Liver disease Flashcards
What indicates hepatitis?
Raised AST and ALT
What is cholestasis?
Bile not reaching duodenum
Obstructive/metabolic
Signs of obstructive cholestasis:
Raised alkaline phosphatase
Raised GGT
What is blocked in large duct obstruction?
Extrahepatic bile duct
What is blocked in primary sclerosis cholangitis?
Large and/or small bile duct
What is blocked in primary biliary cirrhosis?
Small interlobular bile duct
What is haemochromatosis?
Autosomal recessive (HFE gene) disorder of iron metabolism that results in iron accumulation - causes abnormal liver enzymes, cirrhosis, hepatomegaly, joint pain and bronze skin
Important liver virology:
Hep B surface antigen
Hep C antibody
Features of hepatitis A:
Faeco-oral route
No chronicity
Hep A IgM = acute
Hep A IgG = previous exposure
Features of acute hepatitis B:
Initially Hep B surface antigen and core-IgM are present
Once virus is cleared these two go away and core-IgG develops
Later still Hep B surface antibody develops (implies immunity)
Features of chronic hepatitis B:
Hep B surface antigen and core-IgG stay risen (IgM falls)
Do not develop Hep B surface antibody
What does Hep B core-IgM indicate?
Acute infection
What does Hep B core-IgG indicate?
Hep B exposure
What should you do if you detect Hep B surface antigen?
Refer
What does Hep B surface antibody (>100) indicate?
Immunity
What are the different phases of Hep B infection?
Phase I = Viral load is high and inflammation is low; immune tolerant (0-18 years)
Phase II = Immune active hepatitis; liver problems (18-51 years)
Phase III = Cirrhosis, non-replicative (51-69 years)
When should you treat Hep B?
High viral load + elevated ALT
Hepatitis C curable treatments:
Ledipasvir/Sofosbuvir combined oral pill - 99% clear rate
OMV/PTV/RTV+DSV+RBV - 100% clear rate
Sofosbuvir/Velpatasvir >95% clear rate
Features of haemochromatosis (end organ failure):
Cirrhosis Skin pigmentation Diabetes Cardiomyopathy Arthritis Pituitary failure
How do you diagnose haemochromatosis?
Raised ferritin (women >200, men >300) and HFE genotype homozygote Biopsy and hepatic iron index if ferritin is raised but HFE negative
What does abnormal LFTs and ferritin >1000 indicate in haemochromatosis?
Cirrhosis
Liver should be biopsied
Diagnosis of primary biliary cholangitis:
+ve anti-Mt Ab
Cholestatic LFTs
Raised IgG
Liver biopsy showing BD damage and granulomatous cholangitis
Signs and symptoms of primary biliary cholangitis:
Asymp/fatigue/pruritis Itching and tiredness Cholestatic jaundice Hyperpigmentation esp over pressure points Xanthelasmas, xanthomata Clubbing, hepatosplenomegaly
Complications of primary biliary cholangitis:
Malabsorption causing osteomalacia or coagulopathy
Sicca syndrome
Portal hypertension causing ascites and vatical haemorrhage
Hepatocellular cancer
Treatment for primary biliary cholangitis:
Ursodeoxycholic acid
Obeticholic acid
How do you diagnose AI hepatitis?
Raised IgG
+ve anti-nuclear antibody
+ve smooth muscle antibody
+ve liver-kidney microsomal antibody
Treatment of AI hepatitis:
Prednisolone
Azathioprine
How do you diagnose primary sclerosis cholangitis?
Liver biopsy for “onion skin” fibrosis + angiography imaging (ERCP or MRCP)
Treat with ursodeoxycholic acid
Males > females
75% association with IBD
Features of alpha 1-antitrypsin deficiency:
Autosomal recessive co-dominant - PiZZ genotype
SOB from panacinar emphysema
Cirrhosis and hepatocellular carcinoma in adults
Cholestasis in children
Diagnosis of alpha 1-antitrypsin deficiency:
Alpha-1-antitrypsin level <25%
Liver biopsy = PAS +ve globules
What is Wilson’s disease?
High urinary copper excretion
Low serum caeruloplasmin
Reduced biliary copper excretion
Features of Wilson’s disease:
Liver cirrhosis
Acute liver failure
Neuropsychological disorders
Kayser-Fleischer rings
Diagnosis of Wilson’s disease:
Biopsy - liver copper >250 ug/g liver dry weight
Genetic tests
Treatment of Wilson’s disease:
Penicillamine
Transplant
What is the difference between non-alcoholic fatty liver disease and non-alcoholic streatohepatitis?
NASH is more dangerous as it is inflammation and fibrosis whereas NAFLD is just fat
What do cirrhotic patients need to be screened for?
HCC
What causes ALT to go up?
Liver cell death
What is spider nave a sign of?
Chronic liver disease
Abnormal oestrogen metabolism
INR in poor liver function?
Raised
What is acutely decompensated cirrhosis?
Long-standing cirrhosis with a recent change
What forms the chronic liver disease screen?
Abdominal ultrasound AI screen Caeruloplasimn Alpha-1-antitrypsin Transferrin saturation Hepatitis
What does a transjugular biopsy of alcoholic hepatitis reveal?
Ballooning of hepatocytes
Neutrophil infiltration
Complication of alcoholic hepatitis (cirrhosis):
Hydrothorax - ascites fill lungs with fluid from the abdomen
Management of cirrhosis:
Give prednisone to bring bilirubin down
Oesophageal vatical banding
Transplant only if abstinent for 4-6 months
Association of liver disease?
Impaired oestrogen metabolism causing gynaecomastia
