Week 10: Liver Biochemistry Flashcards
What are the general symptoms for acute liver disease? (3)
Mild
Self-limiting
Progressive to chronic.
What are the general features that indicate chronic liver disease? (1)
Structural changes = affects liver function
What are the initial symptoms of liver disease? (3)
Non-specific
Easily Fatigued
Nausea
What are the common symptoms of liver disease? (2)
Appetite/Weight loss
What is the difference between compensated and decompensated liver disease? (1)
Compensated: Liver function maintained after liver damage.
Decompensated: Liver function compromised after liver damage.
What are the symptoms of decompensated liver disease? (6)
Arms/Legs muscle loss
Abdomen + lower body swelling
Ab. Pain
Pruritus
Bruising
Gums/Nose Bleeding
What are the signs of liver disease? (9)
Jaundice
Palmar Erythema
Finger Clubbing
Spider Naevi
Ascites (ab. swelling)
Dilated Ab. blood vessels
Varices
Neurological changes
Hepatic Flap
Xanthelasmas
What are the causes of liver disease? (7)
Alcohol
Viral infections (Hep. A-E)
Fatty Liver
Malignancy (HCC)
Immune Disease (Autoimmune Hepatitis)
Inherited + Metabolic Disorders (Wilson, a1-antitrypsin deficiency)
Drugs + Toxins
Give e.g. of drugs that can cause liver disease. (4)
Paracetamol
Phenytoin
Oral Contraceptives
Methotrexate
What is the reference range for albumin?
34-45g/L
Where in the body is albumin made? (1)
Made in the liver.
What is the half-life of Albumin? (1)
Half-life = 20 days.
What is the general level of albumin in acute liver disease? (1)
Normal
Explain the importance of Albumin. (1)
Useful guide to severity of chronic liver disease.
What causes is considered when albumin levels are low? (1)
Extrahepatic
What are the symptoms of hypoalbuminemia? (5)
Oedema
Appetite changes
Muscle breakdown
Dry Skin
Ab. weight gain
What are the potential causes of hypoalbuminemia? (4)
Heart Failure
Diabetes
Vitamin deficiency
Severe burns
What are the general features for ALT? (4)
A.K.A. Alanine Transferase
Released from hepatocytes when damaged.
Cytosol enzyme
Liver specific than AST
Also indicates drug-induced reaction.
What is the reference range for ALT? (1)
0-40 IU/L
What is the reference range for AST?
0-40 IU/L
What are the general features for AST?
A.K.A. Aspartate Transferase
Released from hepatocytes when damaged.
Which part of the body can you find AST? (6)
Heart
Pancreas
Kidney
Lung
Muscle
RBC
What is the AST:ALT ratio for hepatocellular injury? (2)
AST < ALT
Chronic liver disease
What is the AST:ALT ratio for established cirrhosis? (4)
AST > ALT
2:1 or greater
Alcoholic Liver Disease
Esp. if GGT = increased.
What is GGT? (6)
A.K.A. Gamma-Glutamyl Transpeptidase
Enzyme
Released in all types of liver dysfunction
Indicator for alcohol abuse
Enzyme inducing drugs
Where in the body is GGT found? (6)
Hepatocytes
Biliary Epithelial Cells
Kidneys
Pancreas
Intestine
Prostate
What is the reference range for GGT? (1)
0-50IU/L
What is ALP? (3)
Alkaline Phosphatase
Isoenzyme
Where is ALP produced? (1)
Hepatocytes
What disease state causes an increase in ALP levels?
Cholestatic disease
What does an isolated rise in ALP not indicate?
Liver dysfunction
What is Bilirubin? (4)
Breakdown RBC product
Transported to liver, attached to albumin.
Billirubin is conjugated in the liver.
Excreted via bile.
What is the reference range for Bilirubin? (1)
5-21umol/L
What factors can increase bilirubin levels? (4)
Liver damage resulting to jaundice.
Biliary tract obstruction
Haemolysis
What is prothrombin? (2)
Made in the liver
Vit. K dependent
What is the range of prothrombin time? (1)
12-16 seconds
What is prothrombin time? (3)
Time taken for clot to form.
Marker of synthetic function.
Excludes vit. K deficiency.
Outline the complications associated with liver disease. (5)
Portal hypertension
Ascites
Encephalopathy
Bleeding Varices
Spontaneous Bacterial Peritonitis (SBP)
What is portal hypertension? (3)
Increase pressure in portal venous system.
Collateral veins develop.
Contributes to ascites + encephalopathy.
What are the treatment options for portal hypertension? (2)
Carvedilol
Propanolol
What is ascites?
Swollen abdomenW
What factors cause ascites? (4)
Fluid acccumulation
Low serum albumin
Portal hypertension
Decrease in aldosterone metabolism
What are the treatment options for ascites?
Low sodium diet
Mobilise fluid excess:
- Diuretics
- Paracentesis
What are the possible causes of encephalopathy? (3)
Occurs with significant liver dysfunction.
Altered BBB permeability (ammonia)
Altered mental state
Asterixis
What is the main treatment aim for encephalopathy? (1)
Reduce ammonia in circulatory system.
What are the treatment options for encephalopathy? (2)
Lactulose
Antibiotics (Rifaximin)
What are the treatment aims for bleeding varices? (3)
Stop/delay blood loss
Treat hypovolaemic shock
Prevent recurrent bleeding.
What are the preventative measures for bleeding (bleeding varices)? (2)
Propranolol + endoscopic ligation
Carvedilol
What are treatment options for bleeding varices? (3)
Vasopressin or Terlipressin
Somatostatin or Octreotide
Balloon Tamponade
What do you need to consider for using PPIs? (1)
Complications can arise in cirrhosis -
Use with caution
What is spontaeneous bacterial peritonitis? (3)
Complication of cirrhosis.
Acute bacterial infection of ascitic fluid.
Mortality (40-70%)
What are the treatment options for acute SBP? (1)
IV antibiotics
What are the treatment options for prophylactic SBP? (2)
For high risk patients
Quinolones (use with caution)
What is pruritus? (1)
Bile salt deposition within the circulation.
What are the treatment options for pruritus? (5)
Depends on severity:
- Moisturising and cooling agents
- Ursodeoxycholic acid
- Antihistamines
- Anion exchange resins
Explain the importance of CIWA-Ar for managing alcohol withdrawal.
CIWA-Ar - scoring system. Monitors alcohol withdrawal and guides need for pharmacological therapy i.e. BZPs.
What is the treatment aims for alcohol withdrawal? (4)
Reduces:
- Mortality
- Withdrawal symptoms duration
- Seizures
- Delirium Tremens
What are the potential cause of muscle cramps? (2)
Diuretics
Vit. D deficiency
What is the treatment for muscle cramps? (1)
Quinine Sulphate
What are the common side effects for Quinine Sulphate when used for muscle cramps? (2)
Thrombocytopenia (low platelet count)
Cardiotoxicity
What do you need to consider when treating pain for patients with liver disease? (5)
Don’t use NSAIDs
Opioids: Morphine, Oxycodone, Fentanyl
Paracetamol
What factors do you need to consider for hepatic blood flow? (2)
Reduced
Increase in systemic bioavailabilty of oral drugs undergoing 1st pass metabolism
What main factor do you need to consider for portosystemic shunting?
60% blood supply diverted
What factors do you need to consider for reduced hepatic cell mass? (2)
Severe disease = 30% capacity
Drugs extensively metabolised in liver.
What factors do you need to consider for reduction in protein binding? (3)
Lower serum albumin
Highly protein drugs
Drug free conc. = increased.
Give e.g. of drugs that can exacerbate liver complications. (4)
Opioids
Benzodiazepines
Diuretics
NSAIDs
Give e.g. of drugs that can induce liver disease.
Statin
NSAIDs
Penicillins
(Can present in weeks/months after medication is started/stopped)
High GGT, bilirubin and ALP means that the patient will have cholestasis.
– True – False
True
High ALT and AST means that the patient has hepatotoxicity. (T/F?)
False
Which of these drugs WILL cause liver impairment?
Digoxin
Rifampicin
Statins
Statins
