Liver and friends Flashcards
1
Q
What are the functions of the liver?
A
- oestrogen regulation
- detoxification
- metabolises carbohydrates
- albumin production
- clotting factor production
- bilirubin regulation
- immunity → Kupffer cells in reticuloendothelial system
2
Q
Acute presentation of liver failure
A
- malaise
- nausea
- anorexia
- jaundice
rare
- confusion
- bleeding
- pain
- hypoglycaemia
3
Q
Chronic presentation of liver failure (11)
A
- ascites
- oedema
- Dupuytren’s contracture
- malaise
- anorexia
- clubbing
- palmar erythema
- xanthelasma
- spider naevi
- hepatomegaly
- bleeding → haematemesis, easy bruising
4
Q
Progression of chronic liver disease
A
- chronic liver condition
- liver damage
- liver symptoms
- liver cirrhosis if prolonged
- liver failure and higher risk of HCC
5
Q
What bloods can be done to investigate liver failure?
A
- liver function tests LFTs
- liver hepatic enzymes
6
Q
What can be measured in LFTs?
A
- serum bilirubin
- serum albumin
- prothrombin time → INR
serum albumin and PT = best indicators of liver function
7
Q
What can be measured in liver hepatic enzymes?
A
aminotransferases
- leak into blood when hepatocytes are damaged
- AST
- ALT → more specific in disease
alkaline phosphate ALP
- raised in intra/extra hepatic cholestatic disease of any cause
gamma-glutamyl transferase GGT
8
Q
What is liver failure?
A
liver loses its ability to repair and regenerate leading to decomposition
decomposition
- hepatic encephalopathy
- abnormal bleeding
- ascites
- jaundice
9
Q
Causes of liver failure
A
- infection → viral hepatitis
- metabolic → Wilson’s, A1AT
- autoimmune → PBC, PSC
- neoplastic → HCC, metastatic disease
- vascular → Budd Chiari, ischaemia
- toxins → PCM, alcohol
10
Q
Signs of liver failure
A
- jaundice
- coagulopathy
- hepatic encephalopathy
- fetor hepaticus = sweet and musty breath/urine
11
Q
Investigations for liver failure
A
clinical examination
bloods
- raised PT/AST/ALT
- toxicology screen
- FBC, U&E
if ascites present → peritoneal tap with M&C
12
Q
Management of liver failure
A
- fluids
- supportive measures
- treat complications
- transplant
13
Q
How do you treat the complications of liver failure?
A
- ascites → diuretics
- cerebral oedema → mannitol
- bleeding → vitamin K
- encephalopathy → lactulose
- sepsis → sepsis 6, Abs
- hypoglycaemia → dextrose
14
Q
What is alcoholic liver disease
A
effect of long term excessive consumption on liver
- alcoholic related fatty liver
- drinking leads to build up of fat in liver
- reverses in 2 weeks if drinking stops - alcoholic hepatitis
- long term drinking → inflammation in liver sites
- mild version is reversible - cirrhosis
- liver made of scar tissue
- irreversible
15
Q
Investigations for alcoholic liver disease
A
- bloods
- US/CT/MRI liver
- endoscopy for varices
- DIAGNOSTIC = liver biopsy
16
Q
What blood results might you see in alcoholic liver disease
A
- raised ALT/AST/PT
- markedly raised GGT
- raised ALP in later stages
17
Q
Management of alcoholic liver disease
A
- stop drinking
- nutritional support
- steroids improve short term outcomes
- treat complications
- transplant
18
Q
What are the complications of alcoholic liver disease?
A
- Wernicke-Korsakoff encephalopathy
- acute/chronic pancreatitis
- oesophageal varices
19
Q
What is Wernicke-Korsakoff syndrome?
A
- alcohol excess = B1 deficiency
- presents with ataxia, confusion, nystagmus, memory impairment
- treatment = IV thiamine, no alcohol
20
Q
What is NAFLD?
A
- non-alcoholic fatty liver disease
- chronic metabolic syndrome relating to processing and storing energy
- increases risk of heart disease, stroke, diabetes
21
Q
Stages of NAFLD
A
- healthy
- steatosis
- steatohepatitis
- fibrosis
- cirrhosis
22
Q
Risk factors for NAFLD (7)
A
- obesity
- poor diet, low activity
- T2DM
- high cholesterol
- middle age onwards
- smoking
- high BP
23
Q
Clinical presentation of NAFLD
A
- asymptomatic
- N,D&V
- hepatomegaly
24
Q
Investigations for NAFLD
A
- US liver for steatosis
- biopsy = DIAGNOSTIC
fibrosis
- enhanced liver fibrosis blood test
- NAFLD fibrosis score
- fibroscan
25
Management of NAFLD
- weight loss
- exercise
- stop smoking
- control diabetes, BP, cholesterol
- avoid alcohol
- treat fibrosis with vitE or pioglitazone
26
What investigations should be performed after abnormal LFTs
- US liver
- hepB and C serology
- autoantibodies → autoimmune hep, PBC, PSC
- immunoglobulins → autoimmune hep, PBC
- caeruloplasmin → Wilson's
- A1AT levels
- ferritin and transferrin saturation → hereditary haemochromatosis
27
What type of virus is hepA?
RNA
- rarer
- developing world
28
How is HepA transmitted?
faecal-oral transmission
- contaminated food
- fly vectors
29
Pathophysiology of HepA
- acute infection
| - usually cleared by host immune system
30
Presentation of HepA
- non specific symptoms → nausea, anorexia, malaise
after 1-2 weeks → liver symptoms
- jaundice
- hepatomegaly
- skin rash
31
Investigations for HepA
LFTs
- raised ALT, bilirubin
- serology
32
Treatment for HepA
- vaccine available
- treatment often not required
- generally supportive
33
Complications for HepA
- rare
| - acute liver failure
34
What type of virus is HepB?
DNA
- present worldwide
35
Pathophysiology of HepB
- acute infection infects hepatocyte
- usually cleared by cellular response
chronic HBV
- if HBsAg >6 months
- depends on age/immunocompetence
- inflammation can last 10 years → cirrhosis
36
Presentation of HepB
- similar acute infection
| - if chronic, then signs of cirrhosis → jaundice, pruritus etc
37
Investigations for HepB
- LFTs, serology
| if Ag after 6 months, confirm chronic HBV
38
Treatment for HepB
- vaccine available → at risk
| - antiviral treatment → tenofovir = pegylated interferon alpha 2a
39
Complications of HepB
if chronic, increased risk of cirrhosis, HCC
40
What type of virus is HepC
RNA
- more common in UK
41
How is HepB transmitted?
- blood products → IVDU
| - sexually → MSM
42
How is HepC transmitted?
blood/blood products → IVDU>sexually
43
Pathophysiology of HepC
- acute infection often asymptomatic → allows progression to chronic
- chronic HCV causes slowly progressive fibrosis
44
Presentation of HepC
- acute = asymptomatic
| - later on = signs of chronic liver disease
45
Investigations for HepC
- LFTs, serology
| - if Ag after 6 months, confirm chronic HCV
46
Treatment for HepC
- revolutionising from interferon based regimens to directly acting antiviral agents
- Ribavirin = expensive
47
Complications of HepC
- chronic liver disease
| - HCC
48
What type of virus is HepD
RNA
49
How is HepD transmitted?
- blood borne
| - IVDU, sexually
50
Pathophysiology of HepD
- unable to replicate on its own
- requires concurrent HBV infection
- makes HepB more likely to progress to cirrhosis/HCC
51
Presentation of HepD
indistinguishable from acute HBV infection
52
Treatment for HepD
same as HBV
53
Complications of HepD
cirrhosis, HCC
54
What type of virus is HepE
RNA
- common in UK
55
How is HepE transmitted
- faeco-oral transmission
| - undercooked meat
56
Presentation of HepE
- 95% asymptomatic
| - usually self-limiting
57
Investigations for HepE
serology
58
Treatment for HepE
- often not required
| - supportive
59
Complications of HepE
- rare
| - can progress to cirrhosis in immunocompromised
60
What is liver cirrhosis?
- diffuse pathological process
- fibrosis
- conversion of normal liver to structurally abnormal nodules → regenerative nodules
- final stage of any chronic liver disease
- irreversible but significant recovery if underlying cause treated
61
Causes of cirrhosis
- alcohol abuse → alcoholic liver disease
- NAFLD
- hepatitis B, C
- haemochromatosis
- Wilson's
- A1AT deficiency
62
Investigations for cirrhosis
DEFINITIVE DIAGNOSTIC = liver biopsy
blood tests
- INR/PT high
- LFTs
- FBC → thrombocytopenia
- serum electrolytes
US and CT → hepatomegaly
63
Treatment for cirrhosis
same as chronic liver disease
conservative
- fluids
- alcohol abstinence
- good nutrition
treat complications of liver failure
DEFINITIVE TREATMENT = liver transplant
64
Complications of cirrhosis
- ascites
- portal HTN
- varices
- jaundice
- coagulopathy
- hypoalbuminaemia
- portosystemic encephalopathy
65
What is ascites?
fluid in the peritoneal cavity
66
Why do you get ascites in cirrhosis
- hypoalbuminaemia → reduced oncotic pressure
- portal HTN → increased hydrostatic pressure
- renal water retention → peripheral arterial vasodilation mediated by NO
67
Causes of ascites
cirrhosis = commonest cause
4 basic mechanisms
- peritonitis = more leaky
- reduced capillary hydrostatic pressure
- reduced colloid oncotic pressure
- peritoneal lymphatic draining
68
Types of ascites
transudate
- <25 protein
- portal HTN, budd chiari, low plasma protein, HF
exudate
- >25 protein
- peritonitis, peritoneal malignancy
69
Presentation of ascites
- shifting dullness
- weight gain
- abdominal distention
- signs of liver disease
- respiratory distress
70
Investigations for ascites
DIAGNOSTIC = aspiration
- albumin
- neutrophil count
71
Treatment for ascites
1. salt restriction
| - diuretics → furosemide, spironolactone
72
Complications of ascites
spontaneous bacterial peritonitis SBP
- infection of ascitic fluid
- most common causes = E.coli then K.pneumoniae
73
Causes of portal HTN
prehepatic
- portal vein thrombosis
intrahepatic
- cirrhosis
- budd chiari
posthepatic
- RHS HF
- IVC obstruction
74
Symptoms of portal HTN
asymptomatic or symptoms of complications
- ascites
- bleeding varices
75
What are bleeding varices
- GI bleed with chronic liver disease
- most patients with cirrhosis develop varices
- only 1/3 bleed → often massive
76
Investigations for varices
1. GOLD STANDARD = upper GI endoscopy
77
Progression of varices
- rupture
- haematemesis
- blood digested
- malaena
78
Treatment for varices
- beta blocker to reduce CO → reduces portal pressure
- nitrate to reduce portal pressure
- band ligation
- trans jugular intrahepatic portosystemic shunt (TIPSS)
79
Management of active bleeding varices
- urgent endoscopy/gastroscopy
- fluid resusictation
- terlipressin or octreotide
- balloon tamponade
GOLD STANDARD = endoscopic therapy → band ligation/scleropathy
80
How do you prevent reoccurrence of varices?
- 60-80% chance of recurrence within 2 years
secondary prophylaxis
- propanolol/isosorbide
- repeat variceal banding
- TIPSS
81
What is biliary colic?
temporary blockage of the cystic duct by gallstones
82
What is bile made of?
- cholesterol
- pigments
- phospholipids
83
What are gallstones?
occur when there is a disturbance to the equilibrium of bile causing solid deposits
made of
- cholesterol → excess production = obesity, fatty diet
- pigment → haemolytic anaemia
- mixed
84
Risk factors of biliary colic
5 Fs
- fat
- female
- forty
- fair
- fertile
85
Presentation of biliary colic
- classic colicky RUQ pain → worse after eating large/fatty meals
- referred shoulder pain
- N&V
86
Investigations for biliary colic
rule out cholecystitis/cholangitis
DIAGNOSTIC = US
1. stones
2. gallbladder wall thickness
3. duct dilation
87
Treatment for biliary colic
- NSAIDs/analgesia
| - optional lap cholecystectomy → gallstones often recur
88
What is acute cholecystitis
inflammation of the gallbladder
89
Pathophysiology of acute cholecystitis
- gallstones block cystic ducts
- buildup of bile → distends gallbladder
- vascular supply may be reduced
- inflammation
90
Presentation of acute cholecystitis
- generalised epigastric pain migrating to severe RUQ pain
- signs of inflammation → fever/fatigue
- pain associated with tenderness and guarding from inflamed gallbladder and local peritonitis
91
Investigations for acute cholecystitis
- positive murphy's sign
- inflammatory markers → FBC, CRP
- US gallbladder → thick walls
92
What is a positive murphy's sign?
- severe pain on deep inhalation with examiners hand pressed into RUQ
93
Treatment for acute cholecystitis
- Abs
- early lap cholecystectomy (within 7 days) or wait 6 weeks
- fluids and analgesia
94
What is ascending cholangitis?
- medical emergency
| - bacteria ascending through biliary tree → septicaemia
95
What are the types of jaundice?
pre-hepatic
- unconjugated bilirubin
- cause = breakdown of RBCs → haemolytic anaemia
hepatic
- unconjugated bilirubin
- cause = hepatitis
post-hepatic
- conjugated bilirubin → itching
- causes = obstruction, stricture, cancer head of pancreas
96
Presentation of ascending cholangitis
- Charcot's triad
| - Reynolds pentad
97
What is Charcot's triad?
- RUQ pain
- jaundice
- fever and rigors
98
What is Reynolds pentad
- Charcot's triad
- confusion
- septic shock
99
Investigations for ascending cholangitis
- amylase/lipase, LFTs, CRP, FBC
- CT/US gallbladder
- MRCP/ERCP
100
Management of ascending cholangitis
- aggressive fluid resuscitation
- IV Abs → penicillins and aminoglycosides
- pressor support
- ERCP
- cholecystectomy when better
101
What is primary biliary cirrhosis
- progressive autoimmune destruction of liver and biliary tree
- leads to fibrosis then cirrhosis
- AMA +ve against PDC-E2
102
Risk factors for PBC
- female
| - associated with autoimmune disease
103
Presentation of PBC
very non-specific
- fatigue
- pruritus
- liver failure symptoms if advanced
104
Investigations for PBC
- AMA
- LFT → GGT/ALP raised
- US gallbladder
- biopsy
105
Management of PBC
ursodeoxycholic acid to reduce cholestasis
106
What is primary sclerosing cholangitis?
progressive sclerosis of biliary tree → chronic cholestasis and ESLD
107
Causes of PSC
- 80% associated with IBD → UC
- p-ANCA and HLA association
- exact mechanism unknown
108
Diagnostic criteria of PSC
- ALP >1.5x normal for >6 months
- cholangiography → biliary strictures → beaded appearance
- liver biopsy consistent with PSC
109
Presentation of PSC
- 50% asymptomatic until advanced
- non specific pruritus and fatigue
- may be diagnosed after presenting with ascending cholangitis
110
Complications of PSC
predisposed to developing
- HCC
- cholangiocarcinoma
- CRC
111
Management of PSC
- liver transplant
| - non known medical management
112
What is acute pancreatitis
- sudden inflammation of pancreas
| - leads to autodigestion of gland → reversible
113
Presentation of acute pancreatitis
- severe epigastric pain radiating to back
- N&V
- fever and chills
- haemodynamic instability
- retroperitoneal haemorrhage → Cullen's and Grey Turner's signs
114
What is Cullen's sign?
superficial oedema with bruising in the subcutaneous fatty tissue around the peri-umbilical region
115
What is Grey Turner's sign?
discolouration of the left flank associated with acute hemorrhagic pancreatitis
116
Complications of acute pancreatitis
- pancreatic pseudocyst
- insulin dependent DM
- ARDS and pleural effusion
- DIC
117
Causes of acute pancreatitis
I GET SMASHED
- idiopathic
- gallstones
- EtOH
- trauma
- steroids
- mumps/malignancy
- autoimmune
- scorpion stings
- hypertriglyceridaemia/hypercalcaemia
- post ERCP
- drugs → tobacco, thiazides
118
Pathophysiology of acute pancreatitis
gallstones
- blockage of bile duct → backup of pancreatic juices
- change in luminal concentration causes Ca2+ release inside pancreatic cells
- trypsinogen activated early → autodigestion
alcohol
- contracts Ampulla of Vater
- obstructs bile clearance
- affects Ca2+ homeostasis
119
What scoring systems are there for acute pancreatitis?
- APACHE
| - Glasgow&Ranson
120
Investigations for acute pancreatitis
- raised amylase, lipase, CRP
- erect chest xray
- CT/US gallbladder
- MRCP
121
Management of acute pancreatitis
- nil by mouth → bowel rest
- aggressive fluid resuscitation
- analgesia
- Abs if necrotising pancreatitis
- ITU/TPN if required
- ERCP/surgery if required
- treat underlying cause ie gallstones
122
What is chronic pancreatitis?
- long standing inflammation from irreversible damage to pancreas
- can manifest as persistent pain and malabsorption in episodes
123
Causes of chronic pancreatitis
- generally caused by chronic alcohol abuse
- CF
- cancer
- autoimmune
- CKD
124
Pathophysiology of chronic pancreatitis
- obstruction of bicarbonate secretion in pancreatic lumen
- early activation of trypsinogen and autodigestion
- replaced by fibrosis
- can be caused by CF/alcohol → increases trypsinogen activation
125
Presentation of chronic pancreatitis
- epigastric pain radiating to back → less than acute, better when leaning forward, worse with alcohol
- N&V
- steatorrhea
- weight loss → malabsorption
- insulin dependent DM
126
Investigations for chronic pancreatitis
- secretin stimulation test
| - CT, MRI, MRCP
127
Management of chronic pancreatitis
- creon
- insulin
- opioids
- alcohol cessation
- dietary modification
- ERCP/surgery if required
128
What is ERCP?
endoscopic retrograde cholangiopancreatography
129
What is infective diarrhoea?
- increased stool frequency and volume
| - decreased consistency
130
Causes of infective diarrhoea
viral
- rotavirus → children
- norovirus
- adenovirus
bacterial
- e.coli
- norovirus
- c difficile
parasites → giardia
Abs
other
- anxiety
- food allergy
chronic
- IBS
- IBD
- coeliac
- bowel cancer
131
Risk factors for infective diarrhoea
- foreign travel
- crowded area
- poor hygiene
132
Causes of infective diarrhoea
viral
- rotavirus → children
- norovirus
- adenovirus
bacterial
- e.coli
- norovirus
- c difficile
parasites → giardia
Abs
other
- anxiety
- food allergy
chronic
- IBS
- IBD
- coeliac
- bowel cancer
133
Risk factors for infective diarrhoea
- foreign travel
- crowded area
- poor hygiene
134
Pathophysiology of haemochromatosis
- mutation in autosomal recessive HFE gene
- increased intestinal iron absorption
- iron accumulates in liver, joints, pancreas, heart, skin, gonads
- organ damage
135
Presentation of haemochromatosis
- slate grey skin → brownish/bronze
- fatigue, arthralgia, weakness
- hypogonadism eg ED
- chronic liver disease, HF, arrythmia
136
Pathophysiology of haemochromatosis
- mutation in autosomal recessive HFE gene
- increased intestinal iron absorption
- iron accumulates in liver, joints, pancreas, heart, skin, gonads
- organ damage → liver fibrosis, cirrhosis, HCC
137
Presentation of haemochromatosis
- slate grey skin → brownish/bronze
- fatigue, arthralgia, weakness
- hypogonadism eg ED
- chronic liver disease, HF, arrythmia
138
Investigations for haemochromatosis
- bloods → iron study, LFTs
- genetic testing
- MRI → detects iron overload
GOLD STANDARD = liver biopsy
139
Treatment for haemochromatosis
1. venesection
2. iron chelation
DEFINITIVE TREATMENT = liver transplant
140
Complications of haemochromatosis
- cirrhosis
- HCC
- diabetes
- heart disease
141
What is Wilson's disease?
- too much copper
| - builds up in liver and CNS
142
Aetiology of Wilson's
- autosomal recessive
| - defective enzyme involved in biliary excretion of excessive copper
143
Pathophysiology of Wilson's
Cu2+ accumulates in
- liver → liver symptoms
- basal ganglia → Parkinson's
- cornea → kayser-Fleischer rings
144
Presentation of Wilson's
- depression
- neurotic behavioural patterns
- Parkinson's symptoms
- hepatitis, cirrhosis
- Kayser-Fleischer ring → copper in cornea, green/brown pigment at outer edge
145
Investigations for Wilson's
1. serum copper and caeruloplasmin reduced
| GOLD STANDARD = liver biopsy
146
Pathophysiology of A1AT deficiency
A1AT gene
- produced in liver
- inhibits neutrophil elastase → produced with inflammation, infection, smoking
- with A1AT deficiency, elastase breaks down elastic unchecked
- affects lung (alveolar wall destruction) and lung
147
What is A1AT deficiency?
- autosomal recessive genetic disorder
| - results in lung and/or liver disease
148
Pathophysiology of A1AT deficiency
- A1AT defi
149
Presentation of A1AT deficiency
lung
- COPD like symptoms
- SOB
- emphysema
liver
- cirrhosis
- hepatitis
- neonatal jaundice
150
Investigations for A1AT deficiency
- bloods → serum A1AT low
- LFTs, PFTs
- chest xray
- liver biopsy
151
What is peritonitis
inflammation of the peritoneum
152
Pathophysiology of peritonitis
- inflammation from infection of irritation
153
Primary causes of peritonitis
- SBP
| - ascites
154
Treatment for peritonitis
- ABCDE management
- find and treat underlying cause
- IV fluids
- IV Abs → 1. broad spec 2. specific for pathogen
- peritoneal lavage → clean cavity
155
Investigations for peritonitis
bloods
- FBC, CRP
- amylase → pancreatitis
- hCG → ruptured ectopic pregnancy
- erect chest xray → air below diaphragm
- abdo xray → bowel obstruction
- abdo CT → ischaemia
ascitic tap and blood cultures
156
Treatment for peritonitis
- ABCDE
157
What is a hernia?
- protrusion of organ through defect in wall of its containing cavity
158
What are the classifications of hernias?
- reducible
- irreducible
- obstructed = intestinal flow stopped
- strangulated = blood supply cut off → ischaemia +/- gangrene
159
What is an inguinal hernia?
protrusion of abdominal contents through inguinal canal
160
Risk factos of inguinal hernia
- male
- chronic cough
- heavy lifting
- past abdominal surgery
161
Presentation of inguinal hernia
- swelling in groin/scrotum
- may be painful
- may be reducible
162
Investigation for inguinal hernia
- clinical diagnosis
| - US/CT/MRI
163
What is a femoral hernia?
bowel come through femoral canal
164
Presentation of inguinal hernia
- mass in upper medial thigh
- may be cough impulse
- likely to be irreducible and strangulate → due to rigidity of canal's borders
165
Investigation for femoral hernia
- clinical diagnosis
| - US/CT/MRI
166
What is a hiatus hernis?
herniation of the stomach through oesophageal aperture of diaphragm
167
Risk factors of hiatus hernia
- obesity
- female
- pregnancy
- ascites
- advanced age
- skeletal deformities
168
Other types of hernias
- incisional = through surgical scar
- epigastric = through linea alba above umbilicus
- umbilical = at umbilicus
169
Investigations for hiatus hernia
- chest xray
- barium swallow
- endoscopy
- oesophageal manometry
170
Management of hernis
SURGERY
171
What is the most common type of liver cancer?
hepatocellular carcinoma 80%
| - prognosis = 3-6 months if unresectable
172
Presentation of HCC
- chronic liver failure
| - maybe abdominal mass
173
Risk factors for HCC
- HCV and HBV
- EtOH
- aflatoxin
174
Investigations for HCC
- LFTs
- clotting studies
- CT/MRI
- ultrasound grounded biopsy
175
Treatment for HCC
depends on staging
- partial hepatectomy/transplant → curative intention
- chemo to downstage and resect
- palliative chemo to prolong life
176
What is the most common type of pancreatic cancer
pancreatic adenocarcinoma 90%
| - 6% 5 year survival
177
Presentation of pancreatic adenocarcinoma
- unrelenting epigastric pain worse at night
- obstructive jaundice +/- pain
- weight loss and anorexia
- palpable gallbladder → courvoisier's sign
- recent diagnosis of DM
- Trousseau's sign
178
Investigations for pancreatic adenocarcinoma
- bloods → carbohydrate antigen 19-9 and LFTs
- CT +/- endoscopic US gallbladder
- biopsy with histological confirmation
179
Management of pancreatic adenocarcinoma
- surgery → Whipple
| - chemo → neoadjuvant, adjuvant, palliative
180
What is Trousseau's sign?
involuntary contraction of the muscles in the hand and wrist that occurs after the compression with a BP cuff
