Jaundice and Chronic Liver Disease

Question 1

What does the liver synthesize?

Answer 1

Clotting factors 
Bile acids 
Glycogen 
Albumin 
Cholesterol, lipoproteins and TG
Hormones (angiotensinogen, insulin like growth factor)

Question 2

What does the liver store?

Answer 2

Glycogen
Vitamins (A, D, B12 & K)
Cu & Fe

Question 3

What happens during the conjugation of bilirubin?

Answer 3

Solubilization

Initially it is bound to albumin (insoluble - unconjugated)
Liver makes it soluble (conjugated)

Question 4

What are some liver function tests?

Answer 4

Bilirubin
Aminotransferases
Alkaline Phosphatase (raised in cholestasis, hepatitis, cirrhosis)
Albumin
Gamma GT (GGT - raised in liver injury / cholestasis)
Prothrombin time

Question 5

What aminotransferases are measured? What can they point to?

Answer 5

AST & ALT (both enzymes present in hepatocytes)

High AST:ALT can indicate ALD

They suggest parenchymal involvement

Question 6

What does elevated alkaline phosphatase indicate?

Answer 6

Obstruction or liver infiltration

Is elevated during pregnancy

Question 7

What does low albumin suggest?

Answer 7

CLD

Important test for synthetic function of the liver

Question 8

What is a prothrombin time test? What’s it useful for?

Answer 8

Tests whether thrombins are forming well

Important bc can stage the degree of liver disease, can help decide who needs transplant

Question 9

What effect does liver cirrhosis have on the spleen?

Answer 9

Cirrhosis can cause splenomegaly because of portal hypertension

Question 10

Clinical signs of liver failure?

Answer 10

Jaundice
Ascites
Variceal bleeding
Hepatic encephalopathy (confusion / reduced cognitive function)

Question 11

Classification of jaundice?

Answer 11

Pre-Hepatic (excess bilirubin/haemolysis/impaired transport)

Hepatic (defective uptake/conjugation/excretion of bilirubin)

Post Hepatic (defective transport by biliary ducts)

Question 12

Signs that jaundice is hepatic in origin?

Answer 12

Risk factors for liver disease in history (IVDU/drugs)

Decompensation (ascites, variceal bleed, encephalopathy)

Asterixis (liver flap)

Question 13

Signs that jaundice is post-hepatic in origin?

Answer 13

Abdominal pain

pruritis/pale stool/dark urine

Palpable gall bladder

Question 14

Investigations for suspected liver failure?

Answer 14

Hep B/C serology 
LFTs (AST/ALT/Albumin)
Bloods
Ferritin/transferrin
Alpha 1 antitrypsin
USS abdomen

Question 15

Advantages of abdomen ultrasound? What can be seen?

Answer 15

Locate site of obstruction
Tells whether there is portal hypertension
Can detect masses in some cases

Cheap, no radiation

Question 16

Procedure of ERCP vs MRCP?

Answer 16

ERCP uses an endoscope to visualize the bile ducts

MRCP uses an MRI machine to view the ducts

Question 17

How is ERCP used therapeutically?

Answer 17

Can be used to stent the biliary tract

Removal of gallstones in CBD

Question 18

What is choledocholithiasis?

Answer 18

Gallstones in the bile duct

Question 19

What are some complications of ERCP?

Answer 19

Sedation issues (cardio/resp)

Pancreatitis

Cholangitis

Bleeding/Perforation

Question 20

What is a Percutaneous Transhepatic Cholangiogram? When is it used?

Answer 20

PTC is an investigation that examines obstruction in the liver/bile duct. There is a dye injected into the liver and then x-rays are taken

It is used for more proximal obstructions/when ERCp isn’t possible due to obstruction etc.

Question 21

When is an endoscopic ultrasound usually performed?

Answer 21

Characterizing pancreatic masses

Tumour staging

Aspirations/biopsy assisting

Question 22

Causes of liver cirrhosis?

Answer 22

Alcohol (#1 cause)
Autoimmune disease (Hep/PBC)
Haemochromatosis 
Hepatitis (B&C)
NAFLD
Drugs (MTX, amiodarone)
CF, Alpha1 antitrypsin deficiency 
Vascular problems (portal hypert.)
Sarcoidosis/etc.

Question 23

Types of chronic liver disease? Differences in presentation?

Answer 23

Compensated and decompensated

Decompensated should show more obvious signs, compensated may require testing to be detected

Question 24

Presentation of cirrhosis?

Answer 24

Ascites 
Portal hypertension
Variceal bleeding 
Splenomegaly
Hepatic encephalopathy

Question 25

What are spider naevi due to?

Answer 25

Lack of testosterone metabolism in the liver - gets converted to estrogen Red dots on skin and even feminization of patients

Question 26

Management of new-onset ascites?

Answer 26

Diagnostic paracentesis (drain fluid & test)

Question 27

Tests done after diagnostic paracentesis of ascites?

Answer 27

Protein and albumin Cell count SAAG (serum-ascites albumin gradient)

Question 28

If SAAG testing of ascites fluid shows gradient of >1.1 g/dl what are possible causes of ascites?

Answer 28

Portal hypertension Or malignancy/heart failure causing portal hypertension

Question 29

If SAAG testing of ascites is <1.1 g/dl what may be causes of the ascites?

Answer 29

``` Malignancy TB Chylous ascites Pancreatic causes Biliary ascites Nephrotic syndrome ```

Question 30

Treatment options for ascites?

Answer 30

``` Diuretics Large volume paracentesis TIPS Aquaretics Liver transplant ```

Question 31

Cause of varicies? | Locations where they can occur?

Answer 31

Portal hypertension Skin - caput medusa Rectal Oesophageal & gastric Stomal

Question 32

What are varicies?

Answer 32

Swollen or enlarged veins

Question 33

Immediate management of varicieal bleeding?

Answer 33

Resuscitate patient - stop bleeding. Done via beta blocker to reduce portal hypertension & endoscopic band ligation if needed Blood transfusion if needed Endoscopy once patient is stable

Question 34

Treatment of varicies?

Answer 34

Endoscopic band ligation Band the vein to close it, if band falls off band again until vein scarred enough so it won't rupture again

Question 35

What is hepatic encephalopathy? Non-cognitive signs?

Answer 35

Confusion due to liver disease Liver flap is an early sign

Question 36

Risk factors for hepatocellular carcinoma?

Answer 36

Cirrhosis Chronic Hep B & C

Question 37

Presentation of hepatocellular carcinoma?

Answer 37

Decompensation of liver disease Abdominal mass/pain Weight loss Bleeding from tumour

Question 38

Treatment options for hepatocellular carcinoma?

Answer 38

Hepatic resection Liver transplant Chemotherapy Local ablation Hormonal therapy (tamoxifen)