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Flashcards in Liver Deck (27):
1

Ligaments of the liver

Falciform ligament: Attaches anterior surface of the liver to the anterior abdominal wall
Coronary & triangular ligaments: Attaches superior surface to the diaphragm

2

Hepatic recesses (spaces)

Suphrenic: Either side of falciform ligament between diaphragm and liver
Subhepatic: Between interior surface of liver and transverse colon
Morison's pouch: Between right kidney and liver. Most commonly where fluid collects when patient is bedridden.

3

Four lobes of the liver

Right lobe and left lobe separated by by falciform ligament
Caudate lobe: Between IVC and fossa formed by ligament venosum (a remnant of the fetal ductus venosus)
Quadrate lobe: Between gall bladder and fossa formesd by ligament teres (remnant of fetal umbilical vein)

4

Portal Triad

Arteriole: Branch of hepatic artery entering liver
Venule: Branch of hepatic portal vein entering liver
Duct: Branch of bile duct leaving the liver

5

Liver nerve innervation

Parenchyma: hepatic plexus (sympathetic: coeliac plexus, parasympathetic: vagus nerve)
Glisson's capsule innervated by the branches of lower intercostal nerves.

6

Hepatitis A virus

small, unenveloped, symmetrical RNA virus (picornavirus).

7

Route of transmission for Hep A

Most ccommonly foecal-oral. Can be by IV drug use

8

Pathophysiology of Hepatitis A

HAV is taken up by hepatocytes
Viral RNA uncoats binds to ribosomes to form polysomes
Utilises RNA polymerase to replicated RNA
Assembled viruses is shed via billary tree into faces

9

Most common form of acute viral hepatitis worldwide

Hepatitis A

10

Highest areas of risk for HAV

Indian subcontinent, Africa, Far east (except japan), Middle east, south and central america

11

Risk factors of HAV

Personal contact.
Certain occupations (for example, staff of large residential institutions, sewage workers).
Travel to high-risk areas.
Male homosexuality with multiple partners.
Intravenous drug abuse.
People with clotting factor disorders who are receiving factor VIII and factor IX concentrates

12

Signs and symptoms of HAV

Fever
Malaise
Nausea & Vomiting
Jaundice
Hepatomegaly
RUQ pain
Acholic stool (clay-coloured)
Headache
Dark urine
Pruritus

13

Investigations for HAV

IgM anti-hepatitis A virus: Usually detected within 5-10 days before onset of symptoms and stays positive for 4-6 months
IgG anti-hepatitis A virus: Starts soon after IgM and lasts for years. In absence of IgM indicated a previous infection or vaccination
LFTs: AST rises more than ALT.
Urea & Creatinine may be elevated

14

Management of HAV

Supportive:
Fluids
Anti-emetics
Rest
Avoid alcohol

15

Hepatitis B virus (HBV)

Double stranded DNA virus (hepadnavirus)

16

Route of transmission of HBV

Percutaneous
Permucosal route
Sexually traansmitted

17

Most common cause of hepatitis

Hepatitis B

18

Pathophysiology of Hepatitis B

HBV enters cell
Core particle enters nucleus
Strand synthesis repaired to form covalently closed circular DNA
Use reverse transcription and forms RNA for translation

19

Signs and symptoms of HBV

70% asymptomatic. They may have flu-like symptoms
jaundice

20

Investigation of HBV

HBsAg, HBeAg, anti-HBe, anti-HBs, anti-HB core.
Quantitative hepatitis B virus DNA.
HBV genotype (for those considered for interferon).
Hepatitis delta virus (HDV) serology.
General liver investigations
FBC.
Bilirubin.
Liver enzymes.
Clotting.
Ferritin.
Lipid profile.
Autoantibody screen.
Caeruloplasmin.

21

Causes of fatty liver disease

Alcohol
HTN
Dyslipidaemia
TPN
Polycystic ovary syndrome
Starvation or rapid weight loss (gastric bypass surgery)
Hep B, Hep C
Amiodarone
Tamoxifen
Glucocorticoids
Tetracycline
Oestrogens
Methotrexate
Thallium
Metabolic disorders

22

Presentation of fatty liver disease

Fatigue
Malaise
Hepatosplenomegaly
Truncal obesity
Tends to be picked up on LFTs

23

Investigations to order if suspecting fatty liver disease

Biopsy is the only definitive test

ALT and AST raised (in NAFLD AST:ALT ratio <1 in AFLD >2)
Bilirubin, ALP, gGGT elevated
FBC (anemia due to hypersplenism)
U&Es abnormal
INR raised
Serum albumin decreased

<20 g of alcohol per day in women and <30 g in men is usually used to allow a diagnosis of NAFLD

24

Management of fatty liver disease

Diet
Exercise
Bariatric surgery is obese

25

Liver cirrhosis

Chronic Hepatitis C (most common in western worlds)
Chronic Hepatitis B
Alcoholic liver disease
Biliary obstruction
Metabolic disorders
Hepatotoxic medication
Haemochromatosis

26

Presentation of liver cirrhosis

Abdominal distention
Jaundice and pruritus
Melaena ( decompensated cirrhosis secondary to GI haemorrhage from gastro-oesophageal varices in portal HTN)
Leukonychia, palmar erythema, spider angiomata
Telangiectasia (red focal lesions, blood vessel dialation)
Parotid gland swelling
Jaundice

27

Investigations to order if suspecting liver cirrhosis

LFTs deranged
gGGT elevated
Albumin, Sodium, platelet count reduced
Viral screen
MRI/CT
Liver biopsy