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Flashcards in Liver Symposium Deck (43)
1

Is liver disease on the rise or decline in the uk?

Liver disease is on the rise

2

What kind of history will someone with parenchymal liver disease give?

Occupation
-Alcohol related (high risk)
-Animal contact
-Industrial exposure

Travel abroad
-Hepatitis-endemic areas
-Malaria

Contacts with jaundice
Sexual relations
Shellfish consumption

Injections: abroad, drug abuse, transfusions, tattoos

Drugs:
-Prescribed
-Over the counter
-Alternative medicines

3

What two categories can liver disease be broken down into?

Parenchymal
Cholicystitis

4

What are the liver function tests?

Markers of damage:
-Transaminases (AST or ALT)
---- Hepatocellular injury
-Alkaline phosphatase
---- Cholestatic
-y-glutamyl transferase
---- Both

TRUE liver function tests
-Albumin
-Bilirubin
-Prothrombin time

5

What is prothrombin time?

Clotting test
Factors II, V, VII and IX produced in liver
INR will go up when problems occur

6

What can you do when deranged LFT causes aren't apparent from history and examination?

Chronic Liver Disease Screen

This may also be done when a cause is apparent and there might be other co-factors

7

What blood tests are involved in a Chronic liver disease screen?

-Autoantibodies , immunoglobulins
-Hepatitis serology
-Caeruloplasmin, Copper
-Ferritin, Fe2+, Transferrin saturation
-a1 antitrypsin
-Epstein Barr Virus (Monospot)
-Cytomegalovirus (Ab + PCR)
-Leptospira
-Alpha fetoprotein (sus cancer)
-Fatty liver disease
----Fasting glucose (diabetes)
---- Lipid profile (hyperlipidaemia)

8

What raises IgA, IgG and IgM in a Chronic liver screen?

IgA = Alcohol
IgG = Autoimmune hepatitis
IgM = Primary biliary cirrhosis

9

What disease does low Caeruloplasmin and high copper show?

Wilson's

10

What disease does Ferritin show?

Haemochromatosis

11

What are the three autoantibody tests in chronic liver screening and what do they exclude/diagnose?

Antimitochondrial = primary billiary cirrhosis

Anti smooth muscle = autoimmune hepatitis

Antinuclear factor = autoimmune hepatitis

12

What are the indications for liver biopsy?

Aetiology
- Unknown parenchymal liver disease
-Unknown focal liver lesion

Staging
-Aetiology of liver disease known but more information required on degree of inflammation and/or degree of fibrosis or cirrhosis

13

What are some of the complications of ERCP?

Sedation Related:
-Respiratory
-Cardiovascular

Procedure Related:
-Pancreatitis
-Cholangitis
-Sphincterotomy
----Bleeding
----Perforation

14

What is PTC?

Percutaneous Transhepatic Cholangiogram (PTC)

Used when ERCP is not possible due to duodenal obstruction or previous surgery

More invasive than ERCP

15

What does EUS stand for in hepatic imaging/procedure?

Endoscopic Ultrasound

Used for:
-Characterising Pancreatic Masses
-Staging of Tumours
-FNA of tumours and cysts
-Excluding biliary microcalculi

16

What is Gilbert's syndrome?

Genetic defect

Affects 5% of adult population

Deficiency of active Uridine Diphosphate Glucuronosyltransferase 1A

Rise in unconjugated bilirubin

Bilirubin rises with fasting

17

What are the common causes of deranged LFTs?

Hepatic:
-Alcoholic cirrhosis and liver hepatitis
-NAFLD
-Viral hepatitis
-Metastatic cancer
-PBC
-Drug induced

Posthepatic
-CBD stone
-Carcinoma of the pancreas

18

What does an isolated rise in bilirubin show?

Gilbert's syndrome

19

What does jaundice with dark urine and pale stools show?

Obstructive liver disease

20

what do prothrombin time and albumin indicate?

Synthetic function of the liver

21

What is an excellent treatment for decompensated cirrhosis?

Liver transplantation

22

What is hepatitis and what are its causes?

Inflammation of the liver
Ranges from sub-clinical disease with deranged LFTs to hepatic necrosis and fulminant hepatic failure

Causes:
-VIRAL or bacterial
-Drugs
-Chemicals
-Toxins

23

What is hepatitis A?

Occurs sporadically or in epidemic form.

Transmission by faecal-oral, sexual or blood

5-14 yrs commonest group

Decreasing prevalence worldwide

Asymptomatic cases very common

Acute disease diagnosed by IgM antibodies

24

Who needs to vaccinated in particular against HAV?

Travellers

Patients with chronic liver disease
-IDU (especially with HCV or HBV)

Haemophiliacs

Occupational exposure
-lab workers

Gay men

25

How does HBV present and how is it transmitted?

Sporadic, endemic and epidemic

Wide variance in prevalence very rare in UK
Common in far east and sub-saharan africa

Transmission:
-Blood
-Sexual
-Faecal-oral

26

What are the 3 outcomes in adult infection of HBV?

80% Subclinical
20% Acute hepatitis
1% Fulminant Hepatitis

27

What are the treatments for HBV and what is the aim of treatment?

Aim of treatment = Suppress Virus

-Interferon (side effects limit use)
-Tenofovir, entecavir
-Lamivudine and Adefovir (viral mutations occur)

28

What is delta virus?

Small RNA virus
-does not code for its own protein coat
-enveloped by HBsAg

Co-infection or super-infection with HBV

Transmission as for HBV

29

What is the natural history of HCV?

10% patients report acute jaundice
Rarely causes acute liver failure

80% chronic HCV infection
Most symptomatic until cirrhotic
May have normal LFT's

30

How do you diagnose HCV?

Screening test HCV ELISA

Confirmatory test HCV PCR
-Detects ongoing chronic infection

Genotyping
-type of virus present

31

What correctable and uncorrectable factors play a role in the progression of liver disease?

Correctable
-Alcohol consumption
-Obesity
-Smoking
-Cannabis

Uncorrectable
-Age at infection
-Gender
-Ethnicity
-Co-infection HBV and HIV
-Immune deficiency

32

What is the treatment for HCV?

Directed antiviral acting drugs.

The aim is to cure

33

What is HEV?

-Previously thought to be limited to tropical countries
-Increasingly recognised in UK
-Commonest cause of acute hepatitis in Grampian
-Self limiting and no long term sequelae
-No specific treatment
-No effective vaccine currently available

34

Which hepatic viral infections are generally self limiting enteric infections?

Hepatitis A and E

35

What Hepatitis infection is aquired in childhood, often causes chronic infection?

Hepatitis B.
Chronic infection very rare in adults.

Hep B is endemic in a large area of the world

36

What is the aim of Hep B treatment?

To suppress the virus

37

What disease does HCV cause in 80% of those infected?

Chronic liver disease

patients with HCV are generally asymptomatic until the late stages of disease.

38

What is the aim of HCV treatment?

Cure the infection

39

List some of the intrahepatic lesions you may observe in imaging

Fatty liver
Simple cyst (benign)
Liver metastasis
Hepatoma

40

Describe the 3 locations of biliary tract lesions and what the lesions might be

In the lumen
-Gall stones, polyps

In the wall
-Changiocarcinoma, benign stricture

External pressure
-Pancreatic cancer, pancreatitis, lymph nodes

41

What patients are put forward for transplantation?

Chronic liver disease with poor predicted survival.

Chronic liver disease with associated poor quality of life

Hepatocellular carcinoma

Acute liver failure

42

What are the absolute contraindications for liver transplantation?

Extra-hepatic malignancy

Active intravenous drug abuse

Active alcohol abuse

Advanced cardiopulmonary disease

43

What are the relative contraindications for liver transplantation?

-Age >70
-Longstanding diabetes mellitus
-Significant sepsis outside the extra hepatic biliary tree
-HBV DNA positivity
-Severe psychiatric disorder
-Active substance misuse
-HIV