| How can we accurately diagnose liver disease? | Through history, physical, few lab tests (acc to findings), radiological tests (most imp is US), and finally liver biopsy if needed.
Usually when we see symptoms we are at the late stages of liver disease |
| Describe briefly liver function and structure. | largest organ, 1-1.5 KG, dual blood supply (20% hepatic artery and 80% portal vein)
Made of hepatocellular part and cholestatic other part (stellate cells, kupfer cells...)
Roles include protein synthesis (albumin, coagulation factors...)/ bile production/ nutrient regulation/ metabolism... |
| What are the most used liver function tests? | Serum Bilirubin (could give either conjugation problem- if conjugated bilirubin is low, not liver disease/ or excretion problem -if conjugated is high, live disease)
Another test is albumin and prothrombin time to measure functionality of the liver (protein synthesis)
Any frank liver failure will need a transplant immediately and cannot survive on any equipment |
| What are the present types of liver diseases? | Hepatocellular/ Cholestatic/ Mixed
Hepatocellular could be injury/ inflammation/ necrosis Such as viral hepatitis and alcoholic liver disease
Cholestatic could be problems in duct such as common duct stone, biliary cirrhosis, drug-induced, obstruction...)
And mixed has both features like obstructive hepatitis. |
| How do risk factors for liver disease determine onset and prominence? | Age (20 years--> viral hepatitis, 60 years--> tumor, 40 years--> alcoholic...)
sex
Hx (drug users we can get hepC) |
| What are the typical symptoms of liver disease? | Most frequent: Fatigue
Jaundice (could be acute (due to viral hepatitis, autoimmune, alcoholic, Wilson's, drug use in decreasing order) , or chronic (usually appears with poor prognosis in end stage disease))
Itching (Cholestatic pattern - ALP and bilirubin)
RUQ pain
Nausea and anorexia
Intestinal bleeding
abdominal distention (in chronic disease due to ascites)
TO NOTE that the liver is a silent killer (usually px appear asymptomatic and symptoms only appear at late stages) |
| What are the things we look for during the diagnosis of liver disease? | Etiology (disease), Staging (fibrosis/ cirrhosis...), Category (hepatocellular, cholestatic) and grading (severe, acute, chronic...) |
| What are the constitutional symptoms in case of liver disease? | We have the non-specific symptoms ( fatigue, weakness, nausea, poor appetite, and malaise)
and liver-disease specific symptoms ( liver-specific symptoms of jaundice, dark urine, light stools, itching, abdominal pain, and bloating.)
Symptoms can also suggest the presence of cirrhosis, end-stage liver disease, or complications of cirrhosis such as portal hypertension |
| What is the key test in case of RUQ pain to get etiology? | US |
| Describe the symptoms of liver disease one by one. | Fatigue (arises with activity, rarely present in morning at rest)
Nausea (may be provoked by eating...)
Vomiting (rarely persistent)
Anorexia (with acute disease, rarely in chronic)
Diarrhea (uncommon)
RUQ pain (accompanied by tenderness over liver area, it arises from stretching Glisson's capsule, usually occurs for liver abscesses, venooclusive disease...)
Itching (occurs with acute disease, early obstructive disease, and some hepatocellular disease, but mostly for cholestatic disease) |
| Talk about jaundice symptom of liver disease. | – hallmark symptom of liver disease patients
– the most reliable marker of severity.
– Jaundice is rarely detectable with a bilirubin level <43 μmol/L (2.5 mg/dL).
(normal bilirubin is 1.5, jaundice appears if bilirubin between 1.5-2 at ear
2-2.5 at frenulum of tongue
2.5 and above in sclera, conjugtiva and skin |
| What are the risk factors for liver disease? | Alcohol use (females 22-30g, males 33-45g for more than 10 years cause chronic liver disease), medications, habits (Obesity), Sex, travel, exposure, drug use, surgery (due to anesthesia...), familial diseases (Wilson's, hemochromatosis, a1 antitrypsin (in case of hx of emphysema)) |
| If a px presents with hx of all hepatitis, liver disease and cancer what is the most suitable etiology?
If also diabetes? | Most likely hepatitis (HepB- vertical transmission)
With diabetes (hemochromatosis - iron overload) |
| Talk about the physical exam findings in liver disease | Usually normal unless acute and severe.
Typical findings icterus/jaundice, Hepatomegaly, hepatic tenderness, Splenomegaly,Spider angiomata (red spots like web than when touched disappear- found normally 3-4 for women and none for men accompanied with estrogen) , palmar erythema (not necessarily for liver disease if accompanied with Dupuytren's contracture (thickening in palm tissue)--> alcoholic |
| What are the laboratory tests done for liver function? | ALT/ AST (when expect hepatocellular)
ALP (when expect cholestatic)
Bilirubin (could be both)
Autoimmune and Ig tests, gamma GT
Albumin and Prothrombin (Synthesis function)
we move in a pattern of dx, first category then acute or chronic then stage |
| What does elevated prothrombin synthesis time indicate? | Either liver disease or vitamin K deficiency.
To differentiate between the two we test factor V levels, if low then liver disease if high then vitamin K deficiency (since it is the only factor independent of vitamin K) |
| What are the imaging techniques used for liver disease? | Most important is the US
for vessel issues and tumors use CT
MRCP for biliary tree dx, and ERCP is more therapeutic for the biliary tree
We also have elastography or fibroscan, which reveals fibrosis, and this technique will eventually replace biopsy as it show fibrosis and cirrohsis (however not inflammation) |
| What are interventional radio techniques? | Interventional Radio:– the biopsy of solitary lesions
– performance of radiofrequency ablation and
chemoembolization of cancerous lesions
– insertion of drains into hepatic abscesse
– measurement of portal pressure
– creation of vascular shunts in patients with portal
hypertension. |
| Talk about liver biopsy | Evaluate px with chronic liver disease, test severity, prognosis tx responsiveness (for autoimmune)
to get dx use IgM and not all Ab. |
