Liver Symposium

Question 1

What causes jaundice?

Answer 1

Increased circulating bilirubin due to altered metabolism/altered metabolism pathway of bilirubin

Question 2

What are the classes of jaundice?

Answer 2

Pre-Hepatic
Hepatic
Post-Hepatic

Question 3

What are the types of hepatic jaundice?

Answer 3

Predictable (dose related) and unpredictable

Question 4

What are the causes of hepatic jaundice?

Answer 4

Cholestasis

Intra-hepatic bile duct obstruction

Question 5

What is the cause of pre-hepatic jaundice?

Answer 5

Increased release of haemoglobin from RBCs due to haemolysis

Question 6

What is the cause of post-hepatic jaundice?

Answer 6

Gallstones

Question 7

What is bilirubin?

Answer 7

A by-product of haemoglobin metabolism, haem part -> bilirubin

Question 8

Bilirubin joins with albumin which the liver helps to solubilise so it can be

Answer 8

excreted in the bile

Question 9

Why might bilirubin be elevated?

Answer 9

Haemolysis
Parenchymal damage
Obstruction

Question 10

What amino-transferases can indicate liver injury?

Answer 10

ALT and AST

Question 11

Is ALT or AST more specific?

Answer 11

ALT

Question 12

If the AST levels > ALT levels, what is indicated?

Answer 12

Liver disease caused by alcohol

Question 13

What is alkaline phosphatase and when might it be elevated?

Answer 13

Enzyme present in the bile ducts, elevated with obstruction or liver infiltration

Question 14

When is Gamma-GT elevated?

Answer 14

With alcohol consumption and some drugs e.g. NSAIDs

Question 15

If alkaline phosphatase and gamma-GT are both raised, what is indicated?

Answer 15

Liver disease

Question 16

What do albumin tests show?

Answer 16

Synthetic function of the liver

Question 17

Low levels of albumin suggest

Answer 17

chronic liver disease, kidney disorders or malnutrition

Question 18

What symptom/sign can be seen in any condition causing a fall in albumin?

Answer 18

Oedema

Question 19

What does prothrombin time determine?

Answer 19

The extent and prognosis of liver dysfunction

Question 20

What is prothrombin time a test of?

Answer 20

Clotting factors

Question 21

What does creatinine test and why is this important?

Answer 21

Tests kidney function
Important as the liver and kidneys are closely related and poor kidney function indicates a poorer prognosis of liver disease

Question 22

Why is platelet count important in determining liver disease?

Answer 22

Liver is an important source of thrombopoetin, cirrhosis resulting in hyperplenism results in low platelets and indicates portal hypertension

Question 23

Give 6 investigations which should be done when investigating liver disease

Answer 23

Immunoglobulins 
Autoantibodies 
Caeruloplasmin copper 
Ferritin 
Alpha-1 antitrypsin 
Hepatitis serology 
Epstein Barr Virus 
Cytomegalovirus 
Leptospira 
Alphafetoprotein 
Fasting glucose/lipid profile

Question 24

What is the treatment for hepatic encephalopathy?

Answer 24

Bowel clear out
Antibiotics for underlying infection
Palliative care
Chemo/radiotherapy

Question 25

What is the treatment for spontaneous bacterial peritonitis?

Answer 25

IV antibiotics Ascitic fluid drainage IV albumin infusion

Question 26

What is the treatment for alcoholic hepatitis?

Answer 26

``` Palliative Treat underlying infections Treat encephalopathy Treat alcohol withdrawal Protect against GI bleeding Airway support/ITU care Steroids if severe - improve short term prognosis Nutritional supplements Thiamine ```

Question 27

What is the treatment of steatohepatitis?

Answer 27

Weight loss and exercise

Question 28

What is the treatment of obstructive jaundice?

Answer 28

ERCP / PTC

Question 29

What is the treatment of ascites?

Answer 29

Diuretics Paracentesis TIPS Aquaretics

Question 30

What is the treatment of portal hypertension?

Answer 30

``` Resuscitation Blood transfusion Endoscopic band ligation Sengstaken-Blakemore tube for uncontrolled bleeding TIPS for re-bleeding ```

Question 31

What is the treatment of chronic hepatitis B?

Answer 31

Interferon Tenofovir Entecavir Lamivudine and Adefovir

Question 32

What is the treatment of hepatitis C?

Answer 32

6 or 12 month treatment Weekly subcutaneous injection of pegylated interferon Daily Ribavirin tablets Protease inhibitor for genotype 1 patients

Question 33

What are the possible treatments of gallstones?

Answer 33

Dissolution Lithotripsy Laparoscopic cholecystectomy Cholecystotomy

Question 34

What are the possible treatments for common bile duct stones?

Answer 34

Laparoscopic/open exploration of CBD ERCP Trans-hepatic stone retrieval

Question 35

What are the possible treatments for cholangiocarcinoma?

Answer 35

``` Surgical bypass Stenting Radio/chemotherapy PDT Surgery - only potentially curative option ```