Liver Flashcards
prehepatic jaundice causes
excess bilirubin production e.g. haemolytic anaemia
hepatic jaundice causes
failure of bile secretion e.g. infection, Wilsons, alpha1-antitrypsin, toxins, autoimmune, neoplasm or Budd-Chiari
post hepatic jaundice
duct obstruction e.g. stones, cancer, PBC, PSC or cholangiocarcinoma
define hepatitis
inflammation of the liver
acute causes of hepatitis
A B C D E, EBC, CMV, drugs, alcohol, Wilsons
chronic causes of hepatitis
B C D, autoimmune, drugs, hereditary
describe Hep A
most common spread faecal-orally often via seafood and being abroad. does not lead to chronic liver disease.
diagnosis of hep A
anti-HAV IgM means an acute infection
what does Hep D present alongside
Hep B
presentation of hep B
jaundice
extra hepatic features e.g. urticarial, glomerulonephiritis and arthritis
diagnosis of Hep B
HbsAg- acute infection HBeAg- active acute infection HBsAb- immunity HBcAb IgG past exposure HBcAb IgM acute or chronic hepatitis
what hep C have an increased risk of?
hepatocellular carcinoma
diagnosis of Hep C
ELISA for HCV antibody
management of acute hep C
interferon
management of chronic Hep C
PEG and ribavirin
describe Hep E
developing world
ELISA for IgG and IgM of anti-HEV
define autoimmune hepatitis
autoimmune disease with anti-smooth muscle antibodies
presentation of autoimmune hepatitis
organomegaly
jaundice
malaise, lethargy, nausea
diagnosis of autoimmune hepatitis
LFTs
IgG elevated
ASMA (type 1) and LKM (type 2)
biopsy
management of autoimmune hepatitis
steroids e.g. prednisolone
immunosuppressants e.g. azathioprine
children: azathioprine or 6MP
three stages of alcoholic liver disease
- steatosis
- alcoholic hepatitis
- alcoholic liver cirrhosis
define alcoholic liver disease
this is damage to hepatocytes caused by chronic consumption of alcohol leading to accumulation of fat (presence of Mallory’s hyaline bodies)
presentation of alcoholic liver disease
loss of appetite, nausea, vomiting abdominal tenderness hepatomegaly fatigue jaundice and ascites
diagnosis of alcoholic liver disease
LFTs
bloods
biopsy
US, CT
management of alcoholic liver disease
removal alcohol
steroids to reduce inflammation
liver transplant
define NAFLD
this is damage to the liver caused by diabetes, obesity and Hyperlipidaemia
risk in NAFLD
cirrhosis and HCC
presentation of NAFLD
- hepatomegaly fatigue pain jaundice ascites
diagnosis of NAFLD
steatosis= US biopsy screening for hepatitis LFTs bloods
management of NAFLD
- lifestyle
- lipid lowering e.g. statins
end stage = TIPS and/or liver transplant
define acute liver failure/fulminant hepatic failure
this is a rapid decline in hepatic function without prior disease
causes of acute liver failure/fulminant hepatic failure
virus
shock
malignancy
drug OD
presentation of acute liver failure/fulminant hepatic failure
jaundice encephalopathy prolonged coagulation and bruising lethargy itch
diagnosis of acute liver failure/fulminant hepatic failure
LFTs, PT, ABGs (metabolic acidosis)
US
management of acute liver failure/fulminant hepatic failure
transplant (drug OD)
itch: sodium bicarbonate bath, colestyramine or ursodeoxycholic acid
calories and fluids
define cirrhosis
the liver is unable to function properly due to the replacement of hepatocytes with scar tissue
presentation of cirrhosis
spider naevi gynaecomastia clubbing organomegaly jaundice encephalopathy portal hypertension (varices, caput medusa, haemorrhoids, ascites)
diagnosis of cirrhosis
Child-Pugh grading
LFTs
CT, MRI, US
management of cirrhosis
paracentesis TIPS (portal hypertension) rifaximin (encephalopathy) diuretics e.g. spironolactone transplant
what do you monitor the cirrhosis for
HCC (AFP)
benign tumours of the liver
- haemangioma
- focal nodular hyperplasia
- hepatocellular adenoma
- cystic lesions
malignant tumours of the liver
- hepatocellular carcinoma (hepatoma)
- fibrolamellar carcinoma
haemangioma
hypervascular tumour
focal nodular hyperplasia
associated with Osler-Weber Redu and haemangioma, central scar containing a large artery, FNA has kupffer cells
hepatocellular adenoma
neoplasms of hepatocytes, no portal tract involvement, associated with OC and anabolic steroids- most are solitary fat lesions, management is weight loss and stop of hormones
what presents with multiple adenomas
glycogen storage disease
two types of cystic lesions
- simple: liquid collection lined by epithelium, no biliary tree involvement
- hydatid: echinocactus granulosis (diagnosis is anti-echinococcus antibodies) management is surgery, PAIR, albendazole
define polycystic liver disease
embryonic ductal plate malformation of the intrahepatic biliary tree
three types of polycystic liver disease
- von Meyenburg complexes
- polycystic liver disease
- autosomal dominant polycystic kidney disease
what is hepatocellular carcinoma associated with?
HBV
HCV
cirrhosis
aflatoxin
presentation of heptocellular carcinoma
weight loss
RUQ pain and mass
liver bruit
liver failure
diagnosis of hepatocellular carcinoma
- AFP (teratoma)
- CT
- biopsy
- US
management of hepatocellular carcinoma
transplant
resection
local ablation e.g. alcohol injection and radio frequency ablation
chemoembolization (TACE) into hepatic artery
fibrolamellar carcinoma
presents in young 5-35
AFP is normal
CT shows stellate scar
management is resection, transplant or for an unresectable tumour then TACE
when is there an increased incidence of a liver abscess?
after dental procedure or infection
presentation of a liver abscess
- fever
- leukocytosis
- abdominal pain
diagnosis of liver abscess
US
management of liver abscess
broad spectrum antibiotics
aspiration/drainage
define Budd-Chiari
thrombus of hepatic veins which causes ischaemia and hepatocyte damage leading to liver failure
presentation of Budd-Chiari
jaundice
tender hepatomegaly
ascites
diagnosis of Budd-Chiari
USS doppler of hepatic veins
management of Budd-Chiari
anticoagulation
recanalization (catheter containing fibrinolytic therapy)
TIPS
what actually causes jaundice?
bilirubin >50
breakdown product of RBCs, goes into hepatocytes and is conjugated by UDP-glucorunyl transferase. Conjugated bilirubin is then secreted into bile.
what to check before liver biopsy?
INR
what causes DTs?
down-regulation of GABA leading to over-excitability when alcohol is removed
presentation of DTs
acute confusion agitation delusions hallucinations tremor tachycardia hypertension hyperthermia ataxia arrhythmias
management of alcohol withdrawal
pabrinex (IV high dose B vitamins)
follow with regular low dose thiamine given to prevent WKS
most common causes of acute liver failure
acute viral hepatitis
paracetamol overdose
liver transplant incision
rooftop
Mercedes-Benz
what drugs to avoid prescribing in liver disease?
avoid drugs that constipate oral hypoglycaemics saline warfarin in enhanced hepatotoxic drugs
why should you avoid drugs that constipate in liver failure?
increases the risk of encephalopathy
examples of hepatotoxic drugs
paracetamol methotrexate isoniazid azathioprine phenothiazine oestrogen tetracycline
four main causes of cirrhosis
alcohol
NAFLD
hep B
hep C
what happens to glycogen in cirrhosis?
there is disrupted storage so muscle/ protein is used as fuel
what is a fibroscan?
scan of the liver to assess elasticity
how often should you endoscope those with cirrhosis who don’t have varices?
every 3 months
diet in cirrhosis
high protein
low sodium
what is hepatorenal syndrome?
cirrhosis + ascites + renal failure
what causes hepatorenal syndrome?
reduction in blood flow leading to the kidney’s being unable to function
fatal without transplant
most common organisms associated with ascites infection (bacterial peritonitis)
e. coli
klebsiella
gram+ve cocci
management of ascites
low sodium spironolactone antibiotics paracentesis TIPS
causes of unconjugated hyperbilirubinaemia
haemolysis
ischaemic hepatitis
Gilbert’s
presentation of unconjugated hyperbilirubinaemia
water insoluble so it is not secreted into the urine
complications of cholestasis/ disrupted bile
OP (vitamin D)
coagulopathy (vitamin K)
absorption of fat-soluble vitamins. Prevent with fat soluble vitamins given
PBC pruritis management
colestyramine
PBC diarrhoea management
codeine phosphate
chromosome defect in Wilson’s disease
AR on chromosome 13
what should normally happen to copper in the body?
incorporated into caeruloplasmin
doesn’t happen in Wilson’s and copper accummulates
diagnosis of Wilson’s
low serum caeruloplasmin urine and serum copper genetics slit lamp screened in cirrhosis biopsy MRI brain
management of Wilson’s
chelating agents e.g. penicillamine or trientine
avoid foods with high copper content
foods with a high copper content
liver chocolate nuts mushrooms shellfish
what is elastase?
enzyme secreted by neutrophils that digests connective tissue
role of alpha-1antitrypsin
inhibits digestion of connective tissue
what is hepatocellular adenoma associated with?
OCP
pregnancy
anabolic steroids
liver transplant types
orthotopic (entire from deceased)
split donation
living donor
