1. NO ALCOHOL - corticosteroids may be used in acute inflammation - ?transplant

Decrease salt intake NO NSAIDS 1. spironolactone 2. furosemide - loop diueutics Paracentesis - drain

Liver Flashcards by Olivia Wood

A AST:ALT ratio of >2 is indicative of…

Alcoholic liver disease

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ALT > AST

Chronic liver disease

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What defines chronic liver disease?

> 6mths

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What are the two types of cirrhosis and describe the differences?

Give 10 clinical signs of cirrhosis

Compensated - asymptomatic
Decompensated - symptomatic

Ascietes
Jaundice
Spider naevi 
Splenomegaly 
Palmar Erthyema
Hepatomegaly 
Gynecomastia
Varices - (in paticular caput medusa) 
Clubbing
Easy bruisinig

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What cell activates by injury to cause fibrosis and eventually cirrhosis?

Hepatic stellate cells

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What are the two types of NAFLD (non-alcoholic fatty liver disease)

NAFL - steatosis (fatty acid build up in cells)

NASH - non-alcoholic steatohepatitis (more serious)
- steatosis + Inflammation and scarring

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Fibrosis isn’t reversible. true or false?

True

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When would we suspect NAFLD?

Abnormal USS or deranged LFTs >3mnths

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How do you treat NAFLD (both NASH and NAFL)?

Weight loss

Exercise

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Why do we worry more about NASH?

Risk of progression to cirrohosis

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What are mallory bodies and in what condition do we find it?

What condition is associated with ballooning degeneration (a form of apoptosis which causes hepatocellular swelling)?

NASH - steatohepatitis
ALD (most commonly)

Damaged intermediate filaments in hepatocytes

NASH - ballooning

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In alcoholic liver disease what causes the damage/fibrosis?

Acetaldehyde (metabolite of alcohol)

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Microscopic differences between fatty liver, alcoholic hepatitis, alcoholic fibrosis and cirrhosis

Fatty liver - fat vacuoles

Hepatitis - hepatocyte necrosis, neutrophils, MALLORY BODIES, fibrosis beginning

Fibrosis - COLLAGEN laid down around cells

Cirrhosis - BANDS OF FIBROSIS separating regeneration nodules of hepatocytes

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Important questions with liver disease

Alcohol consumption (how much and how long)
Travel
Risk behaviour
Any over the counter/herbal

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Treatment of ALD?

NO ALCOHOL

corticosteroids may be used in acute inflammation
?transplant

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‘Speckled’ liver

Cardiac cirrhosis (due to R sided heart failure causing hepatic congestion)

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How do you diagnose cirrhosis?

Biopsy which will show:

Regenerating nodules of hepatocytes
AND
Bands of fibrosis separating these nodules

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How is cirrhosis graded?

Child-Pugh score

A - well compensated
B - functional compromise
C - decompensated

MELD score - 3 month mortality

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What score is used to see if someone qualifies for transplant?

UKELD score

UK score for end stage liver disease

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What is portal hypertension and what does it result from?

increase of hydrostatic pressure within portal vein or tributaries

Increase resistance to portal flow
Increase portal venous inflow

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How does ascites occur (in relation to liver disease)?

Cirrhosis causes increases hydrostatic pressure in splanchci vessels -> release NO (vasodilate) -> decreased blood vol -> baroreceptors in kidneys activate RAAS -> sodium and water retention -> decreased osmotic pressure (from decreased albulium) -> liquid in peritoneum

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Signs of ascites?

Huge stomach
Shifting dullness (due to liquid)

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Treatment of ascites

Decrease salt intake
NO NSAIDS

spironolactone
furosemide - loop diueutics

Paracentesis - drain

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Hepatorenal syndrome

Kidney failure in those with severe liver damage

RAAS activation causes renal vasoconstriction (to try fix vasodilator)

late complication of decompensated cirrhosis/ascietes

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Acute liver failure definiton Clinical features of acute liver failure How do you treat it?

(Any insult to liver causing damage in previously normal liver) Defined as causing encephalopathy and impaired protein synthesis Classic jaundice etc. N+V & anorexia Rest = 3-6mnths recovery + monitor

Paracetamol and liver

Glutathione stores breakdown reactive TOXIC intermediate NAPQ1 into cysteine acid conjugates

How do you treat paracetamol overdose?

Acetlycysteine - replenishes glutathione stores

Diagnostic feature of hydatid cyst?

Daughter cysts of the periphery (appears as dark mark on CT)

What is the most common liver tumour in non-cirrhotic patients?

Haemanginoma Most often asymptomatic and seen on autopsy

Metastatic cancer is more common than primary live cancer in the absence of liver disease. True/False?

True

How is haemanginoma seen on US?

Well demarcated echogenic spot

Describe the typical appearance of focal nodular hyperplasia?

Central scar with a large artery and radiating branches to the periphery

Describe the histological differences between focal nodular hyperplasia and hepatic adenoma?

FNH - made up of hepatocytes + bile ducts + sinusoids + KUPPFER CELLS Hepatic adenoma - just hepatocytes

What two drugs is hepatic adenoma associated with?

Anabolic steroids (common in bodybuilders) The pill

Hepatic adenoma is more common in what sex? In what sex is it more likely to become maligant?

Females Males

Focal nodular hyperplasia has the potential to become malignant. True or false?

False

How would you treat hepatic adenomas?

Males - always surgical removal Females >5cm - surgery <5cm - annual MRI

Primary liver tumours are more common than secondary liver tumours. True or false?

False Most liver tumours come from colon mestastes - (think portal system)

What is the tumour marker used for HCC?

Alpha feto protein (AFP) (>400mg) | must not be diagnosed on this purely - some tumours do not increase levels

Patient with HCC may present with ascietes. True or false?

True

What is the first line of treatment in HCC?

Resection followed by transplant

What drug can be administered in HCC as a last resort to increase life by months?

Sorafebnib | kinase inhibitor -> inhibits proliferation of cancer cells

What is the macroscopic difference between ALD and NASH?

There is none The difference is made on a history of patients alcohol consumption

What is the difference between diagnosis of the two forms of non-alcoholic liver disease?

NAFL - USS NASH - liver biopsy

What is micronodular cirrhosis associated with?

Alcoholic liver disease - ALD

What liver carcinoma is more common in younger patients, will not cause a rise in AFP and on CT will show stellate scar with radial septa showing persistent enhancement?

Fibro-lamellar carcinoma

How do you investigate for liver cysts?

What can cause hydatid liver cysts? How must be looked out for on US as a diagnostic tool? How is it managed?

Echinococcus granulosus (tape worm) -> associated with live stock Daughter cysts (buzzword) Surgery - most common

What causes polycystic liver disease? Name the 3 types

Embryonic ductal plate malformation -> malformation of bile ducts -> numerous cysts throughout liver Von Meyenburg Complexes - completely benign and asymptomatic ADPKD (autosomal dominant polycystic kidney disease) - can have maifestations in liver Polycystic liver disease - genetic disease - more of a problem

How is polycystic liver disease managed?

Aim is to halt cyst growth Most commonly - somatostain analogue - sandostatin (reduces liver volume) Surgery/transplant if very symptomatic

What can cause abscess formation in liver? How does it present? How do you investigate? How do you treat?

Pus forming cysts E.coli, klebsellia and step milleri (most common) ``` Nausea and vomiting Jaundice Abdo pain ~malaise for several months (v similar to ascending cholangitis) Hepatomegaly ``` US/aspiration - diagnose CT - for more complex Broad spectrum IV antibiotics Aspirate for more specific antibiotic treatment 4 weeks of antibiotic treatment afterwards

What is haemochromatosis? What gene and chromosome is the abnormality found on? What kind of inheritance? Describe classic presentation How is it diagnosed? How is it managed?

Excess iron deposits in organs in paticular liver HFE - chromosome 6 - autosomal recessive Bronzed diabetic - Diabetes mellitus - Bronze skin pigmentation - Hepatomegaly Measure serum ferritin (iron) Venesection - remove excess iron

What is Wilson's disease? How does it present? Investigate? How is it managed?

Autosomal recessive disorder causing reduced ceruloplasmin (copper transporter) Kaysler-Fleisher rings Liver disease Increase in urinary copper reduced serum copper PENICILLAMINE

Where is most copper deposited in the brain in a patient Wilson's disease?

Basal ganglia

What should be suspected in young females taking oral contraceptive with deranged LFTs? What causes it?

Autoimmune hepatitis T cells directed against hepatocyte surface antigens

How do you investigate and diagnose autoimmune hepatitis?

Raised LFTs ASMA and ANA +ve - type 1 LKM +ve - type 2 Liver biopsy

How do you manage autoimmune hepatitis

Corticosteroids + azathioproine

What is spontaneous bacterial peritonitis? How is it diagnosed? How is it treated?

Bacterial infection in the peritoneum NEUTROPHILS in tap will be >250 - important Co-trimaxazole

What is hepatic encephalopathy? How does it present? How is it treated?

Increased ammonia in blood (highly toxic) LIVER FLAP Confusion Drowsiness General mental disfunction Lactulose Antibiotics e.g. rifaximin (supress colonic flora)

What are ASMA antibodies associated with? | What are AMA antibodies associated with?

``` ASMA = autoimmune hep AMA = PBC ```

Liver Flashcards

(60 cards)