Liver disease CPC

Question 1

What is this

and explain the rest of the architecture in terms of bile, blood, epithelium and sinusoids

Answer 1

Liver

• central vein on the LHS
• Portal triad on RHS (portal vein at top, then below hepatic artery, then bile duct)

bile going from central vein -> portal triad

blood going from portal triad -> sinusoid -> central vein

Sinusoids have a discontinuous epithelium meaning that blood can pass into the space of Disse to interact with hepatocytes

Question 2

Tell me the difference between the cells in these zones

Answer 2

3 - most metabollically active
also most likely to be affected by reduced blood supply as they recieve oxygen last

Question 3

What is direct bilirubin?

Answer 3

conjugated bilirubin

Question 4

indirect bilirubin?

Answer 4

unconjugated

Question 5

Complete bilirubin?

Answer 5

Total conjugated + unconj

Question 6

What test do you do if bilirubin does not settle in a newborn?

Answer 6

DAT test or coombs and unconjugated bilirubin

to test for haemolysis

Question 7

raised bilirubin with all other normal blood tests? (incl blood film and ALP)

Answer 7

Gilbert’s

Question 8

inheritence of gilberts?

Answer 8

autosomal recessive

Question 9

how many people carry the gilberts gene and how many of the population have it

Answer 9

50%, thus 6% of population has it

Question 10

is gilberts common

Answer 10

yes really common - 1 in 20

Question 11

how to diagnose gilberts

Answer 11

worsened by fasting

Question 12

pathophysiology of gilberts

Answer 12

UDP glucuronyl transferase activity reduced to 30%

this enzyme usually conjugates bilirubin

so increased unconjugated bilirubin but do not have bilirubinaemia (as this is tightly bound to albumin)

Question 13

is urobilinogen in urine normal

Answer 13

yes

Question 14

What test is most representative of liver function?

Answer 14

Prothrombin time (INR)

Question 15

Sky high ALT - cause of liver failure?

Answer 15

paracaetamol

Question 16

What indicates need for a liver transplant in paracetamol overdose?

Answer 16

If the PT is higher in seconds since the hours they took the overdose

if not they will be fine

Question 17

Answer 17

Hepatic

AST and ALT are very high - which means it is hepatic

ALP is up but not really high (<120 is normal). Would be really really high in obstructive (more than the AST and ALT)

ViraL&raquo_space;> ALT would be higher (L - L)
AST:ALT ratio of 2:1&raquo_space;> Alcoholic hepatitis or cirrhosis

Do serology for the viruses +/- biopsy

Question 18

Prognosis of hepatitis A?

Answer 18

good - you get it and cured or dead

i.e. if you survive (which most do in the UK) you get IgG forever and are cured

Question 19

buzzwords for alcoholic hepatitis

Answer 19

ballooning and mallory denks

scarring and fibrosis in cirrhosis - by collagen

Question 20

What is caused by vitamin B1 deficiency? And what is vitamin B1?

Answer 20

B1 - thiamine

Beri-beri!

Question 21

why do you get gynaecomastia w liver failure?

Answer 21

liver cannot break down oestrodiol

Question 22

Answer 22

Chronic stable liver disease not liver failure

Question 23

three signs of portal hypertension?

Answer 23

Caput medusae

and SPLENOMEGALY
(NOT hepatomegaly)

and ASCITES (shifting dullness)

not telangiectasia

Question 24

What does a flapping tremor show, why?

Answer 24

Liver failure because liver cannot remove toxins thus toxins (?ammonia) are poisoning the brain

Question 25

micronodular cirrhosis - cause?

Answer 25

alcoholic cirrhosis

Question 26

what causes itching in jaundice

Answer 26

bile salts/acids

obstructive jaundice

Question 27

what is courvoisier’s law?

Answer 27

in the prescence of jaundice, if the gall bladder is palpable, the cause is unlikely to be gall stones

this is because the gall bladder with stones is usually small and fibrotic

therefore could be pancreatic cancer…

pancreatic ca is painless
gallstones are painful