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Gastrointestinal Pathology > Liver Conditions > Flashcards

Liver Conditions Flashcards

1
Q

What are the major liver diseases?

A

Alcohol related liver disease
Viral hepatitis
NAFLD
Autoimmune diseases

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2
Q

What ae the 5 main causative organisms of viral hepatitis?

A 
A
B 
C
D
E
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3
Q

What type of viruses are hep A and E?

A

Enteric viruses

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4
Q

What type of viruses are hep B, C and D?

A

Parenteral viruses

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5
Q

What do hepatitis A and E viruses cause?

A

Self limiting acute infections

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6
Q

What hepatitis viruses cause chronic disease?

A

B
C
D

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7
Q

Transmission of Hep A

A

Faceal oral
Sexual
Blood

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8
Q

Where is Hep A predominant?

A

Poor sanitation

Dirty water

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9
Q

Presentation of HAV

A 
Asymptomatic very common
Jaundice
Liver enzymes high 
Fever
Feeling unwell
Slowly get better
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10
Q

What is the maximum time to get better after HAV?

A

4 months

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11
Q

Commonest age group to get Hep A?

A

5 - 14 y / o

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12
Q

How is acute disease of HAV diagnosed?

A

IgM antibodies

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13
Q

Who gets immunised for HAV?

A 
Travellers
Patients with chronic liver disease
IVDU (especially with HCV or HBV)
Haemophiliacs 
Occupational exposure (lab workers)
MSM
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14
Q

What does MSM stand for?

A

Men who have sex with men

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15
Q

HBV structure

A

Shell covers the virus
Active bit of virus inside
Inside contains core antigen and surface antigen
E antigen protein is secreted out

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16
Q

What parts of the HBV can be detected on blood tests?

A

E antigen

Cannot detect core antigen

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17
Q

Antigens of HBV

A

Hepatitis surface antigen - HBsAg
Hepatitis e antigen - HBeAg
Hepatitis core antigen - HBcAg - active replication

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18
Q

What is a sign of active replication in HBV?

A

HBV DNA

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19
Q

Presence of Anti-HB indicates what?

A

Protection from virus (either by immunisation or previous exposure)

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20
Q

Presence of IgM anti HBc indicates what? Why?

A

Acute infection
If IgM is present then the virus has been present in the last 6 months
If this is not present then have had the virus for a more chronic length of time

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21
Q

Which antibodies are in the core?

A

IgM

IgG

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22
Q

Approach to HBV infection

A

If negative - nothing to worry about
If positive - then find out if active or not
Then find out if acute or chronic

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23
Q

Progression of pathology of Hep B virus

A 
Chronic hep B 
Can go to either
1. no further progression OR
2. Cirrhosis 
Cirrhosis can lead to 
- HCC
- ESLD
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24
Q

What does HCC stand for?

A

Hepatocellular carcinoma

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25
Q

What does ESLD stand for?

A

End stage liver disease

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26
Q

Patients with chronic Hep B who progress to cirrhosis have a higher risk of what?

A

Hepatic decompression and development of HCC

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27
Q

What approx. % of chronic Hep B patients will progress to cirrhosis, HCC or liver failure?

A

15 - 40%

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28
Q

What % of liver transplants are related to Hep B?

A

5 - 10%

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29
Q

Treatment of HBV

A

Pegylated interferon injection
Oral antiviral drugs
- adefovir
- entecavir

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30
Q

What % of the Scottish population is infected with Hep C?

A

1%

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31
Q

What % of patients infected with Hep C have a chronic hep C infection?

A

85%

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32
Q

Presentation of Hep C

A

10% report acute jaundice
Most asymptomatic until cirrhotic
May have normal LFTs

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33
Q

What type of virus is hep C?

A

RNA

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34
Q

Natural history of HCV infection

A 
1. exposure 
15% will resolve 
2. 85% chronic infection 
80% will then stabilise
3. 20% Progress to cirrhosis 
75% will become slowly progressive after this
4. 25% Progress to HCC or death
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35
Q

What accelerates the process from cirrhosis to HCC in HCV?

A

HIV

Alcohol

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36
Q

What % of patients with Hep C get cirrhosis?

A

20%

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37
Q

Diagnostic test for Hep C

A

Anti HCV antibody

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38
Q

Treatment of Hep C

A

Pegy interferon

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39
Q

What type of virus is Hep D?

A

Small RNA virus

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40
Q

What is Hep D enveloped by?

A

HBsAg

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41
Q

What does Hep D coinfect with? Can it survive on its own?

A

HBV

Cannot support itself

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42
Q

Transmission of HDV

A

Same as HBV

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43
Q

Which hepatitis virus is very resistant to treatment and therefore very difficult to treat?

A

HDV

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44
Q

What type of disease does HEV cause?

A

Zoonotic disease

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45
Q

What does HEV cause in pregnancy?

A

Fulminant hepatic failure

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46
Q

Features of HEV

A

Self limiting

No long term sequelae

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47
Q

Treatment for HEV

A

No treatment

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48
Q

Is there a vaccine for HEV?

A

No

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49
Q

What is the 3 entities of non alcoholic fatty liver disease?

A
  1. simple steatosis
  2. Non alcoholic steatohepatitis
  3. Fibrosis and cirrhosis
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50
Q

Definition of steatosis

A

Abnormal retention of lipids in a cell

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51
Q

Risk factors of non alcoholic fatty liver disease

A 
DM
Obesity
Hypertriglyceridemia
HTN
Age
Hispanic ethnicity
Genetics (PNPLA3 gene)
52
Q

What does NAFLD stand for?

A

Non alcoholic fatty liver disease

53
Q

Pathology / Natural history of NAFLD

A
  1. normal liver
  2. 10-35% steatosis
  3. 12 - 40% NASH +/- fibrosis
  4. 15% cirrhosis
54
Q

What does NASH stand for?

A

Non alcoholic steatohepatitis

55
Q

Investigations for NAFLD?

A 
AST/ALT ratio 
Indirect markers- enhanced liver fibrosis panel (ENF)
Cytokeratin-18
USS
Fibiroscan 
MRI/CT
MR spectroscopy
Liver biopsy
56
Q

What does MR spectroscopy do?

A

Quantifies fat

57
Q

Criteria for low risk NAFLD

A 
Age < 45
DM absent
BMI < 30
AST: ALT <1 (AST150
Albumin normal > 34
58
Q

Criteria for high risk NAFLD

A 
Age > 45
DM present
BMI > 30
AST:ALT >1 (AST>ALT)
Low < 150
Low < 34
59
Q

Treatment of NAFLD

A 
Diet 
Weight reduction 
Exercise
Insulin sensitizers e.g. metformin 
GLP-1 analogues e.g. liraglutide 
Farnesoid nuclear receptor ligand
Vitamin E 
Weight reduction surgeries
60
Q

Examples of autoimmune liver diseases

A 
Autoimmune hepatitis
Primary biliary cholangitis (PBC)
Primary sclerosing cholangitis (PSC)
Autoimmune cholangiopathy 
IgG 4 disease
Overlap syndromes
61
Q

What gender gets autoimmune hepatitis more?

A

Female

62
Q

3 types of antibodies in autoimmune hepatitis

A

Type 1; ANA, SMA
Type 2; LKM1
Type 3; SLA

63
Q

What antibody is VERY high in autoimmune hepatitis?

A

IgG

64
Q

Diagnostic test for autoimmune hepatitis

A

Liver biopsy

65
Q

Treatment of autoimmune hepatitis

A

Steroids then

Long term azathioprine

66
Q

Which gender gets primary biliary cholangitis more?

A

Females (92-95%)

67
Q

What antibody is elevated in PBC?

A

IgM

68
Q

What is the diagnostic test for PBC?

A

Anti-mitochondrial antibody positive

69
Q

Treatment of PBC

A

UDCA

Bile acid treatment

70
Q

What gender gets PSC more?

A

M > F

71
Q

Which antibody is found to be positive in PSC?

A

PANCA

72
Q

What is the investigation of choice for PSC?

A

MRCP

73
Q

Treatment of PSC

A

Treatment of liver conditions

Biliary stents

74
Q

Who gets a liver transplant?

A

Chronic liver disease with poor predicted survival
Chronic liver disease with associated poor quality of life
Hepatocellular carcinoma
Acute liver failure
Genetic diseases e.g.
- primary oxaluria
- tyrosemia

75
Q

Contraindications to liver transplant

A

Active extrahepatic malignancy
Hepatic malignancy with macrovascular or diffuse tumour invasion
Active or uncontrolled infection outside of the hepatobiliary system
Active substance or alcohol abuse
Severe Cardiopulmonary or other co morbid conditions
Psychosocial factors that would likely preclude recovery after transplantation
Technical and or anatomical barriers
Brain death

76
Q

How are patients prioritised for liver transplant in acute liver failure?

A

Acetaminophen-induced ALF

  • list if arterial pH < 7.3 or arterial lactate > 3.0 after adequate fluid resus
  • strongly recommend if arterial lactate > 3.5 after early fluid resus
  • list if all 3 occur < 24 hours
    1. Grade 3 or 4 HEC
    2. INR > 6.5
    3. Creatinine > 300

Nonacetaminophen-induced ALF

  • list if INR > 6.5 and encephalopathy present
  • If 3 of these present irrespective of grade of encephalopathy
    1. < 10 y/o or > 40 y/o
    2. Interval from jaundice to encephalopathy of > 7 days
    3. INR at least 3.5
    4. Serum bilirubin at least 300
    5. Unfavourable cause
  • seronegative hepatitis
  • idiosynactric drug reaction
  • wilsons disease
77
Q

How do we prioritise who gets a liver transplant in cirrhosis?

A

Child Pugh scoring A, B and C
MELD score - decides who gets livers
UKELD - decides who gets livers first

78
Q

What does MELD look at?

A

Bilirubin
Creatinine
INR

79
Q

What does UKELD look at?

A

Bilirubin
Sodium
Creatinine
INR

80
Q

Post op care after a liver transplant includes…..

A 
ICU care
Prophylactic antibiotics
Prophylactic anti fungal drugs 
Anti rejection drugs - a combination of
- steroids
- azathioprine
- tacrolimus/cyclosporin
81
Q

Presentation of spontaneous bacterial peritonitis

A

Ascites
Abdominal pain
Fever

82
Q

Management of SBP

A

IV Cefotaxime

83
Q

Who with ascites requires antibiotic prophylaxis and what with?

A 
Patients who 
- have had an episode of SBP
- Fluid protein < 15 
- Child pugh score of at least 9 
- hepatorenal syndrome 
USING CIPROFLOXACIN
84
Q

What does HBsAg imply?

A

Acute disease (present 1 - 6 months)

85
Q

What does anti-HBS imply?

A

Immunity (either exposure or immunisation)

86
Q

What is anti-HBS negative in?

A

Chronic disease

87
Q

What does Anti-HBc imply?

A

Previous or current infection

88
Q

IgM vs IgG Anti-Hbc

A

IgM acute

IgG persists

89
Q

Inheritance of haemochromatosis

A

Autosomal recessive

90
Q

Presentation of haemochoromatosis

A 
Early symptoms
- fatigue
- erectile dysfunction 
- arthralgia (hands usually)
'Bronze skin' pigmentation 
DM
Liver; signs of chronic liver disease
Cardiac failure secondary to cardiomyopathy 
Hypogonadism (secondary to cirrhosis and pituitary dysfunction)
Arthritis (esp of hands)
91
Q

What is wilsons disease?

A

Excess copper deposition in the tissues

92
Q

Inheritance of wilsons disease

A

Autosomal recessive

93
Q

Pathology of wilsons disease

A

Increased copper absorption from small intestine

Decreased hepatic copper excretion

94
Q

Gene defect in wilsons disease

A

10 - 25 y/o

95
Q

Children presentation vs young adult presentation of wilsons disease

A

Children - present with liver disease

Adult - Present with neurological disease

96
Q

Presentation of wilsons disease

A 
Liver
- hepatitis
- cirrhosis
Neruological 
- basal ganglia degeneration 
- speech, behavioural and psych problems often the first manifestation 
- asterixis, chorea, dementia, parkinsonism 
Kayser-Fleischer rings
Renal tubular acidosis 
Haemolysis 
Blue nails
97
Q

Investigations for wilsons disease

A

Reduced serum caeruloplasmin
Reduced serum copper
Increased 24 hour copper excretion

98
Q

Treatment of wilsons disease

A

Penicillaemine 1st line

99
Q

Another name for Budd-Chiari syndrome

A

Hepatic vein thrombosis

100
Q

What is budd-chiari syndrome usually seen in the context of?

A

Underlying haematological disease

Another procoagulant condition

101
Q

Causes of Budd-chiari syndrome

A

Polcythaemia rubra vera
Thrombophilia
Pregnancy
OCP

102
Q

Classic triad of budd chiari syndrome

A

Abdominal pain - sudden onset and severe
Ascites
Tender hepatomegaly

103
Q

Investigations of budd chiari syndrome

A

USS with doppler

104
Q

In a patient with NAFLD, what is the test used to aid the diagnosis of liver fibrosis?

A

Enhanced liver fibrosis testing

105
Q

What would point towards the diagnosis of wilsons disease?

A

A combination of liver and neurological signs

106
Q

What is the most common cause of HCC worldwide?

A

Hep B

107
Q

What is the most common cause of HCC in Europe?

A

Hep C

108
Q

What does PSC look like on ERCP?

A

Classic ‘beaded’ strictures

109
Q

What is the investigation of choice for liver cirrhosis?

A

Transient elastography (fibroscan)

110
Q

Another name for transient elastrography

A

Fibroscan

111
Q

What can be a useful diagnostic marker for HCC?

A

Raised AFP

112
Q

What is the mainstay of treatment in haemachromatosis?

A

Regular Venesection

113
Q

Early signs of haemachromatosis

A

Fatigue
Erectile dysfunction
Arthralgia

114
Q

Who is autoimmune hepatitis commonly seen in?

A

Young females

115
Q

How may types of autoimmune hepatitis are there?

A

3

116
Q

Explain type I autoimmune hepatitis

A

ANA and/or anti smooth muscle antibodies

Affects both adults and children

117
Q

Explain type II autoimmune hepatitis

A

Anti-liver/kidney microsomal type 1 antibodies (LKM1)

Affects children only

118
Q

Explain type III autoimmune hepatitis

A

Soluble liver-kidney antigen

Affects adults in middle age

119
Q

Presentation of autoimmune hepatitis

A

May present with signs of chronic liver disease
Acute hepatitis (only 25% present like this)
- fever, jaundice etc
Amenorrhea common

120
Q

Investigation of autoimmune hepatitis and what does it show?

A

Liver biopsy

Inflammation extending beyond the limiting plate ‘piecemeal necrosis’, bridging necrosis

121
Q

Management of autoimmune hepatitis

A

Steriods, other immunosuppressants (e.g. azathioprine)

Liver transplant

122
Q

What is the triad of acute liver failure?

A

Encephalopathy
Jaundice
Coagulopathy

123
Q

Most common organism causing SBP

A

E coli

124
Q

What is the commonest cause of liver failure in the UK?

A

Paracetamol overdose

125
Q

What is right heart failure associated with (to do with liver)?

A

Firm, smooth, tender and pulsatile liver edge

126
Q

Blood results on haemachromatosis

A

Raised transferrin saturation
Raised ferritin
Low TIBC

Gastrointestinal Pathology (26 decks)

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