4.6 cirrhosis and complications of liver disease

Question 1

What are the consequences of NAFLD

Answer 1

portal hypertension: oesophageal, gastric varices, ascites, hepatorenal syndrome
HCC

Question 2

what ascitic fluid analysis indicates portal hypertension?

Answer 2

serum albumin-ascitic fluid albumin gradient >11g/L

Question 3

What is the management of ascites?

Answer 3

salt restriction
Diuretics (spirnolactone, frusemide)
Monitor weight, U&E, urine sodium

Question 4

What is the treatment for diuretic resistant ascites?

Answer 4

Large volume paracentesis with albumin

Question 5

What is the treatment of spontaneous bacterial peritonits

Answer 5

IV antibiotics for 5 days

give prophylactic antibiotics if there is a history in patients with GI bleeding

Question 6

What is the definition and what are the features and signs of hepatic encephalopathy?

Answer 6

Impaired neuropsychiatric syndrome due to acute or chronic liver disease

features: personality, sleep and memory changes

Physical signs: asterixs and number connection tests

Question 7

What is the treatment for hepatic encephalopathy?

Answer 7

treat precipitating factors
high protein diet
consider branched amino acids if protein not tolerated
Antibiotics to sterilise gut (rifaximin, metronidazole)

Question 8

What is the criteria for hepatorenal syndrome?

Answer 8

Acute or chronic liver disease plus low GFR, no other cause of renal failure

no response to fluid challenge
urine volume plasma osmol
urine RBC <130

Question 9

What is type 1 hepatorenal syndrome?

Answer 9

Rapid decline in renal function (2 x fold change in creatinine (BAD PROGNOSIS about 2 weeks)

Question 10

What is type 2 hepatorenal syndrome?

Answer 10

Impaired renal function but stable over a long period; diuretic resistant ascites - median survival 3-6 months

Question 11

What is the treatment for hepatorenal syndrome?

Answer 11

Exclude other causes of renal failure
Vasoconstrictors to reduce vasodilation(NE)
Dialysis if transplant is planned

Question 12

What is the management of an acute variceal bleed?

Answer 12

Airway protection 
Replenish blood volume 
Dont overtransfuse 
Antibiotics 
In patients with chronic liver disease consider fresh frozen plasma, lactulose and thiamine

Question 13

How can you stop variceal bleeding?

Answer 13

Endoscopy, drugs (vasopressin, somatostatin, beta blockers), balloon tamponade, TIPS, surgery

Question 14

What is the role of vasopressin in stopping variceal bleeding and what are the side effects?

Answer 14

reduces splanchnic blood flow

SE: gut, coronary ischaemia

Question 15

What is the role of somatostatin in stopping variceal bleeding and what are the side effects?

Answer 15

reduce splanchnic flow - used to treat acute bleed and prevent rebleed
SE: uncommon

Question 16

What is the role of beta blockers in stopping variceal bleeding and what are the side effects?

Answer 16

non selective will reduce portal blood flow by decreasing CO (B1) and splanchnic (B2)

Question 17

When should you suspect HCC?

Answer 17

general deterioration, weight loss, worsening liver function, jaundice and ascites, mass on liver imaging or rising AFP

Question 18

What is AFP?

Answer 18

produced by the foetal liver and increased in HCC

Question 19

What is the surveillance for HCC?

Answer 19

Abdominal US + AFP every 6 monyhs

Liver CT

Question 20

What is the treatment for HCC?

Answer 20

Small tumor (up to 5cm or 3 up to 3cm): with good liver function surgery, with impaired transplant

For others: alcohol injection, chemoembolization