Acute and Chronic Liver Disease Flashcards
Functions of the liver?
- production of bile
- for fat digestion - reception and metabolization of absorbed products from digestion
- detoxification of toxic substances received from digestion
- storage and release of carbohydrates
- production of proteins - primarily plasma proteins
e.g. albumin, clotting factors
What is acute liver injury?
hepatocellular dysfunction causing coagulopathy (INR >1.5) and encephalopathy in someone without known liver disease
Causes of acute liver injury?
- Acute viral hepatitis
- Drug-induced liver injury: acetaminophen (Panadol), idiosyncratic drug reactions
- Alcohol hepatitis
- Wilson disease
- Autoimmune hepatitis
What is acute liver failure?
- ALT, AST more than 10 times ULN in person without previous chronic liver disease
PLUS - Hepatic encephalopathy OR prolonged prothrombin time (raised INR >1.5)
Management of acute liver failure?
- Address cause if possible
- More frequent monitoring of LFTs, urea, electrolytes, glucose, INR in intensive care
- Supportive management of volume status (i.e., give fluids gently)
- Watch for adrenal insufficiency (similar to septic shock) and consider trial of hydrocortisone
- NAC (N-acetylcysteine) if acetaminophen OD
- Controversial: antibiotic ppx, fresh frozen plasma, blood and urine cultures
Distinguishing between acute and chronic liver disease?
- Remember cirrhosis is a manifestation of CLD (not acute)
- Look for physical exam findings that there are chronic issues
- Imaging can help
What is cirrhosis?
Diffuse destruction of hepatic parenchyma which is replaced by scar tissue and regenerating nodules
Describe the liver progression to cirrhosis?
healthy liver > fatty liver > liver fibrosis > cirrhosis of liver
Symptoms of cirrhosis?
- Anorexia
- Weight loss
- Fatigue
- Yellow eyes
- Pruritus
- GI bleeding
- Increasing abdominal girth
- Impotence and loss of sexual drive
Chronic liver disease physical findings?
- palmar erythema
- terry nails
- Dupuytren contracture
- spider angiomata
- encephalopathy - confusion
- sparse body hair
- muscle wasting
- hobnail fibrotic liver
- dilated vessels
- ascites
- jaundice - yellow, itchy skin
- low blood pressure
- in men - gynecomastia and testicular atrophy
Describe the lab findings in cirrhosis?
- Elevated bilirubin
- Moderately elevated liver injury markers (ALT, etc.) –> however, in some cases the ALT can be normal
- Increased INR
- Reduced albumin
- Hyponatremia due to inability to excrete free water (due to antidiuretic hormone secretion)
- Thrombocytopenia – due to portal hypertension and congestive splenomegaly
Diagnosis of cirrhosis?
- Easy when multiple physical examination findings are present
- Ascites plus low platelets are helpful findings
- Imaging: ultrasound shows small liver with irregular edges, ascites, nodules in the liver tissue
- Non-invasive serological tests: AST-platelet ratio (APRI), FIB-4
- Non-invasive imaging tests: transient elastography
- Liver biopsy: gold standard test, with limitations
Complications of cirrhosis?
- Hepatocellular carcinoma (liver cancer)
- Decompensation: Ascites, Spontaneous bacterial peritonitis, Portosytemic encephalopathy
- Hepatorenal syndrome – acute renal failure
Most common causes of cirrhosis?
- Viral hepatitis C and B
- Alcoholic hepatitis
- Non-alcoholic steatohepatitis (NASH)
- Hemochromatosis
- Less common causes: many, including autoimmune hepatitis and Wilson disease
Hepatitis A and E and liver disease?
hepatitis A and E cause acute hepatitis but not chronic forms
Hepatitis B?
Diagnosis? Risk factors?
- diagnosis: Hepatitis B is diagnosed with HBsAg
- risk factors: HBV more common in people born prior to vaccine and in people with family history (i.e., mother-to-child transmission)
Hepatitis C?
Diagnosis? Risk factors?
diagnosis: diagnosed with 2 stage approach: HCV antibody and then confirmed with HCV RNA (viral load)
risk factors: HCV common in people who inject drugs, have multiple transfusions
What is alcoholic cirrhosis? Causes?
- History of significant alcohol consumption for many years (probably at least 5 years).
- One definition of significant is >210 grams per week in men and >140 grams per week in women
Alcohol units?
units = strength (ABV) x volume (ml)/1000
- One Carlsberg (330 ml) has ~15 grams of alcohol
- Chibuku super (1.25 Liters) has ~40 grams of alcohol
What is found on physical examination and lab findings in alcoholic cirrhosis?
- physical exam is typical for cirrhosis
- there is no specific test for alcohol cirrhosis: except possibly AST:ALT ratio >2
Nutritional issues in patients with alcoholic cirrhosis?
- Malnutrition in 20-60% of patients
- Heavy alcohol use can reduce dietary calorie intake, esp. when alcohol comprises >50% of calories/day.
- Reduced calories impairs nutrient digestion and absorption, decrease protein synthesis, increase catabolism of gut proteins.
- Acute alcohol use also causes gut mucosal erosions
- Heavy drinkers are thin
- Protein deficiencies are common
- Vitamin/mineral deficiencies also common: thiamine, folate, iron, and vitamin B6
Treatment of alcoholic cirrhosis?
- Treatment is usually supportive
- Referral to substance use treatment is critical
- Avoid other hepatotoxic medications
What is non-alcoholic steatohepatitis (NASH)?
Liver fat accumulation (called Non-alcohol Fatty Liver) that leads to inflammation and progressive chronic liver disease (NASH is when inflammation is present)
Epidemiology of NASH?
NAFL common now in upper-income countries: up to 40% have liver fat
Risk factors of NASH?
central obesity, type 2 DM, dyslipidemia, and metabolic syndrome