liver top tier Flashcards

1
Q

liver failure =

types
key features

A
  • Liver failure= liver loses ability to repair
  • Acute failure = acute liver injury, previously normal liver
  • Acute- on-chronic failure = liver failure as a result of decompensation of chronic liver disease
  • Key features = encephalopathy, jaundice, coagulopathy, ascites
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

liver failure pathophysiology

A
  • injury/death to hepatocytes
  • Particular damage in zone 3 around central vein - least blood supply
  • Neutrophils kill them
  • Apoptosis (due to damage)
  • Autoimmune
  • Inflammation
  • Fibrosis - cirrhosis is irreversible , but fatty liver damage is reversible
  • Function decline
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

fatty liver disease pathophysiology

  • two states + their features
  • two causes
A

simple steatosis

  • Hepatocytes balloon due to fat accumulation
  • perivenular fibrosis (small amounts)

–> inflammation –>

steatohepatitis (= fatty liver disease)

  • Hepatocytes balloon due to fat accumulation
  • inflammation and fibrosis
  • Hepatocytes accumulate cytoskeleton protein as unable to use it due to dysfunction (mallory bodies)
    • Neutrophils come to kill em - hepatocyte necrosis

both reversible
this is the case for both causes : alcoholic and non-alcoholic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

encephalopathy
- pathophysiology

wernickes’s

  • pathophysiology inc cause
  • triad presentation
  • treatment
A
  • Ammonia not cleared by the liver, builds up in the circulation and passes to the brain
  • Astrocytes try to clear ammonia by converting glutamate → glutamine. Excess glutamine causes imbalance in osmotic pressure so fluid into cells → cerebral oedema
  • Permanent brain damage as ammonia is neurotoxic (halts Krebs cycle, less ATP)

wernicke’s encephalopathy:

  • Thiamine reserves exhausted - malnutrition, alcoholism
  • Triad (most don’t have all 3)
  • – Ataxia
  • – Nystagmus (involuntary eye movements)/ ophthalmoplegia (paralysis / weakness of eye muscles)
  • – Confusion
  • Acute onset
  • Reversible : treat with IV thiamine
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

causes of acute liver failure

A

Viral hepatitis +other infections eg, bacteria, parasites

  • Rarely C (mainly chronic)
  • Cytomegalovirus
  • EBV
  • Herpes

Drugs

  • Drugs started recently are the relevant ones
  • Paracetamol overdose is common
  • Alcohol,
  • antidepressant -amitriptyline
  • NSAIDs
  • ecstasy , cocaine
  • Antibiotics -ciprofloxacin, doxycycline, erythromycin

Vascular

  • Congestion (venous congestion from right sided heart failure or obstruction of the hepatic vein)
  • Obstruction
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

chronic causes of liver failure

chronic triggers - acute deterioriation of chronic disease

A
  • Viral hepatitis (not A/e - acute)
  • Non alcoholic/ alcholic steatohepatitis
  • Autoimmune
  • Metabolic liver disease – Genetic - wilsons and A1AT deficiency
  • Cancer - hepatocellular carcinoma
  • Vascular

Chronic triggers (acute deterioration of chronic disease)

  • Constipation
  • Drugs
  • Infection
  • GI bleed
  • Alcohol withdrawal
  • Low Na, K, glucose
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

risk factors for non-alc liver failure (conditions, not patient characteristics)

A

Obesity
Diabetes
Hyperlipidemia
High risk of thrombosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

encephalopathy presentation and test for it

A

Test: count down in 7s form 100, count animal in a min, spell World backwards, dot-dot, draw 5 point star

1) Altered mood/behaviour, sleep disturbance
2) Drowsy, Confusion, slurred speech, +/- asterixis
3) incoherent, restless, asterixis, stupor
4) Coma

(Liver flap = asterixis – flapping tremor with wrist extended)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

liver failure signs

A
Jaundice
Encephalopathy 
Fever
Hypertension
Hyper-reflexia 
Fetor hepaticus = patient smells like pear drops
Small liver
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

acute liver failure symptoms

A
Jaundice 
\+ Itching (bile salt collects under skin)
\+ Unusual stool/urine
Bleeding (coagulopathy) 
Myalgia 
GI/abdominal pain
Lethargy
malaise
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

chronic liver failure symptoms

A
Ascites is rare
Spider naevus (red vessel skin mark, 5+ is pathological) 
Bruising 
Wasting 
Clubbing (nails)
Palmar erythara - red hands
jaundice is rare
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

paracetomol overdose - signs/investigations

A
Increased prothrombin time
ALT/AST rly high - 1000
Metabolic acidosis
Raised creatinine
Hypoglycaemia -gluconeogenesis is inhibited
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

liver failure investigations

A

Bloods

  • High bilirubin
  • Low albumin
  • Long prothrombin time, high INR
  • LFTs = enzymes released from hepatocytes due to damage… High AST/ALT
  • U/Es
  • Low glucose - no gluconeogenesis
  • Blood culture
  • Lipids

ultrasound/MRI/CT

  • look for biliary obstruction
  • Nodular outline=cirrhosis
  • tumours
  • varices
  • Liver/Spleen size
  • Grades encephalopathy - electroencephalogram
  • dopple

Microbiology- determine cause (is it infection)

  • Ascites fluid
  • Urine culture
  • Blood culture
  • Viral serology/ immunology - Look for antigen/ antibodies of virus, and autoantibodies

biopsy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

liver failure management

A
  • Symptom management
  • – Eg analgesia - opiates paracetamol, be careful
  • Treat underlying cause
  • – N-acetyl cystine (NAC) for paracetamol poisoning - and glucose if hypoglycemic
  • – Gallstone removal/crushing/dissolution
  • – Cancer treatment
  • – Antivirals
  • Electrolyte balance, acid base balance
  • Correct clotting defects - give IV platelets, vitamin K, plasma
  • Liver transplant
  • Careful with drug prescription (eg hypoglycaemic/constipation/blood thinned effects)
  • Antihypertensives - not ACEi
  • Proton pump inhibitors to reduce GI bleed risk
  • Mannitol for raised intercranial pressure
  • Monitor glucose and give IV if necessary
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

what drug is given for paracetamol poisoning

A

N-acetyl cystine (NAC

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

liver failure complications

A
Hypoglycaemia 
Bleeding (coagulopathy)
Encephalopathy 
Varices 
Vulnerable to infection
Malnutrition 
Impotence
Amenorrhea
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

risk factors/ causes for pancreatitis

A
I GET SMASHED
Idiopathic
Gallstones (f)
Ethanol - alcohol (m)
Trauma (kids)
Steroid
Mumps
Autoimmune
Scorpion venom
Hyperlipidemia
ERCP - endoscopic retrograde cholangiopancreatography (following this)
Drugs (eg corticosteroids, NSAIDs, diuretics)

Pregnancy
neoplasia/malignancy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

pancreatitis pathophysiology

A
  • Inflammation of pancreatic gland, initiated by acute injury
  • Premature activation of pancreatic enzymes (eg amylase!) which cause pancreatic inflammation by enzyme mediated autodigestion
  • Prematurely activated enzymes digest vessel walls in pancreas, causing leakage of fluid into tissues → oedema, inflammation, hypovolemia, potential haemorrhage
  • Destruction of islet of langerhans → less beta cells → less insulin→ hyperglycaemia
  • Lipolytic enzymes cause fat necrosis → skin discolouration (Cullen’s Grey turner’s local, bruise-like).
  • The released fatty acids bind to Ca → white precipitates in fat and potentially hypocalcemia

Chronic = irreversible fibrosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

pancreatitis signs

A
Hypovolemia
Tachycardia
Jaundice
Fever 
Dehydration
Hypotension 
Cullen’s sign = periumbilical bruising
Grey Turner’s sign = left flank bruising
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

pancreatitis symptoms

A
Oedema
Pain
- Upper abdominal / epigastric/central abdominal
- Radiates to back
- Relieved by sitting forward
Anorexia
nausea/ vomiting
Tetany = intermittent muscle spasms (due to hypocalcaemia)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

pancreatitis invesitgations

A

Bloods

  • Inflammation - high wbc
  • High glucose
  • Raised serum amylase - 3x! But drops quite quickly
  • Raised serum lipase
  • Cultures -see if infection

Temperature
HR
BP

Urine
- Raised urine amylase

Imaging

  • CXR/Ultrasound – Maybe gallstones (cause)
  • CT/MRI- see necrosis extent
  • CXR - excludes perforation differential diagnosis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

how is pancreatitis scored

and why

A

Glasgow + Ranson /APACHE 2 scoring systems
Factors = age, neutrophils, calcium, glucose (obesity/conditions too in APACHE2 ) in first 48/24 h

for prognosis and treatment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

pancreatitis management

A
  • Nil by mouth. Nasogastric tube for supplements – reduce pancreatic enzyme release
  • fluid replacement (Crystalloid / saline IV) - (lost in third-space sequestration = goes somewhere in body, not balancing with ECF)… to increase urine flow rate and stabilise vital signs (Temp, HR, breathing rate, BP)
  • Analgesia - opiates
  • Antibiotics - if proven infection (blood cultures)
  • Surgical drainage of fluid collections/cysts
  • Insulin - in glucose needs correcting (Take over liver functions)
  • Calcium correction (liver function impaired)
  • Cholecystectomy - may cause recurrent episodes
  • Stop risk factors (alcohol, smoking)
  • Enzyme replacement ? if chronic
  • LMW heparin = DVT/PE prophylaxis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

complications of pancreatitis

A
Hyperglycaemia
Hemorrhage - shock
Hypocalcemia 
Renal failure
ARDS - acute respiratory distress
Coagulopathy , thrombosis
Fistulae 

If bursts → digests insides = necrosis
Bile duct strictures
Steatorrhea
Low insulin- diabetes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
how bad is alcoholic liver disease.
main cause of liver death
26
alcoholic liver disease risk factors/ cause
alcohol - do not need to be alcoholic / dependent | some genetic component
27
how does fibrosis cause portal hypertension
due to increased vascular resistance which is due to cirrhosis and architectural distortion (decreased outflow) and splanchnic vasodilation (increased inflow)
28
how does portal hypertension cause varices
New vessels form + small vessels vasodilate | Shunts
29
alcoholic liver disease pathophysiology
- Ethanol metabolised in liver, resulting in increase in NADH /NAD ratio. This causes increased fatty acid synthesis and less fatty acid oxidation → fatty acid accumulation, which are esterified to glycerides (tri/di). these is defective balance between free fatty acid oxidation (breakdown) and synthesis (to triglycerides) - Also causes impaired carbohydrate and protein metabolism → centrilobular necrosis of hepatic acinus - - Hepatocytes become swollen with fat (steatosis)--- fatty liver , but no cell damage → reversible! - Sometimes, collagen in deposited around central hepatic veins (perivenular)→ fibrosis → cirrhosis - Alcohol also enhances the effect of toxic metabolites of drugs on the liver - Kupffer cells release TNF-alpha → ROS is released → tissue injury, fibrosis - fibrosis --> portal hypertension --> varicies - Polymorphonuclear leukocytes infiltrate → hepatocyte necrosis - and alcoholic cirrhosis
30
fatty liver presentation
often no symptoms nausea, vom , diarrhea hepatomegaly
31
alcoholic hepatitis presentation
- Few symptoms - Mild jaundice - Signs of chronic liver disease - ascites, bruising, clubbing, dupuytren’s contracture (fingers bend towards palm due to fibrosis in tendons) - Abdominal pain, if severe - hepatomegaly - ankle oedema
32
alcoholic cirrhosis presentation
final stage of alcoholic liver disease - alcohol dependancy - Signs of chronic liver disease - ascites, bruising, clubbing, dupuytren’s contracture (fingers bend towards palm due to fibrosis in tendons)
33
alcoholic liver disease investigation
- Liver biopsy → histology - see fatty infiltration - Liver function tests - raised - ultrasound/CT shows fatty infiltration - Coagulopathy (prothrombin, INR), higher serum bilirubin seen in alcoholic hepatitis and cirrhosis
34
alcoholic liver disease management
Alcohol cessation - Treat withdrawal with lorazepam / diazepam - Diet - high in vitamins and proteins, reduce salt intake - IV thiamine to prevent encephalopathy after withdrawal - Treat infections (hepatitis) - Liver transplant (if sober ) - Avoid aspirin/NSAIDs if severe
35
non alcoholic liver disease cause
diet induced!!-- high fructose/ fat intake metabolic syndrome - central obestiy - dyslipidaemia - hypertension - impaired glucose tolerance - insulin resistance
36
alcoholic liver disease - cause?
ethanol --> acetyl coA --> fatty acids
37
final stage of liver disease= | - features
cirrhosis (fibrosis) - irreversible - hepatocyte necrosis - hyperplastic nodule formation (deterioration of architecture) - shrunk liver
38
causes of liver cirrhosis
aka causes of liver disease - as liver cirrhosis is end stage liver disease! ``` chronic viral hepatitis - B, C (most common worldwide) alcoholic liver disease (most common in west) haemochromatosis non-alcoholic liver disease medications/drugs coeliac wilsons A1AT deficiency autoimmune hepatitis billiary cirrhosis ```
39
liver cirrhosis presentation
``` parotid glands swell asterexis spider naevi jaundice hepatosplenomegaly (small liver i thought) ascites abdominal pain clubbing nail changes muscle cramps caput medusae palmar erythema dupuytren's contracture bruising ankle swelling oedema loss of body hair ```
40
liver cirrhosis complications + their pathophysiology
portal vein drains from gut to liver. ineffective draining due to 1) increased vascular resistance 2) architectual distortion (decreased outflow) --> increase in pressure (so there is backflow. this is called portal hypertension the high BP causes splanchnic dilation to compensate but this increases inflow - ascites - varicocele - cardiomyopathy - varicies - clubbing - dupuytrens contracture - spider naevi, palmar erythema, caput medusae - carcinoma - spontaneous bacterial peritonitis - hepatic encephalopathy - coagulopathy
41
cirrhosis pathophysiology
- liver damage - hepatocyte necrosis/ apoptosis - ROS released stellate cells usually dormant, activated in cirrhosis (ROS) - further stimulating macrophages (kupffer cells) to release cytokines (TNFalpha, IL6, IL18, TGF) --- further necrosis ! --- TGF causes stellate cells to become myofibroblasts - which secrete collagen (fibrosis) - stellate cells secrete chemokines --> attract more innate immune cells - inflammation! --> necrosis and fibrosis - function reduces (fibrosis is nonfuncitioning ofc)
42
types of cirrhosis
cirrhosis has regenerating nodules (non damaged) within fibrous septa micronodular = <3mm nodules, uniform. caused by alcohol / billiary tract disease macronodular - varies in size, caused by chronic viral hepatitis
43
portal hypertension causes
Cirrhosis portal vein/IVC obstruction R heart failure schistosomiasis (infection)
44
cirrhosis management
- Good nutrition inc reduced salt intake - Hep A/B vaccination - Avoid hepatotoxins - -- NSAIDs - may cause GI bleed/ renal impairement - -- alcohol - Treat ascites (fluid restriction, low salt diet, spironolactone (K sparing diuretic) + paracentesis + albumin infusion) - Ultrasound screening for hepatocellular carcinoma - 6monthly - Treat underlying cause to prevent worsening - Liver transplant if no response to therapy (last resort)
45
varicies =? - whats worrying - treatment
new vessels form + small vessels vasodilate shunts if rupture --> - abdominal pain - acute blood loss - hypotension (pallor), rectal bleeding - chronic liver damage - ascites - splenomegaly - life threatening if oesophageal endoscopy to find source of bleeding - B blocker to reduce pulse rate to decrease portal pressure - Liver transplant, - variceal banding, - using endoscopy - Balloon tamponade to reduce bleeding by placing pressure on varice (if banding fails) - TIPS - shunt from portal vein to hepatic vein - Resuscitate if hemodynamically unstable -- blood transfusion, vitamine k and platelets and vasopressin/somatostatin (vasoconstriction) - prophylactic antibiotics
46
biliary colic =
pain associated with gallstone obstruction of cystic or common bile duct . Intermittent, comes and goes
47
what do chole and choledocal and cholang refer to
``` Chole = gallbladder Choledocal = bile duct (large) cholang = bile duct (small, intrahepatic) ```
48
what is cholecystitis presentation dif diagnosis and how to differentiate complications
Cholecystitis, = gallbladder inflammation (as a result of gall stone obstruction) - Progresssive pain - Palpable GB - Murphys sign (catch in breath when RUQ pressed) - Sepsis signs - rarely!!!! mainly no - Jaundice (Mirizzi) ``` Pancreatitis (serum amylase high) Appendicitis Peptic ulcer (endoscopy) Liver abscess (US) Pneumonia (CXR) MI (ECG) Perforated bowel ``` - Perforation (--> air) - Abscess
49
ascending cholangitis = presentation treatment and its complications
bile duct inflammation Travels up Due to choledocolithalis (bile duct stones) Charcots triad - Fever - Jaundice (not in cholecystitis) - RUQ pain ``` ERCP = endoscope + pull out stone Complications - Pancreatitis (irritation → inflammation → goes up) - Bleeding - failure - unremoved ```
50
mirizzi's syndrome
stone in gallbladder (neck) presses on bile duct causing jaundice
51
empyema =
gallbladder fills with pus
52
primary sclerosing cholangitis (PSC) - gender - presentation - investigations - treatment - complications
diffuse inflammation, long term, causing scarring of bile ducts (not just common bile duct) , causing stricture m>f or m=f different sources Fatigue Anorexia Indigestion Jaundice (+ pruiritus) LFTS: Alk phos, bilirubin ANA, P-ANCA (antinuclear antibody, perinuclear anti-neutrophil cytoplasmic antibodies) MRI Liver transplant - Low prognosis Complications - UC
53
biliary dyskinesia = - presentation - who (age, gender) - treatment
= pain with no gall stones (no pathology) = dyskinesis refers to inability to move, gall bladder ineffective squeezing of bile out RUQ pain after fatty food Women >50 Remove gall bladder
54
primary billiary cirrhosis PBC vs primary sclerosing cholangitis PSC associated with what disease increased risk of ?
associated PBC - RA, sjorgrens PSC - IBD increased risk PBC - hepatocellular carcinoma PSC -cholangiocarcinoma
55
primary billiary cirrhosis PBC vs primary sclerosing cholangitis PSC gender
PBC - f>>M PSC - m>f
56
primary billiary cirrhosis PBC vs primary sclerosing cholangitis PSC age
PBC- 40-60 PSC - 10-30
57
primary billiary cirrhosis PBC vs primary sclerosing cholangitis PSC diagnosis
``` PBC +AMA (anti mitochondrial antibody) raised IgM liver biopsy US high ALP ``` ``` PSC ANCA (anti-neutrophil cytoplasmic antibodies) ANA antibiody liver biopsy US/MRI ```
58
primary billiary cirrhosis PBC vs primary sclerosing cholangitis PSC presentation
both: fatigue, pruiritus PBC : xanthelasma (demarcated yellow cholesterol deposits around eye) sore joints dry eyes PSC : jaundice charcots triad (fever (inc rigors), RUQ pain, jaundice) can have xanthelasma?
59
gallstones epidemiology - typical person - race
female fat fertile forty (rare before 30) more common = scandivians, s america. less common = asia, africa
60
gallstone risk factors
- Female - age -- 40, fertile - Pregnancy (reduced gallbladder motility) - smoking - High cholesterol diet/ fatty food (excess cholesterol pigment) - contraceptive pill - Rapid weight loss conditions - Crohns - Sickle cell - Primary biliary cirrhosis - Obesity - liver cirrhosis - diabetes (reduced gallbladder motility) - haemolysis (excess pigment)
61
cholestasis = causes presentation
Bile static - not going anywhere Due to obstruction - Cholelithiasis - Choledocal lithilasis - Tumours signs/symptoms - Jaundice + itchy + dark urine + pale stools - RUQ pain - intermittent colic - Can be painless - Weight loss, low appetite - Lethargy - Steatorrhea (no fat absorbed) - float
62
gallstone types - form where - made of
both form in gall bladder mainly. due to stasis cholesterol gallstone (majority) - large, often solo - excess cholesterol or deficiency of bile salts / phospholipids (Relative) bile pigment stones - formed mainly of Ca2+ - small, crumbly, fragile, irregular - hemolysis --> bilirubin increased --> excess - can be black or brown (different composition)
63
gallstone symptoms
``` Pain (= biliary colic) Sudden onset epigastric/RUQ Severe, constant, crescendo Intermittent, comes and goes Radiation to R shoulder Often mid evening- late / post prandial Can be painless - most are asymptomatic Associated with nausea/vomiting Jaundice + itching + dark urine + pale stools Weight loss, low appetite Lethargy Steatorrhea (not fat absorbed = fat in stools = float) ``` Can be asymptomatic Don't need to treat NOT Flatulence Fat intolerance Dyspepsia (impaired digestion)
64
murphys sign. = indicates what
Breathe in an press in RUQ and LUQ Positive = painful RUQ only positive in ascending cholangitis, cholecystits
65
what does gallbladder look like in acute cholecystitis
small gallbladder, thick walls
66
acalculous cholecystitis
gallbladder inflammation due to cause that is not gallstones
67
what is risk of chronic billiary inflammation
will go to dysplasia then neoplasia
68
general investigations into biliary diseases
imaging - stones, cancers, inflammation, fluid (eg around gallbladder), duct dilation bloods - wbc, - LFTs - AST/ALT, bilirubin, alkaline phosphate examination - tender RUQ
69
gallstone treatment
stone dissolution - for cholesterol stone - by increasing bile salt (rare) - by reducing cholesterol- statins laproscopic cholecystectomy - Gallbladder removal - For any symptomatic complication of gallstones antibiotics surgery to remove stones - balloon, basket, crushing, stent placement - ERCP analgesia, fluids
70
biliary colic vs acute cholecystitis vs cholangitis - which have which of the following - - RUQ pain - - fever / high WBC - - jaundice
biliary colic = RUQ pain acute cholecystitis = RUQ pain + fever/high WBC cholangitis = all 3 : RUQ pain + fever/high WBC and jaundice (this is charcots triad)
71
courvoisiers sign
painless jaundice + palpable gallbladder = pancreatic / billiary cancer (until proven otherwise)
72
what is painless jaundice + palpable gall bladder (until proven otherwise)
pancreatic/ biliary cancer | courvoisiers sign