6. Liver Disease Notes Flashcards
Which condition(s) is/are jaundice more common in?
- PBC
- Steatotic cholangitis
- Cirrhosis
PBC and Steatotic Cholangitis ( but jaundice may be present in Cirrhosis)
Signs of cirrhosis on the hands and legs
- Clubbing
- Luekonychia
- Duputryen’s contracture (ALD in particular)
- Palmar erythema
- Flapping tremor ( encephalopathy)
- Bruising
- Ankle oedema
- Leg bruising
What clotting factor does the liver not make?
VII
Signs of cirrhosis on the trunk
- Axillary hair loss
- Gynaecomastia
- Spider naevi
What drugs can cause gynaecomastia
Spironolactone, digoxin, metronidazole
Signs of cirrhosis on the abdomen
- Hepatomegaly
- Splenomegaly
- Ascites
- Dilated veins
- Testicular atrophy
- Umbilical hernia
What drug can be used for ascites ( caused by portal hypertension?)
Carvedilol
What is the treatment for bleeding oesophageal varices
- Resusc
- Endoscopic therapy with Band ligation
- Terlipressin ( vasoconstrictor)
- Balloon tamponade
- TIPPS
Primary and Secondary prophylaxis for variceal bleeds
Primary - Non selective B blocker and variceal band ligation
Secondary - Band ligation and propanolol/carvedilol
Treatment for ascites
- Sodium restriction
- Spironolactone (NOT loop diuretics - too strong)
- Paracentesis (resistant ascites)
When in AST high when ALT may be normal ( ratio >2)
Alcoholic liver injury
When does ALT and not AST increase
HCV, fatty liver ( unless very serious)
In what non-pathological state is ALP increased
Last trimester
In what group of people is GGT increased
Heaver drinkers ( esp those with liver disease)
Those on enzyme-inducing meds
How is unconjugated bilirubin transported in blood?
How does it get conjugated and where?
How does bilirubin get into the SI
What does conjugated bilirubin get excreted as?
- With albumin
- In the liver, with glucronic acid
- Through the biliary system
- Urobilinogen, after conversion by bacterial proteases
Which Hep viruses
- are transmitted faeco-orally
- commonly result in chronic infection
- are blood borne
- have vaccine
- A and E
- B and C
- B and C
- A
Sx of HAV and complications
- Jaundice
Complications:
- Fulminant hepatitis
- Cholestatic hepatitis
Incubation period of HAV
30 (15-50)
What are HEV epidemics assoc with
Contaminated drinking water
How is HEV commonly transmitted
- Foodborne, through uncooked meat such as pork, or molluscs
- Contaminated water
- Blood transfusion and transplanted organs
- Vertical transmission
Most common cause of acute hep in UK
HEV
How is HCV commonlly transmitted
Blood borne through shared needles
Which Hep Viruses are likely to cause cirrhosis
HCV
Can HCV be cured, and if so, with what?
Yes, with combination therapies
What can cause HBV to be reactivated
Iatrogenic causes
Oncological causes
What defines Hep B as being chronic?
HBsAg +ve > 6 mo
Are anti HBe and Hbs present in chronic Hep B
No
What is an indicator to acute HBV infection
HBsAg main indicator
IgM Anti-HBc- highest in acute infn, and in acute LF HBsAg may be negative but IgM may be present
Is HBe Ag present in chronic HBV infection
No,negative in certain infections, HBV DNA usually lower in these pts
Can HBV be cured, and if so, with what?
Pegylated interferon
Oral antivirals
Which HEV genotypes are more common in developing countries compared to developed countries? Difference in transmission
1 and 2 - Faeco-oral vis infected water
vs 3 and 4 - Faeco-oral via infected pig meat, direct exposure to pigs or infected water`
Age at infection of HEV (1,2 vs 3,4)
15-30yo vs >50
Is HEV self-limiting
Yes
Does HEV cause chronic hep
Yes in genotype 3
HEV treatment
Ribavarin in immunocompetent, although rarely used.
Interferon a and ribavarin in chronic HEV infxn in immunosuppressed
Ribavarin for ?
HCV in decompensated cirrhosis, HEV in immunosuppressed and sometimes in immunocompetent
which group is more liely to get chronic HEV infxn?
Solid organ transplant individuals
Main serology when acute hepatitis has resolved?
HBsAg negative
Risk of reactivation is HBsAg positive compared to HBsAg negative but core Ab positive
Higher if HBsAg +ve
What to treat HBV in pregnancy
Tenovir if viral load>200000 IU in third trimester
Sexually transmitted Hep Viruses
B and D mainly
Features of viral hep
headache, myalgia, arthralgia, nausea and anorexia usually precedes the development of jaundice by a few days to 2 weeks.
Which viral heps are more likely to cause cirrhosis
B and C
ALT in Viral Hep
200-2000
Vehicles of transmission of HAV in occassional outbreaks
Shellfish and water
What is diagnostic of HAV infxn
HAV IgM
How to provide immediate protection soon after exposure to HBV
Give IMMUNISATION or immune serum globulin ( esp in >60yo or immunocompromised indiv)
If vaccination to HBV is given, will anti HBc and HBs present?
HBs yes, HBc no
What does seroconversion to e ag in HBV suggest
Seroconversion to e antigen (i.e. loss of HBeAg and development of anti-HBe antibody) indicates a partial immune control of the virus and is associated with a significant drop in viral load
Is chronic HBV infxn more common in children or adults
children
What does HBeAg negativity in chronic hep mean
HBV mutants that escape from immune regulation
Who gets antiviral therapy for Hep B
Those with sever liver injury and INR >1.5, or protracted course with persistent sx >4 weeks
LFT in HCV
LFTs may be normal or show fluctuating serum transaminases between 50 and 200 U/L
Diagnosis of acute HEV infection
Diagnosis of acute infection is usually based on detection of anti-HEV IgM antibodies
In which groups can HEV be more serious
nfection with genotype 1 or 2 virus during pregnancy carries a high risk of acute liver failure, which has a high mortality. Hepatitis E also causes more severe disease in those with underlying cirrhosis, resulting in decompensation or acute-on-chronic liver failure.
Which patiens are at higher risk of HCC
Viral Hep and Haemachromatosis patients
NASH CRN Scoring System for fibrosis stages:
Centrilobular peri-sinusoidal fibrosis
+ Periportal fibrosis
+ bridging fibrosis
cirrhosis
What inherited metabolic disorders can cause fibrosis
Hemachromatosis, wilsons, a1-antitrypsin
What drug can cause liver fibrosis
Methothrexate
Liver enzymes in MASLD
AST and GGT elevated, ALT normal , ferritin slightly elevated
What is MetALD
MASLD + Increased alcohol intake
How to risk stratify pt with MASLD/MASH?
FIB-4
Ix for NAFLD
- USS
- FIB-4
- Fibroscan
- Liver Biopsy : Can give NAS score and fibrosis stage
Possible surgical tx for NAFLD and side effects
Laparoscopic sleeve gastroscopy, chronic diarrheoa
Blood Tests for ALD
Elevated AST, ferritin and GGT ( higher than for NAFLD)
Ferritin and transferrin level in haemachromatosis
Ferritin and transferrin both high
Investigations in cirrhosis of the liver
- USS (fat) , Fibroscan (stiffness) - esp for those with indeterminate firbosis scores, Fib4, biopsy - GOLD STANDARD
- Ascitic tap if ascites present, to culture fluid
- UGIE for varices
Clinical features of NAFLD
Often aSx but may have assoc RUQ discomfort
What drugs cause fatty liver
tamoxifen, amiodarone and corticosteroids.
Is ALT or AST higher in advanced NAFLD
AST
Expected liver biopsy obs for NAFLD
- steatosis, hepatocellular injury and inflammationwith mainly centrilobular, acinar zone 3 distribution
- perisinusoidal fibrosis is characteristic feature of NAFLD
How to determine Tx for NAFLD
Based on FIB-4, and TE if indeterminate risk
- Low risk, lifestyle advice (GP)
- High risk, address CV risks and assess for portal HT and HCC (hep clinic)
How to differentiate cholecystitis from cholangitis
Murphy’s sign positive for cholecystitis and fever and raided inflammatory markers
Charcot’s triad for cholangitis - RUQ pain, jaundice and fever
