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GI and liver > Liver disease > Flashcards

Liver disease Flashcards

1
Q

What are the functions of the normal liver?

A
  • Glucose and fat metabolism
  • Protein synthesis e.g. albumin and clotting factors
  • Detoxification and excretion
  • Defence against infection
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2
Q

Describe key histological arrangements in the liver

A
  • Arranged in acinar or lobular models (hepatocytes)
  • Blood runs in sinusoids in close proximity to the hepatocytes to enable lots of metabolic activity
  • Bile flows out and blood flows in through portal tracts forming a hexagonal structure around a central vein which drains into the hepatic vein
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3
Q

How is acute and chronic liver injury defined in terms of time?

A

Acute: <6 months
Chronic: >6 months

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4
Q

How does acute liver injury present histologically?

A
  • Acute hepatocyte injury and death
  • Cell death can occur by necrosis or apoptosis
  • Usually characterised by inflammation
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5
Q

How does acute liver injury more commonly present physiologically?

A
  • Malaise
  • Nausea
  • Anorexia
  • Jaundice
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6
Q

How does chronic liver injury present histologically?

A
  • Continued inflammation causes fibrosis so there is a lack of liver regeneration
  • Stellate cells activate and cytokines cause fibrosis deposition
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7
Q

How does chronic liver injury present more commonly physiologically?

A
  • Ascites
  • Oedema
  • Hematemesis
  • Malaise
  • Anorexia
  • Wasting
  • Easy bruising
  • Itching
  • Hepatomegaly
  • Abnormal LFTs
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8
Q

How does acute liver injury less commonly present physiologically?

A
  • Confusion (encephalopathy)
  • Bleeding
  • Liver pain
  • Hypoglycaemia
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9
Q

How does chronic liver injury present less commonly physiologically?

A
  • Confusion

* Jaundice

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10
Q

Why does oedema occur in chronic liver injury?

A

Due to low albumin

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11
Q

Why does hematemesis occur in chronic liver injury?

A

Due to oesophageal or stomach varices

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12
Q

Name the 3 key liver function tests

A
  • Serum albumin
  • Bilirubin
  • Prothrombin time
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13
Q

What is serum abumin a marker of?

A

Synthetic function

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14
Q

In normal function, is bilirubin usually conjugated or unconjugated?

A

Unconjugated

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15
Q

What is prothrombin time a marker of?

A

Synthetic function

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16
Q

Why is prothrombin time a sensitive marker of acute and chronic liver disease?

A

Because it has a short half-life

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17
Q

A deficiency of which vitamin will cause a prolonged prothrombin time?

A

Vitamin K deficiency

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18
Q

Name the 2 important areas of liver biochemistry

A
  1. Aminotransferases

2. Alkaline phosphate

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19
Q

What are the 2 aminotransferases?

A
  1. Aspartate aminotransferase (AST)

2. Alanine aminotransferase (ALT)

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20
Q

Where is aspartate aminotransferase (AST) present?

A

Liver, heart, muscle, kidney and brain

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21
Q

What can cause a rise in aminotransferase (AST)?

A
  • Hepatic necrosis
  • MI
  • Muscle injury
  • Congestive heart failure
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22
Q

Where is alanine aminotransferase (ALT) present?

A

The liver

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23
Q

What can cause a rise in alanine aminotransferase (ALT) ?

A

Liver disease

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24
Q

Where is alkaline phosphate present?

A
  • Liver
  • Bone
  • Intestine
  • Placenta
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25
Q

When might alkaline phosphate be raised?

A
  • Intrahepatic disease
  • Extrahepatic cholestatic disease
  • Hepatic infiltrations (e.g. metastases)
  • Cirrhosis
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26
Q

What is jaundice?

A

Yellowing of the skin (+/- sclera) due to raised serum bilirubin

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27
Q

What is pruritus?

A

Itching

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28
Q

Why does skin go yellow in jaundice?

A

Raised serum bilirubin causes bile salt deposition in the skin

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29
Q

What are the 2 areas of classification of jaundice?

A
  • Unconjugated – ‘pre-hepatic’

* Conjugated – ‘cholestatic’

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30
Q

Give 2 causes of unconjugated jaundice

A
  1. Gilbert’s syndrome

2. Haemolysis

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31
Q

What can cholestatic jaundice be further divided into?

A

Hepatic and post-hepatic

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32
Q

What is Gilbert’s syndrome?

A

Deficiency in UDP glucuronyl transferase

33
Q

Give a cause of hepatic cholestatic jaundice

A

Liver disease e.g. hepatitis

34
Q

Give a cause of post-hepatic cholestatic jaundice

A

Bile duct obstruction e.g. gallstones

35
Q

In pre-hepatic jaundice what is urine like?

A

Normal

36
Q

In pre-hepatic jaundice what are stools like?

A

Normal

37
Q

In cholestatic jaundice what is urine like?

A

Dark

38
Q

In cholestatic jaundice what are stools like?

A

May be pale

39
Q

In pre-hepatic jaundice, is there itching?

A

No

40
Q

In cholestatic jaundice, is there itching?

A

Maybe

41
Q

In pre-hepatic jaundice what are liver tests like?

A

Normal

42
Q

In cholestatic jaundice what are liver tests like?

A

Abnormal

43
Q

What might dark urine, pale stool and itching sugget?

A

Cholestatic not pre-hepatic

44
Q

What key symptoms may also be present in jaundice?

A
  • Biliary pain
  • Rigors
  • Abdomen swelling
  • Weight loss
45
Q

What key points of past medical history should be asked about in jaundice?

A
  • Biliary disease/intervention
  • Malignancy
  • Heart failure
  • Blood produces
  • Autoimmune disease
46
Q

What tests should you do investigate jaundice?

A

• Liver enzymes
• Biliary obstruction
• Further imaging
• CT
- Magnetic resonance cholangiopancreatography (MRCP)
- Endoscopic retrograde cholangiopancreatography (ERCP)

47
Q

Where do most gallstones form?

A

In the gallbladder

48
Q

What are the 2 types of gallstone?

A

Cholesterol and bile pigment

49
Q

What percentage of gallsones are cholesterol stones?

A

70%

50
Q

What percentage of gallsones are bile pigment stones?

A

30%

51
Q

What is the most common symptom of gallstones?

A

Most are asymptomatic

52
Q

What are the 3 classifications of gallstones?

A
  • Gallbladder stones
  • Intrahepatic stones
  • Extrahepatic stones
53
Q

What are the risk factors for gallstones?

A
  • Female
  • Fat
  • Fertile
  • Smoking
54
Q

What are the main causes of gallstones?

A
  • Obesity and rapid weight loss
  • Diet high in animal fat and low in fibre
  • Diabetes mellitus
  • Contraceptive pill
  • Liver cirrhosis
55
Q

Are cholesterol gallstones usually small or large?

A

Large

56
Q

Are cholesterol gallstones usually solitary or more numerous?

A

Solitary

57
Q

How do cholesterol gallstones form?

A

There is cholesterol crystalisation in bile

58
Q

Give 4 reasons for cholesterol gallstones to form

A
  1. Relative deficiency in bile salts and phospholipids
  2. Relative excess of cholesterol in bile
  3. Reduced gallbladder motility and stasis
  4. Crystalline promoting factors in bile e.g. mucus and calcium
59
Q

What are bile pigment stones mostly formed of?

A

Calcium (Ca2+)

60
Q

Describe the key features of bile pigment stones

A
  • Friable (easily crumbled)
  • Irregular
  • Mostly calcium
61
Q

What is the main cause of bile pigment stones?

A

Haemolysis

62
Q

What are the main types of bile pigment stones?

A

Black and brown

63
Q

Describe the composition of black bile pigment stones

A

Made of calcium bilirubinate and a network of mucin glycoproteins that interlace with salts e.g. calcium bicarbonate

64
Q

Describe the composition of brown bile pigment stones

A

Calcium salts

65
Q

In which patients are black bile pigment stones usually seen?

A

Patients with haemolytic anaemias

66
Q

In what conditions are brown bile pigment stones usually found?

A

In bile stasis and/or biliary infection

67
Q

How would you manage gallbladder stones?

A
  • Laparoscopic cholecystectomy

* Bile acid dissolution therapy

68
Q

How would you manage bile duct stones?

A 
• ERCP with sphincterotomy and:
- Removal (balloon or basket)
- Crushing (mechanical or laser)
- Stent placement
• Surgery for large stones
69
Q

What proportion of bile acid dissolution therapy procedures are successful?

A

<1/3

70
Q

What are the 4 drug mechanisms involved in causing liver damage?

A
  • Disruption of intracellular Ca2+ homeostasis
  • Disruption of bile canalicular transport mechanisms
  • Induction of apoptosis
  • Inhibition of mitochondrial function, which prevents fatty acid metabolism and accumulation of lactate and reactive oxygen species
71
Q

What are the 3 types of drug-induced liver injury?

A
  1. Hepatocellular
  2. Cholestatic
  3. Mixed
72
Q

What is the usual onset for a drug-induced liver injury?

A

1-12 weeks

73
Q

What are the main causes of drug-induced liver injuries?

A
  • Antibiotics
  • CNS drugs
  • Immunosuppressants
  • Analgesics
  • GI drugs
  • Dietary supplements
  • Multiple drugs
74
Q

Give 4 antibiotics which cause DILI

A
  • Augmentin
  • Flucloxacillin
  • TB drugs
  • Erythromycin
75
Q

Give 2 CNS drugs which cause DILI

A
  • Chlorpromazine

* Carbamazepine

76
Q

Give 1 analgesic which causes DILI

A

Diclofenac

77
Q

What type of GI drugs may cause a DILI?

A

PPIs

78
Q

Name 6 types of drug which do not cause DILI

A
  • Low-dose aspirin
  • NSAIDs except diclofenac
  • Beta blockers
  • Ace inhibitors
  • Thiazides
  • Calcium channel blockers

GI and liver (8 decks)

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