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Medicine Phase 2a GI > Liver general > Flashcards

Liver general Flashcards

(68 cards)

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1
Q

Functions of the liver

A

Glucose and fat metabolism
Detoxification and excretion
Protein synthesis
Defence against infection (reticulo-endothelial system)

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2
Q

Give examples of chemicals in the body which are detoxified and excreted

A

Biilirubin
Ammonia
Drugs/hormones/pollutants

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3
Q

Example of proteins synthesised by the liver

A

Albumin

Clotting factors

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4
Q

Types of liver injury

A

Acute

Chronic

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5
Q

What can result from acute liver injury

A

Recovery

Liver failure

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6
Q

Acute causes of liver failure

A 
Viral (A, B, EBV)
Drugs, Alcohol
Vascular
Obstruction
Congestion
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7
Q

Chronic causes of liver failure

A

Recovery
Cirrhosis
Liver failure (varies, hepatoma)

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8
Q

Presentation of acute liver injury

A

Malaise, nausea, anorexia
Occasionally jaundice (doesn’t occur with everyone)
Rare:
-Confusion (encephalopathy)
-Bleeding
-Liver pain
-Hypoglycaemia (since liver breaks down glycogen to glucose, also the liver is the bodies major glucose store)

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9
Q

Presentation of chronic liver injury

A 
Ascites
Oedema (varices)
Malaise
Anorexia
Wasting
Easy bruising (since the liver produces clotting factors)
Itching
Hepatomegaly
Abnormal LFTs
Rare = Jaundice, Confusion
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10
Q

What are ascites?

A

Fluid accumulation in the peritoneal cavity

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11
Q

Examples of Liver Function Tests (LFTs)

A

Serum albumin
Bilirubin
Prothrombin time

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12
Q

Examples of liver biochemistry tests - is this a types of liver function test?

A

Liver biochemistry tests give NO index of liver function:
Aminotransferases
Alkaline Phosphate

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13
Q

In acute liver disease, what is expected from initial albumin levels?

A

May be normal

Low albumin is a bad prognostic sign

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14
Q

In LFTs, is bilirubin normally all conjugated or unconjugated?

A

All unconjugated

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15
Q

What can cause prolonged prothrombin time and what can it be a marker of?

A

Marker of synthetic function.
Sensitive indicator due to its short half-life for both acute and chronic liver disease.
Longer P time can result from vitamin K deficiency.

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16
Q

What is effect of biliary obstruction on Prothrombin time?

A

Biliary obstruction leads to low concentration of bile salts
Results in poor absorption of vitamin K and thus deficiency in vitamin K means reduced coagulation and longer prothrombin time

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17
Q

Give examples of amino-transferases that can be measured to assess liver biochemistry
Where are amino-transferases found?

A 
Enzymes are found in hepatocytes and leak into blood with liver cell damage.
Aspartate aminotransferase (AST)
Alanine aminotransferase (ALT)
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18
Q

Which aminotransferase is more specific to the liver?

A

ALT - Alanine Aminotransferase
Rise only occurs in liver disease
AST also present in heart, muscle, kidney and brain

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19
Q

In what other cases are Aspartate aminotransferases high, other than liver damage?

A

Hepatic necrosis
Myocardial infarction
Muscle injury
Congestive cardiac failure

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20
Q

What colour is bilirubin?

A

Yellow (contributes to colour of bile)

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21
Q

What are bile pigments formed from

A

Haem portion of Hb when old/damaged erythrocytes are broken down in the spleen and liver

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22
Q

What is the predominant bile pigment?

A

Bilirubin

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23
Q

What cells break down old or damaged erythrocytes and where are these cell found?

A

Macrophages

Spleen, bone marrow, liver (Kupffer cells here)

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24
Q

When erythrocytes are ingested by macrophages, what are they initially broken into?

A

Haem and globin

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25
What is globin broken down into
Amino acids which can be used to generate new erythrocytes in the bone marrow
26
What is haem broken down into
Biliverdin Fe2+ (transported to bone marrow to be implemented into new erythrocytes by transporter transferrin) CO
27
What happens to biliverdin from haem breakdown?
Biliverdin is reduced by biliverdin reductase into UNCONJUGATED BILIRUBIN (toxic and must be secreted)
28
Why is unconjugated bilirubin bound to albumin in the blood
Lipid soluble and thus insoluble in blood | Must be transported bound to albumin to the liver
29
What happens to unconjugated bilirubin when it reaches the liver
GLUCURONIDATION In liver, unconjugated bilirubin undergoes the addition of a glucuronic acid to make it soluble to be excreted under the action of UDP Glucuronyl Transferase, which converts it to CONJUGATED bilirubin
30
What enzyme converts unconjugated bilirubin to conjugated bilirubin
UDP Glucuronyl Transferase
31
In what condition do you have a deficiency in UDP Glucuronyl transferase and what is the result of this?
Gilbert's syndrome | Raised unconjugated bilirubin
32
What happened to conjugated bilirubin once it enters the small intestine
Travels until it reaches the Ileum or beginning of colon, where it is reduced under the action of intestinal bacteria to form Urobilinogen
33
How is Urobilinogen formed
Conjugated bilirubin undergoes hydrolysis reaction under the action of intestinal bacteria, reducing it to form urobilinogen (glucuronic acid group is removed)
34
What happens to urobilinogen once formed
10% is reabsorbed into the blood and bound to albumin (as is lipid soluble) and transported back to the liver. 90% remaining is oxidised by a different type of intestinal bacteria to form stercobilin
35
What happens to the 10% of urobilinogen that is transported back to the liver
Urobilinogen oxidised to urobilin Here it is either recycled into bile or transported into the kidneys where it is excreted in urine - responsible for yellowish colour of urine
36
What happens to stercobilin
Excreted into faeces - responsible for the brownish colour
37
Types of jaundice
Unconjugated aka Pre-hepatic | Conjugated (Hepatic and Post-hepatic) aka Cholestatic
38
What causes the yellow discolouration of the skin in jaundice
Raised serum bilirubin
39
Give examples of Unconjugated or pre-hepatic causes of jaundice
``` Gilberts syndrome (deficiency in UDP Glucuronyl transferase) Haemolysis ```
40
Give examples of causes of (Conjugated/Cholestatic) Hepatic jaundice
``` Liver disease: Hepatitis -Viral (A, B, C, EBV) -Drug -Immune -Alcohol Ischaemia Neoplasm Congestion (congestive heart failure) ```
41
What is EBV
Epstein–Barr virus | Herpes simplex virus
42
Causes of post-hepatic jaundice
``` Bile duct obstruction due to: Gall-stone in Bile Duct Gall-stone in gallbladder/cystic duct pressing on the Common Bile) - Mirizzi syndrome Stricture Blocked stent ```
43
Describe presentation of Pre-hepatic jaundice
Urine = Normal Stools = Normal Itching = No Liver tests = normal
44
Describe presentation of Cholestatic (hepatic or post-hepatic) jaundice
Urine = dark Stools = may be pale Itching = maybe Liver tests = Abnormal
45
Useful questions for diagnosis jaundice
``` Dark urine, pale stool, itching? (if yes then likely cholestatic, not pre-hepatic) Symptoms? Past History? Drug Hx Social Hx ```
46
Jaundice: What symptoms would you ask about?
Biliary pain (right upper abdomen that radiates to shoulder) Rigors Abdomen swelling Weight loss
47
Jaundice: What past history topics would you ask about?
``` Biliary disease/intervention? Malignancy? Heart failure? Blood products? Autoimmune disease? ```
48
What topics of social history would you ask in jaundice/liver disease
``` Alcohol? Potential Hepatitis contact: -Irregular sex? -IV drug use? -Exotic travel? ```
49
Diagnostic tests of liver
Liver enzymes - very high AST/ALT suggests liver disease | Biliary obstruction - 90% have dilated intrahepatic bile ducts on ultrasound
50
What is a hepatocellular carcinoma
cancer of the hepatocyte
51
Hepatocellular carcinoma clinical presentation
Fever, malaise, weight loss Right upper quadrant pain, jaundice (late) Hepatomegaly, ascites
52
Hepatocellular carcinoma aetiology
Hep B and C, Aflatoxin, alcohol, haemochromotosis, cirrhosis and anabolic steroids
53
Hepatocellular carcinoma epidemiology
90% of primary liver cancers (however 90% of cancer in the liver is a result of metastasis)
54
Hepatocellular carcinoma diagnosis
CT and biopsy
55
Hepatocellular carcinoma treatment
Surgery to resect individual tumours. | Liver transplant if multiple
56
Define liver failure
Loss of the livers ability to regenerate or repair
57
Types of liver failure
Fulminant hepatic failure Late-onset hepatic failure Chronic decompensated hepatic failure
58
Liver failure clinical presentation
``` Hepatic encephalopathy Abnormal bleeding Ascites Jaundice Mental state shows drowsiness and confusion, due to cerebral oedema ```
59
What are the differences between the types of liver failure
Time of liver failure relative to illness: Fulminant hepatic failure = within 8 weeks of onset of underlying illness Late-onset hepatic failure = 8-26 wks since onset of underlying illness Chronic decompensated hepatic failure = latent period >6 months
60
Liver failure pathophysiology
Depends on aetiology. Generally: the destruction of hepatocytes, the development of fibrosis in response to chronic inflammation, the destruction of the architecture of the nodules of the liver removes the ability of the liver to adequately perform functions, repair and regenerate
61
Liver failure aetiology
``` Various: Toxins Infections Neoplastic e.g. Hepatocellular carcinoma Metabolic Others e.g. Acute fatty liver of pregnancy, ischaemia, autoimmune liver disease ```
62
Liver failure aetiology examples of toxins
Alcohol | Paracetamol poisoning
63
Liver failure aetiology examples of infections
Viral hepatitis Epstein-Barr virus CMV
64
Liver failure aetiology examples of Metabolic causes
Wilsons A1AT deficiency Haemochromatosis
65
Liver failure epidemiology
1/100,000 | Paracetamol poisoning most common cause in acute liver failure
66
Liver failure diagnosis
``` Raised bilirubin Glucose low (no gluconeogenesis) ```
67
Liver failure treatment in more severe cases
Transplant
68
Complications of liver failure
Infection Haemorrhage (Hypoglycaemia)

Medicine Phase 2a GI (35 decks)

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