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GASTROENTEROLOGY > Chronic Liver Disease (CLD) > Flashcards

Chronic Liver Disease (CLD) Flashcards

1
Q

Causes:

What is the biggest cause?

Obesity - what type of liver disease does it cause?

CHRONIC viral hepatitis:

What 2 types of hepatitis can cause chronic disease?

What 2 other pathogens can cause liver disease?

A

Alcohol - ALD

Non-alcoholic fatty liver disease - NAFLD

(USUALLY PART OF THE METABOLIC SYNDROME)

Hep B and C

CMV and EBV

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2
Q

Causes:

Autoimmune - 3

Genetic - 3

A 
Autoimmune hepatitis - AIH 
Primary biliary cirrhosis - PBC
Primary sclerosing cholangitis - PSC
-----
Hereditary haemochromatosis (HH)
Alpha 1 antitrypsin deficiency (A1AD)
Wilson's disease
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3
Q

Causes:

Drugs:

  • Immunosuppressor - m
  • Anti-arrhythmic - a
  • Anti-hypertensive - m
A

Methotrexate

Amiodarone

Methyldopa - alpha-2 adrenergic receptor agonist

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4
Q

Stages of CLD (ALD or NAFLD):

What happens in stage 1?
What happens in stage 2?
What happens in stage 3?
What happens in stage 4?

Up to what stage is it reversible?

A

Steatosis (aka fatty liver) - either NAFLD or ALD

Steatohepatitis - fatty liver + progressive inflammation (Mallory bodies are seen histologically)

Cirrhosis

Hepatocellular carcinoma (HCC)

Stage 3

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5
Q

Presentation - clinical:

It is often found incidentally. What 3 ways may it be discovered?

Other presentations:

  • Skin - 2
  • Anal/oesophageal/umbilical
  • Legs and tummy
  • Brain
A

Abnormal LFTs
Raised MCV - ALD
Abnormal clotting

Jaundice
Pruritis - bile acid 
Bleeding varices 
Ascites/oedema 
Hepatic encephalopathy
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6
Q

Presentation - exam - palpation:

You get hepatomegaly in the early stages. Why does it shrink in later stages?

Why do you also get splenomegaly?

A

Due to cirrhosis

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7
Q

Presentation - exam - hands:

5 signs on examination of the hands and why?

A

Leukonychia (low albumin) - white streaks on nails

Clubbing

Dupuytren’s contracture

Palmar erythema - raised oestrogen

Hyperdynamic circulation - warm hands even though patients complain it’s cold

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8
Q

Presentation - exam - face:

What may you notice around the eyes?

What may happen to the parotid glands as a result of alcohol?

What else may you notice on the skin of the face?

A

Xanthelasma - cholesterol high

Parotid enlargement

Spider naevi

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9
Q

Presentation - exam - trunk:

What may you notice on the skin of the trunk?

What 2 things may you notice in men and why?

A

Spider naevi

Gynecomastia and loss of body hair - due to increased oestrogen

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10
Q

Investigations - general:

Bloods:
- The first blood test you should obviously do

  • What is a typical finding, especially in those with alcohol problems?
  • Why do you measure platelets?
  • What should be measured which could be contributing to encephalopathy?

U&E:

  • What does a raised urea suggest?
  • What does a raised urea:creatinine ratio suggest?
  • Why should you be cautious with a normal creatinine level in those with CLD?

Synthetic function tests for liver:

Why do you measure PT/INR?
Why do you measure albumin?
Why do you measure glucose?

A

LFTs

Macrocytic anaemia especially in ALD

Thrombocytopenia develops due to hypersplenism and myelosuppression.

B12 and folate

GI bleeding as digested blood is a source of urea- oesophageal varices

Renal impairment (e.g. hepatorenal syndrome)

They have malnutrition and loss of muscle bulk and may have a low creatinine; therefore beware a creatine in the ‘normal’ range may still have significant impairment of renal function.

Highly sensitive test of liver function

Poor prognostic sign

Low gluconeogenesis

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11
Q

Investigations of causes:

What viral serology should be done? - 4

Why do you do auto-antibodies?

What can be measured to look for alpha-1 antitrypsin deficiency?

What may be measured for hereditary haemochromatosis?

What can be measured for Wilson’s?

A

HBV
HBC
CMV
EBV

Looking for autoimmune cause (e.g. PBC)

Alpha-1 antitrypsin

Ferritin and transferrin sats - usually raised

Serum ceruloplasmin - low
Raised urine copper

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12
Q

Investigations:

What is the enhanced liver disease (ELF) test?

What patient should have it done every 3 yrs?

What score can be used to assess the severity of liver cirrhosis?

A

Calculates a score to determine the presence of advanced liver fibrosis based on 3 biomarkers (e.g. hyaluronic acid)

NAFLD

Child-pugh classification

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13
Q

Investigations - Imaging:

Abdo USS used as first-line. What do the following signs indicate:

  • Bright liver
  • Small liver

What else may you see on USS? - 4

A

Steatosis - stage 1

Late cirrhosis 
---
Focal liver lesions
Hepatic vein thrombosis 
Splenomegaly - portal hypertension 
Gallstones
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14
Q

Investigations - Imaging:

What does a FibroScan measure?

Why is it useful?

What other modality can be used for varices, portal hypertension and architecture changes?

What modality can be used for focal lesions?

A

USS-based measure of liver fibrosis

It is a non-invasive alternative to biopsy for cirrhosis diagnosis

Contrast CT

MRI

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15
Q

Investigations - Biopsy:

Indications - 3

What can’t it distinguish between?

What is it not useful for?

Complications - 4

A
  • Determines degree of disease
  • Post-transplant to look for infection
  • Investigate focal lesions if their nature is unclear from imaging

ALD and NAFLD/NASH (non-alcoholic steatohepatitis)

Acute failure

Pain
Major bleeding
Damage to other organs
Death

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16
Q

Management - Early stages:

Advice for those with NAFLD/NASH?

Advice for those with ALD?

Why should the be monitored and how?

A

Diet
Exercise
Alcohol

Alcohol abstinence

To monitor progress to cirrhosis
FibreScan

17
Q

Management - Cirrhosis - Monitoring to prevent complications:

What score should be used to monitor them every 6 months?

What does cirrhosis increase the risk of?

What is looked for every 3 yrs by endoscopy?

What bone problem can occur in a patient with liver disease?

Ascites and SBP are checked regularly. What is SBP?

A

MELD (Model for End-stage Liver Disease) score

HCC - using US and AFP

Oesophageal varices

Osteoporosis - Due to lack of Vit D absorption - fewer bile is made so less absorption of fats

An acute bacterial infection of ascitic fluid. Generally, no source of the infecting agent is easily identifiable, but contamination of dialysate can cause the condition among those receiving peritoneal dialysis (PD).

18
Q

Management - Cirrhosis - Rx:

What jab can be given to them?

What vitamins might need supplementation? - 3

What cardiac medication can be given for varices?

What is an alternative to the medication?

Why do they develop osteoporosis and therefore need screening?

What is the last option?

A 
HAV
HBV 
--- 
Thiamine 
B12
Folate
---
Propranolol
Endoscopic variceal band ligation (VBL)

Due to lack of Vit D absorption - fewer bile is made so less absorption of fats

Transplantation

19
Q

List some complications of CLD?

A 
Portal hypertension
Oesophageal varices and upper GI bleeds
Ascites and SBP
Hepatorenal syndrome
Acute on chronic liver failure 
HCC
20
Q

Acute decompressed liver disease:

What is it?

Why is it different from acute liver failure?

How does it present?

What is the most common cause?

A

Acute deterioration in a patient with CLD

The patient has not previous has no existing liver disease.

Jaundice 
Coagulopathy 
Ascites (+/- SBP)
Hepatic encephalopathy (confusion)
Sepsis 
Variceal upper GI bleed

Alcohol

21
Q

Acute decompressed liver disease:

Triggers mnemonic - CRASH-CV

A 
Cancer 
Rx - hepatotoxic drugs - para
Alcohol 
Sepsis and SBP
Haemorrhage (variceal)

Clots - portal vein thrombosis
Viral hepatitis

A lot of these are both triggers and complications of worsening liver function

22
Q

Alcoholic hepatitis:

Define

Presentation - 4

A

Acute onset of jaundice, liver failure and systemic inflammation due to heavy alcohol consumption, usually of long duration.

Jaundice
Fever
Tender hepatomegaly
Worsening of underlying cirrhosis if present - ascites and enceph

23
Q

Alcoholic hepatitis:

What blood test would indicate the infection?

What blood test would indicate impaired liver function? - 2

How medication is given for 4 wks?**

A

Raised WBC - neutrophils

Abnormal LFTs - raised AST and ALT
Raised PT/INR

Prednisolone PO 4wks

24
Q

Alcoholic hepatitis:

What blood test would indicate the infection?

What blood test would indicate impaired liver function?

How medication is given for 4 wks?

A

Raised WBC - neutrophils

Abnormal LFTs - raised AST and ALT
Raised PT/INR

Prednisolone PO 4wks

25
Q

Portal hypertension:

Pathophysiology

Complications:

  • oesophagus and anal
  • spleen
  • umbilicus
A

Physical (cirrhosis) and chemical (raised endothelin)
Reduction in hepatic microvessel radius
Increased resistance in the portal vein

Varices - oesophageal and anal
Splenomegaly
Caput medusae - umbilical

26
Q

Varices:

Where can they be found?

What medication is given to prevent them and reduce the risk of bleeding by lowering portal hypertension? - T

What can be done if the medication is not enough?

A

Oesophageal (lower oesophagus) and anal

Terlipressin

(Propranolol used but not in emergency)

Variceal band ligation

27
Q

Ascites:

Give 2 reasons why ascites happens in liver disease?

What infections can cause it?

A

Portal hypertension - numerous causes
Low albumin - Protein-losing enteropathy - Coeliac, IBD

TB
Pancreatitis

28
Q

Ascites:

A tap allows the SAAG to be calculated. What does SAAG stand for?

How do you calculate it?

What does a high SAAG mean?

What does a low SAAG mean?

A

Serum ascites albumin gradient

Serum albumin - ascites albumin

High gradient - transudative meaning its is portal HTN

Low gradient - exudative meaning HCC/pancreatitis/TB

29
Q

Ascites - Other tests of ascitic fluid:

Why do:

  • Red and WBC count
  • Culture
  • Glucose
  • LDH - lactate dehydrogenase
  • Amylase
A

Infection

Infection

Low in peritoneal carcinomatosis or bowel perforation

High in SBP and really high in bowel perforation

High in pancreatitis

30
Q

Ascites - Management:

What needs to be excluded?

Diet changes - 2

What medication can be given? - 2

What can be used to get rid of some fluid?

TIPS is used for chronic ascites. What does it stand for?

A

SBP

Salt restrict
Fluid restrict

Spironolactone +/- furosemide

A tap

Transjugular intrahepatic portosystemic shunt

31
Q

SBP:

What does it stand for?

Pathophysiology?

What is the usual pathogen?

What does it increase the risk of?

A

Spontaneous bacterial peritonitis

Portal hypertension
Weakened gut mucosal defence
Infection of ascitic fluid

E. coli

Hepatorenal syndrome

32
Q

SBP:

Can be asymptomatic. 3 symptoms they may experience?

What on the ascitic tap suggests SBP?

Management:

What AB is used if mild?

What 2 ABs can be used if severe?

A

Fever
Vomiting
Abdo pain

Neutrophils

Co-amoxiclav PO

Piperacillin IV
Tazobactam IV

33
Q

Hepatorenal Syndrome:

What is it?

How is it diagnosed?

The RAS response seen in portal HTN leads to …..?

What 3 things may precipitate it?

Why is terlipressin given for it?

A

Kidney failure without a known cause in the presence of severe liver disease

Diagnosis of exclusion - no sign of kidney disease

Vasoconstriction causing renal hypoperfusion

SBP
Ascitic tap
Variceal bleed

Splanchnic vasoconstrictor

34
Q

What are the 2 stages between normal liver and fibrosis/cirrhosis?

A
  1. Normal
  2. Steatosis
  3. Steatohepatitis
  4. Fibrosis/cirrhosis
35
Q

How do bile sequestrants work?

A

Cholestyramine binds to bile acids in the intestine. This prevents their absorption, and the cholestyramine/bile acid complexes are eliminated in the stool. As a result, the body loses bile acids. To compensate for this loss, the liver increases the conversion of cholesterol to bile acids.

IT IS THE BILE ACIDS CAUSING ITCH!!

GASTROENTEROLOGY (54 decks)

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