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Hepatobiliary > Liver and gall disease > Flashcards

Liver and gall disease Flashcards

1
Q

Summarise the Liver’s Blood Supply in 3 points

A

Arterial:

(1) [OXYGENATED, NUTRIENT POOR] Proper Hepatic Artery
(2) [NUTRIENT RICH, OXYGEN POOR] Hepatic Portal Vein
(3) [OXYGEN + NUTRIENT POOR] = Hepatic Veins

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2
Q

Bile flow: Produced, Function, Types

A

In liver as PRIMARY BILE ACIDS + SALTS
metabolism of fats
Primary or Secondary

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3
Q

Functions of liver (5)

A

(1) Detoxification
-filters and cleans blood of waste products
-drugs, hormones
(2) Immune functions
-fights infections and diseases
-RE system
(3) Involved in synthesis of clotting factors, proteins, enzymes, glycogen and fats
Production of bile and breakdown of bilirubin
(4) Energy storage (glycogen and fats)
(5) Regulation of fat metabolism
Ability to regenerate

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4
Q

Microanatomy

A

Organised in lobules with central (hepatic vein)

Hexagon - portal triads in the “corner”

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5
Q

Types of liver injury

A

Acute
–>viral (A,B, EBV), drugs, alcohol, vascular –> liver failure
–> recovery
Chronic
–>recovery
–>cirrhosis –> liver failure (varices, hepatoma)
–> alcohol, viral (B, C), autoimmune, metabolic (iron, copper) –> liver failure (varices, hepatoma)

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6
Q

Presentation of acute liver injury

A 
Asymptomatic
abnormal LFTs
Malaise, nausea, anorexia
Jaundice 
Confusion - think ALF
*rarer*:
Bleeding 
Liver pain
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7
Q

Presentation of chronic liver injury

A 
Ascites, oedema
Haematemesis (varices)
Malaise, anorexia, wasting 
Easy bruising
Itching
Hepatomegaly, 
Abnormal LFTs
*rarer*:
Jaundice
Confusion
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8
Q

Serum “liver function tests” (LFTs)

A 
Albumin
ALP – Alkaline phosphatase
GGT – gamma GT
ALT – Alanine Aminotransferase
AST – Aspartate Aminotransferase
Bilirubin 
Globulin 
Prothrombin time (PT)/ INR
Platelet count
-normal LFTs and normal PT and platelet count do not exclude liver disease/ cirrhosis, but while normal the function is relatively preserved
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9
Q

Albumin
Bilirubin
Prothrombin time (PT)

A

Give some index of liver function

  • if normal would suggest a “preserved” liver function
  • appears normal
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10
Q

ALP – Alkaline phosphatase
GGT – gamma GT
AST – Alanine Aminotransferase
ALT – Aspartate Aminotransferase

A

Give no index of liver function

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11
Q

Jaundice causes: (pre, hepatic, post)

A

Pre-hepatic
-haemolysis
Hepatic
-cirrhosis
-acute hepatitis (viral, alcoholic, autoimmune, drug-induced)
-infiltration of the liver by tumours
Post-hepatic (obstruction of biliary outflow)
-gallstones
-external compression: pancreatitis, lymphadenopathy, pancreatic tumour, ampullary tumour

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12
Q

Bilirubin: what? metabolism? and excretion? what happens if in XS?

A

Breakdown product of haemoglobin
Metabolised in liver
Excreted via 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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13
Q

What is meant by Liver Cirrhosis?
What is it as a result of?
Which tissue is dominant and what is the overall result?
What is the implication of blood flow here?

A

SCARRING of the liver
Result of chronic LONGSTANDING DAMAGE to the liver where SCAR TISSUE replaces healthy tissue (exceed healing capacity of liver) –> leading to disruption of LIVER ARCHITECTURE
= resistance to blood flow through the liver, leading to PORTAL HYPERTENSION and its complication(s)

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14
Q

Causes of chronic liver disease: most common

A

Alcohol
Non Alcoholic Steatohepatitis (NASH)
Viral hepatitis (B, C)

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15
Q

Jaundice: First Sign + Cause

A

Scleral jaundice usually first noted

Due to > bilirubin

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16
Q

Less common causes of chronic liver disease (4)

A

(1) Immune
- autoimmune hepatitis
- primary biliary cirrhosis
- primary sclerosing cholangitis
(2) Metabolic
- haemochromatosis
- Wilson’s
- alpha 1 antitrypsin deficiency…
(3) Vascular
- Budd-Chiari
(4) Drugs
- amiodarone

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17
Q

Weekly safe limits

A

14 units

18
Q

Harmful drinking

A

15-28 units

19
Q

Hazardous drinking (very heavy)

A

> 28 units

20
Q

Binge drinker

A 
Men = >10 units in one session
Women = >7 units in one session
21
Q

Taking an alcohol history

A

1 unit = 8g EtOH
= half pint normal beer/ lager
= small glass of wine
= pub measure of spirits

22
Q

Hepatitis B

Type of virus, Transmissions, Immunity and effectiveness of Tx

A 
DNA virus
Reads in hepatocyte genome
Persists in liver even if no longer in blood
Can reactivate
Mainly transmitted via intercourse/ vertically
Early infection: chronicity
Vaccination available
Longterm treatment
23
Q

Hepatitis C

Type of Virus, Transmissions, Immunity and effectiveness of Tx

A

RNA virus
Mainly transmitted through IVDA; needles blood products
Once cleared = cleared
Reinfection possible - no immunity
Time limited treatment - well tolerated, 90% cure
No vaccination

24
Q

Non-alcoholic fatty liver disease: Risk Factors, LFT signs, Epidemiology

A 
On the rise; often unrecognised
Risk factors
-diabetes
-obesity
-hypertension
-dyslipidaemia = metabolic syndrome
LFTs may be normal; even in advanced disease
Affecting 20% of Western population
25
Q

Iceberg of fatty liver disease: OUTLINE THE TIMELINE between Normal Liver and Hepatic Cell Carcinoma

A 
HCC
NASH CirrhosisNASH
NAFLD with abnormal LFT
NAFLD normal LFT
Normal liver
26
Q

UK HCV prevalence

A 
<1%
2-400,000
IV drug use
Medical treatment abroad
Blood donation screening 1991
27
Q

Complications of cirrhosis (4)

A

(1) Portal hypertension
- ascites
- varices ± haemorrhage
- hypersplenism → thrombocytopenia (↓ platelets)
(2) Hepato-renal syndrome
(3) Encephalopathy
(4) Hepatocellular carcinoma

28
Q

Signs of chronic liver disease (7)

A

Jaundice
-sign of decompensation in chronic liver disease
Leuconchia
-white nails fro hypoalbuminaemia (not liver disease specific)
Palmar erythema
Spider naevi
-sign of advanced liver disease but does not imply decompensation
Gynaecomastia
-sign of liver disease (related to low testosterone) but can also be drug related (spironolactone)
Finger clubbing
-not liver specific
Ascites
-advanced liver disease - decompensation

29
Q

What should we think of in terms of risks when treating a patient with Liver Disease? (3)

A

(1) Potential for increased bleeding in patients with liver disease
-coagulopathy
-thrombocytopenia
(2) Potential for increased drug toxicity in patients with advanced liver disease
-caution should be used in prescribing medications metabolized in the liver
(3) Infection risk, consider extra precautions if higher risk of injury (double gloves)
Hep B vaccination
HCV now very treatable

30
Q

How to manage a patient with Liver Disease (5)

A

(1) Comprehensive medical and dental histories
(2) Appropriate laboratory investigations
- full blood count (FBC)
- prothrombin Time (PT)
- LFTs
(3) Consultation with and/or referral to treating physician(s) prior to dental treatment
(4) Minimise soft tissue trauma during dental procedures
(5) Consideration hospital setting for advanced surgical procedures or coagulopathic pts

31
Q

Stages of (chronic) liver disease (NCPH, Pre-cirrhotic, Cirrhosis)

A 
NCPH = non-cirrhotic portal hypertension
-often due to vacular problems in liver
-tolerating bleeding well and clotting generally intact
-relatively rare (pts generally aware)
Pre-cirrhotic
-no effect on dental work
-may be asymptomatic
Liver cirrhosis
32
Q

Dental considerations in liver disease - medications

A

(1) Caution in prescribing meds metabolised in liver and/ or impair haemostasis -> NSAIDs
(2) anaesthetics: local (amides) and general (halothane)
(3) increased DILI with flucoloxacillin and co-amoxylav

33
Q

Spotting liver cirrhosis (COMPENSATED AND DECOMPENSATED)

A 
Compensated
-invisible
-blood can be normal
-risk low
Decompensated
-visible
-abnormal blood tests
-risks high
34
Q

Prognosis in cirrhosis (diagram)

A 
Time (big to small)
Bilirubin (small to big)
Albumin (big to small)
-as it gets lower ascites develops
INR small to big
Encepalopathy over time
35
Q

Complications of chronic liver disease: chronic (2)

A

Malnutrition

Bone disease

36
Q

Complications of chronic liver disease: acute (6)

A 
GI bleeding and ascites (due to portal hypertension)
Jaundice
Hepatic encepalopathy
Renal impairment
Coagulopathy
Infection
37
Q

Name 4 Specific Treatments for Liver Disease (ACUTE):

A

Diuretics
Nutrition support
Supplements
Propanolol

38
Q

Name 5 Specific Treatments for Liver Disease (CHRONIC):

A 
Antiviral
Immunosuppression
Relieving obstruction
Venesection
Detox from alcohol
39
Q

What is Hepatic Encephalopathy?
How can it present in CHRONIC liver disease?
-

A

One of several features of decompensation
Difficult to spot if subtle
Can present as overt confusion in patient with CLD

40
Q

Recognising hepatic encephalopathy

A

Confusion
Altered behaviour
Coma
Collateral history

41
Q

How to test for hepatic encephalopathy

A 
Serial 7s from 100
"baby hippopotamus"
5-star drawing
Number connection test
Ammonia level >50 (poor correlation)

Hepatobiliary (3 decks)

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