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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?

A

14 units

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
Q

Risk factors of non-alcoholic fatty liver disease?

A

Diabetes, obesity, hypertension, dyslipidaemia = metabolic syndrome

26
Q

Chronic viral hepatitis features?

A

B and C cause chronic hep = 500 million people infected
Transmitted through blood and body fluids
Kill 1.5 million/yr

27
Q

Prevalence of HCV in the UK?

A

<1% 2-400,000

28
Q

What is the most common cause of hep C?

A

IV drug use and tattooing

Med treatment abroad

29
Q

Prevalence of HBV worldwide?

A

2 billion

30
Q

Features of hep B?

A 
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
Q

Hep C features?

A

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
Q

Stages of chronic liver disease?

A

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
Q

What is cirrhosis of the liver?

A

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
Q

How to spot compensated and decompensated liver cirrhosis?

A

Compensated:

  • Invisible
  • Blood can be normal
  • Low risk

Decompensated:

  • Visible
  • Abnormal blood tests
  • High risk
35
Q

Prognosis in cirrhosis - child-pugh score?

A 
A = 5-6 points = compensated, no risks and low mortality
B = 7-9 = increased chance
C = 10-15 points, do poorly
36
Q

Complications of chronic liver disease?

A

Acute:

  • GI bleeding
  • Ascites
  • Jaundice
  • Hepatic encephalopathy
  • Renal impairment
  • Coagulopathy
  • Infec

Chronic:

  • Malnutrition
  • Bone disease
37
Q

What does portal hypertension look like?

A 
Red spot = high risk of bleeding
Low platelet count = thrombocytopenia
Large stomach (ascites)
38
Q

What can hepatocellular carcinoma impact?

A

Can complicate liver cirrhosis

In hep B can occur in Pre-cirhotic liver disease

39
Q

Signs and symptoms of chronic liver disease?

A

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
Q

Hepatic encephalopathy features?

A

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
Q

How to recognise Hepatic encephalopathy?

A

Confusion
Altered behaviour
Coma
Collateral history

42
Q

How to test for Hepatic encephalopathy?

A

Serial 7s
5 star drawing
Number connection test
Ammonia level >50 - poor correlation

43
Q

Treatment of liver disease?

A 
Symptomatic:
Diuretics
Nutrition support
Supplements
Propranolol
Specific:
Antiviral
Immunosuppression
Relieving obstruction
Venesection
44
Q

Dental considerations in liver disease?

A

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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