Liver et al Flashcards
Main 4 points in acute liver failure
Hepatic encephalopahty
Jaundice
Coagulopathy
With no evidence of serious prior liver disease.
Time scale and classification of acute liver disease
Hyperacute = within 7days Acute = 8-29 days Subacute = 4 to 12 weeks
Also Fulminant = within 2 weeks and subfulminant within 2-12weeks.
Risk factors for acute liver failure
Chronic alcohol use
Poor nutrition
Older age (over 40)
Narcotic use
Causes of acute liver failure
Paracetamol toxicity Viral hepatitis - HBV and HAV Budd-Chiari syndrome CMV, EBV Autoimmune liver disease Wilson's disease Alpha-1 antitrypsin deficiency.
S+S of acute liver failure
Jaundice
Symptoms of hepatic encephalopathy - altered mood, sleep disturbance, slurred speech, confused.
Abdo pain
Nausea and vomiting
O/E:
Signs of hepatic encephalopathy - apraxia, liver flap, stupor.
Jaundice
Hepatomegaly
How to test for apraxia
Copy a 5 point star
Show me how to brush your teeth, use a hammer, comb your hair etc etc
Ix for acute liver failure
Laboratory: FBC U+E LFT Clotting and synthetic liver function BM Paracetamol levels Viral hepatitis antibodies Copper studies, alpha1-anti trypsin levels etc etc Blood culture, urine culture, ascitic tap mc+s
Imaging: Abdo USS CT/MRI of liver CT head Doppler USS of liver and portal vein.
Management of acute liver failure
In ITU 🌈
A-E including urinary catheter, NG tube, frequent BMs.
Treat cause.
Treating complications of acute liver failure
1) Cerebal oedema
2) Ascites
3) Hypoglycaemia
4) Encephalopathy
1) 20% Mannitol IV
2) Fluid and salt restriction, diuretic e.g spironolactone.
3) 10% glucose IV
4) Lactulose + Rifaximin.
List 5 hepatotoxic drugs
Pyrazinamide, Isoniazid (TB) Paracetamol Methotrexate Azothioprine Infliximab
Liver function test:
Which are markers of hepatocellular damage?
Which are markers of the liver’s synthetic function
Damage = ALT, AST, ALP, gamma-GT.
Synthetic liver function = PT, Albumin and bilirubin.
Interpreting ALT and ALP
ALT = mostly found within hepatocytes so if serum levels high = injury to hepatocytes. ALP = high concentrations in liver, bile duct and bone tissue, if serum levels high = cholestasis.
Therefore:
a >10X rise in ALT and a <3X rise in ALP = hepatocellular injury.
a >3X rise in ALP and a <10X rise in ALT = cholestasis.
And can have a mixed picture too.
List some functions of the liver
Bile production - stored in gallbladder.
Metabolise fat soluble vitamins e.g. vitamin D hydroxylation.
Drug metabolism using CYP450 enzymes.
Conjugation and elimination bilrubin
Synthesis of plasma proteins e.g. albumin
Synthesis of clotting factors
Gluconeogenesis
Pathophysiology of cirrhosis
Fibrosis and loss of normal liver architecture to abnormal, regenerative nodules.
Causes of cirrhosis
Chronic HBV and HCV Non-alcohol fatty liver diease Chronic alcohol Alpha1-antitrypsin deficiency Wilson's disease Budd-Chiari syndrome Drugs = methotrexate Primary biliary cholangitis
Presentation of liver cirrhosis
Abdo distension Jaundice Itch Easy bruising Poor memory Fatigue and weakness Peripheral oedema
O/E: LOTS!!!
Hands = Leuconychia (white nails), clubbing, palmar erythema, spider naevi, Dupuyren’s contracture.
Face = telangiectasia, xanthelasma, yellowing of sclera in eyes (jaundice)
Abdo = gynaecomastia, hepatomegaly, visible collateral vessel sin the abdo wall. Ascites + shifting dullness and fluid thrill on percussion.
Other = muscle wasting, loss of pubic hair, testicular atrophy on men.
Investigating cirrhosis and expected results
Laboratory: LFT - raised liver enzymes. Gamma-GT - raised. Albumin - low PT and INR - high FBC Ascites tap mc+s Find cause - viral hepatitis antibodies serology, ferritin, alpha1-antitrypsin levels.
Imaging: Abdo US + duplex Abdo CT/MRI Liver biopsy Transient elastography
What will you see in the histology of a liver biopsy in cirrhosis
Loss of hepatic architecture.
Bridging fibrosis.
Nodular regeneration.
Classification of liver cirrhosis
Child-Pugh-Turcotte Score.
Based on: (BAAIN mnemonic) Bilirubin Ascities Albumin low INR high Encephalopathy
Class = level of cirrhosis and determines life expectancy.
End-stage liver disease score
Model of End-Stage Liver Disease score uses bilirubin, sodium, creatinine and INR/PT to assess liver disease.
Used in liver transplant list.
Management of cirrhosis
Lifestyle advice = avoid alcohol, exercise to avoid muscle wasting, good nutrition, avoid hepatotoxic drugs (NSAIDs).
Management of ascites = fluid restriction, low salt diet, spironolactone +/- furesomide, daily weight.
Liver transplant list appropriateness.
Fluid restriction level in ascites and target weight loss with spironolactone
Max 1.5L per day.
Aim for up to 0.5g/day of weight loss.
Complications of cirrhosis
Hepaticellular carcinoma Coagulopathy Encephalopathy Sepsis Spontaneous bacterial peritonitis Hypoglycaemia Oesophageal varicies (and GI haemorrhage)
Spontaneous bacterial peritonitis
Ascites + sudden deterioration.
Commonly E.coli, Klebsiella
Rx = Cefotaxime or Tazosin
Can give prophylactic Ciprofloxacin.
Portal triad and another thing which helps bile flow
Portal vein
Hepatic artery
Bile duct
Found in a corner of each liver lobular.
Bile canaliculi.
Decompensated cirrhosis
Acute deterioration in a patient with chronic liver disease.
Precipitated by: infection (Spont bac peritonitis), high alcohol intake, drugs (NSAIDS, opiates), portal vein thrombus.
S+S: jaundice, increasing ascites, hepatic encephalopathy, AKI, oesophageal varices haemorrhage/GI bleed.
Ix: Vital signs, FBC, U+E, LFT, coagulation, blood glucose, blood cultures, ascitic tap MC+S, urine dipstick, CXR and AXR. Alcohol intake history.
Rx: A to E assessment, treat cause (ABx, FFP/transfusion, lactulose + Rifaxmin)
Grading of hepatic encephalopathy
West-Haven criteria
Compound involved in hepatic encephalopathy
Serum ammonia build up causing glutamine excess in brain which draws fluid in = cerebral oedema.
Name 3 metabolic liver diseases and how are they all inherited
Hereditary haemochromatosis, Chr 6
Wilson’s disease, Chr 13
Alpha-1 antitrypsin deficiency, Chr 14
All autosomal recessive 🧬
Pathophysiology of hereditary haemochromatosis
Autosomal recessive.
Inherited on chromosome 6, HFE gene.
Lack of hormone HEPCIDIN which regulates iron levels.
Increased iron absorption from intestine.
Deposits of iron in liver, heart, skin, joints and pancreas.
More common in males as females loose blood and hence iron during menses.
S+S of hereditary haemochromatosis
Early in life = asymptomatic, tiredness, arthralgia, low libido.
Mid-life = slate-grey tinged skin pigmentations, arthralgia, DM, fatigue and weakness, hepatomegaly, signs of cirrhosis and chronic liver disease, cardiac arrythmias.
Where is the arthralgia common in HH
2nd and 3rd metacarpophalangeal in hands.
Investigating hereditary haemochromatosis
Iron studies:
Serum transferrin saturation = >45% (specific marker).
Serum ferritin = raised.
Serim TIBC = low/normal
LFT HFE gene testing. MRI Liver biopsy + Perl's stain = iron loading and fibrosis. Liver FibroScan
Ix extra-hepatic manifestations: echocardiogram, BM/HbA1c/OGTT.
Management of hereditary haemochromatosis
Weekly venesection - target ferritin <50mcg/L.
Monitor for DM and arrhythmias.
Consider for transplant.
Pathophysiology of Wilson’s disease
Autosomal recessive.
Mutation in chromosome 13.
Copper retention in liver and basal ganglia due to impaired excretion in the liver.
Presentation of Wilson’s disease
Early in life = Liver disease signs (hepatitis, cirrhosis).
Young adults = CNS signs (tremor, dysarthria, dystonia, dementia, ataxia).
Psych = depression, change in libido, personality change, poor memory.
O/E:
Kayser-Fleischer rings from copper in iris.
Blue nails
Hypermobile joints
Grey tinged skin
Hepatomegaly and signs of cirrhosis (spider naevi, jaundice, ascites, bruising).
Investigating Wilson’s disease
Copper studies:
24hr urinary copper excretion = high
Serum copper = low
Serum caeruloplasmin = low
LFT = raised enzymes. Hepatic biopsy = high copper levels. Slit-lamp exam = Kayser-Fleischer rings. Head MRI = degeneration of basal ganglia. Genetic testing for Wilson's disease
Management of Wilson’s disease
Lifestyle advice = avoid copper rich foods (chocolate, mushrooms, liver meat). Avoid alcohol and hepatotoxic drugs.
Chelation agent to bind to copper and excrete in urine = penicillamine (oral)
Prevent copper absorption = zinc compounds.
Liver transplantation appropriateness.
Screen family!
Drug for chelation of copper in Wilson’s disease
Penicillamine
S/Es = rash, nausea, anaemia, haematuria etc etc.
Pathophysiology of alpha1-antitrypsin deficiency
Autosome recessive.
Chromosome 14, SERPINA1 gene.
Loss of protease inhibitor involved in inflammatory cascade causing serpinopathy.
Loss of neutrophil elastase enzyme action.
S+S of alpha1-antitrypsin deficiency
Mostly males.
Symptoms fo COPD in under 40yrs e.g. productive cough, SOBOE, wheeze.
Symptoms of cirrhosis e.g. ascites, jaundice, confusion, hepatomegaly, cholestasis.
Investigating alpha1-antitrypsin deficiency
Serum alpha1-antitrypsin levels = low –> genetic testing/phenotyping.
Spirometry = obstructive pattern.
CXR
LFTs - raised enzymes.
Liver biopsy = diastase-resistant globules, +ve for Periodic acid Schiff
Management of alpha1-antitrypsin deficiency
Lifestyle advice - smoking cessation, annual influenza vaccine.
Treat as for COPD
Monitor LFT, screen for HCC.
Drug to help pruritus in liver disease
Colestyramine.
Pathophysiology behind autoimmune hepatitis
Autoantibodies against hepatocyte surface antigen cause inflammation and necrosis.
T-cell mediated attack.
Associated with HLA-DR3
Common patients with autoimmune hepatitis
Females. Not usually that old, under 40yrs.
Presentation of autoimmune hepatitis
Acute = 40% present acutely.
Fever, jaundice, abdo pain.
Subacute = gradual onset jaundice, pruritus, hepatomegaly, abdo discomfort, signs of cirrhosis (confusion, ascites)
CFx of other autoimmune diseases e.g. arthralgia, bowel dysfunction (UC).
Investigating autoimmune hepatitis
LFT - raised transaminases, ALT/AST >1.5X.
FBC - anaemia, low WCC, low platelets esp if splenic dysfunction too.
Criteria:
Serum protein electrophoresis for autoantibodies - ANA, ASMA, LKM1.
Hypergammaglobulinaemia esp IgG
Liver biopsy - mononuclear infiltrates of portal and periportal areas, piecemeal necrosis, fibrosis, cirrhosis.
What is seen in liver biopsy of autoimmune hepatitis
Mononuclear infiltrates in portal and periportal areas = interface hepatitis.
Piecemeal necrosis
Fibrosis.
Management of autoimmune hepatitis
1) Prednisolone - high dose then reduce after 1 month for maintenance.
2) If corticosteroids CI can use Azathioprine or if not responsive to mono therapy use in combo.
Liver transplant
Definition of portal hypertension
Increase in portal venous pressure due to increase in hepatic vascular resistance and hepatic blood flow. Commonly caused by chronic end-stage liver disease.
The raised pressure opens up venous collaterals to connect the portal and system circulation.
Clinically significant if pressure gradient is >10mmHg.
Causes of portal HTN
Prehepatic - before portal vein in liver:
- Congenital atresia
- Portal venous thrombus
- Extrinsic compression by tumour.
Hepatic:
- Cirrhosis
- Chronic hepatitis
- Sarcoid granulomata.
Post-hepatic - block in hepatic vein:
- Budd-Chiari syndrome
- Constrictive pericarditis
- Right heart failure
Sites for portal-systemic circulation collaterals
Gastro-oesophageal junction = oesophageal varices.
Anterior abdo wall = visible as caput medusae around umbilical area.
Ano-rectal junction
Retroperitoneal viscera.
Effects of portal HTN on systemic circulation
Produce hyperdynamic circulation Bounding pulse Hypotension Increases cardiac output Salt and water retention = hypervolaemia and hypernatraemia.
Presentation of portal HTN
Presents as chronic liver disease mostly - jaundice, alcohol consumption, ascites, hepatomelgay, splenomegaly, hepatic encephalopathy, visible collaterals on abdo wall, spider naevi, gynaecomastia, liver flap, oesophageal varicies bleed.
Vital signs = bounding pulse, low BP but warm peripheries.
Investigating portal HTN
Abdo USS. Doppler US of portal vessels. Spiral CT Endoscopy for oesophageal varices. hepatic venous pressure gradient (>10mmHg)
Bloods:
LFT, U+E, FBC, clotting profile, PT.
Find cause - iron studies, copper studies, hepatitis serology etc etc
Management of portal HTN
Reduce BP = non-selective beta blockers (propranolol), nitrates.
Surgical = transjugular intrahepatic bypass shunt.
Treat or manage cause - diuretics, salt and fluid restriction,
Hepatopulmonary syndrome
Complication of portal HTN
Hepatic dysfunction, hyperaemia, extreme vasodilation.
Common cause of haemoperitoneum
Trauma + HCC
Common cancers in the liver
Most common are due to metastasis from breast, bronchus and GI tract.
Primary liver tumours = hepatocellullar carcinomas.
Risk factors/Causes for hepatocellular carcinoma
MALE Hepatitis B and C virus. Heavy, chronic alcohol consumption. Metabolic syndrome and obesity. Non-alcohol fatty liver disease.