Hepatology

Question 1

What does elevation in AST and ALT indicate?

Answer 1

ACUTE hepatocellular injury. NOTE = in CLD they can be low - so not a marker of severity of chronic LD

ALT - more specific to liver cytoplasm of hepatocytes

AST - found in mitochondria so can be elevated in heart and muscle damage too.

Question 2

Causes of mild increase in ALT (2-3 times upper limit)

Answer 2

Fatty liver

Question 3

Causes of mod increase in ALT ( x5)

Answer 3

Damage secondary to:

ETOH/Fatty/Drugs/Infections

Question 4

Severe increase in AST (x10) causes?

Answer 4

Viral hepatitis

Hypoxia

Question 5

ALT and ALP increased together?

Answer 5

Arise from canalicular surface of bile duct

SO if both are increased then cause is liver origin (cholestasis)

IF isolated ALP - then bone - pagets, metastasis, decreased Vit D

Question 6

Isolated ALP increase? DDx?

Answer 6

Usually bone cause

Pagets, metastatic disease, Decreased Vit D

Question 7

What are the types of cholestasis?

Answer 7

Intrahepatic (usually caused by liver not making enough bile) and Extrahepatic (Usually obstruction in ducts outside the liver)

Question 8

Causes of Intrahepatic cholestasis

Answer 8

1. Estrogen (inhibits bile production) - pregnancy, OCP, anabolic steroids.
2. Neonatal hepatitis

Question 9

Causes of extrahepatic cholestasis?

Answer 9

1. Gall stones in the duct
2. Primary sclerosing cholangitis - Scar tissue builds in the ducts - leading to blockage
3. Biliary atresia in newborn
4. Pancreatic carcinoma can physically block the duct

Question 10

Symptoms of cholestasis

Answer 10

Jaundice, Pruritis

In chronic obstructive jaundice - can lead to xanthomas

As bile is not being excreted into the faeces - you get pale stools.

As urobilinogen is being cleared from the kidneys - you get dark urine

Question 11

What are two causes of liver cirrhosis where you’ll see elevation in cholestatic enzymes?

Answer 11

Primary billiary cirhosis

and Primary sclerosing cholangitis

Normally cirhossis you dont see elevations in cholestatic enzymes - this is the exception.

Question 12

What are causes of hepatocellular damage (seen as elevation of ALT and AST) on LFT?

Answer 12

1. ALCOHOLIC LIVER disease
2. Viral Hepatitis
3. Ischaemic injury (LDH x 1.5 times ALT)
4. Drugs - methotrexate, paracetamol
5. NAFLD/NASH
6. Haemochromotosis
7. Wilsons
8. Alpha 1 Anti Trypsin Deficiency
9. Autoimmune hepatitis

Question 13

What are the causes of extrahepatic cholestasis on LFT? WHat happens to billirubin?

Answer 13

Billirubin goes up in these conditions

1. Choledocolithiasis
2. Acute cholangitis
3. Primary Sclerosing Cholangitis
4. Mirizzi Syndrome.
5. Malignancy -pancreatic, Cholangiocarcinoma,

Question 14

What are the causes of intrahepatic cholestasis?

Answer 14

Normal Bili

Primary biliary cirrhosis

Primary sclerosing cholangitis

Drugs - oestrogen

Toxins

Alcoholic hepatitis and Viral Hepatitis

Malignancy (eg secondaries in older people, often low alb)

Pregnancy

Genetic disorders

Graft versus host disease

Post liver transplant

Question 15

What might cause an ISOLATED bilirubin rise (without affecting cholestatic enzymes)

Answer 15

Haemolysis

Gilberts syndrome

Question 16

How would you differentiate between intrahepatic and extrahepatic jaundice?

Answer 16

Billi is elevated in extrahepatic, and usually normal in intrahepatic.

Upper abdominal ultrasound is the ix of choice.

Question 17

Mild elevation in Liver function seen in GP?

Answer 17

Repeat in seven days.

ASK/Think about investigating for:

Hep B/C - EBV, CMV

Alcohol injury

Fatty liver/NASH

Fe overload

IF neg - can look for Rarer causes:

Wilsons,

Autoimmune

Alpha1 antitrypsin

Question 19

Initial investigations for Abnormal LFT

Answer 19

Liver U/S

Hepatitis B and C serology

Iron studies

Coagulation studies (synthetic function)

Question 20

Name two potentially hepatotoxic medications?

Answer 20

Sodium Valproate

Methotrexate

Question 21

How much greater than ALT should ALP be in cholestasis

Answer 21

approx 3 times is significant

Question 22

Hepatic complications of ETOH?

Answer 22

Fatty liver disease

Alcoholic hepatitis

Alcoholic cirrhosis

Question 23

Red flags for potential ETOH abuse?

Answer 23

Impotence

Social disruption - impaired work performance, domestic violence

FHx of ETOH abuse

Vague abdominal pain and nausea

Question 24

What are the CAGE questions for ETOH?

Answer 24

Have you felt the need to Cut down

Have you felt Annoyed at the suggestion you may have an ETOH problem

Have you felt Guilty about excessive drinking

Do you need an Eye opener in the morning

One for each positive response - a score of 2 or more suggests problematic drinking.

Question 25

What examination findings would you look for in a patient with ETOH abuse?

Answer 25

1. Blood pressure - (hypertension) 2. Enlarged and/or tender liver 3. Peripheral stigmata of Chronic liver disease 4. Signs of cardiomyopathy

Question 26

Investigation findings in ETOH abuse?

Answer 26

Elevated WCC - Leucocytosis Raised Transaminase levels - classicaly AST: ALT in a ratio of 2:1 (neither over 300 usually) Decreased synthetic function: Elevated bilirubin, Prolonged prothrombin time, HYPOALBUMINAEMIA Fe Studies, and viral hepatitis serology - to identify concurrent haemochromatosis of viral hepatitis

Question 27

Management approach for ETOH abuse?

Answer 27

1. Assessment - Severity of ETOH problem Significant Comorbidities Social Circumstances 2. Consider Brief intervention eg FLAGS tool (feedback, listening, advice, goals and strategies. 3. Consider if patient requires withdrawl management 4. Psychosocial interventions: Referral for CBT, motivational interviewing, relapse prevention counselling. 5. Pharmacotherapies - naltrexone, acamprosate, Disilfuram 6. Support services: Alcoholics Anonnymous, SMART recovery Australia

Question 29

Side effects of acamprosate?

Answer 29

Question 30

Side effects of naltrexone

Answer 30

Question 31

Side effects of disulfiram

Answer 31

Question 32

What are the stages of alcohol withdrawl?

Answer 32

Question 33

How would you treat a patient with acute alcohol withdrawl

Answer 33

_{Many alcohol-dependent people require no medication when withdrawing from alcohol}. _Supportive care including information on the withdrawal syndrome, monitoring, reassurance and a low-stimulus environment are effective in reducing withdrawal severity._ _{If medication is required, a benzodiazepine loading dose technique may be used. The patient is given repeated doses of diazepam until symptoms have diminished to an acceptable level. Diazepam is effective in the prevention and treatment of acute alcohol withdrawal seizures. Because of the relatively large doses usually given, and the long half-life of diazepam, it may not be necessary to give any further medication for withdrawal relie} **diazepam 20 mg orally, every 2 hours until symptoms subside. A cumulative dose of 60 mg daily is usually adequate.**

Question 34

What is Gilberts Syndrome?

Answer 34

Isolated hyperbillrubinaemia - often asymptomatic - (need to exclude haemolysis first) - Gilberts is genetic - increased unconjugated bili. Can present with jaundice during stress/intercurrent illness.

Question 35

What is Hep D?

Answer 35

RNA virus that requires co-infection Hep B in order to infect a patient. Presents with concurrent infection with Hep B OR super infection in a patient with pre-existing Hep B Can cause a severe CLD Prolonged PegInterferon works in some patients. Needs specialist referral

Question 36

How is Hep E transmitted

Answer 36

Faecal oral. Causes an acute hepatitis. Usually hx of travel to Parts of Africa, South East Asia, Middle East, Mexico. Contaminated food (pigs, shellfish)

Question 37

What markers exist for monitoring a patient with liver cirrhosis?

Answer 37

AST: ALT - ratio \> 1 Prolonged APPT and increased INR Hypoalbuminaeamia Platelets (thrombocytopenia in splenomegaly)

Question 38

Patient presents with Cirrhosis - what investigations to determine cause?

Answer 38

U/S LFT Viral serology A,B,C , EBV, CMV Iron studies Serum copper Alpha 1 antitrypsin Anti SMA, Anti Microscomal antibody,

Question 39

Investigations to monitor progress of Cirhosis

Answer 39

FBE - 6 monthly - look for pancytopenia Synthetic function - COag, Albumin, LFT UEC Avoid toxins Fibroscan/U/s Immunise - Pneumococal, Hep A and B, Influenza Monitor for comorbidiites like osteoporosis, vitamin D deficiency

Question 40

Goals of Mx in Cirrhosis

Answer 40

Treat cause Prevent superimposed insults to the liver (Avoid etoh) Identify hepatotoxic meds or meds which need dose adjustment early Manage symptoms and lab abnormalities Prevent, ID and treat Complications Determine appropriateness and timing of liver transplant

Question 41

Common complications of liver cirrhosis

Answer 41

Ascites Hepatorenal syndrome Varices and variceal bleeding Portal vein thrombosis HCC Portopulmonary hypertension Hepatic encephalopathy Spontaneous bacterial peritonitis

Question 42

Definition of liver cirrhosis

Answer 42

Progressive hepatic fibrosis characterised by distortion of hepatic architecture and formation of regenerative nodules.

Question 44

Symptoms and signs of cirrhosis?

Answer 44

Question 45

Clinical manifestiations of haemochromatosis

Answer 45

Question 46

Explain Hep B results?

Answer 46