Station 1 - liver

Question 1

What general signs indicate chronic liver disease?

Answer 1

Cachexia, icterus, excoriation, bruising

Question 2

What signs in the hands indicate chronic liver disease?

Answer 2

Leuconychia, clubbing, dupuytrens contractures, palmar erythema

Question 3

What signs in the face indication chronic liver disease?

Answer 3

xanthelasma, parotid swelling, fetor hepaticus

Question 4

What signs in the chest/abdo indicate chronic liver disease?

Answer 4

spider naevi and caput medusa, reduced body hair, gynaecomastia and testicular atrophy

Question 5

Describe hepatomegaly, what do you need to look for?

Answer 5

A mass in the RUQ that moves with respiration, that you are not able to get above, dull to percuss

• estimate size
• smooth v craggy/nodular (malignancy/cirrhosis)
• Pulsatile (TR in CCF)
• Auscultate - bruit over liver (hepatocellular carcinoma)

Question 6

Underlying cause hepatomegaly:

-tattoos/needle marks

Answer 6

infectious hepatitis

Question 7

Underlying cause hepatomegaly:

-Slate-grey pigmentation

Answer 7

Haemochromatosis

Question 8

Underlying cause hepatomegaly::

-cachexia

Answer 8

Malignancy

Question 9

Underlying cause hepatomegaly:

-Midline sternotomy scar

Answer 9

CCF

Question 10

What evidence of treatment signs can be looked for in chronic liver disease?

Answer 10

Ascitic drain/tap sites, surgical scars

Question 11

What signs indicate decompensated liver disease?

Answer 11

3 ‘A’s

• Ascites (shift in dullness)
• Asterixis (liver flap)
• Altered consciousness (encephalopathy)

Question 12

What are the causes of hepatomegaly?

Answer 12

The big three:

• Cirrhosis (alcoholic)
• Carcinoma (secondaries)
• CCF

Plus:

• Infective (HBV/HCV)
• Immune (PBC, PSC and AIH)
• Infiltrative (amyloid and myeloproliferative disorders)

Question 13

What are the initial investigations for hepatomegaly?

Answer 13

Bloods:

• FBC/Coag/U+Es/LFTs/Glucose
• US abdo
• tap ascites if able

Question 14

What are the investigations for cirrhotic liver disease?

Answer 14

Liver screen bloods
-autoantibodies and immunoglobulins
-hepatitis B / hepatitis C serology
-Ferritin (haemochromatosis)
-Caeruloplasmin (wilson's disease)
-Alpha 1 antitrypsin
-AFP (hepatocellular carcinoma)
Hepatic synthetic functions
-INR (acute)
-Albumin (chronic)

Liver biopsy for diagnosis and staging

ERCP (diagnose/exclude PSC)

Question 15

What are the investigations for malignant hepatomegaly?

Answer 15

Imaging - CXR and CT CA
Scopes - OGD and colonoscopy
Liver biopsy

Question 16

What are the complications of liver cirrhosis

Answer 16

Variceal haemorrhage
Hepatic encephalopathy
SBP

Question 17

What is the 1 year survival rate according to child-pugh classification?

Answer 17

A: score 5-6 100%
B: score 7-9 81%
C: score 10-15 45%

Question 18

What are the causes of ascites?

Answer 18

Cirrhosis
Carcinomatosis
CCF

Question 19

What treatment can be used for ascites in cirrhotics?

Answer 19

• Abstinence from alcohol
• Salt restrictions
• Diuretics 1kg wt loss/day
• Liver transplantation

Question 20

What are the causes of palmar erythema?

Answer 20

• Cirrhosis
• Hyperthyroidism
• Rheumatoid arthritis
• Pregnancy
• Polycythaemia

Question 21

What are the causes of gynaecomastia?

Answer 21

• Physiological: pubity and senility
• Kleinfelters syndrome
• Cirrhosis
• Drugs: spironalactone, digoxin
• Testicular tumour/orchidectomy
• Endocrinopathy e.g. hypo/hyperthyroid and addisons

Question 22

What autoantibodies are found in primary biliary cirrhosis?

Answer 22

• Antimitochondrial antibody (M2 subtype)

- Increased IgM

Question 23

What autoantibodies are found in primary sclerosing cholangitis?

Answer 23

• ANA

- Anti-smooth muscle

Question 24

What autoantibodies are found in autoimmune hepatitis?

Answer 24

• Anti-smooth muscle
• Anti-liver/kidney microsomal type 1 (LKM1)
• ANA may be positive