Jaundice and chronic liver disease

Question 1

What are the synthetic functions of the liver? Try and give some examples

Answer 1

clotting factors
carbohydrates 
bile acids
proteins - albumin 
lipids - cholesterol
hormones - angiotensin, thrombopoetin

Question 2

What are the detoxification functions of the liver?

Answer 2

drugs, urea from ammonium, insulin and hormone breakdown and bilirubin metabolism

Question 3

What are the immune functions of the liver?

Answer 3

combat infection, neutralise and destroy toxins and clear the blood of bacteria

Question 4

What substances does the liver store?

Answer 4

clotting factors, glycogen, iron and copper, vitamins eg B12, K, A, D

Question 5

What is bilirubin initially bound to?

Answer 5

albumin

Question 6

What 3 ways can bilirubin be elevated?

Answer 6

pre-hepatic - haemolysis
hepatic - parenchymal damage
post hepatic - obstructive eg bile ducts, duodeunum

Question 7

Where are aminotransferase enzymes present?

Answer 7

in hepatocytes

Question 8

Is ALT or AST ore specific?

Answer 8

ALT

Question 9

What can a AST/ALT ratio give an indication of?

Answer 9

alcoholic liver disease

parenchymal involvement and damage

Question 10

Where is alkaline phosphatase found?

Answer 10

bile ducts

Question 11

What is alkaline phosphatase raised with?

Answer 11

obstruction or liver infiltration

Question 12

Where is alkaline phosphatase also present and give an example of when it may be raised without bile duct involvement

Answer 12

placenta, bone marrow and intestines

pregnancy

Question 13

What is Gamma GT? What is it raised with?

Answer 13

non specific enzyme used in conjunction with alkaline phosphatase to confirm liver involvement
alcohol and drug use eg NSAIDS

Question 14

What is albumin an important test for?

Answer 14

synthetic function as produced by the liver

Question 15

What can low levels of albumin suggest?

Answer 15

chronic liver disease, malnutrition and kidney disorders

Question 16

What prothrombin time measure?

Answer 16

time taken for the blood to clot - tells of liver dysfunction and clotting factors

Question 17

What is prothrombin time used for?

Answer 17

to calculate a score to decide the stage of liver disease and transplantation lists

Question 18

What is creatine test important for?

Answer 18

determining survival from liver disease and critical for transplantation assessment

Question 19

Why does cirrhosis lead to splenomegaly?

Answer 19

due to portal hypertension and the spleen chewing up the platelets

Question 20

What are the 4 main symptoms of liver dysfunction?

Answer 20

jaundice, ascites, variceal bleeding and hepatic encephalopathy

Question 21

What is jaundice?

Answer 21

Yellowing of the skin, tissues and SCLERAE due to excess circulating bilirubin

Question 22

What plasma level is jaundice detectable at?

Answer 22

> 34 micromol/L

Question 23

What is the differential diagnosis for jaundice and what is the key difference between them?

Answer 23

carotenemia

no yellowing of the sclerae

Question 24

What are pre hepatic causes of jaundice?

Answer 24

increased bilirubin and impaired transport

Question 25

What are hepatic causes of jaundice?

Answer 25

defective bilirubin uptake, conjugation and excretion

Question 26

What are post hepatic causes of jaundice?

Answer 26

defective bilirubin transport by biliary ducts

Question 27

What are the symptoms and signs of pre hepatic jaundice?

Answer 27

history of anaemia eg fatigue, dyspnoea, chest pain acholuric jaundice - excessive unconjugated bilirubin pallor, splenomegaly

Question 28

What are the symptoms and signs of hepatic jaundice?

Answer 28

risk factors of liver disease (IVDU) decompensation - ascites, encephalopathy and variceal bleeding CLD signs - spider naevi, gynaecomastia ascites and asterixis

Question 29

What is asterixis?

Answer 29

flapping tremor

Question 30

What are the symptoms and signs of post hepatic jaundice?

Answer 30

abdominal pain eg gallstones cholestasis, pale stool, pruirits, high colour urine palpable gallbladder - malignancy

Question 31

What is a liver screen?

Answer 31

hepatitis B and C serology, serum immunoglobulins, ferritin, fasting glucose etc

Question 32

What can an ultrasound look for and confirm in a patient with jaundice?

Answer 32

extra or intra hepatic location and cause of obstruction portal hypertension, stage disease

Question 33

What is the differences between ERCP and MRCP?

Answer 33

ERCP can take biopsy and stent but uses sedation and radiation and dyes. only image bile ducts. MRCP can be claustrophobic

Question 34

What are some complications of ERCP?

Answer 34

sedation related - CVS, resp | procedure related - pancreatitis, cholangitis and with sphincterotomy can lead to bleeding and perforation

Question 35

When is PTC used?

Answer 35

when ERCP not possible due to previous surgery or duodenal obstruction hilar stenting

Question 36

What are the disadvantages of PTC?

Answer 36

Invasive and risk liver bleed due to puncturing

Question 37

What is possible to do with an EUS?

Answer 37

biopsy, aspirate, stage tumours of pancreas

Question 38

What are some chronic liver diseases?

Answer 38

chronic hepatitis, tumours, chronic cholestasis, steatosis, fibrosis and cirrhosis

Question 39

What are some causes of liver cirrhosis?

Answer 39

alcohol, autoimmune, chronic viral hepatitis, NFLD, drugs, CF, unknown and sarcoidosis

Question 40

What are the 3 autoimmune diseases which cause cirrhosis?

Answer 40

PBC, PSC and autoimmune heaptitis

Question 41

What are the pathological changes to the liver during cirrhosis?

Answer 41

injury - smaller, fibrosed and scarred | blocks nutrient entry so the pressure rises and blood has to bypass channels

Question 42

How does compensated cirrhosis present?

Answer 42

usually picked up by a screening test and abnormal LFTs

Question 43

How does decompensated cirrhosis present?

Answer 43

ascites, variceal bleeding, hepatic encephalopathy

Question 44

How else can cirrhosis present?

Answer 44

hepatocellular carcinoma

Question 45

What is the use of ultrasound with ascites?

Answer 45

detect shifting dullness and fluid

Question 46

What clinical signs are important to look for with ascites?

Answer 46

spider naevi, gynaecomastia, palmar erythema and abdominal veins

Question 47

What is fetor hepaticus?

Answer 47

characteristic breath smell, foul in portal hypertension

Question 48

What can ascites do to JVP?

Answer 48

Raise

Question 49

What test MUST be done on any patient presenting with ascites?

Answer 49

diagnostic paracentesis

Question 50

What does diagnostic paracentesis look for?

Answer 50

protein and albumin, cell count, SAAG

Question 51

What can SAAG tell us?

Answer 51

check if it is related liver (>1.1g)

Question 52

How is ascites treated?

Answer 52

diuretics, large volume aspiration and TIPs

Question 53

What are varices?

Answer 53

Due to portal hypertension at porto-systemic anastomoses - enlarged veins

Question 54

Where can varices be found?

Answer 54

skin, oesophagus, rectal, stomal and posterior abdominal wall

Question 55

What are the management options for varices?

Answer 55

resuscitate patient, blood transfusion and emergency endoscopy band ligation by endoscope

Question 56

What is hepatic encephalopathy?

Answer 56

Confusion due to liver disease

Question 57

What is the cause of hepatic encephalopathy?

Answer 57

metabolites to the brain and cross the blood brain barrier as they are not being metabolised in the liver

Question 58

What clinical conditions are common to be found in someone with hepatic encephalopathy?

Answer 58

GI bleed, infection, dehydration

Question 59

What are the clinical signs of hepatic encephalopathy?

Answer 59

flapping tremor - foetor hepaticus

Question 60

How is hepatic encephalopathy treated?

Answer 60

broad spectrum antibiotics, fluids, laxatives, transplant

Question 61

How does someone with hepatocellular carcinoma present?

Answer 61

mass, decompensated liver disease, pain, weight loss, bleeding

Question 62

How Is hepatocellular carcinoma diagnosed? - marker and scans

Answer 62

AFP | US, CT, MRI

Question 63

List 4 ways to treat hepatocellular carcinoma

Answer 63

liver resection chemotherapy radiofrequency ablation liver transplantation