Chronic liver disease

Question 1

Chronic liver disease definition

Answer 1

Liver disease that persists beyond 6 months

Question 2

what are different causes of chronic liver disease

Answer 2

Chronic hepatitis
Chronic cholestasis
Fibrosis and Cirrhosis
Others e.g. steatosis
Liver tumours

Question 3

Cirrhosis causes

Answer 3

Alcohol

Autoimmune – autoimmmune hepatitis, PBC (Primary Biliary cholangitis), PSC (Primary Sclerosing Cholangitis)

Haemochromatosis

Chronic Viral hepatitis: B & C

Non-alcoholic fatty liver disease (NAFLD)

Drugs (MTX, amiodarone)
Cystic fibrosis, α1antitryptin deficiency, Wilsons disease,

Vascular problems (Portal hypertension + liver disease)

Cryptogenic

Others: sarcoidosis, amyloid, schistosomiasis

Question 4

Clinical presentation of cirrhosis
Compensated chronic liver disease

Answer 4

Routinely detected on screening tests
Abnormality of liver function tests

Question 5

Clinical presentation of cirrhosis
Decompensated chronic liver disease

Answer 5

Ascites
Hepatorenal syndrome
Variceal bleeding
Hepatic encephalopathy

Question 6

common presentation of cirrohsis in both compensated and non comensated patients

Answer 6

Hepatocellular carcinoma

Question 7

clinical features of ascites

Answer 7

Physical exam reveals dullness in flanks and shifting dullness (approx 1500cc).

Can be confirmed by U/S which can detect up to 100cc.

Corroborating evidence:
Spiders, palmar erythema, abdominal veins, fetor hepaticus
Umbilical nodule
JVP elevation
Flank haematoma

Question 8

diagnosis ascites

Answer 8

All patients with new-onset ascites should have a

DIAGNOSTIC PARACENTESIS
Studies needed on initial evaluation

Protein & albumin concentration
Cell count and differential
SAAG (serum-ascites albumin gradient)

> 1.1g/dl portal HTN related (97% accuracy)
< 1.1g/dl nonportal HTN causes(97% acc)

Question 9

transudative ascites
high albumin gradient

Answer 9

> 1.1 g/dl
Portal hypertension
CHF
Constrictive pericarditis
Budd Chiarri
Myxedema
Massive liver metastases

Question 10

exudative ascites

Answer 10

< 1.1 g/dl
Malignancy
Tuberculosis
Chylous ascites
Pancreatic
Biliary ascites
Nephrotic syndrome
Serositis

Question 11

ascites treatment

Answer 11

Diuretics
Large volume paracentesis
TIPS
Aquaretics
Liver transplantation

Question 12

Hepatorenal syndrome

Answer 12

Volume expansion with Albumin
Vasopressors
Terlipressin
Octreotide
TIPSS
Liver transplantation

Question 13

Variceal haemorrhage

Answer 13

Due to portal hypertension
Varices at porto-systemic anastomoses
Skin – Caput medusa
Oesophageal & Gastric
Rectal
Posterior abdominal wall
Stomal
Medical emergency

Question 14

portal hypertension characteristics

Answer 14

caput medusae
rectal varices
osophageal varices

Question 15

management of Variceal haemorrhage

Answer 15

Resuscitate patient
Good IV access
Blood transfusion as required
Emergency endoscopy

Question 16

what happens during emergency endoscopy

Answer 16

Endoscopic band ligation
Add Terlipressin for control
Sengstaken-Blakemore tube for uncontrolled bleeding
TIPSS for rebleeding after banding

Question 17

Hepatic encephalopathy

Answer 17

Confusion due to liver disease
Graded 1-4
Precipitants: GI bleed, infection, constipation, dehydration, medication esp. sedation
Flap – asterixis and foetor hepaticus
Treat underlying cause
Laxatives – phosphate enemas and lactulose
Neomycin, Rifaximin-broad spectrum non absorbed antibiotic
Repeated admissions with HE is an indicator for liver transplant

Question 18

Hepatic encephalopathy cause

Answer 18

Precipitants: GI bleed, infection, constipation, dehydration, medication esp. sedation

Question 19

Hepatic encephalopathy treaatment

Answer 19

Treat underlying cause
Laxatives – phosphate enemas and lactulose
Neomycin, Rifaximin-broad spectrum non absorbed antibiotic
Repeated admissions with HE is an indicator for liver transplant

Question 20

Hepatocellular carcinoma

Answer 20

Commonest cause of liver cancer
Occurs in the background of cirrhosis
Occurs in association with chronic hepatitis B & C

Question 21

Hepatocellular carcinoma presentation

Answer 21

Decompensation of liver disease
Abdominal mass
Abdominal pain
Weight loss
Bleeding from tumour

Question 22

Hepatocellular carcinoma diagnosis

Answer 22

Tumour markers: AFP
Radiological tests
Ultrasound
CT scan
MRI
Liver biopsy done very rarely

Question 23

Hepatocellular carcinoma treatment

Answer 23

Hepatic resection
Liver transplantation
Chemotherapy
Locally delivered: TACE (Transcatheter arterial chemo-embolization)
Systemic chemotherapy
Locally ablative treatments
Alcohol injection
Radiofrequency ablation
Sorafenib (Tyrosinase kinase inhibitor)
Hormonal therapy: Tamoxifen