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830 > Liver Disease Patho > Flashcards

Liver Disease Patho Flashcards

1
Q

Functions of the Liver

A
  1. Digestive: processing/storing of fats, carbohydrates, proteins, vitamins, minerals
  2. Endocrine: metabolism of glucocorticoids, mineralcorticoids, sex hormones
  3. Hematological: temporary storage of blood, synthesis of bilirubin from hemoglobin degradation, synthesis of clotting factors
  4. Excretory: excretion of bile, cholesterol, synthesis of urea
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2
Q

Liver Disease

A
  • Caused by a variety of factors
  • Begins as an injury which is on-going and thus continues to cause damage
  • Disease progression is not linear and time to progression can be variable
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3
Q

Stages of Liver Injury

A
  1. Hepatitis
  2. Fibrosis
  3. Cirrhosis
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4
Q

Hepatitis

A
  • General term for inflammation of liver

- Can be due to alcohol, viral infections, autoimmune disease, fat, medications, illicit substances

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5
Q

Fibrosis

A
  • Ongoing inflammation causes progression to fibrosis
  • Liver attempts to heal itself during inflammation and gets scarring
  • Collagen in liver that encapsulates damaged tissue or is replaced by collagen
  • Fibrolytic changes effect blood flow through liver and liver functions
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6
Q

Cirrhosis

A
  • Advanced fibrosis with distortion of hepatic vasculature
  • Results in impaired hepatocyte function, increased intrahepatic resistance, impairment of all functions, and risk of development of HCC
  • Compensated or decompensated
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7
Q

Compensated Cirrhosis

A
  • Liver retains functionality despite damage
  • Typically see some changes in laboratories (decline in albumin/platelet levels), but otherwise no symptoms
  • Often not diagnosed
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8
Q

Decompensated Cirrhosis

A
  • Laboratory changes, patients experience clincal events as a result of loss of hepatic function
  • Key events: ascites, encephalopathy, jaundice
  • Late event: Hepatocellular carcinoma (HCC - liver cancer)
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9
Q

Signs/Symptoms of Liver Disease

A
  • Right upper quadrant pain
  • Hepatosplenomegaly
  • Jaundice
  • Caput medusae
  • Spider nevi
  • Edema
  • Ascites
  • Gynecomastia
  • Loss of body hair
  • Fatigue
  • Confusion
  • Malaise
  • Respiratory difficulties
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10
Q

Liver Function Evaluation

A
  • No single test for all the functions

- Must look at all functions and piece together to get the big picture

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11
Q

Synthetic Function

A
  • “Making things”
  • Albumin - important for osmotic pressure and for drug protein binding in PK
  • INR: liver makes all coagulation factors AND most of their inhibitors
  • Bilirubin: byproduct of hemoglobin degradation which is conjugated and excreted by liver
  • Enzymes: Markers of liver damage
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12
Q

Indirect (unconjugated) Bilirubin

A
  • Elevations usually due to hemolysis (med. related)

- Gilbert’s disease: lack of glucoronosyltransferase

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13
Q

Direct (conjugated) bilirubin)

A
  • Elevations due to blockage of bile duct (gall stones)
  • Elevations due to liver disease
  • *Liver can still conjugate even with substantial damage**
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14
Q

Liver Enzyme

A
  • AST: aspartate transaminase (other organs too)
  • ALT: alanine aminotransferase, liver specific (<19 for women, <30 for men)
  • ALP/Alk Phos: alkaline phosphatase - found in bone also
  • *Once liver cells are severely destroyed, enzymes will not be elevated**
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15
Q

Other Lab Clues

A
  • CBC: cirrhosis may be associated with blood count abnormalities
  • Hemoglobin/Hematocri: : complications of cirrhosis, blood loss
  • Thrombocytopenia: platelets <150,000, platelets get destroyed by portal hypertension causing them to back up in spleen and be damaged/destroyed from high pressure
  • Neutropenia: bone marrow suppression from cirrhosis
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16
Q

Physical Manifestations of Cirrhosis

A
  • Altered Hormone Metabolism: spider angiomata, gynecomastia, or loss of body hair
  • Bile Blockage/Increased Bilirubin: jaundice and pruritus
  • Palmar erythema: non-specific finding which could be due to changes from cirrhosis
17
Q

Liver Disease Complications

A
  1. Portal Hypertension
  2. Ascites
  3. Hepatic Encephalopathy
  4. Hepatorenal Syndrome
  5. Infections
18
Q

Portal Hypertension

A
  • Blood can’t get through liver, results in collateral/alternate pathway development
  • Causes varices and circulatory abnormalities
19
Q

Varices

A
  • Impediment of blood flow through liver results in development of collaterals or alternative pathways for blood flow
  • Vessels swell/engorge with blood leading to a bleed risk and increased pressure
  • High bleed/rebleed risk (>50% in patients having a bleed in last 10 days)
  • Slow bleeds are common with portal hypertension
20
Q

Circulatory Abnormalities

A
  • Portal pressure increases, systemic pressure decreases to compensate
  • Leads to splanic vasodilation, hypoperfusion of kidneys, and CO increases to compensate
  • Spleen changes => platelet sequestration
  • RAAS stimulated and water/salt retained from kidney changes
21
Q

Ascites

A
  • Accumulation of lymph in peritoneal cavity
  • Can be due to hypoalbuminemia and portal hypertension
  • Hypoalbuminemia: reduced osmotic pressure
  • Portal hypertension can force the fluid into the abdominal cavity from vessel dilation from RAAS activation, often seen as fluid in abdomen and edema in lower extremities
  • Infection can develop in this fluid: spontaneous bacterial peritonitis (SBP)
22
Q

Hepatic Encephalopathy

A
  • Neurological impairment ranging from confusion to coma
  • Ammonia levels can correlate with level of encephalopathy, but don’t use as a guideline to treat
  • Also associated with accuulation of nitrogenous substances from gut and accumulation of GABA by endogenous benzo-like substances
23
Q

Hepatorenal Syndrome

A
  • Kidneys compensate for liver dysfunction
  • Also try to compensate for changes in systemic pressure
  • Kidneys use RAAS and water/salt retention to try to normalize perfusion, but this also causes major stressors and renal impairment
  • SBP, infections, and major bleeds can also further renal failure
24
Q

Infections

A
  • Liver plays big role in innate/adaptive immunity
  • Compromised with altered blood flow
  • Portal hypertension also increased infection risk by causing bacterial translocation or compromised spleen immune function from splenomegaly
25
Q

Testing for Liver Disease

A
  • APRI or FIB-4 to assess likelihood of fibrosis and cirrhosis
  • Ultrasound, CT, and MRI can also identify cirrhosis
  • Transient elastography measures liver stiffness (cirrhosis)
  • Biopsy: gold standard but minimally used since invasive
26
Q

MELD Score

A
  • Risk of 3-month mortality

- Used to evaluate for liver transplant

27
Q

Child Pugh Score

A
  • Used to stage degree of liver dysfunction in cirrhosis patients
  • Most commonly used to identify drug dosing adjustments needs for liver dysfunction
  • A: mild dysfunction (5-6 points), B: moderate dysfunction (7-9 points), and C: severe dysfunction (>9 points)
28
Q

Encephalopathy Scores

A
  • None: 1 point
  • Moderate: 2 points
  • Severe: 3 points
29
Q

Ascites Scores

A
  • Absent: 1
  • Mild-moderate: 2
  • Severe-refractory: 3
30
Q

Bilirubin Scores

A
  • <2 : 1 points
  • 2-3: 2 points
  • > 3: 3 points
31
Q

Albumin Scores

A
  • > 3.5: 1 point
  • 2.8-3.5: 2 points
  • <2.8: 3 points
32
Q

INR Scores

A
  • <1.7: 1 point
  • 1.7-2.3: 2 points
  • > 2.3: 3 points

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