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S2.1 Gastrointestinal > Liver Disease > Flashcards

Liver Disease Flashcards

1
Q

What are the general functions of the liver?

A

Synthesis of compounds
Detoxification
Immune function
Storage

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2
Q

What does the liver synthesise?

A

Clotting factors
Bile acids
CHOs (gluconeogenesis, glycogenolysis, glycogenesis)
Proteins e.g. albumin
Lipids (cholesterol, lipoprotein, TG synthesis)
Hormones (angiotensinogen, insulin-like GF)

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3
Q

What does the liver detoxify?

A

Urea production from ammonia
Bilirubin metabolism
Breakdown of insulin and hormones
Drug metabolism

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4
Q

What does the liver store?

A

Glycogen
Vitamins A, D, B12, K
Also copper and iron

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5
Q

What are the different types of liver function tests?

A 
Bilirubin
Alanine Transaminase
Aspartate aminotransferase
Alkaline Phosphatase
Gamma GT
Albumin
Prothrombin time
Creatinine
Platelet count
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6
Q

What are symptoms and signs of deteriorating liver function? (Seen during examination, not lab results)

A 
Serious:
Jaundice
Ascites
Variceal bleeding
Hepatic encephalopathy
Spider naevi
Palmar erythema
JVP elevation
Gynaecomastia
Loss of axiliary and pubic hair
Muscle wasting?
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7
Q

What investigations might be done in suspected liver failure/disease?

A

EUS/USS
ERCP/MRCP
Percutaneous transhepatic cholangiogram

Liver screen

  • Hep B/C serology
  • Autoantibody profile, serum Ig
  • caeruloplasmin and copper
  • ferritin and transferrin saturation
  • alpha-1 anti-trypsin
  • fasting glucose and lipid profile
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8
Q

What are ERCP/MRCP and how do they compare?

A

Endoscopic retrograde cholangiopancreatography
Magnetic resonance cholangiopancreatography

Usual comparisons between invasive imaging vs MRI

  • radiation vs no radiation
  • complications
  • failure rate
  • range

ERCP therapeutic however

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9
Q

What is percutaneous transhepatic cholangiography?

A

More invasive than ERCP
Used when ERCP not possible due to duodenal obstruction or previous surgery
Hilar stenting

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10
Q

What is the definition of ‘Chronic’ liver disease?

A

Any liver disease persisting for over 6 months

  • chronic hepatitis
  • chronic cholestasis
  • fibrosis and cirrhosis
  • others e.g. steatosis
  • liver tumours
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11
Q

What is the clinical presentation of cirrhosis?

A

Compensated chronic liver disease

  • routinely detected on screening tests
  • abnormality of LFTs

Decompensated chronic liver disease

  • ascites
  • variceal bleeding
  • hepatic encephalopathy

Loss of normal liver structure
Replaced by nodules of hepatocytes and fibrous tissue
Complications
- altered liver function
- abnormal blood flow
- increased risk of hepatocellular carcinoma

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12
Q

Causes of cirrhosis?

A 
Alcohol
Hep B/C
Immune-mediated liver disease (autoimmune, primary biliary cholangitis)
Metabolic disorders (excess iron, excess copper)
Obesity/Diabetes mellitus
Cryptogenic (most common)
NAFLD
Drugs (MTX, amiodarone)
CF, alpha-1 antitrypsin deficiency
Vascular problems
Sarcoidosis, amyloid, schistosomiasis
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13
Q

What is ascites and how is it confirmed?

A 
Fluid in peritoneal cavity
Shifting dullness (~1500mL)
Ultrasound can confirm
Corroborating evidence
- spider naevi, palmar erythema, abdominal veins, fetor hepaticus
- umbilical nodule
- JVP elevation
- flank haematoma
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14
Q

What tests are done on ascitic fluid?

A

Diagnostic paracentesis
- protein/albumin concentration
- cell count and differential
- SAAG
> 1.1g/dL = portal HTN related (97% accuracy)
< 1.1g/dL = non portal HTN related (97% accuracy)

Optional

  • Culture, gram staining
  • Glucose, amylase
  • LDH

Unusual

  • TB culture, cytology
  • triglyceride, bilirubin
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15
Q

Treatment for ascites?

A 
Diuretics
Large volume paracentesis
TIPS
Aquaretics
Liver transplantation
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16
Q

How is variceal haemorrhage related to liver disease and how is it treated?

A 
Portal hypertension can cause varices (oesophageal, gastric, skin, rectal, abdomen, stomal)
Medical emergency
- resus
- IV access
- transfusion if required
- emergency endoscopy
- endoscopic band ligation
- Terlipressin
- Sengstaken-Blakemore tube for uncontrolled bleeding
- TIPS for rebleeding after banding
17
Q

What is hepatic encephalopathy? What can cause it and what are associated symptoms? How is it treated?

A

Confusion due to liver disease
Graded 1-4

Precipitants

  • GI bleed
  • infection
  • constipation
  • dehydration
  • medication especially sedation

Flapping tremor and foetor hepaticus are associated

Treat cause
Laxatives - phosphate enema and lactulose
Neomycin, rifaximin
Repeated admissions with HE is indicator for liver transplant

18
Q

What is viral hepatitis? What are the possible outcomes?

A

Inflammation of liver resulting in death of liver cells

Outcomes

  • resolution (A, E) - enteric viruses - usually self-limiting
  • liver failure (A, B, E)
  • chronic hepatitis and cirrhosis (B, C)
19
Q

What is the treatment for hepatitis B?

A 
Pegylated interferon
Oral antivirals
- Lamivudine
- adelovir
- entecavir
- telbivudine
- tenofovir
20
Q

Positive lab findings in liver disease (specifically alcoholic liver disease)?

A 
Raised bilirubin
AAT/ALT ratio >2
Raised gamma glutamyl transferase and AlkP
Macrocytosis
Thrombocytopenia (low platelets)
USS fatty liver
Alcohol
21
Q

What staging/scoring systems are used in alcohol abuse?

A 
CAGE
FAST
- 20+ possible dependency
- 16-19 higher risk
- 8-15 increasing risk
22
Q

Treatment for alcoholic liver disease?

A 
Encephalopathy treatment
Treat infection
Treat alcohol withdrawal
Protect against GI bleed
Airway protection/ICU care
Steroids (only if severe (alcoholic hepatitis score >9))
Nutritional treatment - thiamine
23
Q

What is the prognosis for alcoholic hepatitis?

A

40% mortality
90% in severe

Dependent on abstinence
Steatohepatitis&raquo_space;> Cirrhosis

Any sign of decompensating liver disease - 30% 5YS
Encephalopathy 36% 1YS

24
Q

How can spontaneous bacterial peritonitis be caused? What are the symptoms?

A

Occurs almost exclusively in those with portal hypertension, usually as a result of liver cirrhosis

Symptoms include

  • abdominal pain
  • fever/rigors
  • renal impairment
  • signs of sepsis, tachycardia, high temperature
25
Q

What investigations might be done in bacterial peritonitis?

A

Ascitic tap

  • fluid protein and glucose levels
  • cultures
  • white cell count

Neutrophil count >0.25x10^9/L
Protein <25g/L
Exclude surgical causes of peritonitis

26
Q

What is the treatment for bacterial peritonitis?

A

IV Antibiotics
Ascitic fluid drainage
IV albumin infusion (20% ALBA)

27
Q

What is Non-alcoholic fatty liver disease?

A

Umbrella term encompassing

  • Simple Steatosis
  • Non-alcoholic steatohepatitis
  • Fibrosis and Cirrhosis
28
Q

What are the risk factors/causes of NAFLD?

A

Associated with components of metabolic syndrome

  • diabetes mellitus
  • obesity
  • hypertriglyceridaemia
  • hypertension

Other risk factors

  • age
  • ethnicity e.g. Hispanics
  • genetic factors e.g. PNPLA3 gene
29
Q

What investigations might be done in suspected NAFLD?

A 
Biochemical tests e.g. AST/ALT ratio
Enhanced liver fibrosis panel (hyaluronic acid, TIMP-1, PIINP)
Cytokeratin-18
USS
Fibroscan
MRI/CT
MR spectroscopy - quantify fat
Liver biopsy

NAFLD scoring
- 3+ = high risk
(age, diabetes, BMI, AST:ALT, platelets, albumin)

30
Q

What is the treatment for NAFLD?

A

Diet and weight reduction
Exercise
Insulin sensitisers e.g. Metformin, Pioglitazone
Glucagon-like peptide-1 (GLP-1) analogues e.g. Liraglutide
Farnesoid X Nuclear Receptor ligand e.g. Obeticholic acid
Vit E
Weight reduction surgery

31
Q

What different type of autoimmune liver disease are there?

A 
Autoimmune hepatitis
Primary biliary cholangitis
Primary sclerosing cholangitis
Overlap syndromes
Autoimmune cholangiopathy
IgG 4 disease
32
Q

What are the stages of bilirubin metabolism?

A

Pre-hepatic

  • breakdown of Hb in spleen to form haem and globin
  • haem converted to bilirubin
  • release of bilirubin into circulation

Hepatic

  • uptake of bilirubin by hepatocytes
  • conjugation of bilirubin in hepatocytes
  • excretion of conjugated bilirubin into biliary system

Post-hepatic

  • transport of conjugated bilirubin in biliary system
  • breakdown of bilirubin conjugate in intestine
  • re-absorption of bilirubin
33
Q

What are the different problems that may occur in each stage of bilirubin metabolism, resulting in jaundice?

A

Pre-hepatic

  • increased release of Hb from RBCs (haemolysis)
  • increased quantity of bilirubin (haemolysis)
  • impaired transport

Hepatic

  • Defective uptake of bilirubin
  • Defective conjugation
  • Defective excretion
  • Cholestasis
  • Intra-hepatic bile duct obstruction (PBC, PSC, tumour)

Post-hepatic

  • Cholelithiasis
  • Diseases of gallbladder
  • Extra-hepatic duct obstruction (stones, tumour of duct, stricture, tumour outside duct
34
Q

Who is targeted for liver transplantation?

A 
CLD with poor predicted survival
CLD with poor QOL
Hepatocellular carcinoma
Acute Liver Failure
Genetic diseases e.g. primary oxaluria, tyrosemia
35
Q

When is liver transplantation contraindicated?

A

Active extrahepatic malignancy
Hepatic malignancy with macrovascular or diffuse tumour invasion
Active and uncontrolled infection outside of the hepatobiliary system
Active substance/alcohol abuse
Severe cardiopulmonary or other comorbid conditions
Psychosocial factors that may affect recovery
Technical/anatomical barriers
Brain death

36
Q

What tests are done to prioritise those in acute liver failure for transplantation?

A 
Arterial pH/lactate
Hepatic encephalopathy
INR
Creatinine
Bilirubin

Child’s Pugh scoring, MELD, UKELD in cirrhosis

37
Q

What actually are ERCP/MRCP?

A

Endoscopic retrograde cholangio-pancreatography
Magnetic resonance cholangio-pancreatography

Visualise ampulla, biliary system and pancreatic ducts
Allows biopsy/cytology, stone removal, stenting, dilatation

S2.1 Gastrointestinal (12 decks)

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