M Ow Flashcards
What are the two types of liver impairment indicated by a blood test?
Cholestatic (obstruction to billary drainage - GGT and ALP elevation
Hepatocellular - think of hepatitis - AST and ALP
Can be mixed.
Albumin is low - this indicates that their is impairment in liver function
What does GGT elevated alone indicate?
Steatosis - fat deposited into liver cells
Caused by alcohol or non-alcoholic fatty liver disease.
Non-alcohoic fatty liver disease is a metabolic syndrome i.e diabetes, dyslipidaemia, hypertension, increased BMI
What are some causes of hepatitis?
Viral hepatitis Alcoholic hepatitis Non-alcoholic hepatitis Autoimmune hepatitis Ischaemic hepatitis Haemochromatosis Drug induced
What type of liver damage do drugs cause?
Cholestasis
Hepatitis
Mixed
What type of liver damage do tumours cause?
Cholestatic or mixed
Primary cancer is hepatocellular carcinoma
Secondary is metastatic
What is the pathway of non-alcoholic fatty liver disease?
Normal liver can become fatty for many reasons. This can develop into streatosis.
This can occasional cause inflammation that develops into hepatic disease, which can progress to cirrhosis.
Caused be excess fat deposition.
What the the features of hepatitis E?
Similar to hepatitis A.
What viruses can cause hepatitis?
EBV, CMV, Hepatitis A, B, C, D and E
What are the symptoms of EBV and CMV infection?
Usually asymptomatic.
EBV causes infection mononucleosis and CMV causes mononucleosis-like syndrome
Systemic symptoms
Presence of atypical lymphocytes
What are the features of autoimmune hepatitis?
Episodic disease - repeated abnormal tests that go up and down
Do an autoimmune screen for certain Abs
Liver biopsy
What are the features of ischaemic hepatitis?
Acute catostrophic.
Not common
Severe shock, from sepsis or bleeding or blood clot to the hepatic artery.
Causes a sudden loss of blood flow to the liver -> high transaminases (AST and (ALT)
What are the features of haemochromatosis?
Hereditary - autosomal recessive
Mutation of the HFE gene (C282Y)
Europeans at high risk
Low hepcidin levels -> increased iron absorption in the GI tract.
Secondary - iron overload or repeated blood transfusions.
Look at the ferritin and iron saturation (high saturation)
What are the features of drug induced liver damage?
What drugs, what supplements, how much, how often for how long.
Paracetamol overdose - antidote is N-acetlycysteine. Narrow window to give antidote.
Are they at risk of self harm?
Many drugs can affect
and present as cholestasis, mixed or predominately hepatitis
What are the features of drug induced liver tumours?
Only happen in patients with underlying cirrhosis or chronic hep B infection
Or metastasis
If AST and ALT are in the thousands what are the possible causes?
- viral
- ischaemia
- paracetamol
What does a AST > 2x ALT suggest?
Alcoholic hepatitis (AST/ALT ratio)
What does a low platelet count in the context of liver disease indicate?
Portal hypertension -> spelnomegaly
Portal hypertension only happens with cirrhosis
What are the investigations to determine the cause of liver damage?
Ultrasound - gallstoners, gallbladder
- Bile ducts not obstructed
- liver look
Hepatitis serology
- HAV IgM
- HAV IgG
HBsAg
HBsAB
HB core antigen
Anti-HCV AB - if positive then do PCR
Iron studies
Liver autoantibodies
How do you treat portal hypertension with ascities?
Give diuretic. Give high protein diet to return albumin levels to normal and cause an increase in osomotic pressure in the blood. Low salt diet. Stop alcohol.
What is a sign of encaphalopathy?
Hepatic flap and not responding
What can initiate a cause of ascities and encapolopathy in someone with cirrhosis?
Any big event, such as pneumonia can cause progression of disease (decompensation)
What is a risk in portal hypertension?
Bleeding from variceal bleed.
What complication can occur in patients with cirrhosis and ascities?
Spontaneous bacterial peritonitis
The bacteria can migrate through an impaired gut barrier and impaired immune system. The bacteria grows in ascities. Must have ascities to develop.
Do an ascitic tap - should be lots of neutrophils
If the transaminisase in the liver test are in the thousands, what can you rule out as a cause?
Alcohol and non-alcoholic fatty liver disease.
Most likely not autoimmune
What are the causes of acute and chronic Hep B?
Acute happens in adults (IV drugs and sex) and chronic happens from birth (child to child and vertical)
Mode of transmission determines.
What are the four important blood tests in hepatitis B?
HBsAg (acute and chronic)
Anti-HBs (Cleared and vaccinated)
HBcAb IgM (recent infection, not long term infection)
HBcAB IgG (acute and chronic and cleared)
There can be times when people are infected with Hep B but are surface antigen negative but core antigen IgM positive.
In a chronic infection, they will be HBcAb IgM negative and HBcAb IgG positive
What are the 4 phases of chronic hepatitis?
1 - Immune tolerant -carriers but not causing damage
2 Immune clearance - the body tries to clear the virus causing inflammation (20-30 years old)
- immune control - the body controls the virus - no damage to the liver
4 immune escape - inflammation comes back causing damage
Patients can go between phases without knowing and they may need treatment so constant monitoring
What causes encephalopathy in liver disease?
The liver is not able to remove toxins from the blood so they accumulate
Ammonia from diet.
Treat with lactulose.