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
2
Q
What are signs of liver disease?
A
Jaundice
Hepatomegaly/hepatosplenomegaly
Spider naevi
Palmar erythema
Bruising (due to abnormal clotting)
Asterix (flapping tremor)
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
4
Q
How is alcoholic liver disease diagnosed?
A
Ultrasound
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
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
7
Q
How does delirium tremens present?
A
Acute confusion
Severe agitation
Delusions/hallucinations
Tachycardia
Hypertension
Hyperthermia
8
Q
How is delirium tremens managed?
A
Oral lorazepam
9
Q
How do you calculate alcohol units?
A
(ml x percentage) / 1000
or L x percentage
10
Q
What is the most common cause of liver disease?
A
Non alcoholic fatty liver disease
11
Q
What are risk factors for NAFLD?
A
Raised cholesterol, obesity, smoking, HTN, T2DM
12
Q
What lab results are seen in NAFLD?
A
ALT is raised more than AST
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.
14
Q
What are causes of liver cirrhosis?
A
Alcoholic liver disease
NAFLD
Hepatitis B/C
Wilson’s disease
Haemochromatosis
15
Q
Why does splenomegaly occur in cirrhosis?
A
Portal hypertension
16
Q
What scoring system can be used to classify liver cirrhosis?
A
Child-Pugh classification
17
Q
What lab results are seen in liver cirrhosis? (LFTs and clotting)
A
Deranged LFTs
Raised prothrombin time
Low albumin
Raised bilirubin
18
Q
Which lab tests are the best indicator of liver function?
A
Albumin + prothrombin Time (synthetic function tests)
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
20
Q
How is liver cirrhosis monitored?
A
Ultrasound and alpha feroprotein checked every 6 months
Check that it has not become hepatocellular carcinoma
21
Q
What are complications of liver cirrhosis?
A
Portal hypertension
Ascites
Malnutrition
Spontaneous bacterial peritonitis
Hepatorenal syndrome
Hepatic encephalopathy
22
Q
Why does malnutrition occur in liver disease?
A
Liver cannot store glucose as glycogen as effectively
Reduced production of protein
23
Q
What does portal hypertension lead to the formation of?
A
Varices (swollen vessels)
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)
25
What is given prophylactically for future variceal bleeding?
Propranolol
26
How is Ascites managed?
Low sodium diet
Spironolactone
Ascites drain/tap
Prophylactic antibiotics against SBP -> oral Ciprofloxacin (in patients w less than 15g/litre of protein
27
How does spontaneous bacterial peritonitis present?
Fever
Abdominal pain
Raised inflammatory markers
Hypotension
28
Which organism is most commonly responsible for spontaneous bacterial peritonitis?
E. coli
Also- Klebsiella
29
How is spontaneous bacterial peritonitis managed?
IV Cefotaxime
30
What is given for prophylaxis of spontaneous bacterial peritonitis?
Oral ciprofloxacin
31
What is hepatorenal syndrome?
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
32
How is hepatorenal syndrome managed?
Liver transplant
33
What is hepatic encephalopathy?
Reduced consciousness and confusion caused by a build up of ammonia in the blood
34
What factors can precipitate hepatic encephalopathy?
Constipation
Infection
GI bleed
35
How is hepatic encephalopathy managed?
Laxative (Lactulose)
Or Antibiotic (rifaximin)
36
What is given for prophylaxis of hepatic encephalopathy?
Lactulose + Rifaximin (rifaximin is an antibiotic that causes decreased ammonia production from gut flora)
37
What is the most common viral hepatitis worldwide?
Hepatitis A
38
How is hepatitis A transmitted?
Faeco-orally (contaminated water and food)
39
What type of virus is hepatitis A?
An RNA virus
40
What type of virus is Hepatitis B?
A DNA virus
41
How is hepatitis B transmitted?
Direct bodily fluid contact (blood, semen)
42
Which marker is raised in acute hepatitis B?
HBsAg
43
Which marker is raised in vaccination or past infection of Hep B?
HBsAb (anti-HbS)
44
Which marker is raised in chronic hepatitis B infection?
HbsAg + Anti-HBc
45
Which type of virus is Hepatitis C?
RNA virus
46
How is Hepatitis C transmitted?
Direct bodily fluids
47
Which hepatitis is most likely to become chronic?
Hepatitis C
48
What are the two types of autoimmune hepatitis and which autoantibodies are associated with each?
Type 1 - anti-nuclear antibodies and/or anti-smooth muscle antibodies
Type 2 - anti liver kidney microsomes 1
49
What are features of autoimmune hepatitis?
Signs of chronic liver disease
May be fever or jaundice
In women - amenorrhoea
50
How is autoimmune hepatitis managed?
Prednisolone or other immunosuppressants e.g. Azathioprine
51
What is ischaemic hepatitis?
Liver inflammation caused by hypoperfusion (patient acutely hypotensive)
Raised ALT
Often also AKI
52
What are drug causes of hepatocellular dysfunction?
Paracetamol
Sodium valproate, phenytoin
Statins
Alcohol
Nitrofurantoin
Amiodarone
Methyldopa
53
What are drug causes of cholestasis?
COCP
Flucloxacillin
Co-amoxiclav
Erythromycin
Sulfonylureas
54
How much paracetamol is needed to cause toxicity?
More than 75mg/kg, or staggered overdose
55
How is paracetamol overdose managed?
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
56
What is primary biliary cholangitis?
Autoimmune condition, destruction of small bile ducts within liver
Causes obstruction of bile outflow (cholestasis)
57
What are symptoms of bile outflow obstruction?
Itching
Xanthelasma
Jaundice, pale stools
58
Which antibody is raised in primary biliary cholangitis?
Anti-mitochondrial antibodies
May also be ANA
59
How is primary biliary cholangitis/cirrhosis managed?
Ursodeoxycholic acid
60
What is primary sclerosing cholangitis?
Inflammation and fibrosis of the intra and extra hepatic bile ducts
Causes obstruction of bile outflow
61
Which condition is associated with primary sclerosing cholangitis?
Ulcerative colitis
62
Which liver condition is associated with ulcerative colitis?
Primary sclerosing cholangitis
63
How does primary sclerosing cholangitis present?
Jaundice
Chronic right upper quadrant pain
Pruritus
Fatigue
Raised bilirubin
Raised ALP
64
Which autoantibody is raised in primary sclerosing cholangitis?
pANCA
65
What is the gold standard investigation for primary sclerosing cholangitis?
MRCP
Shows beaded appearance of biliary strictures
66
Which liver condition causes a beaded appearance/biliary strictures on MRCP?
Primary sclerosing cholangitis
67
How is primary sclerosing cholangitis managed?
Liver transplant
68
Which drug can be used to help with pruritus in PBC/PSC?
Colestyramine
69
What are risk factors for the development of gallstones?
Fat, fair, female, forty
70
How do gallstones present?
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
How are gallstones diagnosed?
First line = Ultrasound
If no stones seen - MRCP
72
How are gallstones managed?
If asymptomatic - no treatment needed
If stones in gallbladder - cholecystectomy
If stones in bile ducts outside of gall bladder - ERCP
73
What is acute cholecystitis?
Inflammation of the gallbladder due to blockage of the cystic duct due to gallstones
74
How does acute cholecystitis present?
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
How is acute cholecystitis diagnosed?
Ultrasound
Raised inflammatory markers (inflammatory markers will not be raised if just regular biliary colic)
76
How is acute cholecystitis managed?
Cholecystectomy within 1 week of diagnosis
77
What is acute cholangitis/ascending cholangitis?
Bacterial infection of the biliary tree, usually due to gallstones or after an ERCP procedure
78
Which organism is most commonly responsible for acute cholangitis?
E. coli
79
Which triad of symptoms is present in acute cholangitis?
Charot’s triad
Fever, jaundice and RUQ pain
80
How is acute cholangitis diagnosed?
Ultrasound is first line
Contrast CT is more sensitive
81
How is acute cholangitis managed?
Fluid resus
IV Abx
ERCP to remove stones
82
What lab results are seen in pre-hepatic jaundice?
Normal to high bilirubin (unconjugated)
Normal AST/ALT
Normal ALP
83
What lab results are seen in hepatic jaundice?
High bilirubin
ALT/AST = Very high
ALP = mildly elevated
84
What lab results are seen in post-hepatic jaundice?
Very high bilirubin
Moderately elevated ALT/AST
Very high ALP
Pale stools, dark urine
85
What are the three main causes of pancreatitis?
Gallstones - gallstones trap flow of bile and this refluxes into the pancreatic duct
Alcohol
Post-ERCP
86
How does pancreatitis present?
Severe epigastric pain radiating to the back
Vomiting
Low grade fever
87
Which two signs are seen in pancreatitis?
Cullen’s sign - bruising around umbilicus
Grey Turners sign - bruising around flanks
88
Which markers are raised in pancreatitis?
Serum amylase and serum lipase
89
How is pancreatitis diagnosed?
Ultrasound (but in practice usually just a clinical diagnosis)
90
How is pancreatitis managed?
Self-limiting - no antibiotics needed
Fluids
Analgesia
91
Which electrolyte can indicate severity in pancreatitis?
Low calcium indicates severity
92
What is the most common cause of chronic pancreatitis?
Alcohol
93
How does chronic pancreatitis present?
Similar to acute but less intense
Pain usually worse after eating
May be symptoms of obstructive jaundice
usually in alcoholics
94
How is chronic pancreatitis diagnosed?
Secretin stimulation test
CT or MRCP
Amylase is usually normal
95
How is chronic pancreatitis managed?
Replacement of pancreatic enzymes (lipase)
96
What is haemochromatosis?
An iron storage disorder where there is excessive total body iron leading to iron deposition in tissues
97
What type of hereditary pattern does haemochromatosis have?
Autosomal recessive
98
How does haemochromatosis present?
Early symptoms - fatigue, erectile dysfunction, Arthralgia
Bronze skin pigmentation
Diabetes mellitus (iron affects functioning of pancreas)
Dilated cardiomyopathy
Hypogonadotropic hypogonadism
Arthritis
99
What lab results are seen in haemochromatosis?
Raised serum ferritin
Raised transferrin saturation
Low total iron binding capacity
100
How is haemochromatosis managed?
First line = venesection
Second line = desferrioxamine
101
What is Wilson’s disease?
Excessive accumulation of copper in the blood
102
What type of hereditary pattern does Wilson’s disease have?
Autosomal recessive
103
How does Wilson’s disease present?
Usually presents between 10-25
Children usually present with liver signs
Young adults usually present with neurological signs
104
What are liver signs of Wilson’s disease?
Chronic hepatitis and cirrhosis
Pruritus
Spider naevi
Jaundice
Palmar erythema
105
What are neurological signs seen in Wilson’s diseases?
Parkinsonism
Concentration and co-ordination difficulties
Psychiatric symptoms - depression/psychosis
Speech difficulty
106
How is Wilson’s disease diagnosed?
Low serum caeruloplasmin (protein which stores copper)
Low serum copper
High urinary copper excretion
Gold standard diagnosis = liver biopsy
107
How is Wilson’s disease managed?
Penicillamine (copper chelating agent)
108
What type of hereditary pattern does alpha-1 anti-trypsin deficiency have?
Autosomal recessive
109
What occurs in alpha-1 anti trypsin deficiency?
Liver = Cirrhosis and Hepatocellular carcinoma
Lungs = Bronchiectasis and emphysema
110
What’s the most common cause of hepatocellular cancer worldwide?
Chronic hepatitis B
111
What are other causes of hepatocellular carcinoma?
Alcohol
Haemochromatosis (not Wilson's disease)
Primary biliary cirrhosis
112
Does Wilson’s disease increase risk of hepatocellular carcinoma?
No
113
Which marker is raised in hepatocellular carcinoma?
Raised alpha-feta protein
114
What is cholangiocarcioma?
Cancer of the bile duct
115
What is the most common type of cholangiocarcinoma?
Adenocarcinoma
116
What is the main risk factor for cholangiocarcinoma?
Primary sclerosing cholangitis (the one that is associated with ulcerative colitis)
117
How does cholangiocarcinoma present?
Painless jaundice
Weight loss
Palpable mass in RUQ
pale stools, dark urine
118
Which bio marker is raised in cholangiocarcinoma?
CA19-9
119
What is the most common type of pancreatic cancer?
Adenocarcinoma
120
Which type of pancreatic cancer causes an obstructive jaundice?
Head of pancreas cancer
121
How does pancreatic cancer present?
Painless obstructive jaundice
Pale stools, dark urine
Raised ALP
Weight loss
New onset DM/worsening glycemic control
122
What is the 2WW criteria for pancreatic cancer?
>40 with painless jaundice
123
How is pancreatic cancer diagnosed? What is seen?
CT Abdomen
Double-duct sign (both common bile duct and pancreatic duct = dilated)
124
What is the criteria for a direct access CT abdomen if 2WW criteria has not been met for Pancreatic cancer?
>60 + weight loss + symptom of pancreatic cancer which is not jaundice
125
How does acute appendicitis present?
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
What lab results are seen in acute appendicitis? How is appendicitis diagnosed?
Raised inflammatory markers
Appendicitis causes a neutrophil predominant leukocytosis
Ultrasound = diagnostic
127
What are key differentials for acute appendicitis?
Ectopic pregnancy
Ovarian cyst rupture/torsion
128
How is acute appendicitis managed?
Appendicectomy
Prophylactic IV Abx
129
What is carcinoid syndrome?
Cancer metastases in the liver which release serotonin into the systemic circulation
130
How does carcinoid syndrome present?
Flushing
Diarrhoea and abdominal pain
Hypotension
Wheeze
Tricuspid insufficiency
131
How is carcinoid syndrome diagnosed?
Raised urinary 5-HIAA
132
How is carcinoid syndrome managed?
Octreotide (somatostatin analogue)
133
What is Gilbert’s syndrome?
An autosomal recessive condition causing defective bilirubin conjugation
Can lead to jaundice during times of stress/illness but otherwise asymptomatic
No treatment required
134
How does Gilbert’s syndrome present?
Jaundice during stress/illness
135
How is Gilbert’s syndrome managed?
No treatment needed
136
What is Budd-Chiari syndrome?
Thrombosis of the hepatic vein
137
What are causes of Budd-Chiari syndrome?
Polycythaemia rubra Vera
Pregnancy
COCP
Thrombophilia
138
What triad of symptoms is seen in Budd-Chiari syndrome?
Sudden onset severe abdominal pain
Ascites
Tender hepatomegaly
139
Which blood result is used to determine if there is any evidence of acute liver failure?
Prothrombin time
140
How do you determine if someone with alcoholic liver disease will benefit from steroids?
Maddrey’s discriminant function - need prothrombin time and serum bilirubin
141
Which condition is Murphy’s sign associated with? What is Murphy's sign?
Acute cholecystitis
Patient stops breathing during inspiration (catch in breath) when palpating gallbladder
142
Which type of hepatitis causes amenorrhoea?
Autoimmune hepatitis
143
Which liver markers are raised in autoimmune hepatitis?
ALT
Bilirubin
144
What medication can be used to help pruritus in PBC/PSC?
Cholestyramine
145
Jaundice: Urinalysis shows bilirubin and absent urobilinogen?
Obstructive jaundice (post-hepatic)
146
What is the acute management of alcohol withdrawal?
Chlordiazepoxide (Lorazepam in delirium tremens)
147
What needs to be given prior to appendicectomy?
Prophylactic IV Abx
148
What are pre hepatic causes of jaundice?
High bilirubin due to increased blood breakdown
```
Haemolytic anaemia
Gilbert syndrome
G6PD
Sickle cell anaemia
Malaria
Thalassaemia
```
149
What are hepatic causes of jaundice?
Due to abnormal liver Metabolism of bilirubin
Acute hepatitis
Chronic hepatitis
Alcoholic liver disease
Non-alcoholic liver disease
150
What are posthepatic causes of jaundice?
Due to blockage of bile ducts leading to obstruction
```
Pancreatic cancer
Ascending cholangitis
Gallstones
Pancreatitis
Primary biliary cholangitis
```
151
What factors are used to determine severity/prognosis in acute pancreatitis?
```
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
How can you determine the cause of ascites and how can you interpret these results?
Ascitic tap for SAAG
SAAG >11 = Liver cirrhosis, heart failure
SAAG <11 = Nephrotic syndrome
153
What is the first line screening test for Wilson's disease?
24 hour urine collection for copper
154
What are complications of pancreatic cancer or chronic pancreatitis?
Diabetes mellitus
Steatorrhoea
Obstruction
155
How does acute liver failure present?
TRIAD
1. Encephalopathy
2. Jaundice
3. Coagulopathy
