Chronic liver disease / cirrhosis Flashcards
what does cirrhosis imply?
irreversible liver damage.
what happens histologically in cirrhosis?
loss of normal hepatic architecture with bridging fibrosis and nodular regeneration
what are the most common causes of cirrhosis?
chronic alcohol abuse
HBV or HVC infection
what are some genetic causes of cirrhosis?
- a1 - antitrypsin deficiency
- Wilson’s disease
- Haemochromatosis
what is a hepatic vein event cause of cirrhosis?
Budd-Chiari
what is a non-alcoholic cause of cirrhosis?
steatohepatitis
what are autoimmune causes of cirrhosis?
primary biliary cholagnitis
autoimmune hepatitis
what drugs cause cirrhosis
amioadorne
methyldopa
methotrexate
what are the signs of liver cirrhosis?
- 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
what are the complications of hepatic failrue?
- coagulopathy (failure of hepatic synthetis of clotting factors)
- encephalopathy
- hypoalbuminia (oedema)
- sepsis (pneumonia, septicemia)
- spontaneous bacterial peritotonits (SBP)
- hypoglycaemia.
what are the complications of portal hypertension
- ascites
- splenomegaly
- portosystemic shunt including oesophageal varies (+- life-treatenign upper GI bleed)
- caput medusa (enlarged superficial periumbilical veins)
what are you at increased risk of developing
- HCC
what do you look for in blood tests?
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
what could the liver ultrasound and duplex show?
small liver or hepatomegaly, splenomegaly, focal liver lesions, hepatic vein thrombosis, reversed flow in portal vein or ascites.
what do you see on an MRI for liver failure?
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.
why should an ascites tap be performed?
Should be performed and fluid sent for urgent MC&S – neutrophils >250/mmcubed indicates spontaneous bacterial peritonitis.
what is the liver biopsy generally used for?
to confirm clinical diagnosis.
how do you generally manage liver failure?
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.
how do you specifically manage liver failure?
High dose ursodeoxycholic acid in PBC may improbe lFT and impove transplant-free survival. Penicillamine for Wilson’s disease.
how do you manage ascitess?
fluid restriction
low salt diet
etc
how do you manage spontaneous bacterial peritonitis (SPB)
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.
how do you manage encephalopathy?
Recurrent episodes may be reduced in frequency with prophylatcit lactulose and rifaximin.
how do you manage renal failure?
Decreased hepatic clearance of immune complexes leads to trapping in kidneys (therefore IgA nepthorpathy +- hepatic glomerulosclerosis)
what is the only definitive treatment for cirrhosis?
liver transplant
what are the acute indications for liver transplant
acute liver failure meeting King’s college criteria.
what are the chronic conditions for liver transplant?
advanced cirrhosis of any cause. hepatocellualr cancer (1 nodule < 5cm or 5 or less nodules < 3cm)
how do you know if the cirrhosis is being decompensated?
- jaundice
- ascites
- encephalopathy
what are the usual suspects of decompensated liver?
- dehydration
- constipation
- cover alcohol use
- infection (spontaneous peritonitis)
- opiate over-use
- an occult GI bleed
