Chronic liver disease / cirrhosis

Question 1

what does cirrhosis imply?

Answer 1

irreversible liver damage.

Question 2

what happens histologically in cirrhosis?

Answer 2

loss of normal hepatic architecture with bridging fibrosis and nodular regeneration

Question 3

what are the most common causes of cirrhosis?

Answer 3

chronic alcohol abuse

HBV or HVC infection

Question 4

what are some genetic causes of cirrhosis?

Answer 4

• a1 - antitrypsin deficiency
• Wilson’s disease
• Haemochromatosis

Question 5

what is a hepatic vein event cause of cirrhosis?

Answer 5

Budd-Chiari

Question 6

what is a non-alcoholic cause of cirrhosis?

Answer 6

steatohepatitis

Question 7

what are autoimmune causes of cirrhosis?

Answer 7

primary biliary cholagnitis

autoimmune hepatitis

Question 8

what drugs cause cirrhosis

Answer 8

amioadorne
methyldopa
methotrexate

Question 9

what are the signs of liver cirrhosis?

Answer 9

• Leukonychia (white nails with lunulae undermarcated, from hypo-albuminaemia
• Terry’s nails – white proximally but distal 1/3rd is reddened by telangiectasia
• Clubbing
• Palmar erythema
• Hyper dynamic circulation
• Dupuytren’s contracture
• Spider naevi
• Xanthelasma
• Gynaecomastia
• Atrophic tests
• Loss of body hair
• Parotid enlargement (alcohol)
• Hepatomegaly
• Or small liver in late disease
• Ascites
• Splenomegaly

Question 10

what are the complications of hepatic failrue?

Answer 10

• coagulopathy (failure of hepatic synthetis of clotting factors)
• encephalopathy
• hypoalbuminia (oedema)
• sepsis (pneumonia, septicemia)
• spontaneous bacterial peritotonits (SBP)
• hypoglycaemia.

Question 11

what are the complications of portal hypertension

Answer 11

• ascites
• splenomegaly
• portosystemic shunt including oesophageal varies (+- life-treatenign upper GI bleed)
• caput medusa (enlarged superficial periumbilical veins)

Question 12

what are you at increased risk of developing

Answer 12

• HCC

Question 13

what do you look for in blood tests?

Answer 13

LFT is normal or increased bilirubin
increased AST, ALT, ALP and gamma GT.

later with loss of function:
decreased albumin, increased PT/INR. decreased platelets indicate hypersplenism.

to find the cause: 
-ferritin 
-iron/total iron binding capacity
- hepatitis 
- serology 
and immunoglobulins 
autoantibodies (ANA, AMA SMA) 
alpha feta proteins 
caeruloplasmin in patients < 40 years old 
alpha a1 antitrypisn

Question 14

what could the liver ultrasound and duplex show?

Answer 14

small liver or hepatomegaly, splenomegaly, focal liver lesions, hepatic vein thrombosis, reversed flow in portal vein or ascites.

Question 15

what do you see on an MRI for liver failure?

Answer 15

Increased caudate lobe size, smaller islands of regeneration nodules, and the presence of the right posterior hepatic notch are more frequent in alcoholic cirrhosis than in virus-induced cirrhosis.

Question 16

why should an ascites tap be performed?

Answer 16

Should be performed and fluid sent for urgent MC&S – neutrophils >250/mmcubed indicates spontaneous bacterial peritonitis.

Question 17

what is the liver biopsy generally used for?

Answer 17

to confirm clinical diagnosis.

Question 18

how do you generally manage liver failure?

Answer 18

good nutrition is vital. Alcohol abstinence. Avoid NSAIDs, sedatives, and opiates.

Coleysteyramine helps prirutis.

Consider ultrasound +- alpha-fetoprotein every 6 months to screen for HCC inthose where this information will change management.

Question 19

how do you specifically manage liver failure?

Answer 19

High dose ursodeoxycholic acid in PBC may improbe lFT and impove transplant-free survival. Penicillamine for Wilson’s disease.

Question 20

how do you manage ascitess?

Answer 20

fluid restriction
low salt diet
etc

Question 21

how do you manage spontaneous bacterial peritonitis (SPB)

Answer 21

Must be considered in any patient with ascites who deteriorates suddenly (may be asymptomatic). Common organisms are E.coli, Klebseialla and streptococci. Treatment:
e.g. Piperacilin with tazobactam or until sensitives known. Give prophylaxis for high-risk patients. (decreased albumin, ^ PT/INR, low ascites albumin or those who have had a previous episode.

Question 22

how do you manage encephalopathy?

Answer 22

Recurrent episodes may be reduced in frequency with prophylatcit lactulose and rifaximin.

Question 23

how do you manage renal failure?

Answer 23

Decreased hepatic clearance of immune complexes leads to trapping in kidneys (therefore IgA nepthorpathy +- hepatic glomerulosclerosis)

Question 24

what is the only definitive treatment for cirrhosis?

Answer 24

liver transplant

Question 25

what are the acute indications for liver transplant

Answer 25

acute liver failure meeting King’s college criteria.

Question 26

what are the chronic conditions for liver transplant?

Answer 26

advanced cirrhosis of any cause. 
hepatocellualr cancer (1 nodule < 5cm or 5 or less nodules < 3cm)

Question 27

how do you know if the cirrhosis is being decompensated?

Answer 27

• jaundice
• ascites
• encephalopathy

Question 28

what are the usual suspects of decompensated liver?

Answer 28

• dehydration
• constipation
• cover alcohol use
• infection (spontaneous peritonitis)
• opiate over-use
• an occult GI bleed