Week 13 Flashcards
What are the broad causes of injury to the liver?
drugs and toxins including alcohol abnormal nutrition / metabolism infection obstruction to bile or blow flow autoimmune liver disease genetic/deposition disease neoplasia
What is meant by fulminant hepatitis?
severe acute, rapidly progressing towards liver failure
What is the definition of cirrhosis?
end stage liver disease
diffuse process with fibrosis and nodule formation
What is the clinical approach to liver disease?
History, symptoms and signs by examination
investigations - bloods, LFTS, haematology, viral and autoimmune serology, metabolic tests
radiology - ultrasound
What are some of the types of diffuse liver disease?
acute hepatitis acute cholestsis fatty liver disease chronic hepatitis chronic biliary disease hepatic vascular disease deposition / genetic disease
What is the appearance of acute hepatitis?
Diffuse hepatocyte injury seen as swelling, some cell death. spotty necrosis. There is an inflammatory cell infiltrate in all areas - portal tracts, interface and parenchyma
What are the causes of acute cholestasis or cholestatic hepatitis?
extrahepatic biliary obstruction
drug injury - antibiotics
What is the appearance of acute cholestasis in histology?
brown bile (bilirubin) pigment, +/- acute hepatitis
Describe hepatitis B on pathology
acute hepatitis plus fibrosis
ground glass cytoplasm in hepatocytes
What are the causes of chronic biliary / cholestatic disease?
primary biliary cholangitis
primary sclerosing cholangitis
What is the historical appearance of chronic biliary disease?
focal, portal predominant inflammation and fibrosis with bile duct injury
Granulomas in PBC
What are the causes of genetic/deposition liver disease?
haemochromatosis
wilson’s disease
alpha 1 antitrypsin
What are the non neoplastic space occupying lesions (focal liver lesions)?
developmental/degenertive cysts
inflammatory - abscess
What is the commonest form of liver cyst?
Von Meyenberg complex (simple biliary hamartoma)
can resemble metastases by naked eye operation
What are the benign and malignant names of liver cell neoplasms?
hepatocellular adenoma hepatocellular carcinoma (HCC)
What are the benign and malignant names of bile duct neoplasms?
bile duct adenoma (rare)
cholangio-carcinoma
What are the benign and malignant names of blood vessels neoplasms in liver?
haemangioma
angiosarcoma
Describe a haemangioma
benign blood vessel tumour
biopsy avoided because risk of bleeding
Describe a hepatic adenoma
rare
mainly young women, often associated with hormonal therapy
risk of bleeding and rupture so excision if large
Describe hepatocellular carcinoma
most common primary liver tumour
usually arises in cirrhosis and associated with elevated serum alpha feto-protein
screening available
What are the normal functions of the liver?
protein, carbohydrate and fat metabolism plasma protein and enzyme synthesis production of bile detoxification storage of protein, glycogen, vitamins and metals immune function
How is the actual function of the liver assessed?
albumin
bilirubin
prothrombin time
How should chronic liver disease be investigated?
ultrasound viral hepatitis serlogy AI - ANA/SMA/LKM (AIH), AMA (PBC) metabolic liver disease- ferritin (haemachromatosis) caeruloplasmin (wilsons) alpha 1 antitrypsin deficiency
How should acute liver injury be investigated?
ultrasound
acute viral hepatitis serology
autoimmune liver disease (ANA, AMA, LKM (AIH), immunoglobulins”
paracetamol levels
What are the most common causes of abnormal liver blood tests?
fatty liver - alcohol in non
chronic viral hepatitis - C
autoimmune liver disease - primary biliary cholangitis, autoimmune hepatitis
haemochromatosis
Describe the progression of alcoholic liver disease
alcoholic steatosis
alcoholic hepatitis
alcoholic cirrhosis
Describe the progression of non-alcoholic fatty disease
steatosis
non-alcoholic steatitic hepatitis
NAFLD cirrhosis
What are the main associations with NAFLD?
obesity, type 2 diabetes and hyperlipidaemia
How can ALD and NAFLD be differentiated with LFTs?
AST:ALT ratio
AST is much higher in ALD
What are the essential features on alcoholic hepatitis?
excess alcohol within 2 months bilirubin >80 for less than 2 months exclusion of other liver disease treatment of sepsis / GI bleeding AST >500 (AST:ALT ration >1.5)
What are the characteristic features of alcoholic hepatitis?
hepatomegaly, fever, leucocytosis and hepatic bruit
What are signs of chronic liver disease?
stigmata: spiders, foetor, encephalopathy
synthetic dysfunction - prolonged prothrombin time, hypoalbuminaemia
What are the signs of portal hypertension?
caput medusa
hypersplenisms
thrombocytopaenia
Describe the cell count in the assessment of ascites
> 500 WBC/cm3 and 250 neutrophils/cm3 suggests spontaneous bacterial peritonitis
inflammatory conditions can also increase WBC count
lymphocytosis suggests TB or peritoneal carcinomatosis
Describe the albumin in the diagnosis of ascites
serum ascites albumin gradient (SAAG) = serum albumin - ascitic albumin
if SAAG >11g/l = portal hypertension
What is the management of ascites?
low salt diet spironolactone furosemide paracentesis transjugular intrahepatic portosystemic shunt liver transplant
What are common precipitating factors for hepatic encephalopathy?
gastrointestinal bleeding infections constipation electrolyte inbalance excess dietary (especially animal) protein
how can hepatic encephalopathy be treated?
lactulose and rifaximin
Describe lithogenic bile
bile becomes lithogenic for cholesterol if there is excessive secretion of cholesterol or decreased secretion of bile salts
excessive secretion of bilirubin (haemolytic anaemia) can cause its precipitation in concentrated bile in the gallbladder
Describe acute cholecystitis
severe RUQ pain, tenderness and fever
leukocytosis and normal serum amylase
usually resolves spontaneously but can progress to empyema, gangrene and rupture
initiated by stone obstruction of cystic duct causing supersaturation of bile and chemical irritation
Describe chronic cholecystitis
may be a sequel to repeated attacks of acute cholecystitis
gallstones are virtually always present
inflammation secondary to chemical damage (supersaturated bile)
rather than bacterial infection
How does acute pancreatitis present?
severe RUQ pain
fever
leukocytosis
raised serum amylase
Describe pancreatic abscess
potential complication of acute pancreatitis
infected pancreatic necrosis
avascular haemorrhagic pancreas good culture medium
drainage or necrosectomy plus antibiotics
Describe a pancreatic pseudocyst
potential complication of acute pancreatic no epithelial lining commonly in lesser sac high concentration of pancreatic enzymes may resolve spontaneously may be drained into stomach
What are the differentials of pancreatic pseuodocysts
mucinous cystic neoplasm - ovarian type
intraductal papillary mucinuos neoplasm
serous cystadenoma
What are the risk factors for pancreatic cancer?
gremlin mutations (BRCA) account for small proportion smoking is by far the biggest risk factor
What are the signs and symptoms of pancreatic cancer?
painless obstructive jaundice
new onset diabetes
abdominal pain due to pancreatic insufficiency or nerve invasion
tumours in head may obstruct pancreatic duct and bile duct - double duct sign on radiology
Describe pancreatic endocrine tumours
rare
may secrete hormones
commonest functional tumour is insulinoma which presents with hypoglycaemia, mainly benign
malignant endocrine tumours have a much better prognosis than pancreatic carcinoma
