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07. Year 2: Alimentary System > Jaundice and Chronic Liver Disease > Flashcards

Jaundice and Chronic Liver Disease Flashcards

1
Q

What is a doctor who deals with the liver called?

A

Hepatologist

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2
Q

What are the different categories of liver functions?

A

Synthetic function

Detoxification function

Immune function

Storage function

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3
Q

What are synthetic functions of the liver?

A

Clotting factors

Bile acids

Carbohydrates

Proteins

Lipids

Hormones

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4
Q

What functions related to carbohydrates is the liver responsible for?

A

Gluconeogenesis

Glycogenolysis

Glycogenesis

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5
Q

What is glycogenolysis?

A

Breakdown of glycogen to glucose

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6
Q

What is glycogenesis?

A

The formation of glycogen from glucose

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7
Q

What is gluconeogenesis?

A

Generation of glucose from non-carbohydrate substances

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8
Q

What protein is the liver responsible for making?

A

Albumin

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9
Q

What lipids is the liver responsible for making?

A

Cholesterol

Lipoprotein and triacylglyerol

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10
Q

What hormones is the liver responsible for making?

A

Angiotensinogen

Insulin like growth factor

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11
Q

What are detoxification functions of the liver?

A

Urea production from ammonia

Detoxification of drugs

Bilirubin metabolism

Breakdown of insulin and hormones

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12
Q

What are immune functions 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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13
Q

What are storage functions of the liver?

A

Stores glycogen

Stores vitamin A, D, B12 and K

Stores copper and iron

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14
Q

What things do liver function tests measure?

A

Bilirubin

Aminotransferases

Alkaline phophotase

Gamma GT

Albumin

Prothrombin time

Creatinine

Platelet count

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15
Q

What is bilirubin a by product of?

A

Haem metabolism

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16
Q

What is bilirubin generated by?

A

Senescent RBCs in the spleen

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17
Q

What is bilirubin bound to when it is unconjugated?

A

Albumin

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18
Q

What does conjugating bilirubin do?

A

Solubilises it

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19
Q

What is bilirubin elevated as a result of?

A

Haemolysis (pre-hepatic)

Parenchymal damage (hepatic)

Obstruction (post hepatic)

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20
Q

What are aminotransferases?

A

Enzymes present in hepatocytes

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21
Q

What are examples of aminotransferases?

A

AST

ALT

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22
Q

What can the AST/ALT ratio point towards?

A

Alcoholic liver disease

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23
Q

What is alkaline phosphotase?

A

Enzyme present in bile ducts

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24
Q

What causes alkaline phosphatase to be elevated?

A

Obstruction or liver infiltration

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25
Q

Other than the bile duct, where is alkaline phosphatase present?

A

Bone

Placenta

Intestines

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26
Q

What is Gamma GT?

A

Non-specific liver enzyme

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27
Q

What causes Gamma GT to be elevated?

A

Alcohol use

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28
Q

What drugs can raise Gamma GT levels?

A

NSAIDs

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29
Q

What do low levels of albumin suggest?

A

Chronic liver disease

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30
Q

Other than liver diseases, what else can cause low albumin levels?

A

Kidney disorders and malnutrition

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31
Q

What does prothrombin time tell?

A

Degree of liver dysfunction

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32
Q

What is prothrombin time used to calculate?

A

Scores to decide stage of liver disease, who needs a liver transplant and who gets a liver transplant

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33
Q

How does cirrhosis of the liver affect the spleen?

A

Causes splenomegaly

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34
Q

What is platelet count being low an indirect marker of?

A

Portal hypertension

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35
Q

What is the clinical presentation of the liver not working?

A

Jaundice

Ascites

Variceal bleeding

Hepatic encephalopathy

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36
Q

What is jaundice?

A

Yellowing of the skin, sclerae and other tissues caused by excess circulating bilirubin

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37
Q

When is jaundice detectable?

A

When total plasma bilirubin levels exceed 34umol/L

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38
Q

What are the different classifications of jaundice?

A

Pre-hepatic

Hepatic

Post-hepatic

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39
Q

What can cause pre-hepatic jaundice?

A

Increased quantity of bilirubin (haemolysis)

Impaired transport

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40
Q

What can cause hepatic jaundice?

A

Defective uptake of bilirubin

Defective conjugation

Defective excretion

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41
Q

What can cause post-hepatic jaundice?

A

Defective transport of bilirubin by the biliary ducts

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42
Q

When is bilirubin unconjugated?

A

Before it arrives in the liver

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43
Q

What are clues from the history for pre-hepatic jaundice?

A

History of anaemic (fatigue, dyspnoea, chest pain)

Acholuric jaundice

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44
Q

What are clues from the history for hepatic jaundice?

A

Risk factors for liver disease (such as IVDU, drug intake)

Decompensation (ascites, variceal bleed, encephalopathy)

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45
Q

What are clues from the history for post-hepatic jaundice?

A

Abdominal pain

Cholestasis (pruritus, pale stools, high coloured urine)

46
Q

What are clues on clinical examination for pre-hepatic jaundice?

A

Pallor

Splenomegaly

47
Q

What are clues on clinical examination for hepatic jaundice?

A

Stigmata of CLD (spider naevi, gynaecomastia)

Ascites

Asterixis

48
Q

What are clues on clinical examination for post-hepatic jaundice?

A

Palpable gallbladder

49
Q

What investigations are done for jaundice?

A

Liver screen

Ultrasound of abdomen (most important test)

50
Q

What is checked in a liver screen with jaundice?

A

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

51
Q

What does an USS for jaundice tell us?

A

Extrahepatic or intrahepatic cause

Site of obstruction

Cause of obstruction

Documents evidence of portal hypertension

52
Q

What are advantages of US for jaundice?

A

Cheap

No radiation

Portable, widely available

Good for gallstones

High specificity

Examines organs as well as biliary system

53
Q

What are advantages of CT/MRI for jaundice?

A

Better for pancreas

High specificity

High sensitivity

Examines organs as well as biliary system

54
Q

What are disadvantages of MRI/CT scan?

A

Expensive

Requires CT/MRI scanner

Radiation (CT only)

55
Q

What does MRCP stand for?

A

Magnetic resonance cholangiopancreatography

56
Q

What is Magnetic resonance cholangiopancreatography (MRCP)?

A

MRI scan that looks at hepatobiliary and pancreatic systems

57
Q

What does ERCP stand for?

A

Endoscopic retrograde cholangiopancreatography

58
Q

What is a Endoscopic retrograde cholangiopancreatography (ERCP)?

A

Endoscopic through the mouth to examine the stomach and duodenum

59
Q

What are advantages of MRCP?

A

No radiation

No complications

60
Q

What are disadvantages of MRCP?

A

5% claustrophobia

Can image outwidth the ducts

61
Q

What are disadvantages of ERCP?

A

Radiation

Sedation

Complications

Failure rate

Only images ducts

62
Q

What is an advantage of ERCP?

A

Therapeutic option

63
Q

How can ERCP be therapeutic?

A

Stenting of biliary tract obstruction

64
Q

What are some sedation related complications of ERCP?

A

Respiratory and cardiovascular problems

65
Q

What are some procedure related complications of ERCP?

A

Pancreatitis

Cholangitis

Sphincterotomy (bleeding, perforation)

66
Q

Other than MRCP and ERCP, USS, MRI and CT what other imaging methods can be used to investigate jaundice?

A

Percutaneous transhepatic cholangiogram

Endoscopic ultrasound

67
Q

What is Percutaneous transhepatic cholangiogram?

A

Radiological imaging used to visualise the anatomy of the biliary tract, contrast is injected into biliary track and x-rays are taken

68
Q

When is Percutaneous transhepatic cholangiogram used?

A

ERCP not possible due to duodenal obstruction or previous surgery

Hilar stenting

69
Q

What is a disadvantage of percutaneous transhepatic cholangiogram?

A

More invasive than ERCP

70
Q

Why is endoscopic ultrasound used?

A

Biopsy possible

Characterising pancreatic masses

Staging of tumours

Fine needle aspirate (FNA) of tumours and cysts

71
Q

When is something considered to be a chronic liver disease?

A

Persists longer than 6 months

72
Q

What are examples of chronic liver disease?

A

Chronic hepatitis

Chronic cholestasis

Fibrosis and cirrhosis

Liver tumours

73
Q

What is the aetiology of cirrhosis?

A

Alcohol

Autoimmune

Haemochromatosis

Chronic viral hepatitis (B and C)

NAFLD

Drugs

Cystic fibrosis

Vascular problems (portal hypertension)

Cryptogenic

Others such as sarcoidosis, amyloid, schistosomiasis

74
Q

What are examples of autoimmune causes of cirrhosis?

A

Autoimmune hepatitis

PBC

PSC

75
Q

What are some pathological changes in the liver with cirrhosis?

A

Infiltrating lymphocytes

Apoptotic hepatocyte

Activated Kupffer cell

Sinusoid lumen with increased resistance to blood flow

76
Q

What are some clinical features of cirrhosis due to compensated liver disease?

A

Routinly detected on screening tests

Abnormalities of liver function tests

77
Q

What is compensated cirrhosis?

A

The liver is coping with the damage and maintaining important functions

78
Q

What is the clinical presentation of decompensated chronic liver disease?

A

Ascites

Variceal bleeding

Hepatic encephalopathy

79
Q

What are ascites?

A

Build up of fluid in the peritoneal cavity

80
Q

What are clinical features of ascites?

A

Physical exam reveals dullness in flanks and shifting dullness

Spider naevi, palmar erthema, abdominal veins, fetor hepaticus

Umbilical nodule

JVP elevation

Flank haematoma

81
Q

What investigation can ascites be confirmed by?

A

USS

82
Q

What should all patients with new-onset ascites have?

A

Diagnostic paracentesis

83
Q

What is a diagnostic paracentesis?

A

Procedure where a needle or catheter is inserted into the peritoneal cavity to obtain ascitic fluid for diagnostic or therapeutic purposes

84
Q

What studies are needed on initial evaluation of ascites?

A

Protein and albumin concentration

Cell count and differential

SAAG (serum-ascites albumin gradient)

85
Q

What does SAAG stand for?

A

Serum-ascites albumin gradient

86
Q

What causes a high albumin gradient in ascites?

A

Portal hypertension

Congestive heart failure

Constrictive pericarditis

Budd Chiarri

Massive liver metstasis

87
Q

What causes a low albumin gradient in ascites?

A

Malignancy

Tuberculosis

Pancreatic

Biliary ascites

Nephrotic syndrome

88
Q

What level of albumin is considered a high albumin gradient for ascites?

A

>1.1g/dL

89
Q

What are treatment options for ascites?

A

Diuretics

Large volume paracentesis

TIPS

Aquaretics

Liver transplantation

90
Q

What is large volume paracentesis?

A

Removal of 5L of fluid or more

91
Q

What does TIPS stand for?

A

Transjugular Intrahepatic Portosystemic Shunt

92
Q

What is a transjugular intrahepatic portosystemic shunt (TIPS)?

A

Procedure that uses image guidance to connect the portal vein to the hepatic vein in the liver

93
Q

What are aquaretics?

A

Class of drugs that promote aquaresis (excretion of water without electrolyte loss)

94
Q

What are varices?

A

Dilated blood vessels

95
Q

What do varices occur due to?

A

Portal hypertension

96
Q

What is the management of variceal haemorrhage?

A

Resuscitate patient

Good IV access

Blood transfusion as required

Emergency endoscopy

Endoscopic band ligation

TIPS for rebleeding after banding

97
Q

What is endoscopic band ligation?

A

Procedure where dilated vein is cut of by a band

98
Q

What is hepatic encephalopathy?

A

Confusion due to liver disease

99
Q

How is hepatic encephalopathy graded?

A

1 to 4

100
Q

What are precipitants of hepatic encephalopathy?

A

GI bleed

Infection

Constipation

Dehydration

Medication especially sedation

101
Q

What is the treatment for hepatic encephalopathy?

A

Treat underlying cause

Laxatives

Neomycin, rifaximin (broad spectrum of non-absorbed antibiotics)

102
Q

What is repeated admission with hepatic encephalopthy an indicator for?

A

Liver transplant

103
Q

What histological class is most responsible for liver cancer?

A

Hepatocellular carcinoma

104
Q

What does hepatocellular carcinoma occur in the background of?

A

Cirrhosis

105
Q

What does hepatocellular carcinoma occur in association with?

A

Chronic hepatitis B and C

106
Q

What is the presentation of hepatocellular carcinoma?

A

Decompensation of liver disease

Abdominal mass

Abdominal pain

Weight loss

Bleeding from tumour

107
Q

What is used to diagnose hepatocellular carcinoma?

A

Tumour markers (AFP)

Radiological tests (USS, CT scan, MRI scan)

108
Q

What tumour marker is used to diagnosed hepatocellular carcinoma?

A

AFP

109
Q

What is the treatment for hepatocellular carcinoma?

A

Hepatic resection

Liver transplantation

Chemotherapy

Locally ablative treatmnts

Sorafenib

Hormonal therapy

110
Q

What are the different ways that chemotherapy can be delivered for hepatocellular carcinoma?

A

Locally delivered

Systemic chemotherapy

111
Q

What are examples of locally ablative treatments for hepatocellular carcinoma?

A

Alcohol injection

Radiofrequency ablation

112
Q

What is sorafenib?

A

Tyrosine kinase inhibitor

07. Year 2: Alimentary System (41 decks)

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