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Finals > Liver > Flashcards

Liver Flashcards

1
Q

Presentation of alcoholic liver disease

A
  • Generally asymptomatic
  • Nausea, vomiting, diarrhoea
  • Abdominal pain
  • Palmar erythema
  • Asterixis
  • Jaundice
  • Spider naevi
  • Gynaecomastia
  • Bruising
  • Ascites
  • Caput medusae (engorged superficial epigastric veins)
  • Hepatomegaly
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2
Q

Bloods in alcoholic liver disease

A
  • FBC = raised MCV
  • LFTs = elevated ALT and AST, raised gamma-GT, ALP raised (later), low albumin, elevated bilirubin (cirrhosis)
    o Ratio of AST:ALT normally >2
  • Clotting = elevated prothrombin time
  • U+Es = deranged in hepatorenal syndrome
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3
Q

Imaging in alcoholic liver disease

A
  • Ultrasound, MRI or CT = fatty infiltration, hepatocellular carcinoma, hepatosplenomegaly, abnormal blood vessel changes and ascites
  • Liver biopsy = alcohol related hepatitis or cirrhosis, Mallory bodies
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4
Q

Management of alcoholic liver disease

A
  • Stop drinking alcohol permanently
  • Consider detoxication regime = treat withdrawal Sx with diazepam
  • Nutritional support with vitamins (thiamine) and high protein diet
  • Prednisolone = improve short term outcomes
    o Maddrey’s discriminant function to determine who would benefit from steroids
  • Referral for liver transplant in severe disease but must abstain from alcohol 3 months prior
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5
Q

Complications of alcoholic liver disease

A
  • Portal hypertension
  • Varices
  • Hepatic encephalopathy
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6
Q

Factors associated with NAFLD

A
  • Obesity
  • Type 2 diabetes
  • Hyperlipidaemia
  • Jejunoileal bypass
  • Sudden weight loss/starvation
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7
Q

Presentation of NAFLD

A
  • Usually asymptomatic
  • Hepatomegaly
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8
Q

Investigations of NAFLD

A
  • Abnormal LFT = ALT > AST
  • US = increased echogenicity
  • Enhanced liver fibrosis (ELF) blood test
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9
Q

Management of NAFLD

A
  • Lifestyle changes  weight loss
  • Gastric banding
  • Insulin-sensitising drugs (metformin, pioglitazone)
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10
Q

Causes of liver cirrhosis

A
  • Alcoholic liver disease
  • Non-alcoholic fatty liver disease
  • Viral Hepatitis (B/D, C)
  • Rarer causes = autoimmune hepatitis, haemochromatosis, Wilson’s disease, alpha-1 antitrypsin deficiency, CF, PBC, drugs (amiodarone, methotrexate)
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11
Q

Presentation of liver cirrhosis

A
  • Abdominal pain
  • Bruising
  • Ankle swelling and oedema
  • Leuconychia
  • Clubbing
  • Palmar erythema
  • Dupuytren’s contracture
  • Asterixis
  • Spider naevi
  • Xanthelasma
  • Hepatomegaly + splenomegaly
  • Ascites
  • Loss of body hair
  • Gynaecomastia and testicular atrophy
  • Caput medusae
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12
Q

Bloods in liver cirrhosis

A
  • LFTs = normal or deranged (if decompensated)
  • Albumin low
  • Prothrombin time raised
  • Hyponatraemia = fluid retention
  • Urea and creatinine = deranged in hepatorenal syndrome
  • Enhanced liver fibrosis blood test
  • Alpha-fetoprotein = tumour marker for hepatocellular carcinoma
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13
Q

Imaging in liver cirrhosis

A
  • Ultrasound = nodularity of liver surface, corkscrew appearance to arteries, enlarged portal vein with reduced flow, ascites, splenomegaly
  • Liver biopsy
  • Fibroscan = check elasticity of liver
  • Endoscopy = oesophageal varices with portal hypertension
  • CT and MRI = hepatocellular carcinoma, hepatosplenomegaly, abnormal blood vessel changes and ascites
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14
Q

Classification of liver cirrhosis

A

Child-Pugh:
- High Bilirubin
- Low Albumin
- High INR
- Ascites
- Encephalopathy
- Lowest score 5. Highest score 15.
- <7 good. >10 bad prognosis
- Risk of variceal bleeding if >8

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15
Q

Management of liver cirrhosis

A
  • High protein, low sodium diet
  • No alcohol
  • Avoid NSAIDs and aspirin
  • Ultrasound and alpha-fetoprotein every 6 months for hepatocellular carcinoma
  • Endoscopy every 3 years for no varices
  • Consider liver transplant
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16
Q

Complications of liver cirrhosis

A
  • Malnutrition
  • Portal hypertension, varices and variceal bleeding
  • Ascites and spontaneous bacterial peritonitis
  • Hepato-renal syndrome
  • Hepatic encephalopathy
  • Hepatocellular carcinoma
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17
Q

What are varices?

A

Swollen, tortuous vessels at gastro-oesophageal junction, ileocaecal junction, rectum, anterior abdominal wall via umbilical vein

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18
Q

Management of stable varices

A

o Propranolol (non-selective BB) = reduces portal hypertension
o Elastic band ligation of varices
o Injection of sclerosant

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19
Q

Management of bleeding varices

A

o Resuscitation
o Vasopressin analogues (terlipressin) = vasoconstriction and slow bleeding
o Coagulopathy with Vit K and fresh frozen plasma
o Prophylactic broad spectrum Abx (cephalosporin)
o Intubation and intensive care
o Urgent endoscopy
o Sengstaken-Blakemore tube if uncontrolled
o Transjugular Intrahepatic Portosystemic Shunt

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20
Q

Causes of liver failure

A
  • Viral = Hep B, C, CMV, cytomegalovirus, EBV, herpes simplex
  • Drugs = Paracetamol, alcohol, anti-depressants, NSAIDS, cocaine, Abx
  • Hepatocellular carcinoma
  • Wilson’s disease or A1A deficiency
  • Acute fatty liver of pregnancy
  • Budd-chiari syndrome
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21
Q

Presentation of liver failure

A
  • Bruising
  • Fever
  • Vomiting
  • Jaundice
  • Signs of hepatic encephalopathy
  • Fetor hepaticus = smells like pear drops
  • Clubbing
  • Dupuytren’s contracture
  • Ascites (rare)
  • Spasticity and hyper-reflexia
  • Plantar response remain flexor until late
  • Hypertension
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22
Q

Signs of hepatic encephalopathy

A

I = altered mood/behaviour, sleep disturbance, dyspraxia
II = increasing drowsiness, confusion, slurred speech, liver flap, inappropriate behaviour/personality change
III = incoherent, restless, liver flap, stupor
IV = coma

23
Q

Bloods in liver failure

A

o High serum ALT and AST, bilirubin
o Low levels of coagulation factors and raising prothrombin time
o Low glucose
o Ammonia levels high
o CMV and EBV serology
o Paracetamol levels

24
Q

Imaging in liver failure

A

o Abdo Ultrasound = liver size and liver pathology
o Electroencephalogram = grading
o CXR
o Doppler ultrasound to see hepatic vein patency

25
Q

Management of liver failure

A
  • Treat cause
  • Paracetamol poisoning = N-acetyl cysteine
  • Monitor glucose levels and administer IV glucose if necessary
  • Signs of raised intracranial pressure = IV mannitol
  • Mineral supplements = calcium, potassium, phosphate
  • Coagulopathy = IV Vit K, platelets, blood/fresh frozen plasma
  • Reduce haemorrhage risk = PPI (lansoprazole) to reduce GI bleeds
  • Prophylaxis against bacterial and fungal infection
  • Urinary and central venous catheters
  • Liver transplant
26
Q

Complications of liver failure

A
  • Sepsis
  • Hypoglycaemia
  • GI bleeds/varices
  • Encephalopathy
  • Cerebral oedema
  • Ascites
27
Q

Risk factors for hepatocellular carcinoma

A
  • Chronic hepatitis B and C
  • Alcohol cirrhosis
  • Non-alcoholic fatty liver disease
  • Haemochromatosis
  • Primary biliary cirrhosis
  • Alpha-1 antitrypsin deficiency
  • Hereditary tyronsinosis
  • Glycogen storage disease
  • Aflatoxin
  • Drugs: oral contraceptive pill, anabolic steroids
  • Diabetes mellitus
  • Metabolic syndrome
28
Q

Presentation of hepatocellular carcinoma

A
  • Asymptomatic for long time and presents late
  • Features of liver cirrhosis  jaundice, ascites, RUQ pain, hepatomegaly, pruritus, splenomegaly
  • Weight loss
  • Anorexia
  • Nausea and vomiting
  • Fatigue
  • Ascites
  • Enlarged, irregular, tender liver
29
Q

Tumour marker for hepatocellular carcinoma

A

Alpha-fetoprotein (AFP)

30
Q

Imaging investigations for hepatocellular carcinoma

A
  • Liver ultrasound and biopsy
    o Biopsy avoided due to seeding
  • CT and MRI = diagnosis and staging
31
Q

Management of hepatocellular carcinoma

A
  • Surgical resection of isolated lesion in early disease
  • Liver transplant is only chance for cure
  • Radiofrequency ablation
  • Transarterial chemoembolisation
  • Kinase inhibitors (sorafenib, regorafenib, lenvatinib) = inhibit proliferation of cells
  • Palliative care
32
Q

What is hereditary haemochromatosis?

A

Inherited disorder (autosomal recessive) of iron metabolism and storage that results in excessive total body iron and deposition of iron in tissues

33
Q

Risk factors for haemochromatosis

A

Alcoholic

34
Q

Presentation of haemochromatosis

A
  • Early Sx  fatigue, erectile dysfunction, arthralgia (often hands)
  • Memory and mood disturbance
  • Bronze/slate-grey skin pigmentation
  • Hair loss
  • Hepatomegaly
  • Hypogonadism = amenorrhoea and erectile dysfunction
35
Q

Investigations for haemochromatosis

A
  • Raised serum iron and ferritin, Transferrin
  • Low total iron binding capacity
  • Genetic testing
  • MRI = Detects iron overload
  • Liver biopsy w/ Perl’s stain  establish extent of tissue damage and disease severity
36
Q

Management of haemochromatosis

A
  • Venesection = regular removal of blood (weekly)
    o Monitor serum ferritin and transferritin
  • Avoid alcohol
  • Diet low in iron (Avoid fruit/fruit juice and white wine)
  • Desferrioxamine (2nd line)
  • Screening = All first-degree relatives
37
Q

Complications of haemochromatosis

A
  • Type 1 diabetes
  • Liver cirrhosis
  • Iron deposits in pituitary and gonads = endocrine and sexual problems
  • Cardiomyopathy
  • Hepatocellular carcinoma
  • Hypothyroidism
  • Chrondocalcinosis/ pseudogout
38
Q

What is Wilson’s disease?

A

Inherited disorder (autosomal recessive) causing excessive accumulation of copper in body and tissues (liver and CNS)

39
Q

Presentation of Wilson’s disease

A
  • Reduced memory
  • Chronic hepatitis  cirrhosis
  • Dysarthria = speech difficulties
  • Dystonia = abnormal muscle tone
  • Parkinsonism (tremor, bradykinesia, rigidity)
  • Asymmetrical motor symptoms
  • Mild depression to full psychosis
  • Kayser-Fleischer rings in cornea
  • Haemolytic anaemia
  • Renal tubular damage  renal tubular acidosis
  • Osteopenia
  • Blue nails
40
Q

Investigations of Wilson’s disease

A
  • Serum caeruloplasmin = low
  • Liver biopsy = increased hepatic copper
  • 24 hour urine copper assay elevated
  • MRI = basal ganglia and cerebellar degeneration
  • Slit lamp examination for kaiser-fleisher rings
  • Genetic analysis of ATP7B gene
41
Q

Management of Wilson’s disease

A
  • Copper chelation (penicillamine/trientene)
  • Avoid foods high in copper = chocolate, nuts, mushrooms
  • Liver transplant
  • Screen siblings
42
Q

Side effects of copper chelation

A

skin rashes, fall in WCC/Hb/platelets, haematuria, renal damage

43
Q

What is alpha-1-antitrypsin deficiency

A

Inherited autosomal recessive condition where deficiency of A1A causes excess of protease enzymes that attack liver and lung tissue and cause liver cirrhosis and lung disease

44
Q

Presentation of A1AD

A
  • Liver cirrhosis after 50 years old
  • Pulmonary basal emphysema after 30 years old
45
Q

Investigations of A1AD

A
  • Serum A1A levels low
  • Liver biopsy = cirrhosis and acid-Schiff-positive staining globules
  • Genetic testing
  • High res CT thorax = pulmonary emphysema
46
Q

Management of A1AD

A
  • Stop smoking
  • Symptomatic treatment and monitor complications
  • Organ transplant
47
Q

Complications of A1AD

A

Hepatocellular carcinoma

48
Q

Associations of autoimmune hepatitis

A
  • Other autoimmune disorders
  • Hypergammaglobulinaemia
  • HLA B8
  • DR3
49
Q

Presentation of autoimmune hepatitis

A
  • Signs of chronic liver disease
  • Acute hepatitis: fever, jaundice
  • Amenorrhoea
50
Q

Investigations of autoimmune hepatitis

A
  • ANA/SMA/LKM1 antibodies
  • Raised IgG levels
  • Liver biopsy  inflammation extending beyond limiting plate ‘piecemel necrosis’, bridging necrosis
51
Q

Management of autoimmune hepatitis

A
  • Steroids
  • Other immunosuppressants (azathioprine)
  • Liver transplantation
52
Q

Indications for transjugular intrahepatic portosystemic shunt (TIPSS)

A

Oesophageal variceal bleeding
Refractory ascites
Budd-Chiari syndrome

53
Q

Complications of TIPSS

A

Hepatic encephalopathy

Finals (23 decks)

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