Liver Function CPC Flashcards
CASE 1
A 20-year old medical student is referred up because of abnormal LFTs.
Bilirubin 32 micromol/l (N 5-17)
1. What are the causes of a high bilirubin?
Pre-hepatic (Unconjugated) - Haemolysis - Do FBC and Film to look for this
Hepatic disease - Repeat LFT’s
Post hepatic (Conjugated) Raised AlkPhos - Obstuctive i.e. Gallstone or pancreas
Gilberts
CASE 1
A 20-year old medical student is referred up because of abnormal LFTs.
Bilirubin 32 micromol/l (N 5-17)
Other LFT’s normal
Cousin had case of jaundice once and normal liver biopsy
2) What should we do ? A. Nothing B. Repeat bilirubin fasting C. Other blood tests D. Abdo Ultrasound E. CT abdomen F. Liver Bx.
B) Repeat bilirubin fasting
CASE 1
A 20-year old medical student is referred up because of abnormal LFTs.
Bilirubin 32 micromol/l (N 5-17)
Repeated Blood tests while fasting
FBC normal
Normal film
LFT’s normal except Bilirubin has gone higher: 45
3) What does he have?
Gilberts Syndrome - Bilirubin high but every other LFT is normal. Bilirubin is made worse by fasting
Gilberts Syndrome
4. How is it inherited ? A. Recessive B. Dominant C. X-linked D. No idea
A) Recessive
Gilberts Syndrome
5. What percentage are carriers? A. 10% B. 20% C. 50% D. 70% E. 80%
C) 50%
What’s the pathology of Gilberts?
UDP glucuronyl transferase activity reduced
Will you find Bilirubinurea in gilberts?
No bilirubinurea as unconjugated bilirubin binds to albumin and doesn’t enter urine
What difference in urine for obstructive jaundice
No/reduced Urobilinogen and dark urine
This is because bilirubin goes into gut and makes stools brown
In a normal person that bilirubin is reabsorbed and turned into urobilinogen which you pee out
- Which is most representative of liver function?
A. Prothrombin time B. Bilirubin C. Alanine Aminotransferase (ALT) D. Aspartate Aminotransferase (AST) E. Alkaline phosphatise (Alk Phos) F. Gamma Glutamyl Transferase (GGT)
A. Prothrombin time
Because all of the other ones leak out when liver is damaged
Whereas prothrombin time measures the activity of the liver producing the clotting factors
Albumin, Bilirubin, and Clotting factors also indicate liver function
- What is the most worrying sign in a patient who has taken a paracetamol overdose?
A. High AST and ALT
B. Prolonged PT
C. Jaundice
D. Raised GGT and ALP
B) Prolonged PT
If PT in seconds is greater than hours of OD, need liver transplant
Chronic alcohol abuser aged 35 presents with jaundice, abdominal pain, nausea.
The bilirubin is 90 micromoles per litre (N 5-17).
- What is your differential diagnosis at this point ?
Pre-hepatic - Gilberts, Haemolysis
Hepatic - Viral/Alcoholic Hep, cirrhosis
Post hepatic - Gallstones, Pancreatic cancer
Chronic alcohol abuser aged 35 presents with jaundice, abdominal pain, nausea.
Liver function tests:
Bilirubin 90.
Alk Phos: 200 (<130)
AST: 1500 (<50)
ALT: 750 (<50)
- What diagnoses do these suggest is causing the jaundice?
A. Pre-hepatic
B. Hepatic
C. Post-hepatic
B. Hepatic
In obstructive - ALP will have the biggest increase
In hepatic - AST/ALT will have the biggest increase
Chronic alcohol abuser aged 35 presents with jaundice, abdominal pain, nausea.
Evidence of ballooning, Mallory Denk bodies, and inflammation of the liver
- What treatment is needed?
Supportive
Stop alcohol
Nutrition
Vitamins - Pabrinex (Vitamins B and C) (Thiamine is the only one needed in this case, but the infusion has em all)
Occasionally steroids if liver inflammation found
Chronic alcohol abuser aged 35 presents with jaundice, abdominal pain, nausea.
- Which of the following conditions is caused by vitamin B1 deficiency?
A. Rickets B. Scurvy C. Pernicious anaemia D. Beri-Beri E. Pellagra F. Neural tube defects
D. Beri-Beri
Chronic alcohol abuser aged 37
Two years later he has:
Multiple Spider Naevi
Dupuytren’s contracture
Palmar Erythema
Gynaecomastia
13. What do these signify? A. Jaundice B. Hepatitis C. Chronic stable liver disease D. Portal hypertension. E. Liver failure F. Obstruction of the bile ducts
C. Chronic stable liver disease
They won’t get better if they stop drinking, but they’ll be stable if they stop drinking
Chronic alcohol abuser aged 40
- Five years later, this is seen on his abdomen.
Veins visible on abdomen
What is it and what causes it?
Visible veins - Caused by portal hypertension. Not Caput Medusae yet.
Caput Medusae when lots of Visible veins radiating out of the umbilicus
Chronic alcohol abuser aged 40
- What else are you MOST likely to find on abdominal examination at this stage, given the visible vein on anterior abdominal wall?
A. Hepatomegaly B. Splenomegaly C. Bilateral palpable kidneys D. A palpable bladder E. An enlarged prostate gland on PR.
B. Splenomegaly
As portal hypertension leads to splenic vein pressure and back up in the spleen
Chronic alcohol abuser aged 40
Examination revealed scrotal oedema and shifting dullness.
What does this suggest?
What would non shifting dullness suggest?
Ascites
Non shifting dullness is just normal fat
Chronic alcohol abuser aged 40 with:
Visible veins
Splenomegaly
Ascites
17. What has happened ? A. Jaundice B. Hepatitis C. Chronic stable liver disease D. Portal hypertension. E. Liver failure F. Obstruction of the bile ducts.
D. Portal hypertension.
All 3 are signs of portal hypertension
Chronic alcohol abuser aged 40 with:
Visible veins
Splenomegaly
Ascites
Admitted to drain ascites but developed a short flap shortly afterwards
18. What has happened ? A. Jaundice B. Hepatitis C. Chronic stable liver disease D. Portal hypertension. E. Liver failure F. Obstruction of the bile ducts.
E. Liver failure
Liver flap is a sign that brain is now being poisoned by something the liver should’ve cleared out (Assumed to be ammonia)
What are the 4 aspects of liver failure
Failed synthetic function n (Hypoglycaemia)
Failed clotting factor and albumin (Easy bleeds/bruising)
Failed clearance of bilirubin (Jaundice)
Failed clearance of ammonia (Assumed to be cause of hepatic encephalopathy)
How to manage liver failure?
Manage Hypoglycaemia
IV Vit K to help with bruising/bleeding
Treat encephalopathy with lactulose
