Liver disease CPC Flashcards
How do you measure the difference between conjugated and unconjugated bilirubin
A direct reaction measures conjugated bilirubin. The addition of methanol causes a complete reaction, which measures total bilirubin (conjugated plus unconjugated); the difference measures unconjugated bilirubin (an indirect reaction).
DIRECT reaction measured conjugated
INDIRECT measures unconjugated
What is paediatric jaundice usually due to
It usually is normal, but the bilirubin should be unconjugated as the cause is usually liver immaturity coupled with a fall in the haemoglobin early in life.
If it doesn’t settle, other rare causes should be looked for including hypothyroidism, other causes of haemolysis (including a Coombes test or DAT), and the unconjugated bilirubin will be useful.
How is gilberts inherited
Recessive- 50% carry the gene so 6% of the population
What is the effect of fasting. What would be the effect of giving phenobarbitone
Worsened by fasting (so bili will increase)
Phenobarbitone induces the liver so bili should fall in this case
What happens in gilberts
UDP glucuronyl transferase activity reduced to 30%
Unconjugated bilirubin tightly albumin bound and does NOT enter urine.
What tests assess liver function
What will you measure in paracetemol overdose, what will you use to assess for liver transplant need.
What if the liver enzymes are really high with paracetemol overdose
Albumin (not a quick marker)
Clotting factors (PT, PTTK)
Bilirubin
Other tests are “enzymes”, not truly tests of liver function.
In paracetemol overdose, if the PT climbs by more than 1 second per hour then they may need to be transferred for a liver transplant.
If the enzymes are really high, it doesn’t tell you how well or badly they are doing. If the enzymes are high and the PT is not rising, thehn they are safe.
What is the treatment for paracetemol overdose
N-acety cysteine
What clotting test do you use to assess warfarin and heparin
Warfarin- PT
Heparin- PTT
What are the types of hepatitis and how would you check
Viral: check viral titres.
Autoimmune - do antibodies
Alcoholic ?
How do you get Hep A
Through water… can only get it once
You’re well for two weeks, jaundice after 4 weeks, IgM after 3 weeks and IgG after 5 weeks
One off infection… no such thing as a carrier, it either kills you or you make antibodies and it’s gone
How does Hep B work
You get it through IVDU/sex
3 months peak HBs Ag and HBe Ag.
You can tell if somebody has had hepatitis B because they will have anti-HBs and Anti-HBe.
In an immunisation they only give Anti-HBs
What if you’re a hep B carrier
You mae antibodies to HBe but not to HBs.
So they have high HBs for 10 years
They are infectious but subclinical
Causes of fatty liver disease other than alcohol
Drugs, diabetes and insulin resistance
Complication of alcoholic hepatitis on histology
Bile can actually be seen in the cannaliculi because for whatever reason the bile gets stuck in the ducts
Defining histological features of alcoholic hepatitus
vs
associated histological features of alcoholic hepatitis
-defining histological features:
liver cell damage
inflammation
fibrosis
-associated histological features:
fatty change
megamitochondria
What is non alcoolic steato hepatitis
NASH
-fatty hepatits can be caused by insulin reistance obesity
What treatment is needed for alcoholic hepatitis
Supportive.
Stop alcohol.
Nutrition:
Vitamins (esp B1, thiamine)
Occasionally steroids.
What is caused by B1 deficiency
Beri-beri (–> wernickes)
What do these things signify:
Multiple spider naevi
Dupuytren’s contracture
Palmar erythema
Gynaecomastia
out of: Jaundice Hepatitis Chronic stable liver disease Portal hypertension. Liver failure Obstruction of the bile ducts.
Chronic stable liver disease
Which of these are you most likely to find on examination given a visible vein on anterior abdominal wall
Hepatomegaly Splenomegaly Bilateral palpable kidneys A palpable bladder An enlarged prostate gland on PR.
Splenomegaly
these three things:
Visible veins
Splenomegaly
Ascites (shifting dullness.)
Mean you have what:
Jaundice Hepatitis Chronic stable liver disease Portal hypertension. Liver failure Obstruction of the bile ducts
Portal HTN
Portal HTN is cuased by what
Portal HTN
What clinical signs are associated with portal HTN
Visible veins, splenomegaly, ascites
What would you do in the case of acute eosophageal rupture
A Sengstaken–Blakemore tube goes down into the stomach and you blow up a balloon. Then you pull it up into the stomach. This presses on the vein.
You give lots of blood as well
Admitted to drain ascites, but developed a flap shortly afterwards.
What do they have:
Jaundice Hepatitis Chronic stable liver disease Portal hypertension. Liver failure Obstruction of the bile ducts
Liver failure
What is liver failure
Failed synthetic function Failed clotting factor and albumin Failed clearance of bilirubin Failed clearance of ammonia (encephalopathy)
Hallmarks of cirrhosis
Pallor due to fat
Micronodules
Affects the whole liver, not localised
What is the nodule composed of
Centrally regenerating hepatocytes, and they are surrounded by fibrous tissur collagen
Differentiate cirrhosis caused by alcohol v viruses
Alcohol-micronodular
Viral-macronodular
What is intrahepatic shunting
Now a scar will connect hte portal triad to the central vein.
So the blood doesn’t come into contact with the hepatocytes, it doesn’t get filtered
So this when you get hepatic encephalopathy
What can you do to solve portal hypertension
TIPPS
This allows you to divert blood from the portal vein to the hepatic vein.
But they get very confused and jaundice!
4 sites of Porto systemic anastomoses
….
Q21: What do scratch marks suggest?
Jaundice Hepatitis Chronic stable liver disease Portal hypertension. Liver failure Obstruction of the bile ducts
Obstruction of the bile ducts.
It means that the jaundice is due to obstruction
What is itching caused by
Colourless BILE SALTS/ACIDS (NOT bilirubin)…. they are blocked from getting into the gut so they get into the bloodstream and are irritants.
They make you itch!!!!!
What is courvoisier’s law
‘gall bladder is palpable in a jaundiced patient…
The cause is gallstones
The cause is pancreatic Ca.
The cause is pancreatic cancer!
In the presence of jaundice, if the gall bladder is palpable, the cause is unlikely to be gall stones.
This is because a gall bladder with stones is usually small and fibrotic and incapable of being large.
What investations would you do for painless but itchy jaundice
Ultrasound abdomen
Dilated bile ducts
Probable metastatic disease
What is obstructive jaundice usually caused by
Obstructive jaundice commonly caused by pancreatic cancer or gallstones
Just to be clear, when do you know there’s cirrhosis, when do you know there’s failure
So you go from alcoholic hepatitis (jaundiced)
Chronic stable liver disease (spider naevi, gynaecomastia, palmar erythema, dupytrens contracture)
Then to cirrhosis (which is characterised by portal HTN, so distended abdo vein, splenomegaly and ascites)
Then liver failure is after all that, when you get hepatic flap and encephalopathy (liver fails to clear ammonia)
Scratch marks indicates which kind of jaundice and why
It indicates OBSTRUCTIVE ONLY.
Because it’s caused by the bile salts.
If it is a hepatic picture, then bile salts will drain fine through the CBD (or might not even be produced at all).
The only cause that you get itching is if the bile salts are blocked from going into the GI tract
What happens to urobilinogen in the urine if there is obstructive picture
It goes down.
Urobilinogen is only produced from the enterocytes, and is then reabsorbed in the gut.
But if no bilirubin can get into the GI tract due to obstruction, there is no urobilinogen produced.
Therefore, there is no uribilinogen in the urine.
Normally you would get at least some urobilinogen in the urine in normal people.
Instead, with obstructive disease, you just get bili in the urine, which makes the urine dark
