Chronic Liver Disease + Alcohol + Drug Injury Flashcards
How long does hepatitis have to occur for to be defined as chronic?
6 months
What are main infective causes of acute hepatitis?
1) Hep A -> E Infection
2) EBV
3) CMV
4) Toxoplasmosis
What are main non-infective causes of acute/chronic hepatitis?
Alcohol, Drugs, Toxins and AI
What are main infective causes of chronic hepatitis?
Hep B, Hep C and Hep E
Can lead to uncontrolled inflammation –> Fibrosis –> Cirrhosis –> HCC
What are the main symptoms of acute hepatitis?
General malaise, myalgia, GI upset, abdominal pain, Raised AST/ALT and jaundice
What are the types of LFT’s done? (2)
1) Serum Liver Enzymes: Hepatocellular and cholestatic
2) Serum bilirubin, albumin, prothrombin
What are the main broad categories of jaundice?
1) Pre-Hepatic (Unconjugated)
2) Cholestatic (Conjugated)
What are the main causes and outcome of acute liver disease?
Causes: Viral hepatitis, drug induced hepatitis, alcohol induced hepatitis, vascular and obstruction
Outcome: Recovery or Liver Failure
Symptoms: Malaise, lethargy, anorexia and jaundice
What are the causes and outcomes of chronic liver disease?
Outcomes: Cirrhosis or Liver failure
Causes: Alcohol, NAFLD, Viral Hepatitis, AI disease, Metabolic and Vascular
Describe Budd-Chiari syndrome
Vascular disease with occlusion of hepatic veins that drain the liver
What are the main signs of chronic liver disease
Ascites, Oedema, Malaise, Anorexia, Bruising, Itching, Clubbing, Palmar erythema and spider naevi
What question should be asked and what drugs can be asked in drug induced liver injury history?
Q: Started any new medication
Drugs: Flucloxacillin, Erythromycin, TB drugs and co-amoxiclav
What drugs don’t usually cause DILI?
LD aspirin, NSAIDS, beta blockers, HRT and CCB
What enzyme is used to remove reactive intermediates of paracetamol, preventing toxicity and liver failure?
Glutathione Transferase
What causes raised unconjugated bilirubin and what will stool/urine appear like?
Pre-Hepatic problem e.g. SCD, spherocytosis
- Stool and Urine normal, no itching and LFT’s normal
What can cause raised conjugated bilirubin and what will urine/stool appear like?
Cholestatic problem: Liver disease/ B-D obstruction
- Dark urine and pale stools –> Itching and abnormal LFT
What are 3 main causes of duct bstruction?
1) Strictures (Narrowing of Vasc.)
2) Carcinoma
3) Gallstones
What are the main causes of hepatic jaundice? What are main symptoms?
1) Viral hepatitis 2) Alcoholic hepatitis 3) Drugs 4) Cirrhosis
Symptoms: Weight loss, abdominal swelling, biliary pain and rigors
What is ascites and pathophysiological causes?
- Accumulation of fluid in peritoneal cavity leading to abdominal distension
a) Local Inflammation e.g. peritonitis
b) Leaky vessels (Hydrostatic and oncotic pressure imbalance)
c) Low flow (cirrhosis, thrombosis and cardiac failure)
d) Low protein e.g. Hypoalbuminaemia
What is the pathogenesis of ascites?
1) ^ Intra-Hepatic resistance leads to portal hypertension –> Ascites
2) Systemic vasodilation leads to secretion of RAAS, NAd and ADh –> Fluid retention
3) Low serum albumin also contributes
What are the 3 main phases of alcohol liver disease?
1) Fatty change: Hepatocytes have triglycerides (steatosis)
2) Alcohol hepatitis
3) Alcoholic Cirrhosis: Destruction of liver architecture and fibrosis
What could histologically be seen indicating diagnosis of alcoholic liver disease?
Neutrophils and fat accumulation within hepatocytes
What is NASH? And what are 3 main causes
Advanced form of non-alcoholic fatty liver disease
1) T2DM 2) Hypertension 3) Obesity 4) Hyperlipidaemia
What is cirrhosis, main causes and treatments?
Necrosis of liver cells –> Fibrosis –> Impairment of hepatocyte function and distortion of liver architecture
MC: Alcohol, Hep. B and Hep. C, Chronic Liver disease
Treat: Transplant, Screening for HCC, deal with the underlying cause
What are the main causes of portal hypertension? What are the potential consequences and pathogenesis of varices?
1) Cirrhosis/Fibrosis (I-H causes) 2) PV Thrombosis (P-H) 3) Budd-Chiari Syndrome
Consequences: Haemorrhage risk from rupturing
PG: Obstruction to portal blood flow, blood diverted into collaterals
Treated by: Endoscopic Therapy (Banding_
What is ascending cholangitis and 3 common symptoms of ascending?
Obstruction of Biliary tract causing bacterial infection (Medical emergency)
CT: Fever, RUQ pain and JAUNDICE
What would the management and investigations be for someone with asc. cholangitis?
Inv: Ultrasound, blood tests (LFT’s), ERCP
Man: IV fluid, IV antibiotics, ERCP to remove stone and stenting
What is acute cholecystitis?
Inflammation of the gall bladder caused by blockage of the bile duct –> Obstruction to bile emptying
RUQ pain, fever, inflammatory markers raised (No jaundice)
RF: Obesity and Diabetes
What are the main primary symptoms and PP of primary sclerosing cholangitis?
Symptoms: Itching, Rigor, Pain and Jaundice (75% IBD)
Inflammation of bile duct -> Strictures and Hardening -> Progressive obliterating fibrosis of bile duct branches -> cirrhosis -> Liver failure
What are 3 symptoms of spontaneous bacterial peritonitis
1) Dull to percussion 2) Temperature 3) Abdominal pain
Investigations for peritonitis?
1) Abdominal x-ray
2) CXR: Air under diaphragm
3) Blood tests: WCC platelets, CRP, reduced blood count
4) CT: Inflammation, ischaemia or cancer
5) ECG: epigastric pain could be related to the heart
6) B-HCG: Hormone secreted by pregnant ladies
What are the 5 main complications of peritonitis?
1) Hypovolaemia 2) Kidney Failure 3) Systemic sepsis 4) Paralytic ileus 5) Pulmonary atelectasis (Lung collapse) 6) Portal pyaemia (pus in portal vein)
What is the main treatment and management for peritonitis?
Man: ABC, treat underlying cause, call surgeon and post-management support
What are the 2 types of ascites?
Exudative: Increased vascular permeability secondary to infection, malignancy or inflammation (peritonitis)
Transudative: Increased venous pressure from cirrhosis, cardiac failure or Hypoalbuminaemia
What are the main signs of ascites and investigations?
1) Flank swelling 2) Dull to percuss/shifting dullness
Investigations: Ultrasound and ascitic tap
What is the treatment for ascites?
1) Restrict sodium
2) Diuretics
3) Drainage
How is Haemochromatosis inherited and which gene is mutated?
Autosomal recessive inheritance
HFE
What is the pathophysiology of haemochromatosis?
Uncontrolled intestinal iron absorption leads to deposition in liver, heart and pancreas -> Fibrosis -> Organ Failure
How would someone with Haemochromatosis be diagnosed?
1) Raised ferritin
2) HFE genotyping
3) Liver biopsy
What histological stain is used and what are the main symptoms of haemochromatosis?
Perl’s Stain
Hepatomegaly, Cardiomegaly, Diabetes mellitus, Hyperpigmentation of skin, Lethargy
