Liver disease Flashcards by Hager Meghrawi

What is the commonest

cause of acute liver failure in the uk

Paracetamol overdose

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What are the three commonest causes of chronic liver disease

Alcoholic
Obesity
Hepatitis B C

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If a patient is jaundiced what blood test is high

Bilirubin

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What does a raised ALT mean?

Intra hepatic problem

Hepatocellular problem

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What does raised ALP mean?

Cholestatic problem
Biliary problem
Problems with bile ducts or the drainage of the liver

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What does albumin look at

Liver synthetic function

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Prothrombin time def

The amount of time it takes for blood to clot after adding thromboplastin

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INR def

Measure of prothrombin time in relation with normal as a ratio

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What makes paracetamol easy to overdose

Effective simple analgesia Narrow therapeutic index

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What is the maximum dose for adults in 1 day

4g/24hr

2 tablets 4 times a day

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What dose of paracetamol is toxic?

Dose> 10g (or 200mg/kg)

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How does toxicity happen from paracetamol?

paracetamol is metabolized by two pathways
eighty-five percent of the paracetamol is conjugated making it water-soluble, meaning it can be excreted in the urine.
the rest is metabolised by by the cytochrome P450 enzyme system in the liver to the metabolite NAPQI
NAPQI = toxic free radical and causes oxidative stress on liver necrosis of the hepatocytes = can lead to liver failure
Normal therapeutic rate means gluathione can redox cycle the NAPQI preventing oxidative stress
Overdose= Gluathione stores used up so increase in NAPQI

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What does NAQPI stand for?

N-acetyl-p- benzoquinoamine

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What is the treatment for Paracetomol overdose?

N-acetylcysteine IV

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When is most and least effective to treat paracetamol overdose?

Within eight hours

Less effective after 24 hours

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What treatment is not normally given in paracetamol for drug overdose? How?

Activated charcoal

correlates to bind to the drug that’s in the stomach and prevents absorption.

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What is acute liver failure?

Onset of hepatic encephalopathy (HE) <8weeks from onset of liver dysfunction

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Explain how hepatic encephalopathy is caused?

Urea cycles stops working because of liver dysfunction
Build up of ammonia and other nitrogen containing metabolites can travel into the systemic circulation and they can get to the brain
cause swelling of the brain
Can develop coning wwhere the intracranial pressure is too high and brain forced through bottom of the skull= fatal

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When is liver failure subacute

2-6 months from onset

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What are the causes of acute liver failure

Paracetamol overdose
Acute viral hepatitis
Drug induced liver injury (DILI)
Autoimmune hepatitis
Wilson's disease

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Types of Non-alcoholic fatty acid disease? From most common to rare?

Fatty liver -70-90%
NASH- 10-30%
Cirrhosis- ~1%

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What is associated with NAFLD

Metabolic syndrome

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What does NAFLD stand for?

Non-alcoholic fatty disease

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What is the metabolic syndrome

T2DM(Type 2 Diabetes mellitus), obesity, hypertension. hypertriglyceridaemia

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what does a bright and enlarged liver mean?

Fatty infiltration of the liver

What does NASH stand for?

non-alcoholic steatohepatitis

What does steatohepatis mean?

Stateo- Fatty Hepat- Liver Itis- Inflamamation

What does NASH NAFLD led on to? How?

Cirrhosis Fibrosis or scarring of the liver liver starts to become damaged And over a long period of time that scar tissue builds up

how do we know what type of NAFLD patients have?

Measure fibrosis level

Ways to measure fibrosis levels

Serum fibrosis scores Fibroscan -sheerwave elastography ELF test Liver biopsy

How do you use Serum fibrosis score?

Using ALT and AST Platelet count Age

What is an ELF test?

Enhanced Liver Fibrosis test | panel of three different fibrosis tests put patients in a high-risk category are low-risk category

What is a sheerwave elastography

Probe put against chest Pressure wave sent between the rib-cage into the liver. pressure wave reflects back measure the amount of pressure, the force which is required for the shear wave to bounce back the stiffer the liver, the more scarring that occurs within the liver.

What is the advantages and disadvantages of Fibroscan over Serum score

Accurate | More expensive and needs specialist (No gp)

What is a non-invasive measure of fibrosis

Serum fibrosis scores Fibroscan -sheerwave elastography ELF test

What is a invasive measure of fibrosis

Liver biopsy

What is the advantages and disadvantages of liver biospy over Fibroscan

Best method gives additional information (e.g. aetiology) Most invasive Risk of bleeding

How does fatty liver disease look like on histology?

Lots of wwhite globulues on pink surface wwhite globulues are fat No other interactions

How does NASH look like on histology?

White globulues =fat | Blue dots = inflammatory cells = Itis

How does cirrhosis look like on histology?

fat globuluses Bluey grey circular outline = collagen = scarring Scarring in the shape of a circular nodule

Where does bilirubin come from?

degradation product of blood cells haemoglobin and red blood cells haemoglobin is broken dowwn to bilirubin

What is the difference between biliverdin and bilirubin in terms of solubility

Biliverdin is soluble in water | bilirubin is insoluble

Where are red blood cells broken down?

In reticuloendothelial system

What happens to bilirubin after it has been conjugated

Metabolised to form urobilinogen Some is absorbed into the portal blood and then to the kidneys In kidneys it is further metabolised into urobilin Some is further metabolised into stercobilin

What is stercobilin used for?

Colouring faeces

What happens if the bilirubin metabolism has been disrupted

Jaundice

What is jaundice the cause of

Liver dysfunction

What 3 types of causes can jaundice be? Examples

Hepatic( liver failure or chronic liver disease with impaired liver function) Prehepatic -Heamolysis (too much blood broken down) Post-hepatic- Gallstones Cancer

What normally happens with chronic liver disease

Fibrosis increases -> Cirrhosis | Increases chances of liver cancer

Why is it hard to treat chronic liver disease?

Clinical symptoms present late at the stage of cirrhosis whcich is hard to treat

How do you try to treat alcohol related liver disease

Abstinence of alcohol

How do you try to treat obesity related liver disease

Lose weight

How do you try to treat hepatitis B and C related liver disease

Antiviral drug

How do you try to treat autoimmune related liver disease

immunosuppression

How do you try to treat Primary biliary cholangitis

Ursodeoxycholic acid DRUG

How do you try to treat Primary sclerosing cholangitis

No effective treatment

How do you try to treat Hemochromatosis

Venesection - take blood away- take iron floating around in their bloodstream down and that takes the pressure off the liver

How do you try to treat Wilson's disease

Take copper levels down using drugs which collate the copper in the gut

What types of cirrhosis are there

Compensated cirrhosis | Decompensated cirrhosis

What is compensated cirrhosis

Cirrhosis with no complications

What is decompensated cirrhosis

Cirrhosis with complications

What complications arise with cirrhosis?

Ascites Hepatic encephalopathy Variceal bleeding

What is ascites?

build-up fluid within the intraperitoneal space wwithin the abdomen

How is cirrhosis hepatic encephalopathy different to liver failure hepatic encephalopathy?

confusion, drowsiness, sometimes coma but no coning and too much intracranial pressure

What is Variceal bleeding

Varices which are veins that become swollen due to portal hypertension

Why does cirrhosis cause portal hypertension

Portal vein and hepatic artery into liver then blood leaves through the portal vein. Cirrhosis causes blood to move harder through the liver forcing it out into the portal causing it to increase in pressure

Why does cirrhosis cause ascites

hydrostatic pressure is pushing fluid out of the portal vasculature and into the abdomen

Where are the most common places for varices to open up due to portal hypertension

Bottom of the stomach | Oesophagus

Why are varices fatal?

They can burst open and having blood in the stomach is not normal

What investigations can be done to find out if a patient has portal hypertension? Why?

``` Platelet count (FBC) Low= hypertension Spleen connected to portal blood supply Spleen becomes congested with blood buildup of platelets within the spleen means there are fewer platelets and the systemic circulation ```

What are the signs of portal hyper tension?

Spider nevi | Palmar erythema

Where would you normally see spider nevi

upper chest or face

What are the assumptions of having cirrhosis? Why not?

Risk of bleeding | Anticoagulant factors stop this

What are varices?

are significantly dilated sub-mucosal veins in GI tract