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41 Cards in this Set
- Front
- Back
- 3rd side (hint)
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What organs are drained by the portal vein |
Stomach Spleen Pancreas Intestines |
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Functions of the liver |
Formation of bile and secretion Nutrients and vitamins metabolism Inactivation of various substances Synthesis of plasma proteins(albumin,acute phase,clotting factors, steroid binding and other hormone binding proteins) Immunity |
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What are the groups of clinical features of liver disease |
Hepatocellular Cholestatic Mixed |
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How do you evaluate a patient with liver disease? |
Establishing the cause Estimating the severity or grading(mild,moderate,severe,active or inactive) Establish the disease stage(staging) |
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What are the typical symptoms of liver disease |
General: fatigue,weakness,nausea,poor appetite Liver specific symptoms: Jaundice Dark urine Light stools Itching Adominal pain Bloating |
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At what bilirubin level is jaundice seen? |
Bilirubin level greater than 2.5mg/dl |
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How much alcoholic use can lead to alcoholic liver disease? |
Greater than two drinks per day in females and greater than 3 drinks per day males |
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What is alcoholism |
It is defined by behavorial patterns and consequences of alcohol intake not by amount |
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How do you assess alcoholism? |
Abuse and dependency |
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What is alcohol abuse? |
Repetitive pattern of drinking alcohol that has adverse effect on social,family,occupational or health status. |
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What is alcohol dependence? |
Alcohol seeking behavior despite its adverse effects |
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How do you assess abuse or dependence to alcohol |
Use the CAGE questions |
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What are the physical findings of early disease? |
Icterus Hepatomegaly Hepatic tenderness Splenomegaly Spider angiomata Palmar erythema Skin excoriation |
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What are the physical findings of advanced liver disease |
Ascites Muscle wasting Edema Dilated abdominal veins Hepatic fetor Aterixis Mental confusion Stupor Coma |
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In male patients with cirrhosis related to alcohol use what are the signs of hyperestrogenemia |
Gynecomastia Testicular atrophy Loss of male pattern hair distribution |
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What is hepatic failure? |
Occurrence of signs and symptoms of hepatic encephalopathy in a person with severe acute or chronic liver disease |
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What are other signs can be elicited in a liver disease patient? |
Umbilical hernia in from ascites Hydrothorax Prominent veins over abdomen Caput medusae Widened pulse pressure Hepatopulmonary syndrome Xanthelesma Tendon xanthoma Parotid enlargement Duputyren's contracture |
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What is the classical triad of hepatopulmonary syndrome |
Liver disease Hypoxemia Pulmonary arteriovenous shunting |
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What are the clinical features of hepatopulmonary syndrome |
Platypnea: Shortness of breath relieved when lying down made worse when standing or sitting Orthodeoxia: Shortness of breath and oxygen desaturation that occur paradoxically upon assumption of upright position |
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What are the differential diagnosis of liver disease? |
Inherited hyperbiluribinemia: Crigler-Najjer Gilbert Syndrome Dubin-Johnson Rotor syndrome
Viral hepatitis(CMV,EBV,ADENOVIRUS,HERPES VIRUS)
IMMUNE AND AUTOIMMUNE: Primary sclerosing cholangitis Primary biliary sclerosis Autoimmune hepatitis
GENETIC LIVER DISEASE: Alpha 1 antitrypsin defeciency Hemochromatosis Wilson's disease
Alcoholic liver disease(fatty liver)
Steatohepatitis
Mycobacterium avium Tuberculosis Sarcoidosis CHOLESTATIC SYNDROMES Biliary atresia Jaundice of sepsis Cholecystitis
DRUG INDUCED LIVER DISEASE Hepatocellular(Isoniazid, acetaminophen)Cholestatic pattern(methyltestosterone)Mixed(sulfonamides,phenytoin)MethotrexateBudd Chiari syndromeHepatocellular Carcinoma Hepatocellular(Isoniazid, acetaminophen) Cholestatic pattern(methyltestosterone) Mixed(sulfonamides,phenytoin) Methotrexate
Budd Chiari syndrome Hepatocellular Carcinoma
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Lab tests to confirm common causes of chronic liver disease |
Hepatitis C- Anti-HCV Alcoholic liver disease- history of abuse and dependency NASH-Ultrasound or CT Hepatitis B- HbsAg and the rest Autoimmune hepatitis- ANA and Smooth muscle antibodies, elevated IgG Sclerosing cholangitis- P-ANCA Biliary cholangitis-mitochondrial antibodies, elevated IgM Hemochromatosis- serum ferritin and iron studies Wilson disease- serum ceruloplastin, hepatic copper levels, HFE gene mutations |
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What tests comprise the liver function tests? |
ALT, AST, ALP, TBIL , DIRECT BILURIBIN , PT, ALBUMIN |
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What are the differentials for isolated unconjugated hyperbilirubinemia |
In the absence of hemolysis in an otherwise healthy patient attribute this to GILBERT SYNDROME |
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What are inflammatory inhibitors of albumin? |
Interleukin 1 Cytokines Tumor necrosis factor |
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Why are serum globulin increased in cirrhosis |
Cirrhotic liver inability to normally clear intestinal bacteria leads to overproduction of these globulin in serum to clear these intestinal bacteria that normally reach the liver through hepatic circulation |
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What is the pathological feature of cirrhosis? |
Fibrosis and distortion in architecture with the formation of regenerative nodules with resultant decrease in mass, hepatocellular function, alteration of blood flow |
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What is the morphological appearance of a cirrhotic liver |
Regenerative parenchyma nodules surrounded by dense bands of fibrous scars and a variable degree of vascular shunting |
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Summarise the effect of alcohol on the liver |
1)absorbed in intestines shunted to liver metabolised to ACETALDEHYDE by Alcohol dehydrogenase in the cytosol: Aceltadehyde is a highly reactive molecule with multiple effects causes oxidative stress by increasing ROS which activates the Kuppffer cells to release profibrogenic Cytokines which in turn activate stellate cells which increase the collagen in extracellular matrix leading to bridging fibrosis and forming regenerative nodules 2) increases intracellular uptake of triglycerides which increase the fatty acids 3)Acetaldehyde impairs protein synthesis, glycosylation, secretion |
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How to treat alcoholic liver cirrhosis generally |
Abstinence from alcohol is the cornerstone of therapy Glucocorticoids given in absence of infections Oral pentoxifylline to reduce inflammation Acamprosate calcium to reduce cravings for alcohol Then manage specific complications |
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What are the major complications of cirrhosis |
Portal hypertension: Ascites, hypersplenism, gastroesophageal varices, spontaneous bacterial peritonitis, gastropathy Hepatorenal syndrome(1n2) Hepatic encephalopathy Hepatopulmonary syndrome Malnutrition Coagulopathy:fibrinolysis, factor defeciency, theombocytopenia Bone disease:osteopenia, osteomalacia, osteoporosis Hematological abnormalities:anemia, hemolysis, neutropenia, thrombocytopenia
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Charles Plays H4oMeBase |
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What is portal hypertension |
Elevation of the hepatic venous pressure gradient greater than 5mmHg |
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What is the mechanism behind portal hypertension |
1)Increased intra hepatic resistance of blood flow through the liver due to cirrhosis 2)Increased splanchnic blood flow secondary to vasodilation within vascular beds |
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Causes of portal hypertension |
Prehepatic:Portal and splenic vein thrombosis Intrahepatic:cirrhosis, schistomiasis, venoocclussive syndrome Posthepatic: Budd-Chiari sybdrome |
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Management of an acute variceal bleed |
Resuscitation with IVF and blood Medical management using vasoconstricive agents(Somatostatin or Octreotide) Balloon tamponade using Sengstaken-Blakemore tube or Minnesota tube Endoscopy(sclerotherapy or variceal band ligation) All this fails then opt for Tranjugular Intrahepatic Porto systemic shunt |
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How is prevention of variceal bleeding recurrence achieved? |
Repeated band ligation B blockers |
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How do you treat ascites |
Mild-dietary restriction of sodium to less than 2grams per day Moderate-diet plus furosemide and spironolactone which can be increased to highest dose if dietary compliance is confirmed When the ascites is refractory then repeated large volume paracentesis or TIPPS may be required |
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What is spontaneous bacterial peritonitis |
Common and severe complication of ascites characterised by spontaneous infection of the ascitic fluid without an intra abdominal source |
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What is Hepatorenal syndrome |
Form of functional renal failure without renal pathology that occurs in patients with advanced liver disease or acute liver failure |
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Types of Hepatorenal syndrome |
Type 1: Progressive impairment in renal function with a significant reduction in creatinine clearance within 1-2 weeks of presentation Type 2: characterised by a reduction in GFR with an elevated serum creatinine which is relatively stable and has a better outcome compared to type 1 |
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What are the precipitating factors of hepatic encephalopthy |
Hypokalemia Infections Increased dietary proteins Electrolyte imbalance GI bleeding Over diuresis Uremia Dehydration Constipation |
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Grading of hepatjc encephalopathy |
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