Liver Symposium Flashcards
Is liver disease on the rise or decline in the uk?
Liver disease is on the rise
What kind of history will someone with parenchymal liver disease give?
Occupation
- Alcohol related (high risk)
- Animal contact
- Industrial exposure
Travel abroad
- Hepatitis-endemic areas
- Malaria
Contacts with jaundice
Sexual relations
Shellfish consumption
Injections: abroad, drug abuse, transfusions, tattoos
Drugs:
- Prescribed
- Over the counter
- Alternative medicines
What two categories can liver disease be broken down into?
Parenchymal
Cholicystitis
What are the liver function tests?
Markers of damage:
- Transaminases (AST or ALT)
- — Hepatocellular injury
- Alkaline phosphatase
- — Cholestatic
- y-glutamyl transferase
- — Both
TRUE liver function tests
- Albumin
- Bilirubin
- Prothrombin time
What is prothrombin time?
Clotting test
Factors II, V, VII and IX produced in liver
INR will go up when problems occur
What can you do when deranged LFT causes aren’t apparent from history and examination?
Chronic Liver Disease Screen
This may also be done when a cause is apparent and there might be other co-factors
What blood tests are involved in a Chronic liver disease screen?
- Autoantibodies , immunoglobulins
- Hepatitis serology
- Caeruloplasmin, Copper
- Ferritin, Fe2+, Transferrin saturation
- a1 antitrypsin
- Epstein Barr Virus (Monospot)
- Cytomegalovirus (Ab + PCR)
- Leptospira
- Alpha fetoprotein (sus cancer)
- Fatty liver disease
- —Fasting glucose (diabetes)
- — Lipid profile (hyperlipidaemia)
What raises IgA, IgG and IgM in a Chronic liver screen?
IgA = Alcohol IgG = Autoimmune hepatitis IgM = Primary biliary cirrhosis
What disease does low Caeruloplasmin and high copper show?
Wilson’s
What disease does Ferritin show?
Haemochromatosis
What are the three autoantibody tests in chronic liver screening and what do they exclude/diagnose?
Antimitochondrial = primary billiary cirrhosis
Anti smooth muscle = autoimmune hepatitis
Antinuclear factor = autoimmune hepatitis
What are the indications for liver biopsy?
Aetiology
- Unknown parenchymal liver disease
- Unknown focal liver lesion
Staging
-Aetiology of liver disease known but more information required on degree of inflammation and/or degree of fibrosis or cirrhosis
What are some of the complications of ERCP?
Sedation Related:
- Respiratory
- Cardiovascular
Procedure Related:
- Pancreatitis
- Cholangitis
- Sphincterotomy
- —Bleeding
- —Perforation
What is PTC?
Percutaneous Transhepatic Cholangiogram (PTC)
Used when ERCP is not possible due to duodenal obstruction or previous surgery
More invasive than ERCP
What does EUS stand for in hepatic imaging/procedure?
Endoscopic Ultrasound
Used for:
- Characterising Pancreatic Masses
- Staging of Tumours
- FNA of tumours and cysts
- Excluding biliary microcalculi
What is Gilbert’s syndrome?
Genetic defect
Affects 5% of adult population
Deficiency of active Uridine Diphosphate Glucuronosyltransferase 1A
Rise in unconjugated bilirubin
Bilirubin rises with fasting
What are the common causes of deranged LFTs?
Hepatic:
- Alcoholic cirrhosis and liver hepatitis
- NAFLD
- Viral hepatitis
- Metastatic cancer
- PBC
- Drug induced
Posthepatic
- CBD stone
- Carcinoma of the pancreas
What does an isolated rise in bilirubin show?
Gilbert’s syndrome
What does jaundice with dark urine and pale stools show?
Obstructive liver disease
what do prothrombin time and albumin indicate?
Synthetic function of the liver
What is an excellent treatment for decompensated cirrhosis?
Liver transplantation
What is hepatitis and what are its causes?
Inflammation of the liver
Ranges from sub-clinical disease with deranged LFTs to hepatic necrosis and fulminant hepatic failure
Causes:
- VIRAL or bacterial
- Drugs
- Chemicals
- Toxins
What is hepatitis A?
Occurs sporadically or in epidemic form.
Transmission by faecal-oral, sexual or blood
5-14 yrs commonest group
Decreasing prevalence worldwide
Asymptomatic cases very common
Acute disease diagnosed by IgM antibodies
Who needs to vaccinated in particular against HAV?
Travellers
Patients with chronic liver disease
-IDU (especially with HCV or HBV)
Haemophiliacs
Occupational exposure
-lab workers
Gay men
How does HBV present and how is it transmitted?
Sporadic, endemic and epidemic
Wide variance in prevalence very rare in UK
Common in far east and sub-saharan africa
Transmission:
- Blood
- Sexual
- Faecal-oral
What are the 3 outcomes in adult infection of HBV?
80% Subclinical
20% Acute hepatitis
1% Fulminant Hepatitis
What are the treatments for HBV and what is the aim of treatment?
Aim of treatment = Suppress Virus
- Interferon (side effects limit use)
- Tenofovir, entecavir
- Lamivudine and Adefovir (viral mutations occur)
What is delta virus?
Small RNA virus
- does not code for its own protein coat
- enveloped by HBsAg
Co-infection or super-infection with HBV
Transmission as for HBV
What is the natural history of HCV?
10% patients report acute jaundice
Rarely causes acute liver failure
80% chronic HCV infection
Most symptomatic until cirrhotic
May have normal LFT’s
How do you diagnose HCV?
Screening test HCV ELISA
Confirmatory test HCV PCR
-Detects ongoing chronic infection
Genotyping
-type of virus present
What correctable and uncorrectable factors play a role in the progression of liver disease?
Correctable
- Alcohol consumption
- Obesity
- Smoking
- Cannabis
Uncorrectable
- Age at infection
- Gender
- Ethnicity
- Co-infection HBV and HIV
- Immune deficiency
What is the treatment for HCV?
Directed antiviral acting drugs.
The aim is to cure
What is HEV?
- Previously thought to be limited to tropical countries
- Increasingly recognised in UK
- Commonest cause of acute hepatitis in Grampian
- Self limiting and no long term sequelae
- No specific treatment
- No effective vaccine currently available
Which hepatic viral infections are generally self limiting enteric infections?
Hepatitis A and E
What Hepatitis infection is aquired in childhood, often causes chronic infection?
Hepatitis B.
Chronic infection very rare in adults.
Hep B is endemic in a large area of the world
What is the aim of Hep B treatment?
To suppress the virus
What disease does HCV cause in 80% of those infected?
Chronic liver disease
patients with HCV are generally asymptomatic until the late stages of disease.
What is the aim of HCV treatment?
Cure the infection
List some of the intrahepatic lesions you may observe in imaging
Fatty liver
Simple cyst (benign)
Liver metastasis
Hepatoma
Describe the 3 locations of biliary tract lesions and what the lesions might be
In the lumen
-Gall stones, polyps
In the wall
-Changiocarcinoma, benign stricture
External pressure
-Pancreatic cancer, pancreatitis, lymph nodes
What patients are put forward for transplantation?
Chronic liver disease with poor predicted survival.
Chronic liver disease with associated poor quality of life
Hepatocellular carcinoma
Acute liver failure
What are the absolute contraindications for liver transplantation?
Extra-hepatic malignancy
Active intravenous drug abuse
Active alcohol abuse
Advanced cardiopulmonary disease
What are the relative contraindications for liver transplantation?
- Age >70
- Longstanding diabetes mellitus
- Significant sepsis outside the extra hepatic biliary tree
- HBV DNA positivity
- Severe psychiatric disorder
- Active substance misuse
- HIV
