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Week 10 -GI > Liver disease wip > Flashcards

Liver disease wip Flashcards

1
Q

What is the vasculature entering and leaving the liver?

A

Incoming: Portal vein and hepatic artery
Outgoing: Hepatic vein

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2
Q

What is cirrhosis?

A
  • End stage liver disease

* Diffuse process with fibrosis and nodule formation

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3
Q

What are the common presenting symptoms of liver disease?

A
  • Jaundice: dark urine, light stool, itch
  • Ankle swelling
  • Abdominal swelling
  • Right upper quadrant pain
  • Nausea/vomiting
  • Fever
  • GI symptoms
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4
Q

What is a classical past medical history of someone with liver disease?

A
  • Previous jaundice, previous cholecystectomy
  • Type 2 diabetes mellitus
  • Obesity
  • thyroid disease and other autoimmune diseases
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5
Q

What is a classical social history of someone with liver disease?

A
  • Drug use

* Alcohol use

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6
Q

What are the standard liver function tests?

A
  • Bilirubin
  • Aspartate aminotransferase (AST)
  • Alanine aminotransferase (ALT)
  • Gamma glutamylytransferase (GGT)
  • Alkaline phosphatase (ALP)
  • Albumin
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7
Q

What is elevated to indicate hepatic causes in LFTs?

A
  • AST
  • ALT
  • GGT
  • +/- bilirubin
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8
Q

What is elevated to indicate cholestatic causes of abnormal LFTs?

A
  • ALP
  • GGT
  • +/- bilirubin
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9
Q

What is a non liver related cause of raised ALP

A

Bone

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10
Q

What is a non liver related cause of elevated AST?

A

Muscle

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11
Q

What is a non liver related causes of isolated raised bilirubin

A

Haemolysis

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12
Q

What is liver function best indicated by?

A
  • Albumin
  • Bilirubin
  • Prothrombin time
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13
Q

What are the broad patterns of diffuse liver disease?

A
  • Acute hepatitis
  • Acute cholestasis or cholestatic hepatitis
  • Fatty liver disease
  • Chronic hepatitis
  • Chronic bililary/cholestatic disease
  • Genetic/deposition disease
  • Hepatic vascular disease
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14
Q

What investigations should be carried out in acute liver disease?

A
  • ultrasound - look for blockage
  • Immunoglobulins look for raised IgG indicating autoimmune liver disease (autoimmune hepatitis)
  • Check paracetamol levels/ look for other drug induced liver injury
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15
Q

What are the causes of acute cholestasis?

A
  • Extrahepatic biliary obstruction

* Drug injury e.g. antibiotics

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16
Q

Describe histology in acute cholestasis

A

Bile stasis = brown bile pigment

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17
Q

Name two liver disease patterns that are very similar to a drug induced liver disease

A
  • Acute hepatitis

* Acute cholestasis/cholestatic hepatitis

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18
Q

What is a specific feature of hepatitis B infection in histology?

A

Ground glass cytoplasm in hepatocytes due to an accumulation of surface antigen

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19
Q

What are the causes of chronic liver disease?

A 
•Chronic viral hepatitis 
   - HBV 
   - HCV
•Autoimmune liver disease
   - autoimmune hepatitis 
   - primary biliary cholangitis 
   - primary sclerosis cholangitis 
•Metabolic liver disease 
   - haemochromatosis 
   - Wilsons disease 
   - alpha 1 antitrypsin deficiency
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20
Q

What are the symptoms of autoimmune hepatitis?

A
  • 12-35% of cases asymptomatic
  • Fatigue/ general ill health
  • Lethargy
  • Weight loss
  • Mild right upper quadrant pain
  • Acute jaundice arthralgia (joint stiffness)
  • Unexplained fever
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21
Q

What are the investigative signs of autoimmune hepatitis?

A
  • Elevated AST and ALT
  • Elevated anti-smooth muscle antibody (SMA)
  • Anti-liver kidney microsomal antibodies (LKM)
  • Increased IgG
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22
Q

What is the treatment of autoimmune hepatitis?

A
  • Corticosteroids (prednisolone; budesonide)

* Azathioprine/mycophenolate

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23
Q

What are the causes of chronic biliary disease?

A
  • Primary biliary cholangitis

* Primary sclerosing cholangitis

24
Q

Describe the histology of chronic biliary disease

A
  • Focal
  • Portal predominant inflammation and fibrosis with bile duct injury
  • Granulomas
25
Q

What is the most common chronic cholestatic liver disease?

A

Primary biliary cholangitis

26
Q

What are the common associations of primary biliary cholangitis?

A
  • Sjögren’s syndrome
  • Systemic sclerosis
  • Rheumatoid arthritis
  • Lupus
  • Hypothyroidism
  • Coeliac disease
27
Q

What biochemistry results are seen in early primary biliary cholangitis?

A

•Elevated gamma glutamyl transferase and alkaline phosphatase

28
Q

What is seen in advanced primary biliary cholangitis?

A

•Elevation in bilirubin

29
Q

What are the common symptoms of primary biliary cholangitis?

A
  • Tiredness
  • Itching
  • In more advanced cases jaundice
30
Q

What is the treatment of primary biliary cholangitis?

A

Ursodeoxycholic acid

31
Q

What stain is used to test for haemochromatosis?

A

Perl’s stain

32
Q

What are the genetic/deposition liver diseases?

A
  • Haemochromatosis - iron
  • Wilson’s disease - copper
  • Alpha-1-antitrypsin deficiency
33
Q

What is the cause of Wilson disease?

A
  • ATP7B mutation

* failure to transport excess copper into the bile leading to copper accumulation

34
Q

What is the inheritance of Wilson disease?

A

•Autosomal recessive

35
Q

What is the presentation of Wilson disease?

A
  • May present with chronic liver disease
  • About half have neurological or psychiatric symptoms
  • Parkinsonism with or without typical hand tremor
  • Masked facial expressions
  • Slurred speech
  • Ataxia
  • Kayser-fleischer rings
36
Q

What is the treatment of Wilson disease?

A
  • Copper chelation: penicillamine or Tridentine

* Oral zinc

37
Q

Describe what haemochromatosis is and how it causes its effects

A 
•Iron accumulation in tissues and organs:
 - liver
 - adrenal glands 
 - heart 
 - skin (bronze appearance) 
 - gonads 
 - joints 
 - pancreas 
•Results in raised ferritin and transferrin saturation
38
Q

What is the inheritance of haemochromatosis?

A
  • Mutation of HFE gene

* Autosomal recessive

39
Q

What is the treatment of haemochromatosis?

A

Venesection

39
Q

What is the treatment of haemochromatosis?

A

Venesection

40
Q

What are the differences between ArLD and non-alcoholic fatty liver disease?

A
  • Greater alcohol intake in ArLD
  • AST/ALT ratio is NAFLD <0.8 but >1.5 in ArLD
  • AST elevated in arid and GGT is more markedly elevated as is MCV
41
Q

Explain the spectrum of ArLD

A
  • Normal liver
  • Exposure of normal liver can lead to steatosis (fatty change, perivenular fibrosis)
  • Severe exposure of normal or steatotic liver can lead to hepatitis
  • Repeated attacks of hepatitis or chronic exposure to a liver experiencing steatosis can lead to cirrhosis (fibrosis and hyper plastic nodules)
42
Q

What are the essential features for an alcoholic hepatitis?

A
  • Excess alcohol within 2 months
  • Bilirubin >80 µmol/l for less than 2 months
  • Exclusion of other liver disease
  • Treatment of sepsis or GI bleeding
  • AST <500 (AST:ALT>1.5)
43
Q

What are the characteristic features of alcoholic hepatitis?

A
  • Hepatomegaly
  • Fever
  • Leucocytosis
  • Hepatic bruit
44
Q

What are the associations with NAFLD?

A
  • Obesity
  • Type 2 diabetes
  • Hyperlipidaemia
45
Q

What are the causes of acute hepatitis?

A
  • Hepatitis viruses A, B, C, D, E
  • Drug injury
  • Autoimmune liver disease
46
Q

What are the causes of acute cholestasis or cholestatic hepatitis?

A
  • hepatitis viruses A, B, C, D, E
  • Drug injury
  • Extrahepatic biliary obstruction
47
Q

What are the causes of fatty liver disease (steatosis and steatohepatitis)

A
  • Drug injury
  • Alcohol
  • Metabolic syndrome e.g. obesity
48
Q

What are the causes of chronic hepatitis?

A
  • hepatitis virus esp B and C
  • Autoimmune liver disease
  • Genetic/deposition liver disease
49
Q

What are the causes of hepatic vascular disease?

A
  • Vascular disease

* Drug injury

50
Q

What are the non invasive tests of liver fibrosis?

A
  • Fibroscan to test transient elastogrpahy

* Commerically available blood tests: enhanced liver fibrosis test and fibro test

51
Q

What is the clinical presentation of cirrhosis?

A 
•Can be incidental: abnormal LFTs
•Decompensation: advanced liver disease: 
 - variceal haemorrhage 
 - hepatic encephalopathy 
 - ascites ± oedema 
 - hepato-renal failure 
 - hepatocellular carcinoma
52
Q

What are the signs of chronic liver disease and/or portal hypertension?

A
  • Spider naevi
  • Palmar erythema
  • Finger clubbing
  • Gynaecomastia
  • Testicular atrophy
  • Dupuytrens contracture
  • caput medusa
  • foetor hepaticas
  • flapping tremor
53
Q

What are the laboratory features of chronic liver disease?

A
  • Thrombocytopenia
  • Prolonged prothrombin time
  • Hypoalbuminaemia
54
Q

What is the assessment of ascites?

A

Diagnostic tap
•>500 WBC/cm3 and/or >250 neutrophils suggest bacterial peritonitis
•Lymphocytosis suggests TB or peritoneal carcinoma
•Serum ascites albumin gradient >11g/l = portal hypertension

55
Q

What is the treatment of Ascites?

A

•Low salt diet
•Diuretics:
- spironolactone (side effects e.g. gynaecomastia, hyperkalaemia, hyponatraemia, impotence)
- Furosemide side effects = hyponatraemia
•Large volume paracentesis

Week 10 -GI (8 decks)

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