liver

Question 1

What are the common features of tricyclic overdose?

Answer 1

features are related to anticholinergic properties
dry mouth, dilated pupils, agitation, sinus tachycardia, blurred vision

Question 2

What are some features of severe tricyclic poisoning?

Answer 2

arrhythmias
seizures
metabolic acidosis
coma

Question 3

What ECG changes are associated with tricyclic overdose?

Answer 3

sinus tachycardia
widening of QRS
prolongation of QT interval

Question 4

How is tricyclic overdose managed?

Answer 4

IV bicarbonate

Question 5

What are the features of autoimmune hepatitis?

Answer 5

signs of chronic liver disease
signs of acute hepatitis: fever, jaundice
amenorrhoea

Question 6

What antibodies are raised in autoimmune hepatitis?

Answer 6

ANA (anti nuclear) / SMA (anti smooth muscle) - type 1
LKM1 (anti liver-kidney microsomal type 1) - type 2

Question 7

What are the characteristic findings in autoimmune hepatitis on liver biopsy?

Answer 7

inflammation extending beyond limiting plate
piecemeal necrosis

Question 8

How is autoimmune hepatitis managed?

Answer 8

steroids, immunosuppressants
liver transplant

Question 9

What is the ratio of AST/ALT in alcoholic hepatitis?

Answer 9

2:1

Question 10

What are some common causes of liver cirrhosis?

Answer 10

alcohol
NAFLD
viral hepatitis (B and C)

Question 11

How is liver cirrhosis diagnosed?

Answer 11

transient elastography - Fibroscan
acoustic radiation force impulse
liver biopsy - risky, many side effects

Question 12

What condition is associated with Courvoisier sign (palpable, non tender, enlarged gallbladder + jaundice)?

Answer 12

cholangiocarcinoma

Question 13

How does Hep E spread?

Answer 13

faecal-oral
often undercooked meat

Question 14

What is the incubation period of Hep E?

Answer 14

3-8 weeks

Question 15

Does Hep E cause chronic disease / increase the risk of HCC?

Answer 15

no

Question 16

Which type of Hepatitis is screened for in pregnancy?

Answer 16

Hep B

Question 17

What is the acute management of oesophageal varices?

Answer 17

1. A-E
2. clotting + transfusion
   - FFP
   - vitamin K
   - platelet transfusion
3. vasoactive agents - terlipressin
4. prophylactic IV ATB - e.g. ceftriaxone
5. endoscopy - band ligation

Question 18

What is prophylaxis for oesophageal varices?

Answer 18

propranolol
EVL - endoscopic variceal band ligation
TIPSS - transjugular intrahepatic portosystemic shunt

Question 19

When should N-Acetylcysteine be used in paracetamol overdose?

Answer 19

• plasma paracetamol concentration is on or above a single treatment line joining points of 100 mg/L at 4 hours and 15 mg/L at 15 hours
• staggered overdose
• patients who present 8-24 hours after ingestion of an acute overdose of more than 150 mg/kg
• patients who present > 24 hours if they are clearly jaundiced or have hepatic tenderness, their ALT is above the upper limit of normal

Question 20

What is a common side effect of N-acetylcysteine?

Answer 20

anaphylactoid reaction - IgE mediated mast cell release

Question 21

How are anaphyloid reactions to N-acetylcysteine managed?

Answer 21

stopping infusion, giving nebulised salbutamol, and restarting IV N-acetylcysteine at a slower rate

Question 22

What are the criteria for liver transplant in paracetamol overdose?

Answer 22

arterial pH < 7.3 24 hrs post ingestion
or ALL of:
- prothrombin time > 100s
- creatinine > 300
- grade 3 or 4 encephalopathy

Question 23

What patients are at an increased risk of developing hepatotoxicity after a paracetamol overdose?

Answer 23

• if taking liver enzyme-inducing drugs (St John’s wort, rifampicin, phenytoin, carbamazepine, chronic alcohol)
• malnourished, fasting

Question 24

What factor can be protective in developing hepatotoxicity after a paracetamol overdose?

Answer 24

acute alcohol intake