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Gastro Finals > Liver disease > Flashcards

Liver disease Flashcards

1
Q

Describe the epidemiology of alcoholic liver disease

A

Common
M > F
Only 10-20% of heavy drinkers develop severe liver disease

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2
Q

Describe the pathophysiology of alcoholic liver disease

A

3 step process:

  • Steatosis: reversible fat deposition
  • Alcoholic hepatitis: inflammation (balloon cells, Mallory Denk bodies//hyaline bodies)
  • Cirrhosis: fibrosis and nodules
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3
Q

Describe the presentation of alcoholic liver disease

A

Steatosis: usually asymptomatic
Hepatitis: acutely may present as acute hepatitis (RUQ pain, jaundice, nausea) but usually chronic with abnormal LFTs
Cirrhosis presentation: fatigue, abdo distension, anorexia, early satiety

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4
Q

Describe the signs of alcoholic liver disease on examination

A

Early stage: no signs, possible enlarged liver in hepatitis
Cirrhosis:
-Dupuytren’s contracture, liver flap (asterixis), palmar erythema
-Spider angiomata, gynaecomastia, loss of body hair, caput medusae
-Abdominal distension, shifting dullness, splenomegaly

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5
Q

Describe the investigations for alcoholic liver disease

A
  • History and examination
  • Scoring scales eg. AUDIT
  • Bloods: FBC, U+Es, LFTs, clotting, antibodies + serology + iron studies (if other causes of hepatitis considered),
  • Liver USS, fibroscan
  • Abdo CT
  • Biopsy can help diagnosis uncommonly done
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6
Q

Describe the management for alcoholic liver disease

A 
Depends on stage + severity
Conservative (mainstay):
-Reduce alcohol consumption, addiction referrals, etc
-Lifestyle advice: weight loss, smoking
-Nutrition: dietician, vitamins, etc
-Vaccinations

Medical:

  • Acute hepatitis: Pabrinex, withdrawal treatment, corticosteroids
  • Cirrhosis: diuretics (furosemide + spironolactone), therapeutic paracentesis

Surgical:
-Transplant

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7
Q

What are the complications of alcoholic liver disease?

A

Acute:
-Fulminant hepatic failure

Chronic:

  • Malnutrition
  • Portal hypertension: varices, ascites (SBP)
  • Decompensated cirrhosis
  • Hepatorenal syndrome
  • Hepatocellular carcinoma
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8
Q

Describe the aetiology of cirrhosis

A

Commonest causes in developed countries:

  • NAFLD
  • Alcoholic liver disease
  • Viral hepatitis

Also:

  • Inflammatory: autoimmune hepatitis, PBC
  • Metabolic liver disease: Wilson’s, haemochromatosis
  • Drugs + toxins
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9
Q

Define cirrhosis

A

End-stage liver disease characterised by fibrosis, remodelling and micronodular regeneration

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10
Q

What are compensated and uncompensated cirrhosis?

A

Compensated: preserved liver synthetic function and no evidence of complications of portal hypertension

Uncompensated:

  • Impaired liver synthetic function: albumin, clotting factors, glucose
  • Signs of portal hypertension: ascites, varices + bleeding
  • Hepatic encephalopathy
  • Jaundice
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11
Q

Describe the presentation of cirrhosis

A

Compensated:

  • Fatigue and weakness
  • Anorexia and weight loss

Decompensation:

  • Abdominal distension + early satiety
  • Haematemesis
  • Oedema
  • Confusion
  • SOB on exertion
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12
Q

Describe the signs of cirrhosis

A

General:

  • Jaundice
  • Sarcopenia

Hands:

  • Palmar erythema
  • Leukonychia
  • Asterixis
  • Dupuytren’s (alcohol)

Chest + abdo:

  • Gynaecomastia + hairless chest
  • Spider naevi, caput medusae, bruising
  • Abdominal distension + shifting dullness, fluid thrill
  • Splenomegaly

Peripheral oedema
+/- raised JVP, bibasal crackles

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13
Q

Describe the investigations for cirrhosis

A
  • History and examination
  • Bloods: FBC, U+Es, LFTs, clotting, antibodies, serology, copper studies, iron studies
  • Liver USS
  • CT/MRI
  • OGD (varices detection)
  • Biopsy is diagnostic but rarely used
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14
Q

Describe the criteria for diagnosing cirrhosis

A

Child-Pugh-Turcotte score used to assess severity
A: albumin. <28, 28-35, >35
B: bilirubin. <34, 34-51, >51
C: clotting. INR <1.7, 1.7-2.3, >2.3
D (istension): ascites. None, mild, moderate
E: encephalopathy. None, mild, severe

Grade A (5-6)
B (7-9)
C (10-15)

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15
Q

Describe the management of cirrhosis

A

Aims: prevent progression, treat underlying disease
Conservative:
-Lifestyle: weight loss, alcohol reduction
-Nutrition optimisation, vitamin replacement

Medical:

  • Treat cause eg. antivirals, iron chelation, lipid lowering
  • Fluid overload: diuretics (spiro +/- furosemide), paracentesis
  • Variceal prophylaxis: beta-blockers or endoscopic ligation

Surgical:
-Transplant

Monitoring:

  • Varices: OGD at Dx and every 1-3 years
  • USS 6monthly for HPCC/progression/ascites
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16
Q

Describe the complications of cirrhosis

A 
1. Ascites + SBP 
Varices + variceal bleeding
Encephalopathy
Hepatorenal syndrome + AKI 
Hepatocellular carcinoma 
Hepatopulmonary syndrome
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17
Q

Describe the presentation + signs of hepatic encephalopathy

A

Confusion and disorientation, behaviour change
Altered consciousness, drowsiness

Slurred speech
Asterixis
Up-going plantars

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18
Q

Describe the pathophysiology of hepatic encephalopathy

A

Raised ammonia levels

Neuroinflammation + oedema

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19
Q

Describe the investigations for hepatic encephalopathy

A
  • Usually will be a BG of cirrhosis/liver signs + symptoms
  • Urine dip, UDS
  • Bloods: FBC, CRP, ESR, U+Es, LFTs, B12 and folate, TFTs, glucose, clotting, blood culture, VBG
  • Liver USS (Dx of cirrhosis if unknown)
  • CT head (rule out bleed/SOL)
  • Paracentesis if ascitic
  • LP if concerned about meningitis eg. pyrexial
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20
Q

Describe the management of hepatic encephalopathy

A

Conservative:

  • Protein restriction
  • Hold sedatives + opioids

Medical:
-Gut ammonia clearance: lactulose or rifamixin

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21
Q

Describe the investigations for ascites

A
  • History and examination
  • Bloods: FBC, CRP, U+Es, LFTs, clotting, cultures, VBG
  • consider infection, decompensation
  • Abdo USS + paracentesis (MCS)
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22
Q

Describe the management of ascites

A

Conservative:

  • Low salt diet
  • Hold NSAIDs, ACEi, nephrotoxics

Medical:
-Diuretics: spiro +/- furosemide

Interventional/surgical:

  • Large volume paracentesis
  • TIPSS (transjugular intrahepatic portosystemic shunt)
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23
Q

Describe the causes of ascites

A

Cirrhosis (75%):

  • Portal hypertension
  • Hepatorenal syndrome

Acute hepatic failure
CCF
Hypoalbuminaemia (nephrotic syndrome)
Ovarian tumours

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24
Q

Describe the features of portal hypertension

A

1) Ascites
2) Varices
3) Splenomegaly

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25
Describe the pathophysiology of portal hypertension
- Obstruction to portal blood flow (pre, hepatic or post) - > increased pressures - > anastamoses (varices), splenomegaly, ascites
26
Describe the epidemiology of autoimmune hepatitis
White females, usually younger
27
Describe the investigations for autoimmune hepatitis
- Bloods: LFTs (ALT ^), liver screen (rule out), antibodies (ANA, SMA, anti-LKM1) - Liver USS - Biopsy usually done
28
Describe the presentation of autoimmune hepatitis
Variable - Asymptomatic + detected on LFTs - > fatigue, anorexia, abdo discomfort, itching - > fulminant liver failure
29
Describe the treatment for autoimmune hepatitis
Conservative: -Lifestyle: diet, weight loss, nutrition, alcohol Medical (mainstay): - Corticosteroids - Immunosuppressants (azathioprine best) Surgical: -Transplant
30
Describe the epidemiology of NAFLD
Very common!! | Commonest cause of chronic liver disease in developed countries
31
Describe the pathophysiology of NAFLD
Hepatic steatosis (fat buildup) - > steatohepatitis - > cirrhosis -> decompensation
32
Describe the presentation of NAFLD
Depends on stage Steatosis: asymptomatic. Typically overweight/obese Cirrhosis presentation
33
Describe the management of NAFLD
Conservative (mainstay): -Lifestyle: weight loss, low fat diet, no alcohol Medical: -Lipid lowering drugs if also indicated Surgical: - Bariatric surgery - Transplant
34
Describe the epidemiology of haemochromatosis
Relatively common in Europeans | 1:10 is carrier, 1:200 affected
35
Describe the pathophysiology of haemochromatosis
Defect in hepcidin function - > iron accumulation - > fibrosis (liver, heart, pancreas most commonly affected)
36
Describe the presentation of haemochromatosis
- In F will present later in life, due to menopause - Arthralgia and fatigue commonly, impotence, hyperpigmentation - T2DM - Abnormal LFTs - Cardiomyopathy
37
Describe the investigations for haemochromatosis
Initial tests: - Bloods: LFTs, classic liver screen, **iron studies (ferritin, transferrin saturation ^) - Liver USS -> MRI - Genetic testing to confirm diagnosis Further: - ECG and echo (check for cardiac comp) - Sex hormones - HbA1c + fasting glucose
38
Describe the management of haemochromatosis
Conservative (mainstay): - Regular phlebotomy - Avoid iron supplements Medical: -Iron chelation (desferrioxamine)
39
Describe the epidemiology of viral hepatitis
Common in developing countries
40
Describe the types of viral hepatitis (name, transmission, acute/chronic presentation)
A: faeco-oral. Acute hepatitis only, usually affects children in endemic areas B: blood/sex. Acute hepatitis, 10% chronic carriers C: blood/sex. Some acute, more chronic. D: blood/sex. Co-occurs with HBV E: faeco-oral. Acute hepatitis
41
Describe the presentation of acute viral hepatitis
``` RUQ pain/discomfort Jaundice and dark urine Fever Malaise N+V ```
42
Describe the investigations for any acute hepatitis presentation
- Bloods: FBC, CRP, U+Es, LFTs, serology (hepatitis, HIV), amylase/lipase, clotting, other liver screen later (iron, copper, antibodies) - Liver USS +/- CT/MRI
43
Describe the serology results for HBV
Various tests: - HBsAg - HBcAg + HbeAg - anti-HBs - anti-HBc Previous vaccination: anti-HBs +, anti-HBc - Previous infection: anti-HBs + anti-HBc + HBsAg - Current infection (early) HBsAg + no antibodies yet Current infection (chronic) HBsAg + anti-HBs + antiHBc +
44
Describe the management of viral hepatitis
Conservative: - Self-limiting (A/E, acute B): rest + NSAIDs - Lifestyle: reduce alcohol, diet Medical: - Acute HBV w failure: antivirals - Chronic HBV: Interferons, nucleoside + nucleotide analogues - HCV: antiviral combinations Surgical: -Transplant
45
Describe the pathophysiology of Wilson's disease
Defect of copper excretion into bile - > copper buildup in liver, eyes, BG - > fibrosis
46
Describe the investigations for Wilson's disease
History + examination (including slit-lamp) 24 hour urine collection Bloods: LFTs, liver screen, serum caeruloplasmin (low), copper (high) MRH for neuro presentation Biopsy diagnostic if uncertain
47
Describe the presentation of Wilson's disease
``` Liver disease: hepatitis/cirrhosis Eyes: Kayser-Fleischer rings Movement disorders- Parkinsonism common, dysarthria, tremor, incoordination Psychosis Dementia ```
48
Describe the management of Wilson's disease
Conservative: -No liver or shellfish Medical: - Initiation: trientine/penicillamine + zinc - Maintenance: zinc forever Surgical: -Transplant (severe liver disease)
49
Define a liver abscess. What are the causes?
``` A localised collection of pus in the liver parenchyma Causes: -Bacterial: E coli, Klebsiella -Fungal -Parasitic: amoebiasis ```
50
Describe the presentation of liver abscess
Fever + chills RUQ pain -> right shoulder pain, cough Anorexia, malaise
51
Describe the signs of liver abscess on examination
Fever RUQ tenderness Palpable liver edge
52
Describe the investigations for liver abscess
Bloods: FBC, CRP, LFTs, cultures, clotting Liver USS -> CT (better) Aspiration + MCS
53
Describe the management of liver abscess
Medical: -Antibiotics eg. Tazocin/Cef+Met or metro (amoeba) Surgical/interventional: -Drainage: percutaneous, surgical, endoscopic approaches
54
Describe the types of benign liver tumours
Neoplasms: - Haemangioma: common - Hepatic adenoma: young F, esp COCP Cysts: - Simple cysts - Congenital polcystic kidney disease - Hydatid (echinococcal): tapeworms
55
Describe the investigations for liver tumours
Bloods: FBC, CRP, LFTs, AFP Liver USS 1st line -> contrast CT/MRI Biopsy
56
Describe the presentation of liver tumours
- Nonspecific - RUQ discomfort - Bloating, early satiety - Anorexia, weight loss, etc
57
Describe the management of liver tumours
Conservative: -Watchful waiting eg. asymptomatic simple cysts Surgical/interventional: - Drainage - Open/lap excision
58
Describe the presentation of acute liver failure
Triad of: jaundice, coagulopathy, encephalopathy - Bruising + bleeding - Disorientation, confusion, drowsiness -> coma - Malaise, nausea
59
Describe the aetiology of acute liver failure
Developed countries: paracetamol OD most common -Others: drug-related, acute viral hepatitis, AI hepatitis Developing: viral hepatitis by far most common
60
Describe the investigations for acute liver failure
- History and examination - Bloods: FBC, CRP, U+Es, LFTs, clotting, liver screen, paracetamol level, toxicology - Liver USS
61
Describe the management of acute liver failure
Conservative: - Avoid any hepatotoxic drugs - Nutrition - Fluid balance management Medical: -Treat cause if possible eg. steroids, NAC, anticoagulation Surgical: -Transplant should be considered for all ALF
62
Describe the complications of acute liver failure
- Progressive encephalopathy - Coagulopathy - Renal failure - Infection - Cerebral oedema
63
Define SBP
Spontaneous bacterial peritonitis is an infection of ascitic fluid, neutrophil count >250 cells/mm3
64
Describe the presentation of SBP
- Generalised abdo pain - Fever, chills - N+V - Altered mental state - GI bleeding
65
Describe the investigations for SBP
- History and examination - Bloods: FBC, CRP, U+Es, LFTs, clotting, cultures, VBG - USS - Diagnostic paracentesis (MCS)
66
Describe the management of SBP
A to E approach - Sepsis 6 if septic - IV BS antibiotics eg. Tazocin/Cef+Met - IV albumin - LVP (large volume paracentesis) - Spironolactone
67
Describe the epidemiology and causes of hepatocellular carcinoma
``` Epi: China, sub-Saharan Africa Causes: -Viral hepatitis -Cirrhosis: alcoholic, NAFLD, PBC etc -Aflatoxins (Aspergillus) ```
68
Describe the screening for HCC
Offered to high risk groups eg. cirrhosis, viral hepatitis | 6 monthly blood test (AFP) and USS liver

Gastro Finals (4 decks)

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