54 - Investigations of liver and pancreatic disease

What organ stores glycogen?

Liver

What symptoms of liver disease are associated with oestrogen excess?

- Gynaecomastia

- Spider naevi

- Liver palms

- Testicular atrophy

What are some systemic symptoms of liver disease?

- Jaundice

- Oestrogen excess

- Bruising

- Pigmentation

- Clubbing

- Ascites

- Encephalopathy

- Oesteomalacia/osteoporosis

How does liver disease cause osteoporosis?

Impaired hydroxylation of vitamin D

How does liver disease cause encephalopathy?

Build up of toxic metabolites such as ammonia damages the brain parenchyma

How is albumin affected by liver disease?

Low

Is prothrombin time increase or decreased with liver disease?

Increased

What are the routine LFTs?

- ALP (alkaline phosphate)

- ALT (alanine aminotransferase)

- Bilirubin

- Albumin

- Protein

- GGT (gamma glutamyl transferase)

What test is completed for viral hepatitis?

Serology

What are the markers of hepatocyte damage?

- ALT and AST (ALT is more accurate)

- Only released by cellular damage

What are the 3 stages of alcoholic liver disease?

1) Hepatic steatosis

2) Alcoholic hepatitis

3) Cirrhosis

Describe the test results seen in hepatic steatosis:

- Mild increase in ALT

- Rasied GGT

Describe the test results seen in alcoholic hepatitis:

- Anaemia

- Raised ALT and AST

- Jaundice

- Raised temperature

With biliary tract damage that impairs excretory function, what is raised?

Conjugated bilirubin

With biliary tract damage that increases synthesis of enzymes lining the bile canaliculi, what is raised?

- ALP

- GGT

What 4 liver diseases raise ALP?

1) Cholestasis

2) Infiltrative disease

3) Space-occupying lesions e.g tumours

4) Cirrhosis (non-specific marker to liver since produced in bone, intestine and placenta)

How can liver and bone ALP be distinguished?

Gel electrophoresis to separate isoenzymes

What can cause an increase in GGT?

- Alcohol

- Anti-epileptics

- Fatty liver

- Heart failure

- Prostatic disease

- Pancreatic disease

- Kidney disease

What is primary biliary cirrhosis?

Autoimmune granulomatous destruction of intrahepatic bile ducts

What are some symptoms of primary biliary cirrhosis?

- Jaundice

- Pruritis

- Fatigue

What test findings are seen with primary biliary cirrhosis?

- Raised IgM

- Raised ALP

- Raised anti-mitochondrial antibodies

What is primary sclerosing cholangitis?

Inflammation and fibrosis of intrahepatic and extrahepatic bile ducts

What disease is primary biliary sclerosing associated to?

IBD

What is the ELF score?

Enhanced liver fibrosis test

What are 3 biomarkers for fibrosis?

1) PIIINP

2) TIMP-1

3) Hyaluronic acid

What are the 3 types of bilirubin measurement?

1) Total

2) Unconjugated (pre-hepatic and hepatic)

3) Conjugated (post-hepatic and hepatic)

How is bilirubin excretion in the urine?

Urobilin (conjugated)

What are the pre-hepatic causes of jaundice?

- Haemolysis

- Ineffective erythropoiesis (spherocytosis)

What are post-hepatic causes of jaundice?

- Gallstones

- Biliary stricture

- Cancer

- Cholangitis

What enzyme converts bilirubin into bilirubin glucaronide in the liver?

UDP glucaronyl transferase

What does a raised AST and ALT but not ALP indicate?

Hepatitis

What does normal AST and ALT but raised ALP indicate?

Obstructive jaundice

How does urine appear in post-hepatic/ obstructive disease?

Dark urine and pale stool

Where does the common bile duct empty into the duodenum?

Sphincter of Oddi

What organ secretes bicarbonate?

Pancreas (contribution from kidney)

What are the cause of acute pancreatitis according to the I GET SMASHED mnemonic/

- Idiopathic

- Gallstones

- Ethanol (alcohol)

- Trauma

- Scorpion stings

- Mumps/malignancy

- Autoimmune

- Steroids

- Hypercalcaemia/ hypertriglyceridaemia

- ERCP

- Drugs

What is the gold standard test for pancreatic function?

Direct pancreatic function test:

- Secretin/CCK, Lundy tests

- Duodenal aspirates