Chronic Liver Disease (CLD) Flashcards
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?
Alcohol - ALD
Non-alcoholic fatty liver disease - NAFLD
(USUALLY PART OF THE METABOLIC SYNDROME)
Hep B and C
CMV and EBV
Causes:
Autoimmune - 3
Genetic - 3
Autoimmune hepatitis - AIH Primary biliary cirrhosis - PBC Primary sclerosing cholangitis - PSC ----- Hereditary haemochromatosis (HH) Alpha 1 antitrypsin deficiency (A1AD) Wilson's disease
Causes:
Drugs:
- Immunosuppressor - m
- Anti-arrhythmic - a
- Anti-hypertensive - m
Methotrexate
Amiodarone
Methyldopa - alpha-2 adrenergic receptor agonist
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?
Steatosis (aka fatty liver) - either NAFLD or ALD
Steatohepatitis - fatty liver + progressive inflammation (Mallory bodies are seen histologically)
Cirrhosis
Hepatocellular carcinoma (HCC)
Stage 3
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
Abnormal LFTs
Raised MCV - ALD
Abnormal clotting
Jaundice Pruritis - bile acid Bleeding varices Ascites/oedema Hepatic encephalopathy
Presentation - exam - palpation:
You get hepatomegaly in the early stages. Why does it shrink in later stages?
Why do you also get splenomegaly?
Due to cirrhosis
Presentation - exam - hands:
5 signs on examination of the hands and why?
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
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?
Xanthelasma - cholesterol high
Parotid enlargement
Spider naevi
Presentation - exam - trunk:
What may you notice on the skin of the trunk?
What 2 things may you notice in men and why?
Spider naevi
Gynecomastia and loss of body hair - due to increased oestrogen
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?
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
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?
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
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?
Calculates a score to determine the presence of advanced liver fibrosis based on 3 biomarkers (e.g. hyaluronic acid)
NAFLD
Child-pugh classification
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
Steatosis - stage 1
Late cirrhosis --- Focal liver lesions Hepatic vein thrombosis Splenomegaly - portal hypertension Gallstones
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?
USS-based measure of liver fibrosis
It is a non-invasive alternative to biopsy for cirrhosis diagnosis
Contrast CT
MRI
Investigations - Biopsy:
Indications - 3
What can’t it distinguish between?
What is it not useful for?
Complications - 4
- 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
Management - Early stages:
Advice for those with NAFLD/NASH?
Advice for those with ALD?
Why should the be monitored and how?
Diet
Exercise
Alcohol
Alcohol abstinence
To monitor progress to cirrhosis
FibreScan
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?
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).
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?
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
List some complications of CLD?
Portal hypertension Oesophageal varices and upper GI bleeds Ascites and SBP Hepatorenal syndrome Acute on chronic liver failure HCC
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?
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
Acute decompressed liver disease:
Triggers mnemonic - CRASH-CV
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
Alcoholic hepatitis:
Define
Presentation - 4
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
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?**
Raised WBC - neutrophils
Abnormal LFTs - raised AST and ALT
Raised PT/INR
Prednisolone PO 4wks
Alcoholic hepatitis:
What blood test would indicate the infection?
What blood test would indicate impaired liver function?
How medication is given for 4 wks?
Raised WBC - neutrophils
Abnormal LFTs - raised AST and ALT
Raised PT/INR
Prednisolone PO 4wks
Portal hypertension:
Pathophysiology
Complications:
- oesophagus and anal
- spleen
- umbilicus
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
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?
Oesophageal (lower oesophagus) and anal
Terlipressin
(Propranolol used but not in emergency)
Variceal band ligation
Ascites:
Give 2 reasons why ascites happens in liver disease?
What infections can cause it?
Portal hypertension - numerous causes
Low albumin - Protein-losing enteropathy - Coeliac, IBD
TB
Pancreatitis
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?
Serum ascites albumin gradient
Serum albumin - ascites albumin
High gradient - transudative meaning its is portal HTN
Low gradient - exudative meaning HCC/pancreatitis/TB
Ascites - Other tests of ascitic fluid:
Why do:
- Red and WBC count
- Culture
- Glucose
- LDH - lactate dehydrogenase
- Amylase
Infection
Infection
Low in peritoneal carcinomatosis or bowel perforation
High in SBP and really high in bowel perforation
High in pancreatitis
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?
SBP
Salt restrict
Fluid restrict
Spironolactone +/- furosemide
A tap
Transjugular intrahepatic portosystemic shunt
SBP:
What does it stand for?
Pathophysiology?
What is the usual pathogen?
What does it increase the risk of?
Spontaneous bacterial peritonitis
Portal hypertension
Weakened gut mucosal defence
Infection of ascitic fluid
E. coli
Hepatorenal syndrome
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?
Fever
Vomiting
Abdo pain
Neutrophils
Co-amoxiclav PO
Piperacillin IV
Tazobactam IV
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?
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
What are the 2 stages between normal liver and fibrosis/cirrhosis?
- Normal
- Steatosis
- Steatohepatitis
- Fibrosis/cirrhosis
How do bile sequestrants work?
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!!
