Liver Flashcards
Which transaminase is more specific for liver damage?
ALT
Raised levels, what do these ratios indicate?
AST:ALT = 1
AST:ALT > 2.5
AST:ALT < 1
Ischamia
Alcoholic hepatitis
Hepatocellular damage e.g. viral hepatitis, pcm OD
Raise ALP and GGT?
cholestasis
Sensitive to alcohol ingestion?
GGT
Inherited causes of liver disease?
hereditary haemochromatosis [deficiency of hepcidin]
Wilson’s disease [deficiency of caeruloplasmin –> excess copper in tissues]
Alpha-1 antitrypsin deficiency [affects liver and lungs]
Gene in hereditary haemochromatosis?
How is it inherited?
HFE
Autosomal recessive
Mech in hereditary haemochromatosis?
increased intestinal absorption of iron –> accumulated in tissues
Sx of hereditary haemochromatosis?
Presents 40-50yo
Early; fatigue, weakness, arthralgia, ED
Late; skin bronzing, DM, cirrhosis, impotence, arrhythmias
Ix in hereditary haemochromatosis?
Iron studies [high ferritin, transferrin saturated, serum iron high] HFE genetic test LFTs MRI liver Liver biopsy with Perl's stain ECG
Serum ferritin not specific?
acute phase protein
mx of hereditary haemochromatosis?
Venesection weekly
Monitor ferritin
low iron diet
+/- liver transplant
Wilson’s genetics?
ATP7B gene
autosomal recessive
Mech in Wilson’s - where is copper deposited?
Disorder of biliary excretion [cant get copper into caeruloplasmin]
liver, basal ganglia
ix in wilsons?
copper studies
slit lamp - KF rings
liver biopsy
MRI - basal ganglia
mx of wilsons?
penicillamine
zince reduces copper absorption
low copper diet [avoid mushrooms, liver, chocolate, nuts]
monitor liver, renal function, FBC, clotting
avoid alcohol + hepatotoxic drugs
pres of wilsons?
young adult with liver abnormalities or movement disorder
Kayser-Fleischer rings in 95%
severe depression +/- parkinsonian sx
organs affected in A1AT deficiency?
Lung –> dyspnoea, wheeze, cough
Liver –> hepatitis, cirrhosis, fibrosis
Ix in A1AT?
Phenotyping
CXR, spirometry
LFT, biopsy
Mx of A1AT?
avoid smoking / alcohol
mx of COPD
monitor LFTs, cirrhosis, screen for HCC
Characteristics of liver failure? (4)
hepatic encephalopathy
jaundice
abnormal bleeding
ascites
Ddx of liver failure?
paracetamol, alcohol, other medications viral hepatitis, EBV, CMV HCC inherited ischaemia, budd-chiari autoimmune
hepatic encephalopathy pathophys?
ammonia build up; crosses BBB; astrocytes clear this by turning glutamate to glutamine
Glutamine causes fluid shift into cells –> cerebral oedema
Signs of chronic liver disease?
caput medusae clubbing leukonychia asterixis palmar erythema spider naevi shifting dullness abnorm bleeding
drug used in paracetamol OD?
what time frame?
what can you use in first hour of ingestion instead?
N-acetylcysteine within first 8h
first hour –> charcoal
mx of high ammonia
lactulose + neomycin
mx of raised ICP
mannitol
mx of ascites
fluid + salt restrict
diuretics
paracentesis
human albumin solution
ascites?
fluid in peritoneal cavity
cause of ascites?
75% - cirrhosis (decreased albumin + portal HTN)
malignancy - GI, ovarian (Meigs)
HF
Nephrotic syndrome
ix in ascites
abdo USS
CXR
LFT
shifting dullness (present if 1500ml)
signs in spontaneous bacterial peritonitis?
guarding
rebound tenderness
pain on palpation
ix in spontaneous bacterial peritonitis
FBC, LFT, U+Es, blood cultures
paracentesis for MC+S (and amylase)
imaging
organisms causing spontaneous bacterial peritonitis
E. coli, enterococci
mx of spontaneous bacterial peritonitis
IV ceftriaxone
End stage liver failure can develop ‘hepatorenal syndrome’
2 types + prognosis?
Mx?
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
pres of advanced/decompensated cirrhosis?
oedema ascites bruising poor memory bleeding varices
cutaneous signs of cirrhosis
FLAPS finger clupping leukonychia asterixis palmar erythema spider naevi/scratch
+ jaundice, dupuytren’s
causes of portal HTN
pre-hepatic [thrombosis, extrinsic compression]
hepatic [cirrhosis, hepatitis, schistosomiasis, granuloma]
post hepatic [budd-chiari, HF]
mx of cirrhosis?
monitoring?
nutrition, alcohol abstinence
monitor for varices & HCC
ix in portal HTN?
AUSS doppler USS Spiral CT endoscopy portal pressure [normal<5, varices>10]
mx of portal HTN
BBs, nitrates
TIPS
1 prevention of varices in portal HTN
propanolol
ix in varices
endoscopy
clotting, group+save, cross match
mx in varices
terlipressin
oesophageal -> band ligation
gastric -> endoscopic injection of N-butyl2cyanoacretate (basically glue)
surgical mx of varices
TIPS
Pres of sudden RUQ pain + rapidly developing ascites
[hepatomegaly + jaundice + renal involvement]
dx?
ix?
Budd-Chiari syndrome (occlusion of the hepatic veins)
Doppler US
Mx of budd chiari?
treat ascites eg TIPS
if due to thrombosis –> warfarin
cause of liver Ca?
10% primary
rest are from stomach, colon, lung, breast
cause of primary HCC?
Hep C
blood marker of HCC?
AFP
liver Ca prevention?
HBV vaccine
alcohol abstinence
screening in high risk {HBV, HCV, cirrhosis)
cause of fatty liver?
metabolic syndrome
PCOS
alcohol
HBV/HCV
ix in fatty liver
biopsy - cells swollen with fat
mx fatty liver
no alcohol
wt loss + exercise
mx of cause
steatohepatitis LFTs?
AST + ALT raised
ALT > AST
histology of acute hepatitis?
chronic?
lobular disarray, inflam cell infiltrate, necrosis, bile duct prolif
lymphoid follicles at portal tract
Hep A
incubation?
spread?
2-6 weeks
faeco-oral
Hep A ix
HAV IgM - acute
HAV IgG - lasts years
Hep A Mx?
for itch?
fluids, antiemetics, rest, avoid alcohol
cholestryamine
what dissolves gall stones?
ursodeoxycholic acid
Hep B
incubation?
spread?
60-90d
parenteral, sexual
HBsAg?
HBsAb?
when are they found?
HBsAg found at current infection
HBsAb indicates immunity post infection/vaccine
Ix in Hep B?
screening?
PCR HBV
viral serology
FBC, LFT, clotting, ferritin, caeruloplasmin
Screen for HCC (USS, AFTP) + other BBVs
prevention of Hep B?
blood screening
safe sex
vaccines
complications of Hep B?
hepatic failure
cirrhosis
HCC
concurrent HCV/HIV
mx of Hep B
48week course of injectable pegylated interferon alpha
Hep C
incubation?
spread?
6 weeks
blood
Sx of Hep C?
85% asympto
more likely to develop chronic
ix in Hep C?
screen?
HCV serology
PCR HCV RNA
LFTs
HIV, HBV
HCC (USS, AFP)
mx of Hep C?
24 weeks of weekly pegylated interferon alpha + daily ribavirin
types of autoimmune hepatitis?
75% type 1: ANA, ASMA
25% type 2: ALKM-1, anti-LC-1
Ix in AI hepatitis
liver biopsy LFT IgG serum protein electrophoresis FBC
mx of AI hepatitis?
monitoring?
vaccines?
prednisolone+azathioprine
6m USS+AFP, liver biopsies
Hep A/B vaccines
ix in liver abscess?
FBC, ESR, LFT, blood cultures, stool MC+S,
USS/CT liver
aspiration + culture
mx of liver abscess?
abx+drainage+fluids+pain relief
pyogenic –> IV ceftriaxone+metronidazole
amoebic–>metronidazole
causes of acute pancreatitis
GETSMASHED
gallstones, alcohol, trauma, steroids, mumps, AI, scorpions, hyperlipidaemia/hypercalcaemia, ERCP, drugs
acute pancreatitis pathophys?
acute inflam –> release of exocrine enzymes –> autodigestion
signs of acute pancreatitis?
Cullen's (periumbilical bruising) Grey-Turner's (flank bruising) Epigastric tenderness+rigidity tachycardia, fever, hypoxaemia jaundice if due to gallstones/alcohol
ix for pancreatitis?
serum amylase, serum lipase FBC, CRP LFT CT w contrast USS ERCP
DDx of acute pancreatitis?
ruptured aortic aneurysm
pancreas severity score?
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
mx of acute pancreatitis
pain relief
IV fluids
NBM
repeat glasgow score + obs
comps of acute pancreatits
early [pulm oedema, shock, DIC, renal dysfunction, haemorrhage]
late [necrosis, abscess, pulm oedema, cyst]
pres of chronic pancreatits
alcohol.. epigastric pain relieved by sitting fwd N+V exocrine dysfunction [malabsorp, wt loss, steatorrhoea] endocrine dysfunction [DM]
mx of chronic pancreatitis
pain relief
replace enzymes
low fat diet
alcohol abstinence
type of pancreatic Ca?
infiltratnig ductal adenocarcinoma
gene in endocrine pancreatic Ca?
MEN1
who gets gallstones?
fair, fat, fertile, female, forty
dx for gallstones?
ix?
when do they get jaundice?
USS is diagnostic
urinalysis, CXR, ECG for exclusion
jaundice when stone moves to CBD
pres of biliary colic
RUQ pain
pres of acute cholectystitis
RUQ pain + fever/WCC
pres of ascending cholangitis
RUQ pain + fever/WCC + jaundice
Charcot’s triad
positive murphy’s sign =
RUQ, 2 fingers, breathe in, halts inspiration, negative on LUQ
USS of acute cholectystitis
thickened GB wall + fluid/air in GB
CBD diameter > 6mm
ix for acute cholectystitis
murphys USS ERCP LFT Bloods
mx of gallstones, colic, acute cholecystitis
NBM
pain relief
IV fluids
consider IV ceftriaxone
+/- surgical –> laparoscopic cholecystectomy
Reynold’s pentad of ascending cholangitis
RUQ + fever + jaundice + altered mental state + hypotension
Infection of bile duct
ix in ascending cholangitis
WCC, ESR, CRP, LFTs
worry about sepsis, pancreas and AKI -> U+E,s amylase, blood cultures
imaging –> USS, contrast CT, MRCP
mx of ascending cholangitis
EMERGENCY
O2 + IV fluids + BC + IVabx [metronidazole+ceftriaxone]
emergency biliary drainage if AKI, shock, DIC..
comps of ascending cholangitis
septic shock AKI systemic dysfunciton liver abscess liver failure
primary sclerosing cholangitis?
chronic inflam + fibrosis –> multifocal biliary strictures
presents 10-30yo male
linked to IBD
ix in primary sclerosing cholangitis
LFT, bilirubin
p-ANCA (linked to IBD)
MRCP / USS
biopsy
seen on biopsy of primary sclerosing choangitis
periductal onion skin fibrosis
which vitamins do you give in cholestatic disorders?
DEAK
mx of primary sclerosing cholangitis?
itch?
prevent progression?
treat strictures with balloon dilation
Cholestyramine for itch
ursodeoxycholic acid + avoid alcohol
primary biliary cirrhosis?
assos with?
progressive AI disease –> destruction of interlobular bile ducts
presents 40-60 female
sjogrens
ix in PBC/
Biopsy - granulomatous
AMA TFT USS MRCP FBC, LFT
Mx of PBC?
ursodeoxycholic acid slows progression
immunosuppression: MTX, steroids
what promotes cholestasis?
oestrogen
COCP
Bloods in cholestasis?
elevated bilirubin
elevated alk phos
elevated GGT
low albumin in chronic
liver failure worry with hypoK and hypoMg
Torsade de pointes –> VF
signs of decomp liver failure
encephalopathy
ascites
asterixis
hepatorenal syndrome
blood supply to liver
80% hepatic portal vein
20% hepatic artery
portal HTN > what?
> 5mmHg
>10 is severe
what does NO do in kidney due to liver failure
causes constriction –> hepatorenal syndrome
[dilation everywhere else in body]
blood tests specific for liver problemos?
albumin
bilirubin
PT
look for in ascitic tap?
polymorphs - sign of spontaneous bacterial peritonitis
isolated rise in ALP
bony mets, vit D deficiency, fracture, osteodystrophy
HBeAg
sign of active replication
HBeAb
sign of current clearing of infection [disappears after beating infection]
IgM
infection at the Moment
IgG
after it is Gone
Worry in Crohns?
worry in UC?
Crohns - small bowel obstruction
UC - toxic megacolon
treatment of Hep B?
pegylated interferon alpha
tenofovir / entecavir
difficult to clear the virus as it is a DNA virus
treatment of Hep C?
AIM TO CURE
