Liver

Question 1

What is the blood supply to the liver?

Answer 1

25% of resting cardiac output
Hepatic artery (branch of coeliac axis)- 25%
Portal vein drains GT and spleen- 75% (normal pressure is 5-8mmHg and flow increases after meals

Question 2

What is the capacity of the gallbladder?

Answer 2

50ml

Question 3

When is hypoalbuminaemia seen?

Answer 3

Chronic liver disease
Malnutrition 
Hypercatabolic states- trauma with sepsis 
Nephrotic syndrome 
Protein losing enteropathy

Question 4

What proteins are synthesised in the liver?

Answer 4

Not y-globulins
Albumin, globulin, fibrinogen
Coagulation factors (NOT VIII)

Question 5

What is serum albumin test?

Answer 5

Marker of synthetic function
Falling number in liver disease is a bad prognostic sign
In acute liver disease initial albumin levels may be normal

Question 6

What is prothrombin time (PT) test used for in liver disease?

Answer 6

Marker of synthetic function
Indicator of both acute and chronic liver disease
(Vitamin K deficiency should be excluded for prolonged `PT)

Question 7

What are aminotransferase tests used for in liver disease?

Answer 7

AST- high levels seen in hepatic necrosis, MI, muscle injury and CCF
ALT- rise only occurs in liver disease

Question 8

What is ALP used for?

Answer 8

Present in canalicular and sinusoidal membranes of the liver
Raised in cholestasis from any cause (intra/extra hepatic)
Cholestatic jaundice
metastases
Cirrhosis
Primary biliary cirrhosis and metastases produce highest levels

Question 9

What is y-glutamyl transpeptidase used for in liver disease?

Answer 9

Induced by drugs like phenytoin and alcohol

In cholestasis the y-GT rises in parallel with ALP as it has a similar pathway of excretion

Question 10

What conditions cause changes in haematology?

Answer 10

Bleeding- hypochromic, microcytic
Alcohol- macrocytosis, sometimes with leucopenia and thrombocytopenia
Hypersplenism- pancytopenia
Cholestasis- abnormal cells and vit K deficiency
Acute liver failure and jaundice- haemolysis
Acute viral hepatitis- aplastic anaemia
Hereditary haemochromatosis- raised serum ferritin

Question 11

What are biochemical tests for liver disease?

Answer 11

A1-antitrypsin- deficiency can produce cirrhosis
A-fetoprotein- high levels indicate hepatocellular carcinoma, in pregnancy suggests neural tube defect, hepatitis, chronic liver disease, teratomas
Serum and urinary copper and serum caeruloplasmin- Wilson’s

Question 12

What serum autoantibodies are seen in liver disease?

Answer 12

AMA- primary biliary cirrhosis
Liver/kidney microsomal antibodies- autoimmune hepatitis
ANCA- primary sclerosing cholangitis

Question 13

When is abdominal ultrasound useful?

Answer 13

Jaundiced patient 
Hepato/splenomegaly
Gallstones
Focal liver lesions 
General parenchymal liver disease 
Assessing portal and hepatic vein patency 
Lymph node enlargement

Question 14

Contraindications for liver biopsy?

Answer 14

Prolonged PT >3s
Platelets <80x10
Ascites
Extrahepatic cholestasis 
Renal transplant

Question 15

What are the physical signs in chronic liver disease?

Answer 15

Xanthelasmas
Parotid enlargement 
Spider naevi
Gynaecomastia
Liver (small or large)
Splenomegaly
Clubbing, Dupuytren's, xanthomas 
Stretch marks
Testicular atrophy
Purpura
Pigmented ulcers
Ascites
Oedema
Neurological- disorientation, drowsy
Hepatic flap 
Fetor hepaticus (portal hypertention thios pass into the lungs

Question 16

What are the causes of hepatomegaly?

Answer 16

Cirrhosis- non-tender firm 
Malignancy- hard irregular 
Right heart failure- firm, smooth, tender
viral hepatitis
glandular fever
malaria
abscess: pyogenic, amoebic
hydatid disease
haematological malignancies
haemochromatosis
primary biliary cirrhosis
sarcoidosis, amyloidosis

Question 17

What should you think of if a patient has liver failure following a cardiac arrest?

Answer 17

Ischameic hepatitis
Diffuse hepatic injury resulting from acute hypoperfusion
Often, it will occur in conjunction with acute kidney injury (tubular necrosis) or other end-organ dysfunction.

Question 18

What predisposes hepatorenal syndrome?

Answer 18

Acute liver failure with deranged creatinine

Question 19

What is wernicke’s encephalopathy?

Answer 19

Common cause of confusion and encephalopathy in alcoholic liver disease patients and is due to a deficiency of thiamine

Question 20

What drugs cause a hepatocellular picture?

Answer 20

paracetamol
sodium valproate, phenytoin
MAOIs
halothane
anti-tuberculosis: isoniazid, rifampicin, pyrazinamide
statins
alcohol
amiodarone
methyldopa
nitrofurantoin

Question 21

Which drugs cause cholestasis (+- hepatitis)?

Answer 21

combined oral contraceptive pill
antibiotics: flucloxacillin, co-amoxiclav, erythromycin*
anabolic steroids, testosterones
phenothiazines: chlorpromazine, prochlorperazine
sulphonylureas
fibrates
rare reported causes: nifedipine

Question 22

Which drugs cause cirrhosis?

Answer 22

methotrexate
methyldopa
amiodarone

Question 23

What is the m rule for primary billiary cholangitis?

Answer 23

IgM
anti-Mitochondrial antibodies, M2 subtype
Middle aged females
The demographic (middle-aged female), history (lethargy, pruritus) and liver function tests (rise in ALP and γGT) all point to a diagnosis of primary biliary cirrhosis (PBC). Anti-mitochondrial antibodies are found in 98% of patients with PBC.

Question 24

What is the Budd-chiari syndrome?

Answer 24

Occlusion of the hepatic vein
Triad of abdo pain, tender hepatomegaly and ascites
Acute, chronic or silent course
Occurs with a higher rate amongst pregnant and those on OC