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Liver Flashcards

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1
Q

Which transaminase is more specific for liver damage?

A

ALT

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2
Q

Raised levels, what do these ratios indicate?
AST:ALT = 1

AST:ALT > 2.5

AST:ALT < 1

A

Ischamia

Alcoholic hepatitis

Hepatocellular damage e.g. viral hepatitis, pcm OD

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3
Q

Raise ALP and GGT?

A

cholestasis

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4
Q

Sensitive to alcohol ingestion?

A

GGT

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5
Q

Inherited causes of liver disease?

A

hereditary haemochromatosis [deficiency of hepcidin]

Wilson’s disease [deficiency of caeruloplasmin –> excess copper in tissues]

Alpha-1 antitrypsin deficiency [affects liver and lungs]

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6
Q

Gene in hereditary haemochromatosis?

How is it inherited?

A

HFE

Autosomal recessive

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7
Q

Mech in hereditary haemochromatosis?

A

increased intestinal absorption of iron –> accumulated in tissues

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8
Q

Sx of hereditary haemochromatosis?

A

Presents 40-50yo

Early; fatigue, weakness, arthralgia, ED

Late; skin bronzing, DM, cirrhosis, impotence, arrhythmias

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9
Q

Ix in hereditary haemochromatosis?

A 
Iron studies [high ferritin, transferrin saturated, serum iron high]
HFE genetic test
LFTs
MRI liver 
Liver biopsy with Perl's stain
ECG
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10
Q

Serum ferritin not specific?

A

acute phase protein

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11
Q

mx of hereditary haemochromatosis?

A

Venesection weekly
Monitor ferritin
low iron diet
+/- liver transplant

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12
Q

Wilson’s genetics?

A

ATP7B gene

autosomal recessive

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13
Q

Mech in Wilson’s - where is copper deposited?

A

Disorder of biliary excretion [cant get copper into caeruloplasmin]

liver, basal ganglia

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14
Q

ix in wilsons?

A

copper studies
slit lamp - KF rings
liver biopsy
MRI - basal ganglia

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15
Q

mx of wilsons?

A

penicillamine
zince reduces copper absorption
low copper diet [avoid mushrooms, liver, chocolate, nuts]
monitor liver, renal function, FBC, clotting
avoid alcohol + hepatotoxic drugs

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16
Q

pres of wilsons?

A

young adult with liver abnormalities or movement disorder
Kayser-Fleischer rings in 95%

severe depression +/- parkinsonian sx

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17
Q

organs affected in A1AT deficiency?

A

Lung –> dyspnoea, wheeze, cough

Liver –> hepatitis, cirrhosis, fibrosis

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18
Q

Ix in A1AT?

A

Phenotyping
CXR, spirometry
LFT, biopsy

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19
Q

Mx of A1AT?

A

avoid smoking / alcohol
mx of COPD
monitor LFTs, cirrhosis, screen for HCC

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20
Q

Characteristics of liver failure? (4)

A

hepatic encephalopathy
jaundice
abnormal bleeding
ascites

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21
Q

Ddx of liver failure?

A 
paracetamol, alcohol, other medications
viral hepatitis, EBV, CMV
HCC
inherited
ischaemia, budd-chiari
autoimmune
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22
Q

hepatic encephalopathy pathophys?

A

ammonia build up; crosses BBB; astrocytes clear this by turning glutamate to glutamine

Glutamine causes fluid shift into cells –> cerebral oedema

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23
Q

Signs of chronic liver disease?

A 
caput medusae
clubbing
leukonychia
asterixis
palmar erythema
spider naevi
shifting dullness
abnorm bleeding
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24
Q

drug used in paracetamol OD?
what time frame?
what can you use in first hour of ingestion instead?

A

N-acetylcysteine within first 8h

first hour –> charcoal

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25
mx of high ammonia
lactulose + neomycin
26
mx of raised ICP
mannitol
27
mx of ascites
fluid + salt restrict diuretics paracentesis human albumin solution
28
ascites?
fluid in peritoneal cavity
29
cause of ascites?
75% - cirrhosis (decreased albumin + portal HTN) malignancy - GI, ovarian (Meigs) HF Nephrotic syndrome
30
ix in ascites
abdo USS CXR LFT shifting dullness (present if 1500ml)
31
signs in spontaneous bacterial peritonitis?
guarding rebound tenderness pain on palpation
32
ix in spontaneous bacterial peritonitis
FBC, LFT, U+Es, blood cultures paracentesis for MC+S (and amylase) imaging
33
organisms causing spontaneous bacterial peritonitis
E. coli, enterococci
34
mx of spontaneous bacterial peritonitis
IV ceftriaxone
35
End stage liver failure can develop 'hepatorenal syndrome' 2 types + prognosis? Mx?
type 1 = rapid (survival of 2 weeks) --> terlipressin with albumin type 2 = last 6 months --> TIPS General mx --> admit to HDU, monitor fluids, stop nephrotoxic drugs, +/- transplant
36
pres of advanced/decompensated cirrhosis?
``` oedema ascites bruising poor memory bleeding varices ```
37
cutaneous signs of cirrhosis
``` FLAPS finger clupping leukonychia asterixis palmar erythema spider naevi/scratch ``` + jaundice, dupuytren's
38
causes of portal HTN
pre-hepatic [thrombosis, extrinsic compression] hepatic [cirrhosis, hepatitis, schistosomiasis, granuloma] post hepatic [budd-chiari, HF]
39
mx of cirrhosis? monitoring?
nutrition, alcohol abstinence monitor for varices & HCC
40
ix in portal HTN?
``` AUSS doppler USS Spiral CT endoscopy portal pressure [normal<5, varices>10] ```
41
mx of portal HTN
BBs, nitrates | TIPS
42
1 prevention of varices in portal HTN
propanolol
43
ix in varices
endoscopy clotting, group+save, cross match
44
mx in varices
terlipressin oesophageal -> band ligation gastric -> endoscopic injection of N-butyl2cyanoacretate (basically glue)
45
surgical mx of varices
TIPS
46
Pres of sudden RUQ pain + rapidly developing ascites [hepatomegaly + jaundice + renal involvement] dx? ix?
Budd-Chiari syndrome (occlusion of the hepatic veins) Doppler US
47
Mx of budd chiari?
treat ascites eg TIPS if due to thrombosis --> warfarin
48
cause of liver Ca?
10% primary rest are from stomach, colon, lung, breast
49
cause of primary HCC?
Hep C
50
blood marker of HCC?
AFP
51
liver Ca prevention?
HBV vaccine alcohol abstinence screening in high risk {HBV, HCV, cirrhosis)
52
cause of fatty liver?
metabolic syndrome PCOS alcohol HBV/HCV
53
ix in fatty liver
biopsy - cells swollen with fat
54
mx fatty liver
no alcohol wt loss + exercise mx of cause
55
steatohepatitis LFTs?
AST + ALT raised | ALT > AST
56
histology of acute hepatitis? chronic?
lobular disarray, inflam cell infiltrate, necrosis, bile duct prolif lymphoid follicles at portal tract
57
Hep A incubation? spread?
2-6 weeks | faeco-oral
58
Hep A ix
HAV IgM - acute | HAV IgG - lasts years
59
Hep A Mx? for itch?
fluids, antiemetics, rest, avoid alcohol cholestryamine
60
what dissolves gall stones?
ursodeoxycholic acid
61
Hep B incubation? spread?
60-90d parenteral, sexual
62
HBsAg? HBsAb? when are they found?
HBsAg found at current infection HBsAb indicates immunity post infection/vaccine
63
Ix in Hep B? screening?
PCR HBV viral serology FBC, LFT, clotting, ferritin, caeruloplasmin Screen for HCC (USS, AFTP) + other BBVs
64
prevention of Hep B?
blood screening safe sex vaccines
65
complications of Hep B?
hepatic failure cirrhosis HCC concurrent HCV/HIV
66
mx of Hep B
48week course of injectable pegylated interferon alpha
67
Hep C incubation? spread?
6 weeks blood
68
Sx of Hep C?
85% asympto more likely to develop chronic
69
ix in Hep C? screen?
HCV serology PCR HCV RNA LFTs HIV, HBV HCC (USS, AFP)
70
mx of Hep C?
24 weeks of weekly pegylated interferon alpha + daily ribavirin
71
types of autoimmune hepatitis?
75% type 1: ANA, ASMA 25% type 2: ALKM-1, anti-LC-1
72
Ix in AI hepatitis
``` liver biopsy LFT IgG serum protein electrophoresis FBC ```
73
mx of AI hepatitis? monitoring? vaccines?
prednisolone+azathioprine 6m USS+AFP, liver biopsies Hep A/B vaccines
74
ix in liver abscess?
FBC, ESR, LFT, blood cultures, stool MC+S, USS/CT liver aspiration + culture
75
mx of liver abscess?
abx+drainage+fluids+pain relief pyogenic --> IV ceftriaxone+metronidazole amoebic-->metronidazole
76
causes of acute pancreatitis
GETSMASHED | gallstones, alcohol, trauma, steroids, mumps, AI, scorpions, hyperlipidaemia/hypercalcaemia, ERCP, drugs
77
acute pancreatitis pathophys?
acute inflam --> release of exocrine enzymes --> autodigestion
78
signs of acute pancreatitis?
``` Cullen's (periumbilical bruising) Grey-Turner's (flank bruising) Epigastric tenderness+rigidity tachycardia, fever, hypoxaemia jaundice if due to gallstones/alcohol ```
79
ix for pancreatitis?
``` serum amylase, serum lipase FBC, CRP LFT CT w contrast USS ERCP ```
80
DDx of acute pancreatitis?
ruptured aortic aneurysm
81
pancreas severity score?
glasgow score - PANCREAS ``` PaO2 < 8kPa Age > 55 Neutrophillia; WCC > 15 Calcium < 2mmol/L Renal; urea > 16mmol/L Enzymes; AST/ALT>200 Albumin < 32g/L Sugar > 10mmol/L ```
82
mx of acute pancreatitis
pain relief IV fluids NBM repeat glasgow score + obs
83
comps of acute pancreatits
early [pulm oedema, shock, DIC, renal dysfunction, haemorrhage] late [necrosis, abscess, pulm oedema, cyst]
84
pres of chronic pancreatits
``` alcohol.. epigastric pain relieved by sitting fwd N+V exocrine dysfunction [malabsorp, wt loss, steatorrhoea] endocrine dysfunction [DM] ```
85
mx of chronic pancreatitis
pain relief replace enzymes low fat diet alcohol abstinence
86
type of pancreatic Ca?
infiltratnig ductal adenocarcinoma
87
gene in endocrine pancreatic Ca?
MEN1
88
who gets gallstones?
fair, fat, fertile, female, forty
89
dx for gallstones? ix? when do they get jaundice?
USS is diagnostic urinalysis, CXR, ECG for exclusion jaundice when stone moves to CBD
90
pres of biliary colic
RUQ pain
91
pres of acute cholectystitis
RUQ pain + fever/WCC
92
pres of ascending cholangitis
RUQ pain + fever/WCC + jaundice | Charcot's triad
93
positive murphy's sign =
RUQ, 2 fingers, breathe in, halts inspiration, negative on LUQ
94
USS of acute cholectystitis
thickened GB wall + fluid/air in GB | CBD diameter > 6mm
95
ix for acute cholectystitis
``` murphys USS ERCP LFT Bloods ```
96
mx of gallstones, colic, acute cholecystitis
NBM pain relief IV fluids consider IV ceftriaxone +/- surgical --> laparoscopic cholecystectomy
97
Reynold's pentad of ascending cholangitis
RUQ + fever + jaundice + altered mental state + hypotension Infection of bile duct
98
ix in ascending cholangitis
WCC, ESR, CRP, LFTs worry about sepsis, pancreas and AKI -> U+E,s amylase, blood cultures imaging --> USS, contrast CT, MRCP
99
mx of ascending cholangitis
EMERGENCY O2 + IV fluids + BC + IVabx [metronidazole+ceftriaxone] emergency biliary drainage if AKI, shock, DIC..
100
comps of ascending cholangitis
``` septic shock AKI systemic dysfunciton liver abscess liver failure ```
101
primary sclerosing cholangitis?
chronic inflam + fibrosis --> multifocal biliary strictures presents 10-30yo male linked to IBD
102
ix in primary sclerosing cholangitis
LFT, bilirubin p-ANCA (linked to IBD) MRCP / USS biopsy
103
seen on biopsy of primary sclerosing choangitis
periductal onion skin fibrosis
104
which vitamins do you give in cholestatic disorders?
DEAK
105
mx of primary sclerosing cholangitis? itch? prevent progression?
treat strictures with balloon dilation Cholestyramine for itch ursodeoxycholic acid + avoid alcohol
106
primary biliary cirrhosis? assos with?
progressive AI disease --> destruction of interlobular bile ducts presents 40-60 female sjogrens
107
ix in PBC/
Biopsy - granulomatous ``` AMA TFT USS MRCP FBC, LFT ```
108
Mx of PBC?
ursodeoxycholic acid slows progression immunosuppression: MTX, steroids
109
what promotes cholestasis?
oestrogen | COCP
110
Bloods in cholestasis?
elevated bilirubin elevated alk phos elevated GGT low albumin in chronic
111
liver failure worry with hypoK and hypoMg
Torsade de pointes --> VF
112
signs of decomp liver failure
encephalopathy ascites asterixis hepatorenal syndrome
113
blood supply to liver
80% hepatic portal vein | 20% hepatic artery
114
portal HTN > what?
>5mmHg | >10 is severe
115
what does NO do in kidney due to liver failure
causes constriction --> hepatorenal syndrome [dilation everywhere else in body]
116
blood tests specific for liver problemos?
albumin bilirubin PT
117
look for in ascitic tap?
polymorphs - sign of spontaneous bacterial peritonitis
118
isolated rise in ALP
bony mets, vit D deficiency, fracture, osteodystrophy
119
HBeAg
sign of active replication
120
HBeAb
sign of current clearing of infection [disappears after beating infection]
121
IgM
infection at the Moment
122
IgG
after it is Gone
123
Worry in Crohns? | worry in UC?
Crohns - small bowel obstruction | UC - toxic megacolon
124
treatment of Hep B?
pegylated interferon alpha tenofovir / entecavir difficult to clear the virus as it is a DNA virus
125
treatment of Hep C?
AIM TO CURE

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