Liver Failure Flashcards
1
Q
How is Alpha-1 Antitrypsin Deficiency inherited
A
AUTOSOMAL RECESSIVE
2
Q
On what chromosome is alpha-1antitrypsin gene located
A
14
3
Q
What is alpha-1-antitrypsin’s main function
A
PROTECT the lungs from neutrophil elastase which can disrupt its connective tissues
4
Q
What two organs does alpha-1 antitrypsin effect
A
Lung and liver
5
Q
What disease does Alpha-1 Antitrypsin Deficiency cause in the lungs
A
emphysema
6
Q
What is emphysema
A
A condition sin which the alveoli enlarged - making it hard to breathe
7
Q
What diseases does Alpha-1 Antitrypsin Deficiency cause in the liver
A
CIRRHOSIS
HEPATOCELLULAR CARCINOMA
8
Q
What is the phenotype of symptomatic patients with Alpha-1 Antitrypsin Deficiency
A
PiZZ phenotype
9
Q
Clinical presentation of Alpha-1 Antitrypsin Deficiency in children
A
Present as liver disease (hepatitis, cirrhosis)
10
Q
Clinical presentation of Alpha-1 Antitrypsin Deficiency in adults
A
Presents as respiratory problems (dyspnoea)
11
Q
When do adults develop cirrhosis from Alpha-1 Antitrypsin Deficiency
A
Over the age of 50
12
Q
How do we diagnose Alpha-1 Antitrypsin Deficiency
A
Serum alpha-1 antiitrypsin levels are LOW
13
Q
How is Alpha-1 Antitrypsin Deficiency treated
A
- NO treatment
- Treat complications of liver disease
- Stop smoking
- Manage emphysema
- Liver transplant
14
Q
What is hepatic failure
A
When liver loses ability to regenerate or repair so that decompensation occurs
15
Q
What is ACUTE hepatic failure
A
Acute liver injury with encephalopathy and deranged coagulation in a patient with a perviously normal liver
16
Q
What is Acute-on-chronic hepatic failure
A
Liver failure as a result of decompensation of chronic liver disease
17
Q
Signs of hepatic encephalopathy caused by hepatic failure
A
- Confusion
- Coma
- Liver flap
- Drowsiness
- Jaundice
- Ascites
18
Q
How does hepatic failure cause hepatic encephalopathy
A
- As liver fails, nitrogenous waste builds up in circulation and passes across BBB = brain damage due to ammonia (halts krebs’ cycle)
NEURAL CELL DEATH
19
Q
How does hepatic failure cause cerebral oedema
A
Astrocytes try to clear the ammonia (using a process involving glutamate -> glutamine), excess glutamine causes osmotic imbalance and a shift of fluid into these cells causing cerebral oedema
20
Q
What is Fulminant hepatic failure
A
- Massive necrosis of liver cells leading to severe impairment of liver function
21
Q
What is hyper acute fulminant hepatic failure
A
Encephalopathy within 7 days of jaundice onset
22
Q
What is acute Fulminant hepatic failure
A
Encephalopathy within 8-28 days of jaundice onset
23
Q
What is subacute Fulminant hepatic failure
A
within 5-26 weeks
24
Q
What disease usually causes fulminant hepatic failure
A
Acute Hepatitis
25
What is the most common cause for Fulminant hepatic failure
Paracetamol overdose
26
Histological aspect of Fulminant hepatic failure
Multiacinar necrosis involving a substantial part of the liver
27
Main causes of Fulminant hepatic failure
1. Virus (Hep A,B,D,E - RARELY C)
2. Cytomegalovirus
3. EBV
4. Heroes simplex virus
5. PARACETAMOL
6. Alcohol
7. Amitriptyline
8. NSAIDS
9. ECSTACY
10. HEPATOCELLULAR CARCINOMA
11. Wilson's Disease or Alpha-1-antitrypsin deficiency
12. Acute fatty liver or pregnancy
28
Clinical presentation of Fulminant hepatic failure
1. Jaundiced
2. Small liver
3. Signs of hepatic encephalopathy
4. Fetor hepaticas
5. Cerebral Oedema
6. Signs of chronic liver disease
7. Fever, vomiting, hypertension
29
Grading of HEPATIC ENCEPHALOPATY
I - Altered mood/Behaviour, sleep disturbance, dyspraxia
II - Increasing drowsiness, confusion, slurred speech +/- liver flap, inappropriate behaviour/personality change
III - Incoherent, restless, liver flap, stupor
IV - Coma
30
Sign of fetor hepaticus
Patient smells like pear drops
31
What are the signs of chronic liver disease
1. Bruising
2. Clubbing
3. Dupuytren's contracture
4. Ascites (RARE)
5. Fever, committing and hypertension
32
What would neurological examination show in liver failure
Spasticity
Hyper-reflexia
Plantar responses remain flexor
33
Differential diagnosis in liver failure
1. Space occupying lesions in th ebrian
2. Cerebral infection
3. Drug or alcohol intoxication
4. Hypoglycaemia, electrolyte imbalance or hypoxia
34
Blood test in liver failure
1. Hyperbilirubinaemia
2. High serum ALT + AST
3. Low levels of coagulation factors and raising PTT
4. Low glucose (glycogen is no longer being stored)
5. Ammonia levels high
35
Name some imaging diagnostics of liver failure
EEG
Ultrasound
CXR
Dopper ultrasound
36
What will an EEG be used for
Grading encephalopathy
37
What will an ultrasound be used for
Define liver size
38
What does the doppler ultrasound show
Hepatic vein potency
39
Why would we be looking at blood cultures, urine cultures and ascitic taps for liver failure
Rule out infections by pathogens
40
How is Paracetamol poisoning treated
N-ACETYL-CYSTEINE
41
How is raised intracranial pressure caused by liver failure treated
IV MANNITOL
42
How is coagulopathy treated
IV VIT K
43
How do we reduce haemorrhage risk
Giving PPI (LANSOPRAZOLE)
44
How is Hepatic failure treated
Monitor glucose and give IV GLUCOSE if needed
2. Mineral supplements
3. Liver transplant
4. Prophylaxis against bacterial and fungal infections
45
What are ascites
Accumulation of free fluids in the peritoneal cavity
46
When are ascites common
Post-Op
47
Main causes of ascites
1. Local inflammation after peritonitis and intra-abdominal surgery
PERITONITIS
ABDOMINAL CANCERS (OVARIAN)
INFECTION (TB)
2. Low protein
Hypoalbuminaemia
Nephrotic syndrome
Malnutrition
3. Low flow
48
How does low protein result in ascites
1. Inability to pull fluid back into intravascular space
| 2. Fluid accumulates in the peritoneum
49
How does low flow cause ascites
1. Fluid cannot move forwards through system (due to a clot)
| 2. Raises pressure in vessels causing fluid to leak out of vessels
50
In what conditions is low flow seen
1. Cirrhosis (portal hypertension)
2. Budd-chary syndrome
3. Cardiac Failure
4. Constrictive Pericarditis
51
What is Budd-chiari syndrome
Occlusion of hepatic veins that drain liver
52
Risk factors for ascites
1. High Na diet
2. Hepatocellular carcinoma
3. Splanchnic vein thrombosis = portal hypertension
53
Clinical presentation of ascites
1. Abdominal swelling
2. Distended abdomen
3. Fullness in flanks + SHIFING DULLNESS
4. Mild abdomiinal pain \5. Severe pain in bacterial peritonitis
6. Respiratory distress and difficulty eating
7. Itching due to jaundice
54
How is ascites diagnosed
1. Demonstrating shifting dullness shows presence of fluid
2. Diagnostic aspiration of 10-20ml of fluid using ascitic tap
3. Protein measurement of ascitic fluid from ascitic tape
55
What does diagnostic aspiration of fluid show
1. RAISED WBC (bacterial peritonitis)
2. Gram stain + culture
3. Cytology to find malignancy
4. Amylase to exclude pancreatic ascites
56
What is worse, transudate or exudates when looking at protein measurements of ascitic fluids
1. Transudate (less bad)
| 2. Exudate (BAD)
57
What protein level is transudate
<30g/L
58
What protein level is exudate
>30g/L
59
How to treat ascites
1. Reduce Na to help liver and reduce fluid retention
2. Increase renal Na excretion
3. Diuretic of choice is an aldosterone antagonist
4. Drain fluid
5. Shunt
60
What aldosterone antagonist is given
ORAL SPIROLACTONE (it spares K+)
61
How much fluid can we drain at a time
5 litres at a time
62
When is fluid drainage done
Relieve symptomatic tense ascites
63
Why is TIPS used in treatments for ascites
1. Used for resistant ascites
| 2. Can be risky
64
What is peritonitis
1. Inflammation of the peritoneum
65
What innervation does the parietal layer have
SOMATIC
66
What innervation does the visceral layer have
AUTONOMIC
67
In what part of of the peritoneum is sensation well localised
ONLY the parietal layer
68
Where is foregut pain felt
EPIGASTRIUM
69
Where is Midgut pain felt
Umbilical
70
Where is HINDGUT pain felt
HYPOGASTRIC
71
What is the peritoneal cavity lined by
Mesothelial cells
72
Role of mesothelial cells in the peritoneal cavity
Produce surfactant which lubricates it
73
How much fluid is contained within the cavity
<100 mL of serous fluid containing <30 g/L of protein (transudate)
74
Role of mesothelial cells lining the diaphragm
Gaps that allow communication between the peritoneum and diaphragmatic lymphatics
75
What proportion of fluid drains through the diaphragmatic lymphatics
1/3 of fluid
76
Where does the remainder 2/3 of fluid drain through
Peritoneal cavity
77
What is primary peritonitis
Inflammation on its own:
1. Spontaneous bacterial peritonitis
2. Ascites
78
How is primary peritonitis diagnosed
Ascitic tap and blood cultures
79
How is primary peritonitis treated
Broad spectrum antibodies
80
How is secondary peritonitis caused
Surgery
81
What bacterias can cause peritonitis
1. gram-NEGATIVE coliforms
| 2. gram-POSITIVE staphylococcus (aureus)
82
Where are staphylococci found
Found on the skin
83
How do staphylococci infect the body
1. Get into the peritoneal cavity through tubes placed through skin and irritate the peritoneum
84
What chemicals can cause SECONDARY peritonitis
1. BILE
2. Old-clotted blood
3. Ruptured ectopic pregnancy with blood release
85
How do chemicals cause peritonitis
Leakage of intestinal contents by irritation
86
Clinical presentation of peritonitis
1. Sudden onset of perforation
2. Poorly localised (irritation of visceral peritoneum) the becomes localised as it irritates parietal peritoneum
3. Rigid abdomen
4. Speedbumps are painful
87
When is perforation with sudden onset seen in peritonitis
With acute severe abdominal pain followed by collapse and shock
88
Why do most people with peritonitis lie still
Cause they do
89
How is pain relieved in peritonitis
resting hands on abdomen (stops movement of peritoneum)
90
what would a blood test show for peritonitis
1. raised WBC and CRP (confirms infection
2. Serum amylase (excludes acute pancreatitis)
3. HCG (excludes pregnancy as a cause)
91
What would an CXR show
Free air under diaphragm - performed colon
| 2. Abdominal x-ray excludes bowel obstruction and forge in bodies
92
How does CT help diagnose peritonitis
Exclude ischaemia as a cause of pain
93
How is peritonitis treated
1. ABC
2. Insertion of nasogastric tube
3. IV fluids
4. IV antibiotics
94
Surgical treatment of peritonitis
1. Peritoneal cleaning of abdominal cavity
95
Complications of delayed treatment
1. Toxaemia and septicaemia (multi-organ failure)
| 2. Kidney failure
96
Complication of surgical intervention for peritonitis
1. Local abscess formation (if patient remains unwell post-op)
97
Where are abscesses found
Pelvic
| Suphrenic
98
How are abscesses diagnosed
Ultrasound
| CT
99
What is paralytic ileum that follows from surgical complications
1. Peristaltic waves in colon stop leading to fluid stagnation causing distended gut and blasting which puts pressure on the stomach and interferes with the diaphragm
BREATHLESSNESS
