Liver Flashcards
Ligaments of the liver
Falciform ligament: Attaches anterior surface of the liver to the anterior abdominal wall
Coronary & triangular ligaments: Attaches superior surface to the diaphragm
Hepatic recesses (spaces)
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.
Four lobes of the liver
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)
Portal Triad
Arteriole: Branch of hepatic artery entering liver
Venule: Branch of hepatic portal vein entering liver
Duct: Branch of bile duct leaving the liver
Liver nerve innervation
Parenchyma: hepatic plexus (sympathetic: coeliac plexus, parasympathetic: vagus nerve)
Glisson’s capsule innervated by the branches of lower intercostal nerves.
Hepatitis A virus
small, unenveloped, symmetrical RNA virus (picornavirus).
Route of transmission for Hep A
Most ccommonly foecal-oral. Can be by IV drug use
Pathophysiology of Hepatitis A
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
Most common form of acute viral hepatitis worldwide
Hepatitis A
Highest areas of risk for HAV
Indian subcontinent, Africa, Far east (except japan), Middle east, south and central america
Risk factors of HAV
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
Signs and symptoms of HAV
Fever Malaise Nausea & Vomiting Jaundice Hepatomegaly RUQ pain Acholic stool (clay-coloured) Headache Dark urine Pruritus
Investigations for HAV
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
Management of HAV
Supportive: Fluids Anti-emetics Rest Avoid alcohol
Hepatitis B virus (HBV)
Double stranded DNA virus (hepadnavirus)
Route of transmission of HBV
Percutaneous
Permucosal route
Sexually traansmitted
Most common cause of hepatitis
Hepatitis B
Pathophysiology of Hepatitis B
HBV enters cell
Core particle enters nucleus
Strand synthesis repaired to form covalently closed circular DNA
Use reverse transcription and forms RNA for translation
Signs and symptoms of HBV
70% asymptomatic. They may have flu-like symptoms
jaundice
Investigation of HBV
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.
Causes of fatty liver disease
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
Presentation of fatty liver disease
Fatigue Malaise Hepatosplenomegaly Truncal obesity Tends to be picked up on LFTs
Investigations to order if suspecting fatty liver disease
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&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
Management of fatty liver disease
Diet
Exercise
Bariatric surgery is obese
Liver cirrhosis
Chronic Hepatitis C (most common in western worlds) Chronic Hepatitis B Alcoholic liver disease Biliary obstruction Metabolic disorders Hepatotoxic medication Haemochromatosis
Presentation of liver cirrhosis
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
Investigations to order if suspecting liver cirrhosis
LFTs deranged gGGT elevated Albumin, Sodium, platelet count reduced Viral screen MRI/CT Liver biopsy
