Chronic liver disease and cirrhosis

Question 1

What is cirrhosis

Answer 1

Cirrhosis is a diffuse pathological process resulting in end stage liver disease, characterised by fibrosis and conversion of normal liver architecture to structurally abnormal nodules known as regenerative nodules.

Question 2

What are the main causes of cirrhosis?

Answer 2

NAFLD
ALD
Hepatitis

Question 3

What is the AST/ALT ratios in ALD and NAFLD?

Answer 3

ALD: > 1.5

NAFLD: < 0.8

Question 4

What are clinical features of decompensated liver disease?

Answer 4

Jaundice, shifting dullness (indicates ascites ), confusion and asterixis (indicates hepatic encephalopathy) and GI bleeding

Question 5

What are signs of liver disease?

Answer 5

• Leukonychia (hypalbuminaemia)
	• Clubbing
	• Palmar erythema
	• Gynaecomastia
	• Dupuytren's contracture 
	• Spider naevia
	• Xanthelasma 
	• Loss of body hair
	• Small testes 
Ascites

Question 6

What blood tests for cirrhosis?

Answer 6

Bloods: LFTs: raised bilirubin, AST/ALT, GGT if ALD

FBC: anaemia may suggest GI bleed, low platelets

Clotting: prolonged PT suggests loss of synthetic function

Autoantibodies: AMA, SMA

AFP

Hepatitis virology

Ceruloplasmin

Alpha 1 antitrypsin

iron studies (HH)

Question 7

What other Ix in cirrhosis?

Answer 7

Imaging: fibroscan showing fibrosis

Endoscopy to check for varices

Question 8

What severity scores used in cirrhosis?

Answer 8

Child Pugh

MELD: mortality

Question 9

What is Rx of cirrhosis?

Answer 9

Treat any underlying cause.

Ascites: diuretics, fluid restriction, low salt diet, therapeutic paracentesis

ALD: glucocorticoids, stop drinking

NAFLD: lose weight, maybe metformin

Transplantation is the only curative option, but is reserved for end stage and patients with HCC

Question 10

What are main complications of liver cirrhosis?

Answer 10

Decompensation: coagulopathy, encephalopathy

Portal hypertension: varices, ascites

SBP

HCC

Hepatorenal syndrome

Question 11

What are the 4 stages of hepatic encephalopathy

Answer 11

1 = mild confusion

2 = disorientation, inappropriate behaviour, drowsy

3 = somnolent but arousable, slurred speech, confused, aggressive

4 = coma

Question 12

what are triggers for hepatic encephalopathy?

Answer 12

• Sepsis
	• Constipation
	• Medications
	• Dehydration
Bleeding

Question 13

What are Sx of hepatic encephalopathy?

Answer 13

• confusion, altered GCS
  
  • asterix: ‘liver flap’
  • constructional apraxia: inability to draw a 5-pointed star
  • triphasic slow waves on EEG
  • raised ammonia level

Question 14

What is Rx for hepatic encephalopathy

Answer 14

• Oral lactulose
○ reduction of intestinal ammonia load through its action as a cathartic and its ability to inhibit ammoniagenic coliform bacteria by acidifying the colonic lumen.

• Oral rifaximin

Question 15

What is hepatorenal syndrome and how is it treated?

Answer 15

Occurs when abnormal haemodynamics result in systemic and splanchnic vasodilation, and renal vasoconstriction.

terlipressin
TIPS
albumin
transplant

Question 16

What are features of HCC

Answer 16

• tends to present late
• features of liver cirrhosis or failure may be seen: jaundice, ascites, RUQ pain, hepatomegaly, pruritus, splenomegaly
• possible presentation is decompensation in a patient with chronic liver disease
• raised AFP
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Question 17

How is HCC treated?

Answer 17

• early disease: surgical resection
  
  • liver transplantation
  • radiofrequency ablation
  • transarterial chemoembolisation
  • sorafenib: a multikinase inhibitor

Question 18

What is SBP?

Answer 18

a form of peritonitis usually seen in patients with ascites secondary to liver cirrhosis.

* ascites
* abdominal pain
* fever

Question 19

How is SBP diagnosed and treated?

Answer 19

• paracentesis: neutrophil count > 250 cells/ul
  
  • the most common organism found on ascitic fluid culture is E. coli

IV Abx. Prophylaxis in patients with recurrent SBP