Liver Diseases Flashcards
4 functions of the liver
Synthetic
Detoxification
Immune function
Storage
What is synthesised in the liver?
Clotting factors Bile acids Carbohydrates - Gluconeogensis, glycogenolysis, glycogenesis Proteins - Albumin Lipids - cholesterol, lipoprotein, TG Hormones - angiotensinogen, ILGF
Describe detoxification processes in the liver
Urea production from ammonia
Drugs
Bilirubin metabolism
Breakdown of insulin and hormones
What is stored in the liver?
Glycogen
Vitamins A , D, B12 and K
Copper
Iron
What is included in Liver Function Tests?
Bilirubin Aminotransferases Alklaine phosphatase Gamma GT Albumin Prothrombin time Creatinine Platelet count
What is unconjugated bilirubin bound by?
Albumin
What leads to bilirubin elevation?
Haemolysis
Parenchymal damage
Obstructive causes
Which aminotransferase is more specific to liver damage?
ALT
AST can rise in heart conditions, muscle damage
AST/ALT ratio can indicate acute liver disease
Where is alkaline phosphatase present?
Bile ducts
Bone
Placenta
Intestines
What leads to an elevated alkaline phosphatase?
Obstruction or liver infiltration
What leads to gamma GT elevation?
Alcohol use
Drugs eg NSAIDs
Low albumin indicates?
Chronic liver disease
Kidney disorders (loss)
Malnutrition (lack protein to produce)
Prothrombin time indicates?
Extent of liver dysfuntion
Useful in staging, indication of surgery
Why is creatinine useful in liver disease?
Indicates renal function which projects survival from liver disease
Assesses need for transplant
Platelet count is an indirect marker of what condition in liver disease?
Portal hypertension
Cirrhosis - leads to splenomegaly 0 leads to low count
Symptoms of liver disease
Jaundice
Ascites
Variceal bleeding
Hepatic encephalopathy
Differential for jaundice
Carotenemia
What sign differentiates carotenemia from jaundice?
Doesn’t affect the sclera
Signs of prehepatic cause of jaundice
Spelnomegaly - haemolysis
Pallor
Signs of hepatic cause of jaundice
Stigmata
Ascites
Asterixis - LIVER FLAP
Signs of post hepatic cause of jaundice
Abdominal pain Pruritus Pale stools Dark coloured urine Palpable gallbladder
What is Courvoisier’s sign?
Palpable gallbladder
Investigations of jaundice
Liver Screen Ultrasound MRCP, ERCP Percutaneous Transhepatic Cholangiogram EUS
What tests are included in a liver screen?
Hepatitis B and C serology Autoantibody profile. serum Igs Caeruloplasmin and copper Ferrritin and transferrin Alpha 1 Antitrypsin Fasting glucose and lipids
Advantages of MRCP vs ERCP
No radiation, complications or sedation
Can image outwith ducts
ERCP therapeutic options
Dilated biliary tree +/- visible stones or tumour
Acute gallstone pancreatitis
Stenting of bilioary obstruction
Post-op biliary complications
Choledocholithiasis
Sphincterectomy
Stone retrieval
Complications of ERCP
Pancreatitis Perforation Sedation - respiratory and cardiac Cholangitis Sphincterectomy - bleeding and perforation
When is PTC indicated instead of ERCP?
Previous surgery
Duodenal obstruction
Name conditions described as chronic liver disease
Chronic hepatitis/cholestasis
Fibrosis and cirrhosis
Steatosis
Liver tumour
Causes of cirrhosis
Alcohol Autoimmune Haemochromatosis Chronic viral hepatitis Non-Alcoholic Fatty Liver Disease Drugs CF Alpha antitrypsin deficiency Wilson's Cryptogenic Portal hypertension Liver disease Sarcoidosis Amyloid Schistosomiasis
Pathological change seen in liver cirrhosis
Infiltrating lymphocytes ECM proteins Apoptosis Activated kupffer cells Sinusoid resistance to blood flow
Signs in compensated liver cirrhosis
Abnormal liver screen and lfts
Signs in decompensated liver cirrhosis
Ascites, Variceal belleding, Encephalopathy
3 Stages of liver cirrhosis
A - Compensated
B - Decompensated
C - Hepatocellular carcinoma
Symptoms that can accompany ascites in liver disease
Spider naevi Palmar erythema abdominal veins fetor hepaticus umbilical nodule Rasied JVP Flank haematoma
Diagnostic test for ascites
Paracentesis
- Protein and albumin concentration
- Cell count and differential
- Serum Ascites Albumin gradient
Components measured in paracentesis
- Protein and albumin concentration
- Cell count and differential
- Serum Ascites Albumin gradient
What cause of ascites is indicated by a protein and albumin concentration of 1.1g/al
Portal hypertension
What conditions are associated with portal hypertension>
Congestive Heart Failure Pulmonary hypertension Constrictive pericarditis Budd Chiari Myxedema Massive liver metastases
What conditions are associated with non-portal hypertension ascites?
Malignancy TB Chylous ascites Pancreatic Biliary Nephrpotic syndrome Serositis
Treatment of ascites
Diuretics Large volume paracentesis TIPS - Transjugular Intrahepatics Portosystemic Shunt Aquaretics Liver Transplant
Why do varices occur?
Portal hypertension
Leads to systemic anastomoses
- Skin, Oesophagus, Gastric, Rectal, Stomal
Management of varices
Resuscitation
IV fluid
Blood transfusion
Emergency endoscopy
Endoscopic band ligation
Terlipression
Sengstaken Blakemore tube - bleeding
TIPS - rebleeding
How is hepatic encephalopathy scored?
Confusion is graded from 1 to 4
What are the precipitants of hepatic encephalopathy?
Bleeding Infection Constipation Dehydration Medication/Sedation
Associated symptoms with hepatic encephalopathy?
Fetor hepaticus
Asterixis
Management of hepatic encephalopathy
Treat underlying cause
Laxatives - phosphate enema and lactulose
Neomycin and Rifaximin - Antibiotics
Supportive - airways, NG tube medication
Presentation of hepatocellular carcinoma
Decompensated liver disease Abdominal pain Mass Weight loss Bleeding
Diagnostic investigations of hepatocellular carcinoma
Elevated AFP
US
CT
MRI
Treatment of hepatocellular carcinoma
Hepatic resection Transplant Chemotherapy Ablation Sorafenib (TKI) Tamoxifen (hormone therapy)
What may be carried out if a patient has repeated incidents of hepatic encephalopathy?
Liver transplant
Significant LFT results
ALT 10 x normal amount - hepatocellular injury
ALT> AST - most liver diseases
AST>ALT - usually 2:1 ratio: Alcoholic hepatitis
ALP 3 x normal
ALP + GGT high = biliary tree damage (cholestasis)
Isolated high ALP - bone, prenancy, Paget’s
GGT high - alcohol intake or drugs
Painless jaundice High ALP, High GGT Lethargy Loss of appetite Heavy drinker Palpable gallbladder Diangosis?
Cholestatic blood results
Pancreatic cancer
