time or an infextion of hepatitis d after b which is a superinfection
Investigation is serology- anti HDV antigens, igm and igg
Treatment is also pegylated inferferon alpha 2
Together both hep increases the likelihood of cirrhosis
hep e- what, a/c, spread, vaccine, investigation, treatment
Ssrna
Spread faecal oraly- through undercooked pork!
Theres a vaccine for it but only in china
Investigation- through serology- HEV IGM/IGG. Also lft
Treatment is also supportive since its self limiting- anti emetics, rest but if leads to chronic liver failure in immunocompromised then can give reverse immunosypressiin
autoimmune hepatitis- who does it affect, types, diagnosis, treatment
rf is girls, autoimmune disease
Type 1 is adult women, after menopause
ana (antinuclear antibodiy)
ASMA- anti smooth muscle antibodies
.SLA/ LP- snti solulve liver antigen
Type 1 is young women- ANTI LKM1- liver kidney microsomes 1, and anti LCA1, anti liver cystosol antigen 1
diagnosis based on serology
treatment- steroids- prednisolone, immunosupressants, end stage is liver transplant
what things are measured in a lft
albumin
bilirubin
prothrombin time
rf for alcoholic liver disease
chronic alcohol, obesity, smoking
whats the most common type of liver disease
alcholic liver diesease
px of alcoholic liver disease
later on - chronic liver failure symptoms
alcohol dependancy
ruq pai
nv
dhiorhea
investigations for chronic liver failure
lft- high biliruben, low albumin, high prothrombin time
fbc- thrombocytopenia, macrocytic non megaloblastic anemia
liver biopsy- confirms extent of cirrhosis and will show mallory cytoplasmic inclusion bodies
treatment for alcoholic liver disease
stop alcohol and give diazepine to help with tremours
healthy diet and low bmi
consider short term steroids to reduce inflammation
liver transplant
complications of alcoholic liver disease
pancreatitis
ascites
hepatic encephalopathy
how to calculate alcohol unit + recommended amount
strength (abv) x vol (ml)/ 1000
- 14 units a week reccoemded max
what is non alcoholic fatty liver disease, presentation, investigation and treatment
excess fat (mainly triglycerides) in liver cells and is chronic
asymtpmatic with general ruq pain, fatigue, jaundice, malaise
ix- first line is ultrasound abdomen, also fbc showing thrombocytopenia and lft derranged
treatment- lose weight, contral rf and take vitamin E!
whats invcluded in biliary tract disease
gallstones/ biliary colic
cholesytitis
ascending cholangitis
what is biliary colic and patho
gallstones get lodged in cystic duct or bile duct causing severe abdominal pain
gallstones are made of mainly cholesterol, and bile. if there’s a gallstone in the gallbladder and the gallbladder contracts it can get lodged in the cystic duct. contraction against the gallstone causes the dull pain.
usually occurs after eating a fatty meal as the fatty acids in the duodenum trigger enteroendocrine cells to secrete cholecystokinin, which causes gallbladder contraction and sphincter of oddi relaxation
rf of biliary colic
4Fs- fat, female, fertile (preggo/ had multiple kids), fourty (older) also fair
px of biliary colid
sudden dull pain in the right upper quadrant or epigastrium, can be refered to right shoulder
pain usually a few hours after eating a fatty meal or at night
also nausea, vomiting, dhiarhea
dx of biliary colic
confimed by abdominal ultrasound!- look for duct dilation, stones, gallbladder wall thickness
crp to rule out cholecystitis and cholangitis
amalysase- to check for pancreatitis
tx of biliary colic
elective laparoscopic cholecystectomy
until then NSAIDS/ analgesia
cholecystitis- what is it and patho
acute inflammation of gallbladder- 95% complication of gallstone
stone is blocking the cystic ducts (either in gallbaldder neck or in cystic duct) so the bile builds up and cant be drained. transmiral inflammation follows
px of cholecystitis
symp:
- RUQ pain, may radiate to right shoulder
- fatigue
signs:
- fever
- ruq tenderness and guarding
- positive murphy’s sign (hand pressed on ruq, severe pain on inhalation)
(basically simmilar to gallstones, just fever and murphys too)
dx of cholecystitis
diagnostic is abdominal ultrasound - stones, thich gallbladder walls,!!, fluid around gallbladder
fbc- leukosytosis and neutrophilia
tx of cholecystitis
management beore surgery- antibiotics, heay analgesia, iv fluids, ng tube if vomiting
LAPROSCOPIC CHOLECYSTECTOMY
what is ascending cholangitis and patho of it
acute inflammation and infection of bile duct due to bile obstruction- mainyl due to gallstones, otherwise from things tht narrow bile duct liek cancer or surgical injury
normally bile flows down bladder and flushes out bacteria, but bc the bile is blocked, intestinal bacteria go up the duodenum to bile duct (hence ascending). bacteria like e. coli
bacteria can go around the gallstoen or through the blockage and get into bile. the bile is under such high pressure so can cause cells lining ducts to widen - so bacteria and the bile can leak into blood stream causing jauncice, hypotension and septic shock
px of ascending cholangitis
charcots triad- RUQ pain, fever, jaundice
reynolds pentad- charcots triad and septic shock, confusion
investigations for ascending cholangitis
Ultrasound +/- endoscopic retrograde cholangiopancreatography ( baso a biliary tree constrast x ray)
blood cultures- work out what pathogen is for abx
FBC, LFT, CRP- leukocytosis, raised alp and bilirubin, raised crp
what is primary biliary cholangitis
autoimmune disease- t cells attack cells lining small bile duct in the liver / intrahepatic autoimmune disease- affects intralobular bile ducts
risk factors for cholangitis
other autoimmune diseases
female
40-50
smoking
patho of primary biliary cholangitis
autoantibodies cause intralobular bile duct damage.
chronic autoimmune granulomatious inflammation
damaged cells let bile through into blood and liver cells, causing cholestasis, causing inflammation and eventually cirrhosis, portal htn
px of primary biliary cholangitis
initially asymptomatic, routine test shows INCREASEDD ANTI-MITOCHRONDRIAL ANTIBODIES
pruritis (itchy skin) and fatigue, then jaundice, hepatomegally
yellow growth near eyelids
complication of primary bilary cholangitis
cirrhosis
malabsorption of fats and adek
osteomalacia
coagulopathy
ix for primary biliary cholangitis
lft- raised alp, raised conj biliruben, low albumin
serology- AMA!!!!!!!!! (anti mitochondrial antibodies)
uss- 1st line imaging
treatment for primary biliary cholangitis
1st line!- ursodexoycholic acid (bile acid analogie- dampens immune response and decreases cholestasis)
for pruritis- cholestyramine
also vit adek supplements
may ultimately need liver transplant
what does high alp signify
signifies a cholestatic problem
what is primary sclerosing cholangitis
autoimmune destruction of intrahepatic and extrahepatic ducts- they become fibrotic
stiffening (narrowing and hardening of bile ducts and inflammation of bile ducts)
causes obstruction of bile flow- causes a backpressure of bile in the liver- causing inflammation (hepatitis), then fibrosis, eventually cirrhosis
risk factor for primary sclerosing cholangitis
male
40-50
stronggg link to irritabel bowel disease (ULCERATIVE COLLITIS!)
presentation of primary sclerosing cholangitis
initially asymptomatic, pruritis, fatigue, jaundice, charcots triad (if cbd involved) hepatosplenomegaly, ibd, chronic right upper quadrant pain
investigation and gold standard for primary sclerosing cholangitis
lft- high ALP, high bilirubin, pANCA, ana
GOLD STANDARD- MRCP- magnetic resonancy cholagiopancreatography to see bile duct lesions
treatment for primary cholangitis
manage- liver transplant, ercp to dilate and stent any strictures (endoscopic retrograde cholangiopancreatography)
ursodeoxycholic acid
cholestyramine
complications primary scerosing cholangitis
acute bacterial choangitis
colorectal cancer
cirrhosis
