Liver Flashcards
Hepatic failure types
fulminant (immediate)
hyperacute
acute
subacute
Hyperacute hepatic failure
encephalopathy within 7 days of onset of jaundice
Acute hepatic failure
encephalopathy within 8-28 days of onset of jaundice
Subacute hepatic failure
5-26 wks
Causes of hepatic failure
Infection
Drugs
Toxins
Vascular
Alcohol
Others
Infective causes of hepatic failure
Viral hepatitis (esp B, C, CMV)
yellow fever,
leptospirosis
Drug causes of hepatic failure
paracetamol overdose
halothane
isoniazid
Toxin causes of hepatic failure
Amanita phalloides mushroom
Carbon tetrachloride
Vascular cause of hepatic failure
Budd Chiarri synd
Venou-vascular occlusive disease
Budd Chiari syndrome sx
triad of :
abdominal pain
ascites
liver enlargement
Budd Chiari synd pathophysiology
thrombosis within hepatic vein
Other causes of hepatic failure
primary biliary cirrhosis
haemochromatosis,
autoimmune hepatitis,
alpha 1-antitrypsin deficiency,
Wilson’s disease,
Sx of hepatic failure
Jaundice
Hepatic encephalopathy
Fetor hepaticus
Astrexis (flap)
Constructional apraxia (cant copy 5 pointed star)
Fetor hepaticus
smells like pear drops
Hepatic encephalopathy pathophysiology
Built up of ammonia due to liver failure
Brain astrocytes pick up, converting glutamate to glutamine
Excess glutamine draws fluid into brain cells
Grade I of hepatic encephalopathy
I. altered mood, sleep disturbance, dyspyraxia
Grade II of hepatic encephalopathy
Confusion,
Slurred speech,
change in behaviour,
+/- flap
Grade III of hepatic encephalopathy
Incoherent,
restless,
liver flap
Grade IV of hepatic encephalopathy
coma
Complications of hepatic failure
Cerebral oedema
Ascites
Bleeding
Hypoglycaemia
Acute rx of hepatic encephalopathy
Lactulose (reduces ammonia)
Neomycin (kills gut ammonia producing bacteria)
Poor prognostic factors for hepatic failure
Grade III-IV encephalopathy
Late-onset hepatic failure (as opposed to fulminant)
Drug induced hepatic failure
>40 yo
Albumin <30
Raised INR
Causes of liver cirrohsis
chronic alcohol
Hep B/C
Terry’s nail
white proximally but distal 1⁄3 reddened by telangiectasia
sign of liver cirrhosis
Early blood results of liver cirrhosis
Raised or normal bilirubin,
Raised AST, ALT, alk phos, γGT
Late bloods of liver cirrhosis
loss of synthetic function : low albumin +/- high INR, PT
Hypersplenism: low WCC and platelets
Child-Pugh grading system assesses what
Liver cirrhosis and risk of bleed
Child Pugh Grading system grades
A: 5-6,
B: 7-9,
C>10
Child Pugh score of above 8 risk
variceal bleed
Factors included in Child-Pugh
Albumin
PT
Ascites
Billirubin
Encephalopathy
Haemochromatosis def
hereditary
deposition of iron in joint, liver, heart, pancreas, adrenal, skin
Haemochromatosis ix
Bloods: raised LFTS, ferritin
Biopsy: Perls stain to quantify iron loading
Haemochromatosis rx
Induction venesect 2yrs: keeo ferritin <50
Maintenance venesect for life
If intolerable: desferrioxamine
α 1 antitrypsin deficiency def
Lung emphysema
Liver cirrhosis and hepatocellular cancer
α1 deficiency genetics
autosomal recessive
α1 deficiency ix
low α1 serum level
α1 deficiency rx
supportive
quit smoking
Inhaled A1AT, liver transplant
Aminotransferase eg
AST
ALT
Changes to aminotransferase levels cause
are released in the bloodstream after hepatocellular injury
ALT is more specific for hepatocellular injury (but also expressed in kidney and muscle)
AST is also expressed in the heart, skeletal muscle, and RBCS
Alkaline phosphatase production
liver
bone (so raised in growing chil- dren)
placenta
kidney
intestine
WCC
Gamma GT production
liver,
pancreas,
renal tubules
intestine
NOT Bone
Cholestasis predominant liver injury blood results
Alk phos and gamma GT raised
AST and ALT MILDLY raised
Primary biliary cirrhosis
Interlobular bile ducts are damaged by chronic autoimmune granulomatous inflammation
–>cholestasis
–> fibrosis, cirrhosis, and portal HTN
Cause of PBC
environmental + genetic
leads to loss of immune tolerance for mitochondrial proteins
PBC antibody
AMA
PBC age of presentation
50
PBC sx
Assymptomatic
Pruritis, lethargy and sleepiness may precede jaundice by yrs
PBC complications
Cirrhosis, HCC
Vit ADEK malabsorption
Reduced bilirubin in gut->coagulopathy and osteomalacia
PBC bloods
cholestasis type picture
PBC rx
symptomatic
prophylaxis ADEK replacement
Ursodeoxycholic acid
Primary sclerosing cholangitis (PSC) def
progressive cholestasis with bile duct inflammation and strictures
Sx of PSC
pruritis +/- fatigue
advanced: ascending cholangitis, cirrhosis
PSC associated disease
Cancers:
- bile duct
- gallbladder
- liver
- colon
PSC bloods
raised alk phos
raised bilirubin
raised gammaglobulinaemia
PSC autoimmune markers
ANA
AMA
ANCA
(may be +ive)
PSC rx
Liver transplant
Ursodeoxycholic may help LFTs
Cholestyramine (pruritis)
Autoimmune hepatitis classification
I. ANA and ASMA +ive, <40yo
II. LKM1 antibody, children
III. SLA or liver pancreas antigen
Autoimmune hepatitis rx
Pred
Azothioprin (if steroids CI)
Non-alcoholic fatty liver disease def
increased fat in hepatocytes (steatosis) ± inflammation (steatohepatitis)
NAFLD rx
Control RFs (DM, obesity)
Bariatric surgery
Monitor LFTs, glucose
Wilsons disease pathophysiology
Cu deposition in liver and CNS
copper incorporation into caeruloplasmin in hepatocytes and its excretion into bile are impaired
Wilsons genetics
autosomal recessive (ch13)
Wilsons weird signs
Kayser–Fleischer (KF) rings: Copper in iris
blue lunulae (nails)
grey skin
Wilsons ix
24hr urine cupper high
serum caeruloplasmin low (not reliable as its an active phase protein)
Wilsons rx
Avoid liver, chocolate, nuts, mushrooms, legumes, and shellfish
Lifelong penicillamine
Screen sibilings
Chronic rx of hepatic encephalopathy
Rifaximin
