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Gastro-intestinal System > Liver > Flashcards

Liver Flashcards

0
Q

What are some causes of liver failure?

A 
Viral hepatitis 
Alcohol 
Drugs e.g. paracetamol, halothane 
Industrial solvents 
Mushroom poisoning
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1
Q

Define and give examples of a portal system.

A

Vein(s) that terminate at both ends in a capillary bed (no valves) - two capillary systems in series

Hepatic portal system
Hypothalamo-hypophyseal portal system

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2
Q

What are some complications of liver failure?

A

Increased susceptibility to infections (bacterial & fungal)

Increased susceptibility to toxins, drugs, hormones

Hyperammonaemia —> hepatic encephalopathy (ammonia not cleared by urea cycle and produced by colonic bacteria)

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3
Q

How can cirrhosis affect the portal system?

A

Shrinkage of liver compresses capillaries and leads to increased pressure in the hepatic portal system -> portal hypertension

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4
Q

What are portosystemic anastomoses? List them.

A

Communication between two blood vessels without any intervening capillary network

                                    PORTAL                     SYSTEMIC OESOPHAGEAL:       left gastric vein              azygos veins

RECTAL: superior rectal vein middle/inferior rectal veins

PARAUMBILICAL: ligamentum teres superior/inferior epigastric veins

RETRO-
PERITONEAL: colonic veins body wall veins

INTRAHEPATIC: hepatic/portal veins inferior phrenic veins

PATENT DUCTUS left branch of portal vein IVC
VENOSUS:

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5
Q

What are some of the complications of portal hypertension?

A

Portosystemic shunting: connections between portal system opens up

Oesophageal varices = enlarged veins in lower oesophagus —> rupture —> massive bleeding (black & tarry or bloody stools, anaemia, haematemesis)

Caput medusae = distended umbilical veins (ligamentum teres reopens) which radiate from the abdomen to join the systemic veins

Rectal varices = enlarged collateral submucosal rectal veins

Ascites (reduced albumin & increased portal pressure)

Spider Naevi (oestrogen dependent - dilated arteriole forming a red papule with radiating prominent capillaries resembles a spider)

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6
Q

What is the difference between rectal varices and haemorrhoids? What is the purpose of the veins in the anorectal junction?

A

Rectal varices only occur in patients with portal hypertension

Haemorrhoids occur equally in patients with and without portal hypertension - prolapse of rectal venous plexus

Increased pressure in veins prevent flatus from escaping (just as veins at the GOJ help close it off)

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7
Q

How can caput medusae be differentiated from IVC obstruction?

A

Harvey’s test

Block off umbilical vein below the umbilicus

Blood flows towards legs - caput medusae

Blood flows towards head via abdominal collaterals - IVC obstruction

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8
Q

What are some of the functions of the liver?

A

Bile production
Metabolism (inc. cholesterol synthesis, gluco/glycogenesis/lysis, lipogenesis)
Protein & vit. D synthesis (inc. albumin, fibrin, prothrombin)
Detoxification
Vitamin & mineral storage
Phagocytosis

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9
Q

Outline the different liver function tests and what each is testing for?

A

Hepatocellular damage —> aminotransferases (ALT/AST) & gamma-glutamyl transpeptidases (gamma-GT)

Cholestasis —> bilirubin & alkaline phosphatase

Synthetic function —> albumin & prothromin time (INR - clotting)

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10
Q

What are the causes of pre-hepatic jaundice?

A

Excessive haemolysis —> excess bilirubin

INHERITED:

  • red cell membrane defects
  • Hb abnormalities
  • metabolic defects

ACQUIRED:

  • immune
  • mechanical
  • acquired membrane defects
  • infections
  • drugs
  • burns

CONGENITAL HYPERBILIRUBINAEMIAS:
- Gilbert’s syndrome (reduced glucuronyl transferase —> reduced conjugated bilirubin) - stress causes jaundice (non-haemolytic jaundice)

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11
Q

What are some typical laboratory findings in pre-hepatic jaundice?

A

Unconjugated hyperbilirubinaemia

Reticulocytosis (excess reticulocytes - immature RBCs)

Anaemia (haemolytic)

Increase LDH (lactate dehydrogenase found in RBCs)

Decreased haptoglobin (binds free Hb)

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12
Q

What are some of the causes of hepatocellular jaundice?

A

Deranged hepatocyte function + some cholestasis (swelling prevents substances leaving the gallbladder)

CONGENITAL:

  • Gilbert’s syndrome
  • …..???

HEPATIC INFLAMMATION:

  • viruses e.g. hepatitis, Epstein-Barr
  • autoimmune hepatitis
  • alcohol
  • haemochromotosis
  • Wilson’s disease (enzyme impairment causing copper accumulation: cirrhosis, tremors, dementia, dysarthria, tubular degeneration, Kayser-Fleischer rings around iris)

DRUGS:

  • paracetamol
  • ….????

CIRRHOSIS:

  • alcohol
  • chronic hepatitis
  • metabolic disorders

HEPATIC TUMOURS:

  • hepatoceullar carcinoma
  • metastases
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13
Q

What are some typical laboratory findings in hepatocellular jaundice?

A

Mixed conjugated and unconjugated hyperbilirubinaemia

Increased ALT/AST (hepatocyte breakdown)

Normal or increased ALP (cholestasis)

Reduced clotting factors

Reduced albumin

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14
Q

What are some of the causes of post-hepatic/cholestatic jaundice?

A

Obstruction of biliary system (intra or extrahepatic cause) which blocks the passage of conjugated bilirubin into the bile canaliculi

INTRAHEPATIC (hepatocyte swelling):

  • hepatitis
  • drugs
  • cirrhosis
  • primary biliary cirrhosis

EXTRAHEPATIC (obstruction distal to bile canaliculi):

  • gallstones
  • biliary stricture
  • carcinoma (head of pancreas, bile duct, porta hepatis lymph nodes, liver metastases)
  • pancreatitis
  • sclerosing cholangitis
  • ascending cholangitis

-> pale stools/dark urine (lack of sterobilinogen/urobilinogen)

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15
Q

What are some of the causes of hepatitis?

A

VIRAL: hep. A, B, C (+ D, Epstein-Barr, CMV, Yellow fever)

AUTOIMMUNE

DRUGS: methyldopa, isoniazid

HEREDITARY: alpha-1-antitrypsin disease, Wilson’s disease

16
Q

Give some examples of the complications of alcoholic liver disease.

A

Hepatocellular carcinoma

Liver failure

Wernicke-Korsakoff syndrome (B1 deficiency - thiamine - which causes lesions in the CNS)

Encephalopathy

Dementia

Epilepsy

17
Q

How does liver cirrhosis occur and damage the liver?

A

Liver cell necrosis —> nodular regeneration & fibrosis —> increased resistance in blood vessels —> deranged liver function

Causes:

  • alcohol
  • hepatitis B/C
  • biliary cirrhosis (primary - autoimmune destruction of bile ducts -> jaundice, pruritis, xanthelasma, hepatosplenomegaly)
  • autoimmune hepatitis
  • haemochromotosis (iron deposition -> cardiomyopathy, diabetes, hypogonadism, hepatitis, hyperpigmentation)
  • Wilson’s disease
18
Q

What are some of the signs & symptoms of liver cirrhosis?

A 
Jaundice 
Anaemia 
Bruising 
Palmar erythema 
Dupuytren's contracture 
Portal hypertension 
Spontaneous bacterial peritonitis 
Flapping
19
Q

What are the typical laboratory findings in liver cirrhosis?

A

Normal or elevated ALT/AST

Increased ALP

Increased bilirubin

Reduced albumin

Deranged clotting

Reduced Na+

20
Q

What is fulminant hepatic failure? What can it be caused by? What are the signs and symptoms?

A

Acute/severe decompensation of hepatic function due to increased metabolic demand, which leads to hepatic encephalopathy within 2 months of liver disease diagnosis

Causes:

  • hepatitis A, D, E
  • paracetamol, isoniazid, ecstasy
  • Wilson’s disease
  • pregnancy
  • Reye’s syndrome (unknown aetiology, variable symptoms e.g. brain, liver, hypoglycaemia)
  • alcohol

Signs & symptoms:

  • jaundice
  • encephalopathy (oedema/toxins)
  • reduced level of consciousness
  • hypoglycaemia (loss of glycogen stores)
  • reduced K+ & Ca2+
  • haemorrhage (coagulopathy)
  • renal failure
21
Q

What is hepatic encephalopathy? What can it be caused by? What are the signs and symptoms associated with it?

A

Reversible neuropsychiatric deficit due to inability of liver to remove ammonia (which shunts to the systemic and crosses the blood-brain barrier)

Precipitated by:

  • sepsis/infection
  • constipation
  • diuretics
  • GI bleeding
  • alcohol withdrawal
  • oedema

Signs & symptoms:

  • flapping tremors
  • reduced level of consciousness
  • personality changes
  • intellectual deterioration

Reduce confusion by treating cause, 10% dextrose + ionic supplements if required, lactulose to cause diarrhoea

22
Q

Where are the common sites of hepatic tumour metastases?

A

Along portal venous drainage

  • neuroendocrine
  • pancreas
  • breast
  • stomach
  • kidney
  • lung
  • ovary
23
Q

What is the difference between the anatomical and functional lobes of the liver?

A

Anatomical: left and right lobes; separated by the falciform ligament

Functional: quadrate lobe (anterior surface) and caudate lobe (posterior surface); defined by ductal and vascular anatomy (right limb of gallbladder, sulcus of vena cava)

24
Q

What structures help suspend the liver in the abdomen?

A

Falciform ligament attaches to anterior abdominal wall

Visceral peritoneum (except for bare area)

Peritoneal folds:

  • Anterior & posterior coronary ligaments (which become the right and left triangular ligaments) attaches to the diaphragm
  • Hepatogastric ligament (attaches to stomach)
  • Hepatoduodenal ligament (attaches to duodenum)

Hepatic veins (portal triad)

25
Q

What is the arterial supply to the liver? What other structures derive arterial blood from this artery?

A

Coeliac trunk —> Common hepatic artery —> Hepatic artery proper —> right & left hepatic arteries

Gallbladder: cystic artery (from hepatic artery proper)

Gastroduodenal artery (from common hepatic artery)

  • > right gastro-omental artery
  • > superior pancreaticduodenal artery

Right gastric artery (from common hepatic artery)

26
Q

What is the difference between a hepatic lobule and a hepatic acinus?

A

Hepatic lobule = hexagonal/triangular area responsible for bile secretions

Hepatic acinus = diamond-shaped area responsible for blood flow and metabolism
- newer model of liver structure; veins feed into each other before entering portal vein, bile ducts as far away as possible from the portal vein

27
Q

What are Kupffer cells?

A

Specialised macrophages present in liver sinusoids

  • recycle Hb by breaking down RBCs
  • phagocytose bacteria
  • stimulate collagen production (impaired in cirrhosis)
28
Q

Which enzyme measured in liver function tests is specific to inflammation of the liver?

A

ALT - found predominantly in the liver

AST - also found in heart, skeletal muscle, RBCs

29
Q

How can the ALT:AST ratio indicate the cause of raised ALT & AST?

A

ALT:AST < 1 = non-alcoholic liver disease e.g. hepatitis A, B, C

ALT:AST > 2 = alcoholic liver disease e.g. alcoholic hepatitis

Gastro-intestinal System (16 decks)

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