Gastrointestinal > Liver Function + Pathology > Flashcards

Liver Function + Pathology Flashcards

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1
Q

Functions of the liver

A
  • Storage: e.g. glycogen, vitamins, iron, copper
  • Synthesis: e.g. glucose, lipids, cholesterol, bile, clotting factors, albumin
  • Metabolic: e.g. bilirubin, ammonia, drugs, alcohol, carbs, lipids
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2
Q

Investigations of liver pathology

A
  • LFTs
  • gamma GT
  • FBCs (thrombocytopenia)
  • bilirubin, albumin
  • USS of liver
  • hep B+C serology
  • HIV screen
  • autoantibodies
  • clotting times
  • ferritin + transferrin (haemochromatosis)
  • caeruloplasmin (wilson’s disease)
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3
Q

What is involved in liver screen?

A
  • hep B+C serology
  • Ferritin + transferrin saturation
  • autoantibodies + immunoglobuins
  • alpha 1 antitrypspin
  • coeliac serology (tissue transglutaminase)
  • LFTs, lipids + glucose
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4
Q

Symptoms of liver pathology

A

Jaundice
Oedema/ascites
Bleeding
Confusion

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5
Q

Signs of chronic liver disease

A
  • spider naevi
  • clubbing
  • palmar erythema
  • ascites
  • Dupuytren contracture
  • leukonychia
  • asterixis - flapping tremor
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6
Q

What can cause acute liver failure?

A

Excessive alcohol
Paracetamol overdose
Virus
Medications e.g. aspirin

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7
Q

What is acute liver failure?

A

Sudden onset of liver pathology symptoms with no previous background of liver disease

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8
Q

Why do we avoid giving children aspirin?

A

Can cause acute liver failure

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9
Q

What is cirrhosis

A

Permanent damage to the liver which results to impaired function + distortion of liver architecture in response to chronic inflammation of the liver

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10
Q

Key feature of liver cirrhosis

A

Nodules
Due to bands of fibrosis

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11
Q

Causes of liver cirrhosis

A
  • alcohol related liver disease
  • non-alcoholic fatty liver disease
  • hep B+C
    .
    rare causes:
  • hemochromatosis
  • wilsons disease
  • alpha 1-antitrypsin deficiency
  • primary sclerosing/biliary cholangitis
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12
Q

What is the best imaging for cirrhosis?

A

FibroScan
determines the degree of fibrosis

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13
Q

Management of chronic liver disease

A
  • treat underlying cause
  • monitoring + managing complications
  • liver transplant
  • Child-Pugh Score
  • MELD score every 6 months
  • USS + alpha-fetoprotein every 6 months for hepatocellular carcinoma
  • endoscopy every 3 years of oesophageal varices
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14
Q

When is a liver transplant considered?

A

when there are features of decompensated liver disease

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15
Q

Features of decompensated liver disease

A

AHOY
- Ascites
- Hepatic encephalopathy
- Oesophageal varices bleeding
- Yellow (jaundice)

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16
Q

What score is used to assess the severity of cirrhosis + prognosis?

A

Child-Pugh Score

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17
Q

Outline the Child-Pugh Score

A
  • assesses the severity of cirrhosis + prognosis
  • each factor scored 1-3
  • ABCDE:
  • Albumin
  • Bilirubin
  • Clotting (INR)
  • Diltation (ascites)
  • Encephalopathy
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18
Q

Complications of cirrhosis

A
  • malnutrition + muscle wasting
  • portal hypertension, oesophageal varices + bleeding varices
  • ascites + spontaneous bacterial peritonitis
  • hepatorenal syndrome
  • hepatic encephalopathy
  • hepatocellular carcinoma
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19
Q

What investigation should be done on all patients with ascites?

A

diagnostic ascitic tap
to look for spontaneous bacterial peritonitis

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20
Q

Stepwise progression of alchol realted liver disease

A
  • alcoholic fatty liver (hepatic steatosis)
  • alcoholic hepatitis
  • cirrhosis
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21
Q

What happens to the liver in alcoholic liver disease over weeks?

A
  • Fatty changes due to fatty deposits > Hepatomegaly
  • Normally reversible
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22
Q

What happens to the liver in alcoholic liver disease over years?

A
  • alcoholic hepatitis
  • inflammatory cells + fatty change
  • jaundice
  • right upper quadrant pain
  • Hepatomegaly
  • leads to cirrhosis
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23
Q

What is Wernicke-Korsakoff syndrome?

A
  • alcohol excess > thiamine deficiency > Wernicke’s encephalopathy + Korsakoff syndrome
  • Wernicke’s encephalopathy: an acute neurological emergency
  • Korsakoff syndrome: chronic memory disorder
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24
Q

Features of Wernicke’s encephalopathy

A
  • confusion
  • disturbance of eye movements
  • ataxia
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25
Features of Korsakoff syndrome
- antegrade + retrograde amnesia - fabrication of false memories
26
Management of alcohol related liver disease
- stop drinking (turning point) (*disulfiram*) - cognitive behavioural therapy - nutritional support - high vitamins + protein diet - treat complications of cirrhosis
27
What infections can cause chronic liver damage?
- **Hepatitis B**: vaccine but no cure | symptomatic - **Hepatitis C**: cure but no vaccine | asymptomatic
28
Outline non-alcoholic fatty liver disease
- associated with insulin resistance - accumulation of triglycerides - inflammation over time > NASH *non alcoholic steatophepatitis*
29
Stages of non-alcoholic fatty liver disease
- non-alcoholic fatty liver disease - non-alcoholic steatohepatitis NASH - fibrosis - cirrhosis
30
Describe the two mechanisms that lead to fatty deposition on liver
- **excessive intake of dietary fats**: increased triglyceride accumulation in liver - **regarding insulin resistance**: impairs ability of liver to respond to insulin > increased breakdown of fats in adipose > accumulation in liver
31
Management of non-alcoholic fatty liver
- weight loss - healthy diet (Mediterranean) - exercise - limit alcohol intake - smoking cessation - control of diabetes, BP + cholesterol
32
Outline hereditary haemochromatosis
- **increased absorption of iron** from small intestines - leads to **excessive deposition** within liver - autosomal recessive - associated with high levels of ferritin
33
Presentation fo haemochromatosis
presents after 40 - chronic tiredness - joint pain - bronze skin - testicular atrophy - ED - amenorrhea - hepatomegaly - mood + memory disturbance
34
Diagnosis of haemochromatosis
- high ferritin - high transferrin - genetic testing for mutation of HFE gene
35
Complications of haemochromatosis
- liver cirrhosis + hepatocellular carcinoma - ED - reduced fertility - cardiomyopathy - hypothyroidism - chondrocalcinosis > arthrisi - secondary diabetes
36
Treatment of hereditary haemochromatosis
**Venesection** Reduces iron in circulation
37
Outline Wilson’s disease
- **decreased copper secretion** from liver to be removed - leads to **increased deposition** in liver - low levels of caeruloplasmin - can effect CNS (seizures, memory loss) - autosomal recessive
38
Presentation of Wilson's disease
- Kayser-Fleischer rings in cornea (brown ring) - chronic liver disease features - abnormal behaviour - depression - cognitive impairment - tremor - dysarthria
39
Investigations of Wilson's disease
- **serum caeruloplasmin** (low) - reduced total serum copper - 24-hour urine copper assay > increased copper excretion - genetic testing - MRI brain - double panda sign
40
Management of Wilson's disease
- **copper chelation** using *penicillamine* or *trientine* - **zinc salts** - inhibits GI copper absorption - liver transplant
41
What autoimmune conditions can damage the liver?
Autoimmune hepatitis Primary biliary cirrhosis Primary sclerosing cholangitis
42
Why can liver disease can jaundice?
Build up of **bilirubin** as liver cannot metabolise it effectively
43
Why can liver disease cause oedema or ascites?
- **decreased synthetic function** - **decrease albumin production** - **decreases osmotic pressure** - fluid moves out more easily . - fibrosis > **compression of liver sinusoids** - exerts **back pressure** on portal vein - **portal hypertension** - fluid moves out into abdominal cavity
44
Why can liver disease cause bleeding issues?
Decreased synthesis of **clotting factors** *e.g easy bruising, nosebleeds, long bleeding time*
45
What is portal hypertension?
When there is increased hydrostatic pressure within the portal venous system due to fibrotic changes in the liver
46
Complications of portal hypertension
Ascites Splenomegaly Varices
47
What are varices?
Dilated veins
48
What is heptaorenal syndrome?
Presence of acute or rapidly deteriorating kidney function due to underlying liver cirrhosis + portal hypertension
49
What are the three location for varices in portal hypertension?
Oesophagus Umbilical Anorectal
50
How does portal hypertension cause oesophageal varices?
- **left gastric vein** normally drains the **lower part of the oesophagus** - in portal hypertension, varices divert blood to the **azygous vein** which drains into the SVC
51
Symptoms of anorectal varices
Rectal bleeding > anaemia Pain Discomfort
52
What are umbilical varices also called?
Caput medusae
53
Venous drainage of the oesophagus
Upper 2/3: **oesophageal veins > azygous vein > SVC** Lower 1/3: **left gastric vein > portal vein**
54
Prophylaxis of bleeding for oesophageal varices
**first line**: B blockers *propanolol* variceal band ligation in B blockers are contraindicated
55
How does hepatorenal syndrome occur?
- presence of cirrhosis + portal hypertension increases NO in gut vasculature - results in splanchnic vasodilation - body perceives as a drop in circulating volume - RAAS activated > systemic vasoconstriction - decreased perfusion to kidney > acute kidney injury
56
Why might someone with liver disease become confused?
Unconjugated bilirubin can pass the blood brain barrier
57
Name the underlying change that causes liver enlargement following chronic alcohol intake
Steatosis (fatty liver)
58
What causes Budd Chiari syndrome?
Hepatic vein becomes blocked or narrowed
59
What is the triad of Budd-chiari?
Abdominal pain Ascites Hepatomegaly
60
How does cirrhosis cause hepatic encephalopathy?
- due to build up of ammonia produced by intestinal bacteria - in cirrhosis, the liver cells have a reduced ability to metabolism ammonia into harmless waste products - and, collateral vessels between portal + systemic circulation mean that ammonia bypasses the liver
61
Grading of hepatic encephalopathy (presentation)
- **Grade 1**: reversed sleep pattern, psychomotor slowing, poor memory - **Grade 2**: lethargy, disorientation, asterixis, agitation - **Grade 3**: drowsy - **Grade 4**: coma
62
Management of hepatic encephalopathy
- **lactulose** - **antibiotics**: *e.g. rifaximin* to reduced intestinal bacteria - **nutritional support**
63
How does lactulose reduce ammonia?
- speeds up transmit time + reduces constipation > removes ammonia before it is absorbed - promotes bacterial uptake of ammonia for protein synthesis - makes the intestines more acidic > killing the bacteria
64
Ascites SAAG Management
Gastrointestinal
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