Liver

Question 1

Bilirubin pathway

Answer 1

Erythrocyte

Heme

Bilirubin

Bilirubin (conjugated)

Question 2

Types of jaundice

Answer 2

Pre-hepatic

Hepatic

Post- hepatic

Question 3

Extrahepatic biliary obstruction

Answer 3

Dilated common bile duct on ultrasound

Gallstones, cancer of pancreatic head, stricture

Question 4

Intrahepatic obstruction

Answer 4

Cholestasis

Question 5

Causes of acutely inflamed liver

Answer 5

Drug induced- flucloxacillin

Alcoholic hepatitis- acute on chronic

Virus- hepatitis A, B, E, CMV, EBV

Autoimmune

PBC

Question 6

Unconjugated hyperbilirubinaemia vs conjugated hyperbilirubinaemia

Answer 6

Determined through bloods

Question 7

Level of bilirubin to be visibly jaundice

Answer 7

> 50

Question 8

Signs of chronic liver disease

Answer 8

Liver flap

Splenomegally

Palma erythema

Ascites

Gynaecomastia

Spider nivae

Caput medussa

Question 9

Hepatitic enzymes

Answer 9

Transaminases

ALT/ GT

Question 10

Reasonable sign of excessive alcohol

Answer 10

Raised gamma GT

Question 11

Raised INR

Answer 11

Liver failure

Warfarin

DIC

Vitamin K deficiency

Question 12

Vitamin K deficiency

Answer 12

2,7,9,10 vitamin K dependent

Can’t be produced so INR increases

Bile needed to absorb fat, can’t come out of bile duct in bile stone so vitamin K deficiency

Question 13

Further blood tests

Answer 13

Hepatitis A ab
Hepatits C ab
Hepatitis BsAg

Autoantibodies

• antimitochondrial antibodies PBC
• anti-smooth muscle, anti nulcaer antibdoy - autoimmune hepatitis

Ferritin- hhaemochromotosis

Copper studies- Wilson’s disease

IgG- raised in autoimmune hepatitis

IgA- raised in alcoholic liver disease

IgM- raised in PBC

Question 14

Autoimmune hepatitis on liver biopsy

Answer 14

Fibrosis

Piecemeal necrosis

Ballooning and rosetting of hepatocytes

Preservation of bile ducts

Question 15

Treatment of autoimmune hepatitis

Answer 15

Immunosuppressants
- steroids- prednisolone

Introduce azathioprine

Question 16

Side effects of prednisolone

Answer 16

Osteoporosis

Diabetes

Cataracts

Question 17

Diagnosis of jaundice

Answer 17

History
Examination
Special investigations
- blood tests
- imaging
- biopsy

Question 18

History symptoms

Answer 18

Pruritis- cholestasis

Weight loss- cancer

Pain- obstructive (stones, cancer)

Fevers- (infection)

Lethargy- many liver diseases

Question 19

Risk factors for jaundice

Answer 19

Alcohol- alcoholic hepatitis

Viral hepatitis risks

• IVDU
• travel
• blood transfusions
• tattoos
• sexual history

Question 20

Routine liver tests

Answer 20

Bilirubin

ALT

AST - cardiac

ALP

GGT

Albumin - only useful if you know there’s liver disease

INR

Question 21

Fibroscan

Answer 21

Transient elastography

Measure of liver stiffness

Correlates with fibrosis

Question 22

Pathway of cirrhosis

Answer 22

Inflammation –>

Fibrosis –>

Cirrhosis

Question 23

Features of reduced metabolic capacity

Answer 23

Coagulopathy

Reuced albumin

Hypoglycaemia

Question 24

Features of portal hypertension

Answer 24

Ascites

Hypersplenism

Question 25

Compensated cirrhosis

Answer 25

No symptoms/ signs Normal LFTs Abnormal imaging Abnormal biopsy

Question 26

Decompensated cirrhosis

Answer 26

Unwell, jaundice, ascites Coagulopathy Low albumin Encephalopathy Abnormal LFTs Abnormal imaging

Question 27

Causes of cirrhosis

Answer 27

NAFLD Alcohol Drug induced VIral hepatitis Biliary disease Autoimmune liver disease

Question 28

Portal vein comes from

Answer 28

Splenic vein Inferior mesenteric vein Superior mesenteric vein

Question 29

Portal hypertension complications

Answer 29

Varices Hypersplenism Hepatic encephalopathy Ascites Hepatorenal syndrome

Question 30

Hypersplenism

Answer 30

Manifests as low platelets Thrombocytopenia

Question 31

Causes of low platelets

Answer 31

Autoimmune disease IDP Bone marrow failure Portal hypertension

Question 32

Varices

Answer 32

Pressure builds up in portal vein and is dissipated to porto-systemic collaterals Veins dilated, causing varices

Question 33

Hepatic encephalopathy

Answer 33

Blood not through liver to be detoxified Ammonia in systemic circulation through collaterals