Liver Flashcards
Acute liver failure Chronic liver disease and cirrhosis (145 cards)
1
Q
Which condition is associated with SBP (spontaneous bacterial peritonitis)
A
Common in ascites caused by hepatic cirrhosis
2
Q
Someone has poor liver function. Name two liver function tests and what changes will occur in disease
A
Increased PT
Decreased albumin
3
Q
Which cells release ALT and AST
A
hepatocytes
4
Q
Which cells release GGT and ALP
A
bile ductal cells
5
Q
Name five causes of cirrhosis/chronic liver disease
A
- alcohol
- Hep B/C
- NAFLD
- autoimmune hepatitis
- haemochromatosis
- wilson’s disease
- PBC
- PSC
- alpha1 antitrypsin
- Drugs
6
Q
How can alcoholic causes of cirrhosis be diagnosed?
A
thorough history + increased AST and ALT, ratio 2:1 (approx)
7
Q
Which cause of cirrhosis is the only one associated with a higher AST to ALT ratio
A
alcohol induced
8
Q
Which cells are damaged as a result of alcohol excess
A
hepatocytes, therefore incr ALT and AST
9
Q
What are the risk factors for Hep B and C?
A
blood exposure e.g. needles, tattoos, IV drugs, blood transfusion
sexual
vertical
geography
10
Q
Which cell is does hep B/C target in the liver? Which biomarkers are raised?
A
hepatocytes, raised ALT ++ raised AST +
11
Q
Name three risk factors for NAFLD
A
central obesity, diabetes, hyperlipidaemia
12
Q
Which LFTs are raised in NAFLD?
A
AST + ALT ++
13
Q
What are the components of autoimmune hepatitis screen?
A
ANA/ASA, IgG
+liver biopsy
14
Q
In which organs can ferritin be deposited in haemorchromatosis?
A
liver, pancreas, heart, skin, joints, gonads
15
Q
What are the complications of ferritin storage in the affected organs?
A
pancreas- diabetes, heart- cardiomyopathy, skin- bronzing, joints- arthritis, gonads- infertility
16
Q
What is the treatment for haemochromatosis?
A
venesection
17
Q
A 23 year old patient presents with a tremor. Which liver related disease could be causing this?
A
wilson’s disease. copper can deposit and sequester in basal ganglia, resulting in tremor
18
Q
Ceruloplasmin test is a diagnostic test for which disease?
A
Wilson’s disease
19
Q
Which liver cells does PBC affect? What are the affected LFTs?
A
SMALL ductal cells. Incr GGT and ALP.
20
Q
What is the pathophysiology of PBC?
A
Autoimmune destruction of small bile ducts due to granulomas, obstructing flow of bile
21
Q
What is the treatment for PBC?
A
liver transplant
22
Q
How does PSC compare to PBC?
A
PSC affects both small and large bile ducts. PBC is autoimmune while PSC is not.
23
Q
Which LFTs are raised in PSC?
A
GGT and ALP
24
Q
In alpha1 antitrypsin deficiency, are the lungs or liver affected first?
A
lungs
25
Which drugs can cause cirrhosis?
methotrexate and isoniazid
26
What are the categories of causes of jaundice?
Pre-hepatic, intrahepatic (failure to conjugate bilirubin in a damaged/inflamed liver or excrete it into bile ducts), and post-hepatic
27
Causes of pre-hepatic jaundice?
hereditary spherocytosis, DIC, G6PD, autoimmune, infection (malaria)
28
Causes of intrahepatic jaundie?
decompensated liver disease/cirrhosis (NAFLD, alcohol, viral)
Acute liver injury (viral)
Drugs
Gilbert's
29
Causes of post-hepatic jaundice?
obstruction of large bile ducts: cholangitis, chlangiocarcinoma, pancreatic mass, cancer
drug or pregnancy induced cholestasis
autoimmune disease (PBC, PSC)
30
Jaundice and breathlessness. Which cause of jaundice are they likely to have?
pre-hepatic (symptoms of anaemia)
31
Pale stools, dark urine. Which cause of jaundice?
post-hepatic
32
Painless jaundice in elderly patient with weight loss. What is the likely cause?
pancreatic malignancy
33
Will bilirubin be positive in dipstick of biliary obstruction, hepatic disease, and haemolytic disease?
positive in obstruction and hepatic disease but not haemolytic disease
34
Which clinical findings on examination would be indicative of decompensated liver disease?
jaundice, shifting dullness/ascites, confusion, asterexis, GI bleeding
35
Why would you look at U&Es when investigating decompensated liver disease?
risk of hepatorenal syndrome, acute renal failure can complicated hepatic function
36
Why would you check CRP in decompensated liver disease?
infection can often trigger decompensation
37
Which investigations form part of a liver screen?
1. Alpha fetoprotein
2. Hepatitis screen
3. ANA
4. alpha 1 antitrypsin
5. ceruloplasmin
6. iron studies
7. coeliac disease
8. TFTs
9. HIV screen
38
Why would you conduct alpha fetoprotein blood test?
liver tumour marker
39
Why would you test for ceruloplasmin?
wilson's disease
40
Why would you do iron studies in jaundiced patient?
to rule out haemochromatosis
41
Why would you do an asicitic tap?
to ID spontaneous bacterial sponitinits
42
Name three causes of hepatic encephalopathy?
sepsis, constipation, medications, dehydration, bleeding
43
Which antibiotic to reduce the risk of recurrent hepatic encephalopathy?
rifaximin
44
What is SAAG?
serum-ascites albumin gradient
45
If SAAG> 11g/L, what will the likely cause of ascites be?
portal hypertension
46
Why do liver disease patients have low platelets?
portal hypertension results in splenomegaly and platelet sequestration
47
Name three reasons why liver disease patients at high risk of bleeding?
prolonged INR due to failing synthetic liver function
Low platelets
Oesophageal and gastric varices
48
What is the management of bleeding in liver disease patient?
```
vit K
withhold anticoag/NSAIDs
Endoscopy?
HDU?
Abx- reduces mortality
```
49
Which two scores stratify the risk of bleeding?
glasgow blatchford and rockall score
50
Patient with IgM and mitcochondrial antibody (AMA). Which condition do they have?
primary biliary cholangitis
51
Patient ANCA positive + jaundice. Which condition is likely causing this?
primary sclerosing cholangitis
52
ANA, ASMA positive, raised IgG. Which condition is causing their jaundice?
autoimmune hepatitis
53
What is the mode of inheritance of haemochromatosis?
autosomal recessive
54
Where can iron be deposited in haemochromatosis?
liver, pancreas, heart, joints, skin, pituitary
55
Which extraheaptic clinical manifestations of haemochromatosis are reversible?
skin discolouration
cardiomyopathy
hepatomegaly
56
Which extrahepatic clinical manifestations of haemochromatosis are irreversible?
```
hepatocellular carcinoma
arthropathy
hypopituitarism
diabetes
cirrhosis
```
57
Patient with ascites. Which abx should you commence?
coamoxiclav
58
What are the signs of de-compensated liver cirrhosis?
asicites, encephalopathy, jaundice, coagulopathy, hypotensive
59
Which diuretics are used in the management of ascites?
furosemide and spironolactone
60
What are three complications of ascites?
1. SBP
2. Malignancy (AFP/HCC)
3. Portal vein thrombus
61
Which guidelines can help with the management of decompensated cirrhosis?
BASL bundle care pathway
62
What are the anatomical sites to perform paracentesis?
2/3 down from umbilicus to ASIS
63
When should you be cautious about performing paracentesis?
if patient has prolonged PT + APTT
64
What is pabrinex?
Vitamin B and C complexes= bright yellow
65
Is Wernicke or Korsakoff irreversible?
Korsakoff is irreversible
66
Can you still have cirrhosis if you have normal LFTs?
Yes!!!!
67
What can be given as adjunct when offering fluids to patients with ascites?
albumin, promotes fluid accumulation in vascular space
68
Give three causes for precipitating hepatic encephalopathy and provide treatment for each
```
UGIB- transfusions and resus
Constipation- laxatives
Infection- appropriate antibiotics
Electrolyte imbalance- replace
Increased alcoholic intake
```
69
Give three management options for treating ascites
aspiration/drain
diuretics- spironolactone and furosemide
fluid restriction, low salt diet
70
List two causes of asterexis
CO2 retention
| uraemia
71
Describe bilurbin metabolism
1. Hb → unconjugated bilirubin by splenic macrophages
2. Unconjugated bilirubin bound to albumin is converted to conjugated bilirubin in liver glucoronyl transferase
3. In colon, colonic bacteria convert cBR to urobilinogen (colourless). 80% of urobilonogen is further oxidised to stercobilinogen. Some urobilinogen is reabsorbed and diverted to liver and re-excreted in bile, the rest is excreted in the urine
72
What is Gilbert's syndrome?
Auto dom partial UDP-GT deficiency
| Jaundice occurs during intercurrent illness
73
What are the results of LFTs of someone who has gilbert's?
normal LFTs
74
How is gilbert's diagnosed?
increased unconjugated bilirubin whilst fasting
75
List three drugs that can cause jaundice
Haemolysis- Antimalarials (e.g. dapsone)
Hepatitis: paracetamol OD, statins
Cholestasis: Sulfonylureas, oral contraceptive pills, fluclox
76
Pre-hepatic jaundice. What would be detected in urine?
no bilirubin
| increased urobilinogen
77
Hepatic jaundice. Urine results?
increased bilirubin
| increased urobilinogen
78
Post hepatic jaundice. Urine?
incr bilirubin
| no urobilinogen
79
LFTs of pre-hepatic?
Incr LDH, AST, unconju-bilurbin
80
LFTs of hepatic jaundice?
```
cBR incre
AST:ALT incr
GGT incr
ALP incr
decreased albumin, increased PT
```
81
LFTs post hepatic jaundice?
Incr cBR
Incr ALT AST
Incr ALP
Incr GGT
82
List three causes of acute liver failure
Infection: Hep A/B, CMV, EBV, leptospirosis
Toxin: EtOH, paracetamol, isoniazid, halothane
Vasc: Budd-Chiari
Other: Wilson’s, AIH
Obs: eclampsia, acute fatty liver of pregnancy
83
State three signs of liver failure
```
jaundice
oedema +ascites
bruising
encephalopathy- asterixis
Foetor hepaticus
Signs of liver disease
```
84
Name a complication of advanced liver failure
hepatorenal syndrome
85
Why is it important to test for glucose in liver disease/failure?
liver is responsible for gluconeogensis and glycogen storage, therefore hypoglycaemia can ensue if liver function is impaired
86
Describe three complications of liver failure
```
bleeding
sepsis
ascited
hypoglycaemia
encephalopathy
seizures
cerebreal oedema
```
87
What is the management of sepsis in patient with liver failure?
tazocin (avoid gent due to nephrotoxicity)
88
Management of ascites?
fluid and salt restrict, spiro, fruse, tap, daily weight
89
Name two drugs that should be avoided in liver failure?
opioids (exacerbation of encephalopathy), oral hypoglyacaemics, warfarin effects, paracetamol, isoniazid
90
List three hepatotoxic drugs
paracetamol
methotrexate
isoniazid
tetracycline
91
Two signs of cirrhosis in hands?
```
Clubbing (± periostitis)
Leuconychia (↓ albumin)
Terry’s nails (white proximally, red distally)
Palmer erythema
Dupuytron’s contracture
```
92
Two signs of cirrhosis in face?
Pallor: ACD
| Xanthelasma: PBC
93
Two signs of cirrhosis in chest?
Spider naevi (>5, fill from centre)
Gynaecomastia
Loss of secondary sexual hair
94
Two signs of cirrhosis in abdomen?
Striae
Hepatomegaly (may be small in late disease)
Splenomegaly
Dilated superficial veins (Caput medusa)
Testicular atrophy
95
List three complications of cirrhosis
1. Decompensation- hepatic failure
2. SBP
3. Portal hypertension
4. Increased risk HCC
96
Three signs of decompensated liver cirrhosis
```
jaundice
encephalopathy
ascited +oedema (hypoalbuminaemia)
coagulopathy
hypoglycaemia
```
97
Three signs of portal hypertension?
```
SAVE
splenomegaly
ascites
varices
encephalopathy
```
98
Which blood test in a liver screen indicates HCC?
alpha-fetoprotein
99
Two signs of cirrhosis on ultrasound?
small/large liver
focal lesions
ascites
100
SBP is infection of what?
ascitic fluid
101
What is the pathophysiology of encephalopathy?
1.↓ hepatic metabolic function
2. Diversion of toxins from liver directly into systemic system.
3. Ammonia accumulates and pass to brain where
astrocytes clear it causing glutamate → glutamine
4. ↑ glutamine → osmotic imbalance → cerebral oedema.
102
Two symptoms of encephalopathy?
asterexis
confusion
seizures
dysarthria (motor speech disorder)
103
List three precipitants of hepatic encphalopathy
```
HEPATICS
Haemorrhage: e.g. varices
Electrolytes: ↓K, ↓Na
Poisons: diuretics, sedatives, anaesthetics
Alcohol
Tumour: HCC
Infection: SBP, pneumonia, UTI, HDV
Constipation (commonest cause)
Sugar (glucose) ↓: e.g. low calorie diet
```
104
What are two agents that cause SBP?
e.coli, klebsiella, strep
105
Treatment of SBP?
tazosin
106
Source of spread for hep B?
blood, body fluids, pergnancy (vertical)
107
Transmission for hep c?
blood
108
transmission hep A?
faecal-oral, seafood
109
NAFLD is associated with which syndrome?
metabolic syndrome
110
what are three features of metabolic syndrome
central obesity
high triglycerides
HTN
hyperglycaemia
111
What is Budd-chiari syndrome?
Hepatic vein obstruction → ischaemia and hepatocyte damage → liver failure or insidious cirrhosis.
112
What is a cause of budd chiari syndrome?
```
hypercoagulable state (myeloproliferative disorder)
Local tumour
```
113
Describe three clinical features of hereditary haemochromatosis
features of iron deposition in different organs
```
Cardiomyopathy
Diabetes
Cirrhosis
Arthritis
Grey skin
```
114
What is the first line treatment for haemochromatosis?
iron removal- routine venesection
115
Blood results for haemochromatosis?
incr ferritin
incr Fe
reduced TIBC
116
65 y/o patient with signs of wilson's disease. Could they have this disease?
no, presents between childhood and 30 (never >56)
117
Why is there reduced Cu in blood in wilson's disease?
Mutation of Cu transporting ATPase
Impaired hepatocyte incorporation of Cu into
caeruloplasmin and excretion into bile
Cu accumulation in liver and other organs
118
Name three clinical features of wilson's disease
```
Kayser-Fleischer rings
Liver disease
Arhtritis
PARKINSONISM
Haemolytic anaemia
```
119
Which neuro disorder is associated with wilson's disease?
parkinson's disease
120
Which autoantibodies can be present in autoimmune hepatitis?
SMA, LKM, SLA, ANA
121
Autoimmune hepatitis can be associated with which other diseases? Name two
thyroiditis
DM
pernicious anaemia
UC
122
How does the pathology of PBC and PSC differ?
PBC= intrahepatic bile duct destruction by chronic granulomatous inflammation
PSC= Inflammation, fibrosis and strictures and intra- and
extra-hepatic ducts.
123
Are most of liver cancer primary or secondary?
90% are secondary
124
Which primary cancers metastasize to the liver?
breast, colon, stomach, lung, uterus
125
State two benign tumours of the liver
cysts
adenomas
haemangiomas
126
Aside from viral hepatitis, name two infections that can cause acute hepatitis
malaria, EBV, syphilis
127
What is the significance of core antibody lab test? cAb
only positive in people exposed to WHOLE virus e.g. current or previous infection, not present in response to vaccinations as only part of the virus is presented
128
Which Hep B marker is a marker for current infection?
sAg- surface antigen
129
Which hep B marker is a marker for previous infection?
sAb- surface antibody
130
Which two tests are required to diagnose current hep b infection?
sAg and DNA
131
How does presence of eAg influence disease?
eAg positive- early disease, highly infectious, high viral load, high risk of liver disease and carcinoma, while if negative then lower risks
132
Name two cancers of the liver
hepatocellular carcinoma, and cholangiocarcinoma
133
What are the symptoms of liver disease?
jaundice- dark urine, light stool, itchy, ankle swelling, abdominal swelling, nausea, vomiting, fever
134
What is the definition of cirrhosis?
!! 1. Diffuse process with 2. Fibrosis and 3. Nodule formation
135
Which blood markers are most helpful to determine actual liver function?
albumin, bilirubin, PT
136
Name three metabolic liver diseases that result in chronic liver injury
1. Haemochromatosis 2. Wilson disease (copper) 3. Alpha1 antitrypsin deficiency
137
What is the treatment for autoimmune hepatitis?
corticosteroids, azathioprine
138
How can NAFLD and alcoholic liver disease be distinguished?
AST/ALT ration >1.5 in ALD
139
What are two features of the glasgow alcoholic hepatitis score?
age, WCC, urea, PT, bilirubin
140
Which liver disease is interface hepatitis a typical feature of?
autoimmune hepatitis
141
List four biochemical signs that you would see in cirrhosis
Increased bilirubin, raised PT, decreased albumin, and low platelets
142
What is the cause of 'bronze diabetes'?
genetic haemochromatosis
143
Name two tests most useful in monitoring response to haemochromatosis management (phlebotamy)
ferritin and transferrin saturation
ferritin= total iron stores
144
Triad of symptoms for Budd-Chiari syndrome?
Budd-Chiari syndrome presents with the triad of sudden onset abdominal pain, ascites, and tender hepatomegaly
145
What is SAAG?
The SAAG is used to determine if the ascites has been caused by portal hypertension or not. A raised SAAG (>11g/L) indicates that it is portal hypertension that has caused the ascites. Budd-Chiari syndrome (hepatic vein thrombosis) is the only option that causes portal hypertension.
All the other options do not cause portal hypertension and would therefore result in a SAAG < 11g/L.
