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Medicine Finals > Liver & Friends > Flashcards

Liver & Friends Flashcards

1
Q

What is the stepwise progression of alcoholic liver disease?

A

1) alcohol related fatty liver - will reverse in around 2 weeks
2) alcoholic hepatitis - inflammation
3) cirrhosis - scar tissue, irreversible

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2
Q

What are signs of liver disease?

A

Jaundice

Hepatomegaly/hepatosplenomegaly

Spider naevi

Palmar erythema

Bruising (due to abnormal clotting)

Asterix (flapping tremor)

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3
Q

What lab results are seen in alcoholic liver disease?

A

Raised ALT and AST - in alcoholic liver disease AST is typically raised much more then ALT (AST:ALT ratio is usually 2:1)

Raised Gamma GT

Increased prothrombin time

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4
Q

How is alcoholic liver disease diagnosed?

A

Ultrasound

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5
Q

How is alcoholic liver disease managed?

A

Stop drinking alcohol

Steroids e.g. prednisolone can improve short term outcomes in hepatitis (dependent on Maddrey’s discriminant function)

Thiamine to prevent wernickes/korsakoffs

Transplant may be needed

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6
Q

How does alcohol withdrawal present?

A

6-12 hours: tremor, sweating, headache, anxiety

12-24 hours: hallucinations

24-48 hours: seizures

24-72 hours: delirium tremens

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7
Q

How does delirium tremens present?

A

Acute confusion

Severe agitation

Delusions/hallucinations

Tachycardia

Hypertension

Hyperthermia

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8
Q

How is delirium tremens managed?

A

Oral lorazepam

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9
Q

How do you calculate alcohol units?

A

(ml x percentage) / 1000

or L x percentage

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10
Q

What is the most common cause of liver disease?

A

Non alcoholic fatty liver disease

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11
Q

What are risk factors for NAFLD?

A

Raised cholesterol, obesity, smoking, HTN, T2DM

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12
Q

What lab results are seen in NAFLD?

A

ALT is raised more than AST

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13
Q

How is NAFLD diagnosed?

A

Ultrasound

Can also do an enhanced liver fibrosis test (ELF blood test) or Fibroscan - fibroscan is moreso used in alcoholic liver disease.

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14
Q

What are causes of liver cirrhosis?

A

Alcoholic liver disease

NAFLD

Hepatitis B/C

Wilson’s disease

Haemochromatosis

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15
Q

Why does splenomegaly occur in cirrhosis?

A

Portal hypertension

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16
Q

What scoring system can be used to classify liver cirrhosis?

A

Child-Pugh classification

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17
Q

What lab results are seen in liver cirrhosis? (LFTs and clotting)

A

Deranged LFTs

Raised prothrombin time

Low albumin

Raised bilirubin

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18
Q

Which lab tests are the best indicator of liver function?

A

Albumin + prothrombin Time (synthetic function tests)

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19
Q

What is seen on ultrasound in liver cirrhosis?

A

Nodular surface of the liver

Corkscrew appearance of the arteries

Enlarged portal vein.

Ascites

Splenomegaly

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20
Q

How is liver cirrhosis monitored?

A

Ultrasound and alpha feroprotein checked every 6 months

Check that it has not become hepatocellular carcinoma

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21
Q

What are complications of liver cirrhosis?

A

Portal hypertension

Ascites

Malnutrition

Spontaneous bacterial peritonitis

Hepatorenal syndrome

Hepatic encephalopathy

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22
Q

Why does malnutrition occur in liver disease?

A

Liver cannot store glucose as glycogen as effectively

Reduced production of protein

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23
Q

What does portal hypertension lead to the formation of?

A

Varices (swollen vessels)

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24
Q

How are bleeding varices managed?

A

Initial resus = Terlipressin to stop initial bleeding, Prophylactic antibiotics should be given

Endoscopy = injection of sclerosis agent + band ligation

If band ligation doesn’t work then TIPS (shunt)

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25
Q

What is given prophylactically for future variceal bleeding?

A

Propranolol

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26
Q

How is Ascites managed?

A

Low sodium diet

Spironolactone

Ascites drain/tap

Prophylactic antibiotics against SBP -> oral Ciprofloxacin (in patients w less than 15g/litre of protein

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27
Q

How does spontaneous bacterial peritonitis present?

A

Fever

Abdominal pain

Raised inflammatory markers

Hypotension

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28
Q

Which organism is most commonly responsible for spontaneous bacterial peritonitis?

A

E. coli

Also- Klebsiella

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29
Q

How is spontaneous bacterial peritonitis managed?

A

IV Cefotaxime

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30
Q

What is given for prophylaxis of spontaneous bacterial peritonitis?

A

Oral ciprofloxacin

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31
Q

What is hepatorenal syndrome?

A

Portal hypertension leads to dilation of portal vessels which leads to loss of blood volume from the kidneys and starvation of blood from the kidneys

Leads to rapidly deteriorating renal function

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32
Q

How is hepatorenal syndrome managed?

A

Liver transplant

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33
Q

What is hepatic encephalopathy?

A

Reduced consciousness and confusion caused by a build up of ammonia in the blood

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34
Q

What factors can precipitate hepatic encephalopathy?

A

Constipation

Infection

GI bleed

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35
Q

How is hepatic encephalopathy managed?

A

Laxative (Lactulose)

Or Antibiotic (rifaximin)

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36
Q

What is given for prophylaxis of hepatic encephalopathy?

A

Lactulose + Rifaximin (rifaximin is an antibiotic that causes decreased ammonia production from gut flora)

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37
Q

What is the most common viral hepatitis worldwide?

A

Hepatitis A

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38
Q

How is hepatitis A transmitted?

A

Faeco-orally (contaminated water and food)

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39
Q

What type of virus is hepatitis A?

A

An RNA virus

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40
Q

What type of virus is Hepatitis B?

A

A DNA virus

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41
Q

How is hepatitis B transmitted?

A

Direct bodily fluid contact (blood, semen)

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42
Q

Which marker is raised in acute hepatitis B?

A

HBsAg

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43
Q

Which marker is raised in vaccination or past infection of Hep B?

A

HBsAb (anti-HbS)

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44
Q

Which marker is raised in chronic hepatitis B infection?

A

HbsAg + Anti-HBc

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45
Q

Which type of virus is Hepatitis C?

A

RNA virus

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46
Q

How is Hepatitis C transmitted?

A

Direct bodily fluids

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47
Q

Which hepatitis is most likely to become chronic?

A

Hepatitis C

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48
Q

What are the two types of autoimmune hepatitis and which autoantibodies are associated with each?

A

Type 1 - anti-nuclear antibodies and/or anti-smooth muscle antibodies

Type 2 - anti liver kidney microsomes 1

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49
Q

What are features of autoimmune hepatitis?

A

Signs of chronic liver disease

May be fever or jaundice

In women - amenorrhoea

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50
Q

How is autoimmune hepatitis managed?

A

Prednisolone or other immunosuppressants e.g. Azathioprine

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51
Q

What is ischaemic hepatitis?

A

Liver inflammation caused by hypoperfusion (patient acutely hypotensive)

Raised ALT

Often also AKI

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52
Q

What are drug causes of hepatocellular dysfunction?

A

Paracetamol

Sodium valproate, phenytoin

Statins

Alcohol

Nitrofurantoin

Amiodarone

Methyldopa

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53
Q

What are drug causes of cholestasis?

A

COCP

Flucloxacillin

Co-amoxiclav

Erythromycin

Sulfonylureas

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54
Q

How much paracetamol is needed to cause toxicity?

A

More than 75mg/kg, or staggered overdose

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55
Q

How is paracetamol overdose managed?

A

If the patient presents within 1 hour -> activated charcoal

If staggered overdose/doubt about time of ingestion - NAC (infused over 1 hour)

Others - check plasma paracetamol concentration 4 hours after ingestion then administer NAC if needed

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56
Q

What is primary biliary cholangitis?

A

Autoimmune condition, destruction of small bile ducts within liver

Causes obstruction of bile outflow (cholestasis)

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57
Q

What are symptoms of bile outflow obstruction?

A

Itching

Xanthelasma

Jaundice, pale stools

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58
Q

Which antibody is raised in primary biliary cholangitis?

A

Anti-mitochondrial antibodies

May also be ANA

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59
Q

How is primary biliary cholangitis/cirrhosis managed?

A

Ursodeoxycholic acid

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60
Q

What is primary sclerosing cholangitis?

A

Inflammation and fibrosis of the intra and extra hepatic bile ducts

Causes obstruction of bile outflow

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61
Q

Which condition is associated with primary sclerosing cholangitis?

A

Ulcerative colitis

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62
Q

Which liver condition is associated with ulcerative colitis?

A

Primary sclerosing cholangitis

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63
Q

How does primary sclerosing cholangitis present?

A

Jaundice

Chronic right upper quadrant pain

Pruritus

Fatigue

Raised bilirubin

Raised ALP

64
Q

Which autoantibody is raised in primary sclerosing cholangitis?

A

pANCA

65
Q

What is the gold standard investigation for primary sclerosing cholangitis?

A

MRCP

Shows beaded appearance of biliary strictures

66
Q

Which liver condition causes a beaded appearance/biliary strictures on MRCP?

A

Primary sclerosing cholangitis

67
Q

How is primary sclerosing cholangitis managed?

A

Liver transplant

68
Q

Which drug can be used to help with pruritus in PBC/PSC?

A

Colestyramine

69
Q

What are risk factors for the development of gallstones?

A

Fat, fair, female, forty

70
Q

How do gallstones present?

A

Biliary colic (due to stones obstructing outflow of bile) - severe colicky RUQ pain

Biliary colic is triggered by meals (esp fatty meals)

May be associated with nausea and vomiting

May be jaundice if in common bile duct

71
Q

How are gallstones diagnosed?

A

First line = Ultrasound

If no stones seen - MRCP

72
Q

How are gallstones managed?

A

If asymptomatic - no treatment needed

If stones in gallbladder - cholecystectomy

If stones in bile ducts outside of gall bladder - ERCP

73
Q

What is acute cholecystitis?

A

Inflammation of the gallbladder due to blockage of the cystic duct due to gallstones

74
Q

How does acute cholecystitis present?

A

Right upper quadrant pain which may radiate to right shoulder

Fever

Tachycardia

Murphy sign - if you place your hand on the RUQ and ask patient to breath in, will be painful

NO JAUNDICE!

75
Q

How is acute cholecystitis diagnosed?

A

Ultrasound

Raised inflammatory markers (inflammatory markers will not be raised if just regular biliary colic)

76
Q

How is acute cholecystitis managed?

A

Cholecystectomy within 1 week of diagnosis

77
Q

What is acute cholangitis/ascending cholangitis?

A

Bacterial infection of the biliary tree, usually due to gallstones or after an ERCP procedure

78
Q

Which organism is most commonly responsible for acute cholangitis?

A

E. coli

79
Q

Which triad of symptoms is present in acute cholangitis?

A

Charot’s triad

Fever, jaundice and RUQ pain

80
Q

How is acute cholangitis diagnosed?

A

Ultrasound is first line

Contrast CT is more sensitive

81
Q

How is acute cholangitis managed?

A

Fluid resus

IV Abx

ERCP to remove stones

82
Q

What lab results are seen in pre-hepatic jaundice?

A

Normal to high bilirubin (unconjugated)

Normal AST/ALT

Normal ALP

83
Q

What lab results are seen in hepatic jaundice?

A

High bilirubin

ALT/AST = Very high

ALP = mildly elevated

84
Q

What lab results are seen in post-hepatic jaundice?

A

Very high bilirubin

Moderately elevated ALT/AST

Very high ALP

Pale stools, dark urine

85
Q

What are the three main causes of pancreatitis?

A

Gallstones - gallstones trap flow of bile and this refluxes into the pancreatic duct

Alcohol

Post-ERCP

86
Q

How does pancreatitis present?

A

Severe epigastric pain radiating to the back

Vomiting

Low grade fever

87
Q

Which two signs are seen in pancreatitis?

A

Cullen’s sign - bruising around umbilicus

Grey Turners sign - bruising around flanks

88
Q

Which markers are raised in pancreatitis?

A

Serum amylase and serum lipase

89
Q

How is pancreatitis diagnosed?

A

Ultrasound (but in practice usually just a clinical diagnosis)

90
Q

How is pancreatitis managed?

A

Self-limiting - no antibiotics needed

Fluids

Analgesia

91
Q

Which electrolyte can indicate severity in pancreatitis?

A

Low calcium indicates severity

92
Q

What is the most common cause of chronic pancreatitis?

A

Alcohol

93
Q

How does chronic pancreatitis present?

A

Similar to acute but less intense

Pain usually worse after eating

May be symptoms of obstructive jaundice

usually in alcoholics

94
Q

How is chronic pancreatitis diagnosed?

A

Secretin stimulation test

CT or MRCP

Amylase is usually normal

95
Q

How is chronic pancreatitis managed?

A

Replacement of pancreatic enzymes (lipase)

96
Q

What is haemochromatosis?

A

An iron storage disorder where there is excessive total body iron leading to iron deposition in tissues

97
Q

What type of hereditary pattern does haemochromatosis have?

A

Autosomal recessive

98
Q

How does haemochromatosis present?

A

Early symptoms - fatigue, erectile dysfunction, Arthralgia

Bronze skin pigmentation

Diabetes mellitus (iron affects functioning of pancreas)

Dilated cardiomyopathy

Hypogonadotropic hypogonadism

Arthritis

99
Q

What lab results are seen in haemochromatosis?

A

Raised serum ferritin

Raised transferrin saturation

Low total iron binding capacity

100
Q

How is haemochromatosis managed?

A

First line = venesection

Second line = desferrioxamine

101
Q

What is Wilson’s disease?

A

Excessive accumulation of copper in the blood

102
Q

What type of hereditary pattern does Wilson’s disease have?

A

Autosomal recessive

103
Q

How does Wilson’s disease present?

A

Usually presents between 10-25

Children usually present with liver signs

Young adults usually present with neurological signs

104
Q

What are liver signs of Wilson’s disease?

A

Chronic hepatitis and cirrhosis

Pruritus

Spider naevi

Jaundice

Palmar erythema

105
Q

What are neurological signs seen in Wilson’s diseases?

A

Parkinsonism

Concentration and co-ordination difficulties

Psychiatric symptoms - depression/psychosis

Speech difficulty

106
Q

How is Wilson’s disease diagnosed?

A

Low serum caeruloplasmin (protein which stores copper)

Low serum copper

High urinary copper excretion

Gold standard diagnosis = liver biopsy

107
Q

How is Wilson’s disease managed?

A

Penicillamine (copper chelating agent)

108
Q

What type of hereditary pattern does alpha-1 anti-trypsin deficiency have?

A

Autosomal recessive

109
Q

What occurs in alpha-1 anti trypsin deficiency?

A

Liver = Cirrhosis and Hepatocellular carcinoma

Lungs = Bronchiectasis and emphysema

110
Q

What’s the most common cause of hepatocellular cancer worldwide?

A

Chronic hepatitis B

111
Q

What are other causes of hepatocellular carcinoma?

A

Alcohol

Haemochromatosis (not Wilson’s disease)

Primary biliary cirrhosis

112
Q

Does Wilson’s disease increase risk of hepatocellular carcinoma?

A

No

113
Q

Which marker is raised in hepatocellular carcinoma?

A

Raised alpha-feta protein

114
Q

What is cholangiocarcioma?

A

Cancer of the bile duct

115
Q

What is the most common type of cholangiocarcinoma?

A

Adenocarcinoma

116
Q

What is the main risk factor for cholangiocarcinoma?

A

Primary sclerosing cholangitis (the one that is associated with ulcerative colitis)

117
Q

How does cholangiocarcinoma present?

A

Painless jaundice

Weight loss

Palpable mass in RUQ

pale stools, dark urine

118
Q

Which bio marker is raised in cholangiocarcinoma?

A

CA19-9

119
Q

What is the most common type of pancreatic cancer?

A

Adenocarcinoma

120
Q

Which type of pancreatic cancer causes an obstructive jaundice?

A

Head of pancreas cancer

121
Q

How does pancreatic cancer present?

A

Painless obstructive jaundice

Pale stools, dark urine

Raised ALP

Weight loss

New onset DM/worsening glycemic control

122
Q

What is the 2WW criteria for pancreatic cancer?

A

> 40 with painless jaundice

123
Q

How is pancreatic cancer diagnosed? What is seen?

A

CT Abdomen

Double-duct sign (both common bile duct and pancreatic duct = dilated)

124
Q

What is the criteria for a direct access CT abdomen if 2WW criteria has not been met for Pancreatic cancer?

A

> 60 + weight loss + symptom of pancreatic cancer which is not jaundice

125
Q

How does acute appendicitis present?

A

Abdominal pain which starts at the umbilical and moves to the right iliac fossa

Tenderness at McBurney’s point

Loss of appetite

Nausea/vomiting

Low grade fever

Right sided tenderness on PR

126
Q

What lab results are seen in acute appendicitis? How is appendicitis diagnosed?

A

Raised inflammatory markers

Appendicitis causes a neutrophil predominant leukocytosis

Ultrasound = diagnostic

127
Q

What are key differentials for acute appendicitis?

A

Ectopic pregnancy

Ovarian cyst rupture/torsion

128
Q

How is acute appendicitis managed?

A

Appendicectomy

Prophylactic IV Abx

129
Q

What is carcinoid syndrome?

A

Cancer metastases in the liver which release serotonin into the systemic circulation

130
Q

How does carcinoid syndrome present?

A

Flushing

Diarrhoea and abdominal pain

Hypotension

Wheeze

Tricuspid insufficiency

131
Q

How is carcinoid syndrome diagnosed?

A

Raised urinary 5-HIAA

132
Q

How is carcinoid syndrome managed?

A

Octreotide (somatostatin analogue)

133
Q

What is Gilbert’s syndrome?

A

An autosomal recessive condition causing defective bilirubin conjugation

Can lead to jaundice during times of stress/illness but otherwise asymptomatic

No treatment required

134
Q

How does Gilbert’s syndrome present?

A

Jaundice during stress/illness

135
Q

How is Gilbert’s syndrome managed?

A

No treatment needed

136
Q

What is Budd-Chiari syndrome?

A

Thrombosis of the hepatic vein

137
Q

What are causes of Budd-Chiari syndrome?

A

Polycythaemia rubra Vera

Pregnancy

COCP

Thrombophilia

138
Q

What triad of symptoms is seen in Budd-Chiari syndrome?

A

Sudden onset severe abdominal pain

Ascites

Tender hepatomegaly

139
Q

Which blood result is used to determine if there is any evidence of acute liver failure?

A

Prothrombin time

140
Q

How do you determine if someone with alcoholic liver disease will benefit from steroids?

A

Maddrey’s discriminant function - need prothrombin time and serum bilirubin

141
Q

Which condition is Murphy’s sign associated with? What is Murphy’s sign?

A

Acute cholecystitis

Patient stops breathing during inspiration (catch in breath) when palpating gallbladder

142
Q

Which type of hepatitis causes amenorrhoea?

A

Autoimmune hepatitis

143
Q

Which liver markers are raised in autoimmune hepatitis?

A

ALT

Bilirubin

144
Q

What medication can be used to help pruritus in PBC/PSC?

A

Cholestyramine

145
Q

Jaundice: Urinalysis shows bilirubin and absent urobilinogen?

A

Obstructive jaundice (post-hepatic)

146
Q

What is the acute management of alcohol withdrawal?

A

Chlordiazepoxide (Lorazepam in delirium tremens)

147
Q

What needs to be given prior to appendicectomy?

A

Prophylactic IV Abx

148
Q

What are pre hepatic causes of jaundice?

A

High bilirubin due to increased blood breakdown

Haemolytic anaemia
Gilbert syndrome
G6PD
Sickle cell anaemia
Malaria
Thalassaemia
149
Q

What are hepatic causes of jaundice?

A

Due to abnormal liver Metabolism of bilirubin

Acute hepatitis
Chronic hepatitis
Alcoholic liver disease
Non-alcoholic liver disease

150
Q

What are posthepatic causes of jaundice?

A

Due to blockage of bile ducts leading to obstruction

Pancreatic cancer
Ascending cholangitis
Gallstones
Pancreatitis
Primary biliary cholangitis
151
Q

What factors are used to determine severity/prognosis in acute pancreatitis?

A 
PANCREAS
P - Low PaO2
A - Age >55
N - Neutrophilia
C - Low calcium
R - renal function - high urea
E - enzymes
A - low albumin
S - high glucose
152
Q

How can you determine the cause of ascites and how can you interpret these results?

A

Ascitic tap for SAAG

SAAG >11 = Liver cirrhosis, heart failure

SAAG <11 = Nephrotic syndrome

153
Q

What is the first line screening test for Wilson’s disease?

A

24 hour urine collection for copper

154
Q

What are complications of pancreatic cancer or chronic pancreatitis?

A

Diabetes mellitus

Steatorrhoea

Obstruction

155
Q

How does acute liver failure present?

A

TRIAD

  1. Encephalopathy
  2. Jaundice
  3. Coagulopathy

Medicine Finals (32 decks)

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