Liver Cases

Question 1

Give 4 features of chronic stable liver disease

Answer 1

Spider naevi
Dupuytrens contracture
Gynaecomastia
Palmar erythema

Question 2

Which enzyme rises the most when the biliary tree is obstructed?

Answer 2

ALP

Question 3

Which symptom indicates the cause of obstructive jaundice?

Answer 3

Painful: Gallstones
Painless: Cancer in biliary tree e.g. Pancreatic

Question 4

Describe the production of bilirubin

Answer 4

1. Reticuloendothelial cells take up RBCs, metabolise Hb into haem + globin
2. Haem further metabolised to iron + unconjugated bilirubin
3. Unconjugated BR binds to albumin to travel to liver

Question 5

What happens to unconjugated bilirubin in the liver?

Answer 5

Glucuronic acid is added to unconjugated BR by glucuronyl transferase
Forms soluble, conjugated BR
Excreted through bile duct to Duodenum

Question 6

Describe the excretion of conjugated bilirubin

Answer 6

Colonic bacteria deconjugate BR to Urobilinogen
80% is oxidised to Stercobilin + excreted in faeces (giving colour)
20% is reabsorbed into blood via enterohepatic circulation to liver.

Question 7

What happens to the 20% of urobilinogen that is reabsorbed into the enterohepatic circulation

Answer 7

Some recycled for bile production
Some reaches kidneys + is oxidised further into Urobilin which is excreted in the urine

Question 8

What happens to bilirubin if the bile duct is obstructed?

Answer 8

Back pressure prevents BR from entering the duodenum
Conjugated BR leaks into blood stream
Patient becomes yellow
No conjugated BR enters gut, no brown pigment in stools- pale stools

Question 9

Where are bile salts made and stored? What is the role of bile salts?

Answer 9

Made by Liver to emulsify fat
Stored in gall bladder
1. Ingest fatty meal
2. Gallbladder squeezes juices out to emulsify fat
3. Once fat emulsified, reabsorb bile salts in ileum
4. Bile salts return via enterohepatic circulation

Question 10

What happens to bile salts if the bile duct is obstructed?

Answer 10

Bile salts leak into circulation
VERY skin irritant
Bile salt deposition leads to scratch marks

Question 11

What key feature of obstructive jaundice is absent in hepatitis?

Answer 11

Scratch marks

Question 12

Give 3 observable features of obstructive jaundice

Answer 12

Scratch marks: bile salts get into skin- irritant
Pale stools: lack stercobilin
Urine: negative for urobilinogen

Question 13

Is it normal to have urobilinogen in the urine?

Answer 13

Yes
Indicates enterohepatic circulation is intact

Question 14

Does itching occur in hepatitis?

Answer 14

No
Enterohepatic circulation is intact
No itching as the liver doesn’t make enough bile salts due to damage

Question 15

What does this picture show? What is this a sign of?

Answer 15

Nutmeg liver
= Heart failure
Pressure builds up in central vein of liver, chronic venous congestion