Liver Disease

Question 1

Categorise the causes of high BR into 3 classes

Answer 1

Pre hepatic - due to haemolysis
Hepatic
Post hepatic - due to biliary obstruction

Question 2

Diagnose the pt based on the following
LFTs : Normal
FBC : Normal
BR : High

Answer 2

Gilberts Syndrome

Question 3

What percentage of the population have Gilberts?

Answer 3

6%

Question 4

What percentage of people are carriers of Gilberts?

Answer 4

50%

Question 5

What is the best way to treat Gilberts?

Answer 5

Do nothing - its not a problem

Avoid fasting as this can make it worse

Question 6

What is the best indicator of liver function?

Answer 6

Prothrombin time

Question 7

What are 2 of the main functions of the liver?

Answer 7

Produce clotting factors and albumin

Question 8

Name 3 liver enzymes

Answer 8

ALT (alpine amino transferase), AST (aspartate amino transferase) and AP (alkaline phosphatase)

Question 9

What causes a rise in liver enzymes? Why?

Answer 9

Liver damage - they leak out into the blood

Question 10

Name 3 causes of hepatitis

Answer 10

Viral, autoimmune, alcoholic

Question 11

Describe 2 pathways of disease progression of Hep A

Answer 11

Infected via faecaloral –> get ill –> make AB –> recover with full immunity (IgG)
OR
Infected via faecaloral –> get ill –> die
NO CARRIERS

Question 12

How is Hep B spread?

Answer 12

Needles / blood

Question 13

Describe Hep B antigens

Answer 13

1 surface (Ag S) and 1 core (Ag E)

Question 14

Describe what happens during Hep B infection, in terms of Ag and AB

Answer 14

Infected with both S Ag and E Ag
Start making Anti-HBe ABs
If you go on to recover, you make Anti-HBs
If not, infection carries on sub clinically

Question 15

Describe what happens during Hep B vaccination, in terms of Ag and AB

Answer 15

Injected with S Ag, so you make Anti-HBs

Question 16

If someone has Anti-HBe in their blood, what does that mean?

Answer 16

They have actually been infected with Hep B at some point

Question 17

If someone has Anti-HBs ABs only in their blood, what does that mean?

Answer 17

They have been vaccinated against Hep B

Question 18

What Ag is used in Hep B vaccination?

Answer 18

S Ag

NOT E ANTIGEN

Question 19

List histological changes in alcoholic hepatitis

Answer 19

Liver cell damage, inflammation, fibrosis
Fatty change
Megamitochondria

Question 20

What is the other similar DDx you must think of when diagnosing alcoholic hepatitis by histology?

Answer 20

NASH (non alcoholic steato-hepatitis)

Question 21

What causes NASH?

Answer 21

T2DM or obesity

Question 22

What is the Tx for alcoholic hepatitis?

Answer 22

Stop alcohol
IV thiamine and B1 (pabrinex)
Nutrition

Question 23

What is a thiamine deficiency called?

Answer 23

Beri Beri

Question 24

List 4 initial signs of liver disease

Answer 24

Palmar erythema
Dupyetrens contracture
Spider naevi
Gynaecomastia

Question 25

If a pt has signs of liver disease but is clinically well, what do they have?

Answer 25

Chronic stable liver disease

Question 26

What do varicose veins on the abdomen indicate?

Answer 26

Portal hypertension

Question 27

List the triad of Sx for portal hypertension

Answer 27

Varicose veins on the abdomen, splenomegaly and ascites

Question 28

What causes portal hypertension?

Answer 28

Cirrhosis - hepatocytes die and regenerate into unstructured nodules, thus increasing BP

Question 29

What life threatening event can be predisposed by portal hypertension? Why?

Answer 29

Haematemesis - haemorrhage of oesophageal vein

Question 30

What is the treatment for haematemesis due to oesophageal bleed?

Answer 30

NG tube with balloon attached inserted down throat to compress bleeding vein

Question 31

Which key sign indicates liver failure?

Answer 31

Asterixis

Question 32

What molecule causes asterixis?

Answer 32

Ammonia

Question 33

Define cirrhosis

Answer 33

Scarring of the whole liver, not just locally, accompanied by a shunting of blood

Question 34

List causes of cirrhosis

Answer 34

Alcoholic fatty liver disease / NASH Viral hepatitis Haemochromotosis, Wilsons Cholangitis

Question 35

Where does blood shunt to in liver cirrhosis?

Answer 35

Spleen or abdominal veins

Question 36

Where are the porto-systemic anastomoses?

Answer 36

Oesophagus, rectum and umbilicus

Question 37

What mechanism causes scratch marks to appear on the skin in abdominal problems?

Answer 37

Bile duct obstruction causing bile salts to leak into blood | Bile salts are itchy!!

Question 38

If a patient presents with jaundice and scratch marks, what could it be?

Answer 38

Pancreatic cancer or gallstones

Question 39

How can the presence of scratch marks help you classify the type of jaundice present?

Answer 39

Scratch marks indicate bile salts in blood, therefore biliary blockage, which is post hepatic jaundice

Question 40

A pt presents with jaundice, enlarged gall bladder, scratch marks and no pain. What is it?

Answer 40

Pancreatic cancer - tumour of head of pancreas blocking bile duct

Question 41

A pt presents with jaundice, scratch marks and intense pain. What is it?

Answer 41

Gallstones

Question 42

A urine dip is negative for urobilinogen. Why is this significant?

Answer 42

Obstruction of bile duct, so post hepatic jaundice | BR --> urobilinogen in gut, which is usually peed out. If this is absent, there's a blockage

Question 43

What 2 other Sx are noticed in bile duct obstruction? Why?

Answer 43

Pale, floating poo - no stercobiligen | Pale urine - no urobilinogen

Question 44

What is Courvoisier's law?

Answer 44

If the gall bladder is palpable in a jaundiced patient, then the cause is pancreatic cancer

Question 45

Explain why Courvoisier's law is correct

Answer 45

Pancreatic cancer blocks bile duct, so previously healthy gall bladder fills with fluid and is palpable. A gallstone would have made the gallbladder thick and fibrosed, so it would not be able to fill with fluid and therefore would not be palpable.

Question 46

What does primary cancer in liver look like?

Answer 46

Single white nodule

Question 47

What does metastatic cancer look like in the liver?

Answer 47

Multiple white nodules