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MD2 Ambulatory Care and Emergency Medicine > Chronic Liver Disease > Flashcards

Chronic Liver Disease Flashcards

1
Q

What are some key functions of the liver?

A 
Synthesis of clotting factors
Glucose homeostasis
Albumin synthesis
Conjugation and clearance of bilirubin
NH3 metabolism
Drug metabolism and clearance
Immune
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2
Q

What function of the liver is INR a function of?

A

Synthesis of clotting factors

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3
Q

What interferes with INR?

A

Warfarin

Nutritionally deficient in vitamin K

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4
Q

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

A

Give vitamin K parenterally for 2-3 days

If INR improves > not liver synthesis issue

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5
Q

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

A

Sinusoids allow movement of larger substances

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6
Q

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

A

Elevation of transaminases

  • ALT
  • AST
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7
Q

What gives very high ALT levels?

A

Acute viral hepatitis
Acute drug toxicity
Ischaemia

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8
Q

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

A

Elevation of

  • ALP
  • GGT
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9
Q

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

A

Biliary obstruction
Liver infiltration
Cholestatic reactions to drugs

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10
Q

What gives a mixed picture of liver enzymes?

A

Alcoholic liver disease

Fatty liver disease

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11
Q

What are the symptoms of chronic liver disease?

A 
Fatigue
Weight loss - muscle/gain - ascites
Haematemesis from varices > bleeding
Ascites > abdominal distension
Encephalopathy > confusion
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12
Q

What are the stigmata of chronic liver disease?

A 
Clubbing
Leuconychia
Palmar erythema
Dupuytren's contracture
Parotidomegaly
Spider naevi
Gynaecomastia
Hepatomegaly
Splenomegaly
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13
Q

What are the investigation results in chronic liver disease?

A 
LFTs
- May be normal
- Low albumin
- Raised bilirubin
- AST > ALT
Coagulopathy
- Prolonged/high normal INR
- Low normal/low platelets
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14
Q

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

A

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

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15
Q

In what conditions can Dupuytren’s contracture be present?

A

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

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16
Q

What is parotidomegaly specifically associated with?

A

Alcoholism

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17
Q

What are the signs of liver decompensation?

A 
Jaundice
Ascites
Bruising
Variceal bleeding
Signs of hepato-renal syndrome
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18
Q

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

A

Primary biliary cirrhosis

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19
Q

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

A

Autoimmune hepatitis

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20
Q

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

A

Autoimmune hepatitis

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21
Q

Which imaging modality is very sensitive for ascites?

A

Ultrasound

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22
Q

How does F4 liver fibrosis cause portal hypertension?

A

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

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23
Q

How can liver disease be assessed after bloods and imaging?

A

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

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24
Q

What are the big 3 causes of chronic liver disease?

A

HBV
HCV
Alcohol

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25
Q

What are the autoimmune 3 causes of chronic liver disease?

A

Autoimmune hepatitis
Primary biliary cirrhosis
Primary sclerosing cholangitis

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26
Q

What condition is primary sclerosing cholangitis associated with?

A

Ulcerative colitis

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27
Q

What are the metabolic 3 causes of chronic liver disease?

A

Haemochromatosis
Wilson’s disease
Alpha 1-antitrypsin deficiency

28
Q

What are the other 3 causes of chronic liver disease?

A

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

29
Q

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

A

Coagulopathy
Bleeding
Ascites
Oedema

30
Q

What happens when there is a failure to excrete bilirubin?

31
Q

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

A

Encephalopathy

32
Q

What happens when there is portal hypertension?

A

Ascites
Splenomegaly
Varices +/- bleeding

33
Q

What is hepato-renal syndrome?

A

Renal failure due to chronic liver disease

34
Q

What is the tumour marker for hepatocellular carcinoma?

A

Alpha foetal protein

35
Q

In what chronic liver diseases does hepatocellular carcinoma occur?

A

Cirrhosis from any cause

HBV without cirrhosis

36
Q

What happens in metabolic failure due to chronic liver disease?

A

Late - hypoglycaemia

Feminisation/masculinisation

37
Q

What does hepatic failure refer to?

A

Porto-systemic encephalopathy

38
Q

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

A

Gastroscopy > screen for varices

39
Q

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

A 
Encephalopathy
Ascites
INR
Albumin
Bilirubin
40
Q

What is hepatic hydrothorax?

A

Ascites > tracks into pleural space

41
Q

What is the preferred diuretic in the management of ascites?

A

Spironolactone

42
Q

How is alcohol-related chronic liver disease treated?

A

Abstinence from alcohol

  • In-patient detox
  • Support/counselling
  • Pharmacological
43
Q

How is HBV-related chronic liver disease treated?

A 
Oral nucleos(t)ide analogues
PEG-IFN
44
Q

How is HCV-related chronic liver disease treated?

A

PEG-IFN + ribavirin +/- new agents

Not if decompensated disease

45
Q

How is haemochromatosis treated?

A

Venesection

46
Q

How is autoimmune hepatitis treated?

A

Prednisolone +/- azathioprine/mercaptopurine

47
Q

How is primary biliary cirrhosis treated?

A

Urso-deoxycholic acid = bile-clearing drug

48
Q

How is primary sclerosing cholangitis treated?

A

ERCP +/- stent/balloon dilatation

49
Q

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

A 
Portal vein thrombosis
Biliary obstruction
- Tumour
- Gallstone
Infection, esp spontaneous bacterial peritonitis
50
Q

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

A

Salt and fluid restriction
Large volume paracentesis = ascitic tap
Diuretics

51
Q

What is the primary prophylaxis for bleeding varices?

A

Variceal band ligation

Non-selective beta-blockers

52
Q

What is the secondary treatment for bleeding varices?

A

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

53
Q

What is hepatic encephalopathy due to?

A

Multifactorial

  • Ammonia build-up
  • Oxidative stress
  • Impaired neurotransmission
54
Q

What can cause encephalopathy?

A 
Drugs
- Benzodiazepines
- Alcohol
- Narcotics
Increased ammonia
- GI bleeding
- Constipation
- Infection
-  Electrolyte imbalance
- Alkalosis
- Hypoxia
Dehydration
Portal vein thrombosis
Primary HCC
TIPSS
55
Q

Define type I hepato-renal syndrome

A

Acute <2 weeks

Severe <20 mL/min

56
Q

Define type II hepato-renal syndrome

A

Slower onset, and less severe than type I

57
Q

Why does the hepato-renal syndrome happen?

A

More blood flowing in portal system

Less blood flowing to kidneys

58
Q

What happens in hepato-renal syndrome?

A

Creatinine rises

Urinary volume and Na fall

59
Q

How does liver cirrhosis increase the risk of osteoporosis?

A 
Cholestasis
Vitamin D deficiency
Physical inactivity
Alcohol excess
Hypogonadism
60
Q

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

A

Liver transplant

61
Q

When should you consider referral for liver transplant?

A

Anyone with decompensated chronic liver disease

62
Q

What are the majority of liver cancer cases associated with?

A

Chronic viral hepatitis

63
Q

Who should be screened for HBV?

A

Individuals from countries of high/intermediate prevalence

64
Q

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

A

Subsequent generations should be tested

65
Q

What other populations need screening for HBV?

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

MD2 Ambulatory Care and Emergency Medicine (29 decks)

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