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Flashcards in CSIM liver Deck (125):
1

commonest cause of liver disease?

NAFLD in 20-30% of population

2

commonest cause of liver death?

alcohol related liver disease - 84%

3

risk factors for NAFLD?

obesity
diabetes
metabolic syndrome
male
age

4

stages of ARLD?

normal - > steatosis - > steatohepatitis - > fibrosis/ cirrhosis

steatosis = infiltration of fat in the liver
steatohepatitis = fat in the liver with inflammation

5

commonest presentation of liver disease?

incidental
- abnormal LFTs
- hepatosplenomegaly
- screening for antibodies / autoantibodies
- raised MCV, abnormal clotting, low platlets

6

why dry eyes / mouth in liver disease?

primary biliary cirrhosis

7

how much alcohol is 1 unit?

10ml

8

definition of a binge?

>10u / sesh

9

raised ALP and GGT indicates what?

cholestasis
malignancy
alcohol

10

raised ALT and AST indicates what?

hepatocyte damage
if 1.5-3 x raised think ALD / NAFLD
if >3x raised think viral, autoimmune or drug induced

11

which anti bodies are present in autoimmune hepatitis?

anti-nuclear antibodies and anti smooth muscle

12

what does a transferrin saturation <45% rule out?

haemochromotosis

13

first line imaging in liver disease?

US

14

what is done when ct is performed?

IV constrast

15

best imaging for focal lesions?

MRI

16

indications for liver biopsy?

chronic liver disease for diagnosis and staging
focal lesions
transplantaion

17

risk associated with liver biopsy?

bleeding

18

what procedure to remove gall stones?

ERCP

19

features of metabolic syndrome?

DM
hypertension
high cholesterol -high LDLs and triglycerides
fatty liver
central obesity

20

effect of metabolic syndrome on urate?

increased urate due to renal damage (hypertension)

21

effect on MCV in alcohol excess?

raised

22

what does a bright liver indicate on US?

NAFLD

23

effect on FBC in cirrhosis

decreased platelets due to portal hypertension

24

significance of AST:ALT ratio?

normally in liver disease AST is LOWER than ALT
in ALD the AST:ALT ratio is > 2:1

25

why wouldnt you do a liver transplant if cancer is >5cm?

probably already spread

26

some reasons for liver transplant?

resistant ascites
encephalopathy
cancer < 5cm
uncontrollable varacele bleeds

27

pancreatic cancer risk is increased with obesity t or f?

true

28

what is the final common pathway in all liver disease?

activation of hepatic stellate cells causes fibrosis

29

what are the 4 key sings of a decompensated liver disease?

asterixsis - hepatic flap
encephalopathy
ascites
jaundice

30

why do you always do a tap in ascites?

check for spontaneous bacterial peritonitis

31

what does asterixis look like?

asymmetrical FLAP

32

causes of raised ferritin?

haemochromotosis
ALD
alcohol excess
obesity - raised triglycerides and a fatty liver

33

would you transplant a liver in an alcoholic?

wait 6 months from their last drink for 2 reasons:
1. make sure they are committed to sobriety
2. in this time some livers can repair sufficently to not need a new liver

34

most common sites of varicele bleeding?

oesophageal
rectal
gastric

35

what drug can be given as prophylaxis for varicele bleeding?

b-blockers

36

tx for varacele bleed?

banding is first line
if this fails can put in a shunt which decreases pressure in portal vein by moving blood to the hepatic vein

37

Mx of ascites?

conservative- reduced fluid (<1.5l/day) and salt intake
medical - diuretics - spironalactone / furosemide
surgical - therapeutic paracentesis (draining)

38

what might the fluid from an ascitic tap be bloody?

clipped a vessel
HCC - about 30% of bloody ascites is due to cancer

39

what must be given when draining fluid from abdomen?

fluids

40

what type of pathogen is most common in SBP?

gram neg. bacilli (e. coli, klebsiella etc.)

41

what secondary prophylaxis is given after SBP?

life long ciprafloxacin

42

what is hepatorenal syndrome?

renal failure in those with healthy kidneys due to liver disease

43

what are the types of HRS?

type 1 - rapidly progressive. often associated with acute renal failure
type 2 - slower course. associated with refractory ascites

44

what is the tx for HRS?

transplant

45

4 precipitating factors for hepatic enceph?

GI bleeding
infection
renal deterioration
constipation

46

tx for hepatic enceph?

regular lactulose +/- phosphate enemas
rifaximin

47

how does rifaximin treat enceph.?

non absorbable abx: reduce gut bacteria so less ammonia produced

48

where does blood from the liver drain?

hepatic vein

49

what is the commonest cause of liver cancer?

cirrhosis

50

why are we cautious of mass biopsy in liver cancer?

risk seeding the tumour

51

how does liver cancer change the blood supply to the liver?

draws blood from the hepatic artery

52

most common site for liver cancer metastasis

lung

53

what are the most common causes for secondary liver cancer?

pancreas
lung
colon
breast

54

which viruses commonly lead to hepatocellular carcinoma

hep b and c

55

most common type of cancer in the liver?

secondary from other sites

56

how can liver cancer lead to Budd- chiari syndrome?

tumour blocks hepatic vein

57

what change in LFTs is seen in HCC?

raised ALP and GGT

58

other than LFTs what is raised in HCC?

AFP (alpha fenoprotein) - released by tumour cells
erythropoitin
ILGF
PTHrP - also released by tumour cells

59

what is fulminant liver failure?

acute liver failure

60

definition of acute liver failure?

syndrome of liver dysfunction, coagulopathy, hepatic encephalopathy in the absence of pre existing liver disease

61

diagnosis of ALF?

increased PT by 4-6 seconds (INR >1.5
AND
development of hepatic enceph.
in the absence of liver disease
in a time frame of less than 6 months

62

top 3 causes of ALF in the west?

paracetamol
indeterminate
idosyncratic drug reaction

63

how does paracetamol cause liver damage?

the major route for metabolism is safe but saturable
when taken in excess the other route of metabolism is used which produces the hepatotoxic metabolite NAPQI

64

whats the antidote for paracetamol ?

NAC - N- acetylecysteine
best if given within 10 hours

65

Ix in ALF?

ammonia
ABG
Lactate
U&Es
FBC
coag - prothrombin time
LFTs
viral serology
toxicology
auto-antibodies

66

differentials for massive transaminases?

Viral- hep A-E, EBV, CMV, HSV, PMV

vascular- hypotension, congestion , hepatic artery thrombosis

drugs / toxins - loads

auto-immune

rare causes - wilsons

67

most common cause of raised transaminases in hospital?

ischaemic hepatitis

68

how does liver failure lead to HE?

3 things occur:

1. cerebral vasomotor dysfunction
2. oedema secondary to ammonia toxicity
3. inflammation due to SIRS

69

how does increased ammonia lead to encephalopathy?

impaired urea synthesis therefore increased ammonia
the brain an act as an alternative ammonia detox pathway: astrocytes take it in and convert it to glutamine
when there is too much ammonia the astrocytes swell

70

how does HE match up with GCS?

grade I - GCS 14 - 15
grade II - GCS 11 - 13

grade III - GCS 8 - 11 (stupor / pre coma)
grade IV - GCS <8 (coma)

71

how should HE grade III and IV be managed?

airway protection and monitoring

72

what is HE grade IV at high risk of?

uncal herniation (transtentorial downwards)

73

how to mx raised ICP?

increase serum osmolality :
-hypertonic saline
-mannitol

reduce temp.

74

how to manage the raised PT in ALF?

dont correct unless bleeding as that masks to LF

75

what LFT picture would you expect in bone cancer?

raised ALP
normal GGT

76

what is PBC?

primary biliary cirrhosis - autoimmune disease of the small bile duct

immune injury -> inflammation / repair -> fibrosis / cirrhosis

77

how is PBC diagnosed?

raised ALP
AMA
histology

2/3 is probable
3/3 is definitive
only definitive diagnosis is with a biopsy although this is rarely done

78

what is PSC?

RARE disease: primary sclerosing cholangitis - autoimmune disease of the large ducts

79

an MRI can be used to visualise what kind of autoimmune liver disease?

PSC, the ballooning of the large vessels is visable

80

what condition does raised ALP and +ve AMA suggest?

PBC

81

who does PBC affect?

90% are women
often older

82

symptoms of PBC?

often asymptomatic

FATIGUE
ITCHINESS

dry eyes / mouth
poor memory
younger patients can present with advanced liver disease

83

what imaging is always done when the ALP is raised and why?

USS to rule out stone / cancer

84

Tx to slow PBC progression?

UDCA -usodeoxycholic acid (bile acid)
fibrates
TRANSPLANT

85

Tx for symptom relief in PBC?

stop itching:
rifampicin
cholestyramine
sertraline

anti histamines DO NOT WORK

no treatment for fatigue

86

which two thing should be specifically monitored in PBC?

OP
cirrhosis

87

+ve ANA, ASMA and IgG indicate what condition?

autoimmune hepatitis

88

who does autoimmune hepatitis effect

more common in women
ANY AGE

89

presentation of autoimmune hepatitis?

asymptomatic
feeling crap: fatigue, anorexia, joint pains
acute hepatitis
1/3 of people have cirrhosis when they present

90

in which autoimmune liver disease do you always biopsy and why?

autoimmune hepatitis;
confirm diagnosis
staging

91

principle of tx for Autoimmune hepatitis?

immunosuppression with steroids
aim for normalisation of ALT and IgG

92

what bloods tests are classically abnormal in PSC?

ANCA +ve (NOT VERY SENSITIVE)
ALP raised

93

who is PSC typically seen in?

old men

94

what happens in PSC?

inflammation and fibrosis of the intra- and extrahepatic bile ducts
there are multifocal bile duct strictures

95

what is closely linked with PSC?

IBD

96

presentation of PSC?

asymptomatic
symptoms aren't as common as in PBC:
- fatigue
- RUQ pain
- itch

jaundice / complications of cirrhosis are not as common as in PBC

97

what is the general difference in the use of MRIs and CTs in liver disease?

CTs for finding cancers
MRIs for identifying bile duct disease

98

what does an MRCP look like an PSC?

string of beads: multi-focal, short annular strictures

99

when there is a cholestatic blood profile, what is the first line investigation? and what next if thats not diagnostic? then what?

USS + check AMA
MRCP
biopsy

100

mx of PSC?

can treat the dominant stricture (surgery)
no real treatment

101

what is screened for in PSC?

IBD with a colonoscopy
cirrhosis

102

which two auto immune conditions CANNOT overlap

PBC and PSC

103

raised IgA in liver disease suggests what?

alcohol
NAFLD

104

raised IgM in liver disease suggests what?

PBC

all the Ms- they have the AMA too

105

autoimmune hepatitis raises which Ig?

IgG

106

who is at risk of a chronic hep E infection?

immunosuppressed

107

when can HEV be detected in the stool?

~3 wks post exposure

108

most common acute hepatitis infection in the UK?

HEV

109

what is the main factor that determine whether HBV is chronic in a patient?

when they acquire the virus
90% of babies that get it vertically / perinatally have chronic infection compared to ~5% of adults

110

HBsAg positive means...

HBV infection

111

HBeAg positive tells you what?

high level of HBV replication – usually high HBV DNA
in practice this is used as a surrogate for measuring DNA level

112

Anti-HBs Ab positive means...

past infection or vaccination

113

Anti-HBeAb is present when?

inactive HBV or the reactivation phase

114

in what phase of infection do liver complications arise?

immune clearance and reactivation

115

definition of chronic hepatitis

>6 months liver inflammation

116

complications of HBV?

cirrhosis
cancer
varicies

117

transmission of HBV?

blood borne
peri natal -mother to child in birth
sexually

118

if you are HBeAg positive what does that mean?

high level of HBV replication
it is a surregate marker for HBV DNA levels

119

which phases of HBV infection do you need to treat and why?

immune clearance
re-activation

these cause cirrhosis

120

surveillance in HBV?

USS
alpha- fenoprotein AFP

121

how common is chronic infection in HCV?

50-80% common

122

how is HCV transmitted?

blood and body fluids(rare)
(90% IV drug users in UK)

123

important times to screen for hep C?

IV or intranasal drug use
any elevation of ALT
transplant before '91

124

effect of drinking when you have HCV?

raises risk of cirrhosis

125

what test can rule our haemochromotosis in the case of raised ferritin levels?

transferrin sat <45% rules it out