Chapter 4- LIVER Flashcards by Rachel Cornish

What is bilirubin?

Product of RBC breakdown, clinical jaundice when bilirubin is >50micromol/L

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What makes up the portal triad

Bile duct
Branch of hepatic artery
Branch of portal vein

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What’s the name of a liver cell

Hepatocyte

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Portal triad leads to what?

Central vein

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What primarily supplies the liver with rich blood supply

The portal vein

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Symptoms of acute alcoholic hepatitis

Raised WBC
Fever
Deterioration in clotting
Large rise in ALT

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What is discrimination function and what does >32 show?

(Prolongation in prothrombin time * 4.2) + (bilirubin/17)

> 32=severe disease

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What 5 things are used in the Glasgow alcohol hepatitis score

Age
WBC
Urea
INR
Bilirubin

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What number signifies a worse prognosis on the Glasgow alcohol hepatitis score?

9 or greater

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List 7 other effects of alcohol

Pancreatitis 
Chronic brain injury
Cardiomyopathy
Myositis 
Neuropathy 
Osteoporosis
Social

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What does NAFLD stand for

Non alcoholic fatty liver disease

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What does NASH stand for

Non alcohol steatohepatitis

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What is non alcohol steatohepatitis

Fat plus significant injury

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What does the NAFLD fibrosis score take into account?

Age
BMI
hyperglycaemia 
Platelet count
Albumin
AST
ALT

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What does a NAFLD fibrosis score of

Predictor of absence of significant fibrosis

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What does a NAFLD fibrosis score of

Intermediate score

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What does a NAFLD fibrosis score of >0.675 predict

Predictor of presence of significant fibrosis

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When do NICE recommend bariatric surgery

For BMI >40 or

BMI 35-40 if coexistence condition that may improve with weight loss

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Did a study show pioglitazone to be worse than placebo for secondary outcomes of NAFLD in diabetics?

No better but not for primary outcomes

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In a study was vitamin E associated with significantly higher rates of improvement in NAFLD in diabetics

YEAH

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What concerns do pioglitazone bring up?

Heart failure and bladder cancer

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Give 7 signs of chronic liver disease

Jaundice 
Bruising
Spider naevi
Dupuytrens contractures
Palmer erythema
Gynaecomastia
Ascites

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What’s gynaecomastia

Man boobs

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What is the child Pugh score used to assess?

The prognosis of chronic liver disease, mainly cirrhosis

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What 5 things are assessed in the child Pugh score

``` Encephalopathy Ascites Bilirubin Albumin INR ```

What can Ascites cause

Umbilical hernia

What are the different grades on the child Pugh score

A B C

Is bed rest good for Ascites?

No it's unhelpful

List ways you can manage Ascites

``` Salt restriction- beware antibiotics and pre prepared foods Diuretics Paracentesis TIPSS Alfa pump Pleurx Transplant ```

Which two diuretics are used for management of Ascites

Spironolactone | Furosemide

How do you treat oesophageal varices?

Glypressin injection

Which antibiotic is best studied for treating infection with Ascites

Ciproxin 500mg BD

Varices are classified by what and give two examples

Their location Esophageal Gastric

Esophageal varices are graded by what?

Their size A- small straight B- enlarged, tortuous, occupies less than 1/3 of lumen C- large, coil-shaped, occupies more than 1/3 of lumen

Name three surgical techniques for helping variceal haemorrhage

Endoscopic scleropathy Endoscopic variceal band ligation Ballooning

What does SBP stand for

Spontaneous bacterial peritonitis

What are the features of spontaneous bacterial peritonitis

``` Mild fever Ascites Deteriorating renal function Encephalopathy Deteriorating liver function Asymptomatic ```

How do you diagnose spontaneous bacterial peritonitis

Ascitic fluid neutrophil count of >250cell/mm^3 or >500white cell/mm^3 Culture into blood culture bottles doubles chance of detecting Clinical suspicion

How do you treat spontaneous bacterial peritonitis

Tazocin 4.5g TDS IV 5days or ciproxin 750mg BD orally If no improvement in 48hrs repeat tap (should be >25% reduction in wcc) Albumin day 1 and 3 reduces renal injury Paracentesis/transplant

What is hepato-renal syndrome

Functional renal impairment in someone with significant liver disease

How many types of hepato-renal syndrome are there

What is type 1 hepato-renal syndrome

Doubling of creatinine over

What's type 2 hepato-renal syndrome

Doubling of creatinine over >6weeks | Irreversible

How do you manage hepato-renal syndrome

Ensure fluid resuscitated Stop diuretics (and other nephrotoxins) Look for SBP (or other infection) Stop beta-blockers

What Is encephalopathy often associated with

Acute GI bleed or infection

What type of syndrome is encephalopathy?

Neurocognitive syndrome

What's encephalopathy difficult to differentiate from

Dementia

How many grades are there to encephalopathy

What's the 5 pointed star used to assess

Grading of encephalopathy

How do you assess/grade encephalopathy

5 point star | Stroop test

How can you treat encephalopathy

``` Avoid sedating drugs Correct electrolytes Treat constipation Seek infection esp. SBP consider intubation Lactulose Night time snack Benzodiazepine antagonists Transplantation ```

What's used to treat alcohol withdrawal

Chlordiazepoxide

Do levels of bilirubin increase in liver disease

Yes they do

Increased bilirubin levels can reduce the absorption of highly lipophilic drugs- why?

Because there is reduced bile salt excretion into intestine (which solubilises fats)

In liver disease there is a possible reduction in biliary clearance which can effect what drugs?

Drugs cleared by the biliary system e.g digoxin, may increase clinical effects so monitor

Drugs that undergo enterohepatic recirculation may have reduced exposure in liver patients.. Why? And give an example

Reduced biliary excretion so less chance of enterohepatic circulation, e.g COC

How does increased levels of bilirubin in liver patients affect protein bound drugs give two examples of protein bound drugs

Bilirubin can compete against the drug molecule for the protein binding site thus increasing the amount of 'free drug' e.g phenytoin, warfarin

What does AST stand for

Aspartate aminotransferase

What does ALT stand for

Alanine transaminase

What is ALT often termed

Liver specific enzyme

In patients with liver disease do they always have raised transaminase enzymes?

No because there's a massive reduction in number of functioning hepatocytes which can give a false normal

What does ALP stand for

Alkaline phosphatase

Raised ALP in isolation may be due to what

Other reasons e.g Paget's disease

What's cholestasis

Where bile cannot flow from the liver to the duodenum

List four liver enzymes

AST ALT ALP GAMMA-GT

Low levels of albumin can cause what

OEDEMA

What is albumin

One of the proteins produced by the liver, has a long half life of 20-26days

In chronic liver disease are levels of albumin high or low

LOW

Are clotting factors produced by the liver?

Yeh man

How does PT/INR change in acute and chronic liver disease

Increases

Generally decreased albumin and raised PT/INR indicate what?

Reduced synthetic function

How does low albumin affect protein binding?

Decreased albumin= decreased protein binding which can increase amount of free drug in highly protein bound drugs e.g phenytoin

What might hepatic encephalopathy be due to?

Passage of neurotoxins to the brain

How can you reduce the nitrogen load from the gut in hepatic encephalopathy?

Lactulose | Bowel enema

Why do you use antibiotics in hepatic encephalopathy?

To lower the amino acid production by decreasing the concentration of ammonia-forming colonic bacteria

What can develop if wernickes encephaolpathy is left untreated

Korsakoff's syndrome

What is wernickes Korsakoff's syndrome

A spectrum of disease resulting from thiamine deficiency, usually related to alcohol abuse

How do you treat wernickes Korsakoff's syndrome

Thiamine orally plus vitamin B complex or multivitamins which should be given indefinitely

What are the key triad of symptoms present in wernickes Korsakoff's syndrome

Mental confusion | Ataxia and ophthalmoplegia

Offer oral thiamine to harmful or dependent drinkers if either of what two conditions apply:

They are malnourished | They have decompensated liver disease

What is pruritus?

Severe itching of skin

What solubilises fats?

Bile salts