Chronic Liver Disease

Question 1

Liver Failure is ?

Answer 1

Often chronic and occurs over a long period and the presents as a sudden deterioration = acute on chronic

Question 2

Presentation? Rx Factors and treatments to consider

Answer 2

Presentation:

• Swelling of feet and abdomen
• tiredness, nausea and weight loss
• jaundice, pruritis
• increased bruising
• Haematemesis/PR bleeding
• Sleep wake reversal, memory problems and confusion = encephalopathy

Risk Factors:

• Alcohol intake
• Past Hx of hepatitis or jaundice
• Hx of drugs, transfusions, tattoos
• Diabetes, cardiac failure, arthropathy, haemachromotoosis

Treatments to ask of:

• Nurtitional, alcohol cessation, avoidance of NSAIDs sedatives and opiates
• Medications - cholestrymine, ursodeoxycholic acid
• Fluid restriction

Question 3

Examination:

Answer 3

General:
Jaundice, abdominal distension, muscle wasting

Hands:
Clubbing and leuconychia, palmar eythema, dupuytren’s contracture, tendon xanthoma

Arms:
hepatic flap, bruising, scratch marks, spider naevi, tattoos, needle marks

Face:
Cushingoid, parotid enlargement
EYE- xanthelesmata, Conj. pallor, KF rings

Chest:
gynaecomastia, loss of axillary hair, spider naevi

Abdo:
distension, striae, caput medusae, scars, hepato/splenomegaly, shifting dullness, bruit

Legs:
bruising, oedema

Question 4

Causes of CLD

Answer 4

FIGCAT

Fatty Liver:

• Alcoholic
• Non-Alcoholic (NAFLD)
  
  • DM, pregnancy, idiopathic

Infectious:

• Hepatitis
  
  • A = acute, B + C = chronic
• EBV
• CMV

Genetic

• Hereditary haemachromotosis
• Wilson’s Disease
• Alpha-1-antitrypsin deficiency

Congestion

• Budd-chiari Syndrome (1 in 1M)
• RHF/CHF

Autoimmune

• Autoimmune Hepatitis (Ab against hepatocyte surface antigen)
• Primary biliary cirrhosis
• Primary sclerosing Cholangitis

Toxins/Drugs:

• Alcohol
• Paracetamol overdose
• Isoniazid, methotrexate, methyldopa, nitrofurantoin

Question 5

Complications of CLD

Answer 5

PESCHARB

1. Portal Hypertension
2. Hepatic encephalopathy/cerebral oedema
3. synthetic dysfunction - coagulopathy, hypoalbuminaemia and feminization
4. Hepatocellular carcinoma
5. spontaneous bacterial peritonitis (SBP)
6. Hepatorenal syndrome (CLF CKD)
7. Ascites
8. Hypoglycaemia

Question 6

Investigations for CLD?

Answer 6

Bedside
- Fluid Balance, weight

Bloods: (fkn everything)

• FBC, CRP (infection, GI bleed, leucopenia and thrombocytopenia suggest hypersplenism)
• Chem (urea synthesised in liver, Cr for HRS, Ammonia for encephalopathy)
• Glucose (?hypo)
• Coags (inc PT, APTT and thrombin time)
• LFTs (AST/ALT = hepatocellular, GGT/ALP = cholestatic picture. AST:ALT ratio > 2 suggests ALD)

LIVER SCREEN
viral serology 
= hepB surface and core antigen, HepC antibody, HepA IgM, CMV and EBV
autoantibodies 
  =ANA - PSC
  =AMA = PBC, AIH
  =ASMA and ALKM1 = AIH
Ferritin 
A-1-antitrypsin 
A-fetoprotein = HCC

Imaging

• Abdo USS +/- portal vein doppler (BC syndrome)
• Fibroscanning
• MRCP

Other

• ascitic tap
• liver biopsy
• paracetamol levels
• OGD

Question 7

Grading Cirrhosis?

Answer 7

CHILD-PUGH SCORE
uses Encephalopathy, ascites, billirubin, albumin and prothrombin time/INR

5-6 mild = class A = 100% 1 year 
7-9 moderate = class B = 80% 1 year 
10-15 severe = Class C = 45% 1 year

Question 8

NP management

Answer 8

low salt diet, fluid restrict
alcohol abstinence
optimise nutrition

Question 9

P management

Answer 9

Treat Underlying cause:

• Hep B - SC PED interferon
• Hep C - oral ribavirin, weekly SC PEG interferon
• Haemochromotosis - venesection
• AIH - steroids
• NAFLD - weight loss, exercise, statin, VitE if not DM

Nutritional:

• NG feeding
• VitB
• Glucose infusion if hypo

Ascites:

• bed rest, fluid restrict, low salt
• Spironolactone - 100mg + frusemide if poor response
• Therapeutic paracentesis with albumin infusion

Varacies:
- B-blockers or variceal band ligation

SPB

• ABx - cefotaxime + metronidazole
• prophylaxis may be needed

Encephalopathy 
- remove precipitating factors 
  = enemas + low protein diet 
- lorazepam for seizures 
- mannitol for cerebral oedema 

Pruritis = cholestrymine
bleeding = VitK
Avoid - gentamicin, naltrexone, NSAIDs, sedatives

Invasive

• TIPSS (trans jugular intrahepatic portosystemic shunt)
• Liver transplant

Screening:
USS +/- alpha-fetoprotein ever 6 months to screen for HCC (especially if Hep B or Hep C)