Chronic Liver Disease Flashcards by Tim Resch

Define Cirrhosis (in pathological terms)

An irreversible consequence of chronic hepatic injury w/ 3 key characteristics

Destruction of liver cells
Chronic inflammation –> fibrosis
Hepatocyte regeneration –> nodules

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What is the underlying pathology of fibrosis?

Due to growth factors released from inflammatory cells/Kupffer cells/hepatocytes
Inflammatory cells due to disease/response to liver cell necrosis

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What is the underlying pathology of nodule formation?

Due to hepatocyte regeneration
Stellate cell activation –> myofibroblasts formed, secrete collagen –> nodules form
Nodules lack vascular/bile drainage connections

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What are the common causes of cirrhosis?

Alcoholic liver disease
Cryptogenic liver disease
Non-alcoholic fatty liver disease
Chronic viral hepatitis

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What are the less common causes of cirrhosis?

AI hepatitis
1o biliary cirrhosis
1o sclerosing cholangitis
Budd-Chiari syndrome
Cystic fibrosis

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What are the very rare causes of cirrhosis?

Haemochromatosis
Wilson’s
a1-antitrypsin deficiency

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What is primary biliary cirrhosis?

AI destruction of intrahepatic bile cannaliculi

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What are the risk factors for primary biliary cirrhosis?

40-60yr old females (90%)

IBD

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How does primary biliary cirrhosis present?

Jaundice
Pruritis
Skin xanthomas

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How is primary biliary cirrhosis diagnosed?

Raised anti-mitochondrial antibodies (AMA)

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What are the management options for primary biliary cirrhosis?

Replacement of fat soluble vitamins

-progressive condition, 6yr average survival

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What is primary sclerosing cholangitis?

Autoimmune inflammation & fibrosis around the bile ducts in the liver
-2o cirrhosis due to chronic biliary obstruction

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What conditions are associated w/ primary sclerosing cholangitis?

IBD (70%)

Cholangiocarcinoma (develops in 10-15%)

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What are the management options for primary sclerosing cholangitis?

No effective treatment except transplantation

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What are the classic sx of chronic liver disease?

Fatigue
Wt loss/anorexia
Jaundice
Leg swelling
Bleeding/bruising
Itching

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What are the classic signs of chronic liver disease?

Nails - leuconychia, clubbing
Hands - palmar erythema, duyputren’s contracture, liver flap
Skin - pigmentation, spider naevi, striae
Feminization - gynaecomastia, testicular atrophy, loss of body hair
Portal HTN - caput medusae, hepatosplenomegaly, ascites
Hepatocellular failure - bruising, prolonged clotting

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What are the signs of decompensated liver disease?

Encephalopathy
Ascites
Jaundice

What factors may precipitate chronic liver disease decompensating?

Alcohol binge
Variceal bleed
Hepatotoxic drugs
Portal/hepatic vein thrombosis

What is the Child-Pugh score?

Gives 1/2 yr mortality scores in chronic liver disease using

total bilirubin
serum albumin
PT/INR
ascites
hepatic encephalopathy

What are the complications of chronic liver disease?

Hepatocellular failure
Portal HTN
Malignant change
Renal failure (hepatorenal syndrome)

How can the severity of chronic liver disease be investigated?

Liver function
   -albumin
   -INR
Liver damage
   -LFTs
Complications
   -U&amp;Es
   -ABG

How can the type of chronic liver disease be investigated?

Liver screen
Imaging
   -USS &amp; duplex
   -endoscopy
   -CT/MRI

What investigations make up a liver screen?

Viral serology
Serum autoantibodies/immunoglobulins
AFP
Fe studies (hereditary haemochromatosis)
Serum copper/caeruloplasmin (Wilson's)
a1-antitrypsin level

What further investigations may be necessary in chronic liver disease?

Ascitic tap (MCS)
Liver biopsy

What is Wilson's disease?

``` Inborn error of copper metabolism Deposition of copper in -liver -basal ganglia -cornea (Kayser-Fleischer rings) ```

What are the appropriate investigations in suspected Wilson's disease?

``` Serum caeruloplasmin (reduced) Urinary copper (increased) Liver biopsy (increased copper) ```

What are the management options for Wilson's disease?

Chelating agents (trientene, D-penicillamine)

What is Haemachromatosis?

Inherited condition of excess iron deposition leading to fibrosis & organ failure

What is the classic triad of sx in Haemachromatosis?

Bronze skin discolouration Hepatomegaly DM (also hypogonadism - impotence, testicular atrophy)

What are the appropriate investigations in suspected Haemachromatosis?

Serum Fe/Ferritin (increased) Total iron binding capacity (decreased) Genetic testing Liver biopsy

What are the management options for Haemachromatosis?

Vensection | -1 unit/wk

What are the common complications of cirrhosis?

Portal HTN (varices) Ascites Encephalopathy

How does portal HTN related to cirrhosis present?

Often asymptomatic/just hepatosplenomegaly 90% develop gastro-oesophageal varices over 10 yrs -1/3 bleed

How does ascites related to cirrhosis present?

Mild abdo pain common | -if severe suspect spontaneous bacterial peritonitis

What are the management options for ascites?

Initial bed rest & fluid restriction/low Na diet Spironolactone Furosemide (if poor response) Therapeutic paracentesis/albumin infusion (large volume)

What are the signs of spontaneous bacterial peritonitis?

Fever Pain Deterioration in prev well pt

How should spontaneous bacterial peritonitis be managed?

IV ceftriaxone | Long term norfloxacin (recurrence high)

What causes encephalopathy?

Accumulation of nitrogenous waste in circulation | Leads to cerebral oedema

What are the grades of encephalopathy?

Grade 1 - altered mood/behaviour, sleep disturbances Grade 2 - increasing drowsiness/confusion Grade 3 - stupor, incoherence, restlessness Grade 4 - coma

What are the management options of encephalopathy?

ICU admission 20o head tilt Oral lactulose w/ regular enemas IV manitol/hyperventilation if cerebral oedema

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Chronic Liver Disease Flashcards

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