Liver

Question 1

Ligaments of the liver

Answer 1

Falciform ligament: Attaches anterior surface of the liver to the anterior abdominal wall
Coronary & triangular ligaments: Attaches superior surface to the diaphragm

Question 2

Hepatic recesses (spaces)

Answer 2

Suphrenic: Either side of falciform ligament between diaphragm and liver
Subhepatic: Between interior surface of liver and transverse colon
Morison’s pouch: Between right kidney and liver. Most commonly where fluid collects when patient is bedridden.

Question 3

Four lobes of the liver

Answer 3

Right lobe and left lobe separated by by falciform ligament
Caudate lobe: Between IVC and fossa formed by ligament venosum (a remnant of the fetal ductus venosus)
Quadrate lobe: Between gall bladder and fossa formesd by ligament teres (remnant of fetal umbilical vein)

Question 4

Portal Triad

Answer 4

Arteriole: Branch of hepatic artery entering liver
Venule: Branch of hepatic portal vein entering liver
Duct: Branch of bile duct leaving the liver

Question 5

Liver nerve innervation

Answer 5

Parenchyma: hepatic plexus (sympathetic: coeliac plexus, parasympathetic: vagus nerve)
Glisson’s capsule innervated by the branches of lower intercostal nerves.

Question 6

Hepatitis A virus

Answer 6

small, unenveloped, symmetrical RNA virus (picornavirus).

Question 7

Route of transmission for Hep A

Answer 7

Most ccommonly foecal-oral. Can be by IV drug use

Question 8

Pathophysiology of Hepatitis A

Answer 8

HAV is taken up by hepatocytes
Viral RNA uncoats binds to ribosomes to form polysomes
Utilises RNA polymerase to replicated RNA
Assembled viruses is shed via billary tree into faces

Question 9

Most common form of acute viral hepatitis worldwide

Answer 9

Hepatitis A

Question 10

Highest areas of risk for HAV

Answer 10

Indian subcontinent, Africa, Far east (except japan), Middle east, south and central america

Question 11

Risk factors of HAV

Answer 11

Personal contact.
Certain occupations (for example, staff of large residential institutions, sewage workers).
Travel to high-risk areas.
Male homosexuality with multiple partners.
Intravenous drug abuse.
People with clotting factor disorders who are receiving factor VIII and factor IX concentrates

Question 12

Signs and symptoms of HAV

Answer 12

Fever
Malaise
Nausea & Vomiting
Jaundice
Hepatomegaly
RUQ pain
Acholic stool (clay-coloured)
Headache
Dark urine
Pruritus

Question 13

Investigations for HAV

Answer 13

IgM anti-hepatitis A virus: Usually detected within 5-10 days before onset of symptoms and stays positive for 4-6 months
IgG anti-hepatitis A virus: Starts soon after IgM and lasts for years. In absence of IgM indicated a previous infection or vaccination
LFTs: AST rises more than ALT.
Urea & Creatinine may be elevated

Question 14

Management of HAV

Answer 14

Supportive:
Fluids
Anti-emetics
Rest
Avoid alcohol

Question 15

Hepatitis B virus (HBV)

Answer 15

Double stranded DNA virus (hepadnavirus)

Question 16

Route of transmission of HBV

Answer 16

Percutaneous
Permucosal route
Sexually traansmitted

Question 17

Most common cause of hepatitis

Answer 17

Hepatitis B

Question 18

Pathophysiology of Hepatitis B

Answer 18

HBV enters cell
Core particle enters nucleus
Strand synthesis repaired to form covalently closed circular DNA
Use reverse transcription and forms RNA for translation

Question 19

Signs and symptoms of HBV

Answer 19

70% asymptomatic. They may have flu-like symptoms

jaundice

Question 20

Investigation of HBV

Answer 20

HBsAg, HBeAg, anti-HBe, anti-HBs, anti-HB core.
Quantitative hepatitis B virus DNA.
HBV genotype (for those considered for interferon).
Hepatitis delta virus (HDV) serology.
General liver investigations
FBC.
Bilirubin.
Liver enzymes.
Clotting.
Ferritin.
Lipid profile.
Autoantibody screen.
Caeruloplasmin.

Question 21

Causes of fatty liver disease

Answer 21

Alcohol
HTN
Dyslipidaemia
TPN
Polycystic ovary syndrome
Starvation or rapid weight loss (gastric bypass surgery)
Hep B, Hep C
Amiodarone
Tamoxifen
Glucocorticoids
Tetracycline
Oestrogens
Methotrexate
Thallium
Metabolic disorders

Question 22

Presentation of fatty liver disease

Answer 22

Fatigue 
Malaise
Hepatosplenomegaly
Truncal obesity
Tends to be picked up on LFTs

Question 23

Investigations to order if suspecting fatty liver disease

Answer 23

Biopsy is the only definitive test

ALT and AST raised (in NAFLD AST:ALT ratio <1 in AFLD >2)
Bilirubin, ALP, gGGT elevated
FBC (anemia due to hypersplenism)
U&amp;Es abnormal
INR raised
Serum albumin decreased

<20 g of alcohol per day in women and <30 g in men is usually used to allow a diagnosis of NAFLD

Question 24

Management of fatty liver disease

Answer 24

Diet
Exercise
Bariatric surgery is obese

Question 25

Liver cirrhosis

Answer 25

Chronic Hepatitis C (most common in western worlds)
Chronic Hepatitis B 
Alcoholic liver disease 
Biliary obstruction
Metabolic disorders
Hepatotoxic medication
Haemochromatosis

Question 26

Presentation of liver cirrhosis

Answer 26

Abdominal distention
Jaundice and pruritus
Melaena ( decompensated cirrhosis secondary to GI haemorrhage from gastro-oesophageal varices in portal HTN)
Leukonychia, palmar erythema, spider angiomata
Telangiectasia (red focal lesions, blood vessel dialation)
Parotid gland swelling
Jaundice

Question 27

Investigations to order if suspecting liver cirrhosis

Answer 27

LFTs deranged
gGGT elevated
Albumin, Sodium, platelet count reduced
Viral screen
MRI/CT
Liver biopsy