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Year 3 TCD > 3. Cirrhosis > Flashcards

3. Cirrhosis Flashcards

1
Q

What is cirrhosis

A

Liver cirrhosis is the result of chronic inflammation and damage to liver cells. When the liver cells are damaged they are replaced with scar tissue (fibrosis) and nodules of scar tissue form within the liver.

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2
Q

What are the most common causes of cirrhosis?

A
  • Alcoholic liver disease
  • Non Alcoholic Fatty Liver Disease
  • Hepatitis B
  • Hepatitis C
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3
Q

What are the rarer causes of cirrhosis?

A
  • Autoimmune hepatitis
  • Primary biliary cirrhosis
  • Haemochromatosis
  • Wilson’s Disease
  • Alpha-1 antitrypsin deficiency
  • Cystic fibrosis
  • Drugs (e.g. amiodarone, methotrexate, sodium valproate)
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4
Q

What is haemochromatosis?

A

It is a condition that causes people to absorb too much iron from their diet.

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5
Q

What is Wilson’s Disease?

A

Wilson’s disease is a genetic disorder in which excess copper builds up in the body.

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6
Q

What are the two main consequences of a cirrhotic liver.

A
  • loss of liver function
  • portal hypertension

These two consequences have their own individual symptoms, and are independent of one another. This means someone can have shocking liver function, but no signs of portal hypertension, and vice versa.

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7
Q

What are the signs and symptoms of a loss of liver function due to a cirrhotic liver?

A
  • Jaundice
  • Bruising (due to abnormal clotting)
  • Decreased drug metabolism (sedatives and opiates be careful with)
  • Decreased hormone metabolism (increased levels of oestrogen especially in men, so therefore they present with gynaecomastia, spider naevi and palmar erythema as well as loss of secondary body hair)
  • Increased rate of sepsis
  • Leukonychia - pale nails (due to decreased albumin)
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8
Q

What are the signs and symptoms of portal hypertension due to a cirrhotic liver?

A
  • Varices (enlarged veins, could be oesophageal or around the umbilicus)
  • Piles
  • Ascites (water retention in the abdomen due to the RAAS axis making the kidneys)
  • Hepatic Encephalopathy (as blood is passing through this varices, there is a build-up of toxins)
  • Renal failure (renal artery constriction)
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9
Q

What is the enhanced liver fibrosis (ELF) blood test?

A

It is the first line recommended investigation for assessing fibrosis in non-alcoholic fatty liver disease.

It checks HA, PIINP and TIMP-1, and uses an algorithm to provide a numerical value denoting the level of fibrosis of the liver.
< 7.7 indicates none to mild fibrosis
≥ 7.7 to 9.8 indicates moderate fibrosis
≥ 9.8 indicates severe fibrosis

It is not currently available in many areas of the country.

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10
Q

What can an ultrasound show in someone with a cirrhotic liver?

A
  • Nodules on the surface of the liver
  • A “corkscrew” appearance to the arteries with increased flow as they compensate for reduced portal flow
  • Enlarged portal vein with reduced flow
  • Ascites
  • Splenomegaly
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11
Q

Ultrasound is also used to screen for what condition in those with a cirrhotic liver? How often should the ultrasound be repeated?

A

Hepatocellular carcinoma.

NICE recommend it be repeated every 6 months.

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12
Q

What is a FibroScan?

A

“FibroScan” can be used to check the elasticity of the liver by sending high frequency sound waves into the liver. It helps assess the degree of cirrhosis.

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13
Q

According to NICE, who should get FibroScans, and how often?

A

NICE recommend retesting every 2 years in patients at risk of cirrhosis:

  • Hepatitis C
  • Heavy alcohol drinkers (men drinking > 50 units or women drinking > 35 units per week)
  • Diagnosed alcoholic liver disease
  • Non alcoholic fatty liver disease and evidence of fibrosis on the ELF blood test
  • Chronic hepatitis B (although they suggest yearly for hep B)
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14
Q

What is used to confirm the diagnosis of a cirrhotic liver?

A

Liver Biopsy

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15
Q

What scales can be used to grade the severity of liver cirrhosis?

A
  • Child-Pugh Score

- MELD Score

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16
Q

What is the child-pugh score?

A

It is used to indicate the severity of cirrhosis and the prognosis. It takes into account 5 features (bilirubin, albumin, INR, Ascites and Encephalopathy) and grades them from 1 to 3.

Therefore the lowest score is 5 and the max (most severe) is 15

17
Q

What is the MELD score?

A

It is used to assess patients with cirrhosis as to whether they need dialysis.

It uses the levels of;

  • bilirubin
  • creatinine
  • INR
  • Sodium

It is recommened by NICE to be used every 6 months in patients with compensated cirrhosis.

18
Q

How is cirrhosis managed?

A
  • Ultrasound and alpha-fetoprotein every 6 months for hepatocellular carcinoma
  • Endoscopy every 3 years in patients without known varices
  • High protein, low sodium diet
  • MELD score every 6 months
  • Consideration of a liver transplant
  • Managing further complications as they arise
19
Q

What is the 5 year survival rate once cirrhosis has developed?

A

50%

20
Q

What are some of the complications of cirrhosis?

A
  • Malnutrition
  • Portal Hypertension, Varices and Variceal Bleeding
  • Ascites and Spontaneous Bacterial Peritonitis (SBP)
  • Hepato-renal Syndrome
  • Hepatic Encephalopathy
  • Hepatocellular Carcinoma
21
Q

How does cirrhosis lead to malnutrition?

A

Cirrhosis leads to;

  • Poor absorption of fats (which then also means poor absorption of fat-soluble vitamins)
  • Altered metabolism of proteins in the liver, and reduced amount of protein production
  • Disruption of the livers ability to store glucose and glycogen

All of this leads to the body using muscle tissue as fuel, leading to muscle wasting and weight loss.

22
Q

How is malnutrition in cirrhosis managed?

A
  • Regular meals (every 2-3 hours)
  • Low sodium (to minimise fluid retention)
  • High protein and high calorie (particularly if underweight)
  • Avoid alcohol
23
Q

What veins feed into the portal vein?

A
  • superior mesenteric vein
  • inferior mesenteric vein
  • splenic vein
24
Q

How does cirrhosis lead to portal hypertension and varices?

A

Liver cirrhosis increases the resistance of blood flow in the liver. As a result, there is increased back-pressure into the portal system. This is called “portal hypertension”. This back-pressure causes the vessels at the sites where the portal system anastomoses with the systemic venous system to become swollen and tortuous. These swollen, tortuous vessels are called varices.

25
Q

Where can varices occur?

A
  • Gastro oesophageal junction
  • Ileocaecal junction
  • Rectum (piles)
  • Anterior abdominal wall via the umbilical vein (caput medusae)
26
Q

How dangerous are varices?

A

Varices do not cause any symptoms or problems, until they start to bleed.

Due to the high blood flow through varices, once they start bleeding patients can exsanguinate (bleed out) very quickly.

27
Q

How are stable varices treated?

A
  • Propranolol reduces portal hypertension by acting as a non-selective beta blocker
  • Elastic band ligation of varices
  • Injection of sclerosant (less effective than band ligation)
  • Transjugular Intrahepatic Portosystemic Shunt, aka TIPS (wire inserted through jugular vein, down the vena cava and into the liver via the hepatic vein. They then make a connection through the liver tissue between the hepatic vein and the portal vein and put a stent in place. This relieves the pressure in the portal system. This is used if all other methods have failed.
28
Q

How are bleeding varices treated?

A

Resuscitation

  • Vasopressin analogues (i.e. terlipressin) cause vasoconstriction and slow bleeding in varices
  • Correct any coagulopathy with vitamin K and fresh frozen plasma (which is full of clotting factors)
  • Giving prophylactic broad spectrum antibiotics has been shown to reduce mortality
  • Consider intubation and intensive care as they can bleed very quickly and become life threateningly unwell

Urgent endoscopy

  • Injection of sclerosant into the varices can be used to cause “inflammatory obliteration” of the vessel
  • Elastic band ligation of varices

Sengstaken-Blakemore Tube is an inflatable tube inserted into the oesophagus to tamponade the bleeding varices. This is used when endoscopy fails.

29
Q

What is ascites and how does cirrhosis lead to ascites?

A

Ascites is basically fluid in the peritoneal cavity. The increased pressure in the portal system causes fluid to leak out of the capillaries in the liver and bowel and into the peritoneal cavity.

30
Q

What is refractory ascites?

A

It is ascites that does not recede or that recurs shortly after therapeutic paracentesis, despite sodium restriction and diuretic treatment

31
Q

How is ascites managed in someone with cirrhosis?

A
  • Low sodium diet
  • Anti-aldosterone diuretics (spironolactone)
  • Paracentesis (ascitic tap or ascitic drain)
  • Prophylactic antibiotics against spontaneous bacterial peritonitis (ciprofloxacin or norfloxacin) in patients with less than 15g/litre of protein in the ascitic fluid
  • Consider Transjugular Intrahepatic Portosystemic Shunt, aka TIPS, in refractory ascites
  • Consider transplantation in refractory ascites
32
Q

What is spontaneous bacterial peritonitis and how does cirrhosis lead to it?

A

This is when the fluid in ascites becomes infected without any clear cause (ie. not secondary to an ascitic drain or bowel perforation).

It occurs in around 10% of patients with ascites, and has a mortality of 10-20%.

33
Q

How does someone with spontaneous bacterial peritonitis typically present?

A
  • Fever
  • Abdominal pain
  • Deranged bloods (raised WBC, CRP, creatinine or metabolic acidosis)
  • Ileus
  • Hypotension

They can be asymptomatic however so have a low threshold for ascitic fluid culture.

34
Q

What is an ileus?

A

Ileus is the medical term for a lack of movement somewhere in the intestines that leads to a buildup and potential blockage of food material.

35
Q

How is spontaneous bacterial peritonitis managed?

A
  • Take an ascitic culture prior to giving antibiotics

- Usually treated with an IV cephalosporin (type of antibiotic) such as cefotaxime

36
Q

What is hepatorenal syndrome and how does cirrhosis lead to it?

A
  1. Hypertension in the portal system leads to dilation of the portal blood vessels, stretched by large amounts of blood pooling there.
  2. This leads to a loss of blood volume in other areas of the circulation, including the kidneys.
  3. This leads to hypotension in the kidney and activation of the renin-angiotensin system.
  4. This causes renal vasoconstriction, which combined with low circulation volume leads to starvation of blood to the kidney.
  5. This leads to rapid deteriorating kidney function.
37
Q

How is hepatorenal syndrome managed?

A

Hepatorenal syndrome is fatal within a week or so unless liver transplant is performed.

38
Q

What is hepatic encephalopathy and how does cirrhosis lead to it?

A

This is thought to be caused by the build up of toxins such as ammonia that affect the brain, as its normally the liver that filters out these toxins.

Year 3 TCD (36 decks)

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