Liver + Biliary 1 Flashcards
How is bilirubin metabolised?
Haem by haem oxidase to iron and biliverdin then into unconjucated bilirubin
Unconjucated -> (UDPGT) conjucated -> into bile -> biliary system -> stercobilinogen/urobilinogen
Pre-hepatic jaundice causes?
Haemolysis and Gilberts
(normal urine)
Raised bilirubin only
Hepatocellular jaundice causes?
Hepatitis, cirrhosis, liver mass and haemochromotosis
Dark urine (conj bilirubin)
Raised AST/ALT
Post-hepatic jaundice causes?
Gallstone, pancreatic cancer, cholangiocarcinoma, PSC, PBS and drugs
Dark urine + pale stools + pruritis (bile salts)
Raised ALP/GGT
Caused of raised AST and ALT?
Symptoms?
Alcoholic, NASH, viral, drugs and autoimmune
RUQ pain, jaundice,hepatomegaly, joint pain, nausea, fatigue, dark urine
Progress and Sx of alcholic liver disease>
Steatosis (after a few days of drinking, no Sx) -> Alcoholic hepatitis ( after long term, nausea, anrexia, weiht loss, hepatomegaly. Severe = fever, jaundice, tachycardia, tender, bruising, encephalopathy, ascites) -> cirrhosis
What mediates damage of the liver?
Mediated b NAD+ which promotes fatty infiltration -> inflammation
Ix for alcoholic hepatitis?
FBC = macrocytic anaemia
LFTs: AST/ALT ratio >2, increased bilirubin, alp, GGT and decreased albumin
Increased prothrombin time
Hepatc USS and liver biopsy
What histological marker indicates alcoholic hepatitis?
Mallory bodies
Mx for alcoholic hepatitis?
Alcohol abstinence + withdrawal (diazepam)
Nutrition
Weight loss and stop smoking
Steroids if severe
Progression of NAFLD?
RFs and Ix?
Steatosis -> NASH -> cirrhosis
Rfs: obesity, insulin resistance and diabetes, hyperlipidaemia, HTN, metbalic syndrome, short bowel syndrome, TPN
LFTS AST:ALT elevated <1, GGT/ALP eleavted and check glucose
Signs of insulin resistance?
Polyuria, polydipsia, ancanthosis nigricands
Mx for NAFLD?
diet and exercise, control RFs e.g. statsins for hyperlipidaemia, good blood sugar control with metformin
Features of Viral Hep A and E
Acute, faeco-oral, supportive management. Avoid alcohol and excess paracetomol
A= acute so travel and water
E = enteric, epidemic, expecting mothers and immunocompromised
Hep B features?
80% acute with RUQ, jaundice, N+V, anorexia
HCC risk
Birthing, blood, Babymaking (sex/MSM)
Coinfection with D increases the risk of liver failure
Treatment for coinfection = peginterferon-a-2a and tenofovir/entecavir
Acute -> supportive
Hep C features?
Chronic
HCC Rf
Blood spread
Treatment = sofosbuvir, ledispavir, grazoprevir
Drug features of hepatitis?
Paracetomol (also NSAIDS< GCs, isonazid, fluclox, erythromycin)
AST/ALT in 1000s
N-acetylcysteine
Autoimmune hepatitis features?
other AI presentation e.g. T1DM, hashimotos, coeliac. F>M
AST/ALT,
ANA, ASMA, AMA
Biopsy = interface hepatitis + plasma cells
What drugs can cause cholestasis?
Co-amoxiclav, nitrofurantoin, OCP
What are the main organs affected by haemochromotosis and types?
LIVER, PANCREAS, skin, pituitar, hearts and joints
Primary : autosomnal recessive and cannot stop GI tract Fe absorption
Secondary: iron overload e.g. multiple transfusions
Primary haemochromotosis pathophysiology?
HFE gene mutation means transferrin binds poorly to receptor to less hepcidin production
Clinical features of haemochromotosis?
75% Asx
Hepatomegaly, bronze skin, DM onset, artharlgia, male incompetence
M earlier than F
May progress to cirrhosis and HCC
Ix for haemochromotosis?
1st transferrring satuation (raised) and serum ferritin (raised) Gene typing for HFE Liver Biopsy (gold)
What is Wilsons, epi + clinical features?
impaired copper excretion so accumulates in liver and brain
Autosomnal recessiver (onset 5-25)
Hepatitis + dementia + parkinsonism i young person
hepatosplenomegaly, abdo pain, jaundice, ascites portal HTN
Kayser-fleischer rings
Ix for Wilsons disease?
1st LFTS (raised transaminases/bilirubin), 24hr urinary copper, slit lamp exam
Decreased serum caeruloplasmin, increased serum free copper and urinary cooper excretion
Genetic testing and liver biopsy are gold standard
Aetiology of Cirrhosis?
alcohol, viral (B/C), autoimmune, haemochromotosis, NASH and chronic biliary disease
Nodule cirrhosis size?
Macronodular = viral Micronodular = alcoholic
Signs of chronic liver disease?
Clubbing, gynaecomastia, dupuytrens contracture, palmar erytherma, spider naevi, jaundice, easy bruising
Where does blood flow from to porto-systemic circulation?
Lower oesophagus, anal canal, imbilicus, splenorenal
What can cause portal hypertension?
Increase pressure in portal vein due to cirrhosis or a clot in hepatic vein e.g. Budd-chiari syndrome
Signs of portal hypertension?
Clubbing, spider naevi, dupuytrens, palmar erytherma, gynaecomastia, brusing
+
Caput medusae, ascites, oesophageal varices
What is the management of cirrhosis?
Treat cause and avoid hepatotoxic drugs
Monitor risk of complications (MELD score, 6 month USS, endoscopy)
Manage complications
What is a complication of cirrhosis?
Portal hypertension
Encephalopathy = treat precipitating event + short term protein restriction, oral lctulose and phosphate enema, avoid sedatives
What are the risk factors for encephalopathy with cirrhosis and MOA?
MOA: increased ammonia metabolised to glutamine = symptoms
RFS: infection, GI bleeding, constipation, high protein diet, zinc deficiency, benzodiazepines
How do you manage ascites?
sodium restriction +- diuretics (spir/fures) +- large vlume paracentesis
How to manage spontaneous bacterial peritonitis?
Abx = cefuroxime + metronidazole
Definition of SBP?
> 250 neutrophils per mmcubed ascitic fluid in absence of other reason e.g. organ inflammation or perforation
Commonly E.coli
Management of varices?
Primary prohphylaxis = Non selective beta blocker, EVL if large
Ruptured (haematemesis) = ABCDE, IV bloods and fluid. If Hb<7g/dl then terlipressin + abx
EVL after resus when stable
Secondary prophylaxis = non selective beta blocker
TIPS procedure if all else fails
