Liver Disease Flashcards
How does liver disease progress? (is similar for no. of pathologies)
- Primary Injury: liver cells are damaged.
2.This causes inflammation
- This causes liver cell injury / death from primary injury or inflam. response
- Fibrosis occurs if cell death is too advanced / regen capacity is exhausted / process has been to extensive: causes pathological scar tissue (fibrosis).
- Eventually fibrotic nodules are formed: this is when we classify as cirrhosis
- A liver can function normally with cirrhosis (& be asymptomatic) but can lead to liver failure or cancer
What drives liver disease progression?
Degree / number of insults
Genetics
Microbiome
Environment
Diet
Drugs and toxins
Is cirrhosis reversible: Y/N?
Is cirrhosis reversible: Yes
Name 4 functions of the liver
Protein synthesis & metabolism
Clotting factors
Urea breakdown
Bile production
Elimination of bilirubin
Hormone metabolism
Drug metabolism
Carbohydrate metabolism
Lipid metabolism
Immunological function
Symptoms of liver disease?
Systemic [2]
Cholestatic? [2]
None
Systemic:
* Weight loss
* Tiredness
Cholestatic (reduction in bile flow)
* Pruritis (itchy skin; Cholestatic liver disease increases levels of bile salt which accumulate under the skin causing itch)
* Pale stools/dark urine
Complications of underlying disease
Signs of Chronic Liver Disease? [5]
Palmar erythema
Spider naevi
(most specific)
Hair loss
Gynaecomastia (man boobs)
Leuchonychia / Clubbing
Proximal wasting
Scratch marks
Xanthelasma
Indicators of liver status:
Which blood tests would be useful to indicate liver function? [2]
Which blood tests would be useful to indicate stage of liver disease? [2]
Which blood tests would be useful to indicate liver function? [2]
* Albumin
* INR (Prothrombin Time)
Which blood tests would be useful to indicate stage of liver disease? [2]
* Platelet count (as spleen enlarges, can have consumption of platelets)
* ALT/AST
What would be indicated if ALT / AST is raised? [1]
Elevated ALT / AST indicates source is hepatic problem
What would be indicated if Alk Phos / γGT is raised? [1]
Elevated Alk Phos / γGT indicates cholestatic problem
AST > ALT indicates what cause of liver disease?
Alcohol
Fat / Metabolic Syndrome
Biliary Disease
Autoimmune
Viral Hepatitis
AST > ALT indicates what cause of liver disease?
Alcohol
Fat / Metabolic Syndrome
Biliary Disease
Autoimmune
Viral Hepatitis
AST:ALT > 1 in alcohol induced liver disease
ALT > AST indicates what cause of liver disease? [2]
Alcohol
Fat / Metabolic Syndrome
Biliary Disease
Autoimmune
Viral Hepatitis
ALT > AST indicates what cause of liver disease?
Alcohol
Fat / Metabolic Syndrome
Biliary Disease
Autoimmune
Viral Hepatitis
Reverses with significant fibrosis
What could be ruled out of causing ALT > 500?
What would ALT of 500-100 indicate is the source?
What would ALT of 1500+ indicate?
ALT:
Alcohol doesn’t put ALT > 500
500 – 1500: autoimmune hepatitis
more than 1500: hepatitis viruses / drugs / ischaemia
Which results in blood tests would help ID aetiology? [3]
Aetiology:
Viral markers
Autoantibodies & Immunoglobulins
Metabolic
* Ferritin / caeruloplasmin / HbA1c
* Alpha1 antitrypsin
* Alphafetoprotein
First Imaging used for liver disease? [1]
What are alternatives? [4]
Ultrasound:
* Biliary tree
* Liver lesions
* Ascites
* Spleen
* Veins
* Other pathology
CT
MRI
ERCP / MRCP
Name 3 further complications that CLD can lead to [3]
Cirrhosis –> Portal Hypertension
Liver Failure
Cancer Malignancy
Name 3 further complications that CLD can lead to [3]
Cirrhosis –> Portal Hypertension
Liver Failure
Cancer Malignancy
How does cirrhosis cause portal hypertension?
Name 3 signs of portal hypertension [3]
- Cirrhosis disrupts the blood flow into the flow from the portal veins: causes increase in pressure (portal hypertension)
- Liver breaks down vasodilatory peptides (if not working, then doesn’t)
- If liver is also not producing albumin, decreases oncotic pressure and pushes liquid out
Dilated abdominal veins
- Caput medusa
Ascites
Splenomegaly
Explain how portal hypertension causes ascites
Liver malfunction:
* Liver breaks down vasodilatory peptides (if not working, then doesn’t)
* Cirrhosis reduces ease of blood flow
* If liver is also not producing albumin, decreases oncotic pressure and pushes liquid out
Causes splachnic vasodilation
Causes reduction in circulating volume in portal system.
(sensed by the kidney (by JGA))
Activates renin system: causes activation of RAAS. Leads to salt and water reab. at kidney
Leads to ASCITES
How do you treat ascites? [3]
Duiretics
Low salt diet
50% 2 year mortalilty –> transplant
Explain how portal HTN leads to bleeding the oesophagus
A result of Portal HTN: blood looks for alternative channels to relieve blood pressure
Occurs in lower oesophagus – causes big baggy, thin walled veins: often ruptures and haemorrages
How can you treat variceal bleeding [4]
What can you give as primary and secondary prophylaxis for variceal bleeding? [2]
Treatment:
Resuscitation
Terlipressin (inhibits portal hypertension with simultaneous reduction of blood circulation in portal vessels) and Antibiotics
Banding or injection sclerotherapy
TIPSS
Primary + secondary prophylaxis beta blockers
Propranolol / Carvedilol
Banding
When is hepatic disease compensated / decompensated?
Hepatic compensation:
* Cirrhotic but continues to function
Hepatic decompensation:
* Portal Hypertension
* Bleeding
* Encephalopathy (NH3 based toxins not cleared)
How is ammonia produced in health? What happens after this?
NH3 is produced when glutamine converted to glutamate
In health: NH3 is converted to urea & excreted in kidney OR in reverse of reaction, back to glutamine
How can you stop the production of NH3 to treat encephalopathy? [2]
Rifaximin: reduces the production of NH3 in the gut
L-Ornithine L-arginine: stops the conversion of glutamate to glutamine
