Liver + biliary Flashcards
Why do you get poor coagulation function in primary biliary sclerosis, biliary cholangitis, stone in the common bile duct?
Cholestasis - the bile salts aren’t released into the intestine and so there is no absorption of fat soluble vitamins (ADEK). Vitamin K is needed to make factors 1972
What auto-antibody is found in primary sclerosing cholangitis?
AMA (Anti-mitochondrial antibody)
What is the diagnostic finding for alcholic hepatitis?
AST:ALT ratio >2:1 (if you see this!!!)
What are AST and ALT
aminotransferases
What does ALP stand for?
Alkaline phosphatase
What are some of the signs you might see in primary biliary cirrhosis?
Xanthelasma (yellow fat deposits around eyes), ascites, hepatosplenomegaly
What is the treatment for primary biliary cirrhosis?
Ursodeoxycholic acid + cholestyramine + vit ADEK supplements
What is the difference between Wilson’s disease and haemochromatosis?
Wilson’s = copper deposition
How would you treat end stage liver disease?
Liver Tx
What is the difference between primary sclerosing cholangitis and primary biliary cirrhosis?
Primary biliary cirrhosis affects intra-hepatic ducts only whilst primary sclerosing cholangitis affects both intra and extra-hepatic bile ducts
What is the treatment for primary sclerosing cholangitis?
Ursodeoxycholic acid
What is the function of ursodeoxycholic acid and cholestyramine?
Reduces cholestatic itch (chelates bile salts)
What do iron studies show in haemochromatosis?
Decreased TIBC, ^ serum Fe and ferritin
What is the main cause of haemochromatosis?
Autosomal recessive mutation to HFE gene
What is the treatment for haemochromatosis?
Venesection
Does Wilson’s disease affect the basal ganglia? How?
Yes - causes Parkinson’s disease
What is the characteristic feature of Wilson’s disease?
Brown rings around iris (Kayser-Fleischer ring)
Give 3 metabolic causes of liver disease (cirrhosis)
Alpha1 anti-trypsin deficiency, haemochromatosis, Wilson’s disease
What investigations would you do to diagnose Wilson’s disease? What would you see?
Liver biopsy (^ copper), DECREASED serum copper, increased urinary 24hr copper
What is the treatment for Wilson’s disease?
Penicillamine or zinc (chelate copper)
What two diseases can alpha1 anti-trypsin deficiency cause?
COPD (emphysema specifically) and chronic liver disease
What is the role of alpha1 anti-trypsin?
Inhibits neutrophil elastase (+ other proteases)
Where is alpha1 anti-trypsin produced?
Liver
How might someone with alpha1 anti-trypsin deficiency present?
Neonatal jaundice
Adults: COPD or liver disease
What would a liver biopsy show in alpha1 anti-trypsin def?
Hepatocytes with ^ intracellular globules of alpha1 anti-trypsin
What is budd-Chiari syndrome?
A veno-occlusive disease by which there is thrombosis in the hepatic vein causing portal HTN. Most commonly caused by a hypercoaguable state (oral contraceptives, malignancy…)
What are the best markers for demonstrating liver function?
PT (coagulopathy) and serum albumin
Why might you get an increase in infection in liver failure/cirrhosis? What might you give them?
Decreased production of complement proteins. Influenzae and pneumococcal vaccination
Why might you get oedema in liver failure/cirrhosis
Reduced albumin production –> decrease in oncotic pressure inside vessels
Why might someone bleed/bruise easily if they have liver cirrhosis?
Reduced production of clotting factors
What are the pre-hepatic causes of portal HTN?
Veno-occlusion
What are the hepatic causes of portal HTN?
Cirrhosis, alcoholic hepatitis, schistosomiasis, idiopathic
What are the post-hepatic causes of portal HTN?
RH F, constrictive pericarditis, Budd chiari
What is normal portal pressure?
5-8mmHg
Explain the progression of alcoholic liver disease
Fatty liver –> alcoholic hepatitis –> fibrosis –> cirrhosis (non-reversible)
What pressure is portal hypertension characterised by?
> 10mmHg
Give 4 complications of liver failure (chronic or acute)
^ infections (reduced complement proteins), bleeding/brusing (reduced clotting factor production), oedema and ascites (reduced albumin), osteoporosis, portal HTN + varices, HCC, AKI, malnutrition, hepatic portosystemic encephalopathy
What is the tumour serum marker for HCC?
Alpha fetoprotein
Why might you become malnourished with liver disease?
Reduced production of bile - no absorption of fat + fat soluble vitamins
Why do those with liver failure/cirrhosis get hepatic porto-systemic encephalopathy?
Normally ammonia produced by gut bacteria is broken down in the liver to urea and CO2; however, due to reduced liver function this doesn’t occur and the ammoia bypasses the liver to the brain (ammonia = toxic)
What does TIPS stand for and how does it cause hepatic encephalopathy?
Transjugular intrahepatic portosystemic shunt. Creates a shunt by which ammonia (produced by gut pathogens) can bypass the liver to the brain
What is the characteristic feature around the eyes in primary biliary cirrhosis?
Xanthelasma
Give 3 causes of ascites that are an exudate
Cirrhosis, R HF, Hepatic venous occlusion
Give 3 causes of ascites that are a transudate
malignancy, nephrotic syndrome, pancreatitis
How does cirrhosis, R HF and hepatic venous occlusion cause ascites?
They cause portal HTN -> decrease in effective arterial volume –> RAAS –> Na+/H2O retention
How do you determine whether someone this a transudate or exudate pleural fluid? Can this be applied to Ascites?
LIGHT’s criteria
What is the difference between exudate and transudate?
Higher LDH (>200) and protein levels (>2.5g/dL) in exudate
How does malignancy cause ascites?
it causes hypoalbuminaemia –> decreased oncotic pressure
What might you ask in a liver/jaundice Hx?
Alcohol? Travel? IVDU/tattoos? Blood transfusion pre-90s? Residence of birth?
How would you treat ascites?
Treat the cause, low salt diet, water retention, k+ sparing diuretic (spironolactone), peritoneocentesis
What are the causes of acute liver failure?
HAV, HBV, Excessive alcohol, paracetamol OD, idiopathic, drug induced (TB drugs)
How does hepatic encephalopathy present?
Irritability/change in mood –> drowsiness –> confusion –> coma death
How might liver disease result in hyponatraemia?
It produces Ang I needed in the RAA system
What should you ask in a patient history if they present with acute liver disease?
Any drugs started recently?
Give an example of a drug that is hepatotoxic
TB drugs (rifampicin, isoniazid, pyrazinamide) and paracetamol
Why do patients with CLD get a coma/confusion? Give 3 reasons
Hepatic encephalopathy (build up of ammonia - as not broken down in the urea cycle by the liver), hypoglycaemia, intracranial event (bleed)
What infections are those with CLD most likely to get?
SPONTANEOUS BACTERIAL PERITONITIS
What is steatosis?
Fatty liver
What causes a cholestatic itch?
Cholestasis - build up of bile in skin
What liver tests give an idea of liver function?
PT and serum albumin
What is the treatment for varices?
Endoscopic ligation banding + propranolol
How do you treat hepatic encephalopathy?
decrease the absorption of ammonia (lactulose) and kill gut bacteria (Abx)
What investigations would you do to determine the cause of chronic liver disease (CLD)?
Viral serology, serology (auto-Ab’s), biochem (iron/copper studies, alpha 1 -AT levels…), bilirubin, USS/CT, LFTs (ALT/AST, PT, serum albumin)
What are the causes of CLD?
Alcoholic
Non-alcoholic fatty liver disease
HBV, HCV
Auto-immune (primary sclerosing cholangitis and primary biliary CIRRHOSIS)
Matabolic causes (Wilson’s disease, haemochromatosis, alpha1-AT def.)
Vascular (Budd Chiari)
What type of cause for portal HTN is Budd Chiari syndrome?
post-hepatic (occlusion of hepatic veins)
What are the signs of chronic liver disease?
Ascites, oedema, haematemesis (varices), spider naevi, palmar erythema, jaundice, confusion/coma, itching, easy bruising, anorexia (not eating), wasting…
What are the causes of acute liver disease?
HAV, HBV, EBV, Paracetamol OD, TB drugs, excessive alcohol
What is charcot’s triad?
Jaundice, fever and RUQ pain
What type of cancer is hepatocellular carcinoma?
Adenocarcinoma - malignant tumour of glandular epithelium
What is charcot’s triad a feature of?
Ascending cholangitis
What is ascending cholangitis?
Infection of the biliary duct
Give 3 causes of ascending cholangitis
CBD gall stone, benign biliary strictures (primary sclerosing cholangitis, post-surgery/ERCP), cancer of the head of the pancreas
What type of jaundice occurs in ascending cholangitis?
Obstructive post-hepatic jaundice
What bacteria commonly cause ascending cholangitis?
E.coli and enterococci
What is biliary colic?
Pain of the upper abdomen that radiates the the R shoulder, associated with vomiting
Why does pain in biliary colic radiate to the R shoulder?
Radiation via the phrenic nerve
What is the presentation of gallstones?
Asymptomatic if in gall bladder
What are the complications of gallstones?
Acute pancreatitis (common duct), ascending cholangitis, cholecystitis, obstructive jaundice
What is acute cholecystitis?
Gallstone in the common bile duct causing inflammation of the gallbladder
Does acute cholecystitis show jaundice?
No
What is the presentation of cholecystitis
Biliary colic pain which then localises to the RUQ (with associated fever)
How would you detect acute cholecystitis? What would this show?
Abdominal USS (shows thickenning of the gall bladder wall + presence of gallstones
What is the treatment for acute cholecystitis?
Cholecystectomy
What is the presentation of a stone in the common bile duct?
Asymptomatic unless it leads to acute ascending cholangitis
Would you treat a stone in a common bile duct or gallstones in the gall bladder?
No unless they were symptomatic
What does USS show if a stone is in the common bile duct?
Dilated CBD + the stone itself
What is ascending cholangitis?
Bacterial infection of the biliary duct
What investigations would you carry out to determine whether someone had ascending cholangitis? What would you see?
^ WCC, Blood culture (E. coli or enterococci), USS (dilated CBD, stone, cancer…), ERCP
What type of features of jaundice would you see in biliary tract disease?
Dark urine + pale stools
What is the most useful imaging technique in ascending cholangitis?
ERCP (as you can drain the duct)
What is the treatment for ascending cholangitis?
IV fluids, analgesia, IV Abx, ERCP (biliary drainage + remove stone)
What clotting factors does the liver not make?
III (tissue factor) and IV (Ca2+)
