Pathogenesis of ascites in liver disease. (sm)
decreased albumin production > decreased osmotic pressure/increased hydrostatic pressure > formation of abdominal fluid > decreased intravacular volume > increased aldosterone (kidney) and increaesd Na+ reabsorption > increased intravascular volume > more abdominal fluid > ascites
Which type of hepatitis requires HBV for replication and why? (sm)
Hep D RNA-virus that cannot exist independently
List the organs in which haemosiderin is deposited in haemochromotosis (and the order of most common > least common). (sm)
Liver > pancreas > myocardium > pituitary gland > adrenal gland > thyroid and parathyroid > joints > skin
Describe the pathogenesis of Hepatitis B. (sm)
Ingestion/inoculation > replication in the liver and viraemia > cellular immune response > apoptosis, necrosis of hepatocytes > inflammation (hepatitis) > bridging hepatocyte necrosis > fibrosis > cirrhosis > liver failure, carcinoma
Interpret these blood test results:
The patient is immune because of vaccination against HBV
What are some less common causes of viral hepatitis?
Less common - EBV, CMV Rare - Herpes simplex, yellow fever
Morphological features of chronic hepatitis? (sm)
Lymphoid aggregates Macrovesicular steatosis Bridging necrosis Fibrous tissue deposition
Which HepB serological marker reflects viral replication? (sm)
List 5 stigmata of chronic liver disease that you will see on physical examination
Abnormal skin pigmentation Erythema Hepatic flap Spider naevi Gynaecomastia Clubbing Jaundice
The persistence of which serological marker is associated with chronic HepB infection?
HBsAg
What is the enzyme required for Hep B virus replication? (sm)
DNA polymerase
Morphological features of acute hepatitis? (sm)
Diffuse swelling Cholestasis Macrophage aggregates Bridging necrosis Inflammatory cells Kupffer cells
Interpret these blood test results: (sm)
The patient has an acute HBV infection.
Pathogenesis of haemochromotosis. (sm)
Recessive mutation > upregulation of iron-specific transporters > excessive iron absorption
You suspect alcoholic liver disease in a patient. What Ix? (sm)
FBC - macrocytosis in absence of anaemia LFTs (GGT) PT Bilirubin Albumin USS/CT Viral hepatitis serologies Liver biopsy - to determine extent of liver damage
What percentage (~) of cirrhosis patients go on to develop hepatocellular carcinoma? (sm)
~5-15%
List 4 drugs that can cause drug-induced hepatitis.
Chlorpromazine Oetrogens NSAIDs Statins Rifampicin Isoniazid Amiodarone Azathioprine Methotrexate
Interpret these blood test results:
The patient has a chronic HBV iunfection. The IgM anti-HBc has waned
What are the 3 patterns of alcoholic liver disease?
1. Fatty change - reverisble 2. Alcoholic hepatitis - irreversible but progression may be arrested 3. Cirrhosis - irrversible
Primary biliary cirrhosis most commonly affects elderly men. True or false?True False
False. Most commonly affects middle-aged women
Aetiology (s) of haemochromotosis. (sm)
Hereditary Excess blood transfusions Iron loading anaemias (thalassemia, sideroblastic anaemia) Liver disease Alcoholic liver disease
Which HepB serological marker is not found in the blood? (sm)
How to improve rates of HepA transmission? (sm)
Improve social conditions - overcrowding, poor sanitation etc Inactivated virus vaccine
What is the most common cause of transmission of Hep B worldwide? (sm)
Tranmission from mother to child - most common cause and carries the highest transmission risk
What are some treatment options for Hep B? (sm)
Interferon alphaLamivudineAdefovir (any of the -virs)Liver transplantation
List 5 clinical manifestations (signs or symptoms) of haemohchromotosis. (sm)
Fatigue Arthropathy Skin pigmentation Impotence Loss of libido, testicular atrophy Cardiac failure/dysrhythmia (due to iron deposition in the heart)
List the steps of ethanol metabolism (with enzymes)
Ethanol ---(ADH)---> Acetaldehyde ---(ALDH)---> Acetate ---> Carbon dioxide + water
List 4 risk factors for Hep C. (sm)
IVDU Unscreened blood products Vertical transmission Needle stick injury
What is the characteristic morphological finding in primary biliary cirrhosis?
Non-caseating granulomatous inflammation
What is the major risk factor for Hepatocellular carcinoma? What are some other risk factors? sm
Chronic Hep B infection (also Hep C) Alcoholism, aflatoxins, cirrhosis, haemochromotosis, obesity/type 2 diabetes
What protein can be found in the blood to diagnose hepatocellular carcinoma? sm
Alpha fetoprotein (AFP) (foetal form of serum albumin, produced by the liver)
List 4 diseases that can cause childhood cirrhosis. sm
Hep B & C Autoimmune hepatitis Wilsons disease Alpha 1 anti-trypsin deficiency Cystic fibrosis
What is Wilson's disease? sm
Autosomal recessive condition in which copper accumulates in the tissues. Causes neurological/psychological issues and liver disease
What does HELLP syndrome stand for and in what patient group would you see it? sm
Haemolysis, elevated liver enzymes, low platelet count Can occur in pre-eclamptic pregnant women
What is the drug thought to be implicated in Reye syndrome?
Aspirin
How much functional capacity of the liver must be lost before hepatic failure ensues? sm
80-90%
What is the pathogenesis of peripheral oedema in hypoalbuminaemia (liver failure)? sm
decreased production of albumin > decreased proteins in the blood > decreased osmotic pressure > hydrostatic pressure is greater than osmotic pressure > fluid extravasates into the tissues