357: Approach to the Patient with Liver Disease Flashcards
Review: Characteristics of the liver
Largest organ of the body
Weight: 1-1.5kg, 1.5-2.5% of lean body mass
Receives dual blood supply: 20% from hepatic artery, 80% from portal vein
Special cell types found in the liver
- Kupffer cells (member of reticuloendothelial system)
2. Stellate cells (Ito or fat-storing)
Review: Zones of the liver based on function
Zone 1: Both arterial and portal venous blood entering the acinus from the portal areas
Zone 3: Flowing through the sinusoids to the terminal hepatic veins
Zone 2: Intervening hepatocytes
Blood flow in portal areas
Zone 1 to Zone 3
Bile flow in portal areas
Zone 3 to Zone 1
Lie within the sinusoidal vascular space and represent the largest group of fixed macrophages in the body
Kupffer cells
Located in the space of Disse; produce collagen and matrix when activated
Stellate cells
Most common liver “function” tests
- Serum bilirubin - measure of hepatic conjugation and excretion
- Serum albumin - measures of protein synthesis
- Prothrombin time - measures of protein synthesis
Basic classification of causes of liver diseases
- Hepatocellular diseases (viral hepatitis, alcoholic liver disease)
- Cholestatic (obstructive) (gallstone or malignant obstruction, primary biliary cirrhosis, some drug-induced liver disease)
- Mixed (cholestatic forms of viral hepatitis, many drug-induced liver diseases)
Goals in evaluation of liver disease
- Establish the etiologic diagnosis
- Estimate disease severity (grading) - e.g. active or inactive; mild, moderate, or severe
- Establish the disease stage (staging) - e.g. early or late; precirrhotic, cirrhotic or end-stage
Most common and most characteristic symptom of liver disease
FATIGUE
*after activity or exercise, intermittent, variable in severity
T or F: Poor appetite with weight loss are more frequent in ACUTE liver disease and rare in CHRONIC disease except in cirrhosis
True
ITCHING in acute liver disease
- Early in obstructive jaundice
- Later in hepatocellular disease (acute hepatitis)
- Preceding onset of jaundice in chronic liver diseases
- Once cirrhosis develops
Hallmark symptom of liver disease;
Most reliable marker of severity
JAUNDICE
Bilirubin level where jaundice is rarely detectable
<43 umol/L (2.5mg/dL)
What does lightening of color of stools and steatorrhea indicate?
Severe cholestasis
Symptom which usually indicates indirect (unconjugated) hyperbilirubinemia and typical of hemolytic anemia, Gilbert’s syndrome and Crigler-Najjar syndrome
Jaundice WITHOUT dark urine
Major risk factors for liver disease sought in clinical history
- Alcohol use
- Medication use (herbal, birth control pills, OTC drugs)
- Personal habits
- Sexual activity (# of lifetime sexual partners, Men: MSM)
- Travel
- Exposure to jaundiced or other high-risk persons
- Injection drug use
- Recent surgery
- Remote or recent blood transfusion
- Occupation
- Accidental exposure to blood or needlestick
- Familial history of liver disease
T or F: Sexual exposure is a common mode of spread of both Hepatitis B and Hepatitis C.
False
Sexual exposure RARE in Hep C
Transmission is more common among HIV-co-infected mothers and linked to prolonged and difficult labor and delivery, early rupture of membranes and internal fetal monitoring.
Hepatitis B or Hepatitis C?
Hepatitis C
Injection drug use is now the single most common risk factor for: Hepatitis B or Hepatitis C?
Hepatitis C
Traveling to developing area of the world, exposure to persons with jaundice, and exposure to young children in day-care centers are risk factors for:
Hepatitis A or Hepatitis E?
Hepatitis A
One of the more common causes of jaundice in Asia and Africa but uncommon in developed nations:
Hepatitis A, Hepatitis B, Hepatitis C or Hepatitis E?
Hepatitis E
Trivia: What does autochthonous means?
Non-travel-related
Occasional cases associated with eating raw or undercooked pork or game (deer and wild boars) occurring predominantly in elderly without typical risk factors for viral hepatitis: Hepatitis C, Hepatitis D, or Hepatitis E?
Hepatitis E
T or F: Hepatitis E are always acute and never chronic?
False
Chronic in immunosuppressed individuals
Alcohol consumption associated with increased rate of alcoholic liver disease
More than 2 drink (22-30g) per day in WOMEN; and 3 drinks (33-45g) in MEN
Defined by behavioral patterns and consequences of alcohol intake and not by the AMOUNT
Alcoholism
Repetitive pattern of drinking alcohol that has adverse effects on social, family, occupational, or health status
Abuse
Defined by alcohol-seeking behavior, despite its adverse effects
Dependence
*More serious and advanced form of alcoholism
Clinically helpful approach to diagnosis of alcohol dependence and abuse through this questionnaire.
CAGE questionnaire (see TABLE 357-2)
C : Cut down
A : Annoyed
G : Guilty
E : Eye-opener
One “yes” response: raise suspicion of alcohol use problem
More than one “yes”: strong indication of abuse or dependence
Signs of ADVANCED liver disease
- Muscle wasting
- Ascites
- Edema
- Dilated abdominal veins
- Hepatic fetor
- Asterixis
- Mental confusion
- Stupor
- Coma
- Bruising
T or F: Spider angiomata and palmar erythema occur only in chronic liver disease
False
Acute and chronic; even in normal individuals; common during pregnancy
Superficial, tortous arterioles fill from the center outward. Occur only on the arms, face and upper torso; pulsatile and difficult to detect in dark-skinned individuals.
spider angiomata, simple telangiectasia or caput medusa?
Spider angiomata
Conditions where marked hepatomegaly can be seen
- Cirrhosis
- Veno-occlusive disease
- Infiltrative disorders: amyloidosis
- Metastatic or primary cancers of liver
- Alcoholic hepatitis
Most reliable physical finding in liver examination
HEPATIC TENDERNESS
T or F: Peripheral edema never occurs without ascites in liver diseases
False
It can occur with or without ascites
Defined as occurrence of signs and symptoms of hepatic encephalopathy in a person with severe acute or chronic liver disease
Hepatic failure
Signs of hepatic encephalopathy
Change in sleep patterns
Change in personality
Irritability
Mental dullness
Slightly sweet, ammoniacal odor than can develop in patients with liver failure
Fetor hepaticus
Appearance of this condition during acute hepatitis is the major criterion for diagnosis of fulminant hepatitis and indicates poor prognosis
Hepatic encephalopathy
How to measure hepatic encephalopathy?
Mental status examination
Use trail-making test
Drawing of abstract objects
Comparison of signature to previous examples
Rare: electroencephalography and visual evoked potentials
Other signs of ADVANCED liver disease
- Umbilical hernia fr ascites
- Hydrothorax
- Prominent veins over the abdomen
- Caput medusa
Condition consisting of collateral veins radiating from the umbilicus and results from recanulation of umbilical vein
Caput medusa
Defined by the TRIAD of liver disease, hypoxemia, and pulmonary arteriovenous shunting
Hepatopulmonary syndrome (HPS)
O2 sat is a reliable screening test
Symptoms of HPS characterized by shortness of breath and oxygen desaturation that occur paradoxically upon the assumption of an upright position
Platypnea (opposite of orthopnea) AND
Orthodeoxia
Skin changes associated with liver disease
- Hyperpigmentation
- Xanthelasma and tendon xanthoma
- Slate-gray pigmentation (w/ hemachromatosis)
- Mucocutaneous vasculitis with palpable purpura
Consist of golden-brown copper pigment deposited in Descemet’s membrane at periphery of the cornea and occur in Wilson’s disease
Kayser-Fleischer rings
Dupuytren contracture and parotid enlargement are suggestive of what conditions?
Chronic alcoholism
Alcoholic liver disease
Most common causes of ACUTE liver disease
- Viral hepatitis (A,B,C)
- Drug-induced liver injury
- Cholangitis
- Alcoholic liver disease
Most common causes of CHRONIC liver disease
- Chronic hepatitis C
- Alcoholic liver disease
- Nonalcoholic steatohepatitis
- Chronic hepatitis B
- Autoimmune hepatitis
- Sclerosing cholangitis
- Primary biliary cirrhosis
- Hemochromatosis
- Wilson’s disease
Define whether alkaline phosphatase elevations are due to liver disease
y-glutamyl transpeptidase
Autoimmune marker to diagnose primary biliary cirrhosis
Antimitochondrial antibody
Autoimmune marker to diagnose sclerosing cholangitis
Peripheral antineutrophil cytoplasmic antibody (P-ANCA)
Autoimmune marker to diagnose autoimmune hepatitis
Anti-nuclear, smooth-muscle, and liver-kidney microsomal antibody
T or F: MRCP is superior to ultrasound and CT in detecting choledocholithiasis but less specific
True
Useful in diagnosis of bile duct obstruction and congenital biliary abnormalities.
ERCP or MRCP?
MRCP
More valuable in evaluating ampullary lesions and primary sclerosing cholangitis.
ERCP or MRCP
ERCP
Modalities used to assess hepatic vasculature and hemodynamics and to monitor surgically or radiologically placed vascular shunts
Doppler ultrasound and MRI
Procedures of choice for identification and evaluation of hepatic masses, staging of liver tumors and preoperative assessment
MRI with contrast-enhancement
Criterion standard in evaluation of patients with liver disease, particularly chronic liver disease
Liver biopsy
Criterion standard in evaluation of patients with liver disease, particularly chronic liver disease
Liver biopsy
Most accurate means of assessing severity and stage of disease, particularly in chronic liver disease
Liver biopsy
Most commonly used well-verified numerical scales for grading activity in chronic liver disease
- Histology activity index
2. Ishak histology scale
Noninvasive tests suggesting advanced fibrosis
- Mild elevations of bilirubin
- Prolongation of prothrombin time
- Slight decreases in serum albumin
- Mild thrombocytopenia (1st indication of worsening fibrosis)
Importance of staging the liver disease
- Prognosis
2. Optimal management of complications
T or F: Patients with cirrhosis are candidates for screening and surveillance for esophageal varices and hepatocellular cardinoma.
True
Patients without advanced fibrosis need not undergo screening.
Reliable staging system for cirrhosis in predicting survival and likelihood of major complications of cirrhosis such as bleeding from varices and SBP.
Modified Child-Pugh classification (Scores: 5-15)
5-6: class A ("compensated cirrhosis")
7-9: class B (candidate for liver transplantation)
10-15: class C
Reliable staging system for cirrhosis in predicting survival and likelihood of major complications of cirrhosis such as bleeding from varices and SBP.
Modified Child-Pugh classification (Scores: 5-15)
5-6: class A ("compensated cirrhosis")
7-9: class B (Indicates cirrhosis [score of >/=7]; candidate for liver transplantation)
10-15: class C
Prospectively derived system designed to predict the prognosis of patients with liver disease and portal hypertension.
Model for End-stage Liver Disease (MELD)
Provides standard critera for listing patient as candidate for liver transplantation
Variables in MELD score
- Prothrombin time expressed as INR ratio
- Serum bilirubin level
- Serum creatinine concentration
Variables in Child-Pugh Classification
- Serum bilirubin
- Serum albumin
- Prothrombin time
- Ascites
- Hepatic encephalopathy
This vaccine is recommended for all patients with liver disease
Hepatitis A vaccine
Optimal regimen for surveillance for hepatocellular carcinoma
Ultrasound of liver at 6-12 month intervals
