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Case 3 > The Liver in Health and Disease > Flashcards

The Liver in Health and Disease Flashcards

1
Q

Which organs is the liver in close relationship with

A

The biliary tract and gallbladder

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2
Q

Describe the vascular relationships of the liver

A

Dual inflow of blood from hepatic artery and portal vein. Outflow of blood from hepatic vein

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3
Q

What does bile drainage follow

A

Hepatic artery and portal vein

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4
Q

What is the hepatic artery a branch from

A

The coeliac artery

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5
Q

What kind of epithelium is there in the liver

A

Glandular epithelium

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6
Q

Where does the gall bladder sit

A

On the under surface of the liver

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7
Q

Describe the biliary tree

A

Right and left hepatic duct form common hepatic duct. Common hepatic duct and cystic duct form common bile duct. Common bile duct and pancreatic duct enter the duodenum via the sphincter of Oddi

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8
Q

What does the epithelium in the gall bladder do

A

Acts to remove water and salts to concentrate bile

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9
Q

What are the functions of the liver

A

Vital organ capable of regenerating. Maintaining metabolic homeostasis. Cytoplasm of hepatocytes contain enzymes to enable homeostasis. Stores nutrients. Detoxifies harmful substances. Bile synthesis

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10
Q

What nutrients does the liver store

A

Glycogen, iron, copper and fat-soluble vitamins

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11
Q

The liver is responsible for the homeostasis of what

A

Carbohydrates, proteins and fats

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12
Q

Where does gluconeogenesis take place

A

In the liver

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13
Q

Describe acetoacetate

A

An energy source (fats) but dangerous if present for a long time

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14
Q

Describe the production of bile

A

RBC breakdown results in the formation of unconjugated bilirubin which binds to albumin in the blood and is transported to the liver. In the liver unconjugated bilirubin becomes conjugated to glucuronic acid in the hepatocytes, Glucuronic acid (conjugated bilirubin) is water soluble and is excreted in bile. Bile is stored and concentrated in the gall bladder before entering the gut

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15
Q

What does unconjugated bilirubin bind to in the blood

A

Albumin

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16
Q

What triggers bile release

A

The presence of fat in the small bowel (duodenum) triggers the release of cholecystokinin (CCK) from I cells of the duodenum and jejunum

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17
Q

What does CCK trigger

A

Production of more bile from the liver, contraction of the gallbladder and relaxation of the sphincter of Oddi

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18
Q

What are portal areas

A

Where blood feeds into the liver

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19
Q

What do terminal venules do

A

Drain blood from the liver

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20
Q

How can the functional unit of the liver be described

A

As a lobule or acnius

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21
Q

Describe a lobule

A

There is a central vein the in centre of each lobule

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22
Q

Describe an acinus

A

There is a portal triad at the centre of each acinus

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23
Q

What is contained in a portal triad

A

Portal vein, hepatic artery, bile duct

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24
Q

How many zones does an acinus have

A

3

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25
Q

Describe zone 1

A

Zone 1 is the very inner zone of an acinus. Zone 1 hepatocutes have better blood supply and are less vulnerable to ischaemia and toxins.

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26
Q

Describe zone 3

A

Zone 3 is the outermost zone of an acinus. Zone 3 hepatocytes are less well oxygenated and more vulnerable to poor perfusion and toxins

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27
Q

What can liver function tests check for

A

Hepatocyte damage and biliary obstructions

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28
Q

What does hepatocyte damage result in

A

Raised transaminases: alanine transferase (ALT), asparate transaminase (AST) and yGluatmyl transpeptidase (yGT)

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29
Q

What is there in chronic conditions

A

Low albumin

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30
Q

What does long term damage to hepatocytes do

A

Reduces capacity to synthesise proteins

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31
Q

What can biliary obstruction result in

A

Raised bilirubin and alkaline phosphatase

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32
Q

What do you get in biliary obstruction

A

Deranged clotting, impaired protein synthesis including clotting factors, lack of vitamin K which requires bile for absorption

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33
Q

When is conjugated bilirubin increased

A

In biliary obstruction

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34
Q

What is alkaline phosphatase produced by

A

Biliary canaliculi

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35
Q

Why is liver disease classified in different ways

A

Because of presentation/ appearance when you take a biopsy/ cause of disease (aetiological factors)

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36
Q

What does liver fibrosis result in

A

Function loss

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37
Q

What does acute liver disease result in

A

Cell death of hepatocytes

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38
Q

Why does acute liver failure lead to hyperbilirubinaemia

A

Acute liver failure results in cell death leading to an increase in enzymes (transaminases) and hepatic encephalopathy resulting in toxic effects on the brain and bilirubin not being conjugated properly. As a result you get conjugated hyperbilirubinaemia

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39
Q

How is chronic hepatitis divided

A

By grade/ stage

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40
Q

How is chronic hepatitis divided by grade

A

By the pattern and degree of inflammation and cell death

41
Q

How is chronic hepatitis divided by stage

A

The degree of fibrosis

42
Q

What is fibrosis

A

Permanent scarring

43
Q

What causes fatty changes in the liver

A

Metabolic stresses, alcohol, pregnancy

44
Q

What causes cholestasis

A

Obstruction, autoimmune disease, viral hepatitis, pregnancy, drugs

45
Q

What is fatty changes in the liver

A

Accumulation of fat (no glycogen so cells don’t take up the stain)

46
Q

What is cholestasis

A

When bile stays in the liver which damages the hepatocytes

47
Q

Describe the natures of hepatocyte necrosis

A

Can be individual cells, zonal or massive

48
Q

What is the end stage of fibrosis

A

Cirrhosis (permanent)

49
Q

What can abnormal storage cause

A

Hemochromatosis

50
Q

What substances can be stored abnormally in the liver

A

Iron, copper, glycogen, lipids

51
Q

What are the most common causes of lipid disease

A

Alcohol, non-alcoholic fatty liver disease (obesity, pregnancy), viral hepatitis

52
Q

What are less common causes of lipid disease

A

Extrahepatic obstruction- gallstones, autoimmune liver disease- primary biliary cirrhosis, drugs-paracetamol, tumours, heart failure, metabolic and storage disease

53
Q

What is hepatitis A

A

Enterovirus

54
Q

How is hepatitis A transfered

A

Faeco-oral transmission

55
Q

What does an outbreak of hepatitis A lead to

A

Acute hepatitis: fever, malaise, jaundice

56
Q

What causes damage to the liver in hepatitis A

A

Serum transaminase

57
Q

What is hepatitis B

A

DNA virus

58
Q

How is hepatitis B transferred

A

Via blood, semen, saliva, IV drug abuse, sexually transmitted, blood donations, mother to child

59
Q

When can hepatitis D cause infection

A

Only in the presence of hepatitis B

60
Q

What does hepatitis B cause in the liver

A

High rate of developing cirrhosis

61
Q

What increases with age in relation to hepatitis B

A

Frequency of clinical disease

62
Q

What decreases with age in relation to hepatitis B

A

Carriers

63
Q

What is hepatitis B called when you are younger

A

A sub clinical infection

64
Q

What is hepatitis B recognised as when you are older

A

A clinical disease

65
Q

How many people with hepatitis B develop chronic hepatitis

A

20% of those with a chronic infection. 10% of those with acute hepatitis get chronic infection. 25% infected get acute hepatitis

66
Q

What can chronic hepatitis cause

A

3% of people get cirrhosis leading to hepatocellular carcinoma

67
Q

What does presence of HBeAg mean

A

High infectivity and severity of the disease

68
Q

What does it mean if HBcAg is present

A

You have infection as cannot vaccinate against core

69
Q

How many people infected with hepatitis C develop chronic hepatitis and chronic liver disease

A

85%

70
Q

What does cirrhosis require

A

Transplantation as there is no cure

71
Q

What is the most common cause of chronic liver disease in the UK

A

Alcohol

72
Q

What happens in the liver if you drink too much alcohol

A

You develop fatty liver disease which results in reversible inflammation. If you continue to drink you get fibrosis then cirrhosis, both of which are irreversible

73
Q

What two drugs can cause dose-dependent toxicity in the liver

A

Paracetamol and methotrexate

74
Q

Describe idiosyncratic drug reactions

A

You inherit specific genes that control the transformation of a drug which leads to drug (and/or toxic metabolite) accumulation e.g. NSAIDs and antiretrovirals

75
Q

Describe non-alcoholic fatty liver disease

A

Same pathological features as alcoholic liver disease

76
Q

Describe autoimmune liver disease

A

Not that common. There are antibodies detected in serum

77
Q

What is primary biliary cirrhosis

A

Destruction of bile ducts

78
Q

What do gallstones result in

A

An obstruction which causes pale stools due to jaundice. As a result there is more bilirubin in the blood instead of in stools resulting in dark urine

79
Q

What are the two types of gallstones

A

Cholesterol and pigment stones

80
Q

Which type of gallstones are more common

A

Cholesterol- 80% (pigment- 20%)

81
Q

What can cause cholesterol stones

A

Increased cholesterol or decreased bile salts

82
Q

Who are at most risk of cholesterol stones

A

4 F’s: female, fair, forty, fat

83
Q

Why are cholesterol stones more common in women

A

Cholesterol stones are more common in the presence of oestrogen. More common in women as oestrogen malabsorption causes a decrease in bile salts= cholesterol stones form

84
Q

Who can pigment stones occur in

A

Increased red cell breakdown- children with sickle cell disease. Chronic biliary infection

85
Q

How does increases red cell breakdown result in pigment stones

A

Increased red cell breakdown results in increased unconjugated bilirubin

86
Q

How do chronic biliary infections result in the formation of pigment stones

A

Glucuronidase is released by injured hepatocytes and bacteria which hydrolyses bilirubin glucuronides, as a result the amount of unconjugated bilirubin increases- pigment stones form

87
Q

What are liver tumours mostly due to

A

Metastatic disease making them a metastatic cancer

88
Q

What are metastatic liver tumours causes by

A

Haematogenous (blood borne) metastases

89
Q

What makes the liver vulnerable to its high level of metastases

A

Dual blood supply

90
Q

What is primary liver cancer called

A

Hepatocellular carcinoma

91
Q

What are the predisposing factors for hepatocellular carcinoma

A

Cirrhosis, hepatitis B and C infection, fungal toxins secondary to food contamination

92
Q

What are causes of just chronic liver disease

A

Hepatitis C, alcohol, NAFLD

93
Q

What are causes of just acute liver disease

A

Paracetamol, hepatitis A, drug reactions

94
Q

What are causes of both acute and chronic liver disease

A

Hepatitis B, autoimmune, tumours

95
Q

What does cytokine production in the liver result in

A

Scarring leading to cirrhosis

96
Q

What happens when cirrhosis occurs in the liver

A

The liver can’t regenerate in the proper way resulting in nodules and therefore scarring. Micro/ macro nodular scarring.

97
Q

What will affect whether someone gets a liver transplantation or not

A

If they are infectious or still drinking

98
Q

What are the issues in end-stage liver cirrhosis

A

Splenomegaly, brusing, bleeding, can’t metabolise oestrogen, ascites, spider naevi, low albumin, portal hypertension, increased risk of sudden cardiac death (due to disturbance of Q-T interval)

Case 3 (9 decks)

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