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Y3 CBLs > CBL 6 Fatty Liver (1) > Flashcards

CBL 6 Fatty Liver (1) Flashcards

1
Q

What’s the most common cause of liver disease in a developed world?

A

Non-Alcoholic Fatty Liver Disease (NAFLD)

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2
Q

Spectrum of NAFLD. (3) forms

A
  • steatosis - fat in the liver
  • steatohepatitis - fat with inflammation
  • progressive disease may cause fibrosis and liver cirrhosis
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3
Q

What is thought to be involved in the pathophysiology of NAFLD?

A

NAFLD is thought to:

represent the hepatic manifestation of the metabolic syndrome -> hence insulin resistance is thought to be the key mechanism -> steatosis

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4
Q

What does Non-Alcoholic Steatohepatitis mean?

A

Non-alcoholic steatohepatitis (NASH)

  • liver changes similar to those seen in alcoholic hepatitis in the absence of a history of alcohol abuse
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5
Q

Factors associated with NAFLD (5)

A
  • obesity
  • type 2 diabetes mellitus
  • hyperlipidaemia
  • jejunoileal bypass
  • sudden weight loss/starvation
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6
Q

Clinical Features of NAFLD

A
  • usually asymptomatic
  • hepatomegaly
  • ALT is typically greater than AST
  • increased echogenicity on ultrasound
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7
Q

Do we screen for NAFLD?

What are the guidelines based on?

A
  • no evidence to support screening for NAFLD in adults, even in at risk groups (e.g. type 2 diabetes)
  • the guidelines are based on the management of the incidental finding of NAFLD - typically asymptomatic fatty changes on liver ultrasound
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8
Q

What’s ELF blood test?

A

Firstly, finding (usually incidental and asymptomatic) of fatty liver changes on USS -> then use ELF blood test:

  • use of the enhanced liver fibrosis (ELF) blood test to check for advanced fibrosis
  • the ELF blood test is a combination of hyaluronic acid + procollagen III + tissue inhibitor of metalloproteinase 1. An algorithm based on these values results in an ELF blood test score
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9
Q

What diagnostic tests/investigations do we do if ELF blood test is not available?

A

Non-invasive tests may be used to assess the severity of fibrosis:

  • FIB4 score or NALFD fibrosis score
  • these scores may be used in combination with a FibroScan (liver stiffness measurement assessed with transient elastography)

(this combination has been shown to have excellent accuracy in predicting fibrosis)

  • Patients who are likely to have advanced fibrosis should be referred to a liver specialist. They will then likely have a liver biopsy to stage the disease more accurately
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10
Q

Management of Non-alcoholic Fatty Liver Disease

A
  • the mainstay of treatment is lifestyle changes (particularly weight loss) and monitoring
  • there is ongoing research into the role of gastric banding and insulin-sensitising drugs (e.g. metformin, pioglitazone)
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11
Q

Diagnosis of metabolic syndrome

A

3 out of 5:

  • diabetes
  • HTN
  • hyperlipidaemia
  • hypertriglyceridaemia
  • obesity
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12
Q

What histopathological changes may be seen in hepatosteatosis

A

Mechanism of formation of Mallory-Denk bodies is unclear. But these are tangles in the cytoplasm

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13
Q

What happens, histologically, in chronic hepatosteatosis?

A

Stellate cells lay fibrotic tissue

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14
Q

What liver enzymes would be increased due to damage to hepatocytes?

A
  • ALT (to a greater extent)
  • AST
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15
Q

What liver enzymes will be increased due to the progression of NAFLD?

(progression from steatosis - steatohepatitis - fibrosis/cirrhosis)

A
  • increase in ALT
  • sometimes increase in AST
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16
Q

How would the picture of increased liver enzymes would look like in alcohol-induced liver disease?

A
  • Increased AST
  • AST:ALT ratio >2
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17
Q

What % of fat content in the liver is considered abnormal?

A

> 5%

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18
Q

Is NAFLD reversible?

A
  • Steatosis and steatohepatitis -> potentially reversible if addressing the cause
  • Fibrosis -> not reversible
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19
Q

Detailed (with values) criteria for metabolic syndrome

A
  • blood pressure >130/85 mmHg
  • serum HDL concentration <1.04 mmol/l in men and <1.29 mmol/l in women.
  • serum TG concentration >1.69 mmol/l
  • fasting plasma glucose >6.1 mmol/l
  • abdominal obesity (waist circumference >102 cm in men and >88 cm in women).
20
Q
A
21
Q

Symptoms of NAFLD

A

•Often asymptomatic, incidental finding on LFTs

Symptoms are vague:

  • fatigue
  • chronic malaise
  • disturbed sleep
  • abdominal pain
22
Q

Signs of NAFLD

*also consider PMH

A
  • raised ALT and AST
  • exclude other aetiology for liver disease
  • USS evidence of fat accumulation
  • raised BMI/ abdominal obesity.
  • metabolic syndrome
  • Check the patient’s record for BMI, glucose, HbA1c, BP, waist measurement.
23
Q

What’s NASH?

A

NASH – necro-inflammation with fibrosis, and has the potential to develop to cirrhosis and hepatocellular carcinoma

24
Q

Patient’s factors that may suggest occurrence of more severe NASH

A
  • Age > 45 years
  • BMI >30kg/m2
  • T2DM
  • Found on USS

*These cases may require further investigation and possible liver biopsy

25
Q

What are the potential causes of raised ALT?

A
  • alcoholic liver disease
  • chronic viral infection (hep B and C)
  • autoimmune hepatitis
  • primary biliary cirrhosis
  • haemochromatosis
  • Wilson’s disease
  • drugs side effects and toxicity (e.g. paracetamol, sulphasalazine, flucloxacillin, amiodarone
26
Q

Diagnostic clues for suspicion of alcohol-related liver disease (2)

A
  • history of excess alcohol consumption
  • possible macrocytosis
27
Q

Diagnostic test for chronic active viral hepatitis that may lead to liver damage

A

Serology for hepatitis B and hepatitis C

28
Q

Diagnostic tests suggestive of autoimmune hepatitis or primary biliary cirrhosis

A

Antibodies:

  • antinuclear
  • smooth muscle
  • anti-mitochondrial
29
Q

What iron studies picture is suggestive of haemochromatosis?

A
  • high iron
  • low TIBC
  • high ferritin
30
Q

What to measure in the investigation of Willson’s disease?

A

Copper excess - measure ceruloplasmin

*ceruloplasmin - copper-carrying protein

31
Q

What factors should be addressed in the treatment of Non-alcoholic fatty liver?

A
  • Weight loss > 5% of body mass by diet and increased physical activity can normalise liver biochemistry

*It has been postulated that if this weight loss is maintained, patients can expect a complete reduction in hepatic steatohepatitis

  • BP, lipid, diabetes management
32
Q

Typical blood result pattern in Alcoholic Liver Disease (ALD)

A

Raised GGT+ ALT+ raised MCV

33
Q

Factors that may make us suspicious of alcohol liver disease rather then non-alco fatty liver disease

A

A combination of:

  • macrocytosis
  • normal or reduced BMI
  • AST:ALT ratio > 2
  • AST is preferentially raised in ALD (compared to NAFLD)
34
Q

If there are no risk factors, can we rule out viral hepatitis?

A

Yes

35
Q

Risk factors for viral hepatitis

A
  • history of travel to countries where the virus is prevalent
  • sexual history—multiple partners, homosexual/bisexual relationships, partners who have travelled to countries where hepatitis is endemic
  • presence of tattoos/ piercings
  • previous use of blood products or blood transfusion
  • intravenous drug abuse
36
Q

What Hep B surface (s) Ag mean?

A

HEP B SURFACE (s) Ag

  • acute or chronic hepatitis B
  • Its presence after 6 months shows chronic hepatitis
37
Q

What HepB e-Ag mean?

A

infectivity

38
Q

What HEP B s- Ab IgG mean?

A

Immunity (mostly from vaccination)

39
Q

What HEP B e Ab mean?

A

infected or immune but low infectivity

40
Q

What Hep B core (c) Ab mean?

A
  • non-specific
  • if the Ig M shows infection in the last 6 months
41
Q

What does HEP B VIRAL DNA mean?

A

Infectivity

42
Q

What, in general, haemochromatosis is?

A

Haemochromatosis is an autosomal recessive disorder of iron absorption and metabolism resulting in iron accumulation

43
Q

Genetics behind haemochromatosis

A
  • autosomal recessive
  • mutations in the HFE gene on both copies of chromosome 6
44
Q

Presenting features of haemochromatosis

A
  • early symptoms include fatigue, erectile dysfunction and arthralgia (often of the hands)
  • ‘bronze’ skin pigmentation
  • diabetes mellitus
  • liver: stigmata of chronic liver disease, hepatomegaly, cirrhosis, hepatocellular deposition)
  • cardiac failure (2nd to dilated cardiomyopathy)
  • hypogonadism (2nd to cirrhosis and pituitary dysfunction - hypogonadotrophic hypogonadism)
  • arthritis (especially of the hands)
45
Q

Anti-LKM antibody

What’s that?

A

Anti - Liver- Kindney microsomial antibody

  • one of several antibodies detected in patient with acute or chronic liver disease
  • these are targeted against antigens of cytochrome P450

Different antibodies:

anti-LKM -1 = autoimmune hepatitis

anti - LKM-2 = drug induced hepatits

anti-LKM-3 = chronic active hepatitis, hep D

Y3 CBLs (13 decks)

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