Cirrhosis Flashcards
What is liver cirrhosis?
where functional liver cells are replaced with scar tissue via fibrosis as a result of chronic inflammation
What causes portal hypertension in liver cirrhosis?
the fibrosis affects the structure and blood flow through the liver, increasing resistance in the vessels
What are the 4 main causes of liver cirrhosis?
1) alcohol-related liver disease
2) non-alcoholic fatty liver disease
3) hepatitis B
4) hepatitis C
Give 7 less common causes of cirrhosis:
1) autoimmune hepatitis
2) primary biliary sclerosis
3) haemochromatosis
4) Wilson’s disease
5) Alpha-1 antitrypsin deficiency
6) cystic fibrosis
7) drugs such as amiodarone, methotrexate and sodium valproate
Give 10 physical signs associated with cirrhosis:
1) spider naevia
2) asterixis (hepatic flap)
3) cachexia (loss of weight)
4) gynaecomastia and testicular atrophy
5) jaundice
6) caput medusae
7) ascites
8) splenomegaly
9) bruising
10) hepatomegaly
Why is palmar erythema seen in cirrhosis?
due to elevated oestrogen levels
Why is bruising seen in cirrhosis?
clotting factor production is impaired (clotting factors are produced in the liver)
What is caput medusae?
distention of paraumbilical veins due to portal hypertension
Why may leukonychia be seen in liver failure/ cirrhosis?
hypalbuminaemia
What are the 7 tests used in a non-invasive liver screen?
1) ultrasound liver
2) hepatitis B and C serology
3) immunoglobulin test
4) caeruloplasmin test
5) alpha-1-antitrypsin levels
6) antibody test
7) ferritin and transferrin saturation
When is a non-invasive liver screen indicated?
abnormal LFT results
What is the role of liver ultrasound in the non-invasive liver screen?
to check for non-alcoholic fatty liver disease (fatty changes appear as increased echogenicity) along with other cirrhotic changes such as nodularity, peritoneal fluid, splenomegaly and enlarged portal vein
Name 3 conditions that are associated with liver autoantibodies:
1) autoimmune hepatitis
2) primary biliary sclerosis
3) primary sclerotising cholangitis
Name 4 autoantibodies screened for in the non-invasive liver screen:
1) antinuclear antibodies
2) smooth muscle antibodies
3) antimitochondrial antibodies
4) antibodies to liver kidney microsome type 1
What is the role of the caeruloplasmin test in the non-invasive liver screen?
caeruloplasmin is the major copper-carrying protein in the blood and so it can be used to check for Wilson’s disease
Is alpha-1-antitrypsin deficiency autosomal dominant or recessive?
Dominant
What is the role of the alpha-1-antitrypsin enzyme?
neutralising neutrophil elastase
Describe how alpha-1-antitrypsin deficiency can cause hepatic damage:
the alpha-1-antitrypsin enzyme is responsible for neutralising neutrophil elastase and without it, elastase in the liver will be broken down
What is the role of testing ferritin and transferrin saturation in the non-invasive liver screen?
to exclude hereditary haemochromatosis
What four molecules are tested for in a liver function test?
1) bilirubin
2) alanine transaminase
3) aspartate transferase
4) alkaline phosphatase
Would albumin levels be raised or low in cirrhosis?
low (the liver produces albumin)
Name 6 blood tests non used in the non-invasive liver screen that can be used to investigate cirrhosis:
1) LFTs
2) serum albumin
3) prothrombin time
4) U&Es
5) alpha-fetoprotein
6) enhanced liver fibrosis (ELF)
Would prothrombin levels be raised or low in cirrhosis?
raised (the liver produces clotting factors)
Describe 2 key changes in U&Es seen in cirrhosis:
1) urea and creatinine become deranged in hepatorenal syndrome
2) hyponatraemia occurs in severe liver disease
Name a tumour marker for hepatocellular carcinoma:
alpha-fetoprotein
What is the first line investigation for fibrosis in NAFLD?
Enhanced liver fibrosis (ELF)
What are the three markers measured in the enhanced liver fibrosis test?
1) HA
2) PIIINP
3) TIMP-1
What value in the Enhanced Liver Fibrosis test indicates advanced fibrosis?
> 10.51
What imaging technique can be used to assess the stiffness of the liver using high frequency sound waves?
transient elastography (fibroscan)
What investigation is the gold standard in diagnosing cirrhosis?
biopsy
What investigation can be used to assess for oesophageal varices (swollen veins)?
endoscopy
What imaging techniques can be used to assess for hepatocellular carcinoma, hepatosplenomegaly, vessel changes and ascites?
CT and MRI
Name 2 cirrhosis severity scoring systems for cirrhosis:
1) MELD score
2) Child-Purgh Score
What does MELD score stand for?
Model for end-stage liver disease
For who and when should the MELD scoring system be used?
in those with compensated cirrhosis every 6 months (NICE)
What are the 5 factors assessed the MELD scoring system?
1) bilirubin
2) creatinine
3) INR
4) sodium
5) dialysis or not
What value does the MELD score formula produce?
3 month mortality as a %
What are the 5 ABCDE factors assessed in the Child-Purgh scoring system?
1) albumin
2) bilirubin
3) clotting (INR)
4) dilation (cirrhosis)
5) encephalopathy
What are the 4 general principles for managing cirrhosis?
1) treating the underlying course (e.g. alcohol, lifestyle, antiviral drugs for hepatitis)
2) monitoring for complications
3) managing complications
4) liver transplant
What is the % 5-year survival rate for cirrhosis?
50%
Name 6 major complications of cirrhosis:
1) hepatocellular carcinoma
2) malnutrition
3) oesophageal varices bleed
4) ascites and spontaneous bacteria peritonitis
5) hepatorenal system
6) hepatic encephalopathy
Describe how cirrhosis can lead to malnutrition:
cirrhosis reduces the amount of protein the liver produces and disrupts the glycogen storage capacity of the liver leading to muscle tissue breakdown.
What two veins does the portal vein branch from?
- superior mesenteric
- splenic veins
Give 3 manifestations of portal hypertension:
1) splenomegaly
2) oesophageal varices
3) caput medusae
Give two prophylactic treatments used to prevent varices from bleeding:
1) non-selective beta blockers e.g. pronanolol
2) variceal band ligation (rubber band wrapped around varices to cut blood flow through the vessels)
Give 3 treatments used for bleeding oesophageal varicies:
1) blood transfusion
2) urgent band ligation
3) vasopressin analogues to cause vasoconstriction and slow bleeding
Name 2 vasopressin analogue drugs:
- teripressin
- somatostatin
Describe the pathophysiology of ascites: (3)
1) portal hypertension causes fluid to leak out of capillaries into the peritoneal cavity
2) the drop in circulating volume causes blood pressure to drop in the kidneys, triggering the RAAS system
3) aldosterone stimulates reabsorption of fluid and sodium in the kidneys which can accumulate in the peritoneal cavity
Give 4 management strategies for ascites:
1) low sodium diet
2) aldosterone antagonists e.g. spironolactone
3) paracentesis (ascitic drain)
4) liver transplant
Name the condition where ascites fluid becomes infected without an identifiable source:
spontaneous bacterial peritonitis
Give 3 symptoms associated with spontaneous bacterial peritonitis:
- fever
- abdominal pain
- ileus (The inability of the intestine to contract normally leading to a build-up of food material.)
What are the two most common organisms found in spontaneous bacterial peritonitis?
- E.coli
- Klebsiella pneumoniae
How is spontaneous bacterial peritonitis treated?
IV broad spectrum antibiotics e.g. piperacillin with tazobactam
What is hepatorenal syndrome?
impaired kidney function caused by changes in blood flow secondary to cirrhosis and portal hypertension
What is hepatic encephalopathy?
a build up of neurotoxic substances such as ammonia that affect the brain, presenting as reduced consciousness and confusion
Give 3 types of management for hepatic encephalopathy?
1) lactulose - to speed up the gut and excrete ammonia
2) antibiotics - to reduce the number of ammonia producing bacteria in the gut
3) nutritional support
What antibiotic is used to treat hepatic encephalopathy and why?
rifaximin (it is poorly absorbed by the gut and so stays in the GI tract for a long time)
