Liver

Front 1

what's grading and staging of liver disease

Back 1

grading: degree of inflammation
staging: degree of fibrosis

Front 2

4 causes of ACUTE liver failure (ALF)

Back 2

DRUGS
alcohol
bile obstruction
viruses (e.g hepA)

Front 3

jaundice can be classified in 2 ways

Back 3

SITE: pre, intra, post - hepatic

TYPE: conjugated/ unconjugated (by liver)

Front 4

what's the cause of pre-hepatic jaundice

Back 4

excess bilirubin (unconjugated) from too much haem broken down:
- haemolysis
- haemolytic anaemias

unconj = not water-soluble (not excreted in urine)

Front 5

what causes intra-hepatic jaundice

Back 5

liver cells INJURED/ DEAD + some cholestasis (intra-hepatic bile ducts):
- ALF
- hepatitis (alcoholic, autoimmune, viral, drug-induced)
- cirrhosis (acute-on chronic/ decompensated)
- bile duct loss (PBC, PSC)
- preg
- storage diseases (Wilson's, haemoachromatosis, a1-antitrypsin def)

Front 6

what causes post-hepatic jaundice

Back 6

bile OBSTRUCTION--> conjugated bilirubin (water-soluble= dark urine, pale stools):
- gallstones in CBD
- congenital biliary atresia
- CBD strictures
- tumours (head of pancreas, cholangiocarcinoma)
- PSC, PBC

Front 7

what the pathology behind liver cirrhosis

Back 7

final common END-PT ....IRREVERSIBLE liver damage
fibrosis & nodular regeneration
loss function

Front 8

2 important complications of liver cirrhosis
- what does each complication lead to (effects)

Back 8

1) PORTAL HTN: ascites, splenomegaly, varices, caput medusae...

2) liver FAILURE: coagulopathy, encephalopathy (liver flap, confusion), hypoglycaemia, sepsis

(also: hepatocellular carcinoma & mallnutrition)

Front 9

what's the progression of alcoholic liver disease with time & which is reversible:
- 2-3d
- 4-6wks
- months-yrs
- yrs

Back 9

- 2-3d.................reversible FATTY liver
- 4-6wks............reversible HEPATITIS
- mnths-yrs.....irreversibleFIBROSIS
- yrs...................irreversible CIRRHOSIS

Front 10

features of ALCOHOLIC hepatitis & NASH/NAFLD (4)

Back 10

hepatocyte NECROSIS
NEUTROPHILS
MALLORY-BODIES
pericellular FIBROSIS

Front 11

what's non-alcoholic steatohepatitis (NASH)
- who
- may lead to fibrosis & cirrhosis (& liver ca)

Back 11

identical pathology to alcoholis liver disease
- non-drinkers
- DM, obese, hyperlipidaemia

Front 12

common & rare causes of viral hepatitis

Back 12

hep A,B,C,D,E
delta agent
EBV
CMV
HSV
yellow fever virus

Front 13

compare outcomes of hep B and C viral hepatitis

Back 13

B: acute fulimant (death), chronic, cirrhosis, ca, asymp

C: chronic, cirrhosis

Front 14

6 causes of CHRONIC hepatitis

Back 14

viral: hep B & C
PBC
PSC
autoimmune
drug-induced

Front 15

PBC;
- pathology & effects
- serology/ test results
- age & sex presentation

Back 15

rare AUTOIMMUNE chronic non-caseating GRANULOMATOUS inflammation = progressive CHOLESTASIS, CIRRHOSES & portal HTN
- obstructive jaundice, AMA (M2 antimicrobial ab's), IgM
- F~50yrs

Front 16

autoimmune hepatitis:
- path
- specific features (test results)
- age & sex presentation

Back 16

Chronic inflammatory.
Auto-ab's: ANA, SMA, LKM, ↑IgG, ↑γGT

young/middle-aged F

Front 17

clinical presentation S&Ss of PBC

specifics in CAPS

Back 17

F~50yrs
asymp
↑Alk phos & γGT
fatigue
PURITIS (itch)
XANTHELASMA
jaundice/ skin pigmentation
portal HTN
hepatomegaly

Front 18

clinical presentation S&Ss of autoimmune hepatitis

Back 18

young/ middle-aged F
ACUTE-on-chronic: jaundice, fatigue, abdo pain, nausea

CLD: leuconychia, clubbing palmar erythema, spider naevi, DUPUYTREN's contrapture (cirrhosis), hepatomegaly, ascites, portal HTN
encephalopathy

PBC, PSC, UC, Graves, EXTRAHEPATIC (urticaria)

Front 19

don't forget drug-induced hepatitis:
- which drugs
- presentation

Back 19

MANY!
mimics any liver disease (acute/ chronic)

Front 20

PSC:
- patho
- age & sex
- stong assoc with which disease
- specific features

Back 20

CHRONIC inflammation/ fibrosis/ strictures intra- & extra- HEPATIC BILE ducts, F~40yrs
- 80% have UC
- post-hepatic jaundice: chronic biliary obstruction
- ↑Alk phos, may have ↑AMA & SMA
- secondary biliary cirrhosis

Front 21

difference between PBC & PSC

Back 21

PBC: commoner, granulomas, intra-heaptic +ve AMA & IgM

PSC: UC, intra & EXTRA hepatic, biliary obstruction- abnormal LFTs, jaundice, cholangitis

Front 22

3 liver storage diseases

Back 22

Haemochromatosis (iron)
Wilson's (copper)
a1-antitrypsin def

Front 23

Haemochromatosis:
- how inherited
- how acquired

- what are the outcomes if untreated (2)

Back 23

1) Autosomal RECESSIVE = ↑iron deposition in liver (& other sites)
2) ↑diet iron/ transfusion/ iron therapy

- cirrhosis, hepatocellular carcinoma

Front 24

clinical presentation & features of haemochromatosis (incl age & gender)

Back 24

middle-aged MEN
asyp...then...
fatigue
arthralgia (iron deposits in joints)
slat-grey skin
DM ('bronze DM')
CLD: hepatomegaly, cirrhosis

Front 25

what's wilson's disease
- key features for Dx

- what 2 diseases does it cause

Back 25

autosomal RECESSIVE ↑Cu in liver & CNS....treatable.
- Kayser-Fleischer rings (deposits in iris)
- lo serum caeruloplasmin
- Cu in urine

CHRONIC hepatitis & NEUROLOGICAL deterioration

Front 26

what's a1-antitryprin def
- inheritance
- what 2 diseases does it cause

Back 26

autosomal RECESSIVE
↓synthesis in liver (enzyme inhibitor)....globules trapped in liver

CLD (cirrhosis) & EMPHYSEMA

Front 27

2 primary tumours of the liver

Back 27

hepatocellular ADENOMA.......................benign ♀

hepatocellular CARCINOMA (HCC)......malignant- 90% of 1° tumours

Front 28

secondary tumours (mets) in the liver are much more common than primary ones.
- S&Ss

Back 28

fever, malaise, anorexia, loss wt, RUQ pain (liver capsule stretch)
late- jaundice
hepatomegaly

Front 29

what diseases is HCC (hepatocellular carcinoma) related with (3)

how does it normally present

Back 29

HBV, HCV
cirrhosis

mas, pain, obstruction

Front 30

cancer associated with the biliary tree

Back 30

cholangiocarcinoma

Front 31

all hepatitis viruses can be ACUTE

which viruses can be CHRONIC?

Back 31

[A (only Acute)]
B C D E

Front 32

whats the lab confirmation for hepatitis infection

Back 32

CLOTTED blood for SEROLOGY

(B: surface antigens & ab's also)

Front 33

which hepatitis virus can only co-exist with hepB and exacerbates the infection

Back 33

hepD

Front 34

hep E:
- similar to which hep virus (clinically and transmission)
- where is it common
- associated with severe disease when

Back 34

similar to hep A (think vowels!)- young adults, ingestion
common in tropics/ INDIA

severe in PREG!

Front 35

how is hep A transmitted?
peak incidence what age?
incidence in UK?
can only cause ACUTE infection (not chronic)
can cause OUTBREAKS!

Back 35

INGESTED!
faecal-oral
poor hygiene/ overcrowding
food & water
- travellers
- young adults
reducing in UK

Front 36

what ab assoc with hep A

control/ prevention?
Treatment

Back 36

clotted blood for serology- IgM

VACCINE & hygiene
monitor for encephalopathy & resolution
NO ANTIVIRALS

Front 37

how is hep B & C transmitted (4)

Back 37

BLOOD (IVDUs)
SEX
DIRECT
VERTICAL transmission (chronic infection more likely)

Front 38

lab confirmation of Hep B
- how long classifies chronic infection
- which component indicates INFECTIVITY
- which component in ACUTE / recent infection
- which component = IMMUNITY

Back 38

>6months = chronic
HBsAg/HBeAg & DNA = INFECTIVE
ant-HBc IgM = current/ recent ACUTE infection
Anti-HBs = IMMUNITY

Front 39

which components in the blood indicates chronic hep B carrier

Back 39

HBsAg >6mnth
Anti-HBc IgG
(+/- eAg/anti-eAg, c IgM)

Front 40

what does anti-HBsAg alone indicate

Back 40

vaccination w/o disease
(or transfusion with blood possessing immunity)

no anti-HBc IgG

Front 41

what does presence of HBsAg & HBeAg indicate

Back 41

incubating infection

Front 42

what does ↑↑↑LFTs, HBsAg/HBeAg, Anti-HBc IgM & anti-HBc IgG indicate

Back 42

ACUTE infection

Front 43

what does anti-HBs & anti-HBc IgG indicate

Back 43

recovery from INFECTION

Front 44

which antibody after HBV infection indicates immunity from NATURAL infection that vaccination doesn't give in addition to anti-HBsAg

Back 44

anti-HBcAg IgG

Front 45

clinical features of viral hepatitis

Back 45

fever, malaise, anorexia, nausea, arthralgia, jaundice, hepatomegaly, splenomegaly, lymphadenopathy

(extra-hepati common in HBV)

Front 46

clinical features of HBV

Back 46

viral hep: fever, malaise, anorexia, nausea, arthralgia, jaundice, hepatomegaly, splenomegaly, lymphadenopathy

+ EXTRA-hepatic: arthralgia, urticaria (itchy rash- pic)

Front 47

control and treatment of HBV

Back 47

minimise blood exposure & safe sex

VACCINATION prophylaxis (e.g travel) & after
ANTIVIRALs:
- peginterferon
- suppresive antivirals (entecavir, Tenofovir)

Front 48

which viral hepatitis (B,C,D,E) is more commonly chronic

Back 48

~85% HCV chronic

Front 49

if an individual tests +ve for anti-HBV, what test is done to assess if they have an active/ past infection

Back 49

VIRAL RNA PCR

Front 50

which 2 viral hepatitis's can be prevented with VACCINE

Back 50

A (acute) & B (prophylaxis & after)

Front 51

3 outcomes for hep A

Back 51

asymp & resolution
acute infection ---> resolution
acute liver failure (rare) ---> death/ resolution

[NB: no chronic infection]

Front 52

outcomes for hep B & C viruses

Back 52

.

Front 53

in chronic viral hepatitis, how many yrs is taken to cirrhosis and hepatocellular carcinoma

Back 53

>20rs Cirrhosis
>30yrs carcinoma

Front 54

what's significant about vertical transmission of hep B to a baby- what pattern of infection do they show

Back 54

more likely to show CHRONIC infection & complications

Front 55

when are antivirals used in viral hepatitis

Back 55

CHRONIC infection only (not acute!)
infalmmation
before complications
adults

Front 56

what test results would confirm you could treat chronic infection with
- HBV
- HCV

how long is considered chronic infection

Back 56

HBV: HBsAg & DNA
HCV RNA present (active)

>6 months

Front 57

what's peginterferon-α
what is it used to treat
✔advantages
✕. disadvantages

Back 57

immune response to viral infection- given via injection as adjuvant for HBV & HCV:
✔sustained
✔predict who will benefit
✕.side effects!
✕. suppression rather than cure
✕. minority benefit

Front 58

2 drugs used in HBV & HCV

Back 58

peginterferon-a & ribavirin

(HBV- also other antivirals)
(HBC- antiviral PROTEASE inhibitors: triple therapy)

Front 59

antivirals for HBV
✔advantages
✕. disadvantages

Back 59

eg Entecavir, Tenofvir
✔safer
✕. supression
✕.resistance
✕.life-long Rx

Front 60

adverse effect of ribavirin (1)

Back 60

anaemia

Front 61

what's triple therapy for HBC
- name 2 antivirals used in triple therapy

Back 61

newer antivirals give in combination with PEGINTERFERON & RIBAVIRIN

PROTEASE inhibitors: TELAPREVIR & BOCEPREVIR

Front 62

side effects of protease inhibitors used in HCV triple therapy:
- Telaprivir
- Boceprevir

Back 62

TELAPRIVIR: puritis, nause, rash, anaemia, rectal pain, diarrhoea

BOCEPREVIR: anaemia, distorted sense & smell

Front 63

define ACUTE liver disease

Back 63

rapid development of liver dysfunction w/o prior liver problems
<6mths
ENCEPHALOPATHY

Front 64

difference between LFTs & TRUE LFTs

Back 64

LFTs: ALT/AST, Alk phos, GGT

TRUE: BR, Alb, PTT

Front 65

important Q's to ask when suspecting ACUTE liver failure (ALF) (6)

Back 65

symps
duration
DH (OTC, herbal, supplements)
TOXINS
INFECTIONs
ALCOHOL
TRAVEL

Front 66

Ix's for acute liver disease (ALD)

Back 66

LFT's (incl alb, BR, PTT)
glucose
Virology & micro (bloods, urine) & AUTOab's (e.g IgM, AMA)
ferratin, caeruloplasmin, a1-antitrypsin
USS
rare- biopsy

Front 67

treatment of ALD

Back 67

3mnth REST
FLUIDS, no alcohol
↑CALORIES- metabolic considerations
treat ITCH (eg. UDCA)
treat hypoglycaemia!!!

Front 68

treatment of PBC & PSC

Back 68

PBC: uresodeoxycholic acid (UDCA)

PSC: corticosteroids & uresodeoxycholic acid (UDCA)

Front 69

what's Budd-chiari syndrome
- what disease / presentations S&Ss can it cause

Back 69

hepatic vein obstruction (eg thrombosis, hypercoaguable, tumour)
acute epigastric pain, N&V, shock, insidious portal HTN, ascites, jaundice & cirrhosis, tender hepatomegaly.

ACUTE LIVER DISEASE (ALD)

Front 70

how long do hepatic reactions to drugs take
- 3 commonly used medication that can cause ALD

Back 70

6 wks
- NSAIDs, amox, co-amoxiclav
(also: euphomisms & imported illegal drugs)

Front 71

define FULMINANT hepatic failre

Back 71

JAUNDICE & ENCEPHALOPATHY in a pt with prev normal liver!!!!!!!!!!!

Front 72

S&Ss of fulminant liver failure

Back 72

JAUNDICE & ENCEPHALOPATHY
hypoglycaemia
coagulopathy
circulatory failure]renal fulure]infection

Front 73

treatment for fulminant hepatic failure:
- SUPPORTIVE
- DEFINITIVE

Back 73

SUPPORTIVE: inotropes & FLUIDS
- renal replacement
- manage complications

TRANSPLANT (life-long immunosupression)

Front 74

some criteria for liver transplants in acute liver FAILURE

Back 74

<pH
↑PTT (clotting) / INR (bleeding)
↑creatinine (renal failure)
jaundice/ encephalopathy
↑lactate
↑bilirubin
>40yrs

Front 75

which cells initiate fibrosis (which eventually leads to cirrhosis)? (2types)

Back 75

activated quiescent hepatic STELLATE cells (HSC)
by-prods of activated KUPFFER cells

Front 76

what type of liver disease does metabolic syndrome predispose to?
(type 2 DM, obese, low HDL, HTN, hyperlipidaemia)

Back 76

NAFL (non-alcoholic fatty liver disease)

Front 77

what type of gramulomas are seen in PBC

Back 77

non-caseating

Front 78

what test results are characteristic for PBC

key

Back 78

↑↑↑alk phos (obstructive LTF's)
AMA ab's type M2 (anti-mitochondrial)

fatigue, itch (PRURITIS), XANTHELASMA, hepatomegaly

Front 79

treatment of PBC

what symptom is a poor indicator

Back 79

uresodeoxycholic acid (helps itch)

jaundice poor indicator

Front 80

distinguish between the 2 types of autoimmune hepatitis
- age
- serum ab's

Back 80

type 1: ADULT, ANA +/- SMA

type 2: CHILDREN, LKM-1

Front 81

histopathology of autoimmune hepatitis- BIOPSY to rule out:
- Wilson's disease, a1-antitrypsin def, viral hep, drug-induced, ...

Back 81

INTERFACE hepatitis
necrosis
eosinophils, lymphocytes & inflam cells
fibrosis / cirrhosis

Front 82

treatment of autoimmune hepatitis

Back 82

corticosteroids (prednisolone)
azathioprine

Front 83

treatment of haemochromatosis

Back 83

venesection

Front 84

hwo to Dx & treat Budd-Chiari syndrome (obstruction of hepatic veins)

Back 84

USS

Recanalisation/ TIPS (transjugular intrahepatic portosystemic shunt)

Front 85

which drug used to treat RA & psoriasis shows does-dependent liver toxicity
what does it cause (in the liver)

Back 85

METHOTREXATE
fibrosis

Front 86

what causes cardiac cirrhosis

Back 86

secondary to RHF:
- tricuspid valve incompetence
- congenital
-rheumatic fever
- constrictive pericarditis/ cardiac tamponade/ effusion)

Front 87

presentation of cardiac cirrhosis

Back 87

CCF/ RHF
hepatomegaly
portal HTN: ascites, varices, caput medusa, liver impairment....

Front 88

which viral hepatitis is most common worldwide

Back 88

HCV

Front 89

treatment for compensated liver cirrhosis

Back 89

reduce salt intake
avoid aspirin & NSAIDs
good nutrition (support)
no alcohol

Front 90

score used to cirrhosis to predict prognosis & variceal bleeding risk

Back 90

CHILD-PUGH

Front 91

how does portal HTN cause renal failure

Back 91

hepatic vessels release vasodilators = ↓systemic MAP = baroreceptor reflex = renal artery myogenic response 'autoregulation' = renal hypoperfusion = failure = accumulate creatinine & urea = toxicity

Front 92

Ix's for ascites

Back 92

spontaneous bacterial infection?- tap & neutrophil count
USS

Front 93

treatment for ascites spontaneous bacterial peritonitis (3)

Back 93

ABX's
TERLIPRESSIN for vascular instability
maintain renal PERFUSION

NUTRITION & NO Na+

Front 94

which drugs to avoid in ascites

Back 94

NSAIDs & aspirin

Front 95

treatment for ascites

Back 95

SPIRONOLACTONE (monitor U&Es)
PARACENTESIS- rapid relief
TIPS
transplant

Front 96

how to quickly relieve ascites

Back 96

paracentesis
x. risk infection
x. encephalopathy
x. hypovolaemia

Front 97

what causes asterixis (liver flap)

Back 97

ammonia not metabolised by liver--> circulates to CNS, affects signalling

Front 98

what can asterixis indicate

Back 98

liver disease
salbutamol use (tremor)
CO2 retention
alcohol-withdrawal
anything neurological