Liver Flashcards
What is the blood supply to the liver?
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
What is the capacity of the gallbladder?
50ml
When is hypoalbuminaemia seen?
Chronic liver disease Malnutrition Hypercatabolic states- trauma with sepsis Nephrotic syndrome Protein losing enteropathy
What proteins are synthesised in the liver?
Not y-globulins
Albumin, globulin, fibrinogen
Coagulation factors (NOT VIII)
What is serum albumin test?
Marker of synthetic function
Falling number in liver disease is a bad prognostic sign
In acute liver disease initial albumin levels may be normal
What is prothrombin time (PT) test used for in liver disease?
Marker of synthetic function
Indicator of both acute and chronic liver disease
(Vitamin K deficiency should be excluded for prolonged `PT)
What are aminotransferase tests used for in liver disease?
AST- high levels seen in hepatic necrosis, MI, muscle injury and CCF
ALT- rise only occurs in liver disease
What is ALP used for?
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
What is y-glutamyl transpeptidase used for in liver disease?
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
What conditions cause changes in haematology?
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
What are biochemical tests for liver disease?
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
What serum autoantibodies are seen in liver disease?
AMA- primary biliary cirrhosis
Liver/kidney microsomal antibodies- autoimmune hepatitis
ANCA- primary sclerosing cholangitis
When is abdominal ultrasound useful?
Jaundiced patient Hepato/splenomegaly Gallstones Focal liver lesions General parenchymal liver disease Assessing portal and hepatic vein patency Lymph node enlargement
Contraindications for liver biopsy?
Prolonged PT >3s Platelets <80x10 Ascites Extrahepatic cholestasis Renal transplant
What are the physical signs in chronic liver disease?
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
What are the causes of hepatomegaly?
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
What should you think of if a patient has liver failure following a cardiac arrest?
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.
What predisposes hepatorenal syndrome?
Acute liver failure with deranged creatinine
What is wernicke’s encephalopathy?
Common cause of confusion and encephalopathy in alcoholic liver disease patients and is due to a deficiency of thiamine
What drugs cause a hepatocellular picture?
paracetamol sodium valproate, phenytoin MAOIs halothane anti-tuberculosis: isoniazid, rifampicin, pyrazinamide statins alcohol amiodarone methyldopa nitrofurantoin
Which drugs cause cholestasis (+- hepatitis)?
combined oral contraceptive pill
antibiotics: flucloxacillin, co-amoxiclav, erythromycin*
anabolic steroids, testosterones
phenothiazines: chlorpromazine, prochlorperazine
sulphonylureas
fibrates
rare reported causes: nifedipine
Which drugs cause cirrhosis?
methotrexate
methyldopa
amiodarone
What is the m rule for primary billiary cholangitis?
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.
What is the Budd-chiari syndrome?
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
