Liver Disease Flashcards
What are the causes of high Bilirubin?
Pre hepatic
Hepatic
Post-hepatice
What is the structure of the liver lobules?
Portal triad -> Sinusiod/ space of Disse-> Central vein
Direction of blood flow
(Bile in opposite directions)
What does the space of Disse do?
Allows blood to get close to the hepatocytes
What is in the portal triad?
Portal vein from gut
Portal artery
Bile duct
What might you see on a liver ultrasound?
Tumour at head of the pancreas
Gallstones
What blood tests might you do after finding high BR?
FBC/ Film (haemolysis) Virology (hepatitis) Amylase (pancreas) Antibodies Repeat BR fasting (hepatic disease)
What is the Van den Bergh test?
The van den Bergh reaction measures serum bilirubin via fractionation.
A direct reaction measures conjugated bilirubin.
The addition of methanol causes a complete reaction, which measures total bilirubin (conjugated plus unconjugated);
the difference measures unconjugated bilirubin (an indirect reaction).
What is paediatric jaundice a sign of?
Might be normal but the bilirubin should be unconjugated as the cause is usually liver immaturity coupled with a fall in the haemoglobin early in life.
If it doesn’t settle, other rare causes should be looked for including hypothyroidism, other causes of haemolysis (including a Coombes test or DAT), and the unconjugated bilirubin will be useful.
What is phototherapy?
Converts bilirubin into two other compounds, lumirubin and photobilirubin which are isomers that do not need conjugation for excretion.
How is Gilbert’s inherited?
Recessive
How many people carry the gene for Gilbert’s?
50%
What is the pathology of Gilbert’s?
UDP glucuronyl transferase activity reduced to 30%
Unconjugated bilirubin tightly albumin bound and does NOT enter urine.
What are the better indicators of liver functions?
- Albumin
- Clotting factors (PT, PTTK)
- Bilirubin
Other tests are “enzymes”, not truly tests of liver function.
Which liver test is best for paracetamol overdose?
PT- quick
Differential for Abnormal LFTs, BR raised?
Pre hepatic (gilberts, haemolysis)
Hepatic (Viral or alcoholic hepatitis, cirrhosis)
Post hepatic (Gallstones, pancreatic cancer)
What does high AST/ALT plus marginal Alk Phos suggest?
Hepatic cause of liver issues (hepatocyte damage)
What is the serology of Hep A?
- Virus in faeces 2-6 weeks after infection- Infectious period
- IgM 3-13 weeks after infection
- IgG 5 weeks plus immunity
What is hepatitis B serology?
- 3 months- High Hep N antigen
- 2-4 months antibodies strat increasing
- After 6 months- antibodies and immunity- no second attack
What is a Hep B carrier?
Some people don’t clear the antigen so they are carriers
What are the histological features of alcoholic hepatitis?
- Mallory denk bodies (cytoskeletons of destroyed hepatocytes)
- Neutrophil inflammation
- Bile accumulation in liver
- Fatty change
- Megamitochondria
What is NASH associated with?
- Insulin resistance
NASH (Non Alcoholic Steato Hepatitis)
What are some signs of chronic stable liver disease?
Multiple spider naevi
Dupuytren’s contracture
Palmar erythema
Gynaecomastia
What is the triad of portal hypertension?
Caput Medusae/ visible veins
Splenomegaly
Ascites
How do we fix a ruptured oesphageal varix?
- Terlipressin
- Sengstaken–Blakemore tube (Apply pressure via balloon)
- Emergency endoscopy and inject to close the bleed
- X match and transfusion
Small nodules and fat histologically denotes what in the liver?
Alcoholic hepatitis?
What are sites of porto systemic anastomoses that can cause issues?
- Oesophageal varices
- Rectal varices
- Umbilical vein recanalising
- Spleno-renal shunt
How do we fix portal hypertension?
TIPS
Transjugular intrahepatic portosystemic shunt
Drops portal pressure BUT can cause encephalopathy
What do excoriation marks suggest with a patient having a background of liver issues?
Bile duct obstruction
Caused by colourless bile salts into circulation
What would increase alk phos?
Obstructive BR
Where do some adenocarcinomas start?
Pancreas
What is courvoisier’s law?
In the presence of jaundice, if the gall bladder is palpable, the cause is unlikely to be gall stones.
This is because a gall bladder with stones is usually small and fibrotic and incapable of being large.
