Liver disease : case studies

Question 1

What are liver function tests?

Answer 1

Blood tests that measure the levels of enzymes and other proteins from the liver.

Question 2

What enzymes are examined in a blood test in order to see if the liver hepatocytes are functioning correctly?

Answer 2

AST and ALT (both transaminases - aspartate and alanine)

Question 3

What enzymes are examined in a blood test in order to see if the bile is flowing correctly?

Answer 3

GGT and ALP (gamma-glutamyl transferase and alkaline phosphatase)

Question 4

What would be a likely cause of elevated AST and ALT?

Answer 4

Inflammation of the hepatocytes (hepatitis) or a trauma/injury to the hepatocytes

Question 5

What would be a likely cause of elevated GGT and ALP?

Answer 5

Blocking/obstruction of the bile ducts (cholestasis) caused by a tumour, gall stones (obstruction) or a fatty liver (slowing down of flow)

Question 6

What are the two main patterns of abnormal liver tests?

Answer 6

Hepatocellular and cholestatic

Question 7

How is hep C spread and what is the most common risk factor?

Answer 7

Spread via blood and greatest risk factor is injecting drug use.

Question 8

Is there a vaccine for hepC?

Answer 8

no only hep A and B

Question 9

What is the name of the drug that used to be very common for treating hepC that caused flu like symptoms? How was it administered?

Answer 9

Interferon via a subcutaneous injection.

Interferon is a cytokine that is naturally produced in the body which helps the immune system to fight off viral infection. Eg when you have the flu your body automatically produces more.

Question 10

What is melaena and what causes it?

Answer 10

Melaena is the production of dark sticky faeces containing blood. This is as a result of bleeding in the GI tract often as a result of a bleeding varices vein.

The black colour is produced as a result of haemoglobin being altered by digestive bacteria and chemicals in the gut.

Question 11

What is the treatment of a burst varices vein the oesophagus?

Answer 11

Using an endoscopy they try to stick a rubber band around the vein or inject it with adrenaline (often dosent work).

Question 12

What is the new treatment only proposed in the last few years and what problems of interferon does it overcome?

Answer 12

Group of drugs called direct acting antiviral agents.

• little symptoms
• taken as tablets over short duration (not injections for up to a year)
• cure rates > 90%

Question 13

What is portal hypertension?

Answer 13

High pressure in the portal vein (difficult for blood to pass through the liver and then into the heart)

Question 14

How does the body react or compensate for portal hypertension?

Answer 14

It forms collaterals (alternate vessels to the portal vein that enlarge in order to try bypass as much blood as possible from the portal vein - an alternate root to the heart)

These are called varices and are commonly found in the oesophagus and stomach. (most commonly the gastro-oesophageal junction)

Question 15

If varcices burst does blood leak or splurt out?

Answer 15

Splurt out - they are under very high pressure!

Question 16

What are the various causes of portal hypertension? (pre hepatic, intra-hepatic and post hepatic)

Answer 16

Pre hepatic = portal vein thrombosis (clot)
Intra-hepatic = cirrhosis, hepatitis, tumour etc
Post hepatic = hepatic vein thrombosis and right sided heart failure

Question 17

Whats the similarity and differences between fibrosis of the liver and cirrhosis?

Answer 17

Both are caused by excessive alcohol exposure.

Fibrosis is caused by repeated or prolonged inflammation but is potentially reversible if the liver not exposed to alcohol or toxin and given time to regenerate.

Cirrhosis occurs when the scarring is no longer reversible.

Question 18

What is hepatic encephalopathy?

Answer 18

A complication or a result of cirrhosis where there is loss of brain function due to build up of toxins in the blood eg ammonia.

It is an indication of advanced cirrhosis

Question 19

Do people with hepC commonly get rid of the virus?

Answer 19

No they are often unable to fight it and about 85% of people will move on to develop chronic infection which can lead to things like cirrhosis.

Question 20

What are some of the signs of hepatic encephalopathy?

Answer 20

Signs of nervous system changes may include:

Shaking of the hands (“flapping”) when trying to hold arms in front of the body and lift the hands

Problems with thinking and doing mental tasks

Signs of liver disease, such as yellow skin and eyes (jaundice) and fluid collection in the abdomen (ascites)

Musty odor to the breath and urine

Question 21

What toxin is most responsible for HE?

Answer 21

Ammonia

Question 22

What is the available treatment of HE?

Answer 22

Lactulose
The mechanism of treatment is not entirely known but it is thought to decrease the ammonia generation by bacteria, converts it to a non absorbable molecule and increases the bowell transit time.

Question 23

What is ascites and what are the two main causes?

Answer 23

Build up of fluid in the peritoneum which causes abdo distension. The two main causes are:

Portal hypertension - fluid pushed out of circulation into peritoneum

low oncotic pressure in portal vein - low protein levels due to low serum albumin means that the vein is less able to hold onto fluid

Question 24

What is the most common cause of portal hypertension and what else can portal hypertension present as?

Answer 24

Cirrhosis

varices, ascites, hepatic encephalopathy, splenomegaly

Question 25

What is Budd-chiari syndrome?

Answer 25

A relatively uncommon condition where the hepatic veins (from which blood flows out of the liver) is blocked by a clot. (acute thrombosis of the hepatic vein).

This is presented with symptoms that occur rapidly and the cause of the clot is most of the time unknown!

Usually presents as acute congestion of the liver causing hepatocellular damage and sever rapid upper abdo pain.

Portal hypertension occurs with rapid ascites.

Mild jaundice.