Liver Disease (08/03/19)

Question 1

What are the 2 main blood supplies for the liver?

Answer 1

Arterial (20% hepatic artery) and Venous (80% portal vein)

Question 2

What are some key functions of the liver?

Answer 2

Metabolism (of hormones, protein, insulin, DRUGS)

Synthesis (of proteins, clotting factors, cholesterol)

Clearance (of bilirubin, drugs, toxins)

Production of Bile

Storage (of fat soluble vitamins (A,D,E,K))

Question 3

How do you classify liver disease?

Answer 3

Classified by PATTERN OF DAMAGE and TIME COURSE over which damage occurs

Question 4

What is cholestatic and hepatocellular?

Answer 4

The types of damage that liver disease can cause. This damage can cause both fibrosis and cirrhosis

Question 5

Define Cholestasis

Answer 5

Liver disease which causes disruption of bile flow.

Question 6

What causes Cholestasis?

Answer 6

INTRAHEPATIC: issue in biliary ductules

EXTRAHEPATIC: mechanical obstruction

Question 7

Which enzymes does Cholestasis effect and how?

Answer 7

Causes INCREASE in BILIRUBIN, ALKALINE PHOSPHATASE, and GAMMA-PLUTAMYLTRANSFERASE

Question 8

Impaired biliary excretion causes what?

Answer 8

Reduced absorption of fatty acids, and accumulation of bile salts which can damage hepatocytes

Question 9

Define Hepatocellular Disease

Answer 9

Injury to hepatocytes caused by toxins or viruses

Question 10

What does injury to hepatocytes cause?

Answer 10

1) Accumulation of fat inside hepatocyte = STEATOSIS
2) Inflammation of hepatocyte = HEPATITIS
3) Cell death = NECROSIS

Question 11

Which enzymes are effected by Hepatocellular disease and how?

Answer 11

INCREASE in TRANSAMINASE, GGT, and BILIRUBIN

Question 12

Define Fibrosis

Answer 12

Extended and persistent damage to hepatocyte.
This causes disruption of blood flow.
Also causes erratic regeneration and nodules.

Question 13

Define Cirrhosis

Answer 13

Uncontrolled Fibrosis over a long period of time.

Question 14

What is the difference between Acute and Chronic liver disease?

Answer 14

Acute= symptoms <6 months. Caused by hepatitis and drugs.

Chronic= symptoms/damage >6 months (permanent structural damage). Further divided into Compensated (remaining part of undamaged liver still keeps body running) and Decompensated (do not have ability to function). Caused by alcohol and chronic viral hepatitis.

Question 15

How to assess liver function?

Answer 15

Perform liver function test and test following:

Bilirubin: Usual range = 5-20 micromol/L.

Transaminases:
     Aspartate transferase (AST) 0-40 iu/L) (found in liver, heart, skeletal muscle, pancrease)
     Alanine Transferase (ALT) (5-30 iu/L)
[However, not all liver disease will raise transaminase enzymes)

Alkaline Phosphatase (ALP) range = 30-120 iu/L. Increased in cholestasis, infiltrative liver disease, and damage to biliary tree

Gamma-Glutamyltransferase (GGT) range = 5-55 iu/L. Levels increased by alcohol, cholestasis, carcinoma of pancrease and GIT.

Question 16

What do bilirubin levels of >50 micromol/L cause?

Answer 16

Clinical Jaundice (yellowing of skin and eyes)

Question 17

What should you look for in Liver function test?

Answer 17

If 2 or more numbers are off.
The values should be 2 times the Upper limit.

However, liver function test can appear normal, even in damaged livers because the liver is so damaged that it does not make enzymes.

Question 18

Other factors to assess liver disease?

Answer 18

Recent travel (Hep A), Tattoos (Hep B/C), Alcohol consumption, Medication.

Biopsy, imaging (liver ultrasound, CT/MRI, ERCP and MRCP)

Question 19

Sign and Symptoms of Liver disease?

Answer 19

Patient may be asymptomatic until severe damage.

Symptoms: fatigue, 
fever, 
abdominal pain, 
Jaundice,
itching (pruritsis), 
pale stools and dark urine,
Spider naevi (broken vessels),
Bruising and Bleeding,

End stage symptoms:
Ascites,
Oesophageal and gastric varces,
Encephalopthy

Question 20

Define Ascites

Answer 20

Accumulation of fluid in peritoneal cavity.

SWOLLEN ABDOMEN

Question 21

Treatment of Ascites

Answer 21

• Fluid/Sodium restriction

- Diuretics (Spironolactone: 100-600mg OD, Furosemide: 40-160mg daily)

Question 22

What is infection of ascitic fluid called?

Answer 22

Spontaneous Bacterial Peritonitis. Classified by neutrophil count >250 cells

Treated with 3rd gen cephalosporins, co-amoxiclav, tazocin.

Question 23

Define Hepatic Encephalopathy

Answer 23

Changes in mood and behaviour, confusion, poor sleep, and eventually delirium and coma.

Question 24

Causes of Encephalopathy

Answer 24

• increased protein load
• reduced ammonia
• electrolyte disturbance
• dehydration
• drugs

Question 25

Treatment of Encephalopathy

Answer 25

• Avoid precipitants and lower ammonia levels

Laxatives (lower ammonia):
Lactulose lq 20-30mls BD-TDS.
If no laxative available, give phosphate enema

Antibiotics (kill gut bacteria which create ammonia):
Metronidzole, Neomycin, Sodium benzoate.
Rifaxamin tablets 550 mg BD

Question 26

Define Portal Hypertension

Answer 26

Caused by increased resitance to flow. Pressure build up forms collateral vessels (VARICES).

Question 27

Treatment of Portal hypertension and Varices

Answer 27

Terlipressin IV 1-2mg then every 4-6hrs

PPI

Antibiotcs (IV broad spectrum for 5 days)

Question 28

Secondary Treatment of Portal hypertension and Varices

Answer 28

Propranolol 20-40 mg BD

Question 29

Define Pruritus

Answer 29

Build up of Bile salts which causes itching

Question 30

Main causes of Liver Disease

Answer 30

1) Drugs
2) Alcohol
3) Viral Hepatitis

Question 31

Which hepatitis is common and enterically transmitted?

Answer 31

Hep A

Question 32

Which Hep. is DNA virus, very contagious?

Answer 32

Hep B