Liver Function And Pathology

Question 1

What are 3 main functions of the liver

Answer 1

• Storage (Fe, Cu, Glycogen, Vitamins)
• Synthetic (Glucose/lipids, Cholesterol, Bile, Clotting factors, Albumin)

Metabolic (Bilirubin, NH3, Drugs, Alcohol, Carohydrates and lipids)

Question 2

Name the 2 main protein made by liver

Answer 2

Albumin

Clotting factors

Question 3

What are 4 specific symptoms of Liver disease?

Answer 3

• Jaundice
• Oedema/ Ascites
• Bleeding/ easy bruising
• Confusion

Question 4

1. Relate the metabolic function of the liver to jaundice

2. Relate the synthetic function of the liver to Oedema/ Ascites

Answer 4

1. Increase in Bilirubin in blood

2. Reduced function to make albumin which exerts oncotic pressure in blood

Question 5

1. Relate the synthetic function of the liver to Bleeding

2. Relate the metabolic function of the liver to Confusion

Answer 5

1. Reduced ability to make clotting factors

2. Reduced ability to detoxify NH3

Question 6

List 4 causes of Acute Liver failure

Answer 6

• Alcohol
• Paracetamol
• Viral
• Medications (Aspirin in children)

Question 7

All causes of liver disease lead to Cirrhosis

What is Cirrhosis?
What does it develop in response to?
What does it lead to?

Answer 7

Permanent damage to liver, resulting in impairment of liver function and distortion of architecture of liver

Develops in response to any chronic inflammation-> Fibrosis and hepatocyte necrosis-> Nodules

Question 8

What are 5 groups causes of Chronic Inflammation leading to Cirrhosis?

Answer 8

• Drugs
• Infection
• Deposition
• Autoimmune
• Other

Question 9

List ways that Drugs can cause chronic inflammation leading to Cirrhosis

Answer 9

1. Iatrogenic causes (unintentional damage)
2. Alcoholic liver disease;
   - Fatty change/ Steatosis (in weeks, usually reversible)-> Hepatomegaly

• Alcoholic hepatitis (Usually over years)->RUQ pain, Hepatomegaly, Jaundice

Question 10

List ways that Infection can cause chronic inflammation leading to Cirrhosis

Answer 10

• Hep B: Vaccine, no cure, Symptomatic
• Hep C: (IV Drug use) Cure, no vaccine, mostly Asymptomatic

(These can also cause hepatocelluar carcinoma)

Question 11

List ways that Deposition can cause chronic inflammation leading to Cirrhosis

Answer 11

1. Non Alcoholic Fatty Liver Disease (NAFLD);
   - Insulin resistance, Triglyceride accumulation in hepatocytes
   - Called Non Alcoholic Steatohepatitis (NASH) if inflammation present
2. Hereditary Haemochromatosis; (Autosomal recessive)
   - Increased Fe absorption-> Increased Ferritin
   - Risk of hepatocellular carcinoma
3. Wilson’s Disease;
   - Reduced Cu secretion from biliary system
   - Reduced Ceruloplasmin (carries Cu in blood)
   - Can affects CNS

Question 12

List ways that Autoimmune abnormalities can cause chronic inflammation leading to Cirrhosis

Answer 12

Autoimmune hepatitis;

• Autoantibodies against hepatocytes (E.g ASMA, ANA)
• PBC (Primary Biliary Cirrhosis, AMA +ve)
• PSC (Primary Sclerosing Cholanitis, AMA-ve)

(PSC associated with IBD, especially Ulcerative Colitis)

Question 13

List ways other than Drugs/ Infection/ Deposition/ Autoimmune that can cause chronic inflammation leading to Cirrhosis

Answer 13

• Budd Chiari
• Glycogen Storage Disorders
• Alpha1 Antitrypsin deficiency

Question 14

What are the 3 main veins of the Portal Circulation

Answer 14

• Inferior Mesenteric Vein (Descending colon)
• Superior Mesenteric Vein (Ascending Colon mainly)
• Splenic Vein

Question 15

Describe the Portal Circulation

Answer 15

• IMV drains into Splenic vein
• Move to the right side, and combine with SMV
• This makes the Portal Vein->Hepatic vein-> IVC

Question 16

Why does Cirrhosis lead to Portal Hypertension?

Answer 16

Cirrhosis of liver-> Fibrosis, reducing expansive capability and compressing Portal Vein-> Hypertension

Question 17

What are 4 consequences of Portal Hypertension?

Answer 17

• Ascites (Increased hydrostatic pressure and reduced albumin production)
• Splenomegaly (Pressure buildup in Splenic circulation)
• Varices (Blood shunts from Portal-> Systemic circulation via anastomoses not normally in use, leading to distension of veins at anastomoses)
• Hepatorenal Syndrome

Question 18

What are 3 common sites where Varices can occur?

Answer 18

• Oesophageal Varices (Can lead to Haematemesis)
• Ano Rectal Varices (Typically painless, rarely bleed)
• Umbilical Varices (‘Caput medusa’ is the clinical sign)

Question 19

Describe and explain Hepatorenal Syndrome (A consequence of portal hypertension)

Answer 19

Acute, rapidly declining kidney function

1. Hypertension affects arterial/ Splanchnic circulation causing Vasodilator release
2. Perceived drop in circulatory volume> RAAS activation
3. Leads to Renal Artery vasoconstriction-> Reduced perfusion

Question 20

Outline how the Biliary System and how bile enters the duodenum

Answer 20

• Bile Canaliculi in Liver form R and L Hepatic Ducts, which combine-> Common Hepatic Duct
• Cystic duct from Gallbladder joins CHD-> Common Bile Duct
• Pancreatic duct joins CBD to later enter Duodenum at Ampulla of Vater
• Sphincter of Oddi controls rate of entry of bile and secretions into Duodenum

Question 21

Gallstones form in the Gallbladder are quite common
What are they made of?

What are 4 risk factors

Answer 21

• Cholesterol/ Bile Pigments/ A mixture (Not normally visible on X Ray)
• Diet and lifestyle
• Female
• 40s
• Pregnancy

Question 22

Gallstones don’t often have any complications. Name 4

Answer 22

• Biliary Colic
• Acute Cholecystitis
• Ascending/ Acute Cholangitis
• Acute Pancreatitis

Question 23

Describe Biliary Colic and it’s presentation

Answer 23

• Sudden onset RUQ pain that lasts for a while, as CCK makes GB contract and GSs pushed up against neck of GB (typically after a fatty meal)
• No inflammation

Question 24

Describe Acute Cholecystitis and it’s presentation

Answer 24

• RUQ pain as Cystic Duct is obstructed by Gallstones
• Inflammation present
• +ve Murphy’s sign (Put hand on right side, breathe in, Gallbladder hits hand + pain)

(Treat: Pain relief, Cholecystectomy)

Question 25

Describe Acute/ Ascending Cholangitis and it’s presentation

Answer 25

- Caused by infection - Gallstone reaches and obstructs CBD Present with Charcot’s Triad; - RUQ pain - Jaundice - Evidence of inflammation

Question 26

Describe Acute Pancreatitis and it’s presentation

Answer 26

- Gallstone in CB at/ after the point at which the Pancreatic Duct joins the CBD - Autodigestion of pancreas - Epigastric pain, which radiates to back - Vomiting - Cullens and Grey Turners’ signs - Raised pancreatic Amylase and Lipase in blood