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Finals > Liver > Flashcards

Liver Flashcards

1
Q

Which transaminase is more specific for liver damage?

A

ALT

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2
Q

Raised levels, what do these ratios indicate?
AST:ALT = 1

AST:ALT > 2.5

AST:ALT < 1

A

Ischamia

Alcoholic hepatitis

Hepatocellular damage e.g. viral hepatitis, pcm OD

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3
Q

Raise ALP and GGT?

A

cholestasis

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4
Q

Sensitive to alcohol ingestion?

A

GGT

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5
Q

Inherited causes of liver disease?

A

hereditary haemochromatosis [deficiency of hepcidin]

Wilson’s disease [deficiency of caeruloplasmin –> excess copper in tissues]

Alpha-1 antitrypsin deficiency [affects liver and lungs]

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6
Q

Gene in hereditary haemochromatosis?

How is it inherited?

A

HFE

Autosomal recessive

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7
Q

Mech in hereditary haemochromatosis?

A

increased intestinal absorption of iron –> accumulated in tissues

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8
Q

Sx of hereditary haemochromatosis?

A

Presents 40-50yo

Early; fatigue, weakness, arthralgia, ED

Late; skin bronzing, DM, cirrhosis, impotence, arrhythmias

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9
Q

Ix in hereditary haemochromatosis?

A 
Iron studies [high ferritin, transferrin saturated, serum iron high]
HFE genetic test
LFTs
MRI liver 
Liver biopsy with Perl's stain
ECG
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10
Q

Serum ferritin not specific?

A

acute phase protein

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11
Q

mx of hereditary haemochromatosis?

A

Venesection weekly
Monitor ferritin
low iron diet
+/- liver transplant

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12
Q

Wilson’s genetics?

A

ATP7B gene

autosomal recessive

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13
Q

Mech in Wilson’s - where is copper deposited?

A

Disorder of biliary excretion [cant get copper into caeruloplasmin]

liver, basal ganglia

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14
Q

ix in wilsons?

A

copper studies
slit lamp - KF rings
liver biopsy
MRI - basal ganglia

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15
Q

mx of wilsons?

A

penicillamine
zince reduces copper absorption
low copper diet [avoid mushrooms, liver, chocolate, nuts]
monitor liver, renal function, FBC, clotting
avoid alcohol + hepatotoxic drugs

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16
Q

pres of wilsons?

A

young adult with liver abnormalities or movement disorder
Kayser-Fleischer rings in 95%

severe depression +/- parkinsonian sx

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17
Q

organs affected in A1AT deficiency?

A

Lung –> dyspnoea, wheeze, cough

Liver –> hepatitis, cirrhosis, fibrosis

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18
Q

Ix in A1AT?

A

Phenotyping
CXR, spirometry
LFT, biopsy

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19
Q

Mx of A1AT?

A

avoid smoking / alcohol
mx of COPD
monitor LFTs, cirrhosis, screen for HCC

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20
Q

Characteristics of liver failure? (4)

A

hepatic encephalopathy
jaundice
abnormal bleeding
ascites

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21
Q

Ddx of liver failure?

A 
paracetamol, alcohol, other medications
viral hepatitis, EBV, CMV
HCC
inherited
ischaemia, budd-chiari
autoimmune
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22
Q

hepatic encephalopathy pathophys?

A

ammonia build up; crosses BBB; astrocytes clear this by turning glutamate to glutamine

Glutamine causes fluid shift into cells –> cerebral oedema

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23
Q

Signs of chronic liver disease?

A 
caput medusae
clubbing
leukonychia
asterixis
palmar erythema
spider naevi
shifting dullness
abnorm bleeding
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24
Q

drug used in paracetamol OD?
what time frame?
what can you use in first hour of ingestion instead?

A

N-acetylcysteine within first 8h

first hour –> charcoal

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25
Q

mx of high ammonia

A

lactulose + neomycin

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26
Q

mx of raised ICP

A

mannitol

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27
Q

mx of ascites

A

fluid + salt restrict
diuretics
paracentesis
human albumin solution

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28
Q

ascites?

A

fluid in peritoneal cavity

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29
Q

cause of ascites?

A

75% - cirrhosis (decreased albumin + portal HTN)

malignancy - GI, ovarian (Meigs)
HF
Nephrotic syndrome

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30
Q

ix in ascites

A

abdo USS
CXR
LFT
shifting dullness (present if 1500ml)

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31
Q

signs in spontaneous bacterial peritonitis?

A

guarding
rebound tenderness
pain on palpation

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32
Q

ix in spontaneous bacterial peritonitis

A

FBC, LFT, U+Es, blood cultures
paracentesis for MC+S (and amylase)
imaging

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33
Q

organisms causing spontaneous bacterial peritonitis

A

E. coli, enterococci

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34
Q

mx of spontaneous bacterial peritonitis

A

IV ceftriaxone

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35
Q

End stage liver failure can develop ‘hepatorenal syndrome’
2 types + prognosis?
Mx?

A

type 1 = rapid (survival of 2 weeks) –> terlipressin with albumin

type 2 = last 6 months –> TIPS

General mx –> admit to HDU, monitor fluids, stop nephrotoxic drugs, +/- transplant

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36
Q

pres of advanced/decompensated cirrhosis?

A 
oedema
ascites
bruising
poor memory 
bleeding varices
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37
Q

cutaneous signs of cirrhosis

A 
FLAPS
finger clupping
leukonychia
asterixis
palmar erythema
spider naevi/scratch

+ jaundice, dupuytren’s

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38
Q

causes of portal HTN

A

pre-hepatic [thrombosis, extrinsic compression]
hepatic [cirrhosis, hepatitis, schistosomiasis, granuloma]
post hepatic [budd-chiari, HF]

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39
Q

mx of cirrhosis?

monitoring?

A

nutrition, alcohol abstinence

monitor for varices & HCC

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40
Q

ix in portal HTN?

A 
AUSS
doppler USS
Spiral CT
endoscopy
portal pressure [normal<5, varices>10]
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41
Q

mx of portal HTN

A

BBs, nitrates

TIPS

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42
Q

1 prevention of varices in portal HTN

A

propanolol

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43
Q

ix in varices

A

endoscopy

clotting, group+save, cross match

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44
Q

mx in varices

A

terlipressin

oesophageal -> band ligation

gastric -> endoscopic injection of N-butyl2cyanoacretate (basically glue)

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45
Q

surgical mx of varices

A

TIPS

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46
Q

Pres of sudden RUQ pain + rapidly developing ascites

[hepatomegaly + jaundice + renal involvement]

dx?
ix?

A

Budd-Chiari syndrome (occlusion of the hepatic veins)

Doppler US

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47
Q

Mx of budd chiari?

A

treat ascites eg TIPS

if due to thrombosis –> warfarin

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48
Q

cause of liver Ca?

A

10% primary

rest are from stomach, colon, lung, breast

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49
Q

cause of primary HCC?

A

Hep C

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50
Q

blood marker of HCC?

A

AFP

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51
Q

liver Ca prevention?

A

HBV vaccine
alcohol abstinence
screening in high risk {HBV, HCV, cirrhosis)

52
Q

cause of fatty liver?

A

metabolic syndrome
PCOS
alcohol
HBV/HCV

53
Q

ix in fatty liver

A

biopsy - cells swollen with fat

54
Q

mx fatty liver

A

no alcohol
wt loss + exercise
mx of cause

55
Q

steatohepatitis LFTs?

A

AST + ALT raised

ALT > AST

56
Q

histology of acute hepatitis?

chronic?

A

lobular disarray, inflam cell infiltrate, necrosis, bile duct prolif

lymphoid follicles at portal tract

57
Q

Hep A
incubation?
spread?

A

2-6 weeks

faeco-oral

58
Q

Hep A ix

A

HAV IgM - acute

HAV IgG - lasts years

59
Q

Hep A Mx?

for itch?

A

fluids, antiemetics, rest, avoid alcohol

cholestryamine

60
Q

what dissolves gall stones?

A

ursodeoxycholic acid

61
Q

Hep B
incubation?
spread?

A

60-90d

parenteral, sexual

62
Q

HBsAg?
HBsAb?

when are they found?

A

HBsAg found at current infection

HBsAb indicates immunity post infection/vaccine

63
Q

Ix in Hep B?

screening?

A

PCR HBV
viral serology
FBC, LFT, clotting, ferritin, caeruloplasmin

Screen for HCC (USS, AFTP) + other BBVs

64
Q

prevention of Hep B?

A

blood screening
safe sex
vaccines

65
Q

complications of Hep B?

A

hepatic failure
cirrhosis
HCC
concurrent HCV/HIV

66
Q

mx of Hep B

A

48week course of injectable pegylated interferon alpha

67
Q

Hep C
incubation?
spread?

A

6 weeks

blood

68
Q

Sx of Hep C?

A

85% asympto

more likely to develop chronic

69
Q

ix in Hep C?

screen?

A

HCV serology
PCR HCV RNA
LFTs

HIV, HBV
HCC (USS, AFP)

70
Q

mx of Hep C?

A

24 weeks of weekly pegylated interferon alpha + daily ribavirin

71
Q

types of autoimmune hepatitis?

A

75% type 1: ANA, ASMA

25% type 2: ALKM-1, anti-LC-1

72
Q

Ix in AI hepatitis

A 
liver biopsy
LFT
IgG
serum protein electrophoresis
FBC
73
Q

mx of AI hepatitis?

monitoring?

vaccines?

A

prednisolone+azathioprine

6m USS+AFP, liver biopsies

Hep A/B vaccines

74
Q

ix in liver abscess?

A

FBC, ESR, LFT, blood cultures, stool MC+S,
USS/CT liver
aspiration + culture

75
Q

mx of liver abscess?

A

abx+drainage+fluids+pain relief

pyogenic –> IV ceftriaxone+metronidazole

amoebic–>metronidazole

76
Q

causes of acute pancreatitis

A

GETSMASHED

gallstones, alcohol, trauma, steroids, mumps, AI, scorpions, hyperlipidaemia/hypercalcaemia, ERCP, drugs

77
Q

acute pancreatitis pathophys?

A

acute inflam –> release of exocrine enzymes –> autodigestion

78
Q

signs of acute pancreatitis?

A 
Cullen's (periumbilical bruising)
Grey-Turner's (flank bruising)
Epigastric tenderness+rigidity
tachycardia, fever, hypoxaemia
jaundice if due to gallstones/alcohol
79
Q

ix for pancreatitis?

A 
serum amylase, serum lipase
FBC, CRP
LFT
CT w contrast
USS
ERCP
80
Q

DDx of acute pancreatitis?

A

ruptured aortic aneurysm

81
Q

pancreas severity score?

A

glasgow score - PANCREAS

PaO2 < 8kPa
Age > 55
Neutrophillia; WCC > 15
Calcium < 2mmol/L
Renal; urea > 16mmol/L
Enzymes; AST/ALT>200
Albumin < 32g/L
Sugar > 10mmol/L
82
Q

mx of acute pancreatitis

A

pain relief
IV fluids
NBM
repeat glasgow score + obs

83
Q

comps of acute pancreatits

A

early [pulm oedema, shock, DIC, renal dysfunction, haemorrhage]

late [necrosis, abscess, pulm oedema, cyst]

84
Q

pres of chronic pancreatits

A 
alcohol.. 
epigastric pain relieved by sitting fwd
N+V
exocrine dysfunction [malabsorp, wt loss, steatorrhoea]
endocrine dysfunction [DM]
85
Q

mx of chronic pancreatitis

A

pain relief
replace enzymes
low fat diet
alcohol abstinence

86
Q

type of pancreatic Ca?

A

infiltratnig ductal adenocarcinoma

87
Q

gene in endocrine pancreatic Ca?

A

MEN1

88
Q

who gets gallstones?

A

fair, fat, fertile, female, forty

89
Q

dx for gallstones?

ix?

when do they get jaundice?

A

USS is diagnostic
urinalysis, CXR, ECG for exclusion

jaundice when stone moves to CBD

90
Q

pres of biliary colic

A

RUQ pain

91
Q

pres of acute cholectystitis

A

RUQ pain + fever/WCC

92
Q

pres of ascending cholangitis

A

RUQ pain + fever/WCC + jaundice

Charcot’s triad

93
Q

positive murphy’s sign =

A

RUQ, 2 fingers, breathe in, halts inspiration, negative on LUQ

94
Q

USS of acute cholectystitis

A

thickened GB wall + fluid/air in GB

CBD diameter > 6mm

95
Q

ix for acute cholectystitis

A 
murphys
USS
ERCP
LFT
Bloods
96
Q

mx of gallstones, colic, acute cholecystitis

A

NBM
pain relief
IV fluids
consider IV ceftriaxone

+/- surgical –> laparoscopic cholecystectomy

97
Q

Reynold’s pentad of ascending cholangitis

A

RUQ + fever + jaundice + altered mental state + hypotension

Infection of bile duct

98
Q

ix in ascending cholangitis

A

WCC, ESR, CRP, LFTs

worry about sepsis, pancreas and AKI -> U+E,s amylase, blood cultures

imaging –> USS, contrast CT, MRCP

99
Q

mx of ascending cholangitis

A

EMERGENCY
O2 + IV fluids + BC + IVabx [metronidazole+ceftriaxone]

emergency biliary drainage if AKI, shock, DIC..

100
Q

comps of ascending cholangitis

A 
septic shock
AKI
systemic dysfunciton 
liver abscess
liver failure
101
Q

primary sclerosing cholangitis?

A

chronic inflam + fibrosis –> multifocal biliary strictures

presents 10-30yo male
linked to IBD

102
Q

ix in primary sclerosing cholangitis

A

LFT, bilirubin
p-ANCA (linked to IBD)
MRCP / USS
biopsy

103
Q

seen on biopsy of primary sclerosing choangitis

A

periductal onion skin fibrosis

104
Q

which vitamins do you give in cholestatic disorders?

A

DEAK

105
Q

mx of primary sclerosing cholangitis?
itch?
prevent progression?

A

treat strictures with balloon dilation

Cholestyramine for itch

ursodeoxycholic acid + avoid alcohol

106
Q

primary biliary cirrhosis?

assos with?

A

progressive AI disease –> destruction of interlobular bile ducts
presents 40-60 female

sjogrens

107
Q

ix in PBC/

A

Biopsy - granulomatous

AMA
TFT
USS
MRCP
FBC, LFT
108
Q

Mx of PBC?

A

ursodeoxycholic acid slows progression

immunosuppression: MTX, steroids

109
Q

what promotes cholestasis?

A

oestrogen

COCP

110
Q

Bloods in cholestasis?

A

elevated bilirubin
elevated alk phos
elevated GGT
low albumin in chronic

111
Q

liver failure worry with hypoK and hypoMg

A

Torsade de pointes –> VF

112
Q

signs of decomp liver failure

A

encephalopathy
ascites
asterixis

hepatorenal syndrome

113
Q

blood supply to liver

A

80% hepatic portal vein

20% hepatic artery

114
Q

portal HTN > what?

A

> 5mmHg

>10 is severe

115
Q

what does NO do in kidney due to liver failure

A

causes constriction –> hepatorenal syndrome

[dilation everywhere else in body]

116
Q

blood tests specific for liver problemos?

A

albumin
bilirubin
PT

117
Q

look for in ascitic tap?

A

polymorphs - sign of spontaneous bacterial peritonitis

118
Q

isolated rise in ALP

A

bony mets, vit D deficiency, fracture, osteodystrophy

119
Q

HBeAg

A

sign of active replication

120
Q

HBeAb

A

sign of current clearing of infection [disappears after beating infection]

121
Q

IgM

A

infection at the Moment

122
Q

IgG

A

after it is Gone

123
Q

Worry in Crohns?

worry in UC?

A

Crohns - small bowel obstruction

UC - toxic megacolon

124
Q

treatment of Hep B?

A

pegylated interferon alpha

tenofovir / entecavir

difficult to clear the virus as it is a DNA virus

125
Q

treatment of Hep C?

A

AIM TO CURE

Finals (20 decks)

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