Liver Disease Quiz

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Questions and Answers

What is a common symptom of liver disease characterized by a yellowish discoloration of the skin and eyes?

Splenomegaly

Ascites

Jaundice (correct)

Portal hypertension

Which condition results from chronic liver disease and leads to increased pressure in the portal system?

Liver cirrhosis

Portal hypertension (correct)

Fatty liver disease

Hepatic encephalopathy

What is primarily responsible for the abnormal fluid accumulation in the abdominal cavity known as ascites?

High pressure in the portal system (correct)

Increased bile production

Decreased blood volume

Increased gallstone formation

Which of the following is NOT a consequence of chronic liver disease?

Decreased portal flow Signup and view all the answers

What condition may arise from chronic liver disease that affects cognitive function?

Hepatic encephalopathy Signup and view all the answers

What is a primary cause of hepatic jaundice?

Interference in bilirubin metabolism by liver cells Signup and view all the answers

Which of the following symptoms is most likely associated with hepatic jaundice?

Yellowing of the skin and eyes Signup and view all the answers

Hepatic encephalopathy is primarily due to which of the following?

Accumulation of ammonia and other toxins Signup and view all the answers

Which condition could lead to portal hypertension?

Liver failure due to viral hepatitis Signup and view all the answers

What is the primary mechanism behind pre-hepatic jaundice?

Excessive breakdown of red blood cells. Signup and view all the answers

What process is primarily disrupted in hepatic jaundice?

Bilirubin conjugation and excretion Signup and view all the answers

Which type of jaundice is characterized by an excess of bilirubin due to liver dysfunction?

Hepatic jaundice. Signup and view all the answers

What distinguishes post-hepatic jaundice from other types?

It involves obstruction of bile flow. Signup and view all the answers

Which clinical sign is most commonly associated with jaundice?

Yellowing of the skin and eyes. Signup and view all the answers

Which of the following conditions could contribute to the development of pre-hepatic jaundice?

Hemolytic anemia. Signup and view all the answers

Study Notes

Hepatobiliary Diseases in Pets - New Diagnostic Approach

This presentation covers hepatobiliary diseases in pets, focusing on a new diagnostic approach.
The author is Prof/ Sabry Moussa, a professor in the Department of clinical veterinary medical sciences at Jordan University of science and technology.
The year of presentation is 2024.

I - Introduction

Discussion of anatomical considerations related to blood flow and bile flow in the liver.
Review of the physiological function of the liver.

II - Diagnostic Approach (Strategies)

Importance of historical information (age, breed predisposition, classification of liver diseases).
Clinical presentation analysis of gastrointestinal signs such as PU/PD, hepatocencephalopathy, coagulopathies, acholic feces, abdominal distension, and jaundice.

III - Clinical Pathology

Hematology (Complete Blood Count - CBC).
Liver involvement (liver enzymes and bilirubin).
Liver function tests, including more specific markers like bile acid, ammonia, bilirubin, and non-specific markers such as total protein (TP), albumin, cholesterol, urea, glucose, and globulin).
Most recent biomarkers (CRP – C-reactive protein, Vit D – Vitamin D, Kallestin – a biomarker, Serum miRNA – microRNA).
Urinalysis and fecal analysis.

IV - Diagnostic Imaging

Survey X-ray.
Ultrasonography.
Computed Tomography (CT), Magnetic Resonance Imaging (MRI), and Scintigraphy.
Endoscopy (including survey laparoscopy and advanced ERCP – endoscopic retrograde cholangiopancreatography).

V - Liver Biopsy

Indications for liver biopsy.
Different biopsy techniques: fine needle aspiration (FNA), tru-cut needle (blind, US-guided, laparoscopic), laparoscopic/laparotomy biopsy (wedge biopsy).
Cytology and histopathology.

Anatomical Considerations

Gross anatomical divisions of the liver include the right, left, caudate, and quadrate lobes.
Each lobe has its own blood supply and biliary drainage.
Portahepatis transmits the hepatic artery, portal vein, and hepatic ducts with lymphatic and autonomic nerves.
Dogs have two separate ducts (pancreatic duct and bile duct)
Cats have a bile duct that joins the pancreatic duct, potentially allowing reflux and mixing of gastric secretions.
Liver internal structure consists of hexagonal functional units called lobules.
Each lobule has a central vein surrounded by hepatic portal veins and hepatic arteries.
Blood vessels connect via capillary-like tubes (sinusoids).
Sinusoids pass through liver tissue containing Kupffer cells and hepatocytes.
The liver receives nutrients and oxygen via two large blood vessels: hepatic artery and portal vein, and has efficient blood drainage.
Bile is produced by the liver, collected in bile canaliculi, merging to form bile ducts.
Intrahepatic ducts drain into right and left hepatic ducts, forming the common hepatic duct.
The common hepatic duct joins the cystic duct, forming the common bile duct, which drains into the duodenum.
Bile either flows directly into the duodenum or is temporarily stored in the gallbladder.

Liver Physiological Functions

Metabolism of carbohydrates, lipids, and proteins.
Storage of essential nutrients, vitamins, and minerals.
Production of vital proteins (prothrombin, fibrinogen, and albumin).
Immunological function through Kupffer cells lining the sinusoids.
Digestive functions (bile production and excretion important for fat emulsification and vitamin K absorption).
Regulation of blood pressure through angiotensinogen activation.
Breakdown and excretion of waste products (ammonia to urea).
Drug metabolism.

Liver Disease Diagnosis

Diagnosis is not always straightforward due to ambiguous or masking symptoms.
Using history, physical examination, liver function tests, medical imaging, and tissue analysis/biopsy are crucial for accurate diagnosis.
Management of liver diseases involves reducing predisposing factors, rehydration, protecting the gastrointestinal tract, avoiding sedatives, and supplementing low protein diets with Zinc for protein and nitrogen metabolism.
Cholecystectomy (surgical removal of gall bladder) is a treatment option for liver diseases.
Antibiotics may be incorporated in the treatment of hepatic diseases. Also relevant to diagnosing, classification, and prevention of issues.
Important for assessing aims of diagnostic evaluation (presence of disease, liver function assessment, definitive diagnosis, monitoring response to treatment).

Liver Disease Etiopathophysiology

Viral hepatitis (canine adenovirus type-1, feline leukemia, feline infectious peritonitis).
Parasites (Toxoplasma gondi, Leishmania infantum, Platynosomun concinnum).
Bacterial infections (Leptospira interrogans).
Mycotic infections (Candidia albicans, Histoplasma capsulatum, Aspergilus fumigates).

Non-Infectious Liver Diseases

Wilson's disease (inherited disease of copper metabolism).
Reactive hepatitis (inflammatory disorder induced by extrahepatic process).
Drug-induced hepatotoxicity (anticonvulsants, antifungals, analgesics, pesticides, herbicides, cleaning agents, and plant toxins).
Endocrine disorders (diabetes mellitus, hyperadrenocorticism, hyperthyroidism).
Autoimmune hepatitis (AIH).

Clinical Manifestations of Liver Diseases

Anorexia.
Depression.
Lethargy.
Weight loss.
Small body stature.
Poor/unkempt hair coat.
Nausea and vomiting.
Diarrhea.
Dehydration.
Polydipsia.
Polyuria.
Muscular hypotonia.
Jaundice.
Bilirubinuria.
Acholic feces.
Metabolic encephalopathy.
Coagulopathies.
Abdominal enlargement, organomegaly, effusion

Hepatic Encephalopathy Clinical Signs

Lethargy.
Depression.
Behavioral changes.
Head pressing.
Circling.
Pacing (animal walking back and forth).
Central blindness.
Seizures (uncommon).
Coma (uncommon).
Hypersalivation (especially in cats).
Plasma ammonia levels, commonly elevated in cases of hepatic dysfunction.

Portal Hypertension and Ascites

Chronic liver disease increases blood flow resistance to the liver, leading to portal hypertension and lymphatic fluid backflow.
Resulting pressure leakage causes blood from capillaries and results in abdominal fluid accumulation (ascites).

Jaundice (Icterus)

Yellowish tinge of skin, eyes, gums, and ears.
Bilirubin accumulation in blood from liver dysfunction.
Pre-hepatic (rapid RBC breakdown, hemolysis), hepatic (liver disease interference), and post-hepatic (bile duct obstruction) jaundice classified based on origin.

Urinalysis

Urine specific gravity reduced in patients with hepatic insufficiency or portosystemic shunts (PSS).
Bilirubinuria is a common finding in dogs but considered abnormal in cats.
Elevated bilirubinuria in dogs suggests hemolytic or hepatobiliary disease.
Uric acid levels increased in cases of severe hepatic insufficiency.
Urate crystalluria in dogs (40-70% with PSS) though not specific.

Abdominocentesis—Fluid Analysis

Moderate to large effusions in dogs with liver disease; simple needle paracentesis for protein assessment, cytological analysis and biochemical analysis.
Abdominal fluid in dogs with post-sinusoidal venous obstruction, which is often red or yellow-tinged, is characterized as modified transudate fluid.
In cats, feline infectious peritonitis and neoplastic effusions are likely modified transudate.

Fecal Evaluation

Absence of fecal pigment (acholic feces) and steatorrhea signifies severe chronic disease due to bilirubin production and excretion issues.
Increased bilirubin and abnormal fecal color can be caused by hemolysis.

Diagnostic Imaging in Liver Diseases

Radiography and ultrasound are common, though alternative imaging techniques are increasingly being used.
Radiography can show hepatic size, shape, and location.
Ultrasound is useful for assessing hepatic parenchyma and biliary tract.
Microhepatia might be visible on lateral radiographs
CT angiography for PSS diagnosis and other hepatic vascular conditions.
MRI also assesses hepatic neoplasia.
ERCP (endoscopic method) precisely diagnoses and treats bile duct conditions.

Liver Biopsy

Liver biopsy offers a definitive way to identify lesions and guide treatment.
Procedure methods preferred: laparoscopy, laparotomy with wedge biopsy (over transcutaneous or needle biopsy) due to high diagnostic accuracy.
Patients must be fasted for 12 hours.
A full coagulation profile must be obtained before biopsy to minimize complications.
Biopsy usually performed on left lateral lobe of liver.
Core specimens and potential cultures and sensitivity tests.

Cytology of Liver Biopsy

Methods of extracting and viewing cytological information.
Common disease/health findings observed through this method (described with images presented in the slides).

Histopathologic Analysis

Microscopic examination of tissue samples to visualize pathological changes.
Different disease findings represented with images of the affected tissues.
Findings are representative of specific types of diseases and levels of severity.

Modified Laparoscopic Approach

Procedure with required materials, use of Tru-Cut needle, and liver inspection methodology

General Considerations

All animal patients need 12-hour fast prior to liver biopsy.
Fine needle aspiration is not usually preferred for liver biopsy as it is not very accurate. Possible exception being in cats for quick diagnosis of hepatic lipidosis.
Large biopsy instruments (14 or 16 gauge) are often used with the aim of getting multiple samples to improve diagnostic accuracy.

Additional Liver Values:

Different values important for evaluating liver function.
Specific diseases usually involve many values for proper diagnosis.

Conclusions

The liver performs crucial bodily functions.
Liver disease, mostly known as hepatitis, can be acute or chronic, caused by various factors.
Progressive disease causes noticeable changes in the liver, including neurological signs, ascites, vomiting and diarrhea.
Advanced imaging plays a significant role in the diagnostic process and management of liver diseases.

Recommendations for dog and cat liver diseases

Early and accurate diagnosis of liver disease.
Proper management of disease for health and immunity.
For life-threatening diseases, surgical gall bladder removal or bile duct stone removal with specific techniques (ERCP).
For cirrhosis, liver transplantation recommended.

References

A list of sources used presented at the end of slides, including author names, publication details, and specific locations for certain papers.

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Description

Test your knowledge on liver disease symptoms and conditions. This quiz covers various aspects of liver-related complications, including jaundice, portal hypertension, and hepatic encephalopathy. Challenge yourself to understand the mechanisms and consequences associated with chronic liver disease.