Liver Conditions Flashcards
What do LFTs show?
- Serum bilirubin - if low indicates liver damage
- Serum albumin - if low indicates liver damage
- Prothrombin time (INR) - increased because less clotting factors
What liver hepatic enzymes are tested for and what do they show?
- Aminotransferases - leak into blood when hepatocytes are damaged
- ALP (Alkaline phosphate) - raised in intra/extra hepatic cholestatic disease of any cause
Liver Failure - Definition
- Liver looses its ability to repair and regenerate leading to decompensation
- Acute - occurs for <22 weeks
- Chronic - when it is a progression of cirrhosis
Liver Failure - Causes (6)
- Infection (viral hepatitis)
- Metabolic (Wilsons)
- Autoimmune (primary biliary cirrhosis)
- Neoplastic (hepatocellular carcinoma)
- Vascular (ischaemia)
- Toxins (paracetamol, alcohol) - most common in UK
Liver Failure - Symptoms (7)
- Nausea
- Anorexia
- Jaundice
- Myalgia
- Coagulopathy (INR increased)
- Altered mood
- Sweet breath/urine
Liver Failure - Investigations (3)
- Bloods - increased prothrombin time, increased AST and ALT
- Toxicology screen - alcohol, overdose
- Peritoneal tap with microscopy and culture if ascites present
Liver Failure - Treatment (5)
- No cure
- Fluids
- Analgesia
- Treat complications
- Transplant
Gallstones - Pathology
- Gallstones made of super concentrated bile blocking of bile duct
- Bile is made of cholesterol, pigments and phospholipids
- Cholesterol stone - from excess production (obesity, fatty diets)
- Pigment - haemolytic anaemia
- Mixed - made of cholesterol and pigment
Gallstones - Symptoms (2)
- On and off right upper quadrant pain
- Worse after eating large fatty meals (triggers gallbladder contraction)
Gallstones - Risk Factors
5Fs: Fat, Fertile, Forty, Female, Family history
Gallstones - Investigations (4)
- Ultrasound - stones, gallbladder thickness, duct dilation
- FBC - rule out inflammation
- LFTs - Raised ALP
- Amylase - rule out pancreatitis
Gallstones - Differential Diagnosis (6)
- Cholecystitis
- Cholangitis
- IBD
- Pancreatitis
- GORD
- Peptic Ulcers
Gallstones - Treatment (3)
- NSAIDS
- Analgesia
- Cholecystectomy (prevents recurring)
Cholecystitis - Pathology
Gall stone blocks ducts → bile builds up → gallbladder distention (swelling) → reduced vascular supply → inflammation
Cholecystitis - Symptoms (2)
- Severe right upper quadrant pain
- Fever or fatigue (inflammation)
Cholecystitis - Investigations (3)
- Positive Murphy’s Sign - severe pain on deep inhalation when hand pressed over RUQ
- Bloods - inflammatory markers
- Ultrasound - thick gallstone walls from inflammation
Cholecystitis - Treatment (4)
- IV antibiotics
- Analgesia
- IV fluids
- Cholecystectomy
Cholangitis - Pathology
Prolonged bile duct blockage → bacteria climb up from the GI tract → biliary tree infection and consolidation → bile can’t enter GI tract → jaundice
Progression from cholecyctitis
5-10% mortality
Cholangitis - Symptoms (4)
- Severe RUQ pain
- Fever
- Jaundice
- May have sepsis or pancreatitis
Cholangitis - Investigations (3)
- Bloods - leukocytosis, raised ALP, bilirubin, CRP
- Blood cultures - identify pathogen
- Ultrasound
Cholangitis - Treatment (3)
- Treat sepsis
- ERCP (endoscopic retrograde cholangiopancreatography) to clear blockage
- Cholecystectomy
Acute Pancreatitis - Pathology
- Inflammation of the pancreas → leakage of enzymes → autodigestion
- Pancreas can heal
Acute Pancreatitis - Causes (mneumonic)
I GET SMASHED
- Idiopathic
- Gallstones (common)
- Ethanol (common)
- Trauma
- Steroids
- Mumps
- Autoimmune (in japanese)
- Scorpion venom
- Hyperlipidaemia
- ERCP
- Drugs (NSAIDs, corticosteroids, ACEi)
Acute Pancreatitis - Symptoms (7)
- Severe epigastric pain radiating to the back, better when leaning forward
- Anorexia
- Fever
- Jaundice
- Grey Turner’s sign (grey abdomen skin)
- Tachycardia
- N&V
Acute Pancreatitis - Investigations (3)
- Serum amylase and lipase - raised
- CRP - infection
- Ultrasound/CT/MRI - exclude gastroduodenal rupture
Acute Pancreatitis - Scoring
- APACHE 2
- Glasgow and Ranson
Acute Pancreatitis - Treatment (4)
- Nil by mouth (drop pancreatic stimulation)
- Analgesics
- Prophylactic antibiotics
- Treat cause (gallstones)
Chronic Pancreatitis - Pathology
- Mostly caused by chronic alcohol abuse but sometimes hereditary, autoimmune or CKD
- Obstruction of bicarbonate secretion in pancreatic lumen → early activation of trypsinogen and autodigestion
Chronic Pancreatitis - Symptoms (4)
- Epigastric pain radiating to back
- Worse after alcohol, better when leaning forward
- Usually older patients than acute
- N&V, DM anorexia, weight loss
Chronic Pancreatitis - Investigations (2)
- Serum amylase and lipase - raised
- Ultrasound/CT/MRI
Chronic Pancreatitis - Treatment (4)
- Stop drinking
- Pancreatic enzyme supplements
- Insulin for DM
- Duct drainage
Alcoholic Liver Disease - Pathology
- Starts with fatty liver - can be reversed by stopping drinking
- Then alcoholic hepatitis - infiltration of polymorphonucleocytes and hepatic necrosis (irreversible)
- Continued drinking leads to cirrhosis - irreversible
Alcoholic Liver Disease - Symptoms
Vague abdominal signs (nausea, vomiting, diarrhoea)
Alcoholic Liver Disease - Investigations (3)
- GGT - very raised
- AST and ALT - mildly raised
- FBC - macrocytic anaemia
Alcoholic Liver Disease - Complication
- Wernicke-Korsakoff encephalopathy - thiamine deficiency causing hyperthalamic changes and soluble atrophy
- Presents with ataxia (wide based gait), confusion, nystagmus (rapid eye movement), memory impairment
- Treat with IV thiamine
Alcohol Units (calculation and recommendation)
- Calculation - strength (ABV) x volume (ml) / 1000 = units
- No more than 14 units a week
Non-Alcoholic Fatty Liver Disease - Epidemiology
Effects roughly 25% of population
Non-Alcoholic Fatty Liver Disease - Risk Factors (3)
- Obesity 70%
- Diabetes 35-75%
- Hyperlipidaemia 20-80%
Non-Alcoholic Fatty Liver Disease - Causes (5)
- Obesity
- Hypertension
- DM
- Hyperlipidaemia
- Hypertriglyceridemia
Non-Alcoholic Fatty Liver Disease - Symptoms (5)
- Usually asymptomatic
- Fatigue
- RUQ pain
- Jaundice
- Heptomegaly
Non-Alcoholic Fatty Liver Disease - Investigations (2)
- LFTs - mildly raised, raised ALT sometimes raised AST
- Ultrasound/CT/MRI
Non-Alcoholic Fatty Liver Disease - Treatment
- No treatment
- Weight loss
Cirrhosis - Description
Loss of normal hepatic architecture with fibrosis causing necrosis and apoptosis of liver cells
Cirrhosis - Causes (6)
- Alcohol abuse (most common in UK)
- Non-alcoholic liver disease
- Hepatitis
- Haemochromatosis
- Wilson’s disease
- Alpha-Antitrypsin deficiency
Cirrhosis - Symptoms (5)
- Ascites
- Clubbing
- Palmar erythema (red palms)
- Spider naevi (visible red blood vessel clusters)
- Peripheral oedema
Cirrhosis - Investigations (3)
- Bloods - low platelets, high IRN, low albumin
- Ultrasound and CT - hepatomegaly
- Liver biopsy (diagnostic)
Cirrhosis - Treatment (3)
- Irreversible
- Abstain from alcohol
- Liver transplant
Portal Hypertension - Causes
- Prehepatic
- Portal vein thrombosis
- Intrahepatic
- Schistosomiasis (most common in developing world)
- Cirrhosis (most common UK)
- Budd Chiari Syndrome
- Posthepatic
- RH failure
- IVC obstruction
Portal Hypertension - Pathology
Endothelin-1 production increased in cirrhosis → more vasoconstriction, reduced NO production in cirrhosis → less vasodilation. Increased resistance → drop in BP → increased CO to compensate → salt and water retention to increase blood volume → hyperdynamic circulation
Portal Hypertension - Symptoms (4)
- Ascites
- Hepatic encephalopathy (neurological disorder)
- Splenomegaly
- Oesophago-gastric varices
Varices - Description
Blood backs up into oesophagus from liver
Varices - Pathology
Veins are thin and not meant for high pressure so rupture → haematemesis (vomiting blood) → blood digested → melaena (dark faeces)
Varices - Investigation
GI endoscopy
Varices - Treatments (4)
- Medical - beta blockers, nitrate
- Surgical - band ligation, trans jugular intrahepatic portosystemic shunt
Hepatitis A - transmission, virus type, investigations, treatment
- Faecol-oral spread
- RNA virus
- Acute and mild infection
- Investigations - bloods (AST/ALT raised, raised IgG and IgM)
- Treatment - supportive (fluids, analgesia etc.), vaccine
Hepatitis B - transmission, virus type, investigation, treatment
- Spreads through blood and bodily fluids
- DNA virus
- Can be severe
- Investigation - HBV assay
- Has vaccine
- Treatment - 1st line: pegylated interferon alpha 2a, 2nd line: Tenofovir (inhibits viral replication)
Hepatitis C - transmission, virus type, investigations, treatment
- Spreads through blood and bodily fluids
- DNA virus
- Can be severe
- Investigation - HBV assay
- Has vaccine
- Treatment - 1st line: pegylated interferon alpha 2a, 2nd line: Tenofovir (inhibits viral replication)
Hepatitis D - transmission, virus type, investigation, treatment
- Spread by blood and bodily fluids
- RNA virus, requires Hep B
- Investigations - bloods for HDV RNA
- Treatment - treat Hep B
Hepatitis E - transmission, virus type, investigation, treatment
- Faeco-oral spread
- RNA virus
- Normally mild
- Investigations - bloods for HVE
- Treatment - supportive (fluids, analgesia etc)
Hepatitis - Complications
- B - 20% chance of cirrhosis
- C - most likely for cirrhosis
- E - only leads to cirrhosis with liver transplant or immunocompromised
Paracetamol normal action
- Phase 2 reactions
- Goes through glucuronidation or sulfation to produce none harmful substances for excretion
- Low glucuronic acid or sulphate means paracetamol undergoes phase 1 reaction
- Metabolised by C1P450 enzyme making NAPQI then added to glutathione to be excreted
Paracetamol Overdose - Pathology
- Too much paracetamol to do phase 2 reaction so has to do phase 1 reaction
- Makes lots of NAPQI but not enough glutathione to convert into a safe form to excrete
- NAPQI causes liver damage
Paracetamol Overdose - Symptoms (4)
- Nausea
- Vomiting
- Anorexia
- Right upper quadrant pain
Paracetamol Overdose - Treatment (2)
- Activated charcoal within 1 hour
- N-acetycysteine after 1 hour or with existing liver damage (replenishes glutathione)
Diarrhoea - Description
Increased stool frequency and volume, decreased consistency
Diarrhoea - Causes (6)
- Viral - rotavirus (children), norovirus, adenovirus
- Bacterial - E coli., salmoella,
- Parasites - giardia
- Antibiotics
- Anxiety
- Chronic - IBD, IBS, coeliac, bowl cancer
Diarrhoea - Risk Factors (2)
- Foreign travel
- poor hygiene
Diarrhoea - Symptoms (3)
- Loose stools, vomiting, abdo cramp
- Viral - fever, fatigue, headache, myalgia (muscle aches)
- Red flags - blood in stool, recent hospital admission, antibiotics, persistent vomiting, weight loss, painless watery diarrhoea
Diarrhoea - Investigations (2)
- Dehydration exam - dry mucus membranes (inside mouth), increased capillary refill time (press on nail not returning to red quickly)
- Stool sample
Diarrhoea - Treatment (5)
- Treat cause
- Oral rehydration
- Anti-motility - loperamide, codeine (stops pooing - not for infection)
- Antibiotics - for gastroenteritis
- Anti-emetics
Haemochromatosis - Pathology
- Mutation in autosomal recessive HFE gene (chromosome 6)
- Increased intestinal iron absorption → accumulates in liver, joints, pancreas, heart, skin, gonads → organ damage
Haemochromatosis - Symptoms (6)
- Fatigue
- Arthralgia (joint stiffness)
- Weakness
- Hypogonadism (erectile dysfunction)
- Slate-grey skin
- Chronic liver disease, heart failure, arrhythmias
Haemochromatosis - Investigations (4)
- Bloods - iron study, LFTs
- Genetic testing - HFE gene chromosome 6
- Liver biopsy (gold standard)
- MRI - detects iron overload
Haemochromatosis - Treatment (3)
- Venesection (reduce RBC)
- Chelation (sticks to iron and removes in urination) - desferrioxamine
- Liver transplant
Wilson’s Disease - Pathology
- Too much copper in liver and CNS
- We don’t know how copper is metabolised but there is an error → copper deposition in liver, basal ganglia, cornea
Wilson’s Disease - Symptoms (4)
- Psychiatric - depression, neurotic behaviour
- CNS - tremor, dysarthria (unclear speech), involuntary movements, dysphagia (difficulty swallowing), reduced memory
- Liver - hepatitis, cirrhosis
- Kayser-Fleischer ring - copper in cornea, green/brown pigment at outer edge of iris
Wilson’s Disease - Investigations (3)
- Serum copper and ceruloplasmin - reduced as copper not in blood but deposited in organs
- 24 hour urinary copper excretion high
- Liver biopsy - diagnostic
Wilson’s Disease - Treatment (3)
- Avoid high copper foods
- Chelating agent - penicillamine
- Liver transplant
Alpha 1-Antitrypsin Deficiency - Pathology
- Autosomal recessive genetic disorder - A1AT gene on chromosome 14
- A1AT produced in liver → inhibits neutrophil elastase produced by neutrophils with inflammation/infection → elastase breaks down elastin too much → affects lung and liver
Alpha 1- Antitrypsin Deficiency - Symptoms (6)
- Lung - shortness of breath, emphysema, COPD
- Liver - cirrhosis, hepatitis, neonatal jaundice
Alpha 1- Antitrypsin Deficiency - Investigation
Bloods - serum A1AT levels low
Alpha1- Antitrypsin Deficiency - Treatment (4)
- No treatment
- Treat complications of liver disease
- Stop smoking (helps lungs)
- Liver transplant
Ascites - Pathology
- Excessive buildup of fluid in peritoneal cavity
- Poor liver function → low albumin → low blood oncotic pressure → fluid loss to peritoneal cavity
- Mostly caused by cirrhosis/liver failure, also caused by late stage cancer, heart failure, pancreatitis
Ascites - Symptoms (2)
- Large distended abdomen
- Shifting dullness - patient lies down, tap on abdomen sounds dull. Patient moves to the side and fluid moves so area of dull sound shifts
Ascites - Treatment (3)
- Low sodium diet
- Spironolactone and Furosemide (diuretics drain fluid)
- Treat cause
Peritonitis - Pathology
- Inflammation from infection or irritation of the peritoneum
- Primary - spontaneous bacterial infection and ascites
- Secondary - from perforation of bowls or appendix, tubes breaking skin
- Infection is usually staph aureus, klebsiella and E coli.
Peritonitis - Symptoms (4)
- Perforations - sudden onset severe abdo pain, generalised shock, collapse
- Secondary - gradual onset, generalised abdo pain progressing to severe localised pain
- Pain relieved by laying hands on abdomen
- Pyrexia, tachycardia, confusion, N&V
Peritonitis - Investigations (3)
- Bloods - amylase (pancreatitis) hCG (ectopic pregnancy)
- Abdo X-ray (exclude bowl obstruction), CT (abdo ischaemia)
- Ascitic tap - look for pathogen
Peritonitis - Treatment (4)
- IV fluids
- IV antibiotics
- Treat underlying cause
- ABCDE because they will be in critical condition
Hernias - Description
Protrusion of an organ through defect in wall of its containing cavity. Can be reducible (push it back in), irreducible, obstructed (intestinal blood supply shut off) or strangulated (organ blood supply cut off)
Inguinal Hernia - description, types, risk factors
- Protrusion of abdo contents through inguinal canal
- Superior and medial to pubic tubercle
- Direct - 20% of cases, medial to inferiour epigastric artery, enters through weakness in wall
- Indirect - 80%, lateral to inferior epigastric artery, enters through deep inguinal ring
- Risk Factors - male, chronic cough, heavy lifting, past abdo surgery
Inguinal Hernia - symptoms, investigation, treatment
- Symptoms - swelling in groin/scrotum, maybe painful, expands with cough (impulse), maybe reducible
- Investigation - ultrasound/CT/MRI
- Treatment - surgery
Femoral Hernia - description, symptoms, investigations, treatment
- Bowel comes through femoral canal
- Likely to be irreducible and strangulated (due to rigid canal borders)
- Symptoms - mass in upper medial thigh, neck is inferior and lateral to pubic tubercle, maybe cough impulse
- Investigations - Ultrasound/CT/MRI
- Treatment - surgery
Hiatus Hernia - description, types, risk factors
- Herniation of stomach through oesophageal aperture (opening) of diaphragm
- Rolling - 20%, part of fundus rolls up through hiatus, lower oesophageal sphincter usually intact
- Sliding - 80%, gastro-oesophageal junction and part of stomach slides up into chest, lower oesophageal sphincter less competent (more likely to get reflux)
- Risk Factors - obesity, female, pregnancy, ascites, old age
Hiatus Hernia - symptoms, investigations, treatment
- Symptoms - heartburn/GORD, dysphagia
- Investigation - chest X-ray, barium swallow (imaging), endoscopy
- Treatment - loose weight, proton pump inhibitor (helps reflux), surgery
