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Medicine > Chronic liver disease (and decompensation) > Flashcards

Chronic liver disease (and decompensation) Flashcards

1
Q

ΔΔ causes chronic liver disease?

A

**• 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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2
Q

define cirrhosis?

A
  • 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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3
Q

complications cirrhosis?

A 
development of liver insufficiency and portal hypertension:
• ascites
• varices +/- bleed
• jaundice
• portosystemic encephalopathy
• AKI
• hepatopulmonary syndromes
• HCC
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4
Q

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

A

a-1 trypsin def

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5
Q

stages of alcoholic/fatty liver disease?

A
  • steatosis (fatty)
  • steatohepatitis (inflammation, Mallory bodies)
  • cirrhosis (irreversible)
  • HCC
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6
Q

commonest cause of abnormal LFTs?

A

NAFLD (25 percent pop in UK)

commoner than ALD

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7
Q

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

A

chronic liver disease

MCV indicated ALD

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8
Q

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

A

chronic liver disease

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9
Q

Ex findings in CLD/cirrhosis?

A
  • 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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10
Q

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

A

HH, hep B, AI hep

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11
Q

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?

A

PBC

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12
Q

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

A

PSC i.e. UC symptoms

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13
Q

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

A

Wilson’s

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14
Q

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

A

AIH or viral hepatitis

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15
Q

Ix chronic liver disease?

A

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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16
Q

cirrhosis prognostic scores?

A

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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17
Q

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

A

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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18
Q

when to refer for transplant?

A 
complication develops (e.g. variceal bleed, encephalopathy, ascites)
\+ MELD score ≥15, the point at which survival with transplant is higher than without
19
Q

complications cirrhosis?

A
  • portal HT
  • oesophageal varices
  • upper GI bleeds
  • ascites + SBP
  • hepatorenal syndrome
  • acute on chronic failure
  • HCC
20
Q

Ex finding of enlarged superficial periumbilical veins?

A

caput medusae

result of portal hypertension

21
Q

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

A

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

22
Q

Sx of decompensated CLD?

A 
• jaundice
• ascites (± SBP)
• encephalopathy (confusion, asterixis)
aslo:
• coagulopathy
• sepsis
• upper GI bleed
23
Q

what is acute on chronic liver failure?

A
  • new/worsening organ failure
  • (liver, kidney, brain, coagulation, circulation, respiratory) • present in a cirrhotic patient
  • 40percent mortality rate at 90 days
24
Q

triggers for decompensated liver disease?

“CRASH-CV”

A 
CRASH-CV:
• Cancer
• Rx: hepatotoxic drugs.
• Alcohol (commonest).
• Sepsis and SBP.
• Haemorrhage (variceal).
• Clots: portal vein thrombosis, ischaemic hepatitis.
• Viral hepatitis.
25
Q

Tx liver decompensation?

A

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

26
Q

commonest cause of decompensated liver disease?

A

alcohol

27
Q

define alcoholic hepatitis?

A
  • acute <3 months
  • Sx: jaundice, malaise, anorexia, D+V
  • Ex: fever, tender hepatomegaly, ascites
  • heavy alcohol consumption (long duration)
28
Q

Tx + Ix alcoholic hepatitis?

A 
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)
29
Q

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

A

AST/ALT ratio >2

30
Q 
effects of alcoholism on:
• CNS
• gut
• blood
• heart
• reproduction
A
  • 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
31
Q

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

A

delirium tremens (alcohol withdrawal)

32
Q

why does ascites happen?

A
  • 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.
33
Q

ΔΔ causes ascites?

A 
• 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
34
Q

diagnostic Ix ascites?

A

• ascitic tap/paracentesis – (perform despite coagulopathy)

  • calculation of the serum-ascites albumin gradient (SAAG)
  • also rbc/wbc
  • culture
  • glucose
  • LDH
  • amylase
35
Q

Tx ascites?

A

conservative
• exclude SBP
• Na+ and fluid restrict

medical
• diuretics: spironolactone ± furosemide
• therapeutic paracentesis

surgical
• transjugular intrahepatic portosystemic shunt (TIPS) for refractory ascites
• transplantation

36
Q

what is hepatorenal syndrome? Tx?

A
  • 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

37
Q

Ix: ascitic tap shows clear/straw coloured fluid?

A

liver cirrhosis

38
Q

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

A

liver cirrhosis

39
Q

Ix: ascitic tap shows cloudy fluid?

A

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

40
Q

Ix: ascitic tap shows bloody fluid?

A 
malignancy (high rbcs)
haemorrhagic pancreatitis (Grey-Turner's sign)
41
Q

Ix: ascitic tap shows milk coloured/chylous fluid?

A

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

42
Q

what is the equation for SAAG?

A

SAAG = (Serum albumin) – (Ascitic fluid albumin)

BLOOD - ASCITES protein

43
Q

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

A

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

44
Q

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

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

Medicine (28 decks)

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