mcq segments Liver Liver anatomy

blood sinusoids space space

histology
hepatocytes
blood monocytes tissue macrophages kupffer cells
storage of vit. A space of Disse ito cells
%25 hepatic artery %75 portal vein blood flow
supply 50% hepatic artery supply blood flow

liver function test
Prothrombin time serum albumin Liver fuction test
liver Investigation synthesitic function of the liver
prothrombin time serum albumin compensating or decompensated
chronic liver disease serum billrubin investigation

liver compensated hepatitis cirrhosis chronic liver disease
or not
serum billrubin prothrombin time serum albumin
relatively half life half life albumin
sever chronic liver disease serum albumin
chronicity + severity

acute liver disease
serum albumin

usually
Liver compensated or not
very short half life prothrombin time prothrombin time
acute liver disease
Liver viral hepatitis acute viral hepatitis
serum albmin prothrombin time compensated or decompensated
biliary prolonged with cholestasis
prothrombin time
prolonged prothrombin time differniate between
obstruction
vit.k injection
decompensation
cholestasis
vit.K injection prothrombin time assesment prothrombin time assesment
decompensation prothrombin time prolonged
1

vit.K absorption bile obstructive jaundice

vit.K injection prothrombin time prolonged cholestasis
prothrombin time
decompensated
liver hepato cellular damage

liver
cupper drugs virus C virus B
hepato cellular damage trans amines
compensated or not wt about the liver
prothrombin time albumin Liver synthestic function
prothrombin albumin decompensated chronic liver disease
time prolonged
hepatic damage more sensitive more specific ALT SGPT
rise tissues SGPT & SGOT

hepato cellular damage once SGPT high
myocardial infraction hepato cellular damage SGOT
acute hepatitis short half life
SGPT
trans amines normal liver cirrhosis examples
sever form mild elevation mild form chronic hepatitis mild elevation

700 liver enzymes acute hepatitis
acute viral hepatitis
function state of the liver Alkaline phosphatase
cholestasis liver alkaline phosphatase
cholestasis
stone in significant cholestasis biliary obstruction cholestasis
2

 cancer pancreas stricture extra hepatic common bile duct

viral alkaline phosphatase
element of swelling of hepatocyte acute or chronic hepatitis
mild biliary intarhepatic biliary obstrcution bile canaliculi narrowing
alkaline phosphatase mildy obstrcution
acute viral alkaline phosphatase
hepatitis

significant biliary obstruction
mechanical
extra hepatic biliary obstruction stricture cancer pancreas
bile salts direct billirubin cholestasis
direct billirubin alkaline phosphatase retain in blood

bile salt retention in blood alkaline phosphatase

alkaline liver alkaline phosphatase
liver Alkaline phophatase amebic liver abscess phosphatase
alkaline phosphatase
Placenta Intestine bone Liver alkaline phosphatase

Liver alkaline phosphatase
hepatic disorder or elevated alkaline phosphatase elevated GammaGT
biliary obstruction
gamma GT
hepato cellular damage gamma GT
enzyme inducer gamma GT alcoholic hepatitis
gamma GT
gamma GT alcoholic hepatitis

 liver gamma Gt
cholestasis alkaline phosphatase cholestasis
more sensitive
very mild biliary obstruction gammaGT more sensitive

alkaline phosphatase gamma GT

trans amines alkaline phosphatase trans amines
liver alkaline phosphatase
alkaline phosphatase mild trans amines hepatitis
alkaline phosphatase markdly elevated biliary obstruction elevaltion
trans amines
bile retention of billirbin inside the liver biliary obstruction
contact with hepato cyte
trans amines hepatocytes irritation bile retention
trans amines alkaline phosphatase trans amines

biliary obstruction blie Liver cholesterol
liver bile retention
billirubin blood bile vascular Liver
cholesterol blood bile salts

biliary obstruction hyper cholestrolemia

hyper hyper lipidemia biliary obstruction liver
primary biliary cirrhosis cholesterolemial
albumin total plasma protien

albumin
normal
total plasm protein high

4

chronic liver chronic liver disease

liver reticulo endothelial system cells disease
reticulo blood antigens organisms phagocytosis
excessive production of hyperplasia endothelial system
gamma globulin
blood
problems multiplemyeloma gamma pathies
multiple myeloma
total plasma protein ESR old male bony ache
multiple myeloma
gamma globulin high total plasma protein
chronic liver disease

unable to remove IgA alcolic liver disease IgA alcoholic liver disease
peripheral blood
IgA execretion in bile serum IgA uptake Liver
GIT
IgG
primary biliary cirrhosis IgM

unconjugated unconjugated hyper billirubinemia

billirubin
unconjugated total billirubin %80 billirubin
hemolysis billirubin
hemolysis

Low hemoglubin -1
high indriect billirubin -2
high reticulocytic count -3
suspect hemolysis
syndrome
conjugation conjugated billirubinemia
hepatocellularfailure biliary obstruction
5

low serum albumin prothrombin timeprolonged

hepato cellular failure decompensated Liver
gamma GT alkaline phosphatase direct billirubin
serum albumin prothrombin time liver compensated

biliary obstruction
obstructive hepato cellular jaundice
Gamma GT alkaline phosphatase investigation
hypo albuminemia prothrombin time prolonged obstruction
liver cell failure

bilirubin acute liver disease serum bilirubin behavior

cholestasis
hepatocyte cholestasis acute hepatitis bilirubin
bilirubin subside swelling
bilirubin liver cirrhosis chronic liver disease
decompensated liver bad sign
( alpha feto ptn tumor marker
) hepatocellular carcinoma
cirrhosis hepatitis alpha feto ptn
hepatoma
metabolite Des-y-carbaxy prothrombin marker
alphafetoptn more specific malignant liver
alpha feto ptn hepatoma sensitive alpha feto ptn
Dubin Bromsulphthalein(BSP)clearance test
Liver Bromsulphthalein dye Johnson syndrome
dye
Bromsulphthalein dye excretion Uptake
excretion uptake liver blood dye

 defect secretion dye retention in liver

Liver uptake dye excrete dye dye .
Dubin Johnson syndrome
sonar Liver size Pattern Lesion
cirrhosis

Intrahepatic biliary dilatation extra hepatic biliary obstruction
common bile duct
investigation common bile duct
)ERCP (Endoscopic Retrograde Cholangio Pancreatography
common bile duct

jaundice obstructive direct bilirubin alkaline
phosphatase Gamma GT
obstructive jaundice
abdominal sonar Intrahepaticbiliary dilatation
common bile duct investigation ERCP
ERCP infection pancreatitis prophylactic
esophagus stomach duodenal canulation ampulla of vater
dye common bile duct dye pancreatic duct
pancreatic duct common bile duct
liver biopsy

hepatomegaly Persistent elevation of trans aminases
elevation of trans aminases

viral marker HBsAg HAantibody HCantibody

marker
autoimmunemarker ANA cupper and iron prolife
7


high level of transaminases
hepato cellular damage damage viral auto immune
cupper iron overload
history of any medication hepto toxic
approach

follow up

.
persistent elevated indication of liver biopsy
viral marker auto immune marker
cupper profile iron profile anesthesia
hepatic support

Liver biopsy unexplained persistent elevation of liver enzymes
focallesions liver Indication of liver biopsy hepatoma
hepatoma biopsy biopsy More dissemination seeding
Precaution liver biopsy platelets
prothrombin time bleeding tendency methods of liver biopsy
trucut or Menghini needle through an intercostal space, in mid axillary line during
expiration using local analgesia

complication injury bleeding

hemobilia liver common bile duct
infection
contra indication bleedingtendency
hepatoma focal lesion in sonar focal
lesion
benign Malignant
8

 technetium-99m ) radio isotopes ( liver

radio activity Gamma camera uptake liver intra venous
of the liver
liver diffuse liver cirrhosis Liver
reticulo endothelial system Liver cirrhosis
technetium- Liver cirrhosis reticulo endothelial system
Liver cirrhosis reticulo endothelial system of the liver uptake 99m
diffuse low uptake
Liver focal lesion hepatoma hepatoma
focal low uptake reticulo endothelial system
diffuse low uptake Liver
cirrhosis
suggest Low uptake focal area Liver
alpha feto ptn virus c hepatoma
liver focal lesion MRI CT scan
benign or malignant focal lesion
Liver focal lesion
liver focal lesion
focal lesion
malignant benign MRI CT scan
alphafetoptn
peritonealdisease laparoscopy
malignant peritoneum mesothelioma T.B. peritonitis peritoneum
malignant deposition in cancer ovary peritoneum deposit
biopsy laparoscope peritoneum peritoneum
lesion
Acute Hepatitis
Inflammation of liver parenchyma Hepatitis
Acute
EBV hepato tropic virus A,B,C viral
Non hepato tropic viruses CMV Herpes
9

 Liver Liver
virus A RNA virus picorna=entero virus incubation period
feco oral
fulmination

malignancy chronicity carrier
acute hepatitis cholestasis
cholestasis A cholestasis
!!!cirrhosis
cirrhosis
marker virus A antibody
antibody of the virus IgM recent infection Ig G old infection
vaccine inactivated virus
vaccine
booster dose 12 vaccine

vaccine
fulminant hepatitis
protection Mainly
endemic areas
Gamma globulin

Immune globulin
recent exposure
Hepatitis A

infection Immune globulin valid

Perfect
endemic Gamma globulin
vaccine

B incubation period A
malignancy chronicity 50
10

 chronic hepatitis of C rule acute hepatitis

chronic
+ve in blood chronic hepatitis rule
5 acute viral hepatitis B
fulmination carrier
carrier completely healthy carrier normal normal
surface antigen positive
Immune response resolution Virus
A&B are not directly cytopathic
Liver immune reaction
immune system resolution

resolution immune system
Liver Immune response hepatitis
pathology viral hepatitis B Invasion viral liver Immune
reaction Liver Immune reaction immune
system hepatitis Immune system
clearance
resolution good immune response Hepatitis

resolution
carrier immune system immune system
interested immune system

!!!
clearance
chronic Hepatitis Immune system
Immune system in-competent
hepatitis chronic
clearance
resolution chronic

carrier degree immune response Immune system
clearance
11

 marker (
)
surface antigen DNA core antigen DNA polymerase
surface antigen core core DNA & DNA polymerase
marker Hepatitis B surface antigen positive viral hepatitis
infection
acute viral hepatitis B surface antigen positive positive
surface antigen clearance
chronic
surface antigen ...
carrier
liver enzymes
biopsy biopsy hepatocyte almost within normal
carrier chronic manifestations
surface antigen positive transaminases acute viralhepatitisB
surface antigen viremia
surface antigen transaminases
surface antibody Immune system
surface antibody
infection vaccine
vaccine

surface antigen genetically engineered surface antibody

surface antibody positive immune
Hepatitis A antibody Hepatitis C antibody Hepatitis B antibody
Hepatitis C antibody positive
Hepatitis C antibody positive virus C
Immune system Immune
Hepatitis B surface antibody Positive Immune
anti-body effective release surface antibody Hepatitis B

12

 core anti gen hepatocyte

hepatocyte Inject core hepatocyte core antigen
core antibody Ig M & Ig G
window gap core anti body Ig M
Infection
negative
surface antigen

surface antibody negative
core antibody Ig M positive window gap
core antibody Ig M
core antibody Ig G

core antibody Ig M recent infection of virus B
recent infection viral B marker markers
surface antigen surface antigen Positive positive

... positive positive
surface antibody positive
core antibody Ig M
core antibody Ig M positive recent infection core
antibody Ig G positive Old infection
acute Hepatitis B infection correlated core antibody Ig M
chronic infection Past infection core antibody Ig G

eAntigen

active active

e Antigen
Hepatitis B DNA PCR

chronic
hepatitis


surface antigen core antibody Ig G
surface antigen positive Hepatitis B

infection Infection acute core
antibody Ig G Infection e' long duration core antibody
Ig G positive positive late surface antigen cleared surface

13

 antigen positive core antibody Ig G positive

Hepatitis B surface antigen chronic carrier

carrier marker almost chronic hepatitis markers
Presentation transaminases pathology biopsy
persistent elevated

Prophylaxis
vaccine vaccine 0-1-6 vaccine
vaccine surface antigen
bloodtransfusion hemodialysis
hemodialysis immune system
vaccine double the dose in immune compromised patients
chronic renal failure
dose
0-1-6

sexual intercourse

PCR negative low viremia transmission
RNA
vaccine
carrier
HIV
vaccine 0-1-6
HBIG Hepatitis immunoglobulin recent exposure
It should be given within 24 hours or at most a week from exposure to infected blood.

Cantibody C antibody Positive

ELISA RIBA infection with virus C
liver active or not

14

 PCR is mandatory PCR Quantitative

active chronicity % 50 malignancy
carrier
sexual transmission
E A fulmination
) (Hepatitis D virus B core
coat B pathogenic virus
Co-infection super infection
B Delta
*** Co-infection
dangerous fulmination
*** super infection virus B infection
delta
super
infection

for example Hepatitis B chronic mild form delta
super infection sever form
clinical
co-infection fulmination
pathology
super
infection
co-infection

co-infection Markers IgM recent delta antibody Ig M
recent
Core antibody Ig M
*** Ig M
super infection marker
core anti body B IgG
delta antibody Ig M
acute viral hepatitis portal tract Inflammatory cells hepatocyte
swelling narrowingcentizonal necrosis (zone 3).
centizonal necrosis acute
non icteric icteric non icteric bilirubin
common


acute virus C
A B C usually

15

 nonicteric

bilirubin

2.5

jaundice
flu like
bone ache

viremia viremia viral hepatitis infectious mononucleosis CMV


anorexia
viral hepatitis SGPT
acute chronic
cirrhosis cirrhosis
retro grade
Non icteric A bone marrow
manifested e' anemia
bone marrow aplasia

Investigation
viral hepatitis manifestation viral hepatitis
feverish bone marrow aplasia

The commonest cause of bone marrow aplasia viral infection
bone marrow aplasia transient
icteric pre icteric
viremia fever Headache malaise

Inflammed
liver swelling
liver

cholestasis

jaundice

hepatocellular jaundice

cholestatic jaundice jaundice cholestasis hepatocellular jaundice

dark urine clay stool

dark urine clay stool
) dark urine(bilirubinuria direct bilirubin clay stool bilirubin
cholestasis intestine direct bilirubin Intestine
stercobilin
jaundice
fever subside
16

jaundice causes of fever

viral hepatitis
fever and jaundice jaundice fever
( general jaundice fever
)
spleen soft tender liver is enlarged On examination
RES hyper plasia
possibilities spleen just palpable on examination fever

tarns esophageal echo & blood culture endocarditis ***
small vegetation echo
Viral hepatitis ***
Transaminases & viral marker
brucella agglutination test brucella ***
paul panel test test mononucleosis ***
EBV antibody Ig G and Ig M test mono spot test test
widal test ***

clinical

differential diagnosis of fever with splenomegaly

differential diagnosis of fever with just palpable spleen
paragraph

investigation manifestation
differential diagnosis

management of a case of fever and just palpable spleen

treatment investigation clinical picture
treatment diagnosis management
investigation clinical picture differential diagnosis
typical infective endocarditis
post icteric

17


SGOT

SGOT short life span

SGPT

acute hepatitis A is less severe than acute hepatitis B, MCQ
cholestasis
A
arthalagia
B more severe serum sickness like
vasculitis complication
C acute pass un noticed
viral

hepatitis
complication

acute chronic chronic cirrhosis acute fulminant

signs of fulmination
hepatic encephalopathy prothrombin time prolonged

cholestasis relapse post hepatitis syndrome

Liver Liver
Liver symptoms
hepatoma very bad sequel
viral hepatitis
unconjugatedbilirubin
extra hepatic manifestation problem solving
aplastic anemia
viral hepatitis bone marrow aplasia
viral hepatitis arthritis
Cryoglobulinemia hepatitis C
immune complex glomerulonephritis B & C C

) hepatitis C cryoglobulin
(
antibody in vitro very active very low temperature

18

 cryoglobulin antibody virus C cryoglobulin

vasculitis glomerulonephritis provoke immune reaction
C glomerulonephritis cryoglobulin
( )
C
C positive cryoglobulin glomerulonephritis

!!!
+
C urine analysis proteinuria
investigation

cryoglobulin in blood C cryoglobulin cryoglobulin
glomerulonephritis
steroid

immune complex vasculitis vascultitispoly arteritisnodosa

Hepatitis B infection C
MCQ poly arteritis nodosa positive hepatitis B surface antigen

investigation bilirubin transaminases transaminases
markedly elevated serum bilirubin normal alkalinephosphatase
mild elevation parenchyma cholestasis

prothrombin time normal prothrombin time acute hepatitis
bad prognosis fulmination

non specific
diet fat
common mistake common acute viral
hepatitis
acute viral hepatitis hepatocyte liver decompensated

19

 restriction hepatic encephalopathy liver cirrhosis

Liver compensated
liver cirrhosis Liver decompensated decompensated
ascites albumin prothrombin time
hepatic encephalopathy
once encephalopathy restriction
malnutrition Immune

deficiency Infection
C
hepatitis G
carrier fulmination acute chronic
CHRONIC HEPATITIS
chronic hepatitis inflammation Liver chronic liver
disease chronic hepatitis cirrhosis
B&C
alpha methyl dopa auto immune hepatitis auto immune hemolytic anemia
hepatitis
Wilson

cupper irritant Liver episodes of hepatitis chronic
cirrhosis
mild form of chronic hepatitis
portal tract mildinflammation in hepatic lobule
Liver architecture activity sever form of
hepatitis
accidently preoperative investigation
transaminases
mild elevation

elevation of transaminases

viral marker auto immune marker cupper iron profile
medication
marker biopsy mild form chronic hepatitis
retrograde viral C Viral B
idiopathic
follow up
biopsy mild from chronic hepatitis
20

 No need for interference

hepato toxic drugs
reassurance avoid
Silymarin
anti-oxidants

Mild form sever form

B delta super infection

hepatic support

sever form
biopsy

inflammatory cells Portal tract Inflammatory cells
central vein Liver bridgingnecrosis piece meal
necrosis
bridging necrosis inflammatory cells portal tract central
vein
piece meal necrosis Liver parenchyma
signs of activity in sever form
biopsy
piece meal bridging
rosette appearance liver cirrhosis
clinical picture hepatitis chronicity jaundice
malaise liver enlarged tender
cirrhosis
auto immune chronic viral hepatitis extra hepatic manifestation

Acute extra hepatic chronic chronic chronic
long standing chronic viral c
extra hepatic manifestation of chronic viral infection arthopathy
C
cryoglobulin
chronic glomerulonephritis
glomerulonephritis

21

renal

membrane proliferative
C commonestglomerulonephritis in Egypt is membrane proliferative
cryoglobulin blood C
biopsy
membrane proliferative
membranous glomerulonephritis hepatitis B

polyarthritis auto immune extra hepatic manifestation

Grave's disease auto hemolytic anemia Hashimoto's thyroiditis
problem solving
auto immune female
Problem ::: female 40 yrs e' enlarged liver enzymes elevated,
thyroid arthropthay

auto immune Liver auto immune thyroid
auto immune hepatitis written
positive ANA lupoid hepatitis *****
antismooth muscle Ab
common positive LKM ( Liver, Kidney, microsomal Ab) ******
soluble liver antigen +ve SLA ) (
ANA lupoid

ANA=
LKM=
SLA=


SLA LKM ASmAb ANA
acute hepatitis chronic hepatitis markers

CBC investigations

22

 SGPT

.....
A ,B,C ANA antisoomth muscle LKM LKM positive
auto immune type 2






dose 30 60
reduction dose maintenance
clinical biochemical check up
full remission maintenance remission

osteoporosis myopathy hyper tension
diabetes mellitus
auto immune disease

gradual withdrawal low dose maintenance
remission

SGPT
SGPT .....
azathioprine
( )



( azathioprine )
cyclophosphamide

23

 Lupus

reduction of the dose of steroid
azathioprine methotrexate
rheumatoid
cyclophosphamide
hepatitis hepatitis B hepatitis C hepatitis B conventional
Interferon every other day hepatitis B 16 weeks
hepatitis C
conventional Interferon almost

pegylated interferon pegasys
one ampule 180

Ribavirin
interferon
indication

hepatitis B replicating HB e Ag positive DNA polymerase
enzyme positive DNA positive PCR
biopsy activity
activity

piece meal bridging
biopsy

other transaminases high

transaminases viral marker Positive viral replication
biopsy

hepatitis C positive PCR biopsy high transaminases

transaminases PCR positive high viremia

24

 biopsy
side effects flu like arthralgia depression
neuropathy bone marrow depression


chronicity

investigations
PCR Liver enzymes
PCR negative
variable

flu like , arthralgia , fever paracetamol
responding
Ribavirin combination hepatitis C
lamivudine antiviral
lamivudine oral

Bilharziasis
peri portal fibrosis no hepatic loss ofarchitecture

bilharziasis
cirrhosis
bilharziasis liver cirrhosis bilhazia

hepatitis
pure bilharziasis fibrosis cirrhosis
pure bilharzial liver Liver decompensated early Late
so late Peri portal fibrosis portal hypertension
endemic bilharzial mixed with post hepatic cirrhosis

25

Portal Liver cirrhosis

liver cell failure hypertension
so late liver cell failure portal hyper tension pure bilharzial

hepato toxic drugs

chronic hepatitis
INH halothane acute hepatitis

INH alphamethyldopa
cholestasis
fatty liver anti-epileptic Na valproate fatty liver
anabolic steroid androgen Peliosis hepatis hepaticpeliosis
paracetamol toxicity fulmination hepatic necrosis
Contraceptive pills Budd chiari
Liver
contraceptive pills
female

contra
captive
pills

female under contra captive adenoma Budd chiari cholestasis

liver pills
Danazol hepatoma
Halothane hepatitis idiosyncrasy
metabolite medication idiosyncrasy
metabolite
hyper sensitivity hyper sensitivity

broncho urticaria anaphylaxis type one hyper sensitivity provoke
idiosyncrasy spasm
metabolite
Problem Post-operative jaundice
Halothane jaundice

accidently ligation of common bile duct hepatotoxic drugs
spontaneous bacterial peritonitis SBP
26

 Infection tapping ascites ascites

spontaneous peritonitis
infection ascites Liver cirrhosis spontaneous bacterial peritonitis
organism lymphatic blood blood born infection
peritonitis
peritoneal cavity Peritoneum
ascites liver cirrhosis
hepatic encephalopathy fever ascites liver cirrhosis
spontaneous bacterial peritonitis diagnosis
positive gram staining gram staining
fluid WBCs count
250 poly morph neutrophils 500 total leucocytic count
SBP
3rd generation cephalosporin
portal vein thrombosis
blood disease polythythemia portal vein
portal infection umbilicus
pancreatic tumors
portal vein bacteremia bacteremia bacteremia pyemia
operation umbilical sepsis phlebitis
ascites portal hyper tension Portal vein
hypo albuminemia portal hypertension ascites
acute sever portal hyper tension portal vein thrombosis
Proto systemic shunt collateral ascites
absorbed ascites portal pressure subside
ascites Portal vein thrombosis
transient ascites
contra captive pills Problem Budd chiari

Pain in Rt hypo chondrium female female under contra captive pills
Budd chiari enlarged Liver
common
polythythemia Budd chiari
hemolytic anemia paroxysmal nocturnal hemoglobuinuria
vascular occlusion
27

negative Liver enlarged and tender Budd chiari syndrome

hepato jugular reflux
Hepatic vein Liver Liver portal vein abdomen
hepato jugular right side of the heart blood to inferior vena cava
Portal squeeze abdmonial compression reflux
right side of the heart hepatic vein Liver vein to the liver
negative hepato jugular reflux hepatic vein
liver enlarged contra captive pills Budd chiari syndrome
negative positive hepato jugular reflux tender
written
pain in the common
Enlarged tender liver
differential tender Liver enlarged examination right hypo chondrium
diagnosis
abemic hepatomaright side failure Budd chiari syndrome Hepatitis
liver
central occulsion Budd chiari veno occlusive disease
vein
Liver transplantation
split liver living donor cadaver liver
Left lobe transplantation
wilson's disease biliary atresia indications
hepato cellular carcinoma
Liver transplantation hepatoma

infection metastasis contra indication

brain heart kidney Liver

Organs Organ
blood group HLA typing receiver donor pre-operative
prednisolone azathioprine cyclosporine

28

 Liver expensive
auxiliary liver transplantation fulminant liver
failure hope
liver normal Liver auxiliary liver
Liver liver Left lobe Liver
liver function fulminant liver failure
auxiliary liver Liver chemo-therapy
graft rejection
oral written sonar Liver sonar
focal lesion
focal lesion granuloma
focal
lesions
in
liver

adenomacarcinomahemangioma granuloma
focal lesion
coin mass Liver
focal lesion liver focal lesion sonar
MRI CT scan alpha feto ptn
MRI CT scan benign malignant hemangioma
granuloma liver
granuloma infection tuberculosis leprosy
syphilis Liver hepato biliary disorder primary
biliary cirrhosis
primary biliary cirrhosis granuloma
Granuloma portal tract fibrosis bile duct drugs
allopurinol
hepatic cyst Echinococcus granulosus cyst calcified in the liver
CT scan radiology liver calcified
Liver & pregnancy
hepatitis A B
Hepatitis B + HB Ig vaccine
hepatitis B + HB Ig vaccine

29

 B virus fulmination

cholestasis of pregnancy cholestasis
swelling hepatocyte
trimester Puritis benign condition
liver pregnancy

HELLP syndrome HELLP syndrome pre-eclampsia
H Hemolysis
EL Elevated Liver enzymes
LP Low Platelet count
HELLP syndrome Pre-eclampsia delivery
Acute fatty liver of pregnancy 3rd trimester
encephalopathy
derlium
encephalopathy
investigation fulminant failure
fatal
hyperemesis gravidarum ( )
Liver enzymes
pregnancy in liver transplant recipient Liver
graft immune
system Pregnant

child classification function state of the liver child classification

function state of the liver
serum albumin serum bilirubin Prothrombintime
function state of the liver liver cirrhosis
ascites
encephalopathy

Mild A
moderate B
sever C

30

 Liver cirrhosis albumin bilirubin Prothrombin time

LIVER CIRRHOSIS
liver cirrhosis haemochromatosis haemochromatosis
written problem solving
haemochromatosis haemochromatosis
excessive
iron
deposition
in
tissue

Liver excessive absorption

iron from intestine Primary haemochromatosis defect
small intestine
excessive absorption of iron
autosomal recessive
iron absorbed tissues male female
female iron overload menstruation

haemochromatosis
liver enlarged liver cirrhosis enlarged
liver shrunken
Liver cirrhosis long standing liver shrunken
haemochromatosis iron overload iron infiltration
heart cardiomyopathy Problem
Heart failure diabetes heart
Liver gonads normal iron deposition pituitary gland
hypo pituitarism adult gonado trophins
hypo gonadism skin hyper pigmented hyper
pigmented skin skin sometimes grayish in color grayish in color
!!! hyper pigmentation dark skin diabetic
47 diabetic nephropathy nephrotic syndrome
dyspnea orthopnea cardiac ischemic heart disease
heart failure

31

 diabetic hepatic liver enlarged

heart failure right sided Liver congested
grayish color hyper pigmentation grayish color relatively
grayish


diabetes diabetic hepatomegaly
type 2 fatty liver
type 1 glycogen infiltration liver diabetes skin
dark item
Joints joints Liver B
C arthopathy lupoid hepatitis arthopathy
viral hepatitis arthopathy Lupoid hepatitis arthropathy Wilson
Haemochromatosis arthopathy
Investigation
iron iron binding capacity Investigation iron overload
transferrin saturation
200 biopsy biopsy
CT scan
pigmentation cirrhosis haemochromatosis
primary biliary hyper pigmented
Iron
500 blood 250 Iron
adult iron

haemochromatosis Iron
60
veno section

follow up Iron profile anemic
iron stores release iron blood blood
RBCs iron iron overload
satisfactory result veno section

32

 haemochromatosis hepato cellular carcinoma cardio myopathy

chelator ( ) )desferal ( desferrioxamine
haemochromatosis
hemosidrosis acquired common acquired hemosidrosis
chronic hemolytic anemia thalassemia
hemolysis RBCs
iron haptoglobin hemopexin
RES chronic hemolytic anemia definitely Iron overload
iron overload iron RES organ parenchyma
primary haemochromatosis iron in organ parenchyma more injurious than
hemosidrosis thalassemia liver function
thalassemia viral hepatitis thalassemia
cardio myopathy
thalassemia hypogonadism haemochromatosis
thalassemia iron over load organ RES organ organ
parenchyma haemochromatosis hemosidrosis
Wilson Wilson written Problem
Wilson Liver enlarged jaundice involuntary movement

Liver cell failure flapping tremors

liver enlarged Involuntary
movement Wilson

Parkinsonism
Liver cirrhosis
Liver cirrhosis parkinsonism

examination
abdomen
abdominal examination
neuro abdomen general examination comment on
comment systems
heart and chest and abdomen
heart just auscultation heart sounds additional sounds Murmurs
Heart Neck vein
33

 cardiology

abdomen

auscultation
murmur !!! anemic

chest auscultation crepitation

TVF Percussion chest

abdomen

liver, spleen and ascites

systems Part general examination

Wilson cupper Wilson

cupper duodenum Liver Liver
ceruloplasmin cupper cupper
Liver bile
cupper
intestine stool
defect Wilson
in ability of the liver to excrete the cupper cupper Liver
bile Liver
liver
haemochromatosis intestine Liver

cupper Liver Haemochromatosis Liver
transplantation Wilson Liver
Wilson ceruloplasmin liver Liver
ceruloplasmin cupper free
two abnormalities in Wilson liver to excrete copper
Liver copper ceruloplasmin ( cupper spelling

34

 - ) cupper
cornea scleral junction Kayser Fleischer ring slit lamp
basal ganglia involuntary movement
Presentation

recurrent attack of hepatitis
recurrent hepatitis
)
(

( viral marker
viral marker auto immune marker negative hepatocellular
damage

iron profile cupper profile )
involuntary

movement basal ganglia
diagnosis
Problem
Wilson cupper blood low urine high
cupper free in blood ceruloplasmin tissues cupper
tissues free

cupper Low in blood and high in urine

ceruloplasmin Low
written discuss iron and cupper overload
iron overload iron cupper over load MCQ
cupper
haemochromatosis
glucosuria
diabetic Wilson free cupper
tubular injury glycosuria tubular defect
free cupper Wilson diabetic
urine glycosuria tubular defect glycosuria tubular injury
post gasterectomy
35

 . Haemochromatosis
glycosuria urine
hemolysis Wilson very mild
chelator cupper
penicillamine penicillamine very toxic
zinc acetate
Liver transplantation
alcoholic liver disease
No.1 fatty liver
fatty liver Mild . fatty liver
heaviness in right hypo chondrium Liver
enlarged some-times tender
fatty liver neutral fat Liver parenchyma without
inflammatory process NASH Nonalcoholic steato-
hepatitis
steatosis fatty liver hepatic steatosis fatty liver

Liver parenchyma inflammatory process

steato hepatitis NASH

fatty liver Mild elevation
fatty liver can be diagnosed by sonar liver is bright bright liver
Liver parenchyma organ parenchyma
sonar CT scan grayish fat
Alcoholic hepatitis
investigation
alcoholic hepatitis
SGOT SGPT SGPT suppressed
deficiency alcohol intake SGPT
content in the liver
liver SGOT SGPT

hepatitis

36

 SGOT SGPT scientific

scientific SGOT SGPT
sever
hepato
cellular
damage
SGOT hepatocyte mitochondria SGPT cytoplasm
hepatocyte SGOT release from mitochondria
SGOT more high SGPT
ratio alcohol
Gamma GT
High Ig A
Mallory's hyaline
biopsy Mallory's hyaline

hyalinematerial hepatocyte alcoholic liver
disease primary biliary cirrhosis
RBCs macrocytic macrocytic non megalo blastic
::: alcoholic liver disease Non megalo blastic macrocytosis
lipid blood Lipid
RBCs macrocytic megalo blastic
-2 chronic liver disease macrocytosis chronic liver disease
RBCs
RBCs chronic liver disease
acanthocyte
chronic advanced liver disease RBCs
acanthocytosis blood RBCs RBCs
spikes acanthocyte
alcoholic cirrhosis
alcoholic cirrhosis very susceptibleHepato cellular carcinoma
cirrhosis hepatoma
post hepatitis cirrhosis hepatoma B hepatoma
hepatoma B C C
haemochromatosis hepatoma
alcoholic cirrhosis hepatoma
37

 primarybiliarycirrhosis
cupper overload
Wilson
cupper protective for the liver against hepatoma
cupper protective
haemochromatosis hepatoma Wilson
factors very liable to alcoholic cirrhosis alcoholic liver
disease dose duration male female malnutrition
Hepatitis B surface antigen positive viral
hepatitis
. anti fibrogenesis colchicine
fibrogenesis
Liver cirrhosis
specific
good nutrition amino acids

alcoholic liver disease
complications of liver cirrhosis portalhyper
tension Portal hyper tension rupture varcies ascites
hepatic encephalopathy Hepatoma
poor prognostic indicator in liver cirrhosis
child classification Liver cirrhosis
ascites Lower limb edema Jaundice bilirubin
albumin Prothrombin time encephalopathy

Problem
primary biliary cirrhosis
problem female itching Itching female
Hepatic lobule Portaltract Inflammatory cells
inflammatory cells granuloma granuloma chronic specific
inflammation granuloma fibrosis fibrous tissue bile
duct ) cholestasis ( biliaryobstruction Obstruction Intra-hepatic
hepatic lobule Peripheries portal tract
38

 cholestasis bile contact hepatocyte bile

irritate the hepatocyte and provoke chemical inflammation liver cirrhosis
manifestation itching jaundice female 45 yrs
itching On examination Liver enlarged primary biliary
cirrhosis
fatsoluble vitamins bile intestine
absorption K bleeding tendency absorption D oesteo-
dystrophy hepatic oesteo-dystrophy hepatic oesteo-dystrophy
D primary biliary cirrhosis
hyperlipidemia Primary biliary cirrhosis

Itching retention bile salts in blood bile acids in blood
central mechanism opioid like
opioid receptor

Itching

!!! itching

( )
Naloxone Naloxone anti-dote
( )
opioid
liver

receptors
central mechanism simply bile salt retention
mechanism
data
primary biliary cirrhosis
differential diagnosis Possibilities

one diagnosis One diagnosis
possibilities
One one

39

 logic Most likely what is the most likely diagnosis

obstructive jaundice Logic
lymphoma renal failure Primary biliary cirrhosis
Liver female
primary biliary cirrhosis primary biliary cirrhosis
Lymphoma spleen liver
primary biliary cirrhosis spleen Liver
female

primary biliary cirrhosis
liver lymphoma differential diagnosis
spleen
) (
anti-body Anti- mitochondrial anti-body specific anti-body

primary biliary auto immune hepatitis Immune mediated liver disease
cirrhosis
Ursodeoxycholate diagnostic liver biopsy
acute hepatitis
cholestasis Ursofalk
cholestasis Liver cirrhosis chronic hepatitis acute hepatitis
cholestasis mild
cholestasis liver cirrhosis chronic hepatitis acute hepatitis
gall bladder

Ursogall sever you can give Ursofalk

Xanthoma Xanthelasma clinical pictures Xanthelasma
Xanthelasma Xanthoma Liver Lipid deposit

erupted Xanthoma lipid deposit on eye lid Xanthelasma
fat buttocks some times on buttocks creases palmer aspect
deposit

bile salt in intestine chelator Cholestyramine supplement Vit. K

entero hepatic circulation
effective

40

 oesteo-dystrophy oesteo malcia

oesteoprosis effective
other immune suppressive drugs azathioprine cyclosporine
Liver transplantation
sclerosing cholangitis vanishing duct syndrome
vanishing duct syndrome

primary biliary cirrhosis
vanishing duct duct liver
hepatic ducto penia
Primary biliary cirrhosis auto immune

arthopathy liver
sclerosing cholangitis intra hepatic extra hepatic
obstructed biliary cyst
Primary biliary cirrhosis sclerosing cholangitis Male female
ANCA ANCA
ANCA positive granuloma , vasculitis

)Liver cell failure (LCF

hypo
Ascites

albuminemia portal hyper tension
pulmonary cardiovascular
blood microcytic hypochromic chronic blood loss normocytic
normochromic hypersplenism macrocytic Macrocytic
chronic liver disease Non megaloblastic advanced liver
disease B12 liver folic acid Liver .....
megaloblastic anemia
Liver disease B12 or folic acid deficiency
macrocytic non megaloblastic deposit of fat RBCs
chronic liver disease fats Liver RBCs
cardio vascular system
vasodilatation ) nitric oxide (NO vaso active intestinal
) peptide (VIP hyper dynamic circulation Pulse
41

 hyper dynamic bigpulse volume vaso dilatation

hypotensive badsign ( ) Liver
cell failure bad sign vaso dilatation

Pulmonary manifestations
centralcyanosis
Opening of the intra pulmonary shunts intra pulmonary shunts venous
arterial cyanosis therapy

therapy
N.B.
Hypoxia( or cyanosis ) due to Fallot , eisenmenger's opening of the intra pulmonary shunts
cyanosis hypoxia Fallot eisenmenger's
intra pulmonary shunts mix venous blood and arterial blood
venous arterial No response to oxygen therapy
venous arterial
hypoxia chest condition Usually hypoxia
chest
adult respiratory distress syndrome therapy
hypoxia shunt
venous arterial advanced chest disease
eisenmenger's syndrome eisenmenger's central
cyanosis shunt chest

skin manifestation spider navei palmar erythema
Terry's nail white nail nail bed Marked opacity
HepaticEncephalopathy problem written
neurological psychiatric manifestions Liver liver
cirrhosis with precipitatingfactor
Pre coma and coma pre coma reversal sleeprhythm
foetor hepaticus Asterixis flappingtermors
dysarthia chorea
42

 liver cell failure involuntary movement

Wilson mechanism
hiccough liver renalfailure
renal failure yawing Liver
disease



Grades of hepatic encephalopathy
gradezero subclinical decline of intellectualfunctions

grade one apathy
gradetwo lethargy verbal stimuli
gradethree stupor vigorous stimuli
gradefour coma coma respond early to pain
early hepatic encephalopathy stage
constructional apraxia test
number connection test
hepatic encephalopathy
flapping tremors

Hepatic encephalopathy

..... .... .... ... metabolite metabolite
... Liver Liver detoxification metabolite
Liver portal vein to bypass the liver systemic circulation
porto systemic shunt Liver disease No1 metabolite
bypass portal hyper tension

43

 toxins metabolites agitation

interfere with kerb's cycle in brain utilization
of glucose
brain Interfere utilization
excited hypoglycemic

Mercaptans falseneurotransmitter aromatic amino acids

branched amino acids
false neurotransmitter
problem hepatic encephalopathy abnormal
behavior excited tremors history chronic
liver disease hepatic encephalopathy
precipitatingfactors Hepatic encephalopathy liver
cirrhosis
liver
GITbleeding GIT bleeding Problem
consequences of GIT bleeding Liver cirrhosis frank

shocked hepatic encephalopathy
diruetics hypokalemia diruetics
high protein diet
Infection
accumulation of ascites

volume

electrolytedisturbances diruetics

re
infusion

accumulation
constipation
44

 infection
spontaneous bacterial peritonitis ascites
delirium excited
subduralhaematoma common in old age trivial trauma
trivial head injury

sub dural behavior
investigations CTscan sub
dural
hypoglycemia
alcoholwithdrawal alcohol withdrawal
diazepam
Sub dural conservative treatment wait and see
hypo glycemia glucose injection

Hepatic encephalopathy diazepam

:::
Controlprecipitatingfactors eradication of bacterialflora Neomycin
partiallyabsorbed

control of precipitating factors
nephrontoxic
stopthediruetics injectionscelrotherapy diruetics
Neomycin 3rd
generation cephalosporin injection spontaneous bacterial peritonitis
3rd
Infection
generation cephalosporin ciprofloxacin
enema
lactulose lactulose
diarrhea lactulose dose
stool stool hard
watery

45

 diarrhea hypo volumia hypo kalemia precipitate and

aggregate the encephalopathy L-dopa
recent trends in treatment of hepatic encephalopathy
haemoperfusion
filter dialysis toxin

hepatic
hepatic encephalopathy GABA
anti body
encephalopathy benzodiazpine symptoms diazepam
diazepam GABA

GABA receptor GABA GABA receptor hyper sensitive
valium GABA receptor
flumazinel Anexate
viable hepatocyte culture
transplantation
sedation MCQ
sedation sedation mandatory
encephalopathy


short acting benzodiazepine
midazolam
flmazinel
Fulminant Hepatic failure
acute liver disease hepatic encephalopathy
originally normal normal
Normal acute viral hepatitis acute viral hepatitis
hepatic encephalopathy
fulminant liver failure written
acute liver failure fulminant acute liver failure acute
viral drugs toxicity fatty liver of
pregnancy reye syndrome feverish fever


rheumatic fever Kawasaki
46

 Kawasaki far east Kawasaki

viral infection chicken pox influenza Para influenza
cervical lymph node
kawasaki
coronary
Investigation

vasculitis myocardial infraction
Kawasaki
very rare
fulminant failure hepatic encephalopathy encephalopathy
hepatic encephalopathy acute
hepatic encephalopathy precipitating factor hepatic encephalopathy
liver cirrhosis precipitating factors
acute encephalopathy fulminant failure
clinical pictures encephalopathy Investigation
bilirubin prothrombintime albumin
sonar liver 3 sonar
Radioisotopescan Liver
no uptake at all Liver Necrosis liver
regenerate
encephalopathy hypo kalemia hypo natremia hypo
glycemia bleeding tendency brain edema brain edema with low
papilledema space occupying lesion
brain edema papilledema waste products
brain capillaries damage blood brain barrier edema
brain edema papilledema
papilledema Increased intra cranial tension brain edema
papilledema
lacticacidosis
liver

Liver transplantation fulminant failure

auxiliaryliver liver
auxiliary liver
47

 Ascites
causes of ascites in absence of intra hepatic liver disease ( intrinsic liver disease)
Liver disease
Non hepatic causes of ascites
right side failure congestiveheartfailure
T.B. mesothelioma peritoneal disease nephrotic syndrome
lymphaticobstruction lymph node cancerovary malignantdeposit
Budd chiari Buddchiariacutepancreatitis mexedema
vascular disease Liver
Important causes
Lower limb edema ascites
( ) Problem solving Local
lower limb edema ascites
mesothelioma peritonitis local disease Local disease
Malignancy in peritoneum malignant
constrictive ascites precox

pericarditis
Localization diuretics Liver cirrhosis
Portal hyper tension
right sided pleural effusion ascites

pleura peritoneum naturalchannel
ovarian ovarian tumor Meig's syndrome Meig'ssyndrome
ovarian tumor syndrome fibroma tumor
Meig's syndrome right sided pleural effusion ascites

Liverfunctions investigations ascites
Laparoscopy
Malignantdeposit peritonealcarcinoma local cause
peritoneal fluid albumin transudate exudate
albumin gradient albumin gradient
Level of ascetic albumin and plasma albumin

48

 ( Liver cirrhosis ) advanced serum albumin

2 Malignancy ( )
exudate
transudate

tansudate Liver cirrhosis heart failure nephrotic syndrome
generalized edema peritoneum transudation
exudate Inflammatory malignant albumin level
ascetic fluid albumin level ascetic fluid 3
exudate
Liver cirrhosis serum albumin
malignant ascites malignant ascetic fluid
serum !!
exudate transudate ascetic albumin plasma albumin
differences plasma
albumin gradient

albumin and ascetic albumin
Differential diagnosis of cirrhotic ascites
differential diagnosis of ascites

management of ascites definition etiology

ascites cirrhosis
malignant ascites mexedema

constrictive pericarditis
ascites ascites liver cirrhosis
right sided heart failure pancreatitis
Treatment of Ascites rest salt restriction fluid restriction

diuretics spironolactone spironolactone gynecomastia very
painful gynecomastia tender
spironolactone Lasix otherwise diuretics
Lasix

sessions
albumin infusion
49


re
replacement of albumin

accumulation criteria safe paracentesis
systems
ascites criteria
criteria
criteria
system
tense lowerlimbedema ascites Lower limb edema

edema
ascites tense
file
Lower limb edema ascites moderate ascites

Serumbilirubin Platelets
serum creatinine otherwise hepato renal failure session

ascites refractory Salt retention hypoalbuminemia
salt restriction diuretic
diuretics
diuretics

Na excretion water Low salt syndrome
diuretics
fluid restriction diuretics

T.B. peritonitis malignantascites
line Le veen shunt ultrafiltration Le veen shunt
jugular vein peritoneum
TIPSS

50

 portal hyper tension relieve ascites TIPSS

Liver decompensated ascites TIPSS

contra indicated TIPSS
portalhyper relieve TIPSS encephalopathy TIPSS
livertransplantation tension
written
Refractory ascites

Ascites cirrhotic ascites refractory ascites

nephrotic constrictive pericarditis mexedema
fluid restriction
diuretic resistance
refractory ascites
lasix 400 full dose spironolactone saltrestriction
diuretic resistance refractory 160
albumin infusion diuretics
TIPSS Ultrafiltration & reinfusion Le veen shunt
transplantation
ascites Intractable ascites
diuretics
encephalopathy diuretics
liver transplantation encephalopathy
refractory diuretic resistance
portal hyper tension
presinusoidal
Periportalfibrosis
Portalveinthrombosis
sarcoidosis
presinusoidal portal hypertension MCQ Congenitalhepaticfibrosis

primarybiliary cirrhosis presinusoidalportalhypertension cirrhosis
granuloma in portal tract
sinusoidal portal hyper tension
Livercirrhosis
51

 postsinusoidal
hepaticveinocclusion (BuddChiarisyndrome )
Centralveinocclusion (veno-occlusive & alcoholic liver disease)
Portal hypertension humoral material
vaso constrictor enothelin
Nitric oxide systemic circulation vaso dilatation
rennin angiotensin aldosterone system stimulation
Portal hyper tension
complication of complication portal hyper tension
portal hypertension
pan cyto penia Hypersplenism rupturevarices
bypass toxins rupture varices renal failure renalfailure
shocked rupture varices portal hyper tension the liver
acutetubularnecrosis renal failure
(porto Hepatic encephalopathy Hepatic encephalopathy ascites
Portal hyper tension systemic encephalopathy )
... portal vein metabolite ... ...
systemic
bypass the liver portal hypertension
three types of circulation
hepatic encephalopathy
infection precipitatingfactors livercirrhosis

Hepatic encephalopathy acute without precipitating

fulminantfailure
factors
hepatic encephalopathy written chronicportosystemicshunt
hepatic encephalopathy
Liver
Problem solving
hepatic hematemesis hematemesis
peptic ulcer rupture varices
Metabolized in gastrin hormone peptic ulcers Liable
gastrin advanced liver disease liver
peptic ulcer
52


presentations rupture varices peptic ulcer hematemesis
peptic ulcer most painful hematemesis
peptic ulcer
painless
profuse
bleeding

rupture varices

systemic vaso
shockencephalopathy Portalhypertension pitressin
octreotide octreotide
constriction terlipressin
stomatostan MCQ
rupture
vaso constriction
mesenteric arteriole intestine vaso constricted blood flow
intestine venous drainage Intestine Portal vein
portal pressure low vaso constrictor portal vein vaso constrictor
mesenteric arteriole indral indral prophylaxis
indral Prophylaxis large dose cardiac out
put Liver cirrhotic ischemic
tachy cardia tachy cardia
B blocker
injection sclerotherapy sclerosing material
bucrylate histoacryl

Sanfgestaken or Minnesotatube momentary transient

best treatment rupture varices injection sclerotherapy
k
Sangstaken or Minnesota tube

53

 portosystemicshunt TIPSS TIPSS

internaljugularvein superior vena cava right atrium
inferior vena cava hepatic vein stent hepatic vein
portal vein tributary

heptic vein
portal vein
portosystemic shunt
encephalopathy theoretically Portal vein toxins hepatic
vein branch tributary portal vein portal vein
Liver cell failure Liver
hepatic vein
decompensated decompensated TIPSS
portal hyper tension liver transplantation
acute attack sclerotherapy
banding in acute attack Ligation
TIPSS
In between attack
prophylaxis of hematemesis
rupturevarices banding injectionsclerotherpay
TIPSS
attack
portal hypertension

pitressinterlipressin octreotide somatostan
portal pressure attack B blocker
tumors benign tumors liver
adenomahemangioma benigntumor in liver hemangioma

sonar CT scan
hepatoma hepatitisB Hepatitis C haemochromatosis
Wilson common
clinical pictures
liver cirrhosis Liver cirrhosis ascites
jaundice

54

 Infection diuretics aggravating factors

normal sonar
MRI CTscan
alpha feto protein focal lesioninliver
hepatoma
erythropoietin like
hepatoma para malignant syndrome

parathyroid hypo glycaemia insulin like material polycythemia
problem solving written hepatoma
malignant cells insulin like material hypo glycaemia
excessive consumption of glucose
focal lesion Liver alpha feto protein investigation
spiral CT scan MRI malignant benign
biopsy localarea withlow uptake hepatoma liverscan
hepatoma
Embolization
gel foam hepatoma artery
Liver compensated liver Localized surgical resection
partial hepatoectomy Localized
Recent non-surgical treatment of hepato cellular carcinoma
Localized radiofrequencyInjection
tumors of the liver
Malignant benign
Secondary , primary
fibrolamellarcarcinoma
B hepatitis C fibrolamellar
better prognosis than hepatoma marker
differential diagnosis of focal lesion in the liver Hepatic nodule
differential diagnosis of mass in the liver
Causes
1. Nodular hyperplasia.
2.Adenoma.
55

3. Haemangioma.
4. Hepatoma.
5. Fibrolamellar carcinoma.
6. Abscess either pyogenic or amoebic.
7. Granulomas (see later).
Nodular regenerative hyperplasia
Small hepatocyte nodules unassociated with fibrosis. It is associated with many
conditions such as connective tissue diseases, blood diseases, & steroids therapy,
the condition usually presents as an abdominal mass, liver biopsy is diagnostic.
Prognosis is good but hepatocellular carcinoma may occur.
Focal nodular hyperplasia
It is a subcapsular liver nodule with central fibrosis. It is almost always asymptomatic
Fatty liver (Hepatic steatosis )
macrovesicular microvesicular
diabetes type 2 diabetes obesity macro
typeone fatty liver diabetes type 2 liver diabetes
type 2 Liver

fattyliver hyperlipidemic obese diabetes
glycogen storage disease glycogen liver infiltration type one diabtes

fattyliver of pregnancy

microvesicular
microcvesicular
tetracyclinetoxicityReye'ssyndrome
lipotropic drugs : choline
fulminantfailure
fatrestriction
fatty liver Nonalcoholic steato hepatitis NASH
fatty changes fatty changes hepatic steatosis
steato
inflamed hepatocyte Liver
liver cirrhosis NASH hepatitis
jaundice Item
unconjugated hyper bilirubinemia causes of indirect hyperbilirubinemia
defect gilbert uptake defect Hemolysis hemolysis
Crigler-Najjar syndrome conjugation

56

causes of direct hyperbilirubinemia

pre hepatic jaundice hemolytic jaundice jaundice
hemolysis
indirectbilirubin indirect bilirubin hemolysis
( ) albumin

hemolysis
stercobilin
urobilinogen
uptake indirect bilirubin hemolysis path way
intestine conjugated bilirubin directbilirubin conjugation
urobilinogen Liver stercobilinogen Intestine
colorless urobilinogen
biliarycirrhosis cholestatic Obstructive jaundice
biliary Investigation scleraolivegreenclaystoolpaindarkurineItching
obstruction
obstruction data obstructive jaundice

Gamma gt alkaline phosphatase direct bilirubin bilirubin
extra hepatic biliary obstruction intra hepatic biliary dilatation
150 common bile duct
water soluble direct bilirubin bilirubin nephropathy
dark albumin
nephropathy
kidney tubules endogenous toxin criteria
acute tubular necrosis
obstructive hepatocellularjaundice
hepatocellular obstructive jaundice
jaundice
conjugation uptake defect
hepatocellular hepatocellular
secretion
bilirubin handling hepatocyte hepatocellular
unconjugated bilirubin defect in uptake
unconjugated bilirubin defect in conjugation
conjugated bilirubin secretion defect

57

 step secretion Obstructive unconjugated conjugated

uptake failure Liver verydifficult liver metabolism
direct two fraction secretion conjugation
indirect

obstruction

obstructive Gammagt alkalinephosphatase
clinically serumalbumin prothrombintime
hepatocellularjaundice liver cell failure
mainly direct bilirubin bilirubin
hepatocellular obstructive
investigation
defect in mild defect in conjugation Partial defect in uptake Gilbert
MCQ conjugation
conjugation uptake
Indirect bilirubin
recessiveautosomal dominant
MCQ

autosomal dominant
indirect
Mild rise in bilirubin

or reticulocytosis normal hemolysis Investigation
gilbert by exclusion
fasting bilirubin MCQ
bilirubin
normal liver function
conjugated bilirubin secretion of what defect in secretion Dubin-Johnson
conjugated bilirubin conjugated bilirubin Liver
other hepatocellular jaundice obstructive absorbed in circulation
Dubin-Johnson gilbert isolated defect in uptake criteria of biliary obstruction
pigment biopsy Liver normal isolated defect in secretion
uptake Liver Dubin-Johnson bromsulphthalein (BSP) Liver

58

 bromsuphthalein dye blood Liver

uptake secretion dye circulation
drop of dye injection dye uptake secretion
Bromsulphthalein Dubin-Johnson
jaundice jaundice
recurrentjaundice
gall bladder
hemolytic gallstone
common bile duct
common bile duct common bile duct
spasm buscopan
periampullarycarcinoma
recurrent jaundice familial jaundice painful jaundice painless jaundice

Amoebic liver abscess
written problem solving
portal vein right lobe of the liver
cecum
streaming effect cecum compartment portal vein
amoeba right lobe of the liver
endemic right hypo chondrim
tenderness liver Lower border of
the liver right costal margin
fist
tenderness
percussion
fist percussion fist
percussion
tender
Intercostal tenderness intercostal
space Liver fist percussion

Investigations
leukocytosis polymorph
alkalinephosphatase
59

 cyst

right pleura

right sided pleural effusion

Anchovysauce
ascites right pleura amoebic liver pleural effusion Liver disease
left sided pleural advanced liver cirrhosis rigth pleura
effusion
commonest cause of pleural effusion is pneumonia
T.B. cirrhotic hepatic pneumonia
broadspectrumantibioticinfusion
MCQ
polymorph leucocyotsis Jaundice + leukocytosis
Neutrophilia
Leucocytosis fulminant liver failure MCQ
tissue damage necrosis in liver like myocardial infraction fulminant failure
Leucocytosis tissue damage
leukocytosis neutrophils amoebic liver
leukocytosis leptospirosis
multiple gall stone in bladder gall stone ascendingcholangitis
common common bile duct jaundice
biliary system Infection biliary system stagnation bile duct
ascending cholangitis stone

60