Liver Flashcards
(104 cards)
1
Q
What are the functions of the liver?
A
- Clotting factor production
- Glycogen storage
- Protein synthesis
- Detoxification
- Bile production
- Glucose and fat metoblism
- Defense against infection- reticuloendothelial system
2
Q
What clotting factors are produced by the liver?
A
10, 9, 7, 2
3
Q
What causes acute liver injury?
A
- Alcohol
- Viral
- Drugs
- Obstruction
- Congestion
4
Q
What causes chronic liver injury?
A
- NAFLD
- Chronic alcoholism
- Viral Hepatits
- Iron overload
- Wilson’s disease
- Carcinoma
- Autoimmune
5
Q
How would acute liver injury present?
A
- Malaise, nausea, anorexia, jaundice
- Rarer= Confusion, bleeding, liver pain, hypoglycaemia
6
Q
How would chronic liver injury present?
A
- Ascites, oedema, haematemesis, malaise, anorexia, wasting, easy bruising, itching, hepatomegaly, abnormal LFT
- Rarer= Jaundice, confusion
7
Q
What are common LFTs?
A
- Serum bilirubin
- Albumin
- Prothrombin time
- Serum liver enzymes
8
Q
What causes unconjugated jaundice?
A
- Pre hepatic= Gilberts, haemolysis
9
Q
What causes conjugated jaundice?
A
- Hepatic= Liver disease
- Post hepatic= Obstruction
10
Q
How will pre-hepatic jaundice present?
A
Normal urine
Normal stool
No itching
Normal LFTs
11
Q
How will cholestatic (hepatic or post hepatic) jaundice present?
A
Dark urine
Pale stool
May have itching
Abnormal LFTs
12
Q
What investigations would be done in a patient who is jaundiced?
A
- V high AST/ALT ratio suggests liver disease
- Biliary obstruction: 90% have dilated intrahepatic bile ducts on ultrasound
- Further imaging: CT, MRI, ERCP
13
Q
How common are gallstones?
A
Very common
1/3 of women over 60
14
Q
What are risk factors for gallstones?
A
Female, fat, fertile
15
Q
What are gallstones generally made of?
A
70% Cholesterol
30% Pigment +/- calcium
16
Q
Where do gallstones most commonly form?
A
Within the gallbladder
17
Q
How would a symptomatic gallbladder gallstone present?
A
- “Biliary” pain
- Cholecystitis
- Maybe obstructive jaundice (Mirizzi)
18
Q
How would a symptomatic bile duct gallstone present?
A
- “Biliar” pain
- No cholecystitis
- Obstructive jaundice
- Cholangitis
- Pancreatitis
19
Q
How are gallbladder stones treated?
A
- Laproscopic cholecystectomy
- Bile acid dissolution therapy
20
Q
How are bile duct stones treated?
A
- ERCP with sphincterotomy and removal or crushing
- Surgery if large stone
21
Q
What is a normal ALT?
A
Under 40
22
Q
What is a normal AST?
A
Under 33
23
Q
What drugs commonly cause DILI?
A
- Antibiotics (augmentin, flucloxacillin, erythromycin etc)
- CNS drugs
- Immunosuppressants
- Analgesics
- GI drugs (PPIs)
24
Q
What is a normal prothrombin time?
A
Less than 10 seconds
25
What is the toxic metabolite of paracetamol?
NAPQI
26
What is the antedote to paracetamol overdose?
N-Acetylcisteine
27
What is the maximum recommended weekly alcohol intake?
14 Units
28
What can cause ascites?
Chronic liver disease
Neoplasia
Pancreatitis, cardiac causes
29
What are varices?
Extra blood vessels that form between the portal and systemic circulations to divert blood away from the damaged liver and portal hypertension
30
How are ascites managed?
- Fluid and salt restriction
- Diuretics
- Large-volume paracentesis+ albumin
- Trans jugular intrahepatic portosystemic shunt
31
What will AFLD progress into?
- Either alcoholic hepatitis
- Or Cirrhosis
- Acute decompensation
32
What is steatosis?
When the liver cells become swollen with fat
33
What causes portal hypertension?
- Cirrhosis
- Fibrosis
- Portal vein thrombosis
34
What is delirium tremens?
Rapid onset delirium triggered by alcohol withdrawal
35
Why are liver patients vulnerable to infection?
- Impaired reticulo endothelial function
- Reduced opsonic activity
- Leucocyte function
- Permeable gut wall
36
What is spontaneous bacterial peritonitis?
The commonest serious infection in cirrhosis. Gives vague symptoms
37
How can liver disease lead to renal failure?
Vasodilated state in liver disease which results in hypoperfusion of kidneys
38
What are some possible causes of coma in patients with chronic liver disease?
- Hepatic encephalopathy
- Hyponatraemia
- Hypoglycaemia
- Intracranial event
39
How is hepatic encephalopathy treated?
Lactulose
40
How is chronic liver disease investigated?
- Viral serology
- Immunology
- Biochemistry
- Ultrasound
- CT or MRI
41
What are the types of hepatitis?
- Viral
- Alcoholic
- Autoimmune
42
How is autoimmune hepatitis treated?
Steroids
43
What is the upper limit of normal for alk phos?
130
44
What are some common symptoms of primary biliary cirrhosis?
```
Asymptomatic
Itching
Dry eyes
Joint pain
Variceal bleeding
Chronic liver disease
```
45
List some liver related autoimmune diseases
- Autoimmune hepatitis
- Primary Biliary cirrhosis/cholangitis
- Primary sclerosing cholangitis
46
How does primary sclerosing cholangitis present?
- Itching
- Pain +/- rigors
- Jaundice
47
A 69 year old male patient presents with fatigue, diabetes, white nails and joint pain. They have a raised ferritin on blood test, with high alcohol intake and a fatty liver. What is it likely to be?
Haemochromatosis
48
How is haemochromatosis treated?
Venesection
49
A 54 year old male presents with abnormal LFTs and chronic liver disease. He has previous alcohol excess and a raised BMI. He is found to have low alpha-1 antitrypsin. What is it likely to be?
Alpha-1 antitrypsin deficiency
50
A 49 year old man presents with abnormal LFTs but is asymptomatic. He has a pmh of type 2 diabetes and hypertension. He is obese, and does not drink. His antibody tests were all normal and he showed no evidence of chronic liver disease, but ultrasound showed fatty liver. What is it likely to be?
Non alcoholic fatty liver disease
51
A 21 year old women travelled to Malaysia and was well throughout the holiday. She was unwell for 3 weeks on return with headache, lethargy, aches, poor apetite and fevers. This was self limitting, but she then noticed yellowing of the skin. What is it likely to be?
Acute hepatitis A
= She will be HepA IgM positive, but Hep A IgG negative
52
A 46 year old woman presents with lethargy, poor appetite, yellow skin and dark orange urine. On examination she has tender hepatomegaly and mild pitting oedema. She has not left the UK in over a year, and has a Egyptian new partner recently. What is it likely to be?
Acute Hepatitis B
= She will be HB IgM Positive, HBsAg positive and HBeAg positve
53
An Egyptian business man presents to clinic on routine screen. He feels well and has not left the UK for the last 5 years. His partner has recently tested positive for acute hepatits B, but he has no jaundice and feels well. On ultrasound, he has a bright echogenic liver texture but with no focal abnormalitiy. What is it likely to be?
Chronic hepatitis B
= He will be HbsAg positive, HBeAg positive and HBcAb positive, but HB IgM negative
54
A 27-year-old man presents underweight with tender liver. He is not jaundiced, but reports that he has used IV heroine and crack cocaine frequently. On ultrasound, he has a cirrhotic liver. What is it likely to be?
- Chronic Hepatitis C
= He will be HCV Ab positive, and HCV PCR positive
55
A 61-year-old man presents with vomitting, weight loss and shooting pain to the right shoulder. He is jaundiced and has a PMH of T2DM. A blood test shows high bilirubin and high alk phos. What is it likely to be?
Gallstones
Diagnosed using CT
56
A 47-year-old man presents with jaundice, but no abdominal pain or weight loss. He has a PMH of HIV, and shows a high ALT, high Alk phos and high bilirubin. Ultrasound and viral screens are all normal. What is it likely to be ?
Acute liver injury as a result of drugs used for HIV treatment
57
A 55 year old femal presents with painless jaundice and itch. She is normal on ultrasound and viral screen. She was prescribe co-amoxiclav recently for diverticulitis. What is it likely to be?
Drug induced liver injury
58
A 20 year old male was admitted with jaundice, and a very high ALT and AST. He also has a very high prothrombin time (32s). He has had a severe toothache for the last week. What is it likely to be ?
Paracetamol induced hepatic failure
59
A 51 year old male presents with very high bilirubin, low albumin, and high AST/ALT. He also has a hight PTT. On ultrasound his liver has a nodular outline. He has excessive alcohol intake, and on biopsy his liver is very fatty. What is it likely to be?
Alcoholic liver disease
60
A 48 year old female presents with jaundice, vague ache in the right upper quadrant, and has nausea. She has autoantibodies, but has all viral antibodies negtive. What is it likely to be?
Autoimmune hepatitis
61
A patient presents with slate-grey skin, several signs of chronic liver disease and a ferritin level> 1mg.
What is their diagnosis?
Haemochromatosis
62
A patient with malaria has just been diagnosed with Jaundice. What type of jaundice are they most likely to have developed given their condition? Describe the colour of their urine and stools.
- Pre-Hepatic Jaundice
- Urine Normal /Yellow /Clear
- Stool Normal / Brown
63
Which types of Hepatitis are typically spread by foecal-oral transmission?
A and E
64
What are the hepatic enzymes?
- Aminotransferases= AST and ALT
- Alk Phos
- GGT
65
What signs / symptoms would you see in cirrhosis?
Ascites, clubbing, palmar erythema, xanthelasma, spider naevi, hepatomegaly, peripheral oedema
66
What are the two most common causes of liver failure in the UK?
- Alcohol
| - Hepatitis
67
What biomarker would be raised if a patient presented with Hepatocellular carcinoma?
Increased AFP
68
Calculate the number of units: A patient drinks 3 glasses of wine a week (each glass is 175ml, 13% strength)
6.8
69
How would a patient present with Wernicke-Korsakoff encephalopathy?
ataxia, confusion, nystagmus, memory impairment
Treat with IV thiamine
70
You are reviewing a 48-year-old man who was admitted with sudden severe abdominal pain, confusion and pyrexia. He has a background of alcoholic cirrhosis and known ascites which is normally asymptomatic. An ascitic tap was done overnight which showed a raised neutrophil count and was sent for urgent microscopy & culture.
What organism is most likely to grow from the ascitic tap?
E Coli
71
A patient presents with history of drinking with dark sticky faeces and blood in her vomit.
```
Which drug would you use to treat her?
Spironolactone
Ciprofloxacin
Propranolol
Amlodipine
```
Propanolol
72
What is contained within Calot's triangle?
Part of the gallbladder
Cystic artery
Right hepatic artery
Bile ducts
73
What percentage of the liver’s blood supply is via the proper hepatic artery?
25%
74
```
Which of the following is not a component of bile?
A) CCK
B) Bilirubin
C) Cholesterol
D) Bicarbonate
E) Lecithin
```
A
75
What stimulated release of bile?
CCK
76
A patient with yellowing of the skin and abdominal pain has a blood test and it is found that there is high levels of unconjugated bilirubin in the blood, but normal levels of conjugated bilirubin. What disease do they have?
Pre hepatic jaundice
77
What is serum alpha-fetoprotein associated with?
Hepatocellular carcinoma
| = Also raised in testicular teratomas
78
An excess of what hormone in liver damage causes palmar erythema and spider naevi?
Oestrogen
79
Which condition is a keysher fleischer ring associated with and which metal is implicated?
Wilson's disease
Copper
80
```
Which of the following liver diseases affects the pancreas and heart and which metal is implicated?
A) Haemochromatosis
B) Hep B
C) Alpha-1-antitrypsin
D) Wilson’s disease
```
Haemochromatosis
Iron
81
Which viral hepatitis is acute only?
A
82
Which viral hepatitis is faeco-oral spread?
A and E
83
Which viral hepatitis is blood-borne?
B,C,D
84
```
What is the characteristic FBC finding in alcoholic liver disease
A) High platelets
B) Macrocytic anaemia
C) Microcytic anaemia
D) Low WCC
```
B
85
```
How to monitor for HCC in patients with cirrhosis
A) LFTs
B) FBC
C) MRI liver
D) AFP + USS
```
D
86
```
Which of the following has a complication of cholangiocarcinoma
A) Autoimmune hepatitis
B) Hep B
C) PSC
D) PBC
```
C
87
What condition would a patient with Charcot's triad likely have?
CHOLANGITIS
88
What are the components of Charcot's triad?
RUQ pain, (2) jaundice, (3) fever and chills.
89
What condition would a patient with Reynolds' pentad likely have?
Ascending Cholangitis
90
What are the components of Reynolds' pentad?
Charcot's triad (RUQ pain, Jaundice, fever and chills) plus altered mental state, and shock
91
What are the four main functions of the liver?
- Glucose and fat metabolism
- Detoxification and excretion
- Protein synthesis
- Defence against infection
92
Give six physical manifestations you might find in a patient with chronic liver disease?
- Ascites
- Caput medusa
- Telangiectasia
- Hepatomegaly
- Splenomegaly
- Peripheral oedema
- Muscle wasting, cachexia
- Spider naevi
- Gynecomastia
93
List four causes of acute liver injury.
- Viral
- Drugs - illicit or medical
- Obstruction (gallstones, strictures, masses/cancer)
- Vascular (thrombosis)
- Alcohol
- Congestion (heart failure
94
List the three main risk factors for gallstones
Female, fair, fat and fertile
95
What imaging is used first line to identify gallstones?
Ultrasound of the abdomen
96
What procedure is used for gallstone retrieval or stenting?
ERCP - endoscopic retrograde cholangiopancreatography which uses endoscopy and fluoroscopy to visualise the biliary tree and allow stone retrieval or stone destruction and/or stenting to be performed.
97
What results would you expect in pre-hepatic jaundice versus cholestatic jaundice when looking at the appearance of the urine and stool and liver function tests?
```
Pre-hepatic= Stools, urine and LFTs are all normal
Cholestatic= Pale stool, dark urine and abnormal LFTs
```
98
What is the most common medication that people intentionally overdose on that can cause liver failure?
Paracetamol
99
What blood tests are most important to measure as indicators of liver function?
Prothrombin time is most useful (part of a clotting screen) and we monitor LFTs also.
100
What infection must be ruled out when ascites is present and how would we test for this?
Must rule out spontaneous bacterial peritonitis by performing paracentesis or extraction of ascitic fluid which is then sent for analysis.
101
What is the ampulla of vater?
The point at which the pancreatic duct and cystic duct drain into the duodenum
102
What are the majority of gallstones made of?
Cholesterol
103
List 3 different types of gallstones
Cholesterol stones
Black stones= High bilirubin
Brown stones= Infective causes
104
In what conditions are there low bile acids?
- Cirrhosis
- Crohn's disease
- Ileal resection
