Liver conditions Flashcards
1
Q
What does an increased ALT and AST indicate?
A
hepatocellular injury i.e. the liver is injured such as alcohol or hep B and C
2
Q
What does an increase is ALP indicate?
A
cholestasis i.e. reduced or blocked bile flow
3
Q
What is the classification of jaundice?
A
prehepatic or unconjugated: haemolysis
conjugated hepatic: hepatitis, ischaemia, neoplasm
conjugated post hepatic: gallstones in bile duct, stricture
4
Q
What is liver failure?
A
Loss of the livers ability to regenerate and repair: destruction of hepatocytes, development of fibrosis, destruction of architecture
5
Q
What is fulminant hepatic failure?
A
necrosis in substantial parts and encephalopathy
6
Q
Why can liver failure present with encephalopathy?
A
ammonia in circulation stops krebs cycle in brain leading to cell death and oedema
7
Q
What causes liver damage?
A
hepatitis A,B,D and E, cytomegalovirus, EBV, herpes simplex, paracetamol overdose, alcohol, Wilson’s disease, carcinoma
8
Q
How does liver damage present?
A
abnormal bleeding, ascites, jaundice and encephalopathy (confusion, liver flap, coma), small liver, fetor hepaticus, cerebral oedema
- acute: encephalopathy and INR below 1.5
- chronic: bruising, clubbing and depuytren’s contracture (thick palm skin)
9
Q
What are differentials of liver failure?
A
cerebral infarction, intoxication,
10
Q
What test do you order for liver failure and what do you expect?
A
FBC: hyperbilirubinaemia, High AST and ALT, increased PTT, hyperglycaemia, high ammonia levels
EEG, ultrasound and cxr
11
Q
How do you treat liver failure?
A
Treat cause
- IV mannitol if ICP rises - IV vitamin K for coagulation - Liver transplant
12
Q
what do you give for a paracetamol overdose?
A
acetylcysteine
13
Q
What is a hernia?
A
Profusion of an organ or part of an organ through a defect of the walls of its contained cavity
14
Q
What is a reducible hernia?
A
can be pushed back
15
Q
What is a irreducible hernia and what subtypes are there?
A
cannot be pushed back
- obstructed: blood flow maintained but intestine obstructed - incarcerated: contents are stuck inside by adhesions - strangulated: blood supply cut off, urged surgery
16
Q
Give three examples of hernia’s?
A
inguinal hernia, hiatus hernia and incisional hernia
17
Q
What is Budd Chair syndrome?
A
hepatic vein obstruction by thrombosis or tumour causing congestive ischaemia and hepatocyte damage
18
Q
What is wilson’s disease?
A
Rare inherited disorder of biliary copper excretion with too much copper in the liver and CNS
autosomal recessive
19
Q
How does wilsons disease present?
A
hepatic problems in children and CNS problems in adults, Kayser-Fleischer ring
24 hour urinary copper excretion is high, haemolysis and anaemia, basal ganglia and cerebellar degeneration
20
Q
How do you treat wilson’s disease?
A
treat with life long chelating agent: penicillamine
21
Q
How is hepatitis A transmitted?
A
from contaminated water and food through faecal-oral route
22
Q
How does hepatitis A present?
A
Jaundice, dark urine and pale stool, hepatosplenomegaly and the jaundice lessens and illness ends
- IgM during acute infection, IgG as a memory (chronic or resolved) and HAV antibodies
23
Q
How do you treat hep A?
A
Notifiable disease: usually self limiting and has an incubation of 2-6 weeks
Treat with supportive treatment, acid alcohol and motor liver function
24
Q
Which type of hepatitis is similar to Hep A?
A
Hepatitis E
25
How is hepatitis B transmitted?
Blood borne and sexually
26
What antibody will you find in hep B?
HBsAg present and if longer than 6 months it means carrier status
27
How do you treat hep B?
Chronic treatment: SC pegylated interferon-alpha 2A or nucleoside analogues (tenofovir)
28
What is required for Hep D?
Hep B
29
What is common in drug users?
Hep C
30
How does portal hypertension occur?
1. Contraction of activated myofibroblasts contribute to resistance in blood flow causing portal HTN
2. that is counteracted by splancinc vasodilation resulting in a drop in BP.
3. CO increases to compensate and salt/water is retained to cause higher blood volume and increased portal flow.
4. This results in the formation of collaterals and varices
31
what is normal portal pressure?
5-8 mmHg
32
At what portal pressure will varices develop and bless?
Develop at above 10
| Bleed at 12
33
What causes portal hypertension?
alcohol and viral cirrhosis are leading causes
pre hepatic: portal vein thrombosis
intrahepatic: cirrhosis, sarcoidosis
post-hepatic : IVC obstruction, pericarditis, HF
34
What causes varices?
portal hypertension
35
How does portal hypertension present?
often asymptomatic but can show splenomegaly or chronic liver disease features
36
How is portal hypertension managed?
Beta blockers i.e. propranolol
37
How do varices present?
present if they have ruptured: haematemesis, melaena (dark sticky faeces), abdominal pain, tachycardia, hypotension and pallor
38
How do you investigate varices?
endoscope
39
How do you treat varices?
treat by resuscitation, give vasopressin (IV terlipressin), correct clotting abnormalities and potentially give blood transfusion
surgery: banding, ballon tamponade or TIPS (shunt)
40
What is cirrhosis?
End stage of all progressive chronic liver disease
41
How does cirrhosis occur?
- Hepatic stellate cells: release cytokines causing further inflammation and necrosis
- Kupffer cells: secrete TNF beta which turns stellate to myofibroblasts, releasing collaged depositions
42
what are the two types of cirrhosis?
micro nodular (less than 3 mm) or macro nodular (varying size)
43
How does cirrhosis present?
leukonyctia (white nail discolouration), clubbing, palmar erythema, dupuytren’s contracture, ascites, ankle swelling and bruising
44
How do you investigate cirrhosis?
LFTs (best indicator is PTT or albumin) and liver biopsy (GS)
45
What indicated hepatocellular carcinoma?
alpha faecalprotein
46
What are complications of cirrhosis?
coagulopathy, encepathopathy, portal hypertension
47
How do you treat cirrhosis?
alcohol abstinence, avoidance of NSAIDs, treat underlying causes
- liver transplant
- regular cancer screening
48
What is non alcoholic fatty liver disease?
Fat accumulation in the liver unrelated to alcohol or viral causes
49
what is the pathology of NAFLD?
Results from fat depositions in the liver but mechanism isn't clear
- Steatohepatitis (NASH): steatosis and inflammation, mallory denk bodies, increased neutrophils
- chronic NASH causes stellar cells to lay down fibrotic tissue leading to cirrhosis
50
What are RF for NAFLD?
50+, BMI over 28, diabetes, hyperlipidemia, HTN
| essentially metabolic syndrome
51
How does NAFLD present?
Even advanced stages can be asymptomatic but a small percentage experiences fatigue, malaise and liver ache
significant damage can cause hepatomegaly, RUQ pain, jaundice and ascites
52
How tests do you order for NAFLD?
LFT (increased ALT rather than AST in alcoholic), Ultrasound and biopsy
53
How do you treat NAFLD?
Steatosis and NASH are reversible by treating underlying cause
- no effective drug treatment
54
How does alcoholic liver disease occur?
Ethanol metabolism results in altered redox potential leading to hepatic accumulationn of FA, centrilobular necrosis and TNF alpha release from Kupffer cells
55
what are the three stages of ALD?
Fatty liver, alcoholic hepatitis and cirrhosis
56
What happens in the fatty liver stage?
cells swell with fat (steatosis) but no cell damage, stellate cells can become collagen producing leading to cirrhosis without hepatitis
57
How does fatty liver present?
asymptomatic, vague abdominal symptoms, hepatomegaly
58
What results would you expect in the fatty liver stage?
increased ALT and AST (more than ALT), CT shows fatty infiltration
59
How do you treat alcoholic fatty liver?
can be reversed with alcohol cessation
60
What happens in alcoholic hepatitis?
infiltration of leukocytes, hepatocyte necrosis, mallory bodies and giant mitochondria
61
How does alcoholic hepatitis present?
jaundice and signs of chronic disease (ascites, clubbing, dupuytren’s contracture)
if severe may show pain and fever
62
What do LFT show in alcoholic hepatitis?
increased ALT and AST (more than ALT), increased bilirubin and PTT
63
how do you treat alcoholic hepatitis?
steroids and alcohol cessation
64
How does alcoholic cirrhosis present?
chronic liver disease signs, features of alcohol dependency
65
What type of cirrhosis is alcoholic cirrhosis?
micronodoular
66
How do you treat cirrhosis?
avoid NSAIDS ad liver transplant
67
Why would you give IV thiamine?
to prevent Wernicke-Korsakoff encephalopathy that can occur from alcohol withdrawal
68
What is chronic pancreatites?
Progressive loss of exocrine tissue which is replaced by fibrosis
69
What is the pathology of chronic pancreatitis?
1. obstruction or reduction in bicarbonate secretion leads to alkaline pH and stabilises trypsinogen
2. conversion into trypsin leads to tissue necrosis and eventual fibrosis
- decrease in bicarbonate can be caused by functional defects in wall (CF or trauma)
- obstruction can arise from protein deposits within duct (alcohol or increased intrahepatic enzyme activity)
70
What causes chronic hepatitis?
LT alcohol excess, CKD, hereditary (trypsinogen gene defect or CF), autoimmune (IgG), trauma, recurrent acute pancreatitis
71
What are RF for chronic pancreatitis?
alcohol, smoking, family history
72
How does chronic pancreatitis present?
pigastric pain that is relived by sitting forward and can be exacerbated by alcohol, nausea, vomiting, anorexia
- exocrine dysfunction (acinus and duct): malabsorption, diarrhoea, steatorrhea, protein deficieny
- endocrine function: diabetes mellitus
73
How do you confirm chronic pancreatitis
Ultrasound, serum amylase and lipase, faecal elastase, CT
74
How do you manage chronic pancreatitis?
- Manage with alcohol cessation and NSAIDs for pain
| - treat associated symptoms
75
What is acute pancreatitis?
Inflammation due to any injury
76
How does acute pancreatitis occur and how does alcohol or gallstones help?
Premature activation of pancreatic enzymes leading to self-perpetuating inflammation, leaky vessels (oedema), destruction of blood vessels, destruction of islets of Langerhans and fat necrosis
Activation can occur through:
- gallstones: obstruction leads to build up, increase in calcium and therefore activation of trypsinogen which becomes trypsin
- Alcohol: contraction of the ampulla of vader leads to obstruction and alcohol interferes with calcium homeostasis
77
What causes acute pancreatitis?
IGETSMASHED: idiopathic, gallstones, ethanol, steroids, mumps, autoimmune, scorpion venom, hyperlipidemia, ERCP and drugs
78
What are RF for acute pancreatitis?
middle aged, young men, gallstones, SLE, sjorgen’s
79
How does chronic pancreatitis present?
Presents with epigastric pain that may be relieved by sitting forward, anorexia, N and V, tachycardia, fever and jaundice
- Grey Turner sign (flank discolouration) and Cullen sign (bruising around umbilicus)
80
What tests do you order for acute pancreatitis?
serum and urinary amylase, serum lipase, xray for gallstones
81
What is a complication of acute pancreatitis?
systemic inflammatory response syndrome (SIRS)
presents with any 2 of: tachycardia 90+, tachypnea 20+, pyrexia over 38 and increased WCC
82
How do you treat acute pancreatitis?
Treat with fluid resuscitation and nil by mouth
- analgesia, catheter, antibiotics and potential drainage
- assess severity with Glascow and Ranson (in 48 hours) or APACHE 2 (within 24 hours)
83
What are two types of gallstones and how do you recognise them?
Cholesterol: 80% of stones, large and solitary, form from excess cholesterol that crystallises
Bile pigment: calcium, viable and irregular
- can be brown or black
(glass like)
84
How are cholesterol stones formed?
excess cholesterol, decreased bile and phospholipids, reduced motility, crystalline promoting factors
85
What causes gallstones?
obesity, rapid weight loss, diabetes, cirrhosis, contraceptive pill
86
What are RF for gallstones?
female, fat, fertile and smoking
87
How do gallstones present?
Majority are asymptomatic but can present with biliary colic
88
What is biliary colic?
RUQ pain that is sudden and severe, can radiate to right shoulder
89
How do you confirm gallstones?
ultrasound
90
What are differentials of gallstones?
IBS, carcinoma, renal colic
91
What are consequences of gallstones?
biliary colic, cholecystitis, mirizzi syndrome (hepatic duct obstruction due to pressure)
92
How do you manage gallstones?
laparoscopic cholecystectomy if symptomatic
- cholesterol stones can be dissolved by increased bile salts and statins
- shock wave lithotripsy to fragment stones for passing
93
What is cholecystitis?
Obstruction of gallbladder emptying leading to distention and inflammation
94
What causes cholecystitis?
gallstones moving to common bile duct
95
How does cholecystitis present?
fever, biliary colic and murphy’s sign (pain when taking in a deep breath and putting fingers on RUQ)
96
How do you investigate cholecystitis and what do you expect to see?
FBC (increase WCC, bilirubin, ALP, ALT), abdominal ultrasound (stones and shrunken gallbladder)
97
What are consequences of cholecystitis?
cholangitis, empyema (collection of pus) pancreatitis
98
How do you treat cholecystitis?
nil by mouth, IV fluids, analgesia, IV antibiotics (cefuroxime) and cholecystectomy
99
What is ascending cholangitis?
Infection of the biliary tree caused by bacteria ascending from duodenal junction
100
What structures form the biliary tree?
pancreatic duct, cystic duct, common hepatic and common bile
101
What causes ascending cholangitis?
gallstones, cancer of head of pancreas, biliary parasites and benign structure after surgery
102
What are RF for ascending cholangitis?
over 50, gallstones
103
How does ascending cholangitis present?
charcot’s triad: fever, jaundice, RUQ pain
dark urine, pale stool and itchy skin
104
What tests do you order for ascending cholangitis and what do you expect?
Order FBC (increased bilirubin, increased ALP, ALT>AST) and trans abdominal ultrasound
- MRI for pigmented stones
105
What are consequences of ascending cholangitis?
Consequences include toxic cholangitis: pus in biliary tree, sepsis, hypotension and organ failure
- can present with reynolds pentad: charcot + sepsis and neurological changes
106
How do you treat ascending cholangitis?
IV antibiotics (cefotaxime and metronidazole), biliary drainage and removal of stones
107
What do gallbladder stones present with?
biliary colic, cholecystitis, mirizzi
108
What do bile duct stones present with?
colic, pancreatitis, cholangitis, obstructive jaundice
