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Phase 2a > Liver and stuff > Flashcards

Liver and stuff Flashcards

1
Q

what does the liver do

A

glucose and fat metabolism
detox and excretion
protein synthesis - albumin/clotting factors
defence against infection - reticuloendothelial system

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2
Q

what does the liver detoxify and excrete

A 
bilirubin
ammonia
drugs
hormones
pollutants
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3
Q

what are the types of liver injury

A 
acute = can recover or progress to liver failure
chronic = can recover, cirrhosis or progress to liver failure
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4
Q

what is tested in liver function tests?

A
  1. serum bilirubin = breakdown of haem, decreases in disease
  2. albumin = produced by liver, decreases in disease
  3. prothrombin time = increase in disease as coagulation factors not produced
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5
Q

what liver enzymes are tested

A

cholestatic = alkaline phosphatase, gamma GT
hepatocellular = transaminases (AST and ALT)
= gives no index of liver function

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6
Q

what can cause renal failure in liver disease

A 
drugs = diuretics/NSAIDS/ACEi/aminoglycosides
infection
GI bleeding
myoglobinuria
renal tract obstruction
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7
Q

why is it important to consider analgesic drugs in liver disease

A

liver sensitive to opiates
NSAIDS cause renal failure
= paracetamol is safest option

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8
Q

what drugs is it important to consider in liver disease

A

sedation diuretics = use short acting benzodiazepines with care
antihypertensives = avoid ACEi
AVOID amino-glycosides

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9
Q

name the viral causes of acute liver disease

A

hep A
hep B
EBV

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10
Q

name 4 causes of acute liver disease

A
  1. idiosyncratic drug reactions
  2. alcoholic hepatitis
  3. vascular occlusion of blood flow to liver/obstruction of hepatic vein
  4. congestion = right sided heart failure causing oedema
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11
Q

what are the sign/symptoms of acute liver diease (8)

A

malaise
nausea
anorexia

jaundice
confusion
bleeding

liver pain
hypoglycaemia

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12
Q

name the viral causes of chronic liver disease

A

hep B

hep C

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13
Q

name the autoimmune causes of chronic liver disease

A

autoimmune hepatitis
primary biliary cholangitis
primary sclerosing cholangitis

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14
Q

name the metabolic causes of chronic liver disease

A

haemochromatosis = excess iron
wilsons disease
alpha 1

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15
Q

how does chronic liver disease present

A

ascites
oedema
haematemesis = vomiting blood

malaise
anorexia
wasting

easy bruising
itching
hepatomegaly
abnormal LFTs
(jaundice/confusion = rare)
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16
Q

what are the consequences of chronic liver dysfunction

A
  1. malnutrition
  2. coagulopathy
  3. endocrine changes = gynaecomastia, impotence, amenorrhoea
  4. hypoglycaemia
  5. variceal bleeding
  6. ascites/oedema
  7. increased infection risk
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17
Q

what is coagulopathy

A

impaired coagulation factor synthesis
vitamin K deficiency
thrombocytopenia

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18
Q

what is gynaecomastia

A

man boobs

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19
Q

how is malnutrition treated

A

naso-gastric feeding

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20
Q

how is variceal bleeding treated (bleeding from varices)

A

endoscopic bandign
propranolol
terlipressin

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21
Q

what is hepatic encephalopathy and how do you treat it

A

= brain disease/damage malfunction due to buildup of toxins that liver was unable to clear
= consequence of chronic liver disease
= treat with lactulose

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22
Q

what is jaundice

A

raised serum bilirubin

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23
Q

name the 3 causes of jaundice

A

pre-hepatic
hepatic/cholestatic
post-hepatic/cholestatic

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24
Q

what is pre-hepatic jaundice

A

caused by factors that increase rate of haemolysis
= haemolytic anaemia
= haemolytic drugs
= sickle cell anaemia

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25
Q

what is hepatic/cholestatic jaundice

A

caused by liver disease
= hepatitis
= cirrhosis
= hepatocellular carcinoma

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26
Q

what is post hepatic/cholestatic jaundice

A

caused by bile obstruction
= pancreatic cancer
= primary sclerosing cholangitis
= gallstones

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27
Q

what signs are important to look out for in jaundice

A

urine and stool colour
abdomen swelling
fever
yellow sclera

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28
Q

what are the symptoms of jaundice

A 
fatigue
fever
rigors
abdominal pain
vomiting
weight loss
itching
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29
Q

what is it important to consider in history of patient with jaundice

A

PMH = biliary disease, malignancy, HF, blood product use, AI diseases
drug history = 2-12 weeks usage
social history = alcohol, hepatitis
family history

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30
Q

what tests are done in cases of jaundice

A

liver enzymes
CT
MRI cholangiogram/endoscopic retrograde cholangiogram
USS

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31
Q

diagnosis of pre-hepatic jaundice

A 
normal LFT
high unconjugated bilirubin (increased bkdown RBC)
normal conjugated bilirubin
normal urobilinogen
normal stool/urine colour
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32
Q

diagnosis of hepatic jaundice

A 
high unconjugated bilirubin 
high conjugated bilirubin (degree of obstruction)
normal/high urobilinogen in urine
dark urine (CB in urine)
pale stool
increased ALT and AST
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33
Q

diagnosis of post-hepatic jaundice

A 
normal unconjugated bilirubin
high conjugated bilirubin (buildup)
decreased urobilinogen in urine
dark urine (high CB)
pale stools 
increased ALT and AST
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34
Q

what is hepatitis

A

inflammation of the liver

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35
Q

name the viral causes of acute hepatitis

A

hep A,B,C,D,E

herpes virus

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36
Q

name the non-viral infection causes of acute hepatitis

A

spirochetes
parasites
mycobacteria
bacteria

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37
Q

name the non infectious causes of acute hepatitis

A 
alcohol
NAFLD
drugs
toxins
pregnancy
autoimmune
hereditary metabolic
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38
Q

what is NAFLD

A

non alcoholic fatty liver disease

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39
Q

what causes hepatitis E

A

RNA virus similar to Hep A

found and spread in pigs/undercooked meat

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40
Q

what is the presentation of Hep E

A

most asymptomatic
usually self-limiting
acute-on-chronic liver failure - especially in immunocompromised
neurological manifestations

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41
Q

how is Hep E treated

A 
acute = support, possibly ribavirin if complications leading to chronic occur BUT mostly just supportive/no trreatment
chronic = reverse immunosuppresion if poss, treat with ribavirin
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42
Q

what is ribavirin

A

antiviral medications used to treat hep C/E often in combination with peginterferon alfa 2a

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43
Q

what is peginterferon alfa 2a

A

= pegylated interferon alfa 2a
used to treat Hep B by itself
Hep C = combined with ribavirin
has common and unwanted side effects

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44
Q

describe Hep D

A

defective RNA virus that requires individual to already have Hep B to contract it
transmitted through blood/bodily fluids
treated with pegylated interferon alfa 2a

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45
Q

what is haemochromatosis

A

autosomal recessive genetic disorder caused by mutation in HFE gene
causes uncontrolled intestinal absorption of iron with deposition in the liver, heart and pancreas

46
Q

what occurs in autoimmune hepatitis

A

abnormal T cell function and autoantibodies attack anomalous hepatocyte surface antigens (they shouldnt be there)
lymphocytes and plasma cells present in histology = indicate cirrhosis (???)

47
Q

what are the symptoms of autoimmune hepatitis

A 
normal hepatitis symptoms
specific = 
polyarthritis
pleurisy
lung infiltrates
glomuleronephritis
no periods
48
Q

what investigations confirm a diagnosis of autoimmune hepatitis

A

bloods = raised bilirubin, AST, ALT, ALP, hypersplenism , low WCC, low Plts
autoantibodies = positive antinuclear antibody
liver biopsy = mononuclear infiltrate = necrosis and fibrosis = cirrhosis

49
Q

how is autoimmune hepatitis treated

A

prednisolone = steroids

liver transplant in severe cases

50
Q

what conditions are associated with AI hep

A 
pernicious anaemia
ulcerative colitis
glomerulonephritis
AI thyroiditis
diabetes mellitus
51
Q

what is NAFLD

A

non-alcoholic fatty liver disease = inflammation and fibrosis of liver caused by fatty deposits

52
Q

what causes NAFLD

A

obesity
hyperlipidemia
diabetes

53
Q

how is NAFLD diagnosed

A

mildly raised LFTs = raised ALT

liver biopsy

54
Q

how is NAFLD treated

A

weight loss
low fat diet
increased physical activity

55
Q

what is the progression of alcoholic liver disease

A

alcoholic fatty liver disease
alcohol hepatitis
cirrhosis
liver failure

56
Q

what is DILI

A

drug induced liver injury

= acute injury to the liver caused by paracetamol or other idiosyncratic reactions to drug

57
Q

what are the types of DILI

A 
hepatocellular = raised ALT
cholestatic = raised alkaline phosphate 
mixed = changes in both ALT and alkaline phosphate
58
Q

what drugs usually cause DILI

A 
antibiotics
CNS drugs 
immunosuppressants
analgesics
GI drugs
59
Q

what is primary biliary cholangitis

A

autoimmune damage occurs to the bile ducts which result in a build up of bile in the liver
primary granulomatous inflammation of the interlobar ducts

60
Q

what are the risk factors for PBC

A

female
40-50
autoimmune
smoking

61
Q

how does PBC present

A 
pruitus from onset
jaundice = due to bike leakage/obstruction
cholestasis 
xanthomas
dry eyes
fatigue
joint pain
hepatomegaly
variceal bleeding
liver failure - ascites
62
Q

what is cholestasis

A

decrease in bile flow due to obstruction

= any condition where substances usually excreted into the bile are retained

63
Q

what autoimmune diseases are associated with PBC

A

sjogrens syndrome
systemic sclerosis
rheumatoid arthritis
lupus

64
Q

name some methods of prevention of Hep B

A

antenatal screening = HBsAg testing
screening/immunisation of sexual/household contacts
universal childhood immunisation
immunisation of healthcare workers

65
Q

how is PBC treated

A

urodeoxycholic acid

cholestyramine or rifampicin for treatment of pruitus

66
Q

what does urodeoxycholic acid do

A

improve pruitus
improve liver enzymes
reduce fibrosis
reduce portal pressure and variceal formation

67
Q

describe how encephalopathy occurs

A

ammonia not cleared by liver = glutamate is converted to glutamine in the brain
= osmotic shift so fluid enters cells = cerebral oedema
symptoms = altered mood, drowsy, confused

68
Q

what is the difference between cholangitis and cholecystitis and what is cholelithiasis

A 
cholangitis = inflammation of bile duct system
cholecystitis = inflammation of the gallbladder
cholelithiasis = gallstones but NO inflammation
69
Q

what is charcots triad

A

fever (with rigors)
jaundice
RUQ pain
occurs as a result of acute cholangitis

70
Q

what are the complications of gallstones

A

cholangitis = inflammation GB due to BD block
acute cholecystitis = if cystic duct impact
jaundice = obstruction
pancreatitis = pancreatic duct blocked
gallstone ileus = occlude intestinal lumen
empyema = GB fill with pus

71
Q

what is portal hypertension

A

high blood pressure in hepatic portal system

can be due to increased flow or increased resistance

72
Q

what causes hepatic vein occlusion

A 
pregnancy
polycythaemia rubra vera
hepatocellular carcinoma
compression of hepatic vein
hepatic vein thrombosis = Budd-Chiari
73
Q

how is hepatic vein occlusion treated

A

anticoagulation
trans-jugular intrahepatic portosystemic shunt (TIPS)
liver transplant

74
Q

what are the symptoms/complications of portal hypertension

A

varices formation = vomiting blood/blood in stool
ascites
encephalopathy/confusion due to poor liver function
reduced platelet/clotting factors

75
Q

how is portal hypertension diagnosed

A

ultrasound (USS)
= dilated portal vein
= shows velocity of portal vein blood flow

76
Q

what are the characteristics of ascites

A 
belly button stick out
tense belly
dull percussion!!!
prominent veins = associated w/liver disease/PH
abdominal distension
flank distension
77
Q

what are the complications of portal hypertension

A 
varices 
= lower 3rd of oesophagus
= stomach
= abdominal wall
= rectum 
(in areas where venous drains into portal vein)
hepatic encephalopathy
ascites
78
Q

describe the formation of ascites

A
  1. increased hepatic resistence = portal hypertension = increased splanchnic blood flow
  2. systemic vasodilation causes increased renin, angiotensin, noradrenaline, vasopressin secretion = water retention
  3. due to liver disease albumin levels = low
  4. due to increased portal pressure, water retention, low albumin = water pushed out of vessels and cannot reenter due to low oncotic pressure
  5. results in ascites forming + gastric/oesophageal varices also form due to PH
79
Q

what causes ascites to form

A

chronic liver disease = portal vein thrombosis/hepatoma/TB
portal hypertension
neoplasia
pancreatitis

80
Q

how are ascites managed

A 
fluid restriction
salt restriction
diuretics = furosemide, spironolactone
large volume paracentesis and albumin
TIPS procedure
81
Q

describe transudate ascites

A

low protein

usually caused by a blood flow issue or oncotic pressure issue

82
Q

what colour is the fluid in ascites

A

should be clear/straw yellow

any other colour indicates possible infection - fever, complications

83
Q

what is steatosis

A

abnormal retention of lipids in liver = fatty liver

84
Q

what is NASH

A

non alcoholic steatohepatitis

85
Q

what are the signs of liver mets

A

hepatomegaly
hard/nodular liver
chronic liver disease = ascites/jaundice (late)

86
Q

what are the normal origins of liver metastases

A

stomach
lung
colon
breast/uterus

87
Q

what is the treatment for liver metastases

A

chemo/radiation/resection possible

but usually terminal diagnosis

88
Q

what investigations confirm a diagnosis of liver mets

A

normal blood
high ferroprotein
imaging for stages and cause = CT
biopsy

89
Q

what is a liver abcess

A

pus filled mass in liver

90
Q

what are the causes of a liver abcess

A
  1. bacterial = E.coli, Klebsiella
  2. amoebic = entamoeba histolytica
  3. worms = echinococcal granulosus (dog tapeworm)
91
Q

what are the symptoms of liver abcess

A

RUQ pain
fever
pyrexia of unknown origin = 2 week fever
high number eosinophils = only in worms

92
Q

how are liver abcesses diagnosed

A

CT/ultrasound shows abcess

93
Q

how are liver abcesses treated

A 
amoeba/bacteria = treat with antibiotics and drainage
worms = treat with albendazole and remove tapeworm
94
Q

what is essential to be careful with in treating liver abcess

A

echinococcal granuloses rupture can cause anaphylaxis

95
Q

what is the blood supply to the Liver

A

hepatic artery = fresh oxygenated blood

portal vein = venous blood from spleen, pancreas, small intestine

96
Q

describe the pathophysiology of paracetamol poisoning and what is the treatment

A

intermediate metabolite of paracetamol causes cellular necrosis
N-acetly cystine (NAC) converts reactive intermediate to stable metabolite

97
Q

what are some key signs of liver failure

A

fetor hepatis = breath smell of pears

asterixis = flapping tremor/liver flap

98
Q

what LFT would indicate alcohol liver disease

A

AST:ALT ratio larger than 2:1

99
Q

what LFT would indicate chronic liver disease

A

ALT > AST

ALT is primary liver enzyme so if raised = liver injury

100
Q

what is damaged if gamma GT is raised

A

biliary system damage

especially if ALP is raised with gamma GT

101
Q

what is murphys sign and where is it seen

A

fingers on RUQ
pain on inspiration on right side only = positive
= cholycystitis

102
Q

what is an ERCP used for

A

diagnose ascending cholangitis

remove gallstones

103
Q

what differentiates PBC and PSC

A 
PBC = AMA positive
PSC = AMA negative
104
Q

what are cullens sign and turners sign and what disease do they present in

A

cullens = umbilical bruising
turners sign = flank bruising
PANCREATITIS

105
Q

describe the blood results for pancreatitis

A

elevated serum lipase and amylase

106
Q

what is given to treat wilsons disease

A

lifelong penicillamine and zinc

107
Q

what can cause peritonitis

A 
primary 
= spontaneous bacterial peritonitis
= ascites
= immunocompromised
secondary
= bowel perforation/ischaemia/inflamm
= TB
108
Q

what is significant about the pain in pancreatitis

A

epigastric radiating to back

relieved by sitting forward

109
Q

what is the hepatocellular carcinoma specific chemotherapy

A

sorafenib

110
Q

what is diagnostic for peritonitis

A

raised blood lactate levels

111
Q

what LFT would be indicative of cirrhosis

A

AST greater than ALT

Phase 2a (15 decks)

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