liver disease

Question 1

standard LFTs (7)

Answer 1

1. Alanine transaminase (ALT)
2. Aspartate aminotransferase (AST)
3. Alkaline phosphatase (ALP)
4. Gamma-glutamyltransferase (GGT)
5. Bilirubin
6. Albumin
7. AI4P
   (8. PT)

Question 2

what are the parameters of the childs pugh score (5)

Answer 2

1. bilirubin
2. albumin
3. INR
4. ascites
5. encephalopathy

Question 3

what is the childs pugh score

Answer 3

score that acts as a predictor of complications/mortality of cirrhosis

Question 4

examples of drugs that can induce liver injury

Answer 4

1. carbamezapine
2. methyldopa
3. minocycline
4. macrolide abx (e.g. Azithromycin, clarithromycin)
5. nitrofurantonin
6. statins
7. sulphonamides
8. terbinaphone
9. methotrexate
10. chlorpromazine

Question 5

what cells lay down fibrotic tissue when hepatocytes are damaged

Answer 5

hepatic stellate cells

Question 6

what is the metavir score (liver)

Answer 6

a system used to assess the extent of inflammation and fibrosis by histopathological evaluation in a liver biopsy of patients with hepatitis C

Question 7

metavir score stages (5)

Answer 7

F0 - no fibrosis
F1 - portal fibrosis without septa (mild)
F2 - portal fibrosis with a few septa -> bridging (moderate)
F3 - numerous septa without cirrhosis (sever)
F4 - cirrhosis -> nodular transformation totally surrounded by fibrosis

Question 8

what is bridging in liver fibrosis

Answer 8

formation of a continuous ridge between the central vein + potal vein or 2 central veins or 2 portal veins of a liver acinar unit

Question 9

at what metavir stage is there concern

Answer 9

F2 - bridging beginning to occur

Question 10

what is fibroscanning

Answer 10

a type of ulstrasound scan used to measure the level of fibrosis of the liver -> fibrotic liver is stiffer and so the US wave is reflected back more

Question 11

where do ALT and AST originate from

Answer 11

the hepatocytes

Question 12

why is PT/INR checked in liver disease

Answer 12

the liver makes clotting factors 2, 7 ,9 and 10 => damage to the liver will reduce production of these leading to longer clotting time

Question 13

what is choleostasis

Answer 13

alteration in bile flow

Question 14

what does an isolated raised ALP indicate the source of the pathology is

Answer 14

a non-liver source e.g. bone

Question 15

what does a raised ALP and GGT indiacte the source of the pathology is

Answer 15

hepatobilary souce -> obstructive liver disease or biliary problem

Question 16

what is fulminant hepatic failure and what markers are raised

Answer 16

acute liver failure -> no pre-existing disease but a clear insult has occured to cause it
markers:
raised INR, ALT, bilirubin, ammonia (leads to brain swelling and multiple organ failure)

Question 17

what is acute on chronic liver failure (ACLF)

Answer 17

chronic liver disease with and acute picture -> acute hepatic decompensation, organ failure and a high risk of short-term mortality

Question 18

what is intrahepatic choleostasis

Answer 18

failure of liver cells to make bile at levelof canaliculus

Question 19

what is extra hepatic cholestasis

Answer 19

large duct obstruction

Question 20

hepatic liver injury picture LFTs

Answer 20

ALT > 5x upper limit
ALP < 2x upper limit

Question 21

cholestatic liver injury picture LFTs

Answer 21

ALT < 2x upper limit
APT >5x upper limit

Question 22

mixed liver injury picture LFTs

Answer 22

ALT 2-5x upper limit
ALP 2-5x upper limit

Question 23

why might COPD history be important in liver history

Answer 23

early emphysema may indicate an alpha-1-antitrypsin deficency (AAT is produced by the liver and acts to protect the lungs)

Question 24

why is travel history important in liver disease

Answer 24

risk of tropical disease, hepatitis etc.

Question 25

examples of signs of chronic liver disease on examination (7)

Answer 25

1. jaundice 2. spider naevi 3. gynacomasteia 4. clubbing 5. ascites 6. palmar erythema 7. bruising easily

Question 26

signs of portal hypertension (4)

Answer 26

1. oesophageal varices -> can present in haematemesis or malena 2. splenomegaly 3. dilated abdominal veins (caput medusa) 4. rectal varices (haemorrhoids)

Question 27

4 liver causes for extremely high ALT (>1000)

Answer 27

1. ischaemia (known Heart failure w new onset ischaemia/arrhythmia -> interruption to blood flow causing death of hepatocytes) 2. drug induced (e.g. paracetemol overdose!) 3. viral hepatitis 4. acute biliary obstruction

Question 28

4 non liver causes for extremely high ALT (>1000)

Answer 28

1. haemolysis 2. myositis/myopathy 3. strenuous exercise 4. sepsis

Question 29

what will fasting lipids in NAFLD show

Answer 29

high cholesterol, low LDL

Question 30

what is haemochromatosis

Answer 30

an disorder where iron-binding protein accumulates in various tissues, typically leading to liver damage, diabetes mellitus, and bronze discoloration of the skin

Question 31

what is the audit-c score

Answer 31

Alcohol Use Disorders Identification Test -> a questionnaire to routinely assess the nature and severity of alcohol misuse

Question 32

when is intervention necessary according to the audit-c score

Answer 32

0-4 -> no action 5-11 -> brief intervention (>3 if over 65yro) 11+ -> likely dependent on alcohol, may need specialist help

Question 33

how many units is a standard pint of beer

Answer 33

2.3 units

Question 34

how many units is a standard (175ml) glass of wine

Answer 34

2.3 units

Question 35

what does an isolated high bilirubin indicate?

Answer 35

gilbert's syndrome (can't conjugate bilirubin due to enzyme deficency)

Question 36

what does high bilirubin and deranged LFTs indicate

Answer 36

bile flow problem

Question 37

what symptoms will intrahepatic cholestasis present with (2)

Answer 37

pruritis, fatigue

Question 38

what must be excluded in pts w isolated high bilirubin

Answer 38

haemolysis -> check reticulocyte count, LDH, haptoglobin

Question 39

what does high bilirubin in the blood but absent in urine indicate

Answer 39

it is entirely unconjugated as can't get into the urine