Liver Diseases Flashcards
Chronic Liver failure- pathology
↪️ occurs in those w/ chronic liver disease
Variceal bleeding
Hepatic encephalopathy
These 2 will contribute to Ascites, indicating hepatic decompensation.
How do u treat Ascites?
Paracentisis Spironolactone (aldosterone antagonist-⬆️ excretion of Na --> H2O.
Hep A pathology
RNA
Faeco-oral route
Whats Acute Liver Failure? Give an example
Failure of liver to maintain vital functions within 6months of symptom onset, without chronic Liver disease (jaundice, hepatic encephalopathy).
E.g. Paracetamol overdose.
Sub-acute presentation
↪️ autoimmune hepatitis
⭐️high mortality- ICU due to multiorgan failure
⭐️Liver transplant
Hep A, what happens?
RNA virus
Faeco-oral route
Contaminated water –> high poverty, poor sanitation.
Can present w/ jaundice & acute hepatitis
No chronic carrier
No acute managment- tx symptoms, supportive
Active immunisation- killed virus
Passive- immunoglobulins.
Hep B
Common DNA Virus -350m in chronic state Infection aquired in infants >90% will become chronic. 5% in adults Effective immunisation: available HBVsAg by recombinant DNA technology Given at birth to infected mothers OR adults at risk Chronic--> hepatocellular cancer --> hepatic decompensation Give: regulated interferon/ nucleosidete
Hep C
RNA virus --> worldwide Blood contact West: drugs Developed: understerilised equipment 20 years after infx cirrhosis NO VACCINATION Pegylated interferon- ribavirin
Hep D-what happens?
Incomplete RNA virus
Require Hep B to oroduce the surgace coat for a complete virus.
⬆️ incidence of heparic decompensation.
Hep E
Small RNA virus Faeco-oral route NO chronic carrier state ⬆️⬆️ mortality in pregnancy NO VACCINE- Tx- supportive
What causes Jaundice?
Xs bilirubin in the extracellulat fluids
Either unconjucated or conjugated >1.5 mg/dl
0.5mg/dl of plasma, unconjugated.
Causes of jaundice?
- ⬆️⬆️ destruction of RBCs (haemolytic jaundice) –> Rapid relases of bilirubin into blood–> Liver; cannot excrete bilirubin as fast as its made.
- Obstruction of bile ducts
- Damage to ️Liver
What happens when there is total obstruction?
Bilirubin cannot be oxidised to urobilinogen –> negative urobilinogen results in urine + faeces - clay colour- lack of stercobilin. (Dark urine)
What can cause obstructive jaundice?
Gall stones Cancer Hepatitis Rate of bilirubin production✔️ Conjugated bilirubin cannot pass from blood to intestines
Bile—> lymph-> most in plasma: conjugated.
Investigations for jaundice?
Diagnosis Hemolytic- unconjugated Obstructive: conjugated Severe obstructive: conjugated in urine (cz unjonjugated bound to albumin) Foam- intense yellow
Whatbare the classifications of jaundice?
Prehepatic- hemolytic Hepatic 1. Congenital defect of hepatocytes 2. Hepatocellular injury or infection Post-Hepatic Obstruction to bile duct
How would u Investigate jaundice?
Bilirubin
ALP: proliferate in the presence of obstruction. When jaundiced: indicator of cholestasis, either intrahepatic or extra-hepatic
Aminotransferases:
AST/ALT: constituents of the hepatocyte.
Raised if hepatocellular damage
Some other measurments of jaundice?
Albumin conentration: synthetic capacity of the liver+ nutritional state of the patient
Clotting factors: synthesised in the liver. Most easily assesed: prothrombin. Vit K is a cofactor of its synthesis.
AFP (alpha feroprotein) for hepatocellular carcinoma
Hepatitis virus markers
Whats vit K?
Fat soluble, cannot be absorbed without bile, from intestines, due to obstruction–> reserves run out.
So!! Prothrombin time is essential before operating jaundiced patients,
When are ALP and AST/ALT raised?
Hepatocellular damage : ALP ⬆️ AST/ALT ⬆️⬆️⬆️
Chopestasis: including extrahepatic biliary obstruction ALP ⬆️⬆️⬆️. AST/ALT ⬆️
Some causes of Portal hypertension (PTHN)
Prehepatic: Portal vein thrombosis
Splenic vein thrombosis
Intrahepatic:
Cirrhosis (80% UK) schistosomiasis (commonest worldwide) sarcoidosis, congenital hepatic fibrosis
Post-Hepatic:
RHF, constrictive pericarditis, Budd-Chari syndrome
What are the risks for variceal haemorrhage?
⬆️ portal pressure, bout 12mmHg
Variceal size
Child-Pugh score (>_8)
What does the child-pugh score inculde + predict?
Risk of variceal bleeding Bilirubin Albumin Ascites Encephalopathy Prothrombin time
When would you suscpect varices as a cause of an upper GI bleed?
Alcohol abuse or cirrhosis
Look for signs: CLD–> encephalopathy, splenomegaly, ascites, hyponatraemia, coagulopathy, thrombocytopaenia.
Variceal primary prophylaxis
W/o tx 30% of cirrhotic varices will bleed.
Reduce to 15% by non-selective b-blocker- propranolol)
2. Repeat endoscopic banding ligation (better for cirrhotic patients)
Secondary prophylaxis of bleeding varices
After initial bleed,
80% will rebleed within 2 Years.
B blocker + endoscopic band ligation
+ transjugular intrahepatic portosystemic shunt (TIPSS) resistant to banding
OR surgical shunt if TIPSS impossible
How do you treat acute varicceal bleeding?
ABC!!
Resuscitate until haemodynamically stable (do not give 0.9% saline)
Correct clotting abnormalities- Vit K + FFP
IV terlipressin bolus
Endoscopic banding (harder to visualise) or sclerotherapy
If bleeding uncontrolled, Balloon tamponade w/ Sengstaken -Blakemore tube
What the Balloon tamponade w/ Sengstaken -Blakemore tube for?
If life threatening variceal bleeding, this can buy time to arrange transfer to liver clinic or surgery decompression.
Uses balloons to compress gastric & oesophageal varices.
Oesophageal ballon-use portable Xray for guidance.
How does TIPSS work?
By shunting blood away from the portal circulation through an artificial side-to-side portosystemic anastomosis created in the liver.
Whats non alcoholic liver disease?
Can lead to cirrhosis (1%) and
Hepatocelluar cancer.
Histological changes: similar to alcoholic liver disease.
1. Simple fatty change
2.’to Fat and inflammation - steatohepatitis, NASH (non alc)
3 fibrosis.
Oxidative stress injury leads to lipid peroxidation in the presence of fatty infiltratiom amd inflammatiom results.
🌟 Fibrosis may then occur, which is enhanced by insulin resistance- which induces connective tissue growth factor.
What are some risk factors for NAFLD?
Obesity
Hyperlipidaemia
Hypertension
T2 DM
NAFLD- liver component of metabolic syndrome.
Insulin resistance universal.
Most pts asx. Hepatomegaly may be present.
Dx: Fatty liver on USS .
Liver biopsy- allows staging.
Most ppl would do one if ALT persistent high x2.
Elastography used to evaluate fibrosis degree.
Mx of NaFLD
Wt loss
Strict HTN control
Statin
