Liver Disease Symposium: Introduction to Liver disease Flashcards
1
Q
4 roles of the liver
A
- Glucose + Fat metabolism
- Detoxification + excretion
- Protein synthesis
- Defence against infection
2
Q
What excretion takes place in the liver
A
- Bilirubin
- Ammonia
- Drugs/hormones/pollutants
3
Q
Through what vessel does blood enter the liver
A
Portal vein + hepatic artery
4
Q
What epithelium lines the hepatic artery, portal vein and bile duct
A
CUBOIDAL EPITHELIUM
5
Q
Result of chronic liver damage
A
Fibrosis
6
Q
What is severe fibrosis of the liver called
A
Cirrhosis
7
Q
Presentation of liver injury
A
- Malaise
- Nausea
- Anorexia
- Jaundice
RARER:
- Confusion
- Bleeding
- Liver pain
- Hypoglycaemia
8
Q
What would liver pain indicate
A
Obstruction
9
Q
Presentation of chronic liver injury
A
- Ascites
- Oedema
- Haematemesis
- Malaise
- Anorexia
- Wasting
- Itching
- Hepatomegaly
- Abnormal LFTs
10
Q
How do we test for liver function
A
- Serum bilirubin
- Albumin
- PTT
11
Q
What cholestatic enzymes are looked at in blood tests
A
- Alkaline phosphatase
2. Gamma-GT
12
Q
What hepatocellular enzymes are looked at in blood tests
A
Transaminases
13
Q
Does looking at serum enzyme give an indication of liver function
A
No
14
Q
What causes pre-hepatic jaundice
A
Haemolysis
Gilberts
15
Q
What causes cholestatic jaundice (conjugated)
A
Liver disease
Bile duct obstruction
16
Q
Why is PTT a good indicator of acute and chronic liver disease
A
Sue to its short half-life
17
Q
What can cause a prolonged prothrombin time
A
Vit K deficiency in biliary obstruction - low conc. of bile salts causes poor absorption of vit K
18
Q
In what disease is alkaline phosphatase levels raised
A
Intrahepatic and extra hepatic cholestatic disease - increased synthesis
Cirrhosis
Hepatic infiltration
19
Q
How do bile pigments form
A
From harm when old/damaged erythrocytes are broken down in the spleen and liver
20
Q
What is the most predominant bile pigment
A
Bilirubin
21
Q
Where is bilirubin extracted
A
Hepatocytes
22
Q
What colour is bilirubin
A
Yellow
23
Q
What is haemoglobin broken down into
A
Haem + global
24
Q
What is global broken down into
A
Amino acids - used to make new erythrocytes
25
What happens to harm
Broken down in bilirubin and Fe2+
26
What happens to biliverdin
Reduced to unconjugated bilirubin
27
Property of bilirubin
Lipid-soluble and insoluble in blood so must be bound to ALBUM
28
Where does bilirubin go
Glucuronidation in the liver
29
Describe the production of conjugated bilirubin
Action of UDP glucuronyl transferase
30
Why does Gilbert's result in pre-hepatic jaundice
Lack of UDP glururonyl transferase
31
Where does the conjugated bilirubin go
Travels to ileum where it is reduced by bacteria into urobilinogen
32
What happens to urobilinogen
Some is absorbed into the blood + bound to albumin
Some is oxidised to form stercobilin
33
What give urine its yellow colour
Urobilinogen
34
What can cause post-hepatic jaundice
1. Gall-stones
| 2. Mirizzi syndrome
35
What is mirizzi syndrome
Stone in gallbladder/cystic duct presses on common bile duct)
36
What questions should i ask as a doctor if suspected jaundice
1. Dark urine, pale stool + itching
2. Biliary pain (radiates to shoulder)
3. Rigors
4. Abdomen swelling
5. Weight loss
past history
Drug history
Social history
37
Test for jaundice
1. High AST/ALT suggests liver disease
Dilated intrahepatic bile ducts on ULTRASOUND - shows bile obstruction
38
What is biliary colic
Term used for pain associated with temporary obstruction of the cystic or common bile duct by a stone migrating from the gall bladder
39
How to detect stone-induced ductular obstruction
Sudden onset, severe but constant and has crescendo characteristic
40
What is cholecystitis
Gallbladder inflammation
41
What doe bile consist of
Cholesterol
Bile Pigments
Phospholipids
42
What gender do gallstones commonly effect
Females
43
What ethnicity do gallstones generally effect
Scandinavians
SA
NA
44
Symptoms of gall stones
Usually asymptomatic
45
Main causes of gallstones
1. Obesity + rapid weight loss
2. Diet high in animal fat + low in fibre
3. Diabetes mellitus
4. Contraceptive pill
5. Liver cirrhosis
46
Risk factors of gallstones
1. Female
2. Fat
3. Fertile = increased risk of gallstones
4. Smoking
47
What is the most common type of gallstone
Cholesterol gallstones
48
Main causes of cholesterol gallstones
Female
Age
Obesity
49
How do cholesterol gallstones form
1. Cholesterol crystallisation in bile
2. Cholesterol held in solution by bile salts and phospholipids which form micelles and vesicles
3. Cholesterol gallstones form in EXCESS cholesterol
50
How does an excess cholesterol arise
TOO little bile salts + phospholipids
| Excess of cholesterol
51
Why will many people with supersaturated bile never develop stones
Balance between cholesterol crystallising and solubilising factors that determines whether cholesterol with crystallise out of solution
52
What other factors contribute to gallstone formation
1. Reduced gallbladder motility and stasis
| 2. Crystalline promoting factors in bile
53
Main cause of bile pigment stones
Haemolysis
54
How do BLACK pigment gallstones from
Calcium bilirubinate and network of mucin glycoproteins that interlace with salts
55
In what diseases are black pigment gallstones seen in
Haemolytic anaemia
Spherocytosis
Sickle cell
Thalassaemia
56
What are brown pigment stones made of
composed of calcium salts
57
When do brown pigment stones form
Presence of bile stasis and/or biliary infection
58
What is the most common cause of brown pigment stones
Recurrent bile duct stones following cholecystectomy
59
What is the problem if gallstones become symptomatic
Start to become recurrent
60
Do gallstones cause dyspepsia, fat intolerance, flatulance
No
61
Define gallstone colic
Pain associated with temporary obstruction of the cystic or common bile duct by a stone migrating out of the gallbladder
62
When do symptoms for gallstone colics com in
Mid-evening + last till early hours of morning
63
Initially where are gallstone colics felt
Pain in epigastrium and radiates to upper right quadrant component (right shoulder + right sub scapular region)
64
Symptoms of gallstone colics
Nausea and committing
65
What is the consequence of acute cholecystitis
Obstruction of gallbladder tempting
66
What is acute cholecystitis caused by
Gallstones
67
Pathophysiology of acute cholecystitis
1. Obstruction = increased gall bladder glandular secretion leading to progressive distension that may compromise vascular supply to gall bladder
68
How do we distinguish from cute cholecystitis from biliary colic
Inflammatory response in acute cholecystitis
69
Where is pain felt in acute cholecystitis
Epigastrium
70
What happens to the pain in acute cholecystitis over time
Localises in right upper abdominal quadrant corresponding to parietal peritoneal involvement (inflammation begins to irritate parietal peritoneum)
71
NON-SPECFIC symptoms of acute cholecystitis
VOMITING
FEVER
LOCAL PERITONITIS
72
What may happen if a stone from acute cholecystitis moves into the common bile duct
Cholangitis and JAUNDICE
73
Differential diagnosis of Biliary colics
1. IBS
2. Carcinoma on right side of colon
3. Pancreatitis
74
Differential diagnosis of acute cholecystitis
Acute episodes of pancreatitis
Peptic ulceration
Basal pneumonia
Intrahepatic abscess
75
How is biliary colic diagnosed
Abdominal ultrasound
76
Blood tests when diagnosing acute cholecystitis
1. RAISED WBC (due to inflammation) and C-reactive protein
| 2. Raised serum bilirubin, alkaline phosphatase and aminotransferase levels
77
Abdominal ultrasound in acute cholecystitis
1. Thick-walled, shrunken gallbladder
2. Pericholecystic fluid
3. Stones
78
Clinical examination of acute cholecystitis
Right upper quadrant tenderness
Murphy's signs
79
What is murphy's sign
Pain on taking a deep breath when examiner places two fingers on right upper quadrant
80
How is acute cholecystitis and biliary colics treated surgically
Laparoscopic cholecystectomy (gallbladder removal)
81
When is surgical intervention for acute cholecystitis and biliary colics needed
symptomatic
82
How is acute cholecystitis non-surgically treated
1. Nil by mouth
2. IV fluid
3. OPIATE ANALGESIA
4. IV antibiotic - CEFUROXIME or CEFTRIAXONE
83
What bacteria are associated with cholecystitis
1. Klebsiella
2. Enterococcus
3. E.coli
84
How are gallstones dissolved
1. Increasing bile salt content
ORAL URSODEOCYCHOLIC ACID
SIMVASTATIN (lowers hcolesterol
85
Why is shock-wave lithotripsy done in acute cholecystitis
1. Shock wave directed on gallbladder stones to turn them into fragments
86
When can shock wave lithotripsy be done
When cystic duct is patent - allows fragments to pass
