Week 6 Flashcards

1
Q

List some of the major functions of the liver

A

Hormone metabolism
Glycogen storage
Synthesis of albumin
Detoxification

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2
Q

When is the sphincter of oddi open and when does it close?

A

The sphincter of oddi is closed between meals and opens during a meal

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3
Q

What does bile contain?

A
Bile acids 
Water and electrolytes 
Cholesterol 
IgA 
Bilirubin
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4
Q

What is meant by enterohepatic recycling?

A

The reabsorption of bile salts in the terminal ileum, which are then transported back to the liver

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5
Q

Drug metabolism often proceeds in two phases. Describe what happens in each of these phases

A

Phase 1 - Drugs are activated by oxidation/ reduction/ hydrolysis - this makes the drug more polar to allow for conjugation
Phase 2 - An endogenous compound is added to the drug to make it more polar

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6
Q

The cytochrome P450 superfamily are haem proteins. Where are these located and what is their function?

A

Located in the endoplasmic reticulum of liver hepatocytes

Mediate oxidation reactions in phase 1 of drug metabolism

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7
Q

What is meant by hepatic encephalopathy?

A

A hepatic coma in which there is an altered level of consciousness as a result of liver failure

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8
Q

In severe hepatic failure, detoxification of which substance can’t occur, causing it to accumulate?

A

NH3

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9
Q

Which membrane does HC03- and Cl- exchange occur at?

A

The duct cell apical membrane

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10
Q

How does hepatic portal blood concentration of bile salts affect their synthesis?

A

A low concentration stimulates synthesis of bile salts

A high concentration inhibits synthesis

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11
Q

Which 2 hormones affect bile secretion?

A

Cholecystokinin

Secretin

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12
Q

Which hormone causes gall bladder contraction and relaxation of the sphincter of oddi?

A

Cholecystokinin

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13
Q

What is meant by ‘Glucuronidation’

A

the transfer of glucuronic acid to the substrate.

forms either; amide/ ester or thiol bonds

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14
Q

Explain the blood supply to the liver

A

The liver has a dual blood supply, from the hepatic arteries and from the hepatic portal vein.
The liver has single drainage, via the hepatic vein.

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15
Q

Which 3 cell types are contained within sinusoidal spaces?

A

Endothelial cells
Kuppfer cells
Stellate cells

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16
Q

How is acute liver failure defined?

A

The rapid development of hepatic dysfunction in a previously healthy liver

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17
Q

Give some examples of ‘LFTs’ and ‘True liver function tests’

A

LFTs;

ALT
AST
ALP
GGT

True liver function tests;

Bilirubin
Albumin
Prothrombin time

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18
Q

List some of the clinical features of acute liver disease

A
Jaundice 
Lethargy 
Nausea 
Itch 
Pain
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19
Q

list some of the causes of acute liver disease

A
Hepatitis 
Drugs 
Cholangitis 
Alcohol 
Malignancy
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20
Q

What are the suitable investigations for acute liver disease?

A

History and examination
LFTs
Ultrasound
Virology

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21
Q

How is acute liver disease treated?

A

Supportive
Fluids
Increased calorie intake
Sodium bicarbonate bath, Cholestyramine or Uresodeoxycholic acid (for the itch)

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22
Q

Why is adequate nutrition important in patients with acute liver disease?

A

Acute liver disease is a hypermetabolic state meaning that there is increased energy requirements

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23
Q

Which drugs can potentially cause acute liver failure?

A

PARACETAMOL

ANTIBIOTICS

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24
Q

Which toxic metabolite can paracetamol accumulate as?

A

NAPQI

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25
Q

List the possible causes of fulminant hepatic failure

A

Paracetamol
Drugs
Viral Hepatitis

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26
Q

What are the possible worrying clinical complications of FHF?

A

Encephalopathy

Hypoglycaemia

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27
Q

How is FHF managed?

A

Referral should happen quickly and patients show due in ITU with supportive care and fluids. Transplantation should be considered.

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28
Q

What are antimicrobials?

A

All agents that act against microorganisms ( Bacteria, fungi, viruses and protozoa)

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29
Q

How is antimicrobial resistance (AMR) defined?

A

When microbes are resistant to one or more antimicrobial agents used to treat infection

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30
Q

What is the difference between vertical and horizontal transmission in terms of antibiotic resistance?

A

Vertical transmission- A bacterium accumulates errors during its replication
Horizontal transmission - Resistant genes are swapped from one microbe to another

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31
Q

Why is resistance to antibiotics on the increase?

A
Use of broad spectrum antibiotics 
Large immunocompromised population 
More chronically ill patients 
Antibiotics used in livestock feed 
Antibiotics released into the environment during pharmaceutical manufacturing
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32
Q

What is meant by antimicrobial stewardship?

A

The optimal selection/ dosage/ duration of antimicrobial treatment that results in the best clinical outcome without impacting subsequent resistance

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33
Q

What are the possible causes of cirrhosis?

A

Chronic alcohol abuse
Drugs
Hepatitis
NASH

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34
Q

What happens to the liver in cirrhosis?

A
In liver cirrhosis, it becomes small and shrunken and fibrosis surrounds the hepatocytes. 
Reduced blood flow to the liver 
Reduced metabolic function 
Portal hypertension 
Reduced plasma proteins 
Shunting of blood
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35
Q

What are some of the signs of cirrhosis/ liver disease?

A
Leuconychia 
Clubbing 
Palmar erythema 
Dupuytren's contracture 
Spider naevi 
Xanthelasma 
Gynaecomastia
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36
Q

What would be the expected findings of the tests done in an investigation of liver failure?

A
Increased bilirubin 
Increased ALT/ ALP and AST 
Increased prothrombin time 
Decreased albumin 
Decreased platelets
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37
Q

How does the kidney respond to low albumin?

A

The kidneys detect low plasma volume and so release renin which leads to the production of aldosterone.
= secondary aldosteronism

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38
Q

What happens to sodium, potassium and water in the body when there is secondary aldosteronism and increased endothelia production?

A

Increased sodium
Decreased potassium
Increased water retention

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39
Q

What are some of the possible consequences of liver cirrhosis?

A

Gut oedema causing poor absorption
Gross oedema and ascites
Liver and kidney congestion
Heart failure

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40
Q

How is liver failure treated?

A
Paracetamol 
Codeine 
(NOT NSAIDs) 
Spirnolactone and the patient advised to restrict fluid intake 
Lorazepam (sedation for encephalopathy)
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41
Q

In terms of pathology, what are the three zones present in the normal liver?

A

Periportal
Mid acinar
Pericentral

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42
Q

Describe the progression from liver injury to cirrhosis

A

Insult to hepatocytes
Inflammation
Fibrosis
Cirrhosis

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43
Q

What are some of the causes of acute liver failure?

A

Alcohol
Drugs
Viruses
Bile duct obstruction

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44
Q

How is jaundice classified?

A
By site and type 
SITE 
- pre hepatic 
-hepatic 
-post hepatic 
TYPE 
-conjugated
-unconjugated
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45
Q

Explain pre-hepatic jaundice

A
There is too much haemoglobin to break down
due to; 
Haemolysis 
Haemolytic anaemias 
Unconjugated bilirubin
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46
Q

Explain hepatic jaundice

A
Liver cells are injured/ dead 
due to; 
Alcoholic hepatitis 
Decompensated cirrhosis 
Bile dict loss 
Pregnancy
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47
Q

Explain post hepatic jaundice

A
Bile can't get in to the bowel but bilirubin formation is normal 
Due to;
Carcinoma at the head of the pancreas 
Gallstrones
Strictures of the common bile duct
48
Q

What are the complications of cirrhosis of the liver?

A

Portal hypertension
Ascites
Liver failure

49
Q

What are the signs of portal hypertension?

A

Oesophageal varices
Caput media
Haemorrhoids

50
Q

Which forms of alcoholic liver disease are reversible and which are irreversible?

A
REVERSIBLE
Alcoholic fatty liver (2-3 day binge) 
Alcoholic hepatitis (weeks to months of alcohol abuse) 
IRREVERSIBLE 
Alcoholic fibrosis (months to years) 
Alcoholic cirrhosis (years)
51
Q

What is the pathology of alcoholic fatty liver disease?

A

Steatosis

52
Q

What is the pathology of alcoholic hepatitis?

A

Hepatocyte necrosis
Neutrophils
Pericellular fibrosis
Mallory bodies

53
Q

What is the pathology of alcoholic fibrosis?

A

Collagen is layed down which walls of hepatocytes and disrupts blood supply

54
Q

What is the pathology of alcoholic cirrhosis?

A

Definitive bands of fibrosis separate regenerative nodules

55
Q

NASH = Non alcoholic steatohepatitis.

It is pathologically identical to alcoholic liver disease but can occur in non-drinkers. What are its causes?

A

Obesity
Diabetes
Hyperlipidaemia

56
Q

How many months of disease defines chronic liver disease?

A

> 6 months

57
Q

List some of the causes of chronic liver disease

A
Hepatitis 
Alcohol 
Drugs 
PSC 
Haemochromatosis 
Wilsons disease 
Alpha 1 antitrypsin 
Budd-Chiari
58
Q

How is NASH/ NAFLD manages?

A

Weight loss and exercise

59
Q

List 3 auto-immune liver diseases

A

PBC (primary biliary cirrhosis)
PSC (primary sclerosing cholangitis)
Autoimmune hepatitis

60
Q

What does PBC involve?

A

Autoimmune response against M2 targets on mitochondrial antibodies

61
Q

How does PBC present?

A

Usually asymptomatic
Can have an itch without a rash
Xanthelasma and xanthomas
More common in women than men

62
Q

What tests are used to diagnose PBC and how is it treated?

A

Positive AMA
Cholestatic LFTs (ALP, GGT)
Liver biopsy

*Urseo deoxycholic acid

63
Q

Are more men or women affected by autoimmune hepatitis?

A

Women

64
Q

How might autoimmune hepatitis present? What are the main extra hepatic associated manifestations?

A

Hepatomegaly
Jaundice
Elevated AST, ALT, IgG and prothrombin time

  • Grave’s disease
  • Ulcerative Colitis
  • Autoimmune thyroiditis
65
Q

What are two genetic predisposing factors for autoimmune hepatitis and which of these is the most severe and involves early onset?

A

HLA DR3 - severe, early onset

HLA DR4 - less severe, late onset

66
Q

How is autoimmune hepatitis treated?

A

Corticosteroids (prednisolone) and azathioprine

67
Q

List 3 possible complications of autoimmune hepatitis?

A

Cirrhosis
Ascites
Encephalopathy
Oesophageal varices

68
Q

What is primary sclerosing cholangitis?

A

An autoimmune destructive disease of large and medium sized bile ducts

69
Q

Which disease is PSC strongly linked to?

A

Ulcerative Colitis

70
Q

What would imaging of the biliary tree in a patient with PSC show?

A

Areas of dilation and areas of restriction

71
Q

Which drug used to treat rheumatoid arthritis and psoriasis can cause fibrosis of the liver?

A

Methotrexate

72
Q

What is haemochromatosis?

A

An autosomal recessive genetic condition involving iron overload

73
Q

Which genes are mutated in haemochromatosis?

A

C282Y and H63D

74
Q

How is haemochromatosis treated?

A

By regular venesection to iron deplete the patient

75
Q

What is Wilson’s Disease?

A

A genetic autosomal recessive disease involving copper over-load due to loss of function of caeruloplasmin

76
Q

What are some of the clinical signs of Wilson’s disease?

A

Cirrhosis
Involuntary movements
Kaiser-Fleischer rings

77
Q

Which conditions (resp and GI) can alpha 1 anti-trypsin deficiency cause?

A
Lung emphysema 
Liver disease (cirrhosis, cholestatic jaundice and hepatocellular cancer)
78
Q

What is Budd-Chiari? How does it present?

A

Thrombosis of hepatic veins

  • Jaundice
  • Tender hepatomegaly
  • Ascites
79
Q

What investigation is done for Budd-Chiari and how i the condition treated?

A

Ultrasound of the hepatic veins

Recanalisation and TIPS

80
Q

Which heart conditions can cause cardiac cirrhosis (liver cirrhosis secondary to right heart pressures)

A

Incompetent tricuspid valve
Rheumatic fever
Constrictive pericarditis

81
Q

How is portal hypertension defined in terms of pressures?

A

Portal vein pressure > 8mmHg

Portal vein - hepatic vein pressure >5mmHg

82
Q

How might compensated cirrhosis present?

A
The patient may look clinically normal and feel well
- may have; 
spider naevi 
clubbing 
palmar erythema
83
Q

How might decompensated cirrhosis present?

A
Jaundice 
Ascites
Encephalopathy 
Bruising 
Increased risk of bleeding
84
Q

How is ascites managed/ treated?

A
Reduce salt intake but maintain nutrition 
Spironolactone 
Paracentesis 
TIPSS 
Transplantation
85
Q

How would encephalopathy present?

A
Altered mood/ behaviour 
Drowsiness 
Liver flap 
Sleep disturbance 
Confusion
86
Q

Oesophageal varices can develop as a consequence of cirrhosis, how would a bleed be treated?

A
B-blockers 
Variceal ligation 
TIPSS
Shunt surgery
Ballon tamponade (EMERGENCY treatment)
87
Q

Which form of hepatitis has faecal-oral spread, a short incubation period, is directly cytopathic but does not involve a carrier state?

A

Hepatitis A

88
Q

Which form of hepatitis is the most infectious, has a long incubation period and is spread by blood, sex and vertical transmission?

A

Hepatitis B

89
Q

Which form of hepatitis is spread by blood, has a short incubation period and involves a chronic/carrier state?

A

Hepatitis C

90
Q

What percentage of PBC patients are female?

A

90%

91
Q

Secondary tumours of the liver (metastases from another organ) are more common than primary tumours. From which organs does cancer most commonly spread to the liver from?

A

Lung
Colon
Pancreas
Breast

92
Q

What does the term ‘cholethiasis’ mean?

A

Gall stones

93
Q

What are the two main types of gall stones? What causes each type?

A

Cholesterol stones (hypercholesterolaemia) and pigment stones (haemolytic anaemia)

94
Q

What are the normal components of bile?

A

Cholesterol
Bile salts
Bilirubin
Phospholipids

95
Q

Which enzyme is responsible for the release of bile from the gall bladder into the second part of the duodenum?

A

CCK

96
Q

What is meant by gallstone ileus?

A

Gallstones enter the intestines through a fistula and cause obstruction (commonly at the ileo-caecal valve)

97
Q

How can gallstones cause pancreatitis?

A

By blocking the sphincter of Oddi

98
Q

What is meant by the term ‘Cholecystitis’?

A

Inflammation of the gall bladder

99
Q

List some of the causes of acute pancreatitis

A

Alcohol
Cholethiasis
Shock
Trauma

100
Q

In acute pancreatitis, there is release of two kinds of pancreatic enzymes; proteases and lipases, what do these cause?

A

Lipases cause intra and peri-pancreatic fat necrosis

Proteases cause tissue destruction and haemorrhage

101
Q

Is pancreatitis more common in males or females?

A

Females

102
Q

What effect does cholecystokinin have on the gall bladder and the sphincter of oddi?

A

Causes contraction of the gall bladder and relaxation of the sphincter of oddi

103
Q

What compound mediated the synthesis of bile salts?

A

CYP7a1

104
Q

What are the three main liver plasma proteins? Which of these is the most abundant?

A

A globulins, B globulins and Albumin.

Albumin is the most abundant.

105
Q

What is the function of a globulins?

A
Transport of; 
Lipids 
Hormones 
Bilirubin 
Dietary metals
106
Q

Give an example of an A globulin and a B globulin

A

A - Caeruloplasmin

B- Transferrin and Fibrinogen

107
Q

Which plasma protein acts as the main determinant of osmotic pressure?

A

Albumin

108
Q

What is the role of chylomicrons in the transport of fats?

A

Transport fat to the liver

109
Q

What is the role of VLDL in the transport of fats?

A

Transport fat to peripheral cells - can involve deposition of cholesterol in vessels

110
Q

What is the role of LDL in the transport of cholesterol?

A

Transport cholesterol to peripheral tissues

111
Q

What is the role of HDL in the transport of cholesterol?

A

Removes excess cholesterol from cells and transports it back to the liver

112
Q

What would the appearance of Anti-HBs in Hep B serology indicate?

A

Indicates immunity either due to previous exposure or due to vaccination

113
Q

What would a positive HBsAg result from Hep B serology indicate?

A

Current infection - it indicates an infectious state

114
Q

What would a positive HBeAg result from Hep B serology indicate?

A

A highly infectious state

115
Q

What would Hep B IgM in Hep B serology indicate?

A

Recent or current Hep B infection

116
Q

What would Hep B DNA indicate if it was present in high amounts?

A

A highly infectious state of current Hep B infection

117
Q

What would a positive Anti-HBe indicate in Hep B serology?

A

Low infectivity