Podcast
Questions and Answers
What is the primary purpose of the FibroScan device?
What is the primary purpose of the FibroScan device?
- To check liver enzyme levels
- To assess liver stiffness (correct)
- To perform liver biopsies
- To measure liver weight
A FibroScan reading of 77.5 kPa indicates nonalcoholic steatohepatitis (NASH).
A FibroScan reading of 77.5 kPa indicates nonalcoholic steatohepatitis (NASH).
False (B)
Which diagnostic tool is considered the best option for liver diagnosis but is also more expensive than FibroScan?
Which diagnostic tool is considered the best option for liver diagnosis but is also more expensive than FibroScan?
MR Elastography
The FibroScan uses a technique known as __________ elastography.
The FibroScan uses a technique known as __________ elastography.
Match the liver conditions with their corresponding interpretations in the chronic setting:
Match the liver conditions with their corresponding interpretations in the chronic setting:
What level of alkaline phosphatase (ALP) suggests cholestasis?
What level of alkaline phosphatase (ALP) suggests cholestasis?
What is the primary precursor of bilirubin?
What is the primary precursor of bilirubin?
Wilson's disease is associated with increased levels of alkaline phosphatase (ALP).
Wilson's disease is associated with increased levels of alkaline phosphatase (ALP).
Heme oxygenase is one of the enzymes involved in the metabolism of bilirubin.
Heme oxygenase is one of the enzymes involved in the metabolism of bilirubin.
How much bilirubin is produced daily in a typical adult?
How much bilirubin is produced daily in a typical adult?
List two sources of alkaline phosphatase (ALP) in the human body.
List two sources of alkaline phosphatase (ALP) in the human body.
Intrahepatic cholestasis is often associated with __________ due to bile acid accumulation.
Intrahepatic cholestasis is often associated with __________ due to bile acid accumulation.
The production of bilirubin occurs at a rate of ____ mg/kg.
The production of bilirubin occurs at a rate of ____ mg/kg.
Match the following markers with their sources:
Match the following markers with their sources:
Match the following sites with their relevance to hemoglobin metabolism:
Match the following sites with their relevance to hemoglobin metabolism:
What is the normal range for total bilirubin levels in mg/dL?
What is the normal range for total bilirubin levels in mg/dL?
High levels of urobilinogen in urine indicate obstruction of the biliary tract.
High levels of urobilinogen in urine indicate obstruction of the biliary tract.
What is the primary substance excreted in feces resulting from deconjugation of bilirubin?
What is the primary substance excreted in feces resulting from deconjugation of bilirubin?
The condition _____ may progress to cirrhosis with portal hypertension.
The condition _____ may progress to cirrhosis with portal hypertension.
Match the following aspects of liver disease progression with their associated complications:
Match the following aspects of liver disease progression with their associated complications:
Which of the following drugs is associated with Bland cholestasis?
Which of the following drugs is associated with Bland cholestasis?
Cholestatic hepatitis can be caused by NSAIDs.
Cholestatic hepatitis can be caused by NSAIDs.
What condition is associated with Amoxiclav?
What condition is associated with Amoxiclav?
Normal albumin levels in the blood range from _____ g/dL.
Normal albumin levels in the blood range from _____ g/dL.
Match the following drugs with their associated liver conditions:
Match the following drugs with their associated liver conditions:
Which of the following viruses is most common in children?
Which of the following viruses is most common in children?
AST levels are always higher than ALT in chronic alcoholic liver disease.
AST levels are always higher than ALT in chronic alcoholic liver disease.
What enzyme level is indicative of alcoholic liver disease?
What enzyme level is indicative of alcoholic liver disease?
The condition where AST is greater than ALT at levels exceeding 1000 U/ltr is known as __________.
The condition where AST is greater than ALT at levels exceeding 1000 U/ltr is known as __________.
Match the liver conditions with their respective enzyme ratio:
Match the liver conditions with their respective enzyme ratio:
Which of the following is the most common virus causing acute hepatitis in children?
Which of the following is the most common virus causing acute hepatitis in children?
Hepatitis E is primarily transmitted through feco-oral routes.
Hepatitis E is primarily transmitted through feco-oral routes.
Name one autoimmune cause of acute hepatitis.
Name one autoimmune cause of acute hepatitis.
The incubation period for Hepatitis A (HAV) is approximately ____ days.
The incubation period for Hepatitis A (HAV) is approximately ____ days.
Match the following hepatitis viruses with their corresponding family:
Match the following hepatitis viruses with their corresponding family:
What is the recommended preventive measure for Hepatitis A prior to travel?
What is the recommended preventive measure for Hepatitis A prior to travel?
Hepatitis E has a higher incidence of complications during pregnancy compared to Hepatitis A.
Hepatitis E has a higher incidence of complications during pregnancy compared to Hepatitis A.
What constitutes Acute Liver Failure (ALF)?
What constitutes Acute Liver Failure (ALF)?
The typical duration for Hepatitis A infection is _____ weeks.
The typical duration for Hepatitis A infection is _____ weeks.
Match the following conditions with their associated characteristics:
Match the following conditions with their associated characteristics:
What type of hyperbilirubinemia is characterized by indirect bilirubin making up 85% or more of total bilirubin?
What type of hyperbilirubinemia is characterized by indirect bilirubin making up 85% or more of total bilirubin?
Gilbert Syndrome results in total absence of UDP-Glucuronosyltransferase activity.
Gilbert Syndrome results in total absence of UDP-Glucuronosyltransferase activity.
What condition is indicative of mixed hyperbilirubinemia in conjunction with transaminitis?
What condition is indicative of mixed hyperbilirubinemia in conjunction with transaminitis?
Direct hyperbilirubinemia occurs when direct bilirubin constitutes ______% or more of total bilirubin.
Direct hyperbilirubinemia occurs when direct bilirubin constitutes ______% or more of total bilirubin.
Match the following syndromes with their characteristics:
Match the following syndromes with their characteristics:
What is the primary function of the canalicular membrane in hepatocytes?
What is the primary function of the canalicular membrane in hepatocytes?
The sinusoidal membrane is involved in the activation of stellate cells.
The sinusoidal membrane is involved in the activation of stellate cells.
Which syndrome is associated with defects in the canalicular membrane of hepatocytes?
Which syndrome is associated with defects in the canalicular membrane of hepatocytes?
The space between sinusoids and hepatocytes is known as the __________.
The space between sinusoids and hepatocytes is known as the __________.
Match the liver disorders with their respective site and affected cell type:
Match the liver disorders with their respective site and affected cell type:
What condition arises due to the activation of myofibroblasts in the liver?
What condition arises due to the activation of myofibroblasts in the liver?
Vitamin A is stored in stellate cells located in the space of Disse.
Vitamin A is stored in stellate cells located in the space of Disse.
What protein is contained in the canalicular membrane of hepatocytes?
What protein is contained in the canalicular membrane of hepatocytes?
Study Notes
FibroScan
- Measures liver stiffness
- Non-invasive method to differentiate between NASH and cirrhosis
- Reading of 77.5 kPa indicates cirrhosis
- Transient elastography device
- MR Elastography is another tool used
- Considered the best diagnostic tool but more expensive
- Used to confirm FibroScan results
Alkaline Phosphatase (ALP)
- Indicates cholestasis when levels are > 4x normal (>560 units/L)
- Normal range: 40-140 units/L
- Decreased levels can indicate Wilson's disease
- Major source: Liver - canalicular membrane of hepatocyte
- Other sources include bone, intestine, kidney, and placenta
Cholestasis
- Associated with: Pruritis (due to bile acid accumulation)
- Jaundice may or may not be present
- Causes:
- Drugs
- Cholangitis
- Sarcoid
- Primary biliary cirrhosis
- Primary sclerosing cholangitis
- Sepsis
Conjugated Hyperbilirubinemia
- Hyperbilirubinemia: >50% direct bilirubin
- ALP > 4 times normal + GGT significantly elevated
Bilirubin
Features
- Production rate: 4mg/kg (300mg/day)
- Precursor: Heme substances
- Metabolizing enzymes: Heme Oxygenase (HOX) and Biliverdin reductase
Hemoglobin (80%)
- Site: Reticuloendothelial system, liver, bone marrow
Excretion
- Pathway: Bile → Biliary pathway → Small intestine
- Urobilinogen in urine:
- Traces: Normal
- High: Extravascular hemolysis
- Absent: Obstruction of biliary tract
- Ileocecal junction & Colon: Degradation by colonic bacteria
- Deconjugation:
- 80%: Excreted in feces (Stercobilinogen)
- 20%: Via enterohepatic circulation → Small amount → Systemic Circulation
Liver Function Test
- Total Bilirubin: 1-1.3 mg/dL
- Unconjugated/Indirect Bilirubin: 0.2-0.9 mg/dL
- Conjugated/Direct Bilirubin: 0-0.3 mg/dL
- Estimated by: HPLC (High-performance liquid chromatography)
- Note: Liver diseases, Hepatic parenchymal disorders, Vascular disorders, Biliary disorders
Progression of Liver Disease
- Acute Hepatitis → may progress → Chronic hepatitis → may progress → Cirrhosis with:
- Portal hypertension
- Hepatocellular carcinoma (HCC)
- Functional failure
Drugs causing cholestasis
Bland cholestasis
- Steroids
- Estrogens
Cholestatic hepatitis
- NSAIDs
- Azathioprine
- Chlorpromazine
Granulomatous hepatitis
- Allopurinol
- Carbamazepine
- Procainamide
Vanishing bile duct syndrome
- Amoxiclav (Amoxicillin + clavulanate)
- Macrolides
- ACE inhibitors (-)
Other Investigations
Synthetic Functions of Liver
Albumin
- Normal levels: 3.5–5.5 g/dL
- Hypoalbuminemia: May indicate liver disease
Hepatocyte Membranes
- Contiguous Membrane:
- Gap junctions between hepatocytes
- Contains MRP-a protein
- Canalicular Membrane:
- Gene: ABCCa
- Function: Excretion of conjugated bile acids (bile salts)
- Defect: Dubin-Johnson syndrome
- Sinusoidal/Basolateral Membrane:
- Cells: Stellate/Ito cells and lipocytes
- Location: Space of Disse
- Function: Storage of vitamin A
- Pathology: Cirrhotic pathology: activation of myofibroblasts → cirrhosis. TGF-β releases
Liver Disorders
| Site | Vessel/Cell | Disorder |
|---|---|---|
| Vascular | Vessel: hepatic vessels/portal vein etc. | Hepatic vein thrombosis (Budd-Chiari Syndrome) |
| Parenchymal | Hepatocyte & sinusoids | Any disease leading to cirrhosis |
| Biliary | Cholangiocyte | Primary biliary cirrhosis, primary sclerosing cholangitis |
Basic Physiology of Liver
Causes of Liver Disease
- Virus (most common):
- HAV (common in children)
- HEV (common in adults)
- Drug/toxin induced
- Ischemic hepatitis
- Alcohol (Values: 300 - 500 u/ltr)
- Note: Severe acute elevations also seen in Acute bile duct obstruction (>1000 U/Ltr).
Alcoholic Liver Disease
- Enzyme level: 300 - 500 U/ltr
- AST > ALT: ALT requires more amount of PLP.
- 2:1: Almost always alcoholic hepatitis.
- 3:1: Definitive Alcoholic hepatitis.
- Acute on chronic alcoholic liver disease: AST > ALT (values >1000 u/ltr).
Chronic Hepatitis
- Mild elevation: Indicates ongoing liver inflammation
Hepatology
Hepatitis A (HAV)
- Rare (1 in 2 lakhs)
- Duration: 8 weeks
- Treatment:
- Conservative (fluid and glucose repletion)
- 150 ml 10% Dextrose
- Complications:
- 1-2% cases
- 20% in pregnancy
- 12 weeks
- Conservative treatment
- Long standing cholestasis
- Steroids
- Prevention:
- HAVRIX 1 mL IM in 2 doses, 6-12 months apart.
- Pre-exposure: at least 2 weeks of travel.
- Post-exposure: within 4 weeks.
- No vaccine
Hepatitis E (HEV)
- 1-2%
- 20% in pregnancy
- Duration: 12 weeks
Note:
- If ALT/AST, AST > ALT > 1000: underlying alcoholic d/s.
- If MELD score: 300-500: alcoholic hepatitis.
- Lab tests: INR, s.Bilirubin, s.Creatinine
Acute Liver Failure (ALF)
- Acute hepatitis + encephalopathy (cerebral edema) + coagulopathy (INR ≥ 1.5) without any pre-existing liver disease.
- Onset:
- Fulminant (hyperacute): Rapid progression (days to weeks)
- Subfulminant: Slow onset (weeks)
Hyperbilirubinemia
-
Indirect Hyperbilirubinemia (unconjugated hyperbilirubinemia):
- Indirect bilirubin: ≥ 85% of total bilirubin
-
Mixed Hyperbilirubinemia/Hepatic jaundice:
- Direct bilirubin: 15-50% of total
-
Direct Hyperbilirubinemia (Conjugated hyperbilirubinemia):
- ≥ 50% total Bilirubin
- Cholestasis
Inherited causes of Hyperbilirubinemia:
- Gilbert Syndrome: Partial deficiency of UDP-Glucuronosyltransferase (only 30% activity)
- Crigler-Najjar Syndrome I/II: Reduced UDP-Glucuronosyltransferase activity
- Rotor Syndrome: Defective transport of bilirubin into canaliculi
- Dubin-Johnson Syndrome: Defective transport of bilirubin into bile. Leads to pigment accumulation in the liver
Acute Hepatitis and Acute Liver Failure
Acute Hepatitis
- Recovery (most common)
- Chronic Hepatitis
- Fulminant Hepatic Failure (rare)
Fulminant Hepatic Failure
- Portal Hypertension (Portal HTN)
- Hepatocellular Carcinoma (HCC)
- Liver Failure
Acute Hepatitis Causes
- Viral:
- HAV (most common in children)
- HEV (most common in adults)
- HBV
- HBV + HDV (coinfection)
- Drugs:
- Paracetamol
- ATT
- Toxins:
- Rat poison (Yellow Phosphorus)
- Mushroom
- Alcohol
- Others:
- Autoimmune hepatitis
- Wilson's disease
- AFLP (Acute Fatty Liver of Pregnancy)
- Budd Chiari syndrome
Hepatitis A (HAV) vs Hepatitis E (HEV)
| Feature | HAV | HEV |
|---|---|---|
| Virus | Picornaviridae family, SS-RNA | Calcivirus family, RNA |
| Mode of transmission | Feco-oral, Sexual/parenteral | Feco-oral >> vertical |
| Incubation period | 30 days | 40 days |
| Heat sensitivity | Sensitive (>85°C) | |
| Features | ||
| - Prodromal phase (2-3 days) | ||
| - Anorexia, nausea, vomiting | ||
| - Malaise, low-grade fever, jaundice | ||
| Cholestatic Hepatitis | ||
| - Extrahepatic features | Tender hepatomegaly (max 2 cm), rash/arthralgia (most common) | |
| - Progression of chronicity | Rare | Not seen |
| - Lab investigations | ↑ALT, AST, ↑S.Bilirubin (mixed pattern), Anti HAV IgM (+) | ↑ ALT, AST, ↑ S.Bilirubin (conjugated), Anti HEV IgM (+) (upto 4 months) |
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Description
Test your knowledge on key diagnostic tools and markers for liver diseases. This quiz covers important topics such as FibroScan, alkaline phosphatase levels, and cholestasis. Assess your understanding of liver conditions and their indicators to better grasp their clinical implications.
