Liver pathology Flashcards

1
Q

What are the functions of the liver?

A
  • Storage
  • Synthetic
  • Metabolic
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2
Q

What is stored in the liver?

A
  • Glycogen
  • Vitamins
  • Iron
  • Copper
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3
Q

What is synthesised by the liver?

A
  • Glucose
  • Lipids/cholesterol
  • Bile
  • Clotting factors
  • Albumin (main protein in systemic circulation)
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4
Q

What is the metabolic function of the liver?

A
  • Detoxifying
  • Bilirubin
  • Ammonia
  • Drugs
  • Alcohol
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5
Q

What are the symptoms of liver pathology?

A
  • Jaundice
  • Oedema/ascites
  • Bleeding
  • Confusion
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6
Q

Why does liver pathology cause jaundice?

A
  • Bilirubin not conjugated by the liver
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7
Q

Why does liver pathology cause oedema/ascites?

A
  • Reduced ability of liver to synthesise albumin
  • Leads to reduced oncotic pressure in the blood
  • Water leaves circulation and cannot be drawn back from interstitium
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8
Q

Why does liver pathology lead to bleeding?

A
  • Reduced clotting factor production
  • Happens over a long period of time unless damage is extreme
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9
Q

Why does liver pathology lead to confusion?

A
  • Impaired ammonia detoxification
  • Ammonia is soluble + diffuses across blood brain barrier
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10
Q

What are the initial symptoms of liver pathology?

A
  • Fatigue
  • Nausea
  • Abdominal pain
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11
Q

What can cause acute liver pathology?

A
  • Alcohol
  • Paracetamol
  • Viruses (EBV, CBV)
  • Medications e.g. aspirin in children
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12
Q

What is the difference between decompensated liver disease and acute liver failure?

A
  • If jaundice, oedema/ascites, bleeding and confusion happen acutely = decompensated liver disease
  • If this occurs without any history of liver disease = acute liver failure
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13
Q

What is cirrhosis?

A
  • Permanent irreversible damage to liver resulting in impairment of function and distortion of liver architecture due to chronic inflammation
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14
Q

Outline how alcoholic liver disease causes a fatty liver

A
  • Usually reversible
  • Alcohol releases glucose as it’s broken down
  • Insulin causes glucose to be stored as starch
  • But if there’s an excessive amount it is stored as triglycerides
  • Fatty deposits build up in the liver
  • Large liver due to fat
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15
Q

Which drugs can cause liver inflammation?

A
  • Iatrogenic drugs that become hepatotoxic
  • Alcohol (alcoholic liver disease)
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16
Q

How does alcoholic liver disease progress?

A
  • Fatty change (weeks) causes hepatomegaly
  • Alcoholic hepatitis (years) causes right upper quadrant pain and jaundice
  • Cirrhosis
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17
Q

Outline alcoholic hepatitis

A
  • See inflammation and inflammatory cells in liver
  • More severe symptoms
  • Jaundice, RUQ pain, hepatomegaly, oedema, ascites
  • Initially reversible but can become permanent if cirrhosis occurs
  • Treat symptoms and reduce alcohol intake
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18
Q

Outline alcoholic hepatitis

A
  • See inflammation and inflammatory cells in liver
  • More severe symptoms
  • Jaundice, RUQ pain, hepatomegaly, oedema, ascites
  • Initially reversible but can become permanent if cirrhosis occurs
  • Treat symptoms and reduce alcohol intake
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19
Q

Which infections can cause inflammation of the liver?

A
  • Hepatitis B - vaccine, no cure, symptomatic
  • Hepatitis C - IV drug use, cure, no vaccine, asymptomatic
  • Hep C can lead to malignancy
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20
Q

What is NAFLD?

A
  • Non-alcoholic fatty liver disease
  • Insulin resistance
  • Triglycerides accumulate in hepatocytes
  • Cause inflammation
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21
Q

What is NASH?

A
  • Non-alcoholic steatohepatitis
  • inflammation
  • more present due to obesity and diabetes
  • Treat symptoms and reduce risk factors e.g. blood glucose levels
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22
Q

What is hereditary haemochromatosis and how does it affect the liver?

A
  • Autosomal recessive
  • Linked to increased ferritin levels
  • Increased absorption of iron from small intestine
  • Increased deposition in the liver
  • Causes inflammation
  • Treated with venesection
23
Q

What is Wilson’s disease and how does it affect the liver?

A
  • Decreased copper secretion from biliary system into circulation for removal
  • Increased deposition of caeruloplasmin in blood
  • Pt will ultimately need liver transplant
  • Causes seizures, tremors and memory problems
24
Q

What are the autoimmune causes of liver inflammation?

A
  • Autoimmune hepatitis - hepatocytes are attacked by the autoantibodies ASMA and ANA
  • Primary biliary cirrhosis due to autoantibody AMA
  • Primary sclerosing cholangitis
25
What are the other causes for liver inflammation?
- Alpha antitrypsin - Glycogen storage disease - Budd-Chiari
26
What does the inferior mesenteric vein drain?
- Descending colon - Drains into splenic vein - Joins with SMV to make portal vein
27
What does the superior mesenteric vein drain?
- Ascending colon
28
What is portal hypertension?
- Main complication of cirrhosis - Build-up of blood in portal venous system
29
Why does portal hypertension occur?
- Fibrotic tissue accumulates - Liver less expansive - Needs to be expansive because venous drainage from majority of GI tract passes through
30
Why does portal hypertension lead to ascites?
- Fibrosis compresses veins - Increase in hydrostatic pressure in portal venous system - Fluid leaks out - Ascites
31
Why does portal hypertension lead to splenomegaly?
- Leads to increased pressure in splenic circulation
32
Why does portal hypertension cause varices?
- Increased pressure in portal circulation - Blood shunts from portal circulation to systemic circulation - Normally there are anastomoses between the 2 circulations, but these should not contain any blood - Increased pressure in portal circulation causes distension of veins at these anastomoses
33
Outline oesophageal varices?
- Superior 2/3 drain into oesophageal veins and then to superior vena cava - Distal 1/3 drains into left gastric vein and then to portal vein - At junction there is crossover of veins where pressure can build - Veins are superficial and fragile - When they get dilated they are liable to rupture - Causes significant haematemesis - Can be life-threatening
34
Where can varices occur in the body?
- Oesophagus - Anorectal - Umbilicus
35
Outline ano-rectal varices
- Occurs between superior rectal vein and middle and inferior rectal veins - Typically painless because they're above the pectinate line - Rarey bleed
36
Outline umbilical varices
- Less common - Only occur if portal hypertension is severe - Ligamentum teres (should be non-functional in adults) connects abdominal wall and circulation - Caput medusa sign - pattern of superficial veins on abdominal wall
37
What is hepatorenal syndrome?
- Failing liver leads to failing kidneys - Kidney deterioration is acute and rapid
38
Outline what happens to result in hepatorenal syndrome
- Portal hypertension backlogs through venous system - Affects arterial circulation coming in (splanchnic) - Vasodilation of splanchnic arteries to reduce pressure in system - Perceived as decreased circulating volume because blood is stuck in portal system - RAAS is activated - Renal artery vasoconstriction occurs - Decreased perfusion - Reduced kidney function
39
Outline the flow of the bile ducts
- Bile ducts in liver coalesce - Form left and right hepatic duct - Left and right hepatic duct form common hepatic duct - Cystic duct from gall bladder joins with common hepatic duct - Forms common bile duct
40
What is the name of the site where the common bile duct and the pancreatic duct empty?
- Ampulla of Vater - Sphincter of Oddi controls rate of release
41
What is biliary colic?
- Constant pain lasting for a few hours and then easing - Gallstones cause sudden onset RUQ pain immediately after eating a large fatty meal
42
What causes biliary colic?
- CCK is released after eating a large fatty meal - CCK release causes gallbladder to contract - Gallstone is pushed up against neck of gallbladder - Causes temporary obstruction to cystic duct and pain - No inflammation
43
How is biliary colic treated?
- Give pain relief - Plan operation to remove gallbladder
44
What is acute cholecystitis?
- RUQ pain - Gallstone impacted in cystic duct so nothing can pass through - Inflammation - Positive Murphy's sign
45
What is Murphy's sign?
- Place hand on right side of liver - Ask patient to take a deep breath in - Gallbladder is pushed down and hits hand - Causes intense pain - Patient will inhale sharply
46
What is ascending cholangitis?
- Infection of biliary tree
47
What are the symptoms of ascending cholangitis?
Charcot's triad: 1. RUQ pain 2. Inflammation 3. Jaundice
48
What causes ascending cholangitis?
- Happens when stone reaches common bile duct - Causes stasis above point of blockage - Causes infection behind stone - Give antibiotics, fluids, surgical removal
49
What forms gallstones?
- Cholesterol - Bile pigments - Mixed
50
What are the risk factors for gallstones?
- Diet - Female - Forties - Pregnancy
51
How are gallstones picked up on imaging?
- Ultra-sound scan
52
What leads to acute pancreatitis?
- Stone in common bile duct either at or after point at which pancreatic duct joins - Causes complete obstruction of bile and enzymes of pancreas - Auto-digestion
53
What are the symptoms of pancreatitis?
- Epigastric pain that goes to the back - Vomiting - Cullen's and Grey-Turner's - Amylase and lipase increase in the blood
54
How do we diagnose pancreatitis?
- Look for raised amylase and lipase in the blood - CT/MRI to look for inflammation - Give lots of fluids for organ support