liver Flashcards
1
Q
ACUTE liver failure is liver failure without _______, with _________pathy and _______ _______pathy, within ___ weeks of onset
A
without chronic liver dis, coagulopathy, hepatic encephalopathy, 28
2
Q
what is the most common cause of acute liver injury?
A
drugs eg alcohol, paracetamol, antidepressants, cocaine, ecstasy
3
Q
4 infective causes of acute liver injury?
A
hep a, hep b, cmv, ebv, malaria, yellow fever
4
Q
why is there systemic multi-organ failure in acute liver failure?
A
The hepatocytes die by necrosis. This means that the liver cannot clear the toxins anymore, so there is an inflammatory response around the body.The systemic inflammatory response causes vasodilation and hypo perfusion, which injures the rest of the organs through ischaemia
5
Q
some symptoms of acute liver failure?
A
asterixis, flapping tremour, fatigue, jaundice, malaise, bleeding, bruising, haptatic encephalopathy, ruq pain, hypoglycaemia, pear drops smell (fetor hepaticus)
6
Q
what would high ALT mean?
A
hepatocyte damage
7
Q
what would high AST mean?
A
alcohol
8
Q
what would high ALP mean?
A
bile duct pathology - if GGT is also raised
bone pathology - if everything else is normal
9
Q
what would high GGT mean?
A
bile duct, obstruction, alcohol, phenytoin
10
Q
what would the clottting profile look like in acute liver failure?
A
low albumin
high inr
high prothrombin time
11
Q
what
what imaging would you use in liver failure?
A
ultrasound to see liver size
doppler to see hepatic and portal veins
12
Q
two supplements you would want to give in acute liver failure?
A
thiamine and folate
13
Q
what can you give for seizures in acute liver failure
A
phenytoin
14
Q
5 aetiologies of chronic liver dis?
A
alcohol inf (hep b/c) alpha 1 antitrypsin def wilsons autoimmune cholangitis ischaemia drug
15
Q
5 pathophysiological/histological features of chronic liver disease?
A
steatosis bands of cirrhosis/fibrosis regenerative nodulues hepatitis balooned hepatocytes irreversible remodelling
16
Q
5 signs of chronic liver dis?
A
sarcopenia coagulopathy ascites hepatomegaly jaundice caput medusa spider naevi palmar erythema asterixis
17
Q
5 symptoms of chronic liver failure?
A
haematemesis fatigue itching bruising anorexia confusion
18
Q
what abnormal lfts are typical of chronic liver failure?
A
high bilirubin
low albumin
high pt
19
Q
how do you assess the amount of fibrosis in the liver?
A
transient elastography
20
Q
what is gold standard for chronic liver disease?
A
liver biopsy (but is rarely done cos spenny)
21
Q
what does fbc in chronic liver dis show?
A
thrombocytopenia
22
Q
how to treat hepatic encephalopathy?
A
laxatives
23
Q
how to treat ascites?
A
aldosterone antagonist or paracentesis
24
Q
how to treat spontaneous bacterial peritonitis?
A
abx
albumin solution
25
cholecystitis vs cholangitis?
```
cholecystitis = inflam of the gallbladder (usually because it is blocked at the neck by a stone)
cholangitis = inflam of the billiary tree tubes - gallstones, ercp, cholangiosarcoma
```
26
3 aetiologies of gall stones?
too much cholesterol
poor bladder emptying
rbc turnover
27
simply, what's in a gallstone?
cholesterol and bile salts
28
what is billiary colic?
intermittent pain caused by temporary obstruction
29
what is acalculous cholecystitis?
inflammation of the gallbladder not caused by a stone
30
where is the pain in gallbladder pathology?
ruq
31
symptoms of biliary colic?
intermittent ruq/epigastric pain
worse after eating
nausea
32
symptoms of acute cholecystitis?
severe constant ruq pain
worse on inspiration
referred to shoulder c3,4, 5 if severe
murphys sign
33
symptoms of ascending cholangitis?
ruq pain
jaundice, dark urine, itching, coagulopathy
rigors
fever
34
how can you treat cholecystitis?
ercp to remove stones
remove the gallbladder if stones are reoccuring
drain the gallbladder
35
4 pathophysiological effects of alcohol on the liver?
uses up NAD and creates NADH
NADH decreases gluconeogenesis and increases fatty acid oxidation
free radicals produced
activates kupffer ells which release TNFa and ROS
oxidative stress leads to more inflammation
end result of all the inflammation is fibrosis
36
3 stages of alcoholic liver disease and are they reversible?
1. alcohol related fatty liver - reverses in 2 weeks
2. alcoholic hepatitis - reverses in 2 months
3. cirrhosis - not reversible
37
presentation of alcoholic fatty liver?
vague or no symptoms
| hepatomegaly
38
5 clinical presentations of hepatitis/cirrhosis?
```
hepatomegaly
jaundice
spider naevi
caput medusa
asterixis
clubbing
oedema
ascites
bruising
high temp
palmar erythema
gynaecomastia
```
39
what do you see on an fbc in alcoholic liver dis?
increased cell volume (macrocytic anaemia)
40
what do you see in alcoholic liver disease, on LFT?
raised AST
slightly raised ALT (AST>ALT)
raised GGT
if severe: low albumin, high PT, high bilirubin
41
3 changes you see on ultrasound, in alcoholic liver dis?
fatty
cirrhosis
ascites
changes in blood vessels
42
why might you do an endoscopy in liver dis?
to look for oesophageal varices
43
two screening question systems for alcoholism?
CAGE
| AUDIT
44
management of alcoholic liver disease?
drinking cessation [supported]
high thymine, high protein diet
short period of steroids
transplant
45
aetiology of pancreatitis? (5)
```
i - iatrogenic - ERCP is most common iatrogenic cause
g - gallstones - most common
e - ethanol
t - trauma
s - scorpion bite
m - measles/mumps/mycoplasma
a - autoimmune
s - steroids
h - hypercalcaemia
e - ERCP
d - drugs eg valproate
```
46
aetiology of chronic pancreatitis? (3)
repeated acute
alcohol
CF
tumours
47
3 enzymes secreted by the pancreas?
amylase, lipase, trypsin
48
2 pathophysiological effects of pancreatitis?
hyperglycaemia
| malabsorption
49
what is the pain like in pancreatitis?
```
severe
generalised or upper abdo
radiating to the back
worse after eating
relieved by sitting forward
```
50
clinical presentations of pancreatitis?
```
cullens/fox sign
grey-turner syndrome
abdo distention
steatorrhoea
nausea/vom
diabetes-like/hyperglycaemia
weight loss
jaundice
```
51
some blood tests you might do in pancreatitis?
```
serum amylase (not specific but 1st line)
serum lipase
hba1c (esp if chronic)
igG4 - if autoimmune suspected
LFT - AST suggests alcohol is a cause
```
52
what imaging for pancreatitis?
USS
| MRCP to look for gallstones
53
an example of a pancreatic enzyme replacement? what could you give it with?
creon
| a PPI
54
What U&E disturbance is there in cirrhosis?
hyponatraemia
| high urea and creatinine
55
on an USS what would you see in cirrhosis?
```
nodules
corkscrew arteries
large portal vein
ascites
splenomegaly
```
56
3 complications of cirrhosis
portal hypertension
varices
ascites
57
where does the portal vein drain from?
superior mesenteric and splenic veins
58
3 common places for varices to form?
varices form where the portal circulation meets the systemic circulation, eg:
- gastro oesophageal junction
- ileo caecal junction
- rectum
- umbilical vein (forms caput medusae)
59
management of stable varices?
- propanolol
- elastic band ligation
- TIPSS: shunt blood from portal --> systemic circ , if refractory to other treatments
60
management of bleeding varices?
fluids
elastic band ligation/schlerotherapy/blakemore tube
-vasopressin analgue eg terlepressin to vasoconstrict
clotting factors and vit K
abx for peritonitis
61
what is ascites?
accumulation of fluid in the peritoneal cavity
62
non liver causes of ascites? (3)
peritonitis
water retention
cardiac failure
63
in portal hypertension, _____ is low, so the ________ releases _______ which worsens ascites
renal perfusion / kidney/ renin
64
transudative vs exudative ascites & some causes of each?
transudative: low protein in the exudate (below 25); caused by portal htn, malnutrition, fluid retention
exudative: high protein - malignancy and pregnancy
65
what does the SAAG (serum albumin ascites gradient) tell you?
if it is more than 11, it is transudative ascites, eg caused by portal hypertension
66
what hormone increases gallbladder contraction?
CCK in response to fatty food
67
what LFT result is the best indicator of liver function in chronic disease?
albumin
68
what is gilbert's syndrome?
gGT deficiency, high bilirubin, jaundice, other LFTs normal, autosomal recessive
69
raised bilirubin and jaundice but normal LFTs suggests..
gilbert's
| haemolytic anaemia
70
if the urine is dark and the stools are pale the cause is most likely..
post hepatic obstruction
71
how does haemolytic anaemia affect jaundice/stools/urine?
there is yellow skin but the pathology is not with the production of bile (so stools not pale) or excretion of it, so the stools and urine are normal
72
in biliary obstruction, are there high levels of conjugated or unconjugated bilirubin?
conjugated bilirubin is high
| unconj and hb are normal
73
which bacteria is associated with bloody diarrhoea, haemolysis, uraemia and anaemia?
ecoli 0157 h7
74
which bacteria is associated with RLQ pain and pork?
yersinia
75
some signs/symptoms of acute hepatitis?
```
malaise
lethargy
myalgia
gi upset
jaundice
pale stools, dark urine
tender hepatomegaly
```
76
what hepatitis cannot be chronic?
A
77
who gets hep D?
only when infected with hep B
78
mode of transmission of hep A?
faecal oral
79
what is significant about hep B?
bad if neonates get it, they develop a chronic infection
it is the only DNA virus, all the others are RNA
presents with jaundice
80
which hepatitis causes neurological symptoms?
E
81
which hepatitis has 2 phases of mild symptoms? what are those symptoms?
hep A
1 - mild - malaise/abdo pain
2 - jaundice
82
3 causes of dysentery?
```
dysentery = watery diarrhoea
cholera
e coli
clostridium perfringens
staph aureus
giardia
crypto
bacillus cereus
```
83
what blood test results would you see in c diff infection?
high crp
high wbc
low albumin
84
5 reasons why you would culture diarrhoea?
```
hypovolaemia
dehydration
for more than a week
blood or mucus
over 70
preg
immunocomp
ibd
public health
```
85
What is haaemachromotosis?
too much iron in the body, due to mutations in HFE protein, iron is deposited around the body resulting in organ damage
86
how is haemachromotosis inherited?
autosomal recessive
87
clinical presentation of haemachromotosis? (5)
```
bronze patches on skin
tiredness
arthritis
hair loss
erectile dysfunction
amenorrhoea
poor cognition/mood
```
88
haematinics in haemachromotosis?
```
ferritin raised (not v specific)
transferrin raised (this is more specific)
```
89
what do you use to see iron in heart and liver in haemachromotosis?
mri
90
treatment for haemachromotosis?
venesection weakly, to remove the iron
91
3 complications of haemachromotosis?
```
t1 diabetes
cirrhosis
hypothyroidism
hypogonadism
cardiomyopathy
chondrocalcinosis
```
92
what is wilsons disease?
too much copper
| due to a mutation in the copper binding protein ATP7B (which removes copper from the liver)
93
how is wilsons disease inherited?
autosomal recessive
94
5 complications/presentations of wilsons disease?
```
liver cirrhosis
neuro problems eg concentration, dystonia, incoordination, parkinsonism
haemolytic anaemia
kidney dysfunction / acidosis
osteopenia
rings in eyes
```
95
where is copper deposited in the brain to cause parkinsonism, how does the presentation differ to parkinsons?
basal ganglia
| wilsons = symmetrical (parkinsons is not)
96
what protein carries copper in serum, how specific is the test? what could you also test?
```
caeruloplasmin
not specific, low in cancer and inflam
24hr urine copper
serum copper - low. free serum copper - high
gold standard = liver biopsy
```
97
management of wilsons disease?
copper chelation with penicillamine or trientene
98
how is alpha 1 antitrypsin deficiency inherited?
autosomal recessive
99
what two organs does alpha 1 antitrypsin affect?
lung (emphysaema) and liver (cirrhosis)
100
what is the pathophysiological effect of alpha 1 antitrypsin deficiency?
alpha 1 antitrypsin breaks down neutrophil elastase
without it neutrophil elastase is overractive
damage to connective tissue
--> fibrosis
101
clinical presentations of liver alpha 1 antitrypsin deficiency?
liver cirrhosis
| the emphysaema develops first so they will already have COPD/barrel chested with cough and dyspnoea
102
what is the test for alpha 1 antitrypsin deficiency?
```
serum alpha 1 antitrypsin levels
liver biopsy - acid schiff pos
ct chest
genetic testing
deranged LFT `
```
103
primary vs secondary peritonitis?
```
primary = spontaneous bacterial peritonitis (e.coli, chlamydia, neisseria)
secondary = bile, barium, trauma
```
104
what is spotaneous bacterial peritonitis?
infection of the peritoneal fluid
105
two conditions where transmural bacterial peritonitis could happen?
pancreatitis, ischaemic bowel
106
what is the pain like in peritonitis?
severe
generalised at first, may be localised if it affects the parietal peritoneum (to shoulder if diaphragm affected)
guarding
relieved by putting hands on abdo, and stretching out
worsened by moving
107
when bowel sounds cease in peritonitis, what has happened?
paralytic ileus - bowel movements inhibited by pain
108
what is a late presentation of peritonitis?
```
circulatory collapse
hippocratic face
thready pulse, cold peripheries
paralytic ileus
still in pain
```
109
what investigations to diagnose peritonitis?
supine x ray - see dilated bowel
erect x ray - see subdiaphragmatic gas
ascitic tap
blood culture
110
what differentials should you exclude in peritonitis and how?
preg -hcg
pancreatitis - aylase
mi - ecg / troponin
lactate, crp and wcc will also be raised
111
Management of peritonitis?
abx
fluid
peritoneal lavage
analgaesia
112
what are the two most common primary liver cancers?
1. hepatocellular carcinoma
| 2. cholangiocarcinoma (of the bile duct)
113
what are liver hemangiomas?
benign, asymptomatic tumours of blood vessels/birthmark
114
what is focal nodular hyperplasia & some important features?
nodule of scar tissue in liver
benign, no malignant potential
more in women, associated with oestrogen
115
a major risk factor for hepatocellular carcinoma?
cirrhosis
| which may have been caused by hep B/C, alcohol, faty liver dis, HBV ..
116
3 risk factors for cholangiosarcoma?
primary sclerosing cholangitis
IBD
Hep B
parasites
117
what is the presentation of cholangiosarcoma?
painless jaundice
118
some presentations of hepatocellular carcinoma?
```
generally late / asymptomatic
weight loss
ruq pain
enlarged, irregular liver
n/v
jaundice
bruit over liver
```
119
a tumour marker for hepatocellular carcinoma?
alpha fetoprotein
120
a tumour marker for cholangiocarcinoma?
CA19-9
121
best imaging / investigation for cholangiosarcoma?
ERCP
122
A drug that can be used in late stage liver cancers?
kinase inhibitors eg sorafenib
123
what type of cancer is pancreatic cancer?
adenocarcinoma
124
where is the most common location in the pancreas for pancreatic cancer to develop?
in the head of the pancreas
125
what kind of jaundice does pancreatic cancer cause & why? what are the symptoms of this?
obstructive jaundice, because as the tumour grows it blocks the pancreatic duct
painless
pale stools and dark urine
126
4 presentations of pancreatic cancer?
obstructive painless jaundice with pale urine and dark stools
itching
weight loss
upper abdo/back pain
mass
new or worsening diabetes
n/v
courveissers - painless obstructive jaundice + palpable gallbladder means gallstones are unlikely
troussea sign -- migratory thrombophlebitis - blood clots that make lumps under the skin = pancreatic malignancy
127
what investigations could you do in ?pancreatic cancer?
CA19-9 - raised but not specific
CT T.A.P
M/ERCP - to stent the bile duct and also take a biopsy
128
Surgery for pancreatic cancer?
pancreatectomy
whipples
ercp for symptomatic management
129
ERCP vs MRCP?
ERCP = endoscopic retrograde cholangiopancreatography
MRCP = magnetic resonance cholangiopancreatography
ERCP is more invasive but better diagnostically
130
what does a hernia feel like (to the patient)?
soft lump
aching
pulling/dragging sensation
131
what is an incarcerated hernia? what can happen as a result?
becomes irreducible and a portion of bowel is stuck through the hole
obstruction --> vomiting, pain, constipation
strangulation --> necrosis
132
what sort of hernias do not need to be managed?
those with a wide neck - there is a lower risk of strangulation/herniation
133
what are the two kinds of inguinal hernias?
direct - through the posterior wall of the inguinal canal. caused by heavy lifting. do not reduce when you press the inguinal ring. wide neck, usually unproblematic
indirect - through the deep inguinal ring into the inguinal canal. congenital. can strangulate. reduce when you press the inguinal ring
134
where is a femoral hernia?
at the top of the thigh
abdominal contents move through the femoral ring into the femoral canal
small neck - complications
135
who gets umbilical hernias?
neonates and old people
in neonates they resolve by themselves
in old people is because of weakening of the abs
136
where is a spigelian hernia?
between the rectus abdominus and linear semilunaris
137
who gets obturator hernias?
old women -- due to pelvic floor damage
| formed by herniation through the obturator foramen at the base of the pelvis
138
what hernias can present as dyspepsia/nausea?
hiatus hernias -- due to herniation of stomach into diaphragm
139
what hernias present with lower groin or thigh pain and a positive howship-rhomberg sign on internal rotation of the hip?
obturator hernias
140
what hernias present with non specific abdo pain and commonly cause complications?
spigelian hernias (between the rectus abdominus and linear semilunaris)
141
how do you get hepatitic encephalopathy?
ammonia - usually metabolised by liver
if liver not working ammonia crosses BBB
ammonia --> glutamate
also draws water in --> cerebral oedema
142
why do you get gynaecomastia in liver dis?
the liver is involved in oestrogen regulation
143
what is leukonychia?
white nails
due to low protein (albumin)
which can indicate liveer failure
144
two examples of autoimmune liver conditions?
primary biliary cholangitis - esp females
| primary scherosing cholangitis
145
if someone with liver failure was actively bleeding what blood product would you give them?
fresh frozen plasma
146
what is the treatment for hep C?
ribavirin
147
what is the treatment for hep b?
first line is pegylated interferon alpha 2a
| second line is tenofovir
148
what happens in paracetamol overdose?
glucoronidation and sulphation pathways are overwhelmed --> produce NAPQI by a CYP
NAPQI is fine if it is added to glutathione, then it can be excreted
in overdose you run out of glutathione --> NAPQI is toxic
149
presentation of paracetamol overdose?
n/v
ruq pain
anorexia
150
treatment of paracetamol overdose?
n-acetylcysteine
| activated charcoal, if presents within an hour
151
what is steatosis?
harmless build up of fat in the liver cells
| can go on to develop steatohepatitis, which is what can cause fibrosis/cirrhosis
152
what is wernicke-korsakoff encephalopathy?
liver associated
ataxia, confusion, nystagmus, memory impairment
treat with iv thymine / vit b1
153
what is budd-chiari syndrome and what does it cause?
occlusion of liver veins --> portal hypertension
154
what does TIPSS stand for?
transjugular intrahepatic portal systemic shunt
155
what is the most common bacteria in spontaneous bacterial peritonitis & what would be the treatment?
e.coli
| cefotaxime
156
where is the ampulla of vater?
between the pancreatic duct and the common bile duct
157
what is the pathophysiology of primary sclerosing cholangitis?
fibrosis and strictures of the bile ducts
= reduced flow of bile
= bile backs up into liver -- hepatitis -- cirrhosis
158
what is the epidemiology of primary sclerosing cholangitis?
male
30-40
strong association with ulcerative colitis
159
presentation of PSC?
```
jaundice
chronic RUQ pain
fatigue
itching
hepatomegaly
signs of cirrhosis
```
160
investigations for PSC? 3
LFT - ALP high, bilirubin may be high, others increase as condition progresses
autoantibodies eg ANA, pANCA, anti-cardiolipin - don't confirm anything but suggest autoimmune cause
MRCP - gold standard
161
in gilberts syndrome, what are the urine and stools like?
even though there is jaundice, the urine and stools are normal, as this is prehepatic jaundice
162
in pre hepatic jaundice, the urine is _____ and the stools are _____
normal
| normal
163
in intrahepatic jaundice, the urine is ____ and the stools are ____
```
urine = dark
stools = normal
```
164
in post hepatic jaundice, the urine is ____ and the stools are _____
dark urine
| pale stools
165
what is the pathophysiology of primary billiary cirrhosis?
autoimmune attack of bile ducts
= build up of bile, cholesterol and bilirubin as they cannot get to intestines
-- put into blood instead
166
what is the epidemiology of primary biliary cirrhosis?
women
autoimmune esp coeliac, hypothyroid
rheum eg RA, Sjogrens
167
what is the presentation of PBC?
```
itch
jaundice
pale stool
abdo pain
fatigue
xanthoma/xanthelasma (cholesterol deposits)
```
168
what is the test for PBC?
```
LFT - ALP raised first
anti-mitochondrial antibodies
ANA - not sensitive or specific
ESR
IgM raised
```
169
what is the treatment for PBC and PSC?
Ursodeoxycholic acid reduces the intestinal absorption of cholesterol
Colestyramine is a bile acid sequestrate
liver transplant
consider immunosupression
170
what is the best investigation to confirm ascending cholangitis?
contrast enhanced dynamic CT
171
what is the treatment for autoimmune hepatitis?
prednisolone - 1st line
| + azathiopurine
172
what is first line treatment for alcohol withdrawal?
chlordiazepoxide
173
what is the most common cause of liver cirrhosis?
alcohol
174
what is the name of the rings in the eyes in wilsons disease?
kayser-fletcher rings
175
which 2 hepatitises have faecal-oral transmission?
A and E
176
what is Murphys sign and what does it show?
pain on inspiration when you palpate the right subcostal area
= cholecystitis
177
cullens and grey turners signs indicate ____
acute pancreatitis
178
what is Charcot's (liver) triad?
fever + rigors
jaundice
RUQ pain
typical of ascending cholangitis
179
marker for testicular seminoma?
ALP
180
Marker for choriocarcinoma?
hCG
choriocarcinoma = cells left behind from pregnancy become cancerous v rare
or a v rare type of testicular cancer
181
what is testicular teratoma like at biopsy?
lots of different cells
182
mallory bodies are associated with?
alcoholic liver damage
183
if the serum ascites-albumin gradient is low what is the cause?
low gradient = exudative
| eg inflam, infection
184
what is the difference between the transmission of hep B and hep C?
B = sex
C = needles
185
why is there decreased immunity in chronic liver disease?
liver does protein synthesis so poor liver function = decreased clotting factors, complement, opsonisation etc
bowel wall may be more permeable
liver regulates immune response
