Liver + friends Flashcards
Define acute liver failure
Rapid decline in hepatic function
Clinical presentation of acute liver failure
- Jaundice
- Abdominal pain
- Hepatic encephalopathy (confusion,insomnia)
- N+V
- Right upper quadrant tenderness
Diagnosis of acute liver failure
- LFT
- Hyperbilirubinemia
- Raised ALT
- Raised AST
- PT/INR (coagulation test)
- INR>1.5
- U&E
- Hepatitis screen (ABCE)
Treatment of acute liver failure
- ITU support
- Monitor and correct glucose + electrolytes
- Liver transplant
- N-acetylcisteine (paracetamol OD)
- Viral hepatitis - ACICLOVIR
Clinical presentation of chronic liver failure
- Oedema
- Gynaecomastia
- Anorexia
- Clubbing
- Easy bleeding + bruising
Aetiology of acute liver failure
- Paracetamol overdose
- Alcohol
- Viral hepatitis
- Drugs
- Obstruction
Aetiology of chronic liver failure
- Alcohol
- Viral hepatitis
- autoimmune
- Metabolic
Define liver cirrhosis
- Fibrosis and conversion of normal liver architecture
- To structurally abnormal nodules (regen nodules)
- Final stage of any chronic liver disease
- Irreversible
Aetiology of liver cirrhosis
- Alcohol abuse
- Hep B and C
- Fatty liver disease
Clinical presentation of liver cirrhosis
- Palmar erythema
- Dupuytren’s contracture
- Jaundice
- Ascites
- Spider naevi
Diagnosis of liver cirrhosis
- serum albumin and PT (INR/PT = high)
- Platelets
- Thrombocytopenia
- U+E
- Biopsy
Treatment of liver cirrhosis
- LIVER TRANSPLANT
- Ascites = diuretics = SPIRONOLACTONE
- Cerebral oedema = MANNITOL
- Bleeding = VIT K
- Encephalopathy = decrease ammonia = LACTULOSE, ANTIBIOTICS, ENEMA
- Hep B - TENOFOVIR
Define ascites
Fluid in peritoneal cavity
Aetiology of ascites
Cirrhosis
pathophysiology of ascites
- Peritonitis = more leaky
- Raised capillary hydrostatic pressure
- Reduced colloid oncotic pressure
- Peritoneal lymphatic draining
How do you distinguish between transudate and exudate ascites
- Transudate = protein<25g/L
- Exudate = protein>25g/L
Aetiology of transudate ascites
- Portal hypertension
- Low plasma protein
- Heart failure
Aetiology of exudate ascites
- Peritonitis
- Peritoneal malignancy
Clinical presentation of ascites
- Shifting dullness - fluid = buoyancy -> tympanic sound on front where air filled bowel loops are, when patient lying supine but dullness on flanks
- Abdominal disetension
- Resp. distress
Diagnosis of ascites
- Physical examination of abdomen
- Diagnostic aspiration (needle for fluid check in abdomen)
Treatment of ascites
- salt restriction
- Diureitcs = FUROSEMIDE
What is SAAG
- Serum-Ascites Albumin Gradient
- Used to determine cause of ascites
- SAAG = (serum albumin) - (albumin level of ascitic fluid)
Aetiology of portal vein hypertension
- Prehepatic = portal vein thrombosis
- Intrahepatic = schistosomiasis, cirrhosis
- Posthepatic = right side heart failure
Transmission of Hep A
Faecal-oral
Epidemiology of Hep A
- Rare
- Poor ends
Pathophysiology of Hep A
- Acute infection
- Usually cleared by host immune system
Clinical presentation of Hep A
NON SPECIFIC SYMPTOMS
1. Nausea
2. Anorexia
3. Malaise
LIVER SYMPTOMS
1. Jaundice
2. Hepatomegaly
3. Skin rash
Diagnosis of Hep A
LFTs
1. Raised ALT (alanine transaminase)
2. Raised bilirubin
3. Serology
Treatment of Hep A
Vaccine
Transmission of Hep B (HBV)
- Blood products (IVDU)
- Sex (MSM)
- Vertical transmission (across generations)
Pathophysiology of Hep B
- Acute infection infects hepatocyte
- Cellular response usually suffices
- Chronic HBV if HbsAg >6months
Clinical presentation of Hep B
- Acute infection symptoms
- chronic -> cirrhosis symptoms
Diagnosis of Hep B
LFTs
Serology
Ag (Antigen) after 6 months = chronic Hep B
Treatment of Hep B
- Vaccine
- Antiviral treatment TENOFOVIR
Transmission of Hep C
- Blood/blood products - IVDU
- More common in UK
Pathophysiology of Hep C
- Acute infection often asymptomatic .˙. can become chronic
- Chronic -> slow progressive fibrosis over years
Clinical presentation of Hep C
Acute = asymptomatic
Chronic = chronic liver disease
Diagnosis of Hep C
LFTs
Serology
If Ag after 6m = chronic HCV
Treatment of Hep C
Interferon based regimens
Transmission of Hep D
Blood borne
- Sex
- IVDU
Pathophysiology of Hep D
- Requires concurrent HBV infection to replicate
- Progression to cirrhosis more likely
Clinical presentation of Hep D
- Vaccine
- Antiviral treatment TENOFOVIR
Transmission of Hep E
Faeco-oral transmission (undercooked meat)
Common in UK
Clinical presentation of Hep E
Asymptomatic
Diagnosis of Hep E
Serology
Treatment of Hep E
Not required but supportive
Define haemochromatosis
- Multi-system disorder
- Dysregulated dietary iron absorption
- Increased iron release from macrophages
Aetiology of haemochromatosis
- Autosomal recessive
- Secondary iron overload by multiple transfusion
Pathophysiology haemochromatosis
Iron accumulates in:
- liver
- joints
- pancreas
- heart
- skin
- gonads
Clinical presentation of haemochromatosis
- Slate grey skin
- Hypogonadism
Diagnosis of haemochromatosis
- Bloods
- Iron
- LFTs
- Liver biopsy
Treatment of haemochromatosis
- Venesection
- Iron chelation
- liver transplant
Define Wilson’s disease
- Excessive copper
- Build up in liver and CNS
Aetiology of Wilson’s disease
- Autosomal recessive
- Defective enzyme involved in biliary excretion of excess copper
Pathophysiology of Wilson’s disease
- Cu2+ accumulates in liver -> liver symptoms
- Cu2+ accumulates in basal ganglia -> Parkinson’s symptoms
- Cu2+ accumulates in cornea -> Kayser-Fleischer rings)
Clinical presentation of Wilson’s disease
- Parkinson
- Depression
- Neurotic behaviour
- Kayser-Fleischer ring
Diagnosis of Wilson’s disease
- 24h urine copper and blood caeruloplasmin
- Liver biopsy
Treatment of Wilson’s disease
- Pencillamine (copper chelation)
- Liver transplant
Define acute pancreatitis
- Sudden inflammation of pancreas
- Auto-digestion of the gland
- reversible
Clinical presentation of acute pancreatitis
- Sever epigastric pain radiating to back
- N+V
- Fever and chills
- Haemodynamic instability
- Retroperitoneal haemorrhage
Aetiology of acute pancreatitis
- Idiopathic
- Gallstones
- Alcohol
- Trauma
- Steroids
Diagnosis of acute pancreatitis
- Amylase/lipase
- LFTs
- CRP
- CT
Treatment of acute pancreatitis
- Nil By Mouth (NBM) - bowel rest
- Aggressive fluid resuss
- Analgesia
- Abx (antibiotics) if necrotising pancreatitis
Define chronic pancreatitis
- Long standing inflammation
- From irreversible damage to pancreas
Clinical presentation of chronic pancreatitis
- Epigastric pain radiating to back
- N+V
- Steatorrhea (fatty stool)
- Weight loss
- Insulin dependent DM
Aetiology of chronic pancreatitis
- Alcohol
- CF
- Cancer
- Autoimmune
Diagnosis of chronic pancreatitis
- Secretin stimulation test
- CT, MRI, MRCP
Treatment of chronic pancreatitis
- Creon (pancreatic enzyme replacement therapy)
- Insulin
- Opioids
- Alcohol cessation
- Surgery
Define biliary colic
Temporary blockade of cystic duct by gallstones
Clinical presentation of biliary colic
- RUQ pain after fatty meals
- Referred shoulder pain
- N+V
Diagnosis of biliary colic
- USG
- LFT
- FBC
- Lipase
Treatment of biliary colic
- Analgesia
- Lap. Cholecystectomy
Define acute cholecystitis
- Blockade of cystic duct
- Leading to build up of bile
- -> transmural inflammation of gallbladder
Clinical presentation of acute cholecystitis
- RUQ pain after fatty meals
- Referred shoulder pain
- N+V
- Fever
- Murphy’s +ve (inspiratory arrest upon applying pressure to RUQ)
Diagnosis of acute cholecystitis
- FBC
- CRP
- LFTs
- USG (ultrasonography)
Treatment of acute cholecystitis
- Lap cholecystectomy (within 7 days)
- Fluids + analgesia for surgery
Define ascending cholangitis
- Medical emergency
- Bacteria ascending through biliary tree
- -> septicaemia
Clinical presentation of cholangitis
- Charcot’s Triad
- RUQ pain
- Jaundice
- Fever + rigors
- Reynol’d pentad
- Charcot’s Triad
- Confusion
- Septic shock
Diagnosis of cholangitis
- Amylase/lipase
- LFTs
- CRP
- FBC
- CT, USG, MRCP, ERCP
Treatment of cholangitis
- Aggressive fluid resuss
- IV Abx -> PENICILLIN & AMINOGLYCOSIDES
- Pressor support
- ERCP
- Cholecystectomy when improved
Define primary biliary cirrhosis
- Progressive autoimmune destruction of liver + biliary tree
- -> fibrosis then cirrhosis