Liver Flashcards
ALT/AST which is more specific for liver damage?
ALT
when levels are raised what do these ratios indicate?
AST:ALT = 1
AST:ALT > 2.5
AST:ALT < 1
AST:ALT = 1
Ischaemia
AST:ALT > 2.5
Alcoholic hepatitis
AST:ALT < 1
High ALT for hepatocellular damage e.g. paracetamol OD with hepatocellular necrosis, viral hepatitis, ischaemic necrosis, toxic hepatitis
What are ALP and GGT elevated in
cholestasis
What is associated with cholestasis and malignant hepatocellular damage + marker of bone turnover
ALP
What is sensitive to alcohol ingestion
GGT
Name 2 inherited causes of liver disease
Hereditary haemochromatosis
Deficiency of iron regulatory hormone hepcidin
Wilson’s disease
Hepatolenticular degeneration - accumulation of copper at tissues
Alpha-1 antitrypsin deficiency
Affects liver and lungs (emphysema)
Gene in hereditary haemochromatosis?
HFE
AR
Mech in Heerditary haemochromatosis
Increased intestinal absorption of iron leading to accumulation in tissues
Sx of hereditary haemochromatosis
Early: fatigue, weakness, arthralgia, erectile dysfunction
Late: skin bronzing, diabetes, cirrhosis (liver signs), impotence, cardiac arrhythmia
Name 3 Ix in Hereditary haemochromatosis
- Iron studies
- Serum ferritin (high) - lots of iron in cells
- Transferrin saturation (>45%) - lots of iron in blood specific
HFE genetic testing
LFTs
MRI - iron overloaded liver
Liver biopsy with Perl’s stain *Liver fibroscan/transient elastography
ECG/ECHO for cardiomyopathy
Why is serum ferritin not very specific
low specificity as acute phase protein
Mx of hereditary haemochromatosis
Venesection/phlebotomy 4-500ml weekly
monitor ferritin
low iron diet
liver transplant - when decompensated
Wilson genetics
AR
ATP7B gene
Mech in wilson - where is copper deposited?
Disorder of biliary excretion of copper
liver , basal ganglia
Name 3 Ix in wilsons
copper studies - low, urinary copper ^^^
slit lamp - kayser fletcher
liver biopsy
MRI - BASAL GANGLIA
name 3 Mx of wilsons
Penicillamine
zinc - reduces copper absorption
low copper diet (avoid mushrooms, liver, chocolate, nuts)
Monitor hepatic function, renal function, FBC and clotting
Avoid alcohol and hepatotoxic drugs
2 organs affected in A1AT deficiency
Lung
Dyspnoea, wheezing, cough i.e. COPD (lung bases commonly)
Liver
Hepatitis, cirrhosis (HCC), fibrosis
Ix in A1AT
Serum A1AT (low) -> phenotyping required
CXR and LuFT
LFT and biopsy
Mx of A1AT ? what do you monitor?
Avoid smoking / alcohol
Mx of COPD
Monitor LFTs , treat cirrhosis, screen for HCC
4 characteristics of liver failure
Hepatic encephalopathy
Jaundice
Abnormal bleeding
Ascites
Name 3 DDx of liver failure
Paracetamol, alcohol, medications (co-amoxiclav, cipro, doxy, erythro, methotrexate, gold)
Viral hepatitis, EBV, CMV
HCC
Wilson’s A1ATd
Ischaemia, Budd-Chiari
AI liver disease
what happens in hepatic encephalopathy
In liver failure ammonia builds up in circulation and crosses BBB. Astrocytes clear this turning glutamate to glutamine.
Glutamine excess causes fluid shift to cells -> cerebral oedema.
Name 3 signs of chronic liver disease
caput medusae Finger clubbing Leukonychia Asterixis (liver flap) Palmar erythema Spider naevi/scratch marks Shifting dullness Bleeding
drug for paracetamol OD
n-acetylcysteine
Mx of high amonia
lactulose + neomycin
mx of raised ICP
mannitol
Mx of ascites
restrict fluid - low salt
diuretics
Drain and Human Albumin Solution
What are ascites
collection of fluid in peritoneal cavity
Most common cause of ascites? Name 2 others
75% - cirrhosis
(decreased albumin + portal hypertension)
Malignancy - GI / Ovarian (meigs)
Heart failure
Nephrotic
Ix in ascites, name 3
Abdo USS
CXR (HF / pleural effusion)
LFT
Shifting dullness
triad OE in spontaneous bacterial peritonitis
Who gets it?
guarding, rebound tenderness, pain on palpation
It is bacterial peritonitis secondary to ascites in people with liver cirrhosis
Name 3 Ix in spontaneous bacterial peritonitis
FBC - *leuocytosis
LFT, *U+E (renal impairment), blood cultures
*Diagnostic paracentesis - for culture and amylase
Imaging - upright AXR and CXR
Name 1 organism commonly causing spontaneous bacterial peritonitis and mx
E.coli, enterococci
IV ceftriaxone
In end stage liver failure 40% develop hepatorenal syndrome … general mx
2 types
Long term Mx
Type 1 - rapid - survival ~2 weeks
terlipressin with albumin
Type 2 - last 6 months
TIPS
Admit to HDU
Monitor fluids
Stop nephrotoxic drugs /diuretics
TRANSPLANT
What happens in advanced/decompensated cirrhosis
oedema, ascites, bruising, poor memory, bleeding varices
Decompensated = caput medusae, hepatic encephalopathy, ascites
Name 3 cutaneous signs of cirrhosis
What is cirrhosis?
NECROSIS –> FIBROSIS –> NODULAR FORMATION
FLAPS
(finger clubbing, leukonychia, asterixis, palmar erythema, spider naevi, scratch (pruritus), jaundice, dupuytren’s
Name 3 causes of portal HTN
Pre hepatic
Portal vein thrombosis, splenic vein thrombosis, extrinsic compression e.g. tumour
Hepatic
Cirrhosis, hepatitis, schistosomiasis, granuloma (sarcoid)
Post hepatic
Budd-Chiari, RHF/CHF, constrictive pericarditis
General Mx of cirrhosis? what 2 conditions do you monitor for?
Adequate nutrition and alcohol abstinence, exercise for muscle wasting
Oesophageal varices and HCC
Ix for portal HTN
Name 3
AUSS for liver/spleen/ascites
Doppler ultrasound - blood flows
Spiral CT for portal vasculature
Endoscopy for oesophageal varices
Portal pressure by hepatic venous pressure gradient (normal < 5, varices > 10)
Mx of portal HTN
Reduce portal venous pressure
-BBs, TIPS (Transjugular Intrahepatic Portosystemic Shunt)
Primary prevention of varicies in portal HTN AND prevention of vatical bleeding once you have them
propranolol
Key Ix in varicies
endoscopy (early)
[clotting, group, cross match]
Mx in varicies
terlipressin
oesophageal -> band ligation
gastric -> endoscopic injection of N-butyl-2cyanoacretate
What if mx of varicies doesnt work
Minnesota tube then —> Transjugular Intrahepatic Portosystemic Shunt
what causes Sudden RUQ pain + rapidly developing ascites
[+ hepatomegaly + jaundice + renal involvement (50%)]
Key Ix?
budd-chiari syndrome
[occlusion of the hepatic veins]
doppler ultrasound
Mx of budd-chiari
Treat asicites - eg TIPS
If due to chronic inferior vena cava thrombosis -> warfarin
Usual cause of liver Ca
only 10% primary
Rest are from stomach, colon, lung, breast
Usual cause of primary HCC
Hep c
[HC causes HCC]
What is screened in high risk of HCC Eg. HBV ± cirrhosis and HCV/alcoholic cirrhosis
USS
AFP
name 2 methods of liver Ca prevention
HBV vaccine,
reduced alcohol,
screen those with cirrhosis
Name 3 causes of fatty liver
metabolic syndrome
PCOS
alcohol
HBV/HCV
Dx Ix in fatty liver
Biopsy: cells swollen with fat
mx fatty liver
no alcohol
wt loss + exercise
mx of cause
What is higher in steatohepatitis - AST or ALT
ALT
Name 2 things on histology of hepatitis ? chronic?
Lobular disarray
Inflammatory cell infiltrate
xone 3 necrosis
bile duct proliferation
chronic = lymphoid follicles at portal tract - classical
hep A
incubation?
spread?
2-6 weeks
feaco oral
Hep A Ix
HAV IgM - acute
HAV IgG - lasts years
LFT (AST:ALT <1)
Hep A Mx ?
For itch?
fluids, antiemetics, rest, avoid alcohol
cholestyramine
What dissolves gall stones
ursodeoxycholic acid
Hep B spread
Incubation?
Parenteral - blood or body fluid
Vertical:
Horizontal: sexual
60-90 days
What is HBsAg
HBsAb
HBsAg - found at current infection (may be produced as vaccine)
HBsAb indicates immunity post infection/vaccine
Ix in Hep B ? Name 2 things you’d screen for
PCR HBV (for response to therapy and viral replication)
Viral serology
FBC, LFT, clotting, ferritin, AA screen, caeruloplasmin
Screen for liver cancer (USS AFP) + Hep C + HIV
3 methods of prevention for Hep B
Blood screening, safe sex, vaccination
Complications of HBV
Fulminant hepatic failureRelapse
Cirrhosis
HCC
Concurrent HCV/HIV (increases progression to cirrhos
HCV spread?
Incubation ?
Blood
6 weeks
Most common sx of HCV
85% aSx -> more likely to develop chronic
Name 3 Ix in HCV
HCV serology
PCR HCV RNA
LFT (AST:ALT < 1) will fluctuate in chronic infection
HIV, HBV testing
Biopsy for degree of inflammation and fibrosis if
What screening in HCV infection
HCC - USS
AFP
Mx HCV
24 weeks weekly SC pegylated interferon alpha
+ daily oral ribavarin (for 6M)
2 types of AI hepatitis
75% Type 1: ANA (anti-nuclear Ab), ASMA (anti-smooth muscle Ab)
Type 2: ALKM-1 (anti-liver-kidney-microsomal), anti-LC-1 (anti-liver-cystolic)
3 Ix in AI hepatitis
Liver biopsy
LFT
Raised IgG
Serum protein electrophoresis
FBC + blood film
Mx AI hepatitis ?
monitor what?
vaccination?
Prednisolone + azathioprine
6M USS + AFP, liver biopsies,
Hep A/B vaccination
Liver abscess- name 3 Ix?
FBC - raised WCC, mild anaemia
Raised ESR
Abnormal LFT
Blood cultures - 50%
Stool microscopy and cultures - cysts or trophozoites of E.histolytica
CXR - right reactive pleural effusion, raised hemidiaphragm
USS/CT liver - show abscess and guide aspiration
Aspiration + culture
Mx of liver abscess
What if pyogenic?
amoebic?
ABX ± drainage + fluids + pain relief
pyogenic - IV ceftriaxone + metronidazole
Amoebic - metronidazole
Causes of acute pancreatitis
GETSMASHED
gallstones, alcohol, trauma, steroids, mumps, AI, scorpions, hyperlipidaemia/hypothermia/hypercalcaemia, ERCP, drugs
what happens in acute pancreatitis
Acute inflammation of pancreas releasing exocrine (secrete via ducts) enzymes causing autodigestion of organ.
Usual cause of acute pancreatitis
Gallstones block bile duct -> back pressure in main pancreatic duct -> periductal necrosis
Name 3 clinical signs of acute pancreatitis
Cullen’s sign (periumbilical bruising)
Grey Turner’s sign (flank bruising) - retroperitoneal haemorrhage
Epigastric tenderness + rigidity (fluid shift to gut and peritoneum)
Tachycardia, fever, hypoxaemia
Jaundice if cause is gallstones/alcohol
Main test for pancreatitis ?
Key Ix for prognosis?
?gallstones?
name 2 imaging
Main - Serum amylase x3 (lipase)
prognosis FBC (leukocytosis), CRP (>200 = pancreatic necrosis)
gallstones LFT (AST:ALT > 3), raised bilirubin Hypocalcaemia, hyperglycaemia, raised urea
Imaging CXR - exclude perforation, shows ARDS CT with contrast is diagnostic USS - swollen pancreas ± gallstones ERCP
Key DDx for acute pancreatitis
ruptured / dissecting aortic aneurysm
Score for pancreatitis severity? 3 parts of it
Modified glasgow score - PANCREAS
PaO2 < 8kPa
Age > 55
Neutrophilia: WCC > 15
Calcium <2mmol/L
Renal, urea > 16mmol/L
Enzymes:
AST/ALT>200 units
Albumin <32g/L
Sugar > 10mmol/L
Mx of acute pancreatitis
Pain relief
(pethidine or buprenorphine ± IV benzodiazepines
IV fluids
Nil by mouth
Repeat glasgow + obs
Name 2 acute and 2 chronic comps of acute pancreatitis
Early: Pulm oedema Shock DIC renal dysfunction Haemorrhage
Late: Necrosis abscess pulm oedema cyst - 4wks after
Presentation of chronic pancreatitis
alcohol…
Epigastric pain relieved while sitting forward
N+V
Exocrine dysfunction: malabsorption, wt loss, diarrhoea, steatorrhoea
Endocrine dysfunction: diabetes mellitus
Mx of chronic pancreatitis
Pain relief
replace enzymes
Low fat diet, alcohol advice
What type are 90% of pancreatic Ca
infiltrating ductal adenocarcinoma
Gene in endocrine pancreatic Ca ?
MEN1 (AD familial cancer syndrome)
Who gets gallstones
Fair, fat, fertile, female and forty
Dx for gallstones ? other Ix?
when do people get jaundiced?
USS is 90-95% sensitive for stones
Urinalysis, CXR, ECG for exclusion
Jaundice if stone moves to CBD
Differentiate gallstones causing... biliary colic Acute cholecystitis Ascending cholangitis Pancreatitis
biliary colic
RUQ pain
Acute cholecystitis
RUQ pain + fever/WCC + positive Murphy’s sign
Ascending cholangitis
RUQ pain + fever/WCC + jaundice - Charcot’s triad
Pancreatitis
Jaundice - raised bilirubin, alk phos, GGT
What is a +ve murphy’s
2 fingers, breathe in, halts inspiration, negative on other side
Seen on USS of acute cholecystitis
thickened GB wall (>3mm) + fluid or air in the GB, CBD diameter >6mm
3 Ix for acute cholecystitis
Murphys USS ERCP LFT Bloods
Managing gallstones, colic, and acute cholecystitis
Non vs surgiclal
NBM
Pain relief - opiods
Iv fluids
(Consider IV Ceftriaxone)
Surgical
Laparoscopic cholecystectomy
Reynolds pentad of ascending cholangitis (infection of bile duct)
RUQ + fever/chills + jaundice + altered mental state + hypotension/tachycardia
[JAH RastaFari]
Name 3 Ix in ascending cholangitis
WCC/ESR/CRP, LFT
Worry about sepsis, pancreas and AKI
U+E, amylase, blood cultures
Imaging
KUB XR + AUSS + contrast CT (best method), MRCP (Magnetic resonance cholangiopancreatography)
Mx of ascending cholangitis
Medical emergency
O2 + IV fluids + BC + IVABX ?metronidazole + ceftriaxone
Emergency biliary drainage if AKI, shock, DIC etc
Name 3 comps of ascending cholangitis
Septic shock AKI All other system dysfunction Liver abscess Liver failure
What happens in Primary sclerosing cholangitis
Chronic inflammation + fibrosis of intra + extrahepatic bile ducts leading to multifocal biliary strictures
Ix in Primary sclerosing cholangitis
bloods - LFT, bilirubin, bile
Igs
-p-ANCA
Imaging
MRCP / USS
-Bead sign
Biopsy
Seen on biopsy of Primary sclerosing cholangitis
periductal onion skin fibrosis
What nutritional supplement for cholestatic disorders?
Vit ADEK
Main mx of
Primary sclerosing cholangitis? for itch?
Prevent progression?
treat strictures with balloon dilation
colestyramine
ursodeoxycholic acid + avoid alcohol
What is primary biliary cirrhosis?
Condition closely related to?
progressive AI disease causing destuction of small interlobular bile ducts
sjorgrens
[SS - Small ducts, Sjorgrens]
Key Ix in PBC ? Name 2 other
***Biopsy - granulomatous
AMA - antimitochondrial antibody
TFT - associated
USS
MRCP - rule out PSC
FBC - raised ESR
LFT - raised ALK phos
Mx of PBC
Ursodeoxycholic acid slows disease progression
Other than that they’re pretty fucked and might wants transplant if it gets repeal bad
What promotes cholestasis - so avoid in many of these conditions
oestrogen
COCP
Seen on bloods with cholestasis
elevated serum bilirubin, elevated alkaline phosphatase (>3x), raised GGT
Low albumin in chronic
Differentiate PSC / PBC
PSC
Linked to IBD + P-ANCA
Male 10-30 [like Dan and his UC]
PBC Sjorgrens / Thyroid , CREST AMA Alk phos raised Female - 40-60
Liverfailure key worry with hypoK and HypoMg
Torsade du pointes
Name 2 signs that mean decompensated liver failure
Liver failure
encephalopathy
ascites
asterixes
Hepatorenal syndrome
Liver blood supply
80% hepatic portal vein
20% hepatic artery
When is portal hypertension
> 5mmHg (<10 is severe)
What does NO do in kidney due to liver failure
causes constriction -> hepatorenal syndrome
[Dilation everywhere else in body]
Which blood tests most specific for liver problems
albumin - low levels indicate failure of synthesis by liver
bilirubin - Rises
PT - raised
what do you look for in ascitic tap
polymorphs - sign of spontaneous bacterial peritonitis
ALT
AST
ALP
ALT - Liver [L]
AST - more Systemic [S]
ALP - bile duct / cholesttasis [Pipes]
Isolated ALP rise
bony mets, vit D deficiency , fracture, renal osteodystrophy
Urine / stool in pre inta post hepatic ?
pre - normal
liver - dark urine
post - dark urine and pale stools
HbeAg
HbeAb
Sign of active replication
Sign of current clearning of infection [Dissapears after full beating of infection]
IgM
IgG
M - infection at the Moment
G - after Gone
Abdo Xray
Big cuddly Spanish Giants
Bones, Calcium, Soft tissue, Gas
Key worry in Crohns / UC
Uc - toxic megacolon
Crohns - Small bowel obstruction
How is Hep B spread?
Commonest is vertical transmission.
Other: needle, transfusion, sexual
Explain the structure of the hep B virus and how this relates to testing for active/previous hep B?
The virus is a DNA virus. The DNA is surrounded by core antigen. This is then surrounded by surface antigen. Between these two layers there are floating E antigens.
If a test result is positive for any of surface antigen, E antigen or viral load (this comes from broken off pieces of viral DNA) then the patient HAS GOT HEP B.
If the patient has previously had hepB, they may have surface antiBODY and E antiBODY and core antiBODY.
If a patient has had a hepB vaccine but never had hepB then they will have the surface hepB antibody but nothing else - this is because this antibody is injected as the vaccine but they will not have the other bits as they haven’t had previous exposure to the virus.
What is the treatment of hepB?
Gold standard = plegylated interferon alpha = weekly injectable for 48 weeks.
other options = oral tenofovir or entecavir.
Difficult to clear the virus as it is a DNA virus.
A patient presents with:
jaundice
pale stools/dark urine
painful splenomegaly
itch
ACUTE HEPATITIS
conjugated bilirubinaemia.
How is hepC transmitted?
parenteral - usually IVDU
diagnosis of hepC
viral serology to look for hepC antibody
PCR - to confirm current infection
They will then undergo a liver fibroscan - looks at the risk of cirrhosis and HCC (if they are higher risk they need AFP surveillance)
tumour marker for HCC
AFP
Treatment of hepC
AIM IS CURE
They will have a fixed combination of two antiretroviral drugs for 12ish weeks depending on the drug.
Don’t know if we need to know the names of these… find in infectious diseases booklet.
hepatitis histology
mallory bodies
swollen hepatocytes
steatosis
alcoholic hepatitis presentation
treatment
rapid onset jaundice
signs of liver disease
investigation = LFT (^^^AST and GGT), FBC (microcytic anaemia), USS
Poor prognosis = PT time (coagulation)
treatment = stop drinking and steroids if doesn’t respond
Non invasive liver screen
genetic disorders
FBC/clotting
LFTs
HepB antigen
EBV/CMV
ANA/anti-smooth muscle
reblead in vatical bleed post OGD
TIPS
