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Systems: Alimentary AB > Jaundice and Chronic Liver Disease > Flashcards

Jaundice and Chronic Liver Disease Flashcards

(106 cards)

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1
Q

What does the liver synthesise?

A
  • Clotting factors
  • Bile acids
  • Carbohydrates
  • Proteins
  • Lipids
  • Hormones
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2
Q

What relating to carbohydrates takes place in the liver?

A
  • Gluconeogenesis
  • Glycogenolysis
  • Glycogenesis
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3
Q

What protein is synthesised in the liver?

A

Albumin

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4
Q

What lipids are synthesised in the liver?

A
  • Cholesterol
  • Lipoproteins
  • TG
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5
Q

What hormones are synthesised in the liver?

A
  • Angiotensinogen

- Insulin like growth factor

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6
Q

What are the detoxification functions of the liver?

A
  • Urea production
  • Detoxification of drugs
  • Bilirubin metabolism
  • Breakdown of insulin and hormones
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7
Q

What is the immune function of the liver?

A
  • Combating infections
  • Clearing the blood of particles and infections including bacteria
  • Neutralising and destroying all drugs and toxins
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8
Q

What is the storage function of the liver?

A
  • Stores glycogen
  • Stores vitamin A, D,B12, K
  • Stores copper and iron
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9
Q

What is bilirubin a by product of?

A

Haeme metabolism

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10
Q

What generates bilirubin?

A

Senescent RBCs in the spleen

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11
Q

Describe the conjugation of bilirubin.

A
  • Unconjugated: initially bound to albumin

- Conjugated: liver helps to solubilise it

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12
Q

What can cause pre-hepatic elevate bilirubin?

A

Haemolysis

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13
Q

What can cause hepatic elevated bilirubin?

A

Parenchymal damage

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14
Q

What can cause post hepatic elevated bilirubin?

A

Obstruction

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15
Q

What are aminotranferases?

A

Enzymes present in hepatocytes

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16
Q

Which aminotransferase is more specific?

A

ALT

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17
Q

What can the AST/ALT ratio point towards?

A

ALD

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18
Q

What can the ST/ALT ration point towards?

A

Parenchymal involvement

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19
Q

What is alkaline phosphatase?

A

Enzyme present in bile ducts

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20
Q

What may elevated alkaline phosphatase suggest?

A
  • Obstruction

- Liver infiltration

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21
Q

Other than the bile ducts, where is alkaline phosphatase also present?

A
  • Bone
  • Placenta
  • Intestines
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22
Q

What is gamma GT?

A

Non-specific liver enzyme

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23
Q

When is gamma GT elevated?

A

Alcohol use

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24
Q

What is gamma GT useful for?

A

Confirm liver source of ALP

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25
What can elevate gamma CT other than alcohol?
Drugs like NSAIDs
26
What is albumin an important test for?
Synthetic function of the liver
27
What can low levels of albumin suggest?
- Chronic liver disease - Kidney disorders - Malnutrition
28
What is an extremely important test for liver function?
Prothrombin time
29
What does the prothrombin time indicate?
Degree of liver dysfunction
30
What is prothrombin time used to calculate?
Scores to decide stage of liver disease, who needs a liver transplant and who gets a liver transplant
31
What is creatinine essentially?
Kidney function
32
What does creatinine determine?
Survival from liver disease
33
What is creatinine testing essential in?
Critical assessment for need for transplant
34
What is an important source of thrombopoietin?
Liver
35
What can splenomegaly be a result of?
Cirrhosis
36
Why are platelets low in cirrhotic subjects?
As a result of hypersplenism
37
What is the platelet count an indirect marker of?
Portal hypertension
38
What are 4 symptoms of liver failure?
- Jaundice - Ascites - Variceal bleeding - Hepatic encephalopathy
39
Jaundice
Yellowing of the skin sclerae and other tissues caused by excess circulating bilirubin
40
When is jaundice detectable?
When total plasma bilirubin levels exceed 34umol/l
41
What is the differential diagnosis for jaundice?
Carotenemia
42
Describe the life of bilirubin.
-RBC release heme -Heme acted on by heme oxygenase to form biliverdin -Biliverdin acted on by biliverdin reductase to form bilirubin -Bilirubin acted on by UGT to for bilirubin diglucuronide Bilirubin diglucuronide excreted in stool or enter enterohepatic recirculation
43
What are the 3 classifications of jaundice?
- Pre hepatic: unconjugated - Hepatic: conjugated - Post hepatic: conjugated
44
What does human waste look like in pre hepatic jaundice?
Normal coloured urine
45
What does human waste look like in hepatic jaundice?
-Very yellow urine
46
What does human waste look like in post hepatic jaundice?
- Very yellow urine | - Pale stools
47
What is the pathology behind pre hepatic jaundice?
- Increased quantity of bilirubin (haemolysis) | - Impaired transport
48
What is the pathology behind hepatic jaundice?
- Defective uptake of bilirubin - Defective conjugation - Defective excretion
49
What is the pathology behind post hepatic jaundice?
Defective transport of bilirubin by the biliary ducts
50
What are the clues in the history of patients with pre hepatic jaundice?
- History of anaemia (fatigue, dyspnoea, chest pain) | - Acholuric jaundice
51
What are the clues in the history of patients with hepatic jaundice?
- Risk factors for liver disease (IVDU, drug intake) | - Decompensation (ascites, varieal bleed, encephalopathy)
52
What are the clues in the history of patients with post hepatic jaundice?
- Abdominal pain | - Cholestasis (pruritus, pale stools, high coloured urine)
53
What are the clues on clinical examination of someone with pre hepatic jaundice?
- Pallor | - Splenomegaly
54
What are the clues on clinical examination of hepatic jaundice?
- Stigmata of CLD (spider naevi, gynaecomastia) - Ascites - Aterixis
55
What are the clues on clinical examination of someone with post hepatic jaundice?
Palpable gall bladder (Courvoiser's sign)
56
What are the investigations carried out for a patient who is jaundiced?
- Liver screen - Abdominal ultrasound - CT/MRI - ERCP - MRCP
57
What is included in a liver screen?
- Hepatitis B and C serology - Autoantibody profile, serum immunoglobulins - Caeruloplasmin and copper - Ferritin and transferrin saturation - Alpha 1 anti-trypsin - Fasting glucose and lipid profile
58
Why is an abdominal ultrasound the most important test?
- Differentiates extrahepatic and intrahepatic obstruction - Delineates site of obstruction - Delineates cause of obstruction - Documents evidence of portal hypertension - Preliminary staging of extent of disease e.g cancer spread
59
What are the features of an ultrasound scan?
- Cheap - No radiation - Portable, widely available - Good for gallstones - High specificity - Lower sensitivity - Examines organs as well as biliary system
60
What are the feature of a CT/MRI scan?
- Expensive - Radiation (CT only) - Requires CT/MRI scanner - Better for pancreas - High specificity - High sensitivity - Examines organs and biliary system
61
What are the features of MRCP?
- No radiation - No complications - 5% claustrophobic - Can image outwith the ducts
62
What are the features of ERCP?
- Radiation - Sedation - Complications - Failure - Only image ducts - Therapeutic option
63
What can therapeutic ERCP be used for?
- Dilated biliary tree with visible stones or tumour - Acute gallstone pancreatitis - Stenting of biliary tract obstruction - Post operative biliary complications
64
What sedation related complications can arise from ERCP?
- Respiratory | - Cardiovascular
65
What procedure related complications can arise from ERCO?
- Pancreatitis - Cholangitis - Sphincterotomy (bleeding/perforation)
66
When is percutaneous transhepatic cholangiogram used?
- ERCP not possible due to duodenal obstruction or previous surgery - Hilar stenting
67
What is a disadvantage of percutaneous transhepatic cholangiogram?
More invasive than ERCP
68
What is possible to collect using endoscopic ultrasound?
Biopsy
69
What is endoscopic ultrasound used for?
- Characterising pancreatic masses - Staging tumours - Fine needle aspiration of tumours and cysts - Excluding biliary microcalculi
70
Chronic liver disease
Liver disease that persist beyond 6 months
71
Give examples of liver diseases which are chronic.
- Chronic hepatitis - Chronic cholestasis - Fibrosis and cirrhosis - Others like steatosis - Liver tumours
72
What is the main cause of cirrhosis?
Alcohol
73
Other than alcohol, what else can cause cirrhosis?
- Autoimmune - Hemochromatosis - Chronic viral hepatitis - NAFLD - Drugs - Cystic fibrosis, a1 anti-trypsin deficiency, Wilson's disease - Vascular problems - Cryptogenic - Other
74
What are the pathological changes which take place with cirrhosis?
- Infiltrating lymphocytes - Extracellular matric proteins - Apoptotic hepatocytes - Activated Kupffer cells - Sinusoid lumen with increased resistance to blood flow
75
What is the clinical presentation of cirrhosis?
- Compensated chronic liver disease picked up by screening test or abnormal LFTs - Decompensated chronic liver disease presents with ascites, variceal bleeding and hepatic encephalopathy - Hepatocellular carcinoma
76
What is found on physical examination of ascite?
Dullness in flanks and shifting dullness
77
How can ascites be confirmed?
Ultrasound
78
What is the corroborating evidence for ascites?
- Spider naevi - Palmar erythema - Abdominal veins - Fetor hepaticus - Umbilical nodule - JVP elevation - Flank haematoma
79
What should all patients with new onset ascites have?
Diagnostic paracentesis
80
What initial investigations are required for ascites?
- Protein and albumin concentration - Cell count and differential - SAAG
81
What is routinely done as part of ascetic fluid analysis?
- Cell count - Protein - Albumin
82
What is optionally done as part of ascetic fluid analysis?
- Culture - Glucose - LDH - Amylase - Gram stain
83
What can be done but is unusual as part of ascetic fluid analysis?
- TB culture - Cytology - Triglyceride - Bilirubin
84
What is unhelpful in ascetic fluid analysis?
- pH - Lactate - Cholesterol - Fibronectin - ADA - CEA
85
SAAG
Serum ascites albumin gradient
86
What does a SAAG of >1.1g/dl point to?
- Portal hypertension - CHF - Constrictive pericarditis - Budd Chiarri - Myxedema - Massive liver metastases
87
What does a SAAG of<1.1g/dl point to?
- Malignancy - Tuberculosis - Chylous ascites - Pancreatic - Biliary ascites - Nephrotic syndrome - Serositis
88
What are the treatment options for ascites?
- Diuretics - Large volume paracentesis - TIPS - Aquaretics - Liver transplantation
89
What are varices due to?
Portal hypertension
90
Where can varices occur?
- Skin - Oesophageal and gastric - Rectal - Posterior abdominal wall - Stomal
91
What is the immediate management for varices?
- Resuscitate patient - Good IV access - Blood transfusion as required - emergency endoscopy
92
Why are varices treated as medical emergencies?
Prone to rupture
93
How are varices treated?
- Endoscopic band ligation - Add Terlipressin for control - Sengstaken-Blakemore tube for uncontrolled bleeding - TIPSS for rebleeding after banding
94
Hepatic encephalopathy
Confusion due to liver disease
95
How is hepatic encephalopathy graded?
1-4
96
What are the precipitants fro hepatic encephalopathy?
- GI bleed - Infection - constipation - Dehydration - Medication - Sedation
97
How is hepatic encephalopathy reversed?
Treat underlying cause
98
What is the treatment usually fro hepatic encephalopathy?
- Laxatives (phosphate enemas and lactulose) | - Broad spectrum non absorbed antibiotic such as neomycin or rifaximin
99
What is repeated admissions with hepatic encephalopathy an indicator for?
Liver transplant
100
What does hepatocellular carcinoma occur in the background of?
Cirrhosis
101
What does hepatocellular carcinoma associated with?
Chronic hepatitis B and C
102
What is the presentation of hepatocellular carcinoma?
- Decompensation of liver disease - Abdominal mass - Abdominal pain - Weight loss - Bleeding from tumour
103
How is hepatocellular carcinoma diagnosed?
- Tumour markers: AFP - Ultrasound - CT - MRI - Liver biopsy (rare)
104
What are the treatment options for hepatocellular carcinoma?
- Hepatic resection - Liver transplantation - Chemotherapy - Locally ablative treatments - Sorafenib (tyrosinase kinase inhibitor) - Hormonal therapy (tamoxifen)
105
What chemotherapy can be used with hepatocellular carcinoma?
- Locally delivered TACE: trans catheter arterial chemo-embolization - Systemic chemotherapy
106
What locally ablative treatments are there for hepatocellular carcinoma?
- Alcohol injection | - Radiofrequency ablation

Systems: Alimentary AB (37 decks)

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