Liver disease Flashcards
1
Q
What is the function of the liver?
A
- Intermediate metabolism
- Storage
- Protein synthesis
- Production of bile
- Detoxification
2
Q
What are the consequences of hepatic dysfunction?
A
Consequences on…
* Bile production
* Metabolic
* Circulation
* Detoxification
* Coagulation
3
Q
What can cause jaundice (icterus)?
A
Pre-hepatic
* Haemolysis - yellow/white MM
Hepatic
* Hepatocyte dysfunction
* Intrahepatic cholestasis
Post-hepatic
* Extra-hepatic cholestasis
4
Q
What is seen with metabolic dysfunction?
A
- Non-specific signs
- Loss of condition
- Weight loss
- Hypoglycaemia
- Hypoalbuminaemia
- Only in chronic disease
- Can contribute to ascites
5
Q
What is seen with circulatory disturbances?
A
- Ascites
- Hypoalbuminaemia
- Portal hypertension
- Sodium and water retention
- Polyuria / polydipsia - cannot concentrate urine (reversible)
- Portosystemic shunts
- cirrhosis
-portal hypertension
6
Q
What problems with detoxification occur with liver damage?
A
- Hepatic encephalopathy
- defective urea formation from ammonia
- increase blood NH3 leads to CNS signs
7
Q
What are signs of hepatic encephalopathy?
What can worsen hepatic encephalopathy?
A
- Anorexia, V & D, PU/PD
- Dullness, aggression, staggering,
blindness, head-pressing, seizures - Worse if…
-High protein meal
-Gastrointestinal bleed
-Dehydration, acid-base imbalance - Increased sensitivity to anaesthetics
8
Q
What is the consequence of lack of coagulation?
A
- Defective production and storage of clotting factors
- Vitamin K malabsorption
- Portal hypertension = GI bleeding
9
Q
What are signs of liver dysfunction in dogs?
A
- Icterus
- Faecal changes
-Grey (acholic)
-Melaena - Hepatic encephalopathy
- Drug intolerance
- Ascites
- Stunted growth (if young)
- Vomiting and diarrhoea
- Polyuria & polydipsia
- Non-specific signs
-Anorexia
-Weight loss
-Weakness
-Poor coat and skin condition
10
Q
Where is jaundice most evident?
A
- Sclera - white part of the eye
11
Q
How would you classify different hepatopathies?
A
Primary =
*Inflammatory disease (infectious/ non-infectious)
* Non-inflammatory disease (non-infectious)
Secondary =
* Non-specific + reversible changes
- Anorexia
- Toxaemia
- Nutritional imbalance
- Metabolic changes
- Infection
12
Q
What is reactive hepatopathies?
A
- Most common liver abnormality
- Little loss of hepatic function
- Reversible
- Treat by correcting underlying disease
13
Q
What are different results of liver biopsies in order of how common they are?
A
- Reactive
- Chronic hepatitis
- Neoplasia
- Toxic
- Steroid
- Nodular hyperplasia
- Cholangitis
- PSS
- Copper
14
Q
What can cause reactive hepatopathy?
A
- IBD
- Bacterial infections
- Periodontal disease
- Rickettsial infections
- Acute pancreatitis
- Diabetes mellitus
- Hyperadrenocorticism
- Hypoadrenocorticism
- Hyperthyroidism
- Haemolytic anaemia
- Septicaemia
- Shock
- Right heart failure
- PLE
- Severe protein restriction & starvation
15
Q
What are infectious inflammatory causes of liver disease?
(bacterial/viral/protozoal)
A
Bacterial
* Leptospirosis
* Bacterial cholangiohepatitis
Viral
* Infectious canine hepatitis
* Canine Herpes virus
* FIP
Protozoal
* Toxoplasma
16
Q
What are non-infectious inflammatory causes of liver disease?
A
- Toxic hepatic disease
- Drug-induced hepatic disease
- All forms of chronic hepatitis
- Canine chronic hepatitis
- Feline lymphocytic cholangitis
17
Q
What are non-inflammatory causes of liver disease?
A
- Congenital portosystemic shunt
- Juvenile hepatic fibrosis
- Feline hepatic lipidosis
- Neoplasia
- Telangiectasis and Peliosis
- Surgical
- Trauma
- Liver lobe torsion - Entrapment
18
Q
What is feline hepatic idiosyncrasies? What can cause it?
A
- Relative deficiency of glucuronyl transferase
Causes =
* Aspirin
* Paracetamol
* Phenols, pine tars, morphine, benzenes, alcohols, barbiturates
19
Q
What does paracetamol toxicity cause in cats?
A
- Relative deficiency of glucuronidation + glutathione conjugation
- Methaemoglobinaemia
- Haemolytic anaemia - depression + dyspnoea
- Facial oedema
- Hepatocellular damage - liver failure + icterus
20
Q
How do you treat paracetamol toxicity?
A
- N-acetylcycsteine
- Vitamin C
- Supportive Tx - IV fluids, antibiotics, activated charcoal
21
Q
What are clinical signs of liver failure in cats? (compared to dogs)
A
- Anorexia and weight loss most common
- Icterus relatively common
- Polyuria / polydipsia - less severe
- Hepatoencephalopathy, increased hypersalivation
- Microhepatica & cirrhosis rarely seen
- Pyrexia common in suppurative cholangitis
- Chorioretinitis or uveitis (FIP, toxoplasmosis)
22
Q
What are differential diagnoses for jaundice in cats?
A
- Cholangitis complex
- FIP (dry-form)
- Lymphoma
- (Cirrhosis)
- Neoplasia
- Lipidosis
- Toxoplasmosis
- Haemolytic anaemia
- Toxic hepatopathy
- Pancreatitis
- Panleucopenia
- Biliary obstruction / bile duct rupture
23
Q
What are the steps to diagnosing liver disease?
A
- History & clinical signs
- Physical examination
- Laboratory evaluation
- Diagnostic imaging
- Liver biopsy
24
Q
What would you look for on physical exam of liver disease?
A
- Icterus - present in serum before eye (can have severe disease without icterus)
- Ascites
- Hepatomegaly / microhepatica
- Pain - abdominal
25
What lab tests would you do for live rdisease?
* Haematology
* Serum biochemistry
* Urinalysis
* Coagulation (before liver biopsy)
* Liver function tests
* Peritoneal fluid cytology (ascites)
26
Regarding liver enzymes what are the hepatocellular + cholestatic markers?
* Hepatocellular markers = ALT + AST
* Cholestatic markers = ALP + GGT
27
With serum biochemistry what will tell you about the liver function?
* Serum proteins (especially albumin)
* Glucose, urea, cholesterol
* Bilirubin
* (Ammonia)
* Bile acids
* Not liver enzymes - only tell damage (leakage enzymes)
28
What would happen to biochemistry results as liver failure progresses?
* Acute hepatitis = raised ALT + ALP
* Chronic hepatitis = raised bile acids
* Cirrhosis = raised bilirubin + decreased albumin
* End stage liver failure = increased clotting + decreased glucose
29
What is the difference between chronic hepatitis + cirrhosis?
* No clinical signs with chronic hepatitis
30
What different diagnostic imaging can be done for liver disease?
* Survey radiographs
* Contrast radiographs - portovenography
* Ultrasonography
* Scintigraphy
31
What can ultrasonography tell you with liver damage?
* Liver size
* Heterogenous parenchyma disease
* Biliary obstruction
* Biliary calculi
* Masses
* Vasculature
- portosystemic shunts
- arteriovenous fistulas
32
What are indications to do a liver biopsy?
* Persistent increases in liver enzymes
* Altered liver size
* Monitoring progressive liver disease
* To evaluate response to treatment
33
What needs to be done before taking a liver biopsy?
* Check clotting profile first
34
What are contraindications for percutaneous biopsy?
* Lack of operator experience
* Small liver, unless ultrasound available
* Focal disease
* Extrahepatic cholestasis
* Bleeding disorder
* Severe anaemia
35
What are different techniques for liver biopsy?
* Percutaneous
- blind
- ultrasound guided 'tru-cut' technique
* Laparoscopy
* Coeliotomy
36
What dogs are predisposed to juvenile hepatic fibrosis?
What is the pathology of juvenile hepatic fibrosis?
* GSD
* Rottweiler
* Progressive fibrosis
* Minimal inflammatory reaction
* Central vein fibrosis + occlusion most common
37
What can be secondary to juvenile fibrosis / cirrhosis?
How do they develop?
* Acquired shunts
- develop from redundant vessels - between portal vein + CVC, portal hypertension often leads to ascites
38
What are different types of canine chronic hepatitis?
* Idiopathic chronic hepatitis
* Lobular dissecting hepatitis
* Drug-induced chronic hepatitis
* Copper-associated hepatitis
- all lead to cirrhosis
38
When would survival be shorter with chronic hepatitis?
If -
- hypoalbuminaemia
- severity of necrosis and fibrosis in the biopsy
- Bridging fibrosis
39
What breeds are predisposed to hepatic portal hypoplasia?
* Small terrier breeds
- often have no clinical signs or portosystemic shunts
+ increased bile acids
40
What are the different feline cholangitis complex + what are the difference?
* Suppurative cholangitis - neutrophils
* Lymphocytic cholangitis - lymphocytes + plasma cells
41
What is idiopathic hepatic lipidosis? What does it lead to?
* Massive hepatic fat accumulation
*leads to
- biliary stasis
- liver failure
- anorexia
- death
42
What are clinical signs of hepatic neoplasia + what are the different types?
* Similar to inflammatory liver disease
* Hepatomegaly - can be irregular shape
* Primary tumours
* Infiltrative
* Metastatic
43
What are different primary neoplasias?
* Hepatocytes
-Hepatocellular carcinoma
-hepatoma
* Biliary - cholangiocarcinoma
* Connective tissue
-fibroma / sarcoma
-haemangioma / haemangiosarcoma
44
What are the principles of treating liver disease?
1. Eliminate causative agent
2. Suppress ongoing disease
3. Optimise regenerative capacity
4. Control complications
45
What does therapy tailored to the clinical picture consist of?
* Dietary modification
* Ursodeoxycholic acid (UDCA)
* Anti-oxidant drugs & glutathione donors
* Treatment of complications
46
What does therapy tailored to biopsy results consist of?
* Inflammatory cells (Neutrophils/Lymphocytes) = antibiotics / immunosuppressives
* Fibrosis = anti-fibrotic drugs
* Copper accumulation = decoppering drugs
* Positive bacterial culture = appropriate antibiotic
47
What dietary management would be needed for hepatic encephalopathy?
* minimise ammonia production =
-protein restriction + modification
- high biological value = dairy + vegetable
48
What dietary management would be needed for chronic active inflammation?
* Reduce inflammation
* Prevent copper accumulation=
* - low copper + high zinc
* - fat soluble vitamins = A, D, E, K,
* - Taurine + L-carnitine for cats
* Add cottage cheese to a standard hepatic diet - high in protein
49
What antibacterial therapy would be needed for hepatic encephalopathy?
* Use based on clinical picture
- Ampicillin
- Metronidazole
50
What antibacterial therapy would be needed for bacterial cholangiohepatitis?
* Need culture + sensitivity (bile + tissue)
51
What are advantages of glucocorticoids?
* Improved well-being
* Appetite stimulation
* Anti-inflammatory
* Immunosuppression
* Anti-fibrotic
52
What are disadvantages of glucocorticoids?
* Steroid hepatopathy
* Predispose to infection
* Fluid retention
* Catabolic
53
What are breeds affected by copper associated hepatopathies?
* Bedlington terriers
* WHWT
* Skye terrier
* Dalmatian
* Labrador
* Doberman
54
What are different decoppering agents?
* Copper chelators
-d-penicillamine
-2,2,2-tetramine (trientine)
* Copper absorption blocker
-oral zinc (give 1hr before feeding)
55
What are the advantages / disadvantages of using adjunctive therapy?
Advantages
* Do not need biopsy results
* Broad spectrum of activity
* Wide safety margin
* Combination therapy used
Disadvantages
* Cost
* Worse compliance if given many drugs
56
What are different examples of adjunctive therapy?
* Ursodeoxycholic acid (UDCA)
* S-Adenosyl methionine (SAMe)
* Milk thistle
* Vitamin E
57
What is ursodeoxycholic acid?
* Hydrophilic 'beneficial' bile salt
- alters bile composition
- stimulates bile flow - contraindicated if complete biliary obstruction
- modulates inflammatory/immune response
58
What is S-adenosyl methionine?
* 'Glutathione (GSH) donor'
= endogenous molecule central to =
- hepatic metabolism
- detoxification
59
What benefit does Silybum mariarnum have? (milk thistle)
* Free-radical scavenger
* Inhibits inflammation
* Inhibit lipid peroxidase
* Inhibit collagen deposition
* Increase glutathionine
60
What are the advantages / disadvantages milk thistle?
Advantages
* Wide safety margin
* No absolute contraindications
* Broad spectrum of activity
Disadvantages
* Cost
* Evidence for efficacy
61
What are complications of liver disease?
* Hepatic encephalopathy + coma
* Ascites + oedema
* Haemorrhage + anaemia
62
With hepatic encephalopathy, what should be done?
* Identify + treat precipitating cause
-Dehydration
-Diuretics
-Alkalosis
-Hypokalaemia
-Gastrointestinal bleeding
* Reduce ammonia concentrations
-low protein diet
-Lactulose
-Antibiotics (ampicillin / metronidazole)
* Lactulose retention enema if coma
63
What can be done to treat ascites + oedema?
* Low sodium diet
* Diuretics
- spironlactone
- occasionally add in furosemide
* Paracentesis
- drain a minimal volume for patients comfort
- Could worsen bodywide protein status
64
What can be done to treat hemorrhage and anaemia?
* Vitamin K injections
* Fresh blood transfusions
* B vitamin injections
* H2 blockers if GI haemorrhage
65
What is high cobalamin associated with in cats?
* Hepatic + neoplastic disease
