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HEPATOBILIARY SYSTEM 303 > Liver and Gall Bladder Disease > Flashcards

Liver and Gall Bladder Disease Flashcards

1
Q

What is portal circulation?

A

Blood from gut (portal circulation) but is oxygen poor and nutrient rich
FLOWS INTO LIVER

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2
Q

What system flows out of the liver? Explain it

A

Bile squashed into gut to help digest food
Bile salts form primary and 2ndry bile acids which are reabsorbed to conserve energyj
BILIARY SYSTEM FLOWS OUT OF LIVER

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3
Q

Microanatomical features of the liver?

A

Lobules with a central hepatic vein

Hexagon - portal triads in the corner

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4
Q

What does the liver do?

A

Detoxification: filters and cleans blood of waste products (drugs and hormones)
Immune funcs: fights infecs and diseases
Synthesis of clotting factors, proteins, enzymes, glycogen and fats
Production of bile and breakdown of bilirubin
Energy storage (glycogen and fats)
Regulate fat metabolism
Ability to regenerate

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5
Q

Regarding metabolism, what does the liver do?

A

Liver maintains continuous supply of energy by controlling the metabolism of CHO and fats

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6
Q

What varies the role of the liver?

A

Fasting, absorption, digestion, metabolism

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7
Q

What regulates the liver?

A

Endocrine glands e.g. pancreas, adrenal, thyroid

Nerves

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8
Q

How to categorise liver injury?

A 
Time: acute (due to hep A,B,E, EBV, drugs, vascular) or chronic (due to alcohol, viral, autoimmune, vascular, metabolic) (chronic = decompensated cirrhosis when bleeding)
Pattern: hepatic vs cholestatic vs mixed
Presentation: asymptomatic vs symptoms
Severity: Cirrhotic vs non-cirrhotic
By cause
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9
Q

Presentation of acute liver injury?

A

Asymptomatic
Abnormal LFTs (liver function tests) and coagulopathy
Malaise, nausea, anorexia
Jaundice

Confusion

Bleeding
Liver pain

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10
Q

Presentation of chronic liver injury?

A

Abnormal LFTs
Hepatomegaly
Malaise, abdo discomfort
Itching

Oedema
Haematemesis 
Easy bruising (coagulopathy)
Jaundice
Confusion
Anorexia, wasting
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11
Q

Name the serum liver function tests (LFTs)

A 
Albumin and billrubin = true LFT
ALP - alkaline phosphatase
GGT - gamma GT
ALT - alanine aminotransferase
AST - aspartate aminotransferase
Bilirubin
Globulin

Platelet count
INR/prothrombin time

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12
Q

What jaundice is usually first noted?

A

Scleral jaundince

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13
Q

What causes jaundice?

A

An increase in bilirubin

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14
Q

What is bilirubin?

A

A breakdown product of haemoglobin

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15
Q

How is bilirubin metabolised?

A

In liver
Excreted via the intestine and renally
If bilirubin rises and is not excreted the motion turns pale
Bilirubin metabolism can be interrupted at various points

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16
Q

Causes of jaundice?

A 
Pre-hepatic:
- Haemolysis (increased substrate)
Hepatic: (intrinsic liver disease)
- Cirrhosis
- Infil of liver by tumours
- Acute hepatitis
Post hepatic (obstruction of biliary outflow)
- Gallstones
- External compression: pancreatitis, lymphadenopathy, pancreatic tumour
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17
Q

Causes of chronic liver disease?

A

Non alcoholic steatohepatitis (NASH)
Alcohol
Viral hepatitis (B, C)

Less common:

  • Autoimmune hepatitis
  • Metabolic: Wilson’s
  • Vascular: portal vein thrombosis
  • Drugs: Chemo
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18
Q

Most common cause of cirrhosis?

A

Alcohol

= alcoholic liver disease is rapidly increasing in number of deaths

19
Q

What is the weekly safe limit of alcohol?

20
Q

How many units is classed as harmful drinking?

A

15-28/week

21
Q

How many units are classed as hazardous drinking?

A

> 28 units

22
Q

How many units for binge drinking?

A

Male >10 units in 1 session

Female >7 units

23
Q

What is one unit?

A

Half a pint of beer/larger
Small glass of wine
Pub measure of spirits

24
Q

Features of non-alcoholic fatty liver disease?

A

Increasing
LFTs may be normal
Affecting 20% of the western population

25
Risk factors of non-alcoholic fatty liver disease?
Diabetes, obesity, hypertension, dyslipidaemia = metabolic syndrome
26
Chronic viral hepatitis features?
B and C cause chronic hep = 500 million people infected Transmitted through blood and body fluids Kill 1.5 million/yr
27
Prevalence of HCV in the UK?
<1% 2-400,000
28
What is the most common cause of hep C?
IV drug use and tattooing | Med treatment abroad
29
Prevalence of HBV worldwide?
2 billion
30
Features of hep B?
``` DNA virus Reads in hepatocyte genome Persists in liver even if no longer in blood Can reactivate Mainly transmitted by intercourse Early infec: chronically Vaccination available Longterm treatment ```
31
Hep C features?
RNA virus Mainly transmitted by IVDA: needs blood products Once cleared = cleared Reinfec possible: No immunity Time limited treatment well tolerated, 90% cure No vaccination
32
Stages of chronic liver disease?
NCPH = non-cirrhotic portal hypertension - Due to vascular problems in liver - Tolerating bleeding well and clotting generally intact - Rare Pre-cirrhotic: - No effect on dental work - May be symptomatic Liver cirrhosis
33
What is cirrhosis of the liver?
Result of chronic longstanding damage to the liver and the liver cannot regenerate Scar tissue replaces healthy tissue = disruption of the liver architecture Increased resistance to blood flow through liver = portal hypertension and its complication
34
How to spot compensated and decompensated liver cirrhosis?
Compensated: - Invisible - Blood can be normal - Low risk Decompensated: - Visible - Abnormal blood tests - High risk
35
Prognosis in cirrhosis - child-pugh score?
``` A = 5-6 points = compensated, no risks and low mortality B = 7-9 = increased chance C = 10-15 points, do poorly ```
36
Complications of chronic liver disease?
Acute: - GI bleeding - Ascites - Jaundice - Hepatic encephalopathy - Renal impairment - Coagulopathy - Infec Chronic: - Malnutrition - Bone disease
37
What does portal hypertension look like?
``` Red spot = high risk of bleeding Low platelet count = thrombocytopenia Large stomach (ascites) ```
38
What can hepatocellular carcinoma impact?
Can complicate liver cirrhosis | In hep B can occur in Pre-cirhotic liver disease
39
Signs and symptoms of chronic liver disease?
Palmer erythema = red bits in palms Spider naevi = advanced disease Gynaecomastia = enlarged breasts in men Leuconychia = white nails from low albumin Finger clubbing Jaundice Ascites = increased fluid in belly - herniation of belly button
40
Hepatic encephalopathy features?
Feature of decompensation Difficult to spot Can present as overt confusion in a pt with CLD Can be disabling Indicates underlying problem (bleed, infec, constipation) or worsening chronic disease Collateral history
41
How to recognise Hepatic encephalopathy?
Confusion Altered behaviour Coma Collateral history
42
How to test for Hepatic encephalopathy?
Serial 7s 5 star drawing Number connection test Ammonia level >50 - poor correlation
43
Treatment of liver disease?
``` Symptomatic: Diuretics Nutrition support Supplements Propranolol ``` ``` Specific: Antiviral Immunosuppression Relieving obstruction Venesection ```
44
Dental considerations in liver disease?
Med and dental histories Lab investigations: FBC, PT, LFTs Consultation with or referral to physicians before dental treatment Consider hospital setting for advanced surgical procedures Increased bleeding in pts with liver disease - coagulopathy, thrombocytopenia Infection risks and double glove Hep B vaccination Caution in prescribing meds that are metabolised in liver or impair haemostasis - Anaesthetics (local - amides and general - halothane) - Anti-platelet - stop 7 days before - Increased DILI with flucloxacillin and co-amoxyclav - Sedatives Potential for increased drug toxicity in pts with advanced liver disease: - Caution in meds metabolised in liver - Avoid NSAIDS - Paracetamol = safest pain killer - Opiates -slow and low

HEPATOBILIARY SYSTEM 303 (2 decks)

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