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BSMS302 > 1. Intro to Hepatology and LFTs > Flashcards

1. Intro to Hepatology and LFTs Flashcards

1
Q

Acute causes of abnormal liver tests

A 
(6 weeks or less)
drugs
viral hepatitis (A,B,C,E)
Autoimmune hepatitis
Wilsons disease
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2
Q

Subacute causes of abnormal liver tests

A 
(6-26 weeks)
drugs
viral hepatitis (A,B,C)
Autoimmune hepatitis
Wilson's disease
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3
Q

Chronic causes of abnormal liver tests

A 
(>26 weeks)
Viral hepatitis (B, C)
Alcohol
NAFLD (non-alcoholic fatty liver disease)
haemochromatosis
A1 antitrypsin deficiency
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4
Q

Wilson’s disease

A

Wilson’s disease is a autosomal recessive disease in which copper builds up in the body.

Symptoms are typically related to the brain and liver.Liver-related symptoms include vomiting, weakness, fluid build up in the abdomen, swelling of the legs, yellowish skin, and itchiness. Brain-related symptoms include tremors, muscle stiffness, trouble speaking, personality changes, anxiety, and hallucinations.
Treated by low copper diet and chelating agent e.g. zinc

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5
Q

Liver tests

A

Wilson’s disease is a autosomal recessive disease in which copper builds up in the body.

Symptoms are typically related to the brain and liver.Liver-related symptoms include vomiting, weakness, fluid build up in the abdomen, swelling of the legs, yellowish skin, and itchiness. Brain-related symptoms include tremors, muscle stiffness, trouble speaking, personality changes, anxiety, and hallucinations.
Treated by low copper diet and chelating agent e.g. zinc

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6
Q

Liver tests -proteins

A

bilirubin 17micromol/l

liver enzymes:
Aspartate aminotransferase (AST) 40iu/l
alanine aminotransferase (ALT) 40iu/l
Alkaline phosphatase (ALP) 200iu.l
Gamma GT 50 iu/l

Albumin 40gm/l

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7
Q

Effects of certain diseases on LFTS

A

transaminases increase if hepatitis

ALP and GGT go up if cholestitis

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8
Q

Liver tests - clotting

A

Prothrombin time
INR (measurement of ratio of measured PT to normal)

Measures extrinsic coagulation pathway - II, V, VII, X and fibrinogen

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9
Q

What to do if LFTs are abnormal?

A

Do a liver screen
Hepatitis serology - Hepatitis A IgM, hepatitis B surface antigen, hep C antibody, Hep E IgG and IgM

ANA, SMA, LKM for autoimmune hepatitis
AMA for primary biliary cholangitis

Alpha 1 antitrypsin (in case of deficiency)

Copper, caeruloplasmin for Wilson’s disease

Ferritin (genetic haemachromatosis)
Ultrasound

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10
Q

What tests are included in hepatitis serology?

A

Hepatitis A IgM, hepatitis B surface antigen, hepatitis C antibody, Hepatitis E IgG and IgM

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11
Q

What to do to look for autoimmune hepatitis?

A

Screen for ANA (antinuclear antibodies), SMA(smooth muscle antibodies) LKM (liver kidney microsome antibodies)

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12
Q

What does AMA screen look for?

A

Antimitochondrial antibodies, like in primary biliary cholangitis

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13
Q

hepatitic disease elevated bloods

A

AST and ALT massively increased but bilirubin normal

Things that start as hepatitic can become cholestatic

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14
Q

Cholestatic elevated bloods

A

bilirubin and ALP raised but AST and ALT normal

e.g. biliary obstruction

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15
Q

Hepatitic causes of abnormal liver tests

A

Viral hepatitis A,B,C,E
Drug induced liver injury (DILI)
Autoimmune hepatitis

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16
Q

Cholestatic causes of abnormal liver tests

A 
Biliary obstruction
Viral hepatits A,B,E
DILI
Autoimmune hepatitis
Primary biliary cirrhosis cholangitis
Primary sclerosing cholangitis
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17
Q

Is cirrhosis reversible?

A

Cirrhosis is generally irreversible
Feature of chronic liver disease
The main feature of cirrhosis is increased pressure in the portal circulation, also known as portal hypertension

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18
Q

Liver failure - what can develop?

A

Coagulopathy and encephalopathy

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19
Q

Onset of liver failure and development of coagulopathy/encephalopathy

A

Acute within 4 weeks
Subacute between 4-12 weeks
Acute on chronic in setting of underlying chronic liver disease

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20
Q

Hyperacute liver failure

A

1 week from jaundice to encephalopathy, ,lowe severity of jaundice, very severe coagulopathy, high intercranial hypertension, good survival rate without emergency liver transplantation

usually caused by paracetamol, hep A and E

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21
Q

Acute liver failure

A

1-4 weeks from jaundice to encephalopathy, moderate jaundice, moderate coagulopathy, high intercranial hypertension, moderate survival rate without emergency liver transplantation

usually caused by hep B

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22
Q

Subacute liver failure

A

4-12 weeks from jaundice to encephalopathy, highly severe jaundice, low coagulopathy, with or without intercranial hypertension, poor survival rate without emergency liver transplantation

non-paracetamol drug-induced liver injury

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23
Q

In acute liver failure…

A

no pre-existing liver disease, coagulopathy, confusion (hepatic encephalopathy)

jaundice
abnormal LFTs
cerebral oedema
increased risk of infections
renal failure (hepatorenal syndrome)
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24
Q

hepatorenal syndrome triad

A

altered liver function, abnormalities in circulation, and kidney failure.

25
How does liver failure affect encephalopathy?
the more acute the liver failure the more swollen the brain
26
Paracetamol overdose
most common cause of acute liver failure - 70,000 cases and 130 deaths a year in UK Intentional overdose recommended dose 4g/day, toxic dose>15g lower toxic dose if pre-existing liver disease, alcohol excess
27
paracetamol metabolism
Usually sulfated or glucuronidate to make safe metabolites but some undergoes CYP-mediated N-hydroxylation and rearrangment to become NAPQI which undergoes toxic reactions with proteins and nucleic acids In overdose, metabolism is shunted to NAPQI
28
How can paracetamol overdose be treated?
with N-acetyl cysteine (NAC) which replenishes glutathione and allows more of the glucuronidation Start NAC immediately if paracetamol OD is suspected, even if don't have paracetamol levels If receive N-acetyl cysteine within 16 hours, then liver failure rarely develops. Some benefit even up to 36 hours In severe cases liver transplant only option
29
How does paracetamol overdose present?
Nausea, vomiting, RUQ pain, confusion Jaundice and liver failure after 3-4 days Very high liver enzymes and prothrombin time If receive N-acetyl cysteine within 16 hours, then liver failure rarely develops. Some benefit even up to 36 hours In severe cases liver transplant only option
30
In cirrhosis...
``` Portal hypertension - varices, ascites, hepatic encephalopathy Jaundice Spiders Enlarged spleen/pancytopenia Renal failure (HRS) Hepatocellular cancer ```
31
What is liver cirrhosis?
Irreversible scarring of the liver
32
What are compensated cirrhosis and decompensated cirrhosis?
Compensated cirrhosis is cirrhosis developed from chronic liver disease in which there are no complications and has a median survival rate of 9 years, whereas decompensated cirrhosis has complications and a medial survival of 1.6 years
33
What complications develop in decompensated cirrhosis?
Variceal haemorrhage, ascites, encephalopathy, jaundice
34
How can decompensated cirrhosis be treated
Orthotopic liver transplant (OLT) otherwise median survival is around 1.6 years before death
35
Stages of cirrhosis
1 - compensated without varices, median survival >12 years, and 1 year mortality 2- compensated with varices - 3% 1 year mortality 3- decompensated with ascites without variceal haemorrhage - 20% 1 year mortality, and around 2 year median survival 4- decompensated with/out ascites with variceal haemorrhage - 57% 1 year mortality
36
What characteristics of cirrhosis increase 1 year mortality and decrease survival rate?
Whether varices are present + Whether it is decompensated ++ Whether there is variceal haemorrhage +++
37
Managing ascites in cirrhosis
Restrict salt Restrict fluid if sodium is low Diuretics - furosemide and spironolactone Large volume paracentesis (LVP) with albumin cover
38
How to treat refractory ascites
``` Recurrent LVP (large volume paracentesis) transjugular intrahepatic portosystemic shunt consider liver transplant long-term drains (if palliative) still undergoing research ```
39
Treating variceal bleed
make them haemodynamically stable, correct coagulopathy and thrombocytopenia IV terlipressin (vasopressin analogue) and IV antibiotics Endoscopy in theatre with anaesthetist present - variceal banding If blood bath - balloon tamponade Non-selective Beta blockers for secondary prophylaxis (propanolol and carvedilol)
40
Hepatorenal syndrome
A type of AKI Functional and fairly rapid renal impairment due to reduced renal perfusion - nothing wrong with the kidney itself Increase in serum creatinine by 50% from baseline within 3 months Type 1 and 2 Terlipressin to treat underlying cause Liver transplant
41
What is terlipressin used to treat?
oesophageal varices and hepatorenal syndrome
42
Difference between type 1 and 2 hepatorenal syndrome?
Type 1 more acute, type 2 less acute, precipitated by infection sepsis etc
43
Hepatic encephalopathy
``` Elevated ammonia (which crossess BBB and causes confusion) diagnosis of exclusion ``` Treat precipitating cause: constipation, diuretics, infection, sedatives, GI bleed Lactulose (non-absorbable sugar) Non-absorbable antibiotics e.g. Rifaximin
44
Acute on chronic liver disease precipitants
``` Viruses drugs alcohol ischaemia surgery sepsis idiopathies ```
45
Types of acute on chronic liver failure
Type A from chronic liver disease Type B from compensated cirrhosis Type C from decompensated cirrhosis (jaundice, ascites, variceal bleeding, hepatic encephalopathy)
46
Result of acute on chronic liver failure
hepatic and extrahepatic organ failure
47
Acute on chronic Liver failure causes
alcohol hep C NAFLD
48
Alcoholic liver disease
Normal liver to fatty liver 90-100% 10-35% of fatty liver undergoes alcoholic hepatitis, 40% of which undergoes cirrhosis 8-20% of fatty liver undergoes cirrhosis
49
Severe alcoholic hepatitis
most serious form of alcohol related injury characterised by jaundice and coagulopathy untreated mortality 40% Various prognostic scores (discrimant function) Steroids and pentoxyfilline
50
Risk factors for Hep C virus transmission
85% recipients of clotting factors made pre 1987 80% Injection drug use 10-20% long-term haemodialysis 4-6% multiple sex partners 5% recipients of blood transfusion prior to July 1992 4-7% infants born to infected women
51
Factors associated with Hep C disease progression
Alochol consumption - 30g/day in men, 20g/day in women (2 drinks a day) Disease acquisition at >40 years Male gender HIV coinfection Hep B virus coinfection immunosuppression
52
Hep C natural history
female, young age at infection - slow progression, >30 years Normal liver -> acute infection -> chronic infection in 80% -> chronic hepatitis -> cirrhosis develops in 20% -> risk of carcinoma, 1-4% a year Fast <20 years with alcohol use or coinfection
53
Types of HCV drugs
NS3/4A protease inhibitors (block translation and polyprotein processing) Grazoprevir, Paritaprevir, Simeprevir, Glecaprevir NS5A inhibitors - Ledipasvir, Ombitasvir, Daclatasvir, Elbasvir, Velpatasvir, Pibrentasvir NS5B RNA polymerase inhibitors - Sofosbuvir, Dasabuvir
54
Non-alcoholic fatty liver disease
Resembles alcoholic liver disease but occurs in absence of alcohol abuse Usually associated with metabolic syndrome: type 2 DM, obesity, HTN, and elevated TG Underlying mechanism is insulin resistance (IR)
55
Spectrum of NAFLD
Fatty liver -> nonalcoholic steatohepatitis (NASH) -> cirrhosis
56
Indications for liver transplant in acute liver failure - in context of paracetamol
ph<7.3 after fluid resuscitation Arterial lactate >3.5 mmol at 4 hours or >3.0mmol/l at 12 hours or PT >100 seconds (INR>6.5) serum creatinine >300mmol/l (3.4mg/dl) Grade 3 or 4 encephalopathy
57
Indications for liver transplant in acute liver failure - no paracetamol
PT >100 seconds (INR>6.5) irrespective of grade of encephalopathy or any three of the following: 1. Age less than 11 or greater than 40 2. Aetiology of non-A/non-B hepatitse, halothane hepatitis or idiosyncratic drug reactions 3. Duration of jaundice of more than 7 days before onset of encephalopathy 4. PT time greater than 50 seconds (INR>3.5) 5. Serum Bilirubin level greater than 17mg/dL (300micromol/l)
58
Indications for liver transplant in cirrhosis
Ascites/SBP (spontaneous bacterial peritonitis) Variceal bleeding hepatic encephalopathy hepatocellular cancer
59
Prognostic scores to prioritise liver transplants in cirrhosis
Child Pugh score - encephalopathy, ascites, bilirubin, albumin, PT/INR MELD and UKELD score: bilirubin, INR, creatinine, Na

BSMS302 (10 decks)

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