Liver Flashcards
5 LFTs (Liver function tests) - GAABA
GGT - Raised in alcoholic liver disease ALP - Raised in biliary tree damage and also in bone resorption (metastases) AST/ALT - Raised in hepatocyte damage Bilirubin Albumin
Progression of chronic liver disease - 5 phases
1) Chronic liver condition
2) Liver damage
3) Liver symptoms
4) Liver cirrhosis
5) Liver failure/risk of hepatocellular carcinoma
Viral hepatitis A/B/C/D/E - Modes of transmission
Hep A - Faeco-oral (contaminated food/water)
Hep B - Blood-borne
Hep C - Blood-borne
Hep D - Blood-borne
Hep E - Faeco-oral (contaminated food/water)
Viral hepatitis - Investigation
Serology - Detect antibodies/antigens
Viral hepatitis A/B - Vaccines
Hep A - Travellers
Hep B - Immunisation
Viral hepatitis A/B/C/E - Treatment
Hep A/E - Supportive
Hep B - Pegylated interferon-alpha 2a/pegasys (immune response)
Hep C - Sofosbuvir (antiviral)
What is the worst combination of viral hepatitis?
Hep B/D
Alcoholic liver disease - Pathophysiology 5 steps
1) Reduced NAD+
2) Reduced fat oxidation
3) Fat accumulation in hepatocytes
4) Liver cell membranes damaged
5) Inflammation and eventual cirrhosis
Alcoholic liver disease - Investigations
GGT raised
AST/ALT raised
FBC - Macrocytic anaemia
Alcoholic liver disease - Treatment
Quit alcohol
Thiamine (malnutrition from alcohol)
NAFLD (Non-alcoholic fatty liver disease) - Risk factors
T2DM
Metabolic syndrome
NAFLD (Non-alcoholic fatty liver disease) - Investigations
Liver fibrosis test
NAFLD (Non-alcoholic fatty liver disease) - Management
Lifestyle - exercise
Screening for obesity-related conditions
Autoimmune hepatitis - Investigations
Antibodies
Liver biopsy
Autoimmune hepatitis - Management
Prednisolone (immunosuppression)
Primary biliary cirrhosis (PBC) - Pathophysiology
Autoimmune destruction of intrahepatic biliary ducts, leading to cholestasis - excess bile and cholesterol in the blood
Primary biliary cirrhosis (PBC) - Signs and symptoms
Excess bile - Jaundice, pruritis (severe itching)
Excess cholesterol - Hyperpigmentation
Primary biliary cirrhosis (PBC) - Investigations
Antibodies LFT - Raised ALP Serum cholesterol - Raised Ultrasound (Abdo) Liver biopsy
Primary biliary cirrhosis (PBC) - Management
Colestyramine (pruritus)
ADEK supplementation
Bisphosphonate (osteoporosis)
Wilson’s disease - Pathophysiology
Hereditary - Autosomal recessive chromosome 13
Excess copper in liver and CNS
Wilson’s disease - Sign
Kayser-fleischer rings (dark rings around iris)
Wilson’s disease - Management
Reduce copper intake
Penicillamine (excretes copper)
Haemochromatosis - Pathophysiology
Hereditary - Autosomal recessive chromosome 6
Excess iron everywhere
Haemochromatosis - Complications
Restrictive cardiomyopathy due to iron deposition Bronze diabetes (hyperglycaemia and skin darkening)
Haemochromatosis - Investigations
Serum ferritin
Haemochromatosis - Management
Reduce dietary iron intake
Desferrioxamine (Remove excess iron)
Alpha-1-antitrypsin deficiency - Pathophysiology
Autosomal recessive chromosome 14
1) Accumulation of alpha-1-antitrypsin in hepatocytes and lack of it in serum
2) Lack of protease inhibition in alveoli
3) Alveolar damage leads to emphysema
Alpha-1-antitrypsin deficiency - Symptoms
COPD symptoms
Alpha-1-antitrypsin deficiency - Investigation
Serum alpha-1-antitrypsin
Alpha-1-antitrypsin - Management
Manage COPD Liver transplant (curative)
Liver cirrhosis - Pathophysiology
Normal smooth liver structure becomes distorted, with nodules surrounded by fibrosis, affecting the liver’s synthetic, metabolic and excretory actions
Liver cirrhosis - Risk factors
Alcohol misuse
Hep B/C
Obesity
T2DM
Liver cirrhosis - 2 Types
Compensated - Liver can still function with no/few symptoms
Decompensated - Liver cannot function adequately and complications arise (jaundice, ascites, etc), at this point it is known as chronic decompensated hepatic failure
Decompensated liver cirrhosis - Causes
Infection
Portal vein thrombosis
Surgery
Liver cirrhosis - Investigation
Liver biopsy
Transient elastography
Screen for HCC every 6 months
Upper GI endoscopy (oesophageal varices)
Liver cirrhosis - Treatment
Liver transplant
What is decompensated liver cirrhosis another name for?
Chronic liver failure
Decompensated liver failure - Symtoms
Jaundice
Ascites
Variceal haemorrhage due to portal hypertension
Portal hypertension - Pathophysiology
1) Endothelin-1 production increased in cirrhosis
2) Increased vasoconstriction/reduced vasodilation
3) Reduced radius, increased resistance
4) Higher pressure in portal system
Portal hypertension - Causes
Portal vein thrombosis
Cirrhosis
Right heart failure
IVC obstruction
Oesophageal varices - Pathophysiology
These vessels are thin and not meant to transport high pressure blood, so can easily rupture
Oesophageal varices - Investigations
Upper GI endoscopy
Oesophageal varices - Treatment
B-blocker (reduce portal pressure)
Nitrate (reduce portal pressure)
TIPSS (surgical portosystemic shunt)
Ascites - Pathophysiology
1) Oedema = hydrostatic pressure>oncotic pressure
2) Oncotic pressure decreases in liver cirrhosis due to hypoalbuminaemia
3) Hydrostatic pressure increases due to portal hypertension and RAAS activation (fluid retention)
Ascites - Causes
Cirrhosis IVC/portal vein thrmbosis Heart failure Inflammation (infection) Pancreatitis Malignancy
Ascites - Signs
Distended abdomen (swollen) - shifting dullness Ascitic tap (drain) - culture
Ascites - Management
Spironolactone (diuretic)
Spontaneous bacterial peritonitis - Causes
Ascites with cirrhosis
Spontaneous bacterial peritonitis - Investigation
Ascitic tap - bugs (e.coli, enterococcus), raised neutrophils
Spontaneous bacterial peritonitis - Management
Cefotaxime (initial antibiotic)
Ciprofloxacin (prophylaxis antibiotic)
Hepatocellular carcinoma - Investigation
CT/MRI Biopsy Raised AFP Bloods - Clotting abnormalities LFTs - deranged
Hepatocellular carcinoma - Treatment
Surgical resection (remove part of liver) Chemo Radiofrequency ablation (RFA)
Secondary liver tumours - 3 Origins (GBB)
GI tract
Breast
Bronchus
Acute liver conditions - 3
Hep A/E
Liver abscess
Drug-induced liver injury (paracetamol overdose)
Acute liver conditions - Presentation
Jaundice
Anorexia
Paracetamol overdose - Management
N-acetyl-cysteine
Amoebic liver abscess - Symptoms
Fever Right upper quadrant abdo pain Weight loss/anorexia Hepatomegaly Night sweats Bloody diarrhoea
Amoebic liver abscess - Microbiology
Entamoeba histolytica via faeco-oral route
Amoebic liver abscess - Investigations
Ultrasound (Abdo)
Serology of entamoeba histolytica
Amoebic liver abscess - Treatment
Abscess drainage
Metronidazole (antibiotic)
Fulminant liver failure - Pathophysiology
Massive necrosis of liver cells leading to liver failure within 8 weeks (fastest type of liver failure)
Fulminant liver failure - Treatment
Liver transplant
ICU
Gallstones - Risk factors
Obesity
Age
Female>male
Biliary colic - Pathophysiology
Gallstone impacted in gallbladder neck temporarily and then dislodged back into gallbladder
Acute cholecystitis - Pathophysiology
Gallstone stuck in gallblader neck and causes inflammation
Acute cholecystitis - Signs and symptoms
Symptoms - Right upper quadrant pain, fever, nausea/vomiting
Sign - Murphy’s sign
Acute cholecystitis - Investigations
Ultrasound (abdo)
Acute cholecystitis - Treatment
Laparoscopic cholecystectomy (gallbladder removal)
Analgesia
Fluids
Ascending cholangitis - Pathophysiology
1) Gallstone stuck in common bile duct
2) Halted flow of bile allows intestinal bacteria (E.coli, enterococcus) to migrate up biliary tree
Ascending cholangitis - Symptoms
Fever RUQ pain Jaundice Hypotension Confusion
Ascending cholangitis - Investigations
Ultrasound (abdo)
MRCP to locate stone
Ascending cholangitis - Treatment
ERCP
Acute pancreatitis - Causes
Gall stones
Alcohol
Trauma
Autoimmune
Acute pancreatitis - Signs and symptoms
Signs - Hypercalcaemia, hyperlipidaemia, hypothermia, abdo distension/tenderness, bruising around umbilicus and flanks
Symptoms - Abdo pain radiating to back, nausea/vom, fever
Acute pancreatitis - Investigations
CT (abdo)
Enzyme levels raised due to inflamed pancreas releasing enzymes
Acute pancreatitis - Treatment
Supportive (fluids, analgesia, nutrition)
ERCP
Furosemide
Metronidazole
Acute pancreatitis - Complications
Sepsis DIC (disemminated intravascular coagulation)
Primary sclerosing cholangitis (PSC) - Pathophysiology
Cholestatic liver disease due to fibrosing inflammatory destruction of both intra and extrahepatic bile ducts
Primary sclerosing cholangitis (PSC) - Causes
Cholangiocarcinoma
Liver cirrhosis
Primary sclerosing cholangitis (PSC) - Investigation
Liver biopsy
MRCP/ERCP
Primary sclerosing cholangitis (PSC) - Treatment
Liver transplant
Ursodeoxycholic acid
Differences between primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) - Site and cause of destruction
PBC - Intrahepatic, inflammation
PSC - Intra/extrahepatic, fibrosis
What is painless jaundice with weight loss indicative of?
Cancer of pancreas head
ERCP - Sites of use
Pancreas
Bile ducts