Case 3 - Decompensated Liver Disease

Question 1

Symptoms to ask about for DLD?

Answer 1

• Bloating
• Confusion/forgetfulness
• Bloody vomit/stool chnage
• Easy bruising?
• Noticible swelling?
• Itchy skin?
• Steattorhoea and dark urine?
• Less urine output

Question 2

Clinical signs to look for on examination for DLD

Answer 2

• Leukonychia
• Dupeytrens contracture
• Spider naevi
• Gynaecomastia
• Hepatomegaly
• Hepatic flap
• Caput medusae
• Clubbing
• Reduced consciousness
• Jaundice

Question 3

Initial investigations for DLD

Answer 3

• FBC - infection? GI bleed?
• LFTs
• Coagulation
• Hepatitis serology
• Abdo USS
• Blood culture
• Ascitic fluid + analysis
• MRCP/ERCP
• AFP - cancer
• Biopsy - cancer?

Question 4

Differentials for jaundice

Answer 4

• Pre hepatic - haemolysis
• Intrahepatic - hepatitis, cirrhosis, liver mets/cancer, paracetamol overdose
• Post hepatic - common bile duct stone, pancreatic cancer, PSC, cholangiocarcinoma

Question 5

Key investigations for patients with jaundice

Answer 5

• Bloods - U&Es, LFTs, FBC
• Blood film if malena
• Fibroscan
• Clotting
• Blood culture
• Hep ABC serology
• US liver and bile ducts
• MRCP/ERCP
• CT/MRI if suspect cancer

Question 6

Why might a patient with CLD be malnourished?

Answer 6

• Decreased absorption due to decreased bile - supplements?
• N+V - antiemetics
• Decreased appetite - ascites - control BP and portal HTN, nutritional supplements
• Alcohol - calorific intake - reduce
• Ensure dentures fit well

Question 7

How should alcohol withdrawal be managed in patients admitted to hospital?

Answer 7

• Admit to hopsital
• Benzodiazepines - long acting eg Diazepam or Chlordiazepoxide, lorazepam sometimes in hepatic failure
• Carbamazepine also effective
• Thiamine
• CIWA - AR tool

Question 8

Mechanism of alcohol withdrawal

Answer 8

• Chronic alcohol consuption leads to enhanced GABA mediated inhibition in CNS (similar to benzos)
• Increased inhibition of NMDA type glutamate receptors
• Alcohol withdrawal = opposite = decreased inhibitory GABA and increased NMDA activation

Question 9

Features of alcohol withdrawal

Answer 9

• 6-12 hours - sweating, tremor, tachycardia, anxiety
• Peak incidence seizures 36hrs
• 48-72 hrs = coarse tremor, delusions, confusion, auditory and visual hallucinations

Question 10

Services available for alcohol addiction

Answer 10

• Alcoholics anonymous
• SMART recovery
• Acamprosate

Question 11

Long term complications of cirrhosis that patient needs to be monitored for

Answer 11

• USS +/- AFP every 6 months for hepatocellular carcinoma
• GI endoscopy every 3 yrs if no oesophageal varices found + not taking propanolol to prevent

Question 12

What is NASH?

Answer 12

• Non-alcoholic steatohepatitis
• Inflammation present in non-alcoholish fatty liver disease
• RF inc DM, high choletserol, obesity