Chronic Liver Disease Flashcards by Srishti D

What are some key functions of the liver?

Synthesis of clotting factors
Glucose homeostasis
Albumin synthesis
Conjugation and clearance of bilirubin
NH3 metabolism
Drug metabolism and clearance
Immune

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What function of the liver is INR a function of?

Synthesis of clotting factors

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What interferes with INR?

Warfarin

Nutritionally deficient in vitamin K

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What can you do if a patient has prolonged INR and you suspect the cause to be vitamin K deficiency?

Give vitamin K parenterally for 2-3 days

If INR improves > not liver synthesis issue

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How are sinusoids in the liver different to capillaries in function?

Sinusoids allow movement of larger substances

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What is the liver enzyme pattern in hepatocellular injury or necrosis?

Elevation of transaminases

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What gives very high ALT levels?

Acute viral hepatitis
Acute drug toxicity
Ischaemia

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What is the liver enzyme pattern in intra- or extra-hepatic cholestasis?

Elevation of

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What gives high levels of ALP and GGT and minor elevation of transaminases?

Biliary obstruction
Liver infiltration
Cholestatic reactions to drugs

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What gives a mixed picture of liver enzymes?

Alcoholic liver disease

Fatty liver disease

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What are the symptoms of chronic liver disease?

Fatigue
Weight loss - muscle/gain - ascites
Haematemesis from varices > bleeding
Ascites > abdominal distension
Encephalopathy > confusion

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What are the stigmata of chronic liver disease?

Clubbing
Leuconychia
Palmar erythema
Dupuytren's contracture
Parotidomegaly
Spider naevi
Gynaecomastia
Hepatomegaly
Splenomegaly

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What are the investigation results in chronic liver disease?

LFTs
- May be normal
- Low albumin
- Raised bilirubin
- AST > ALT
Coagulopathy
- Prolonged/high normal INR
- Low normal/low platelets

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What do you look for on examination in chronic liver disease?

Stigmata of chronic liver disease
Signs of underlying aetiology
Signs of decompensation

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In what conditions can Dupuytren’s contracture be present?

Chronic liver disease (alcohol)
Manual labour
Anti-epileptics
Diabetes

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What is parotidomegaly specifically associated with?

Alcoholism

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What are the signs of liver decompensation?

Jaundice
Ascites
Bruising
Variceal bleeding
Signs of hepato-renal syndrome

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In what condition is anti-mitochondrial Ab (AMA) positive?

Primary biliary cirrhosis

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In what condition is anti-smooth muscle Ab (ASMA) positive?

Autoimmune hepatitis

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In what condition is anti-LKM (ALKM) positive?

Autoimmune hepatitis

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Which imaging modality is very sensitive for ascites?

Ultrasound

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How does F4 liver fibrosis cause portal hypertension?

Very difficult for blood to get through liver > increased portal BP

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How can liver disease be assessed after bloods and imaging?

Liver biopsy
- Staging fibrosis useful if alters management
FibroScan alternative in HCV cases

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What are the big 3 causes of chronic liver disease?

HBV
HCV
Alcohol

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What are the autoimmune 3 causes of chronic liver disease?

Autoimmune hepatitis Primary biliary cirrhosis Primary sclerosing cholangitis

What condition is primary sclerosing cholangitis associated with?

Ulcerative colitis

What are the metabolic 3 causes of chronic liver disease?

Haemochromatosis Wilson's disease Alpha 1-antitrypsin deficiency

What are the other 3 causes of chronic liver disease?

Non-alcoholic fatty liver disease (NASH) Budd-Chiari (hepatic vein thrombosis) Chronic biliary obstruction

What happens when there are low levels of albumin and/or clotting factors?

Coagulopathy Bleeding Ascites Oedema

What happens when there is a failure to excrete bilirubin?

Jaundice

What happens when there is a buildup of waste products (ammonia)?

Encephalopathy

What happens when there is portal hypertension?

Ascites Splenomegaly Varices +/- bleeding

What is hepato-renal syndrome?

Renal failure due to chronic liver disease

What is the tumour marker for hepatocellular carcinoma?

Alpha foetal protein

In what chronic liver diseases does hepatocellular carcinoma occur?

Cirrhosis from any cause | HBV without cirrhosis

What happens in metabolic failure due to chronic liver disease?

Late - hypoglycaemia | Feminisation/masculinisation

What does hepatic failure refer to?

Porto-systemic encephalopathy

In the setting of chronic liver disease, what investigation should be carried out before a trans-oesophageal echocardiogram?

Gastroscopy > screen for varices

What are the categories for assessment of chronic liver disease in the Child-Pugh score?

``` Encephalopathy Ascites INR Albumin Bilirubin ```

What is hepatic hydrothorax?

Ascites > tracks into pleural space

What is the preferred diuretic in the management of ascites?

Spironolactone

How is alcohol-related chronic liver disease treated?

Abstinence from alcohol - In-patient detox - Support/counselling - Pharmacological

How is HBV-related chronic liver disease treated?

``` Oral nucleos(t)ide analogues PEG-IFN ```

How is HCV-related chronic liver disease treated?

PEG-IFN + ribavirin +/- new agents | Not if decompensated disease

How is haemochromatosis treated?

Venesection

How is autoimmune hepatitis treated?

Prednisolone +/- azathioprine/mercaptopurine

How is primary biliary cirrhosis treated?

Urso-deoxycholic acid = bile-clearing drug

How is primary sclerosing cholangitis treated?

ERCP +/- stent/balloon dilatation

What should you consider if jaundice occurs suddenly in someone with chronic liver disease?

``` Portal vein thrombosis Biliary obstruction - Tumour - Gallstone Infection, esp spontaneous bacterial peritonitis ```

How is fluid retention treated in the context of chronic liver disease?

Salt and fluid restriction Large volume paracentesis = ascitic tap Diuretics

What is the primary prophylaxis for bleeding varices?

Variceal band ligation | Non-selective beta-blockers

What is the secondary treatment for bleeding varices?

Octreotide/terlipressin Antibiotics > reduce bacterial translocation Endoscopic banding/sclerotherapy Senstaken-Blakemore tube Trans-jugular intra-hepatic porto-systemic stent/shunt (TIPSS)

What is hepatic encephalopathy due to?

Multifactorial - Ammonia build-up - Oxidative stress - Impaired neurotransmission

What can cause encephalopathy?

``` Drugs - Benzodiazepines - Alcohol - Narcotics Increased ammonia - GI bleeding - Constipation - Infection - Electrolyte imbalance - Alkalosis - Hypoxia Dehydration Portal vein thrombosis Primary HCC TIPSS ```

Define type I hepato-renal syndrome

Acute <2 weeks | Severe <20 mL/min

Define type II hepato-renal syndrome

Slower onset, and less severe than type I

Why does the hepato-renal syndrome happen?

More blood flowing in portal system | Less blood flowing to kidneys

What happens in hepato-renal syndrome?

Creatinine rises | Urinary volume and Na fall

How does liver cirrhosis increase the risk of osteoporosis?

``` Cholestasis Vitamin D deficiency Physical inactivity Alcohol excess Hypogonadism ```

What is the last-line treatment for chronic liver disease?

Liver transplant

When should you consider referral for liver transplant?

Anyone with decompensated chronic liver disease

What are the majority of liver cancer cases associated with?

Chronic viral hepatitis

Who should be screened for HBV?

Individuals from countries of high/intermediate prevalence

What should be done if the first generation is found to be HBsAg positive?

Subsequent generations should be tested

What other populations need screening for HBV?

``` Household contacts Sexual contacts IVDU Multiple sex partners MSM Prisoners Those with - HCV - HIV Dialysis All pregnant women All on immunosuppressants ```