Liver Flashcards
Stages of chronic liver disease?
Fibrous expansion, bridging, cirrhosis - cancer development
Consequences of decompensation in chronic liver disease
Bleeding
Jaundice
Ascites
Encephalopathy
What is Cholestasis?
When bile does not enter the duodenum.
Signs/Features of Cholestasis?
Pale fatty stools, Dark Urine, Jaundice and raised ALP.
In what situations does ALP increase?
ALP is produced by cells lining the biliary ducts in the liver and so will rise in bile duct obstruction (causing cholestasis), intrahepatic cholestasis and infiltrative diseases of the liver.
In what situations are AST and ALT likely to rise?
Situations involving liver cell necrosis. Hepatitis, Alcohol induced liver toxicity, shock, sepsis.
What clinical signs are there at end stage liver failure?
In order of severity:
ALT raised
Jaundice
INR prolonged
Encephalopathy
Why do we produce bile?
Bile salts are crucial for digestion and the absorption of fats and fat soluble vitamins
Removal of endogenous waste products/drugs
Liver disease risk factors?
Alcohol intake Obesity/Diabetes Parenteral Virus (hepatitis) Autoimmune disease FH PMH of associated symptoms
Physical signs of Chronic Liver disease?
Jaundice Palmar Erythema Spider Naevi Xanthelasmata Gynaecomastia Signs of portal hypertension
What is liver cirrhosis? What can cause liver cirrhosis?
Long term liver damage resulting in fibrous tissue replacing the normal liver parenchyma
Alcoholic liver disease
Non-alcoholic fatty liver disease
Hepatitis
Clinical plan when dealing with liver disease?
Cirrhotic liver disease
- Look for and try to prevent complications (portal hypertension, cancer risk)
Non-Cirrhotic
- Diagnose cause of abnormality
- Prevent progression
What is Hepatic Compensation and Decompensation?
Compensation happens in cirrhotic liver disease as it has come on over a longer time, Liver and associated systems have adapted to decreased liver function.
In an acute event such as a Bleed, Sepsis, Hypovolaemia this does not happen which leads to Jaundice, coagulopathy, renal dysfuction, Encephalopathy
Consequences of portal hypertension?
Varices (oesophageal, gastric)
Hypersplenism (low platelets)
Ascites (Renal dysfunction, Na+ problems)
How is arterial volume maintained in early and late stage cirrhotic disease?
early: Plasma expansion increased cardiac output.
Late: Vasoconstrictor and antinatriuretic factors causing sodium and water retention.
Management of ascites?
Salt and water restriction
Diuretics
Seek and treat precipitants
What is Hepatorenal syndrome?
Rapid deterioration in renal function in liver disease patients.
Pathogenesis of Hepatic Encephalopathy?
Ammonia.
CNS GABA receptors.
Central neurotransmitters and circulating aminoacids.
Blood flow and cell swelling
Purpose of a Liver biopsy?
Surgical:
Confirm presence of Liver neoplasm
Determine the nature of the neoplasm
Exclude underlying pathology
Medical:
Aetiology
Staging
Do you need to do HLA matching for transplant livers?
No
3 Possible Liver autoimmune disorders?
Autoimmune chronic active hepatitis
Primary Biliary Cirrhosis
Primary sclerosing cholangitis
Difference in type 1 autoimmune hepatitis and type 2
Type 1 can affect all ages and is generally less severe than 2, treatment failure is rare and there is a broad range of disease.
Type 2 generally affects pts in childhood, Is more severe and treatment is less successful.
Hepatitis causes?
- Viral
- Fatty liver disease
- Metabolic (e.g. haemochromatosis)
- Autoimmune
- Drugs
Risks of Ascites?
Spontaneous bacterial peritonitis
Treatment for hepatic encephalopathy?
Lactulose
What cells in the liver promote fibrosis?
Stellate cells
Differences in nodules in Viral cirrhosis and in Non-alcoholic/alcoholic liver cirrhosis?
Viral cirrhosis has larger nodules (macronodular)
The opposite in Non-alcoholic/alcoholic liver cirrhosis, they are smaller, micronodular
Examples of medications that can cause liver issues?
Paracetamol (Cell necrosis) Steroids COCP Allopurinol Penicillin
How can you test for Haemochromatosis and Haemosiderosis?
Perls stain.
Treatment of spontaneous bacterial peritonitis?
Ciprofloxacin and Cefotaxime
Consequences of hepatitis?
Cell death
Inflammation and release of enzymes from dying cells
Reduced functional capacity:
o Raised transaminases
o Unable to handle bilirubin
o Unable to make proteins
How do you assess the Liver protein synthesis function?
Albumin level and clotting function
What role does the liver have in metabolism?
- Protein, lipid, carbohydrate
* Stores fat and carbohydrate
Process of exogenous drug metabolism in the liver?
Drug bound to protein enters liver sinusoids
Passive diffusion to space of Disse
Entry to hepatocyte:
o Passive diffusion
o Active transport
Metabolism in hepatocytes:
o Phase 1 (CYP450 etc.)
o Phase 2 (conjugation)
Exit liver:
o Via space of Disse- blood-kidney
o Via bile duct
Percentage of compensated liver disease pts with varices?
40% increases to 60% if they have ascites
Portal pressure where they are at risk of bleeding?
> 12mm/hg
Normal = 5mm/hg
Testing for hepatic encephalopathy?
Neurophysiology
Paper pencil
computerised
Main medical types of liver disease?
Fatty liver disease e.g alcoholic/non-alcoholic
Chronic hepatitis e.g. viral
Biliary disease e.g. primary sclerosing cholangitis
Iron overload e.g Haemochromatosis, haemosiderosis
Metabolic disease e.g. Wilsons disease.
What is AMA?
Anti-mitochondrial antibody, present in 95% of Primary biliary sclerosis
Features of primary biliary sclerosis
AMA seen in 95% of patients
Novosphingobium aromaticivorans may be associated
Female:Male 9:1
Some genetic factors - higher incidence in first degree relatives
