Chronic Liver disease symposium Flashcards
What is Cirrhosis?
- the final inflammation pathway of the liver happens after fibrosis
What are the clinical outcomes of cirrhosis?
- Jaundice
- Impaired immune system
Reduced metabolic capacity:
- coagulopathy
- reduced albumin
- hypoglycaemia
Portal Hypertension
- Ascites
- Hypersplenism
- Varices
- Hepatic Encephalopathy
What are the causes of Cirrhosis?
- Non-alcoholic fatty liver
- Alcohol
- Drug-induced
- Viral hepatitis
- Biliary disease
- Autoimmune liver disease: autoimmune hepatitis, primary biliary cholangitis, primarily sclerosing cholangitis
- Haemochromatosis
- also the same cause as high/abnormal Liver function Test results*
- Wilson disease
What is the presentation of compensated cirrhosis?
- ‘well’ patient
- some symptoms & signs or asymptomatic
- abnormal/ normal LFTs
- abnormal imaging; fibrous scan
- abnormal biopsy
What is the presentation of decompensated cirrhosis?
- unwell patient
- jaundiced
- encephalopathy
- coagulopathy
- low albumin
- ascites
- abnormal LFT’s
- abnormal imaging
What is portal hypertension?
- when the sinusoids and other vascular structures in the liver become fibrotic
- this reduces the compliance of the sinusoids and vascular pathways, increasing the resistance of the portal venous blood into the liver
- this increase the blood pressure in the liver = hypertension (10-12mhg)
What is the result of portal hypertension?
- high pressure in the liver causes back pressure in the GI portal system
- can cause an enlarged spleen, can result in a low platelet count
- dilated veins around the spleen: splenic varices
- varices around the oesophagus and top of the stomach: oesophageal varices
- these veins are at risk for haemorrhaging
- ascites
- hepatic encephalopathy, toxins like ammonia a bypass the liver and go to other areas i.e the brain
How would you treat a GI bleed due to varices bleeding caused by portal hypertension?
- OGD ( endoscopy)
- banding the varices to prevent further bleeding
Drugs
- give i.v terlipressin: vasoconstrictor which is specific to the portal circulation reduces bleeding
- i.v antibiotics: to prevent spontaneous bacterial peritonitis- bacteria from GI going from the intestines into the peritoneal cavity into the ascites
- Detox regimen (if its due to alcoholism)
What is the treatment for hepatic encephalopathy?
- give laxatives
- opens the bowels to excrete thee excess protein which can be converted to toxic ammonia
- also reduces the bacterial load in the gut that is converting the protein to ammonia
- pH in the bowel is changed which is not favourable to these bacteria
How is bilirubin formed and excreted?
What are the three categories that can cause Jaundice?
Pre-haptic
Hepatic
Posthepatic (most likely)
Explain Pre-haptic jaundice
- haemolytic anaemia: excess destruction of red blood cells, leads to excess bilirubin, the liver cannot keep up not enough albumin to bind to the bilirubin
- leads to excess unconjugated (lipid-soluble) bilirubin the blood
- this causes mild jaundice
Explain Hepatic Jaundice
- Gilbert’s syndrome: reduction in the level of conjugating enzymes in the liver - increase levels of unconjugated bilirubin
- causes mild jaundice, usually in times of fasting/starvation or during illness i.e flu
- acute hepatitis
Explain post hepatic jaundice
- extrahepatic biliary obstruction: occurs in the bile duct
What is the use of ultrasound in jaundice?
- to identify if the jaundice is obstructed or unobstructed
- is the obstruction extrahepatic or intrahepatic?
What key things should you ask as a jaundiced patient?
- Pruritus (itching)
- Weight/appetite loss: malignancy
- Pain: gall bladder stone
- Fevers
- Lethargy
- Other illnesses
- Alcohol
- Viral hepatitis risks: IVDU, travel, blood transfusions, tattoos, sexual history
- Drug History: flucloxacillin
- Family history
What are signs can be seen on examination that would indicate Chronic Liver disease?
Jaundice
Spider naevi
Palmar erythema
Leuconychia
Dupuytren’s contracture
Ascites
Gynaecomastia
Splenomegaly
What is key to be monitored in Routine Liver Tests?
- Bilirubin
- Alanine aminotransferase (ALT): hepatocyte damage
- Aspartate aminotransferase (AST): hepatocyte damage
- Alkaline phosphatase (ALP): bile duct damage, makes this high
- Gamma-glutamyltransferase (GGT): bile duct damage makes this high (can be increased in some individuals who drink excessively)
• Albumin: (anything causing inflammation can cause high albumin)
• International Normalised Ratio (INR): the ability to make clotting proteins
What are some additional blood tests that can follow an LFT investigation?
- Viral serology: shows the presence of Hep. C
- Autoimmune Screen: looking for antibodies to show autoimmune hepatitis or primary biliary cholangitis ( specific to antimitochondrial antibody)
- Immunoglobulins: can be indicative of autoimmune hepatitis increased IgM
- Ferritin: a marker of iron stores, may indicate hemochromatosis (genetically driven) –> CLD and cirrhosis
- alpha-1 antitrypsin
- Copper + Caeruloplasmin: Wilson disease (rare condition) –> cirrhosis
What is MRCP and what can it be used to image?
- Magnetic resonance cholangiopancreatography
- used to visualise the biliary and pancreatic duct
- can be used to identify stones and other obstructions
What is an ERCP and what is the imaging used for?
Endoscopic retrograde cholangiopancreatography
- use fluoroscopy and x-ray to give imaging of obstruction in the pancreaticobiliary system
- can use a stent at the end of the catheter to remove the stone
What is a fibroscan?
- noninvasive way to identify if the liver has fibrosis or cirrhosis
- transient elastography
- a measure of liver stiffness which correlates with fibrosis
- can still use a liver biopsy using a needle
What two categories could you provisionally place a patients liver function tests into when trying to make a diagnosis?
- Hepatic picture: raised Alanine aminotransferase (ALT) linked more with the hepatocytes
or
- Cholestatic picture: raised Alkaline phosphatase (ALP) linked more with the biliary system
