Liver and stuff Flashcards
(111 cards)
1
Q
what does the liver do
A
glucose and fat metabolism
detox and excretion
protein synthesis - albumin/clotting factors
defence against infection - reticuloendothelial system
2
Q
what does the liver detoxify and excrete
A
bilirubin ammonia drugs hormones pollutants
3
Q
what are the types of liver injury
A
acute = can recover or progress to liver failure chronic = can recover, cirrhosis or progress to liver failure
4
Q
what is tested in liver function tests?
A
- serum bilirubin = breakdown of haem, decreases in disease
- albumin = produced by liver, decreases in disease
- prothrombin time = increase in disease as coagulation factors not produced
5
Q
what liver enzymes are tested
A
cholestatic = alkaline phosphatase, gamma GT
hepatocellular = transaminases (AST and ALT)
= gives no index of liver function
6
Q
what can cause renal failure in liver disease
A
drugs = diuretics/NSAIDS/ACEi/aminoglycosides infection GI bleeding myoglobinuria renal tract obstruction
7
Q
why is it important to consider analgesic drugs in liver disease
A
liver sensitive to opiates
NSAIDS cause renal failure
= paracetamol is safest option
8
Q
what drugs is it important to consider in liver disease
A
sedation diuretics = use short acting benzodiazepines with care
antihypertensives = avoid ACEi
AVOID amino-glycosides
9
Q
name the viral causes of acute liver disease
A
hep A
hep B
EBV
10
Q
name 4 causes of acute liver disease
A
- idiosyncratic drug reactions
- alcoholic hepatitis
- vascular occlusion of blood flow to liver/obstruction of hepatic vein
- congestion = right sided heart failure causing oedema
11
Q
what are the sign/symptoms of acute liver diease (8)
A
malaise
nausea
anorexia
jaundice
confusion
bleeding
liver pain
hypoglycaemia
12
Q
name the viral causes of chronic liver disease
A
hep B
hep C
13
Q
name the autoimmune causes of chronic liver disease
A
autoimmune hepatitis
primary biliary cholangitis
primary sclerosing cholangitis
14
Q
name the metabolic causes of chronic liver disease
A
haemochromatosis = excess iron
wilsons disease
alpha 1
15
Q
how does chronic liver disease present
A
ascites
oedema
haematemesis = vomiting blood
malaise
anorexia
wasting
easy bruising itching hepatomegaly abnormal LFTs (jaundice/confusion = rare)
16
Q
what are the consequences of chronic liver dysfunction
A
- malnutrition
- coagulopathy
- endocrine changes = gynaecomastia, impotence, amenorrhoea
- hypoglycaemia
- variceal bleeding
- ascites/oedema
- increased infection risk
17
Q
what is coagulopathy
A
impaired coagulation factor synthesis
vitamin K deficiency
thrombocytopenia
18
Q
what is gynaecomastia
A
man boobs
19
Q
how is malnutrition treated
A
naso-gastric feeding
20
Q
how is variceal bleeding treated (bleeding from varices)
A
endoscopic bandign
propranolol
terlipressin
21
Q
what is hepatic encephalopathy and how do you treat it
A
= brain disease/damage malfunction due to buildup of toxins that liver was unable to clear
= consequence of chronic liver disease
= treat with lactulose
22
Q
what is jaundice
A
raised serum bilirubin
23
Q
name the 3 causes of jaundice
A
pre-hepatic
hepatic/cholestatic
post-hepatic/cholestatic
24
Q
what is pre-hepatic jaundice
A
caused by factors that increase rate of haemolysis
= haemolytic anaemia
= haemolytic drugs
= sickle cell anaemia
25
what is hepatic/cholestatic jaundice
caused by liver disease
= hepatitis
= cirrhosis
= hepatocellular carcinoma
26
what is post hepatic/cholestatic jaundice
caused by bile obstruction
= pancreatic cancer
= primary sclerosing cholangitis
= gallstones
27
what signs are important to look out for in jaundice
urine and stool colour
abdomen swelling
fever
yellow sclera
28
what are the symptoms of jaundice
```
fatigue
fever
rigors
abdominal pain
vomiting
weight loss
itching
```
29
what is it important to consider in history of patient with jaundice
PMH = biliary disease, malignancy, HF, blood product use, AI diseases
drug history = 2-12 weeks usage
social history = alcohol, hepatitis
family history
30
what tests are done in cases of jaundice
liver enzymes
CT
MRI cholangiogram/endoscopic retrograde cholangiogram
USS
31
diagnosis of pre-hepatic jaundice
```
normal LFT
high unconjugated bilirubin (increased bkdown RBC)
normal conjugated bilirubin
normal urobilinogen
normal stool/urine colour
```
32
diagnosis of hepatic jaundice
```
high unconjugated bilirubin
high conjugated bilirubin (degree of obstruction)
normal/high urobilinogen in urine
dark urine (CB in urine)
pale stool
increased ALT and AST
```
33
diagnosis of post-hepatic jaundice
```
normal unconjugated bilirubin
high conjugated bilirubin (buildup)
decreased urobilinogen in urine
dark urine (high CB)
pale stools
increased ALT and AST
```
34
what is hepatitis
inflammation of the liver
35
name the viral causes of acute hepatitis
hep A,B,C,D,E
| herpes virus
36
name the non-viral infection causes of acute hepatitis
spirochetes
parasites
mycobacteria
bacteria
37
name the non infectious causes of acute hepatitis
```
alcohol
NAFLD
drugs
toxins
pregnancy
autoimmune
hereditary metabolic
```
38
what is NAFLD
non alcoholic fatty liver disease
39
what causes hepatitis E
RNA virus similar to Hep A
| found and spread in pigs/undercooked meat
40
what is the presentation of Hep E
most asymptomatic
usually self-limiting
acute-on-chronic liver failure - especially in immunocompromised
neurological manifestations
41
how is Hep E treated
```
acute = support, possibly ribavirin if complications leading to chronic occur BUT mostly just supportive/no trreatment
chronic = reverse immunosuppresion if poss, treat with ribavirin
```
42
what is ribavirin
antiviral medications used to treat hep C/E often in combination with peginterferon alfa 2a
43
what is peginterferon alfa 2a
= pegylated interferon alfa 2a
used to treat Hep B by itself
Hep C = combined with ribavirin
has common and unwanted side effects
44
describe Hep D
defective RNA virus that requires individual to already have Hep B to contract it
transmitted through blood/bodily fluids
treated with pegylated interferon alfa 2a
45
what is haemochromatosis
autosomal recessive genetic disorder caused by mutation in HFE gene
causes uncontrolled intestinal absorption of iron with deposition in the liver, heart and pancreas
46
what occurs in autoimmune hepatitis
abnormal T cell function and autoantibodies attack anomalous hepatocyte surface antigens (they shouldnt be there)
lymphocytes and plasma cells present in histology = indicate cirrhosis (???)
47
what are the symptoms of autoimmune hepatitis
```
normal hepatitis symptoms
specific =
polyarthritis
pleurisy
lung infiltrates
glomuleronephritis
no periods
```
48
what investigations confirm a diagnosis of autoimmune hepatitis
bloods = raised bilirubin, AST, ALT, ALP, hypersplenism , low WCC, low Plts
autoantibodies = positive antinuclear antibody
liver biopsy = mononuclear infiltrate = necrosis and fibrosis = cirrhosis
49
how is autoimmune hepatitis treated
prednisolone = steroids
| liver transplant in severe cases
50
what conditions are associated with AI hep
```
pernicious anaemia
ulcerative colitis
glomerulonephritis
AI thyroiditis
diabetes mellitus
```
51
what is NAFLD
non-alcoholic fatty liver disease = inflammation and fibrosis of liver caused by fatty deposits
52
what causes NAFLD
obesity
hyperlipidemia
diabetes
53
how is NAFLD diagnosed
mildly raised LFTs = raised ALT
| liver biopsy
54
how is NAFLD treated
weight loss
low fat diet
increased physical activity
55
what is the progression of alcoholic liver disease
alcoholic fatty liver disease
alcohol hepatitis
cirrhosis
liver failure
56
what is DILI
drug induced liver injury
| = acute injury to the liver caused by paracetamol or other idiosyncratic reactions to drug
57
what are the types of DILI
```
hepatocellular = raised ALT
cholestatic = raised alkaline phosphate
mixed = changes in both ALT and alkaline phosphate
```
58
what drugs usually cause DILI
```
antibiotics
CNS drugs
immunosuppressants
analgesics
GI drugs
```
59
what is primary biliary cholangitis
autoimmune damage occurs to the bile ducts which result in a build up of bile in the liver
primary granulomatous inflammation of the interlobar ducts
60
what are the risk factors for PBC
female
40-50
autoimmune
smoking
61
how does PBC present
```
pruitus from onset
jaundice = due to bike leakage/obstruction
cholestasis
xanthomas
dry eyes
```
```
fatigue
joint pain
hepatomegaly
variceal bleeding
liver failure - ascites
```
62
what is cholestasis
decrease in bile flow due to obstruction
| = any condition where substances usually excreted into the bile are retained
63
what autoimmune diseases are associated with PBC
sjogrens syndrome
systemic sclerosis
rheumatoid arthritis
lupus
64
name some methods of prevention of Hep B
antenatal screening = HBsAg testing
screening/immunisation of sexual/household contacts
universal childhood immunisation
immunisation of healthcare workers
65
how is PBC treated
urodeoxycholic acid
| cholestyramine or rifampicin for treatment of pruitus
66
what does urodeoxycholic acid do
improve pruitus
improve liver enzymes
reduce fibrosis
reduce portal pressure and variceal formation
67
describe how encephalopathy occurs
ammonia not cleared by liver = glutamate is converted to glutamine in the brain
= osmotic shift so fluid enters cells = cerebral oedema
symptoms = altered mood, drowsy, confused
68
what is the difference between cholangitis and cholecystitis and what is cholelithiasis
```
cholangitis = inflammation of bile duct system
cholecystitis = inflammation of the gallbladder
cholelithiasis = gallstones but NO inflammation
```
69
what is charcots triad
fever (with rigors)
jaundice
RUQ pain
occurs as a result of acute cholangitis
70
what are the complications of gallstones
cholangitis = inflammation GB due to BD block
acute cholecystitis = if cystic duct impact
jaundice = obstruction
pancreatitis = pancreatic duct blocked
gallstone ileus = occlude intestinal lumen
empyema = GB fill with pus
71
what is portal hypertension
high blood pressure in hepatic portal system
| can be due to increased flow or increased resistance
72
what causes hepatic vein occlusion
```
pregnancy
polycythaemia rubra vera
hepatocellular carcinoma
compression of hepatic vein
hepatic vein thrombosis = Budd-Chiari
```
73
how is hepatic vein occlusion treated
anticoagulation
trans-jugular intrahepatic portosystemic shunt (TIPS)
liver transplant
74
what are the symptoms/complications of portal hypertension
varices formation = vomiting blood/blood in stool
ascites
encephalopathy/confusion due to poor liver function
reduced platelet/clotting factors
75
how is portal hypertension diagnosed
ultrasound (USS)
= dilated portal vein
= shows velocity of portal vein blood flow
76
what are the characteristics of ascites
```
belly button stick out
tense belly
dull percussion!!!
prominent veins = associated w/liver disease/PH
abdominal distension
flank distension
```
77
what are the complications of portal hypertension
```
varices
= lower 3rd of oesophagus
= stomach
= abdominal wall
= rectum
(in areas where venous drains into portal vein)
hepatic encephalopathy
ascites
```
78
describe the formation of ascites
1. increased hepatic resistence = portal hypertension = increased splanchnic blood flow
2. systemic vasodilation causes increased renin, angiotensin, noradrenaline, vasopressin secretion = water retention
3. due to liver disease albumin levels = low
4. due to increased portal pressure, water retention, low albumin = water pushed out of vessels and cannot reenter due to low oncotic pressure
5. results in ascites forming + gastric/oesophageal varices also form due to PH
79
what causes ascites to form
chronic liver disease = portal vein thrombosis/hepatoma/TB
portal hypertension
neoplasia
pancreatitis
80
how are ascites managed
```
fluid restriction
salt restriction
diuretics = furosemide, spironolactone
large volume paracentesis and albumin
TIPS procedure
```
81
describe transudate ascites
low protein
| usually caused by a blood flow issue or oncotic pressure issue
82
what colour is the fluid in ascites
should be clear/straw yellow
| any other colour indicates possible infection - fever, complications
83
what is steatosis
abnormal retention of lipids in liver = fatty liver
84
what is NASH
non alcoholic steatohepatitis
85
what are the signs of liver mets
hepatomegaly
hard/nodular liver
chronic liver disease = ascites/jaundice (late)
86
what are the normal origins of liver metastases
stomach
lung
colon
breast/uterus
87
what is the treatment for liver metastases
chemo/radiation/resection possible
| but usually terminal diagnosis
88
what investigations confirm a diagnosis of liver mets
normal blood
high ferroprotein
imaging for stages and cause = CT
biopsy
89
what is a liver abcess
pus filled mass in liver
90
what are the causes of a liver abcess
1. bacterial = E.coli, Klebsiella
2. amoebic = entamoeba histolytica
3. worms = echinococcal granulosus (dog tapeworm)
91
what are the symptoms of liver abcess
RUQ pain
fever
pyrexia of unknown origin = 2 week fever
high number eosinophils = only in worms
92
how are liver abcesses diagnosed
CT/ultrasound shows abcess
93
how are liver abcesses treated
```
amoeba/bacteria = treat with antibiotics and drainage
worms = treat with albendazole and remove tapeworm
```
94
what is essential to be careful with in treating liver abcess
echinococcal granuloses rupture can cause anaphylaxis
95
what is the blood supply to the Liver
hepatic artery = fresh oxygenated blood
| portal vein = venous blood from spleen, pancreas, small intestine
96
describe the pathophysiology of paracetamol poisoning and what is the treatment
intermediate metabolite of paracetamol causes cellular necrosis
N-acetly cystine (NAC) converts reactive intermediate to stable metabolite
97
what are some key signs of liver failure
fetor hepatis = breath smell of pears
| asterixis = flapping tremor/liver flap
98
what LFT would indicate alcohol liver disease
AST:ALT ratio larger than 2:1
99
what LFT would indicate chronic liver disease
ALT > AST
| ALT is primary liver enzyme so if raised = liver injury
100
what is damaged if gamma GT is raised
biliary system damage
| especially if ALP is raised with gamma GT
101
what is murphys sign and where is it seen
fingers on RUQ
pain on inspiration on right side only = positive
= cholycystitis
102
what is an ERCP used for
diagnose ascending cholangitis
| remove gallstones
103
what differentiates PBC and PSC
```
PBC = AMA positive
PSC = AMA negative
```
104
what are cullens sign and turners sign and what disease do they present in
cullens = umbilical bruising
turners sign = flank bruising
PANCREATITIS
105
describe the blood results for pancreatitis
elevated serum lipase and amylase
106
what is given to treat wilsons disease
lifelong penicillamine and zinc
107
what can cause peritonitis
```
primary
= spontaneous bacterial peritonitis
= ascites
= immunocompromised
secondary
= bowel perforation/ischaemia/inflamm
= TB
```
108
what is significant about the pain in pancreatitis
epigastric radiating to back
| relieved by sitting forward
109
what is the hepatocellular carcinoma specific chemotherapy
sorafenib
110
what is diagnostic for peritonitis
raised blood lactate levels
111
what LFT would be indicative of cirrhosis
AST greater than ALT
