Liver disease Flashcards
List the functions of the hepatocyte with examples
Synthesis
- Albumin
- Lipoproteins
- Coagulation factors (2, 7, 9, 10)
- Glycogen
- Urea
- Bile salts
- Cholesterol
Excretion/Detoxification
- Bilirubin
- Bile salts
- Ammonia
- Alcohol
- Drugs
- Toxins
Storage
- CHO, lipids, iron, copper,
- vitamins A,D,E,K
Distinguish between acute and chronic liver disease
-
ACUTE
- Onset days, weeks after exposure
- Resolve within 3 months (usually)
-
CHRONIC
- Present for more than 6 months
- Lead to and are associated with cirrhosis (or irreversible scarring of the liver)
List some categories of liver syndromes
- Acute hepatitis
- Hepatobiliary disorders – cholestasis (impaired bile flow)
- Chronic liver disease/cirrhosis
- Without liver failure (compensated cirrhosis)
- With liver failure (hepatic decompensation)
- Hepatic malignancies (infiltration) - primary or secondary
- Isolated hyperbilirubinemias (not due to above)
List some acute liver diseases
- Viral hepatitis (HAV, HBV, HCV, HDV, HEV,
other –CMV, EBV) - Other infections: bacterial, parasitic
- Toxic - hepatic drug reactions
- Vascular disorders (eg. cardiac failure - ischaemia reperfusion injury)
- Fatty liver disorders - more often chronic
- Alcoholic liver disease - more often chronic
- Autoimmune hepatitis - more often chronic
- Other metabolic disorders, e.g., haemochromatosis, Wilson’s disease
List the features of acute hepatitis aka hepatocullular necrosis
Acute hepatitis (hepatocellular necrosis)
- Anorexia (profound), nausea, vomiting
- Lethargy
- Jaundice common
- Scleral icterus especially in people of colour
Acute hepatitis (hepatocellular necrosis)
- also:
- Dark urine: bilirubin-uria
- Tender (soft) liver
- Acute liver failure - not making clotting factors hence bruising/bleeding,
prolonged coagulation time (not corrected by vitamin K injection)
- Liver biochemistry: ALT >10 fold increased;
changes in BR, GGT, ALP less specific
Definec holestasis and describe the presenting symptoms
Cholestasis
- Impaired bile flow
- Jaundice common
- Dark urine: bilirubinuria
- Pale stools
- Malabsorption - long chain fatty acids,
fat-soluble vitamins (impaired coagulation)
- Pruritus
List the causes of biliary obstruction
There are many causes, the most common of which is due to mechanical obstruction of CBD
- gallstones: pain, fever, jaundice (triad)
- malignancy: pancreatic head, bile duct, other
- scarring: primary or secondary sclerosing cholangitis
- infection eg cholangitis, parasites
Some molecular (“medical”) causes
- Drug-induced cholestasis (eg amoxycillin/clavulanic acid)
- Cholestasis of pregnancy
- Primary biliary cholangitis (PBC, formerly known as PB cirrhosis)
List soem common causes of chronic liver disease
Common causes of CHRONIC liver disease
- Hepatitis viruses (B, C)
- Alcohol (NHMRC 2021 guidelines) vs 2009
- no more than 10 std drinks a week, no more than 4 in a day
- Metabolic disorders
- Non-alcoholic fatty liver disease (NAFLD, MAFLD), including non-alcoholic steatohepatitis (NASH, MASH) -> can progress to cirrhosis
- Iron storage disorder - haemochromatosis
List some rarer causes of chronic liver diseases
- Drugs and other toxins, e.g., methotrexate, arsenic
- Metabolic disorders
- Copper storage disorder - Wilson’s disease (children, young adults)
- Glycogen storage diseases (babies)
- Autoimmune diseases
- autoimmune hepatitis
- primary biliary cholangitis (PBC)
- primary sclerosing cholangitis
Describe the presentation of liver failure with portal hypertension
- Ascites
- Dilated abdominal wall veins
- Muscle wasting (check shoulders, buttocks, thighs)
- Fullness left flank (splenomegaly)
Describe ascites pathophysiology
- Cirrhosis
- Low albumin
- Low colloid oncotic pressure -
- High portal pressure
- Increased capillary hydrostatic pressure
- High aldosterone and ADH
- Na+, water retention
- Low albumin
Inevitably leading to
- Fluid transudation
- ascites
Describe the features of cirrhosis and deceompensated liver failure
- Jaundice
- Ascites
- Impaired protein synthesis, coagulopathy
- Catabolism: muscle wasting
Describe some of the features of hepatic encephalopathy
- mood or personality swings
- behaviour and impulse control issues
- problems with memory, concentration, thinking
- consciousness, lucidity, sleep pattern changes
- coordination and motor function issues
- loss of autonomy, ability to self-care
- issue of clearing ammonia
Describe the complications of cirrhosis
- Portal hypertension
- Portal hypertensive gastropathy (vascular ectasia - oozy lining of stomach, vessels markedly dilated)
- Oesophago-gastric varices (catastrophic upper gastrointestinal bleeding)
- Thrombocytopenia (TPO down)
- Ascites/ hepatic encephalopathy
- Bacterial infection – impaired immunity (reduced complement synthesis), especially spontaneous bacterial peritonitis, septicaemia, pneumonia
Metabolic Defects
- Hypoglycemia
- Gluconeogenesis, glucose intolerance, diabetes
- Impaired drug clearance (CYP-mediated metabolism, hepatic blood flow)
Circulatory Disorders
- renal failure - hepatorenal syndrome (renin-angiotensin-aldosterone, ADH activation)
- hepatopulmonary syndrome (NO–> hypoxia, clubbing, pulmonary hypertension)
Briefly describe HCC
- 2nd most common cause of cancer death worldwide
- Incidence trebled in Australia and USA last 3 decades
- Regard as a complication of cirrhosis (>90% of cases)
- Most common in chronic viral hepatitis (B, C, B+C)
- … and longstanding cirrhosis, especially males, HBV/HCV, alcohol, fatty liver (NASH)
- Cholangiocarcinoma – less common; different associations e.g., primary sclerosing cholangitis, schistosomiasis
