Liver pathology

Question 1

What is the definition of acute liver disease?

Answer 1

Any insult causing damage to a previously healthy liver, over a duration of less than 6 months

Question 2

What is acute liver failure defined as?

Answer 2

Encephalopathy and prolonged coagulation

Question 3

How might acute liver disease present clinically?

Answer 3

Jaundice
Lethargy
Nausea
Anorexia
Pain
Itch
Arthralgia (joint pain)
Abnormal LFTs

Question 4

What are ten causes of acute liver disease?

Answer 4

Viral (hepatitis, EBV etc.)
Drugs (ask about paracetamol)
Shock liver
Cholangitis
Alcohol
Malignancy
Chronic liver disease
Budd Chiari
Acute fatty liver of pregnancy
Cholestasis of pregnancy

Question 5

What is shock liver?

Answer 5

Hepatic ischaemia

Question 6

What investigations should be done in acute liver disease?

Answer 6

History
Examination
LFT's 
Prothrombin time
Ultrasound
Virology
Liver biopsy (rarely)

Question 7

What treatment can be given to soothe itch associated with liver disease?

Answer 7

Sodium bicarbonate bath
Cholestryamine
Uresodeoxycholic acid

Question 8

What antibiotics might cause liver disease?

Answer 8

Co-amoxiclav
Flucloxacillin
NSAIDs

Question 9

Which self-bought drugs do patients often talk about in history for liver disease?

Answer 9

“Fat burners”

“Protein powders”

Question 10

What is the definition of fulminant hepatic failure?

Answer 10

Jaundice and encephalopathy in a patient with a previously normal liver

Question 11

What are some of the complications of fulminant hepatic failure?

Answer 11

Encephalopathy
Hypoglycaemia
Coagulopathy
Circulatory failure
Renal failure
Infection

Question 12

Where are the anastomoses between the portal system and the systemic venous system?

Answer 12

Oesophageal & gastric venous plexus (base of oesophagus)
Umbilical vein
Retroperitoneal collateral vessels
Haemorrhoidal venous plexus (rectum)

Question 13

What may happen to the anastomoses between the systemic and portal venous systems in portal hypertension?

Answer 13

Dilatation
May become varicosed
Rupture

Question 14

What defines portal hypertension?

Answer 14

Portal vein pressure above the normal range of 5 to 8 mm Hg

Question 15

What are some prehepatic causes of portal hypertension?

Answer 15

Portal vein thrombosis

Occlusion secondary to congenital portal venous abnormalities

Question 16

What are some intrahepatic causes of portal hypertension?

Answer 16

Distortion of liver architecture:
Presinusoidal: schistosomiasis, non-cirrhotic portal hypertension
Postsinusoidal: cirrhosis, alcoholic hepatitis, congenital hepatic fibrosis

Question 17

What is Budd-Chiari syndrome?

Answer 17

A condition caused by occlusion of the hepatic veins

Question 18

What are some of the signs and symptoms in Budd-Chiari syndrome?

Answer 18

Jaundice
Right upper quadrant pain
Hepatomegaly
Ascites
Elevated liver enzymes

Question 19

What are the three commonest causes of liver cirrhosis?

Answer 19

Alcohol
Hepatitis C
Non-alcoholic fatty liver disease

Question 20

What is compensated cirrhosis?

Answer 20

Cirrhosis of the liver with an otherwise clinically normal patient - may be an incidental finding

Question 21

What is decompensated cirrhosis?

Answer 21

Liver failure

Question 22

What are some of the signs of compensated liver cirrhosis?

Answer 22

Spider naevi
Palmar erythema
Clubbing
Gynaecomastia
Hepatomegaly
Splenomegaly

Question 23

What are some of the signs of decompensated liver cirrhosis?

Answer 23

Jaundice
Ascites
Encephalopathy
Bruising

Question 24

What is encephalopathy?

Answer 24

Brain injury arising from advanced cirrhosis of the liver

Question 25

In patients with excess alcohol intake, what vitamin supplementation is necessary?

Answer 25

Vitamin B supplements - thiamine

Question 26

What are two common complications of vitamin deficiency associated with liver cirrhosis?

Answer 26

Osteoporosis | Osteomalacia

Question 27

How is ascites treated?

Answer 27

Improvement of underlying liver disease Treatment of infection, if any Reduce salt intake Diuretics - preferably spironolactone, add loop in recurrent ascites

Question 28

What is a transjugular intrahepatic portosystemic shunt?

Answer 28

An artificial channel within the liver that establishes communication between the inflow portal vein and the outflow hepatic vein

Question 29

What is spontaneous bacterial peritonitis?

Answer 29

The development of peritonitis (infection in the abdominal cavity) despite the absence of an obvious source for the infection Can be a translocated bacterial infection of ascites

Question 30

How is the diagnosis of spontaneous bacterial peritonitis made?

Answer 30

Aspiration of fluid | Neutrophil count >250 cells/mm3

Question 31

What treatment is given in spontaneous bacterial peritonitis?

Answer 31

Antibiotics and albumin infusion

Question 32

What is non-alcoholic fatty liver disease?

Answer 32

Fatty liver or steatohepatitis in the absence of another cause

Question 33

What is the "two-hit" theory of NAFLD?

Answer 33

First hit - excessive fat accumulation | Second hit - oxidative stress, pro-inflammatory cytokine release e.g. TNF-alpha, ischaemia-reperfusion injury

Question 34

What antibodies can be found in the blood in autoimmune hepatitis?

Answer 34

Antinuclear antibodies Anti-smooth muscle antibodies Raised IgG

Question 35

What is primary biliary cirrhosis?

Answer 35

An autoimmune disease of the liver marked by the slow progressive destruction of the small bile ducts of the liver

Question 36

What antibodies are present in the blood in primary biliary cirrhosis?

Answer 36

Anti-mitochondrial antibodies | Raised IgM

Question 37

What is liver failure?

Answer 37

Inadequate synthesis of albumin, clotting factors and glucose and inadequate metabolism and elimination of endogenous products e.g. bilirubin, nitrogenous waste, hormones etc.

Question 38

What are some of the causes of hepatomegaly?

Answer 38

CRAM & FAIL Cancer Right heart failure Alcoholic liver disease Myeloproliferative diseases Fatty liver Amyloidosis Iron - haemochromatosis Lymphoma & leukaemia

Question 39

Why might right heart failure cause hepatomegaly?

Answer 39

The IVC has no valves - backlog of pressure from right heart will extend to liver

Question 40

What is haemochromatosis?

Answer 40

An issue with iron metabolism & secretion leading to build up in the body Can be congenital

Question 41

What are some of the signs of haemochromatosis?

Answer 41

``` Skin discolouration Diabetes Joint involvement (e.g. arthritis) Pituitary - sexual dysfunction Heart failure ```

Question 42

How is haemochromatosis treated?

Answer 42

Removal of a pint of blood every week until ferratin falls below 100 Then - remove 3/4 units a year

Question 43

What three markers in blood characterise autoimmune hepatitis?

Answer 43

Increased IgG Antibodies against liver specific and non-liver specific proteins Infiltration of: monocytes, macrophages, lymphocytes, plasma cells, macrophages and mast cells

Question 44

What antibodies may be present in autoimmune hepatitis?

Answer 44

Anti-smooth muscle antibodies | Anti-nuclear antibodies