Liver Disease

Front 1

What is the normal range of serum bilirubin and above what level do you see jaundice?

Back 1

Normal = 3-20 umol/L

Above 35 umol/L = visible jaundice

Front 2

Majority of bilirubin is secreted by what and as what?

Back 2

Majority of bilirubin (99%) secreted as urobilin in stool.

Front 3

List steps in bilirubin processing incl. where things happen

Back 3

1. Spleen

- RBC broken into Haem + globin

- Haem broken into bilirubin + Iron

2. Circulation

- Bilirubin + albumin = unconjugated bilirubin forms

3. Liver

- Glucoronic acid conjugates bilirubin

- Bile formed and stored in gallbladder

4. Gut

- Bile broken down into urobilinogen and stercobilinogen

5. Stercobilinogen excreted in feces, Urobilinogen excreted in urine. Some urobilinogen reabsorbed by liver. 

Front 4

What is bile made of?

Back 4

Bile = Bilirubin + cholesterol + bile salts

Front 5

Most common hereditary cause of increased bilirubin

Back 5

Gilbert's syndrome - mild decrease in  glucuronyltransferase activity

Front 6

Enzyme that conjugates bilirubin

Back 6

 glucuronyltransferase

Front 7

What is hereditary spherocytosis

Back 7

Hereditary spherocytosis is an auto-hemolytic anemia characterized by the production of red blood cells (RBCs) that are sphere-shaped (spherocytosis) rather than the normal biconcave disk shaped (donut-shaped) RBCs. This shape is more prone to rupture. 

One cause of prehepatic jaundice. 

Front 8

List 8 causes of prehepatic jaundice

Back 8

- hemotlytic anaemia

- hereditary spherocytosis

- thalassaemias

- G6PD deficiency

- sickle cell anaemia

- drugs

- large hematoma being degraded (transient)

- neonatal jaundice

Front 9

List 9 causes of intrahepatic jaundice

Back 9

Hepatocellular disease

Viral infections (hepatitis A, B, and C)

Chronic alcohol use

Autoimmune disorders

Intrahepatic malignancy 

Other

Drugs (e.g. paracetamol o/d)

Pregnancy

Parenteral nutrition

Sarcoidosis

Primary biliary cirrhosis

Primary sclerosing cholangitis

Front 10

List causes of post-hepatic jaundice

Back 10

- Gall stones / cholelithiasis

- Tumor of head of pancreas

- Biliary tract tumors

- Pancreatitis

Front 11

Urine and stools in cholestasis

Back 11

Dark urine as most bilirubin is being secreted via urine (since bile/chole flow into gut is blocked/stasis)

Pale stools because bile flow into gut is blocked. Bile gives stool the characteristic brown color. Without it, stools are pale. 

Front 12

One examination sign in patients with increased hemolysis

Back 12

Splenomegaly

Front 13

What could scratch marks be due to in a patient presenting with jaundice

Back 13

Pruritis due to bile salts deposition in the skin

Front 14

What is the yellowing of sclera and skin in Jaundice called?

Back 14

Icterus

Front 15

Investigations in jaundice

Back 15

LUV SCUBA

* LFTs

* Urine urobilinogen + urine bilirubin

* Virology (Hep viruses + EBV + CMV)

* Serum bilirubin 

* Coagulation studies 

* Ultrasound (?bile ducts obstruction)

* Blood screen (?anemia)

* Amylase (?pancreatitis)

Front 16

What type of jaundice?

Conj br - raised

Unconj br - normal

Back 16

Post-hepatic

Front 17

What type of jaundice?

Conj br - normal

Unconj br - raised

Back 17

Pre-hepatic 

Front 18

Urine bilirubin in pre-hepatic jaundice?

Back 18

Absent (i.e. normal)

Front 19

Urine bilirubin in post-hepatic jaundice?

Back 19

Increased

Front 20

Presence of bilirubin in urine indicates what?

Back 20

High levels of conjugated bilirubin in the blood

Front 21

Liver disease in which copper accumulates. What is it called and what is one sign of it? 

Back 21

Wilson's disease and the signs in brown rings near the inside edge of the iris (copper deposition). 

The sign is called Kayser-Fleischer Rings.

Front 22

Observable signs of liver disease. (13 - FLASH PADLOCKS)

Back 22

FLASH PADLOCKS

* Clubbing

* Leukonychia

* Palmar erythema

* Spider naevi (upto 5 are normal)

* Fetor hepaticus

* Asterixis

* Ascites

* Lymphadenopathy

* Kayser-Fleischer rings (Wilson's disease)

* Bronze discolorisation (Iron)

* Dupuytren's contracture

* Caput medusae (portal htn)

* Hemorrhoids

* Oesophageal varices

* Oedema

* Scratch marks (pruritis)

Front 23

Two hepatomegalic diseases, and one hepatoatrophic disease.

Back 23

Hepatomegaly - hepatitis (inflammation), and fatty liver

Atrophic - cirrhosis

Front 24

Two types of hepatotoxicity

Back 24

Type A - intrinsic - predictable

Type B - idiosyncratic - unpredictable

Front 25

4 presentation types of hepatotoxicity

Back 25

1. Hepatitis-like 

2. Cholestasis

3. Steatosis

4. Zonal necrosis

Front 26

Common causative agents of:

 

hepatitis-like injury

Back 26

Isoniazid

 

Phenytoin

Front 27

Common causative agents of:

 

cholestatic injury

Back 27

Rifampicin

 

Augmentin

 

Carbamazepine

Front 28

Common causative agents of:

 

steatotic injury

Back 28

Amiodarone,

 

Tetracycline (abxs),

 

Protease inhibitors (antivirals),

 

Methotrexate

Front 29

Investigations in suspected hepatotoxicity

Back 29

- FBC

- LFTs

- INR

- U&C

- Ultrasound of liver and gallbladder

- Abdo CT

- Liver biopsy if needed

Front 30

Management in patient w hepatotoxicity

Back 30

1. ABC

2. Stop offending drug if known

3. Antidote if available

4. Correct electrolyte imbalances

5. Analgesia

6. Liver transplant if damage to liver is too severe and widespread