Chronic Liver Disease + Alcohol + Drug Injury

Question 1

How long does hepatitis have to occur for to be defined as chronic?

Answer 1

6 months

Question 2

What are main infective causes of acute hepatitis?

Answer 2

1) Hep A -> E Infection
2) EBV
3) CMV
4) Toxoplasmosis

Question 3

What are main non-infective causes of acute/chronic hepatitis?

Answer 3

Alcohol, Drugs, Toxins and AI

Question 4

What are main infective causes of chronic hepatitis?

Answer 4

Hep B, Hep C and Hep E

Can lead to uncontrolled inflammation –> Fibrosis –> Cirrhosis –> HCC

Question 5

What are the main symptoms of acute hepatitis?

Answer 5

General malaise, myalgia, GI upset, abdominal pain, Raised AST/ALT and jaundice

Question 6

What are the types of LFT’s done? (2)

Answer 6

1) Serum Liver Enzymes: Hepatocellular and cholestatic

2) Serum bilirubin, albumin, prothrombin

Question 7

What are the main broad categories of jaundice?

Answer 7

1) Pre-Hepatic (Unconjugated)

2) Cholestatic (Conjugated)

Question 8

What are the main causes and outcome of acute liver disease?

Answer 8

Causes: Viral hepatitis, drug induced hepatitis, alcohol induced hepatitis, vascular and obstruction
Outcome: Recovery or Liver Failure
Symptoms: Malaise, lethargy, anorexia and jaundice

Question 9

What are the causes and outcomes of chronic liver disease?

Answer 9

Outcomes: Cirrhosis or Liver failure
Causes: Alcohol, NAFLD, Viral Hepatitis, AI disease, Metabolic and Vascular

Question 10

Describe Budd-Chiari syndrome

Answer 10

Vascular disease with occlusion of hepatic veins that drain the liver

Question 11

What are the main signs of chronic liver disease

Answer 11

Ascites, Oedema, Malaise, Anorexia, Bruising, Itching, Clubbing, Palmar erythema and spider naevi

Question 12

What question should be asked and what drugs can be asked in drug induced liver injury history?

Answer 12

Q: Started any new medication
Drugs: Flucloxacillin, Erythromycin, TB drugs and co-amoxiclav

Question 13

What drugs don’t usually cause DILI?

Answer 13

LD aspirin, NSAIDS, beta blockers, HRT and CCB

Question 14

What enzyme is used to remove reactive intermediates of paracetamol, preventing toxicity and liver failure?

Answer 14

Glutathione Transferase

Question 15

What causes raised unconjugated bilirubin and what will stool/urine appear like?

Answer 15

Pre-Hepatic problem e.g. SCD, spherocytosis

- Stool and Urine normal, no itching and LFT’s normal

Question 16

What can cause raised conjugated bilirubin and what will urine/stool appear like?

Answer 16

Cholestatic problem: Liver disease/ B-D obstruction

- Dark urine and pale stools –> Itching and abnormal LFT

Question 17

What are 3 main causes of duct bstruction?

Answer 17

1) Strictures (Narrowing of Vasc.)
2) Carcinoma
3) Gallstones

Question 18

What are the main causes of hepatic jaundice? What are main symptoms?

Answer 18

1) Viral hepatitis 2) Alcoholic hepatitis 3) Drugs 4) Cirrhosis
Symptoms: Weight loss, abdominal swelling, biliary pain and rigors

Question 19

What is ascites and pathophysiological causes?

Answer 19

• 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

Question 20

What is the pathogenesis of ascites?

Answer 20

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

Question 21

What are the 3 main phases of alcohol liver disease?

Answer 21

1) Fatty change: Hepatocytes have triglycerides (steatosis)
2) Alcohol hepatitis
3) Alcoholic Cirrhosis: Destruction of liver architecture and fibrosis

Question 22

What could histologically be seen indicating diagnosis of alcoholic liver disease?

Answer 22

Neutrophils and fat accumulation within hepatocytes

Question 23

What is NASH? And what are 3 main causes

Answer 23

Advanced form of non-alcoholic fatty liver disease

1) T2DM 2) Hypertension 3) Obesity 4) Hyperlipidaemia

Question 24

What is cirrhosis, main causes and treatments?

Answer 24

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

Question 25

What are the main causes of portal hypertension? What are the potential consequences and pathogenesis of varices?

Answer 25

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_

Question 26

What is ascending cholangitis and 3 common symptoms of ascending?

Answer 26

Obstruction of Biliary tract causing bacterial infection (Medical emergency)
CT: Fever, RUQ pain and JAUNDICE

Question 27

What would the management and investigations be for someone with asc. cholangitis?

Answer 27

Inv: Ultrasound, blood tests (LFT’s), ERCP
Man: IV fluid, IV antibiotics, ERCP to remove stone and stenting

Question 28

What is acute cholecystitis?

Answer 28

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

Question 29

What are the main primary symptoms and PP of primary sclerosing cholangitis?

Answer 29

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

Question 30

What are 3 symptoms of spontaneous bacterial peritonitis

Answer 30

1) Dull to percussion 2) Temperature 3) Abdominal pain

Question 31

Investigations for peritonitis?

Answer 31

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

Question 32

What are the 5 main complications of peritonitis?

Answer 32

1) Hypovolaemia 2) Kidney Failure 3) Systemic sepsis 4) Paralytic ileus 5) Pulmonary atelectasis (Lung collapse) 6) Portal pyaemia (pus in portal vein)

Question 33

What is the main treatment and management for peritonitis?

Answer 33

Man: ABC, treat underlying cause, call surgeon and post-management support

Question 34

What are the 2 types of ascites?

Answer 34

Exudative: Increased vascular permeability secondary to infection, malignancy or inflammation (peritonitis)
Transudative: Increased venous pressure from cirrhosis, cardiac failure or Hypoalbuminaemia

Question 35

What are the main signs of ascites and investigations?

Answer 35

1) Flank swelling 2) Dull to percuss/shifting dullness

Investigations: Ultrasound and ascitic tap

Question 36

What is the treatment for ascites?

Answer 36

1) Restrict sodium
2) Diuretics
3) Drainage

Question 37

How is Haemochromatosis inherited and which gene is mutated?

Answer 37

Autosomal recessive inheritance

HFE

Question 38

What is the pathophysiology of haemochromatosis?

Answer 38

Uncontrolled intestinal iron absorption leads to deposition in liver, heart and pancreas -> Fibrosis -> Organ Failure

Question 39

How would someone with Haemochromatosis be diagnosed?

Answer 39

1) Raised ferritin
2) HFE genotyping
3) Liver biopsy

Question 40

What histological stain is used and what are the main symptoms of haemochromatosis?

Answer 40

Perl’s Stain

Hepatomegaly, Cardiomegaly, Diabetes mellitus, Hyperpigmentation of skin, Lethargy