Hepatology - medicine

Question 1

What are the general clinical signs of liver disease?

Answer 1

vague, non-specific
Inappetence
Lethargy
Weight loss
Vomiting
PUPD

Question 2

What specific signs of liver disease are there?

Answer 2

Icterus
Coagulopathy
Ascites
Hepatic encephalopathy

Question 3

What is prehepatic jaundice?

Answer 3

Accelerated haemolysis
eg. IMHA

Question 4

What is hepatic jaundice?

Answer 4

Liver cells arent working properly to clear bilirubin from the blood

Question 5

What is post hepatic jaundice?

Answer 5

disease of biliary system eg. Inflammation or blockage

Question 6

Why do ascites form during liver disease?

Answer 6

Liver is main site of albumin production
Controls oncotic pressure - if reduced then fluid leaks out of capillaries

Question 7

What skin pathology can arise due to liver disease?

Answer 7

Hepatocutaneous syndrome - thickened cracked paw pads

Question 8

What are the hepatocellular enzymes in small animals?

Answer 8

ALT
AST

Question 9

What are the cholestatic enzymes?

Answer 9

ALP
GGT

Question 10

What can cause elevated hepatic enzymes?

Answer 10

Primary disease - toxins, infections, immune mediated
Secondary disease - systemic inflammation, vacuolar hepatic change, hypoxaemia, endocrinopathies

Question 11

What does the magnitude of the liver enzyme elevations tell us about the disease?

Answer 11

NOT prognostic
Often low with secondary hepatopathy
Can be anything with primary hepatopathy
May fluctuate

Question 12

What are 3 tests that are evidence of hepatic dysfunction?

Answer 12

Elevated bile acids/ammonia - bile acid stimulation test
Hyperbilirubinaemia
Coagulation derangement - PT/APPT

Question 13

What are two infectious inflammatory causes of hepatocellular disease?

Answer 13

Neutrophilic cholangitis (bacteria)
Leptospirosis

Question 14

What are two sterile inflammatory causes of hepatocellular disease?

Answer 14

Chronic hepatitis
Lymphocytic cholangitis - immune mediated liver disease in cats

Question 14

What drug can cause hepatocellular disease?

Answer 14

Phenobarbitone - antiepileptic drugs

Question 15

What are some common causes of cholestatic disease?

Answer 15

Pancreatitis
Neutrophilic/lymphocytic cholangitis
Biliary rupture/obstruction
Gall bladder mucocoele
Lipidosis
Neoplasm compressing biliary tree

Question 16

What can cause a small liver?

Answer 16

Portovascular disease
Chronic hepatopathy

Question 17

What can cause a large liver?

Answer 17

Acute hepatic insult
Vacuolar change
Neoplastic or inflammatory disease

Question 18

What does the gall bladder look like on ultrasound?

Answer 18

Cut kiwi

Question 19

What minimally invasive diagnostics can you do for liver disease?

Answer 19

Abdominal effusion analysis
Specific infectious disease testing - lepto, FIP

Question 20

What should you do before hepatic sampling?

Answer 20

Check platelets, PT, aPTT first for clotting function
Know blood type for if haemorrhages
Give preventative vitamin K maybe

Question 21

When should you FNA in liver disease?

Answer 21

When you suspect:
Diffuse infiltrative hepatic disease
Diffuse metabolic disease
Focal hepatic pathology

Question 22

When should you biopsy liver disease?

Answer 22

When you suspect:
Inflammatory disease
Neoplastic disease

Question 23

What are the different techniques for biopsy/surgery for hepatic sampling?

Answer 23

Ultrasound guided percutaneous needle - tru-cut
Laparoscopy
Laparotomy - complete surgery

Question 24

What are the practicalities of tru-cut percutaneous needle biopsy?

Answer 24

Is a referral level procedure Need a lack of ascites

Question 25

What are the complications of hepatic sampling?

Answer 25

Haemorrhage Ascites Clinical deterioration May be unnecessary/non diagnostic

Question 26

What is the term for getting a sample of bile from the liver/gall bladder?

Answer 26

Cholecystocentesis

Question 27

When should you do a cholecystocentesis?

Answer 27

If suspect bacterial biliary infection - so can do bile cytology/culture To rule this out in other cases eg. hepatic lipidosis

Question 28

What are the contraindications for cholecystocentesis?

Answer 28

Biliary obstruction Gall bladder wall pathology/mucocoele

Question 29

When is surgery indicated for liver disease?

Answer 29

If there is abdominal free fluid Hepatic mass lesion Gall bladder compromise Gall bladder mucocoele Obstructive biliary disease

Question 30

How is liver disease in cats different?

Answer 30

Enzyme elevations variable Short enzyme half lives Often have non-specific signs Usually have comorbidities

Question 31

What is an immune mediated liver disease in cats?

Answer 31

Lymphocytic cholangitis

Question 32

What treatment is preferable for a congenital portosystemic shunt?

Answer 32

Surgical correction - improves QOL long term Stabilise medically first

Question 33

What is the medical therapy for hepatic encephalopathy? What is used to reduce ammonia levels?

Answer 33

Diet modification - less animal protein, more plant protein, feed cottage cheese Lactulose - converts ammonia to ammonium ion so it is trapped in colon

Question 34

What is the general therapeutic treatment of liver disease?

Answer 34

Diet modification - restrict copper Antioxidants Anti-inflammatory/immunosuppressives Choleretics - improve bile flow

Question 35

What are the main antioxidant drugs?

Answer 35

N-acetyl-cystine - IV Milk thistle extracts/isolates - oral S-Adenosyl-L-methionine (SAMe) Vitamin E

Question 36

What is a choleretic drug?

Answer 36

Ursodeoxycholic acid (UDCA) - synthetically derived bile acid which reduces bile viscosity so increases bile flow

Question 37

What two liver diseases do you use antimicrobials in?

Answer 37

Neutrophilic cholangitis Bacterial cholangiohepatitis

Question 38

What antimicrobials do you use for liver disease?

Answer 38

Ideally culture and sensitivity Amoxicillin clavulanate if not

Question 39

What is portal hypertension?

Answer 39

Increased resistance to blood flow through the liver

Question 40

What are the consequences of portal hypertension?

Answer 40

Secondary shunting GI wall oedema (splanchnic bed) Ascites

Question 41

How do you treat portal hypertension?

Answer 41

Treat cause Blood pressure reduction drugs: Spironolactone - aldosterone antagonist which limits fluid accumulation Sodium restriction

Question 42

What liver related disease are bedlingtons predisposed to?

Answer 42

Copper associated chronic hepatitis

Question 43

What is the decoppering therapy for dogs with copper associated chronic hepatitis?

Answer 43

Chelator - D-penicillamine Dietary copper restriction Zinc supplements - not alongside chelators though

Question 44

How long does de-coppering take?

Answer 44

6-9 months

Question 45

What is the most important management aspect of feline hepatic lipidosis?

Answer 45

Nutritional support - tube feeding to stop fat mobilistation

Question 46

What is the treatment for feline hepatic lipidosis?

Answer 46

Tube feeding - 40-60 kcal/kg/day Antioxidants - SAMe, vit E UDCA - choleretic Supportive - fluids, antiemetic, opioids

Question 47

What liver condition can be caused by very bad dental disease?

Answer 47

Reactive hepatopathy