Liver Symposium: Viral liver disease/alcohol related problems/liver transplantation issues

Question 1

What is jaundice?

Answer 1

Yellowing of the skin, sclerae and other tissues e.g. eyes, caused by excess circulating bilirubin

Question 2

At what level of bilirubin can jaundice become detectable?

Answer 2

Total plasma bilirubin levels exceed 34μmol/L

Question 3

What is the lifespan of a RBC?

Answer 3

120 days

Question 4

What happens to the haem part of the RBC after it dies?

Answer 4

Converted to Biliverdin (Unconjugated – Insoluble form) and then in the Liver it is converted to Bilirubin (Conjugated – Soluble form)

Question 5

Where is unconjugated Bilirubin found?

Answer 5

Pre-hepatic

Question 6

Where is conjugated Bilirubin found?

Answer 6

Hepatic & Post-hepatic`

Question 7

What type of jaundice is most likely to occur in an obstructive condition?

Answer 7

Post-hepatic

Question 8

Where is most conjugated bilirubin excreted?

Answer 8

Stool

A little to the kidney for urine

Question 9

What will occur in pre-hepatic jaundice?

Answer 9

Increased quantity of bilirubin (Haemolysis) and impaired transport No urine change

Question 10

What will there have been a history of in pre-hepatic jaundice?

Answer 10

Anaemia
Acholuric jaundice
Pallor
Splenomegaly

Question 11

What will occur in hepatic jaundice?

Answer 11

Defective uptake of bilirubin
Defective conjugation
Defective excretion e.g. Liver failure

Question 12

What are the signs of hepatic jaundice?

Answer 12

Stigmata of CLD e.g. Spider naevi
Gynaecomastia
Ascites
Asterixis (Flapping tremor)

Question 13

What occurs in post-hepatic jaundice?

Answer 13

Defective transport of bilirubin by the biliary ducts

Question 14

What are signs of post-hepatic jaundice?

Answer 14

Abdominal pain
Cholestasis e.g. Pruritis (Itching - Bile salts deposit in the skin as the duct is blocked), Pale stools & High coloured urine)

Question 15

How does a palpable gallbladder occur in post-hepatic jaundice?

Answer 15

Obstruction in the bile duct past the cystic duct, can’t go anywhere and will back up causing an enlarged Gall Bladder Due to gall stones of liver cancer

Question 16

What is Gilbert’s syndrome?

Answer 16

Genetic defect that results in a rise in unconjugated bilirubin and this bilirubin rises with fasting

Question 17

In relation to jaundice, what is dark urine and pale stool indicative of?

Answer 17

Obstructive jaunduce

Question 18

What should be checked in the history in relation to jaundice?

Answer 18

Occupation, Travel abroad, Contacts with jaundice, Sexual relations, Shellfish consumption, Injections & Drugs

Question 19

What time will be elevated with liver disease?

Answer 19

Prothrombin time (Factors II, V, VII & IX)

Question 20

What six hepatic causes are there for deranged LFTs?

Answer 20

Alcoholic cirrhosis/hepatitis
Viral hepatitis
PBC
Non-alcoholic Fatty Liver Disease (NAFLD)
Metastatic cancer
Drug induced

Question 21

What is a post-hepatic cause for deranged LFTs?

Answer 21

CBD stone

Carcinoma of the pancreas

Question 22

What tests should be done for Haemachromatosis?

Answer 22

Ferritin
Fe2+
Transferrin saturation

Question 23

In what cases is a Hepatitis A (IgM) serology seen?

Answer 23

Acute liver disease

Question 24

When should an AFP test be done?

Answer 24

Suspected liver cancer

Question 25

What tests should be done for fatty liver disease?

Answer 25

``` Fasting glucose (Diabetes) Lipid profile (Hyperlipidaemia) ```

Question 26

Why is urine clear in pre-hepatic jaundice?

Answer 26

Unconjugated bilirubin insoluble in water Unconjugated bilirubin circulates bound to albumin Albumin is too large to fit through the glomerulus

Question 27

Why is urine dark in cholestatic jaundice?

Answer 27

Urine is dark because conjugated bilirubin is soluble in water, it circulates unbound and is free to pass through glomerulus Stools are pale because stercobilinogen does not reach the stool

Question 28

What is a good treatment for decompensated cirrhosis?

Answer 28

Liver transplant

Question 29

What are the differences between ERCP & MRCP?

Answer 29

ERCP - Radiation, Sedation, Complication (Sedation or Procedure related), Failure rate, Only images ducts & Therapeutic option *ERCP is both diagnostic and therapeutic* MRCP - No radiation/complications, Claustrophobia & Images with outwith ducts

Question 30

What steps should be taken in managing obstructive jaundice?

Answer 30

Relief of obstruction Prevent complication Prevent recurrence

Question 31

What should be done when treating ascending cholangitis?

Answer 31

Prompt drainage | Control infection

Question 32

What is ascending cholangitis?

Answer 32

Biliary tree infection

Question 33

What is hepatitis?

Answer 33

Inflammation of the liver

Question 34

What are the causes of hepatitis?

Answer 34

Viral/Bacterial Drugs Chemicals Toxins

Question 35

When does hepatitis A occur, how is it transmitted and how is it diagnosed?

Answer 35

Occurs sporadically or in epidemic form Transmitted by Faecal-Oral, Sexual or Blood Acutely diagnosed by IgM antibodies

Question 36

When does hepatitis B occur, how is it transmitted and how is it prevented?

Answer 36

Sporadic, endemic and epidemic Blood, Sexual and Faecal-Oral Prevention - Vaccination, Blood product screening, Clean needles, Discourage IDU, Alter sexual practices & Safe disposal of sharps

Question 37

How should Hepatitis B be treated?

Answer 37

Interferon Tenfovier, entecavir Lamivudine and Adefovir (Viral mutations occur)

Question 38

How does Hepatitis C present'?

Answer 38

Most asymptomatic until cirrhotic | May have normal LFTs

Question 39

What can Hepatitis C result in?

Answer 39

Liver failure or Hepatoma

Question 40

How is Hepatitis C transmitted and treated?

Answer 40

Transmitted - IDU, Tattoo, Sexual, Unknown & Blood products Treated - 6-12 month treatment of direct anti-viral drugs

Question 41

How does Hepatitis E present and what is its treatment?

Answer 41

Self-limiting with no long-term sequelae | No specific treatment or effective vaccine made yet

Question 42

What type of biliary tract lesions are there?

Answer 42

Lumen - Gallstones & Polyps Wall - Cholangiocarcinoma & Benign structre External pressure - Pancreatic cancer, Pancreatitis & Lymph nodes

Question 43

What are the contraindications for liver transplant?

Answer 43

Advanced cardiopulmonary disease | Extra-hepatic malignancy