Liver: case studies

Question 1

Cholestatic enzymes

Answer 1

GGT (gamma-glutamyl transferase) and ALP (alkaline phosphatase)

This often indicate a mass or biliary obstruction

Question 2

Inflammation enzymes

Answer 2

ALT (alkaline-transferase) and AST (aspartate-transferase)

Question 3

What causes jaundice?

Answer 3

Elevated bilirubin. causes yellow sclera and skin.
Due to a biliary obstruction (bile release), or hepatocellular injury (lysis)

Haemolysis also causes bilirubin

Question 4

What measure the livers synthetic function

Answer 4

Prothrombin Ratio (clotting factors)
Albumin

Question 5

What measure the livers detox function

Answer 5

NH3 ammonia levels, if not detoxified they can build up in the brain > hepatic encephalopathy

Question 6

If the AST and ALT are really high, what is the much common cause to look at first?

Answer 6

Viral infection, most commonly Hep A, B, C

Question 7

Why should you be worried about blood transfusions pre 90’s

Answer 7

Because there wan’t the regulations there are now, so potentially carrier of infection. eg) hep B and C

Question 8

Chronic Hepatitis A

Answer 8

Doesn’t exist, Hep A is benign and self-limiting

Question 9

How do you determine if viral hepatitis is acute of chronic

Answer 9

Acute: first 6 months
Chronic: post 6 months

Question 10

Causes of Hep B and Hep C, how are they transmitted, what do they cause and available treatment?

Answer 10

Causes of Hep B:
*** sexually transmitted
drug use
mother to child
horizontal transmission

Causes of Hep C
***Drug use
blood transfusion
low sexual transmission risk
mother to child
occupational
tattoo

Both transmittable through blood

Can lead to cirrhosis and hepatocellular carcinoma (if aqquired later some Hep B patients will resolve)

There is a vaccine for Hep B but not Hep C (incurable)

Question 11

Interferon

Answer 11

Old drug for HCV, many adverse side -effects, low success rate (50%), a cytokine so gives flu like effect.
-given as a sub-cutaneous injection
Initially alone
the interferon + ribavirin

Question 12

Breakthrough HCV treatment

Answer 12

Direct-acting Antiviral agents
-tablets
- Cure rates >90%
Been the cause of declining need for liver transplants

Question 13

Oesophageal/ gastric Varices

Answer 13

Due to pressure increase due to portal hypertension (associated with cirrhosis), these are dangerous as they have potential to bleed.

Treatments: ‘Banding’, suck varices up into a cap, rubber band strangles varices and stops the bleeding

This may need to be done several times, but they can REFORM, so it’s only temporary!

Question 14

Portal circulation consists of?

Answer 14

Portal Vein: that drains nutrient rich blood from the GI tract and spleen to the liver
venous blood passes through the
Liver > IVC > heart

Question 15

Portal Hypertension

Answer 15

High pressure in the portal vein, more resistance making it harder for blood in the portal circulation to return to the heart.
Portosystemic shunts/collaterals form, that enlarge and try to divert blood away from the portal system to the heart > varices

Question 16

Two most common place to get varices

Answer 16

1) Gastro-oesophageal Junction: work upwards

2) Stomach: particularly fundus

Question 17

Normal Portal BF vs Cirrhosis (Portal hypertension)

Answer 17

BP: 55mmHg
Supplies 3/4 Blood flow to liver (70% O2)
100% blood > hepatic vein > systemic circulation

BP: 12mmHg
portosystemic shunts formed > varices

Question 18

Liver intitially ______ then progressively ______

Answer 18

Liver intitially elarged then progressively shrinks

Question 19

Is fibrosis reversible?

Answer 19

Potentially if the liver is allowed time to regenerate by removing inflammatory cause. If this doesn’t occur&raquo_space; cirrhosis ‘irreversible scarring’

Question 20

What causes fibrosis

Answer 20

repeated bouts of inflammation

Question 21

Can the liver function with cirrhosis?

Answer 21

When it is mild, as the liver is good at compensating, huge reserve capacity. However as it progresses more and more function is lost (liver failure at 80-90%)

Question 22

Hepatic Encephalopathy. Early and late symptoms

Answer 22

Build up of NH3 toxins in the brain due to liver failure. THe liver is unable to detoxify substances from the bacterial metabolism. Also portosystemic shunts bypass the liver entirely (no detox at all). You get a build up of ammonia in the blood (passes blood-brain barrier)

Early Symptoms: mood and personality change. Inverted sleep pattern. (hard to diagnose)

Late Symptoms; Confusion and bizarre behaviour, drowsiness and coma.

Question 23

Treatment of HE

Answer 23

Lactulose

• normally a laxative to treat constipation
• decrease ammonia production by bacteria
• makes it a non-absorbable substance > excreted

For management but not definitive treatment.

Question 24

Ascites

Answer 24

fluid accumulation in the peritoneum > abdominal distention.
Often caused by portal hypertension
-Elevated hydrostatic pressure in PV > fluid moves out of circulation
-Low oncotic pressure in PV (low serum albumin) unable to hold onto fluid

Question 25

Hypersplenism

Answer 25

1) Splenomegaly : swollen spleen

2) Low platelet count: platelets going through spleen are destroyed at a higher rate

Question 26

People can donate upto _____% of their liver

Answer 26

50%

Question 27

Definitive treatment for liver failure

Answer 27

Liver transplant

Question 28

Acute thrombosis of Hepatic veins

Answer 28

Budd-Chiari

• outflow of blood from liver obstructed
• liver becomes congested > hepatocellular damage
• Results in PH with ascites forming

Question 29

Fulminant

Answer 29

very severe and sudden

Question 30

Causes of Budd-Chiari

Answer 30

75% no obvious cause
25% cause identifies
-tumor
-pregnancy
-Contraceptive pill
-clotting disorders

Question 31

Management of Budd-Chiari

Answer 31

Portocaval shunting to divert blood flow

• TIPSS (transjugular intrahepatic portosystemic shunt): reduces resistence of BF to liver, done for PH
• surgical

Anticoagulation : thin blood and dissolve clot

Diuretics