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Liver Failure Flashcards

1
Q

How is Alpha-1 Antitrypsin Deficiency inherited

A

AUTOSOMAL RECESSIVE

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2
Q

On what chromosome is alpha-1antitrypsin gene located

A

14

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3
Q

What is alpha-1-antitrypsin’s main function

A

PROTECT the lungs from neutrophil elastase which can disrupt its connective tissues

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4
Q

What two organs does alpha-1 antitrypsin effect

A

Lung and liver

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5
Q

What disease does Alpha-1 Antitrypsin Deficiency cause in the lungs

A

emphysema

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6
Q

What is emphysema

A

A condition sin which the alveoli enlarged - making it hard to breathe

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7
Q

What diseases does Alpha-1 Antitrypsin Deficiency cause in the liver

A

CIRRHOSIS

HEPATOCELLULAR CARCINOMA

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8
Q

What is the phenotype of symptomatic patients with Alpha-1 Antitrypsin Deficiency

A

PiZZ phenotype

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9
Q

Clinical presentation of Alpha-1 Antitrypsin Deficiency in children

A

Present as liver disease (hepatitis, cirrhosis)

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10
Q

Clinical presentation of Alpha-1 Antitrypsin Deficiency in adults

A

Presents as respiratory problems (dyspnoea)

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11
Q

When do adults develop cirrhosis from Alpha-1 Antitrypsin Deficiency

A

Over the age of 50

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12
Q

How do we diagnose Alpha-1 Antitrypsin Deficiency

A

Serum alpha-1 antiitrypsin levels are LOW

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13
Q

How is Alpha-1 Antitrypsin Deficiency treated

A
  1. NO treatment
  2. Treat complications of liver disease
  3. Stop smoking
  4. Manage emphysema
  5. Liver transplant
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14
Q

What is hepatic failure

A

When liver loses ability to regenerate or repair so that decompensation occurs

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15
Q

What is ACUTE hepatic failure

A

Acute liver injury with encephalopathy and deranged coagulation in a patient with a perviously normal liver

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16
Q

What is Acute-on-chronic hepatic failure

A

Liver failure as a result of decompensation of chronic liver disease

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17
Q

Signs of hepatic encephalopathy caused by hepatic failure

A
  1. Confusion
  2. Coma
  3. Liver flap
  4. Drowsiness
  5. Jaundice
  6. Ascites
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18
Q

How does hepatic failure cause hepatic encephalopathy

A
  1. As liver fails, nitrogenous waste builds up in circulation and passes across BBB = brain damage due to ammonia (halts krebs’ cycle)

NEURAL CELL DEATH

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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

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20
Q

What is Fulminant hepatic failure

A
  1. Massive necrosis of liver cells leading to severe impairment of liver function
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21
Q

What is hyper acute fulminant hepatic failure

A

Encephalopathy within 7 days of jaundice onset

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22
Q

What is acute Fulminant hepatic failure

A

Encephalopathy within 8-28 days of jaundice onset

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23
Q

What is subacute Fulminant hepatic failure

A

within 5-26 weeks

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24
Q

What disease usually causes fulminant hepatic failure

A

Acute Hepatitis

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25
Q

What is the most common cause for Fulminant hepatic failure

A

Paracetamol overdose

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26
Q

Histological aspect of Fulminant hepatic failure

A

Multiacinar necrosis involving a substantial part of the liver

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27
Q

Main causes of Fulminant hepatic failure

A
  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
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28
Q

Clinical presentation of Fulminant hepatic failure

A
  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
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29
Q

Grading of HEPATIC ENCEPHALOPATY

A

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

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30
Q

Sign of fetor hepaticus

A

Patient smells like pear drops

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31
Q

What are the signs of chronic liver disease

A
  1. Bruising
  2. Clubbing
  3. Dupuytren’s contracture
  4. Ascites (RARE)
  5. Fever, committing and hypertension
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32
Q

What would neurological examination show in liver failure

A

Spasticity
Hyper-reflexia
Plantar responses remain flexor

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33
Q

Differential diagnosis in liver failure

A
  1. Space occupying lesions in th ebrian
  2. Cerebral infection
  3. Drug or alcohol intoxication
  4. Hypoglycaemia, electrolyte imbalance or hypoxia
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34
Q

Blood test in liver failure

A
  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
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35
Q

Name some imaging diagnostics of liver failure

A

EEG
Ultrasound
CXR
Dopper ultrasound

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36
Q

What will an EEG be used for

A

Grading encephalopathy

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37
Q

What will an ultrasound be used for

A

Define liver size

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38
Q

What does the doppler ultrasound show

A

Hepatic vein potency

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39
Q

Why would we be looking at blood cultures, urine cultures and ascitic taps for liver failure

A

Rule out infections by pathogens

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40
Q

How is Paracetamol poisoning treated

A

N-ACETYL-CYSTEINE

41
Q

How is raised intracranial pressure caused by liver failure treated

A

IV MANNITOL

42
Q

How is coagulopathy treated

43
Q

How do we reduce haemorrhage risk

A

Giving PPI (LANSOPRAZOLE)

44
Q

How is Hepatic failure treated

A

Monitor glucose and give IV GLUCOSE if needed

  1. Mineral supplements
  2. Liver transplant
  3. Prophylaxis against bacterial and fungal infections
45
Q

What are ascites

A

Accumulation of free fluids in the peritoneal cavity

46
Q

When are ascites common

47
Q

Main causes of ascites

A
  1. Local inflammation after peritonitis and intra-abdominal surgery

PERITONITIS
ABDOMINAL CANCERS (OVARIAN)
INFECTION (TB)

  1. Low protein
    Hypoalbuminaemia
    Nephrotic syndrome
    Malnutrition
  2. Low flow
48
Q

How does low protein result in ascites

A
  1. Inability to pull fluid back into intravascular space

2. Fluid accumulates in the peritoneum

49
Q

How does low flow cause ascites

A
  1. Fluid cannot move forwards through system (due to a clot)

2. Raises pressure in vessels causing fluid to leak out of vessels

50
Q

In what conditions is low flow seen

A
  1. Cirrhosis (portal hypertension)
  2. Budd-chary syndrome
  3. Cardiac Failure
  4. Constrictive Pericarditis
51
Q

What is Budd-chiari syndrome

A

Occlusion of hepatic veins that drain liver

52
Q

Risk factors for ascites

A
  1. High Na diet
  2. Hepatocellular carcinoma
  3. Splanchnic vein thrombosis = portal hypertension
53
Q

Clinical presentation of ascites

A
  1. Abdominal swelling
  2. Distended abdomen
  3. Fullness in flanks + SHIFING DULLNESS
  4. Mild abdomiinal pain \5. Severe pain in bacterial peritonitis
  5. Respiratory distress and difficulty eating
  6. Itching due to jaundice
54
Q

How is ascites diagnosed

A
  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
Q

What does diagnostic aspiration of fluid show

A
  1. RAISED WBC (bacterial peritonitis)
  2. Gram stain + culture
  3. Cytology to find malignancy
  4. Amylase to exclude pancreatic ascites
56
Q

What is worse, transudate or exudates when looking at protein measurements of ascitic fluids

A
  1. Transudate (less bad)

2. Exudate (BAD)

57
Q

What protein level is transudate

58
Q

What protein level is exudate

59
Q

How to treat ascites

A
  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
Q

What aldosterone antagonist is given

A

ORAL SPIROLACTONE (it spares K+)

61
Q

How much fluid can we drain at a time

A

5 litres at a time

62
Q

When is fluid drainage done

A

Relieve symptomatic tense ascites

63
Q

Why is TIPS used in treatments for ascites

A
  1. Used for resistant ascites

2. Can be risky

64
Q

What is peritonitis

A
  1. Inflammation of the peritoneum
65
Q

What innervation does the parietal layer have

66
Q

What innervation does the visceral layer have

67
Q

In what part of of the peritoneum is sensation well localised

A

ONLY the parietal layer

68
Q

Where is foregut pain felt

A

EPIGASTRIUM

69
Q

Where is Midgut pain felt

70
Q

Where is HINDGUT pain felt

A

HYPOGASTRIC

71
Q

What is the peritoneal cavity lined by

A

Mesothelial cells

72
Q

Role of mesothelial cells in the peritoneal cavity

A

Produce surfactant which lubricates it

73
Q

How much fluid is contained within the cavity

A

<100 mL of serous fluid containing <30 g/L of protein (transudate)

74
Q

Role of mesothelial cells lining the diaphragm

A

Gaps that allow communication between the peritoneum and diaphragmatic lymphatics

75
Q

What proportion of fluid drains through the diaphragmatic lymphatics

A

1/3 of fluid

76
Q

Where does the remainder 2/3 of fluid drain through

A

Peritoneal cavity

77
Q

What is primary peritonitis

A

Inflammation on its own:

  1. Spontaneous bacterial peritonitis
  2. Ascites
78
Q

How is primary peritonitis diagnosed

A

Ascitic tap and blood cultures

79
Q

How is primary peritonitis treated

A

Broad spectrum antibodies

80
Q

How is secondary peritonitis caused

81
Q

What bacterias can cause peritonitis

A
  1. gram-NEGATIVE coliforms

2. gram-POSITIVE staphylococcus (aureus)

82
Q

Where are staphylococci found

A

Found on the skin

83
Q

How do staphylococci infect the body

A
  1. Get into the peritoneal cavity through tubes placed through skin and irritate the peritoneum
84
Q

What chemicals can cause SECONDARY peritonitis

A
  1. BILE
  2. Old-clotted blood
  3. Ruptured ectopic pregnancy with blood release
85
Q

How do chemicals cause peritonitis

A

Leakage of intestinal contents by irritation

86
Q

Clinical presentation of peritonitis

A
  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
Q

When is perforation with sudden onset seen in peritonitis

A

With acute severe abdominal pain followed by collapse and shock

88
Q

Why do most people with peritonitis lie still

A

Cause they do

89
Q

How is pain relieved in peritonitis

A

resting hands on abdomen (stops movement of peritoneum)

90
Q

what would a blood test show for peritonitis

A
  1. raised WBC and CRP (confirms infection
  2. Serum amylase (excludes acute pancreatitis)
  3. HCG (excludes pregnancy as a cause)
91
Q

What would an CXR show

A

Free air under diaphragm - performed colon

2. Abdominal x-ray excludes bowel obstruction and forge in bodies

92
Q

How does CT help diagnose peritonitis

A

Exclude ischaemia as a cause of pain

93
Q

How is peritonitis treated

A
  1. ABC
  2. Insertion of nasogastric tube
  3. IV fluids
  4. IV antibiotics
94
Q

Surgical treatment of peritonitis

A
  1. Peritoneal cleaning of abdominal cavity
95
Q

Complications of delayed treatment

A
  1. Toxaemia and septicaemia (multi-organ failure)

2. Kidney failure

96
Q

Complication of surgical intervention for peritonitis

A
  1. Local abscess formation (if patient remains unwell post-op)
97
Q

Where are abscesses found

A

Pelvic

Suphrenic

98
Q

How are abscesses diagnosed

A

Ultrasound

CT

99
Q

What is paralytic ileum that follows from surgical complications

A
  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

Year 2 (155 decks)

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