Liver Flashcards
A AST:ALT ratio of >2 is indicative of…
Alcoholic liver disease
ALT > AST
Chronic liver disease
What defines chronic liver disease?
> 6mths
What are the two types of cirrhosis and describe the differences?
Give 10 clinical signs of cirrhosis
Compensated - asymptomatic
Decompensated - symptomatic
Ascietes Jaundice Spider naevi Splenomegaly Palmar Erthyema Hepatomegaly Gynecomastia Varices - (in paticular caput medusa) Clubbing Easy bruisinig
What cell activates by injury to cause fibrosis and eventually cirrhosis?
Hepatic stellate cells
What are the two types of NAFLD (non-alcoholic fatty liver disease)
NAFL - steatosis (fatty acid build up in cells)
NASH - non-alcoholic steatohepatitis (more serious)
- steatosis + Inflammation and scarring
Fibrosis isn’t reversible. true or false?
True
When would we suspect NAFLD?
Abnormal USS or deranged LFTs >3mnths
How do you treat NAFLD (both NASH and NAFL)?
Weight loss
Exercise
Why do we worry more about NASH?
Risk of progression to cirrohosis
What are mallory bodies and in what condition do we find it?
What condition is associated with ballooning degeneration (a form of apoptosis which causes hepatocellular swelling)?
NASH - steatohepatitis
ALD (most commonly)
Damaged intermediate filaments in hepatocytes
NASH - ballooning
In alcoholic liver disease what causes the damage/fibrosis?
Acetaldehyde (metabolite of alcohol)
Microscopic differences between fatty liver, alcoholic hepatitis, alcoholic fibrosis and cirrhosis
Fatty liver - fat vacuoles
Hepatitis - hepatocyte necrosis, neutrophils, MALLORY BODIES, fibrosis beginning
Fibrosis - COLLAGEN laid down around cells
Cirrhosis - BANDS OF FIBROSIS separating regeneration nodules of hepatocytes
Important questions with liver disease
Alcohol consumption (how much and how long)
Travel
Risk behaviour
Any over the counter/herbal
Treatment of ALD?
- NO ALCOHOL
- corticosteroids may be used in acute inflammation
- ?transplant
‘Speckled’ liver
Cardiac cirrhosis (due to R sided heart failure causing hepatic congestion)
How do you diagnose cirrhosis?
Biopsy which will show:
Regenerating nodules of hepatocytes
AND
Bands of fibrosis separating these nodules
How is cirrhosis graded?
Child-Pugh score
A - well compensated
B - functional compromise
C - decompensated
OR
MELD score - 3 month mortality
What score is used to see if someone qualifies for transplant?
UKELD score
- UK score for end stage liver disease
What is portal hypertension and what does it result from?
increase of hydrostatic pressure within portal vein or tributaries
Increase resistance to portal flow
Increase portal venous inflow
How does ascites occur (in relation to liver disease)?
Cirrhosis causes increases hydrostatic pressure in splanchci vessels -> release NO (vasodilate) -> decreased blood vol -> baroreceptors in kidneys activate RAAS -> sodium and water retention -> decreased osmotic pressure (from decreased albulium) -> liquid in peritoneum
Signs of ascites?
Huge stomach Shifting dullness (due to liquid)
Treatment of ascites
Decrease salt intake
NO NSAIDS
- spironolactone
- furosemide - loop diueutics
Paracentesis - drain
Hepatorenal syndrome
Kidney failure in those with severe liver damage
RAAS activation causes renal vasoconstriction (to try fix vasodilator)
late complication of decompensated cirrhosis/ascietes
Acute liver failure definiton
Clinical features of acute liver failure
How do you treat it?
(Any insult to liver causing damage in previously normal liver)
Defined as causing encephalopathy and impaired protein synthesis
Classic jaundice etc.
N+V & anorexia
Rest = 3-6mnths recovery + monitor
Paracetamol and liver
Glutathione stores breakdown reactive TOXIC intermediate NAPQ1 into cysteine acid conjugates
How do you treat paracetamol overdose?
Acetlycysteine - replenishes glutathione stores
Diagnostic feature of hydatid cyst?
Daughter cysts of the periphery (appears as dark mark on CT)
What is the most common liver tumour in non-cirrhotic patients?
Haemanginoma
Most often asymptomatic and seen on autopsy
Metastatic cancer is more common than primary live cancer in the absence of liver disease. True/False?
True
How is haemanginoma seen on US?
Well demarcated echogenic spot
Describe the typical appearance of focal nodular hyperplasia?
Central scar with a large artery and radiating branches to the periphery
Describe the histological differences between focal nodular hyperplasia and hepatic adenoma?
FNH - made up of hepatocytes + bile ducts + sinusoids + KUPPFER CELLS
Hepatic adenoma - just hepatocytes
What two drugs is hepatic adenoma associated with?
Anabolic steroids (common in bodybuilders)
The pill
Hepatic adenoma is more common in what sex?
In what sex is it more likely to become maligant?
Females
Males
Focal nodular hyperplasia has the potential to become malignant. True or false?
False
How would you treat hepatic adenomas?
Males - always surgical removal
Females >5cm - surgery
<5cm - annual MRI
Primary liver tumours are more common than secondary liver tumours. True or false?
False
Most liver tumours come from colon mestastes - (think portal system)
What is the tumour marker used for HCC?
Alpha feto protein (AFP) (>400mg)
must not be diagnosed on this purely - some tumours do not increase levels
Patient with HCC may present with ascietes. True or false?
True
What is the first line of treatment in HCC?
Resection followed by transplant
What drug can be administered in HCC as a last resort to increase life by months?
Sorafebnib
kinase inhibitor -> inhibits proliferation of cancer cells
What is the macroscopic difference between ALD and NASH?
There is none
The difference is made on a history of patients alcohol consumption
What is the difference between diagnosis of the two forms of non-alcoholic liver disease?
NAFL - USS
NASH - liver biopsy
What is micronodular cirrhosis associated with?
Alcoholic liver disease - ALD
What liver carcinoma is more common in younger patients, will not cause a rise in AFP and on CT will show stellate scar with radial septa showing persistent enhancement?
Fibro-lamellar carcinoma
How do you investigate for liver cysts?
US
What can cause hydatid liver cysts?
How must be looked out for on US as a diagnostic tool?
How is it managed?
Echinococcus granulosus (tape worm) -> associated with live stock
Daughter cysts (buzzword)
Surgery - most common
What causes polycystic liver disease?
Name the 3 types
Embryonic ductal plate malformation -> malformation of bile ducts -> numerous cysts throughout liver
Von Meyenburg Complexes - completely benign and asymptomatic
ADPKD (autosomal dominant polycystic kidney disease) - can have maifestations in liver
Polycystic liver disease - genetic disease - more of a problem
How is polycystic liver disease managed?
Aim is to halt cyst growth
Most commonly - somatostain analogue - sandostatin (reduces liver volume)
Surgery/transplant if very symptomatic
What can cause abscess formation in liver?
How does it present?
How do you investigate?
How do you treat?
Pus forming cysts
E.coli, klebsellia and step milleri (most common)
Nausea and vomiting Jaundice Abdo pain ~malaise for several months (v similar to ascending cholangitis) Hepatomegaly
US/aspiration - diagnose
CT - for more complex
Broad spectrum IV antibiotics
Aspirate for more specific antibiotic treatment
4 weeks of antibiotic treatment afterwards
What is haemochromatosis?
What gene and chromosome is the abnormality found on? What kind of inheritance?
Describe classic presentation
How is it diagnosed?
How is it managed?
Excess iron deposits in organs in paticular liver
HFE - chromosome 6 - autosomal recessive
Bronzed diabetic
- Diabetes mellitus
- Bronze skin pigmentation
- Hepatomegaly
Measure serum ferritin (iron)
Venesection - remove excess iron
What is Wilson’s disease?
How does it present?
Investigate?
How is it managed?
Autosomal recessive disorder causing reduced ceruloplasmin (copper transporter)
Kaysler-Fleisher rings
Liver disease
Increase in urinary copper
reduced serum copper
PENICILLAMINE
Where is most copper deposited in the brain in a patient Wilson’s disease?
Basal ganglia
What should be suspected in young females taking oral contraceptive with deranged LFTs?
What causes it?
Autoimmune hepatitis
T cells directed against hepatocyte surface antigens
How do you investigate and diagnose autoimmune hepatitis?
Raised LFTs
ASMA and ANA +ve - type 1
LKM +ve - type 2
Liver biopsy
How do you manage autoimmune hepatitis
Corticosteroids + azathioproine
What is spontaneous bacterial peritonitis?
How is it diagnosed?
How is it treated?
Bacterial infection in the peritoneum
NEUTROPHILS in tap will be >250 - important
Co-trimaxazole
What is hepatic encephalopathy?
How does it present?
How is it treated?
Increased ammonia in blood (highly toxic)
LIVER FLAP
Confusion
Drowsiness
General mental disfunction
Lactulose
Antibiotics e.g. rifaximin (supress colonic flora)
What are ASMA antibodies associated with?
What are AMA antibodies associated with?
ASMA = autoimmune hep AMA = PBC
