LIVER and GI Flashcards
what can acute and chronic liver injury lead to?
acute - liver failure or recovery
chronic - liver failure, cirrhosis or recovery
what is the differene in cells in acute vs chronic liver injury?
acute - cell damage/loss
chronic - fibrosis
what can cause acute liver injury?
viral (A,B, EBV)
drug
alcohol
Vascular
Obstruction
Congestion
what can cause chronic liver injury?
alcohol
viral (B,C)
autoimmune
metabolic (iron, copper)
what are the presentations of acute liver failure?
malaise - feeling ill/unwell
nausea
anorexia
jaundice
what are the presentations of chronic liver injury?
ascites
oedema
haematemesis (varices)
malaise
anorexia
wasting
easy bruising
itching
hepatomegaly
abnormal LFTs
what things do serum liver function tests measure?
- Serum bilirubin, albumin, prothrombin time
- Serum liver enzymes:
cholestatic: alkaline phosphatase (ALP), gamma-GT (GGT)
hepatocellular: transaminases (AST, ALT)- liver/muscle damage
what does elevated unconjucated billirubin show?
pre-hepatic
what does elevated conjucated bilirubin show?
post hepatic - bile duct obstruction
what can cause pre hepatic jaundice?
Haemolysis, Gilberts
what can cause hepatic jaundice?
Hepatitis: viral, drugs immune, alcohol
Ischaemia
Neoplasm
Congestion (CCF)
what can cause post hepatic jaundice?
Gallstones.
Surgical strictures.
Extra-hepatic malignancy - pancreatic
Pancreatitis.
Parasitic infection - inflammation
what does very high AST/ALT normally show?
liver damage- liver disease/hepatitis/injury
how is biliary obstruction shown on imaging?
dilated intrahepatic bile ducts on ultrasound
what are risk factors for gallstones?
female, fat, fertile
ileal disease
TPN- Total parenteral nutrition
clofibrate - drug lowers cholesterol
where do most gallstones form?
gallbladder
how do you distinguish gallstones in gallbladder vs bile duct?
gallbladder - cholecystitis
bile duct - cholangitis and/or pancreatitis, obstructive jaundice
how are gallbladder stones managed?
- Laparoscopic cholecystectomy
- Bile acid dissolution therapy (<1/3 success
how are bile duct stones managed?
- ERCP with sphincterotomy and: removal (basket or balloon) crushing (mechanical, laser..) stent placement
- Surgery (large stones)
what are the most common reason for drug induced acute liver failure?
- paracetamol
- idiosynchratic drug reaction - unpredicatable, uncommon reaction
what are the types of drug induced liver injury?
Hepatocellular - ALT >2 ULN, ALT/Alk Phos ≥ 5
Cholestatic - Alk Phos >2 ULN or ratio ≤ 2
Mixed - Ratio > 2 but < 5
what drugs cause DILI?
- antibiotics - (Augmentin, Flucloxacillin, Erythromycin, Septrin, TB drugs)
- CNS Drugs (Chlorpromazine, Carbamazepine Valproate, Paroxetine)
- immunosupressants
- Analgesics/musculskeletal (Diclofenac…)
- Gastrointestinal Drugs (PPIs…)
- Dietary Supplements
what drugs do not cause DILI?
Low dose Aspirin
NSAIDs other than Diclofenac
Beta Blockers
HRT
ACE Inhibitors
Thiazides
Calcium channel blockers
how is paracetamol induced fulminant hepatic failure managed?
- N acetyl Cysteine (NAC)
- Supportive to correct:
-coagulation defects
- fluid electrolyte and acid base balance- renal failure
- hypoglycaemia
- encephalopathy
what are Paracetamol-induced liver failure severity indicators ?
- Late presentation - (NAC less effective >24 hr)
- Acidosis (pH <7.3)
- Prothrommbin time > 70 sec
- Serum creatinine ≥ 300 µmol/l
what causes ascites?
- Chronic liver disease - cirrhosis (most)
+/- Portal vein thrombosis - Neoplasia (ovary, uterus, pancreas…)
- Pancreatitis
- heart failure
- kidney disease
- TB
what is the pathogenesis of ascites?
- increased intrahepatic resistance + systemic vasodilation
- causes portal hypertension and secretion of RAAS, noradrenaline, vasopressin
- causes fluid retention and ascites
what is the management of ascites?
- fluid and salt restriction diet
- diuretics - spironolactone +/- ferosemide
- large-vol paracentesis (fluid drainage)
- trans-jugular intrahepatic portosystemic shunt (TIPS)
what can mallorys hyalin with neurophils and fat suggest on a stain?
injured liver cells - fatty liver due to alcohol
what does fatty liver lead to?
alcoholic hepatitis/ cirrhosis
then acute decompensation
what causes portal hypertension?
- cirrhosis
- fibrosis
- portal vein thrombosis
what is a complication of ascities (bacterial)?
Spontaneous bacterial peritonitis
how is Spontaneous bacterial peritonitis managed?
- antibiotic prophylaxis
- consider liver transplant
how is Spontaneous bacterial peritonitis
distinguished?
- neutophils in ascitic fluid
- often gram -ve stain - use blood culture bottles for this
what are some tests for encephalopathy?
Serial 7’s
WORLD backwards
Animal counting in 1 minute
Draw 5 point star
Number connection test
what are the causes of chronic liver disease?
- alcohol
- NASH
- viral hepatitis - B, C
- immune - autoimmune hepatitis, primary biliary cirrhosis, sclerosing cholangitis
- metabolic - wilsons, haemochromatosis
- vascular - Budd-Chiari
what do laborartory tests show when testing for autoimmune hepatitis?
- Elevated liver enzymes (ALT, AST).
- High serum globulin or gamma-globulin levels.
- Presence of autoantibodies - eg ANA, ASMA, ALKM-1, SLA/LP
what is essential to diagnose autoimmune hepatitis?
liver biopsy
- Shows interface hepatitis, lymphoplasmacytic infiltration, rosette formation of hepatocytes, and, in chronic cases, fibrosis or cirrhosis
what are differential diagnosis of autoimmune hepatitis?
- viral hepatitis
- alcoholic liver disease
- non-alcoholic fatty liver disease
- drug-induced liver injury
how is autoimmune hepatitis treated?
- corticosteroids - Prednisone or prednisolone
- azathioprine in comination with above
- immunosuppressants
- liver transplant in liver failure
what are the clinical presentations/ laboratory tests for primary biliary cholangitis?
- more common in females
- fatigue and itching
- abdo pain & jaundice
- elvated ALP and GGT
- +ve antimitochondrial antibody AMAs - 95% of cases
- elevated serum bilirubin and liver enzymes in advanced disease
- elevated IgM levels
what are the treatment options for Primary Biliary Cholangitis?
- Ursodeoxycholic Acid (UDCA) - improves survival
- Obeticholic Acid (OCA) - if above is not tolerated
- Cholestyramine for pruritus
- liver transplant
what are the treatment options for Primary sclerosing Cholangitis?
- Ursodeoxycholic Acid (UDCA) - improves LFTs, not survival
- Cholestyramine for pruritus
- liver transplant
what condition is Primary Sclerosing Cholangitis linked to?
IBD usually ulcerative colitis
what condition is Primary biliary Cholangitis linked to?
sjogren syndrome
rheumatoid artharitis
systemic sclerosis
what is inflammed in Primary Biliary Cholangitis (PBC) vs Primary Sclerosing Cholangitis (PSC)?
PBC - intrahepatic bile duct
PSC - intra and extrahepatic bile duct
what does Primary Sclerosing Cholangitis present with?
- itching
- pain +/- rigors
- cholangitis
- raised ALP and GGT
- more common in males than females
how is Primary Sclerosing Cholangitis diagnosed?
blood tests - raised ALP, AST/ALT
antibodies - anti-smooth muscle, anti-nulcear, PANCA
MRCP - gold standard - “beads on a string”
what is Haemochromatosis?
genetic disorder characterized by excessive absorption and accumulation of iron in the body
what is the most common gene mutation in Haemochromatosis?
C282Y
H63D
- autosomal recessive
how is a diagnosis made for Haemochromatosis?
- suggested by raised ferritin and transferrin levels
- confirmed by genotyping and liver biopsy
what can alpha1-antitrypsin deficiency lead to?
liver disease
emphysema - protein deficiency in blood
what do 50% of cases with hepatcellular carcinoma produce?
alpha fetoprotein
what are risk factor for non-alcoholic fatty liver?
- obesity
- diabetes
- hyperlipidaemia
what are the LFTs in non-alcoholic fatty liver?
mildly elevated
what is NASH?
Nonalcoholic Steatohepatitis
- advanced form of fatty liver disease - also includes inflammation and liver cell damage aswell as fat
- may progress to cirrhosis or hepatocellular carcinoma
what may hepatic vein occlusion be caused by and be treated with?
caused by thrombosis, membrane obstruction, veno-occlusive disease
treated by: anticoagulants, TIPS - shunt
what are the main causes of diarrhoea?
infections - bacteria/viruses
inflammation - chrons
loss of absorptive area - coeliac
Pancreatic disease
Drugs - antibiotics
colon cancer
IBS
what is the main difference in causes of acute/chronic diarrhoea?
acute - viral/bacteria
chronic - parasites or non infectious
what pathogens cause watery diarrhoea?
cholera
staph aureus
rotavirus
norovirus
giardia
(non-inflammatory)
what pathogens cause bloody, mucoid diarrhea?
shingella
e.coli
salmonella
c.diff
campylobacter jejuni
(inflammatory)
whats the most common cause for travellers diarrhoea?
Enterotoxigenic e.coli
what does ETEC, EHEC, EIEC cause?
ETEC - non invasive watery diarrhoea - LT and ST entertoxins
EHEC - Shiga-like toxin. Can cause Haemolytic Uraemic Syndrome (HUS)
EIEC - similar to shingella
what are symptoms of cholera infection and how is it treated?
- “rice water” diarrhoea, vomiting, dehydration
- doxycyline and fluids
what bacteria causes peptic ulcers?
helicobacter pylori
how is H.plori tested for?
breath test
stool antigen test
blood test
what are the tests for peptic ulcers?
test for H.pylori
endoscopy with biopsy
barium contrast x ray - highlights ulcers
ct scan or mri in complications
what is the treatment for peptic ulcers?
CAP - Clarithromycin, Amoxicillin (antibiotics), PPI eg omeprazole (reduce stomach acid)
- H2 blockers - reduce stomach acid to lesser extent
-antacids
- cytoprotective agents for lining of stomach
how is acute cholecystitis diagnosed and treated?
- examination (murpheys sign), bloods/ultrasound to confirm- urgent diagnosis needed
- iv fluids, analgesia, antibiotics, surgery
what are the main symptoms of acute cholecystitis?
- RUQ or epigastric pain
- fever
- leucocytosis
what is charcots triad?
3 symptoms indicating bile ducts problems
- fever
- jaundice
- RUQ pain
what is the treatment of Ascending cholangitis?
- antibiotics
- ERCP
- gallstone removal
what causes enteric fever (typhoid fever)?
salmonella typhi
what are symptoms of enteric fever?
- prolonged fever
- abdo pain, green diarrhoea, maybe constipation
- headache, malaise
- rose spot rash on trunk
- relative bradycardia
how is enteric fever diagnosed?
- blood cultures
- bone marrow culture, if blood -ve, more sensitive
- stool culture - shows extend of shedding
what is the treatment for enteric fever?
antibiotics - azithromycin, ciprofloxacin, cephalosporins
- need early diagnosis and antibiotics ASAP
what are complications of enteric fever?
GI bleed
Perforation / peritonitis
Myocarditis
Abscesses
what is the stool/urine colour in jaundice?
pre-hepatic - stool normal, urine slightly dark/normal
hepatic - stool normal/pale, urine dark
post-hepatic - stool pale, urine dark
what jaundice causes itching?
post-hepatic
sometimes hepatic
what jaundice has both conjucated and unconjucated bilirubin elevated?
hepatic
what are the liver enzymes tests for pre hepatic jaundice?
normal
generally, when are alkaline phosphate ALP levels elevated?
- liver disease - eg hepatitis
- impairment of bile flow eg. bile duct obstruction, primary biliary cirrhosis, and cholangitis.
- bone disease eg pagets
- GI eg celiac
when is Gamma-Glutamyl Transferase (GGT) elevated?
- biliary outflow obstruction
- Primary Biliary Cholangitis
- liver disease
- HF, pancreatitis etc
what does elevated Aspartate Aminotransferase (AST) liver enzyme show?
indicates hepatocellular damage
- but not specific to liver - can be elevated with muscle damage
what do elevated levels of Alanine Aminotransferase (ALT) show?
- hepatocellular damage - (more specific then AST)
how much is one unit of alcohol?
8 grams or 10ml of pure alcohol
how do work out number of units in an alcoholic drink?
Strength of the drink (% ABV)
x
Amount of liquid (Litres)
what is the guideline for drinking per week?
no more than 14 units
what are some alcohol withrawal syndromes?
Tremulousness
Activation syndrome - characterized by tremulousness, agitation, rapid heartbeat and high blood pressure
Seizures
Hallucinations
Delirium tremens - can be severe/fatal
what syndrome is caused by pre-natal exposure of alcohol?
Foetal Alcohol Spectrum Disorder (FASD)
what is the alcohol harm paradox?
the observation that people of low socioeconomic status (SES) tend to experience greater alcohol-related harm than those of high SES, even when the amount of alcohol consumption is the same or less than for individuals of high SES
what do the NICE Guidance 24 : Alcohol-use disorders: preventing alcohol use disorders target?
- price, availability, marketing of alcohol
- licensing
- screening and brief interventions
- supporting children and young people
- referral
what alcohol harm preventions are there in the UK?
- Minimum Unit Pricing
- Restriction on alcohol advertising
- dry january - enables choice
- Alcohol labelling (industry self-regulation), Drinking guidelines
- Media campaigns
what is at risk drinking?
A pattern of drinking which brings about the risk of physical or psychological harm – Screening tools
what is harmful drinking?
Harmful drinking a pattern of drinking which is likely to cause physical or psychological harm
what is Alcohol use disorder or Alcohol dependence?
diagnoses based on DSM-V criteria for AUD or ICD criteria for dependence.
Not solely defined by consumption levels, but also by behavioural, cognitive and physiological responses or problems related to alcohol use.
what are some alcohol screening questions and tools?
- A Clinical Interview – a single question about heavy drinking days
- FAST - Fast Alcohol Screening Test
- AUDIT - Alcohol Use Disorders Identification Test
- CAGE Questions
what are some medications for alcohol dependence?
- Acamprosate Calcium (Campral)
- Disulfiram (Antabuse).
- Nalmefene (Selincro).
- Naltrexone also in drug dependence
what is a positive score in the FAST screening tool?
3 or more
what do the scores in an AUDIT screening indicate?
up to 7 - low risk - no intervention
8-15, 16-19 - increasing/high risk - brief advice
over 20 - possible dependance - referral
what are the CAGE questions for drinking alcohol?
C - cutting down?
A - Annoyed you by people saying to cut down?
G - Guilty feeling about dreeking
E - Eye-opener - taking a drink in the morning?
- 2 or more +ve responses indicate a likely problem
what is the FRAMES interventions for at-risk dinking?
Feedback about the risk of personal harm or impairment
Stress personal Responsibility for making change
Advice to cut down or, if necessary, stop drinking
Provide a Menu of alternative strategies for changing drinking patterns
Empathetic interviewing style
Self efficacy: intuitive style which leaves patient enhanced in feeling able to cope with goals they have agreed