pathological end-stage of any chronic liver disease fibrosis and conversion of normal liver architecture to structurally abnormal nodules irreversible in its advanced stages, although there can be significant recovery if the underlying cause is treated

Chronic liver disease (and decompensation) Flashcards by Ailsa Bell

ΔΔ causes chronic liver disease?

**• infection: hepatitis B and C, CMV, EBV
**• diet: ALD, NAFLD
• AI: AIH, PBC, PSC
• genetic: HH, a-1 trypsin def, Wilson’s disease
• drugs: methotrexate, amiodarone, methyldopa

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define cirrhosis?

pathological end-stage of any chronic liver disease
fibrosis and conversion of normal liver architecture to structurally abnormal nodules
irreversible in its advanced stages, although there can be significant recovery if the underlying cause is treated

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complications cirrhosis?

development of liver insufficiency and portal hypertension:
• ascites
• varices +/- bleed
• jaundice
• portosystemic encephalopathy
• AKI
• hepatopulmonary syndromes
• HCC

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Hx: patient presents with CLD Sx (jaundice, pruritus, bleeding varices, ascites/oedema, hepatic encephalopathy, anorexia, weight loss, fatigue)
+ SOB?

a-1 trypsin def

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stages of alcoholic/fatty liver disease?

steatosis (fatty)
steatohepatitis (inflammation, Mallory bodies)
cirrhosis (irreversible)
HCC

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commonest cause of abnormal LFTs?

NAFLD (25 percent pop in UK)

commoner than ALD

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Hx: often Asx and discovered incidentally: abnormal LFTs, +/- ↑MCV, abnormal clotting?

chronic liver disease

MCV indicated ALD

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Hx: patient presents with jaundice, pruritus, bleeding varices, ascites/oedema, hepatic encephalopathy, anorexia, weight loss, fatigue?

chronic liver disease

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Ex findings in CLD/cirrhosis?

hepatomegaly in earlier stages, but later shrinks as it becomes cirrhotic
splenomegaly (due to portal hypertension)
hands: leukonychia (↓albumin), clubbing, Dupuytren’s contracture, palmar erythema, hyperdynamic circulation
face: xanthelasma, parotid enlargement, spider naevi
trunk: spider naevi, gynecomastia, body hair loss

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Hx: patient presents with CLD Sx (jaundice, pruritus, bleeding varices, ascites/oedema, hepatic encephalopathy, anorexia, weight loss, fatigue)
+ arthritis?

HH, hep B, AI hep

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Hx: patient presents with CLD Sx (jaundice, pruritus, bleeding varices, ascites/oedema, hepatic encephalopathy, anorexia, weight loss, fatigue)
+ sicca - dry eyes, skin pigmentation, signs of bile build up from cholestasis: pruritus and xanthelasma?

PBC

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Hx: patient presents with CLD Sx (jaundice, pruritus, bleeding varices, ascites/oedema, hepatic encephalopathy, anorexia, weight loss, fatigue)
+ bloody diarrhoea?

PSC i.e. UC symptoms

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Hx: patient presents with CLD Sx (jaundice, pruritus, bleeding varices, ascites/oedema, hepatic encephalopathy, anorexia, weight loss, fatigue)
+ neuromotor and psychiatric features?

Wilson’s

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Hx: patient presents with CLD Sx (jaundice, pruritus, bleeding varices, ascites/oedema, hepatic encephalopathy, anorexia, weight loss, fatigue)
+ previous episodes of acute jaundice?

AIH or viral hepatitis

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Ix chronic liver disease?

BEDSIDE:

BLOODS:
• LFTs
• FBC: ↑MCV (ALD; uncommon in NAFLD), ↓platelets (cirrhosis) ↓wbc + plts indicate hypersplenism
• U+E: ↑urea = GI bleeding, ↑urea and creatinine = renal impairment e.g. hepatorenal syndrome
• later, ↓synthetic function of liver: ↑PT/INR
• ↓albumin (poor prognostic)
• ↓glucose (↓gluconeogenesis)

cause:
• viral serology: hep B/C, CMV, EBV
• AI (ANA, AMA, SMA)
• a-1 antitrypsin
• HH: ↑ferritin
• Wilson’s: ↓serum ceruloplasmin, ↑24h urine copper, slit lamp test for Keiser-Fleischer rings
• enhanced liver fibrosis (ELF) test: 3 biomarkers, every 3 yrs for NAFLD to identify cirrhosis risk

IMAGING:
• abdominal US
- bright: steatosis
- small: late cirrhosis
- focal liver lesions
- hepatic vein thrombosis.
- splenomegaly: portal hypertension
- GS
• transient elastography (FibroScan):
- US-based measure of liver fibrosis.
- non-invasive alternative to biopsy for cirrhosis diagnosis
• contrast CT
- good for varices, portal HT, and architecture changes (e.g. in cirrhosis).
• MRI: best for focal lesions
• MRCP

SPECIAL:
• ascitic tap (SBP?)
• biopsy
- can’t distinguish ALD vs. NAFLD/NASH, or in ALF, and might miss disease spot

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cirrhosis prognostic scores?

MELD score
Child-Pugh score

(ELF score is based on 3 biomarkers taken every 3 yrs in NAFLD, to identify cirrhosis risk)

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Tx chronic liver disease - from ALD, NAFLD, to cirrhosis?

conservative
• NASH/NAFLD: diet, exercise, limit alcohol
• ALD: alcohol abstinence
• Fibroscan (transient elastography) 2 yearly
• MELD score 6 monthly
• HCC screening: 6-monthly US and AFP
• varices: 3-yearly OGD
• OP: DEXA
• ascites +/- SBP: fluid and Na+ resrict, spirinolactone, Ex regularly!

medical
• pioglitazone or vitamin E if high ELF score
• cholestyramine if itch
• hep A/B immunisation
• vit thiamine, B12, folate
• varices: propranolol or endoscopic variceal band ligation (VBL)
• if rebleed: transjugular intrahepatic portosystemic shunt (TIPS)

surgical
• transplantation

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when to refer for transplant?

complication develops (e.g. variceal bleed, encephalopathy, ascites)
\+ MELD score ≥15, the point at which survival with transplant is higher than without

complications cirrhosis?

portal HT
oesophageal varices
upper GI bleeds
ascites + SBP
hepatorenal syndrome
acute on chronic failure
HCC

Ex finding of enlarged superficial periumbilical veins?

caput medusae

result of portal hypertension

Hx: CLD with ascites who suddenly deteriorates with fever, V, abdo pain?

SBP!
250 neutrophils/μL
E.coli, Klebsiella, strep
Tx co-amoxiclav PO, pip/tazo IV if severe

Sx of decompensated CLD?

• jaundice
• ascites (± SBP)
• encephalopathy (confusion, asterixis)
aslo:
• coagulopathy
• sepsis
• upper GI bleed

what is acute on chronic liver failure?

new/worsening organ failure
(liver, kidney, brain, coagulation, circulation, respiratory) • present in a cirrhotic patient
40percent mortality rate at 90 days

triggers for decompensated liver disease?

“CRASH-CV”

CRASH-CV:
• Cancer
• Rx: hepatotoxic drugs.
• Alcohol (commonest).
• Sepsis and SBP.
• Haemorrhage (variceal).
• Clots: portal vein thrombosis, ischaemic hepatitis.
• Viral hepatitis.

Tx liver decompensation?

conservative: • dietician review ± NG tube • alcohol withdrawal medical • fluids • Tx electrolyte disturbances (esp. K+, Ca2+, Mg2+, PO43-) • Tx AKI (hepatorenal syndrome) • thiamine IV • Abx if SBP, UTI, pneumonia, C. diff, or cellulitis • rescusc if upper GI bleed surgical • transplantation may be needed but is typically reserved for those already listed before the acute decompensation

commonest cause of decompensated liver disease?

alcohol

define alcoholic hepatitis?

* acute <3 months * Sx: jaundice, malaise, anorexia, D+V * Ex: fever, tender hepatomegaly, ascites * heavy alcohol consumption (long duration)

Tx + Ix alcoholic hepatitis?

``` BLOODS: • ↑wbc (neutrophils) ↑ MCV • LFT: ↑AST and ↑ALT (>2 times upper limit), AST/ALT ratio >2, ↑BR. • ↑PT/INR • +/- biopsy ``` * infection? Tx * STOP alcohol obvs * chlordiazepoxide or lorazepam for withdrawal * vit K IV, thiamine PO * nutrition * monitor weight, bloods, kidney function * prednisolone PO 4 weeks (Maddrey score)

what ratio of AST to ALT would you expect in alcoholic hepatitis?

AST/ALT ratio >2

``` effects of alcoholism on: • CNS • gut • blood • heart • reproduction ```

* CNS - memory, neglect, cortical atrophy, fits, falls, wide based gait, neuropathy, confabulation/Korsakoffs, Wernicke's (IM vits) * GUT - obesity, D, V, ulcers, varices, pancreatitis, ca, oes rupture * BLOOD - ↑MCV, anaemia from BM depression, GI bleed, folate def, haemolysis, sideroblastic anaemia * HEART - arrhythmias, HT, cardiomyopathy * REPRODUCTION - testicular atrophy, ↓T/P, ↑O

Hx: patient presents confused, with tremor, high HR and hypotensive, tremors, and hallucinations of animals crawling over skin? +/- fits

delirium tremens (alcohol withdrawal)

why does ascites happen?

* portal hypertension * → splanchnic vasodilation due to ↑vasodilators * ↑NO (↑synthesis and/or ↓clearance) * → renin-angiotensin-aldosterone (RAS) response * → Na+and fluid retention * peripheral arterial vasodilation hypothesis * ↓albumin may also contribute due to ↓oncotic pressure.

ΔΔ causes ascites?

``` • portal hypertension: - cirrhosis (commonest cause of ascites) - IVC or portal vein thrombosis - portal lymphadenopathy -CHF - constrictive pericarditis - Budd-Chiari syndrome • HCC or liver mets • infection and inflammation: TB, pancreatitis • ↓albumin: nephrotic syndrome, protein losing enteropathy (e.g. coeliac, IBD) • myxoedema ```

diagnostic Ix ascites?

• ascitic tap/paracentesis – (perform despite coagulopathy) - calculation of the serum-ascites albumin gradient (SAAG) - also rbc/wbc - culture - glucose - LDH - amylase

Tx ascites?

conservative • exclude SBP • Na+ and fluid restrict medical • diuretics: spironolactone ± furosemide • therapeutic paracentesis surgical • transjugular intrahepatic portosystemic shunt (TIPS) for refractory ascites • transplantation

what is hepatorenal syndrome? Tx?

* AKI in presence of cirrhosis /ALF * diagnosis of exclusion * RAS response seen in portal hypertension leads to regional vasoconstriction * renal hypoperfusion * +/- precipitated by SBP, paracentesis without volume expansion, or variceal bleed Tx • terlipressin – a splanchnic vasoconstrictor • human albumin solution • refer for possible liver transplantation

Ix: ascitic tap shows clear/straw coloured fluid?

liver cirrhosis

Ix: ascitic tap shows clear/straw coloured fluid and low wbcs?

liver cirrhosis

Ix: ascitic tap shows cloudy fluid?

SBP (high protein and wbcs - neutrophils) perforated bowel pancreatitits (high amylase)

Ix: ascitic tap shows bloody fluid?

``` malignancy (high rbcs) haemorrhagic pancreatitis (Grey-Turner's sign) ```

Ix: ascitic tap shows milk coloured/chylous fluid?

lymphoma TB (high protein, low glucose, high wbcs - lymphocytes) malignancy (high rbcs)

what is the equation for SAAG?

SAAG = (Serum albumin) – (Ascitic fluid albumin) BLOOD - ASCITES protein

A high SAAG (>1.1g/dL) suggests?

the ascitic fluid is a transudate (portal hypertension/↑pressure in portal vein): • cirrhosis • hepatic failure • venous occlusion e.g. Budd Chiari syndrome • fulminant hepatic failure • alcoholic hepatitis • Kwashiorkor malnutrition

A low SAAG (<1.1g/dL) suggests?

``` the ascitic fluid is an exudate (inflammation or malignancy): • malignancy • infection • pancreatitis • nephrotic syndrome ```

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Chronic liver disease (and decompensation) Flashcards

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