What LFT do you measure to look for cholestasis?
- Bilirubin
- Alkaline phosphatase
What LFT do you measure for synthetic function?
- Albumin
- Prothrombin time
What is jaundice?
-Yellow pigmentation of the skin and eyes
Explain pre-hepatic jaundice
- Jaundice from haemolytic causes eg excessive haemolysis
- > Liver is unable to cope with excessive bilirubin and you get unconjugated hyperbilirubinaemia and reticulocytosis
Give some causes of pre-hepatic jaundice
- Inherited -> red cell membrane defects
- Congenital -> Gilbert’s syndrome
- Aquired -> Infection
Explain hepatic jaundice
- Deranged hepatocellular function whereby hepatocytes cannot extrete bilirubin
- Conjugated and unconjugated hyperbilirubinaemia
Explain LFTs in hepatic jaundice
- Both AST and ALT raised to reflect liver damage
- Abnormal prothrombin time
Give some causes of hepatic jaundice
- Hepatitis (Any eg alcoholic, viral, autoimune)
- Drugs (paracetamol)
- Cirrhosis
- Hepatic tumours
Explain post-hepatic jaundice
-Caused by obstruction of the billiary tree preventing conjugated hyperbilirubinaemia as passageway blocked
Explain the LFTs found in post-hepatic jaundice
- Normal or slightly high AST/ALT due to mild liver damage from pressure
- High ALP
Give some causes of post-hepatic jaundice
-Hepatitis, primary biliary cirrhosis, gallstones, stricture, pancreatic tumour
What is a cholangiocarcinoma?
-Carcinoma of the bile duct
What is hepatitis?
-Inflammation of the liver in which you get acute hepatocyte breakdown with synthetic failure
List some causes of hepatitis
- Viral (A,B,C,d)
- Autoimmune
- Drugs
- Hereditary
What LFT do you measure for hepatocellular damage?
- ALT/AST
- g-glutamyl transpeptidse (g-GT)
Describe the progression of alcoholic liver disease
- Fatty liver
- Alcoholic hepatitis
- Cirrhosis
Describe some complications which ca arise from alcoholic liver disease
- Hepatocellular carcinoma
- Liver failure
- Wenicke-Korsakoff syndrome
- Encephalopathy
- Dementia
- Epilepsy
Name 2 conditions which can cause confusion and CNS disturbances as a result of alcohol abuse
- Wernicke-Korsakoff syndrome
- Hepatic encephalopathy
What causes wernicke-korsakoff?
-Thiamine deficiency
What is liver cirrhosis?
-Liver cell necrosis followed by nodular regeneration and fibrosis resulting in increased resistance to blood flow and deranged liver function
Name some causes of liver cirrhosis
- Hepatitis B and C
- Alcohol
- Billiary cirrhosis
- Autoimmune hepatitis
- Haemochromocytosis
- Wilsons disease
What are the clinical features of cirrhosis?
- Jaundice
- Anaemia
- Bruising
- Palmar erythema
- Dupuytrens contracture
- Portal hypertension
What is palmar erythema?
-reddening of palms over thenar and hypothenar eminences
What is Dupuytren’s contracture?
-Fixed forward curvature of one or more fingers
What do LFTs show in cirrhosis?
- Elevated AST/ALT
- Elevated ALP
- Elevated Bilirubin
- Low Albumin
- Deranged clottinf
How is liver cirrhosis managed?
- Stop alcohol intake
- Treat complications
- Transplant
What is primary biliary cirrhosis?
-Chronic destruction of bile ducts leading to jaundice, pruritis and xanthalasma
What is hereditary haemochromotosis?
-An autosomal recessive condition in which abnormal iron transport results in ion deposition in various organs including heart, pancreas, liver and skin
What is wilson’s disease?
-Autosomal recessive condition resulting in disordered copper transport leading to deposition in liver (cirrhosis), basal ganglia (tremor) and kidney(tubular degeneration)
What is portal hypertension?
-Increase in portal venous pressure by >20mmHg
Name some intrahepatic causes of portal hypertension
- Cirrhosis
- Hepatoportal sclerosis
- Sarcoidosis
- Schostosomaisis
Describe the porto-systemic anastomoses
- Oesophageal vein and azygous system
- Superior rectal vein and inferior rectal veins
- Portal veins and veins of ant. abdominal wall
What are the clinical manifestations of portal hypertension?
- Ascites
- Splenomegaly
- Spider naevi
- Caput medusae
- Osophageal/rectal varices
What are spider naevi?
-Swollen blood vessels underneath the skin in the distribution of SVC
What is fulminant hepatic failure?
-Increased metabolic demand which causes acute and/or sever decompensation of hepatic function causing hepatic encephalopathy within 2 months of diagnosis
Give some causes of fulminant hepatic failure
- Hepatitis A, D and E
- Drugs (paracetamol/ecstasy)
- Wilson’s disease
- Alcohol
- Pregnancy
Gove some features of fulminant hepatic failure
- Jaundice
- Encephalopathy
- Hypoglycaemia
What is hepatic encephalopathy?
-Reversible neuropsychiatric deficit which results from a decreased ability to remove ammonia from the blood
What can precipitate hepatic encephalopathy?
- Sepsis/infection
- Diuretics
- Alcohol withdrawal
- GI bleed
What are the clinical features of hepatic encephalopathy?
- Flapping tremor
- Personality change
- Intellectual deterioration
What is cholelithiasis?
-Gallstones
State some risk factors of gallstones
- Female
- Increasing age
- Obesity
- Diet
- Drugs
Describe the stones which can occur in gallstones
- Cholesterol stones
- Pigment stones
- Mixed
What is biliary colic?
-Intermittent pain caused by contraction of the gall bladder in attempt to move the stone
What is cholecystitis? How does it present?
- Inflammation of the gallbladder caused by gallstones leading to oedema and mucosal ulceration
- Often presents with pain and SIRS/sepsis
What is mucocoele?
-Mucus secretion causing painful distension of the gall bladder
Name 3 complications of gallstones
- Ascending cholangitis
- Obstructuve jaundice
- Acute pancreatitis
What is gallstone ileus?
-Gallstone erodes through mucosa of gallbladder and through into duodenum -> can move and obstruct ileus
What is charcot’s triad and what does it represent?
- RUQ pain, jaundice and fever
- Ascending cholangitis
What is pancreatitis?
-Inflammation of the pancreas caused by effects of enzymes released from pancreatic acini
What are the causes of acute pancreatitis?
- Gallstones
- Ethanol
- Trauma
- Scorpion bite
- Mumps
- Autoimmune
- Steroids
- Hyperlipidaemia
- ERCP
- Drugs
What damage do protease, lipase and elastase cause in pancreatitis?
- Protease destroys tissue
- Lipase causes fat necrosis
- Elastase causes blood vessel destruction
What are the clinical manifestations of pancreatitis?
- Severe pain
- Vomiting
- Dehydration
- SIRS
What is chronic pancreatitis?
-Parenchymal destruction, fibrosis, loss of acini and duct stenosis
What are the clinical features of chronic pancreatitis?
- Pain
- Malabsorption (steatorrhoea, wt loss)
- DM
- Jaundice
What are most pancreatic carcinomas?
-Ductal adenocarcinoma
What is the prognosis like for pancreatic carcinomas?
-Very poor (account for 5% of all ca deaths)
What are the risk factors for pancreatic carcinomas?
- Smoking
- Beta napthylamine
- Familial
What are the clinical features of pancreatic carcinoma?
- Initially asymptomatic
- Pain, vomiting, malabsorption, diabetes
What is shifting dullness indicative of?
-Ascites
Why does ascites form in cirrhosis?
- Portal hypertension causes a rise in systemic venous pressure
- Liver damage causes a reduced synthetic function and thus reduced albumin production
- Together low oncotic pressure and high hydrostatic pressure cause fluid to move out of the peritoneal capillaries into the peritoneal space
How can oesophageal varices present?
-Haematemesis
Where does oesophageal venous system meet the systemic circulation?
-Oesophageal branch of left gastric vein and azygous system
Name 3 disease processes which would increase the breakdown of RBCs
- Haemolytic anaemia
- Malaria
- Sickle cell anaemia
What is the function of UDP-glucuronyl transferase?
-Conjugate bilirubin with glucaronic acid
Why do people present with pale stools and dark urine in jaundice?
- Pale stools because no bilirubin is reaching the GI tract -> normally bilirubin converted to stercobilin which gives faeces their colour
- Dark urine as bilirubin is in the urine
What would be present in a blood test if pancreatitis was present?
-Amylase
Why is ALT more specific than AST?
- ALT is located only in hepatocytes
- AST is also present in myocardium
Which LFT is specific of alcoholic liver disease?
-g-GT
What does an ALT:AST ratio less than 1 indicate?
-Viral hepatitis
What does an AST:ALT>2 indicate?
-Alcoholic disease