Liver and stuff Flashcards
what does the liver do
glucose and fat metabolism
detox and excretion
protein synthesis - albumin/clotting factors
defence against infection - reticuloendothelial system
what does the liver detoxify and excrete
bilirubin ammonia drugs hormones pollutants
what are the types of liver injury
acute = can recover or progress to liver failure chronic = can recover, cirrhosis or progress to liver failure
what is tested in liver function tests?
- serum bilirubin = breakdown of haem, decreases in disease
- albumin = produced by liver, decreases in disease
- prothrombin time = increase in disease as coagulation factors not produced
what liver enzymes are tested
cholestatic = alkaline phosphatase, gamma GT
hepatocellular = transaminases (AST and ALT)
= gives no index of liver function
what can cause renal failure in liver disease
drugs = diuretics/NSAIDS/ACEi/aminoglycosides infection GI bleeding myoglobinuria renal tract obstruction
why is it important to consider analgesic drugs in liver disease
liver sensitive to opiates
NSAIDS cause renal failure
= paracetamol is safest option
what drugs is it important to consider in liver disease
sedation diuretics = use short acting benzodiazepines with care
antihypertensives = avoid ACEi
AVOID amino-glycosides
name the viral causes of acute liver disease
hep A
hep B
EBV
name 4 causes of acute liver disease
- idiosyncratic drug reactions
- alcoholic hepatitis
- vascular occlusion of blood flow to liver/obstruction of hepatic vein
- congestion = right sided heart failure causing oedema
what are the sign/symptoms of acute liver diease (8)
malaise
nausea
anorexia
jaundice
confusion
bleeding
liver pain
hypoglycaemia
name the viral causes of chronic liver disease
hep B
hep C
name the autoimmune causes of chronic liver disease
autoimmune hepatitis
primary biliary cholangitis
primary sclerosing cholangitis
name the metabolic causes of chronic liver disease
haemochromatosis = excess iron
wilsons disease
alpha 1
how does chronic liver disease present
ascites
oedema
haematemesis = vomiting blood
malaise
anorexia
wasting
easy bruising itching hepatomegaly abnormal LFTs (jaundice/confusion = rare)
what are the consequences of chronic liver dysfunction
- malnutrition
- coagulopathy
- endocrine changes = gynaecomastia, impotence, amenorrhoea
- hypoglycaemia
- variceal bleeding
- ascites/oedema
- increased infection risk
what is coagulopathy
impaired coagulation factor synthesis
vitamin K deficiency
thrombocytopenia
what is gynaecomastia
man boobs
how is malnutrition treated
naso-gastric feeding
how is variceal bleeding treated (bleeding from varices)
endoscopic bandign
propranolol
terlipressin
what is hepatic encephalopathy and how do you treat it
= brain disease/damage malfunction due to buildup of toxins that liver was unable to clear
= consequence of chronic liver disease
= treat with lactulose
what is jaundice
raised serum bilirubin
name the 3 causes of jaundice
pre-hepatic
hepatic/cholestatic
post-hepatic/cholestatic
what is pre-hepatic jaundice
caused by factors that increase rate of haemolysis
= haemolytic anaemia
= haemolytic drugs
= sickle cell anaemia
what is hepatic/cholestatic jaundice
caused by liver disease
= hepatitis
= cirrhosis
= hepatocellular carcinoma
what is post hepatic/cholestatic jaundice
caused by bile obstruction
= pancreatic cancer
= primary sclerosing cholangitis
= gallstones
what signs are important to look out for in jaundice
urine and stool colour
abdomen swelling
fever
yellow sclera
what are the symptoms of jaundice
fatigue fever rigors abdominal pain vomiting weight loss itching
what is it important to consider in history of patient with jaundice
PMH = biliary disease, malignancy, HF, blood product use, AI diseases
drug history = 2-12 weeks usage
social history = alcohol, hepatitis
family history
what tests are done in cases of jaundice
liver enzymes
CT
MRI cholangiogram/endoscopic retrograde cholangiogram
USS
diagnosis of pre-hepatic jaundice
normal LFT high unconjugated bilirubin (increased bkdown RBC) normal conjugated bilirubin normal urobilinogen normal stool/urine colour
diagnosis of hepatic jaundice
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
diagnosis of post-hepatic jaundice
normal unconjugated bilirubin high conjugated bilirubin (buildup) decreased urobilinogen in urine dark urine (high CB) pale stools increased ALT and AST
what is hepatitis
inflammation of the liver
name the viral causes of acute hepatitis
hep A,B,C,D,E
herpes virus
name the non-viral infection causes of acute hepatitis
spirochetes
parasites
mycobacteria
bacteria
name the non infectious causes of acute hepatitis
alcohol NAFLD drugs toxins pregnancy autoimmune hereditary metabolic
what is NAFLD
non alcoholic fatty liver disease
what causes hepatitis E
RNA virus similar to Hep A
found and spread in pigs/undercooked meat
what is the presentation of Hep E
most asymptomatic
usually self-limiting
acute-on-chronic liver failure - especially in immunocompromised
neurological manifestations
how is Hep E treated
acute = support, possibly ribavirin if complications leading to chronic occur BUT mostly just supportive/no trreatment chronic = reverse immunosuppresion if poss, treat with ribavirin
what is ribavirin
antiviral medications used to treat hep C/E often in combination with peginterferon alfa 2a
what is peginterferon alfa 2a
= pegylated interferon alfa 2a
used to treat Hep B by itself
Hep C = combined with ribavirin
has common and unwanted side effects
describe Hep D
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
what is haemochromatosis
autosomal recessive genetic disorder caused by mutation in HFE gene
causes uncontrolled intestinal absorption of iron with deposition in the liver, heart and pancreas
what occurs in autoimmune hepatitis
abnormal T cell function and autoantibodies attack anomalous hepatocyte surface antigens (they shouldnt be there)
lymphocytes and plasma cells present in histology = indicate cirrhosis (???)
what are the symptoms of autoimmune hepatitis
normal hepatitis symptoms specific = polyarthritis pleurisy lung infiltrates glomuleronephritis no periods
what investigations confirm a diagnosis of autoimmune hepatitis
bloods = raised bilirubin, AST, ALT, ALP, hypersplenism , low WCC, low Plts
autoantibodies = positive antinuclear antibody
liver biopsy = mononuclear infiltrate = necrosis and fibrosis = cirrhosis
how is autoimmune hepatitis treated
prednisolone = steroids
liver transplant in severe cases
what conditions are associated with AI hep
pernicious anaemia ulcerative colitis glomerulonephritis AI thyroiditis diabetes mellitus
what is NAFLD
non-alcoholic fatty liver disease = inflammation and fibrosis of liver caused by fatty deposits
what causes NAFLD
obesity
hyperlipidemia
diabetes
how is NAFLD diagnosed
mildly raised LFTs = raised ALT
liver biopsy
how is NAFLD treated
weight loss
low fat diet
increased physical activity
what is the progression of alcoholic liver disease
alcoholic fatty liver disease
alcohol hepatitis
cirrhosis
liver failure
what is DILI
drug induced liver injury
= acute injury to the liver caused by paracetamol or other idiosyncratic reactions to drug
what are the types of DILI
hepatocellular = raised ALT cholestatic = raised alkaline phosphate mixed = changes in both ALT and alkaline phosphate
what drugs usually cause DILI
antibiotics CNS drugs immunosuppressants analgesics GI drugs
what is primary biliary cholangitis
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
what are the risk factors for PBC
female
40-50
autoimmune
smoking
how does PBC present
pruitus from onset jaundice = due to bike leakage/obstruction cholestasis xanthomas dry eyes
fatigue joint pain hepatomegaly variceal bleeding liver failure - ascites
what is cholestasis
decrease in bile flow due to obstruction
= any condition where substances usually excreted into the bile are retained
what autoimmune diseases are associated with PBC
sjogrens syndrome
systemic sclerosis
rheumatoid arthritis
lupus
name some methods of prevention of Hep B
antenatal screening = HBsAg testing
screening/immunisation of sexual/household contacts
universal childhood immunisation
immunisation of healthcare workers
how is PBC treated
urodeoxycholic acid
cholestyramine or rifampicin for treatment of pruitus
what does urodeoxycholic acid do
improve pruitus
improve liver enzymes
reduce fibrosis
reduce portal pressure and variceal formation
describe how encephalopathy occurs
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
what is the difference between cholangitis and cholecystitis and what is cholelithiasis
cholangitis = inflammation of bile duct system cholecystitis = inflammation of the gallbladder cholelithiasis = gallstones but NO inflammation
what is charcots triad
fever (with rigors)
jaundice
RUQ pain
occurs as a result of acute cholangitis
what are the complications of gallstones
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
what is portal hypertension
high blood pressure in hepatic portal system
can be due to increased flow or increased resistance
what causes hepatic vein occlusion
pregnancy polycythaemia rubra vera hepatocellular carcinoma compression of hepatic vein hepatic vein thrombosis = Budd-Chiari
how is hepatic vein occlusion treated
anticoagulation
trans-jugular intrahepatic portosystemic shunt (TIPS)
liver transplant
what are the symptoms/complications of portal hypertension
varices formation = vomiting blood/blood in stool
ascites
encephalopathy/confusion due to poor liver function
reduced platelet/clotting factors
how is portal hypertension diagnosed
ultrasound (USS)
= dilated portal vein
= shows velocity of portal vein blood flow
what are the characteristics of ascites
belly button stick out tense belly dull percussion!!! prominent veins = associated w/liver disease/PH abdominal distension flank distension
what are the complications of portal hypertension
varices = lower 3rd of oesophagus = stomach = abdominal wall = rectum (in areas where venous drains into portal vein) hepatic encephalopathy ascites
describe the formation of ascites
- increased hepatic resistence = portal hypertension = increased splanchnic blood flow
- systemic vasodilation causes increased renin, angiotensin, noradrenaline, vasopressin secretion = water retention
- due to liver disease albumin levels = low
- due to increased portal pressure, water retention, low albumin = water pushed out of vessels and cannot reenter due to low oncotic pressure
- results in ascites forming + gastric/oesophageal varices also form due to PH
what causes ascites to form
chronic liver disease = portal vein thrombosis/hepatoma/TB
portal hypertension
neoplasia
pancreatitis
how are ascites managed
fluid restriction salt restriction diuretics = furosemide, spironolactone large volume paracentesis and albumin TIPS procedure
describe transudate ascites
low protein
usually caused by a blood flow issue or oncotic pressure issue
what colour is the fluid in ascites
should be clear/straw yellow
any other colour indicates possible infection - fever, complications
what is steatosis
abnormal retention of lipids in liver = fatty liver
what is NASH
non alcoholic steatohepatitis
what are the signs of liver mets
hepatomegaly
hard/nodular liver
chronic liver disease = ascites/jaundice (late)
what are the normal origins of liver metastases
stomach
lung
colon
breast/uterus
what is the treatment for liver metastases
chemo/radiation/resection possible
but usually terminal diagnosis
what investigations confirm a diagnosis of liver mets
normal blood
high ferroprotein
imaging for stages and cause = CT
biopsy
what is a liver abcess
pus filled mass in liver
what are the causes of a liver abcess
- bacterial = E.coli, Klebsiella
- amoebic = entamoeba histolytica
- worms = echinococcal granulosus (dog tapeworm)
what are the symptoms of liver abcess
RUQ pain
fever
pyrexia of unknown origin = 2 week fever
high number eosinophils = only in worms
how are liver abcesses diagnosed
CT/ultrasound shows abcess
how are liver abcesses treated
amoeba/bacteria = treat with antibiotics and drainage worms = treat with albendazole and remove tapeworm
what is essential to be careful with in treating liver abcess
echinococcal granuloses rupture can cause anaphylaxis
what is the blood supply to the Liver
hepatic artery = fresh oxygenated blood
portal vein = venous blood from spleen, pancreas, small intestine
describe the pathophysiology of paracetamol poisoning and what is the treatment
intermediate metabolite of paracetamol causes cellular necrosis
N-acetly cystine (NAC) converts reactive intermediate to stable metabolite
what are some key signs of liver failure
fetor hepatis = breath smell of pears
asterixis = flapping tremor/liver flap
what LFT would indicate alcohol liver disease
AST:ALT ratio larger than 2:1
what LFT would indicate chronic liver disease
ALT > AST
ALT is primary liver enzyme so if raised = liver injury
what is damaged if gamma GT is raised
biliary system damage
especially if ALP is raised with gamma GT
what is murphys sign and where is it seen
fingers on RUQ
pain on inspiration on right side only = positive
= cholycystitis
what is an ERCP used for
diagnose ascending cholangitis
remove gallstones
what differentiates PBC and PSC
PBC = AMA positive PSC = AMA negative
what are cullens sign and turners sign and what disease do they present in
cullens = umbilical bruising
turners sign = flank bruising
PANCREATITIS
describe the blood results for pancreatitis
elevated serum lipase and amylase
what is given to treat wilsons disease
lifelong penicillamine and zinc
what can cause peritonitis
primary = spontaneous bacterial peritonitis = ascites = immunocompromised secondary = bowel perforation/ischaemia/inflamm = TB
what is significant about the pain in pancreatitis
epigastric radiating to back
relieved by sitting forward
what is the hepatocellular carcinoma specific chemotherapy
sorafenib
what is diagnostic for peritonitis
raised blood lactate levels
what LFT would be indicative of cirrhosis
AST greater than ALT
