Liver History and Exam Flashcards
5 signs of decompensation/failure?
Jaundice – bilirubin
Pruritis – bile
Bleeding varices – portal hypertension
Ascites/oedema – portal hypertension (can also get caput medusae
Encephalopathy – build up of ammonia and other toxic products
PMH:
What iatrogenic Rx do you need to ask about which could introduce Hep B or C?
What diseases should you ask about for metabolic syndrome?
What does previous jaundice suggest?
What does previous surgery increase the risk of? - 3
Transfusion/injections
Weight
T2DM
HTN
Hep B and C - IVDU
Biliary stricture
Retained stones
Hepatic metastases
Fix:
What 3 diseases are you asking about in FH?
For viral hepatitis, what could you ask about?
Haemochromatosis
Wilson’s disease
Alpha-1-trypsin deficiency
Any contacts unwell
SHx:
What should you ask about in social history to see if there could be any Hep E?
What would you ask about to look for Hep B or HIV infection? - 3
What recreational drugs should we have in mind?
What should you not forget if they are quite sporty or have a high muscle mass?
Travel history (Hep E commoner in 3rd world countries)
IVDU
Sexual history
Tattoos
Cocaine
Amphetamines
Ask about anabolic steroid use - Liver damage from anabolic steroids can cause a condition called cholestasis.
Ddx:
You would need to take a full medication history!!!
Immunosuppressants and chemo agents should also be asked!
Ddx:
You would need to take a full medication history!!!
Immunosuppressants and chemo agents should also be asked!
Discriminating symptoms for:
What disease causes hyperpigmentation?
What autoimmune liver disease could also cause hyperpigmentation?
What could bloody diarrhoea suggest?
What does weight loss suggest?
What does a SOB/Emphysema picture suggest?
What does dry eyes and mouth suggest?
Pigmentation - PBC, Haemochromatosis
Bloody diarrhoea – PSC (IBD patients)
Weight loss – Malignancy
SOB/emphysema – AAT deficiency
Dry eyes/mouth – PBC
Discriminating symptoms for:
3 main symptoms of biliary colic pathology or cholangitis? - do next q at same time
What 2 extra symptoms would then suggest cholestasis?
What is the main symptom of haemochromatosis which should point you towards it?
Abdo pain
Fever
Rigors
Pruiritis
Jaundice
Arthritis/arthralgia
Examination:
Hands - 4
Chest and back - 1
Abdomen - 3
What is important to check for in men?
What do you notice in the eyes of patients with suspected Wilson’s Disease?
Clubbing
Leukonychia
Palmar erythema
Asterixis
Spider naevi
Scratch marks
Hepatosplenomegaly
Ascites
Loss of secondary sexual characteristics - gynaecomastia, hair loss
Kayser-Fleisher rings (Golden brown discolouration)
What are the 5 imaging stages?
USS CT MRI FIBROSCAN Liver biopsy
(1) USS is the first line imaging.
Ultrasound is good at assessing:
· Degree dilatation biliary tree
· Stones in gallbladder
· Size, patency and flow of hepatic and portal veins
· Space occupying lesions (detectable if >1cm)
It is less good at assessing??? - 2
CT is next - JUST READ
It is good at characterising lesions in the Liver, such as hepatocellular carcinoma (HCC), liver metastases and liver abscesses. It is good at identifying vascular problems, including bleeding, hepatic artery thrombosis or portal vein thrombosis.
CT is also good at evaluating complications of biliary and gallbladder disease, in particular when the diagnosis is unclear or when alternative diagnoses need to be excluded.
CT is sensitive for detecting biliary ductal dilatation, intra-hepatic bile duct tumours, pancreatic tumours and the level of biliary obstruction. CT does not always visualise biliary stones.
It is less good at assessing:
· Stones in the common bile duct
· Liver Parenchyma – in particular the degree of fibrosis or cirrhosis
(2) MRI is good at visualising blood vessels, ducts and hepatic tissue. It is good at diffuse liver disorders (fatty liver, Haemochromatosis) and assessing focal lesions (haemangiomas, HCC, metastasis). However it is less accessible compared to CT due to the time it takes to undertake imaging.
What are some contraindications?
Metal implants - pacemakers
Claustrophobia
Unable to hold breath easily
(3) MRCP:
What does it stand for?
What imaging modality is used for this?
Allows detailed imaging of all the gallbladder and biliary structure?
(3) ERCP:
What does it stand for?
What can be done curatively?
What are 3 risks?
ERCP has been largely by ERCP for diagnosis!
Magnetic resonance cholangiopancreatography (MRCP)
MRI
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Endoscopic retrograde cholangiopancreatography (ERCP)
Tissue sampling
Stone removal
Duct dilatation
Stent placement
Pancreatitis - introduction of bacteria
Perforation
Bleeding
(4) Fibroscan:
What does it measure?
What imaging modality is used for this?
What is the last part of diagnosis - not needed for all?
Looks at the elasticity of the liver - changes with cirrhosis
US - specialised style
Liver biopsy
Broadly a liver biopsy can help in two ways:
To establish a diagnosis, where there is diagnostic uncertainty
Assessing disease severity, including staging or grading of liver disease e.g. to stage degree fibrosis or cirrhosis, or grading degree of autoimmune hepatitis
