Liver Tutorial Flashcards
How does hepatitis often present?
- raised ALT compared to ALP
- Moderate jaundice
- Smooth, tender hepatomegally
How does hepatitis A present?
Flu like illness - anorexia, myalgia, nausea and headaches
Last 2 days felt better but now jaundice
Causes of hepatitis
- Serology - Hep A,B,C (hep C often subclinical)
- Autoimmune
- EBV
- Meds eg NSAIDs
- Paracetamol overdose
How does cholangiocarcinoma present?
- Painless jaundice - months
- Aypyrexial
- Very high ALP compared with ALT
Could also be pancreatic malignancy
How to tell between pancreatic maliganncy and biliary malignancy?
ERCP - stent if stricture present, get brushings to do histological testing on
Presentation of ascending cholangitis
- RUQ pain
- Fever
- Jaundice
- History of gallstones/biliary colic
Differential for ascending cholangitis triad
Liver abscess - USS scan to see if dilated bile ducts (AC) or holes in liver with fluid levels (abscess)
Abx for ascending cholangitis
Tazocin IV (Piperacillin and Tazobactam - beta lactamase inhibitor)
What is presentation of primary biliary cholangitis?
- Pruritus
- Mild jaundice
- Antimitochondrial antibody positive
- Liver US normal
What is primary biliary cholangitis?
Autoimmune destruction of small bile ducts within liver
Parenchymal damage
Leads to cirrhosis
Primary biliary cholangitis vs primary sclerosing cholangitis
- PBC - affects small ducts, more common, antimitochondiral ab +ve
- PSC - affects ANY duct, no antibody - use ERCP and MRCP to diagnose
Treatment for primary biliary cholangitis
Ursodeoxycholic acid - bile acid replacement, decreases damage to liver
How to tell cause of ascites?
- Do SAAG - serum ascitic albumin gradient
- This shows the portal pressure
- Serum albumin minus ascitic albumin
- If more than 11g/L this shows portal HTN = cirrhosis
- If less, must be no cirrhosis so other cause of ascites inc cancer? TB? Nephrotic syndrome?
What are those with cirrhosis at risk of that can present as general unwellness?
- Spontaenous bacterial peritonitis
- Translocation of gut microbes into ascitic fluid = multiplication
- Treat with antibiotics
Which are more at risk of peritonitis if bowel ruptured cirrhotic patients or malignancy?
- Cirrhotic patients as their ascitic fluid is just water and sugar as fluid build up is due to increased hydrostatic pressure
- In malignancy the vessels become more permeable = leakage of proteins inc immunoglobulins which can kill microbes
Which conditions which cause ascites cause a high SAAG?
- Heart failure
- Cirrhosis
What can be a post hepatitis C complication that can present years later with fatigue?
- Hep C associated hepatocellular carcinoma
Tumour marker for hepatitis C associated hepatocellular carcinoma
AFP - alpha feto protein
Treatment for hepatocellular carcinoma
If less than 3cm - offer liver transplant
If 5cm or more - offer embolisation and chemotherapy - block blood supply
What value of HCV RNA PCR suggests no detectable infection?
Less than 15 copies / ml means virus is undetectable
Meaning of HBsAg?
- Hepatitis Surface Antigen
- If present shows that infection of heptatits B is present
What is HBcAb IgM?
- Hepatitis B core antibody IgM / aka IgM anticore
- If positive shows infection is acute, if not infection is chronic
What is HBeAg?
- Hepatitis B e antigen
- If positive shows virus is rapidly multiplying
What is HBeAb?
- Hepatitis B e antibody
- If present shows body is having immune response to hepatitis B
When do we treat hepatitis B?
- If pregnant - within last 3 months of pregnancy to decrease viral load and decrease chance of passing onto baby via vaginal canal
- If signs of liver damage
- When no immune response and signs of liver damage
When do we not treat hepatitis B?
- When no signs of liver damage
- When no immune response but no signs of damage
This is because 95% of people with mature immune systems will clear infection
What can present with previous flu, now jaundice with normal LFTs, FBC and urine sample?
- Gilberts syndrome - autosomal recessive disease
- Triggered by stress, alcohol, infection, lack of sleep
- When RBC are haemolysed, liver conjugates bilirubin to become soluble. People with Gilberts syndrome are slower at this
What can cause jaundice and pruiritis post cellulitis treatment, normal USS and no autoantibodies?
- Cholestasis - will have obstructive picture ie high ALP but USS will be normal
- Cholestasis caused by antibiotic treatment eg Co-amoxciclav (clavulanic acid portion) or Flucloxacillin
How would primary sclerosing cholangitis present?
- Similar scenario to cholestasis caused by abx
- No signs on USS and no positive autoantibodies
- Diagnose via MRCP
Treatment for Hep C - active infection but no fibrosis
- 12 weeks antiviral drugs - then no follow up
Treatment for Hep C active infection with fibrosis
- 12 weeks antivirals
- Then monitor via US and AFP for hepatocellular carcinoma as at increased risk every 6/12
What to do if previous Hep C infection (HCV ab positive but RNA low) and no fibrosis?
Resolved - do nothing
Iron studies in haemochromatosis
- High ferritin
- High serum iron
- Low TIBC
Why is TIBC low in iron overload?
- There is no transferrin free to bind to iron
- As there are high iron levels in the blood
- So all of it is bound
- So transferrin does not have capacity to bind to anymore iron
What must you do to monitor haemochromatosis?
MRI to check iron load of liver and cardiac effects
Treatment for iron overload haemochromatosis
500ml blood venesection weekly
Haematinics for alcholic
- High ferritin - acute phase protein, high in chronic liver disease
- High MCV
- Low folate
- High GGT
Haematinics for malnutrition from coeliac
- Low ferritin
- Low serum iron
- High MCV
- Low folate
- But normal B12
- Low calcium
Why is B12 normal in coeliac?
- Absorbed in terminal ileum
- Folate is low as it is absorbed by proximal bowel ie duodenum
- This is where we take biopsy via endoscopy from to diagnose coeliac (2nd part duodenum)
Main causes malnutrition UK
- Coeliac
- Crohns
- Chronic pancreatitis
Chrons and pancreatitis painful
What tests prove autoimmune hepatitis?
- ANA positive
- Anti smooth muscle antibody positive
- Then biopsy liver
Anaemia of chronic disease haematinics
- Iron low
- TIBC low
- Ferritin high - inflammation
What regulates ferritin levels?
- Hepcidin - more hepcidin = higher ferritin levels = more iron stored and less available in plasma
- Bodys defence to infection, reduce iron availability of bacteria
How is fatty liver disease diagnosed?
USS liver and kidney in same field
If liver is brighter than kindey = fatty liver
Follow up for diagnosis of fatty liver
- Enhanced liver fibrosis screen
- Fibroscan –> if no fibrosis then no risk of cirrhosis
- If yes there is risk
- Weight loss needed in fatty liver disease with potential Vitamin E
