Liver disease Flashcards
What are the 3 main causes of liver disease?
Alcohol misuse, obesity and hepatitis disease (chronic infection)
List 6 main functions of the liver?
- Production and excretion of bile
- Metabolism of proteins, fats and carbohydrates
- Conversion of ammonia to urea
- Blood detoxification
- Synthesis of plasma proteins (albumin and clotting factors)
- Storage of glycogen, vitamins and minerals
How does liver disease often present?
(MOST) Silent – incidental finding on investigations (blood test, imaging) Acute liver failure Chronic liver disease Acute on chronic liver failure presentation
What is liver fibrosis? State one thing that can cause it.
Chronic Inflammation of the liver leading to the formation of scar tissue.
Cause- Hepatitis C
What is liver cirrhosis?
When the extensive scars and development of conncetive tissue block the flow of blood through the liver causing liver function to decrease
List 6 causes of cirrhosis
- Alcohol
- Obesity (metabolic syndrome)
- Viral hepatitis (B /C)
- Biliary disease
- Autoimmune
- Metabolic disease
State 3 metabolic diseases which can cause cirrhosis
Haemochromatosis / Wilson’ disease / alpha1-antitrypsin disease
What is the meaning of a well compensated and a decompensated liver cirrhosis?
Well compensated- liver is scarred but still able to perform most its basic functions at some level
Decompensated- acute deterioration in liver function
What are the risk factors for liver disease which should be considered in history taking?
Co-morbidities Alcohol history Drug history Illicit drugs, OTC meds Risk factors for viral hepatitis, sexual history, transfusions Personal family history Professional history Travel history
State some systemic and obstructive symptoms of liver disease?
-Systemic Fatigue Weight loss -Cholestatic / Obstructive Itching / pruritus Pale stools / dark urine
List 9 signs of liver disease
- Palmar erythema (reddening of palms)
- Clubbing
- Leukonychia (white discoloration of the nails)
- Dupuytren’s contractures (one or more fingers become permanently bent in a flexed position)
- Hair loss
- Gynaecomastia
- Spider naevi (>5)
- Proximal wasting
- Bruising
- Xanthelasma
- Organomegaly
- Hypogonadism
- Jaundice
Which tests can be done to examine chronic liver disease?
Clotting time - INR
Albumin levels
Complete blood count (CBC) – looking at platelets
What do you tests to monitor on going liver damage?
Hepatobiliary enzymes – ALT, AST, GGT, ALP
What is assessed to establish the amount of bilirubin in the blood?
Unconjugated vs conjugated
bilirubin test
Name the 4 biliary enzymes and where they are produced?
-Aspartate aminotransferase (AST)
Produced by heart, kidney, muscle
Hepatitis
-Alanine aminotransferase (ALT)
Liver
More liver specific than AST
-Alkaline phosphatase (ALP)
Biliary epithelium – released in cholestasis (reduction or stop of bile flow)
Bone and placenta
-Gamma-glutamyl transferase (GGT)
Hepatocellular
Cholestasis; alcohol
What does this indicate:- ↑ALT and AST ?
Hepatic pictire
What does this indicate:- ↑ALP and GGT ?
cholestatic picture
What does this indicate:- AST > ALT?
Likely alcohol related
What does this indicate:- ALT > AST?
likely virus-induced
When alcohol is the cause of the liver damage what would the ALT value be?
> 500
Less than
What does this indicate:- ALT 500 – 1500?
suspect autoimmune hepatitis
What does this indicate:- ALT >1500?
think of viral causes, drugs, ischaemia
Why might the platelet count be low in liver disease?
Reduced production by bone marrow
Sequestration
Increased destruction
Which 2 imaging techniques are used to determine level of fibrosis or presence of cirrhosis?
liver elastography and MR elastography, ultrasound, CT, MRI, MRCP / ERCP
How does portal hypertension develop in liver diease?
-75% of blood flowing through the liver is from the portal system
- cirrhotic scarring means Blood in the portal vein does not flow easily through the liver
This increases the hydrostatic pressure in the portal system
List other causes of portal hypertension
Decreased production of albumin
Decreased oncotic pressure
Increased passage of fluid through the vessel
Decreased hormone metabolism
Relaxed endothelium
Impaired barrier function
What causes ascitis?
Increased hydrostatic pressure
Decreased oncotic pressure
Decreased barrier function
List 5 complications of portal hypertension
Ascites
Distended abdominal veins
Splenomegaly
Portosystemic varices
Picture of portal hypertension system
List 3 signs of decompensated cirrhosis
Encephalopathy
Ascites
Bleeding
List 6 causes of decompensation
Sepsis Bleeding Drugs e.g. NSAIDs, sedatives Alcohol Venous occlusion Hepatocellular carcinoma
List 6 treatments of hepatocellular carcinoma
Alcohol injection Transarterial chemoembolization Radiofrequency ablation Antiangiogenic drugs Surgical resection Transplanation (Milan criteria)
At what age is a liver transplant likley to be declined?
70 y
List 6 treatments of alcoholic liver diease
Community support Detox / rehab Outpatient appointments Emergency admissions Nutritional deficiencies Transplantations
State another cause of cirrhosis not outside of liver disease
Malignancy
What are the clinical findings associated with autoimmune hepatitis?
Characterised by high ALT; positive ASMA
Can present with jaundice and liver failure
What are the clinical findings associated with Primary sclerosing cholangitis ?
cholestatic picture of LFTs – pruritus and jaundice
positive ANA, ASMA
MRCP and ERCP can be diagnostic (beading of biliary tree)
What can cause Hepatic Encephalopathy?
Sepsis, bleeding, drugs (opiates) deteriorating liver function, constipation
Name one main physical clinical asing associated with Hepatic Encephalopathy. What causes this to happen?
Hepatic flap (ammonia has crossed the blood brain barrier)
What is Primary biliary cholangitis?
Progression destruction of small bile ducts; positive AMA
Name 5 other conditions which can cause abnormal liver blood test results?
Sepsis Cardiac Certain rheumatological conditions Chronic obstructive pulmonary disease Chronic kidney disease
