Liver Disease

Question 1

What are the roles of the liver?

Answer 1

Protein synthesis (clotting factors, albumin)
Glucose and fat metabolism
Detoxification and excretion
Defence against infection (Kupffer cells art of reticuloendothelial system)

Question 2

Acute liver injury results in damage and loss of cells through necrosis or a____

Answer 2

apoptosis

Question 3

Chronic liver damage leads to _____

Answer 3

fibrosis

Question 4

Severe forms of chronic liver damage is termed _____ where wide fibrous septa join the portal tracts and central veins

Answer 4

cirrhosis

Question 5

Name some causes of acute liver injury

Answer 5

Viral (A,B EBC)
Drug
Alcohol
Vascular
Obstruction
Congestion

Question 6

Name some causes of chronic liver injury

Answer 6

Alcohol
Viral (B, C)
Autoimmune
Metabolic (iron, copper)

Question 7

What is the presentation of acute liver injury?

Answer 7

Malaise, nausea, anorexia, jaundice

Can also have:
confusion, bleeding, liver pain, hypoglycaemia

Question 8

What is the presentation of chronic liver injury?

Answer 8

Ascites/oedema, haematemesis (varices causing vomiting blood), malaise, anorexia, wasting, easy bruising, itching, hepatomegaly, abnormal LFTs

Can also have:
jaundice, confusion

Question 9

What are other conditions to consider when there are symptoms of acute liver injury?

Answer 9

Is there an obstruction?
Is there a malignancy?

Question 10

What tests give some index of liver function?

Answer 10

Serum bilirubin, albumin, prothrombin time.

Not serum liver enzymes (they indicate whether there is damage)

Question 11

Cholestatic enzymes are those found in the bloodstream when there is an accumulation of ____ components in liver due to impaired flow of ____.

Answer 11

bile

Question 12

Name 2 cholestatic liver enzymes

Answer 12

Alkaline phosphatase
Gamma-GT

Question 13

H__________ enzymes are made in the liver involved in various metabolic processes but may leak into the blood if there is damage or inflammation of the liver.

Answer 13

Hepatocellular

Question 14

Name some hepatocellular liver enzymes

Answer 14

transaminases (ALT and AST)

Question 15

What is jaundice?

Answer 15

Raised serum bilirubin

Question 16

What is an indicator of pre-hepatic jaundice?

Answer 16

Unconjugated bilirubin

Question 17

What is Gilbert’s syndrome?

Answer 17

Mild deficiency of UDP-glucuronosyltransferase so lack of conjugation of bilirubin. Is generally benign.

Question 18

True or false: non-conjugated bilirubin is water soluble

Answer 18

False
Therefore, less easily excreted

Question 19

Other than Gilbert’s syndrome, what is another cause of pre-hepatic jaundice?

Answer 19

Haemolysis (liver’s ability to conjugate bilirubin becomes overwhelmed so more unconjugated bilirubin in bloodstream)

Question 20

Bilirubin is a product of…

Answer 20

haemoglobin breakdown

Question 21

The normal serum bilirubin in adults is…

Answer 21

1.2 mg/dl

Question 22

What organs are involved in the reticuloendothelial system which contain macrophages to break down RBCs?

Answer 22

Spleen, liver and bone marrow

Question 23

What does unconjugated bilirubin bind to in order to travel to the liver?

Answer 23

Albumin

Question 24

True of false: unconjugated bilirubin can cross the BBB?

Answer 24

True, it is lipophilic and neurotoxic which is why it needs to be conjugated

Question 25

The enzyme UDP-glucuronosyltransferase adds a g_____ a___ to make conjugated bilirubin.

Answer 25

glucuronic acid

Question 26

The conjugated bilirubin travels into the g_____ and mixes with bile before being squirted into the intestines.

Answer 26

gallbladder

Question 27

In the large intestines, the conjugated bilirubin is metabolised by the gut flora and converted into...

Answer 27

urobilinogen

Question 28

The urobilinogen either is excreted in the faeces of enters the bloodstream and travels to...

Answer 28

Either the kidneys and urinated out or Returns to liver.

Question 29

What is the recycling of bilirubin to the liver called?

Answer 29

Enterohepatic circulation

Question 30

What causes intra-hepatic jaundice?

Answer 30

Conditions that damage the liver ie. liver disease eg Viral hepatitis, non-alcoholic or alcoholic fatty liver disease, tumours, drugs, metabolic disease, autoimmune conditions)

Question 31

What would tests show in intra-hepatic jaundice?

Answer 31

Increased unconjugated bilirubin due to less conjugation occurring. Also high transaminases (ALT, AST and APT) which are released when the liver is damaged

Question 32

What causes post-hepatic jaundice

Answer 32

Bile duct obstruction (cholestasis) due to: Strictures, gallstones, tumours. Slows flow of bile, conjugated bilirubin backs up into liver and accumulates. Damages liver so increased transaminases. Often no urobilinogen made so low levels in urine.

Question 33

What is pale stool a signs of?

Answer 33

No conjugated bilirubin can reach the intestine, suggesting cholestasis

Question 34

Other than pale stool, what is another sign of cholestasis?

Answer 34

Dark urine Reflux of conjugated bilirubin into blood is then excreted in the urine.

Question 35

True or false: there may be itching with pre-hepatic jaundice?

Answer 35

False There may be with cholestatic jaundice (intra-hepatic of post-hepatic)

Question 36

With biliary obstruction, 90% have dilated intrahepatic b____ d____ on ultrasound

Answer 36

bile ducts

Question 37

What imaging can you do for jaundice?

Answer 37

Ultrasound Magnetic resonance cholangiogram Endoscopic retrograde cholangiogram

Question 38

Where do most gallstones form?

Answer 38

Gallbladder

Question 39

What are gallstones made of?

Answer 39

Cholesterol, pigment and calcium

Question 40

What are risk factors of gallstones?

Answer 40

Being female, fat, fertile (also liver disease, ileal disease, TPN, clofibrate)

Question 41

True or false: most patients with gallstones are asymptomatic

Answer 41

True

Question 42

Intrahepatic bile duct stones (hepatolithiasis) contain mostly ____ pigment and cholesterol stones

Answer 42

brown

Question 43

Gallbladder stones (cholecystolithiasis) contain c_____ stones

Answer 43

cholesterol (black pigment)

Question 44

True or false: cholangitis and pancreatitis are present with gallstones in the bile duct but not gallbladder

Answer 44

True

Question 45

How do you manage gallbladder stones?

Answer 45

Laparoscopic cholecystectomy Bile acid dissolution therapy (not very successful)

Question 46

How do you manage bile duct stones?

Answer 46

ERCP (Endoscopic retrograde cholangiopancreatography) with sphincterotomy and: removal, crushing or stent placement. or for large stones, surgery

Question 47

Weight loss and jaundice could be caused by gallstones or a....

Answer 47

malignancy

Question 48

30% of acute hepatitis is due to...

Answer 48

drug-induced liver injury (DILI)

Question 49

What drug causes half of drug-induced liver injury?

Answer 49

Paracetamol

Question 50

What are common sources of drug-induced liver injury

Answer 50

Antibiotics CNS drugs Immunosuppressants Analgesics GI drugs (eg PPIs) Dietary supplements Multiple drugs

Question 51

How do you manage paracetamol induce fulminant hepatic failure?

Answer 51

N acetyl cysteine (NAC) Supportive to correct coagulation defects, fluid electrolyte and acid base balance, renal failure, hypoglycaemia, encephalopathy

Question 52

What are causes of ascites?

Answer 52

Chronic liver disease Portal vein thrombosis Hepatoma TB Neoplasia Pancreatitis Cardiac causes

Question 53

How do you manage ascites?

Answer 53

Fluid and salt restriction Diuretics large-volume paracentesis and albumin Trans-jugular intrahepatic portosystemic shunt (TIPS)

Question 54

Acute alcohol-related injury causes hepatocyte b_____ and is mediated by neutrophils

Answer 54

ballooning

Question 55

Alcohol changes the way that hepatocytes metabolise and produce ___

Answer 55

fat

Question 56

Fat accumulation in hepatocytes is called s_____

Answer 56

steatosis

Question 57

What is the main cause of liver death in the UK?

Answer 57

alcoholic liver disease (ALD)

Question 58

Why can cirrhosis cause varices?

Answer 58

Cirrhosis causes fibrosis and increased hepatic resistance so increased splanchnic blood flow which can varices

Question 59

Why are liver patients vulnerable to infection?

Answer 59

Impaired reticuloendothelial function reduced opsonic activity (proteins that activate phagocytosis)

Question 60

What do you give for encephalopathy?

Answer 60

Lactulose

Question 61

Autoimmune hepatitis usually requires what for diagnosis?

Answer 61

Liver biopsy (usually lymphocytes and plasma cells in portal tracts and lobular parrenchyma. Damage causes apoptosis or necrosis.

Question 62

Primary sclerosing cholangitis (autoimmune condition of bile ducts) can lead to s____ and gallstones

Answer 62

strictures

Question 63

What may cause iron deposition in the heart?

Answer 63

Haemochromatosis Also may deposit in heart and pancreas. Autosomal recessive. Raised ferritin and transferrin saturation.

Question 64

Causes of chronic liver disease

Answer 64

Alcohol Non-alcoholic steatohepatitis (NASH) Viral hepatitis (B,C) Immune (autoimmune hepatitis, primary biliary cirrhosis, sclerosing cholangitis) Metabolic (haemochromatosis, Wilsons, a1 antitrypsin deficiency) Vascular (Budd-Chiari)