Cirrhosis Flashcards
name the causes of liver cirrhosis
Alcohol-related liver disease
Non-alcoholic fatty liver disease (NAFLD)
Hepatitis B
Hepatitis C
name some of the rare causes of liver cirrhosis
Autoimmune hepatitis
Primary biliary cirrhosis
Haemochromatosis
Wilsons disease
Alpha-1 antitrypsin deficiency
Cystic fibrosis
Drugs (e.g., amiodarone, methotrexate and sodium valproate
What are some of the examination findings for liver cirrhosis
Cachexia (wasting of the body and muscles)
Jaundice caused by raised bilirubin
Hepatomegaly (enlargement of the liver)
Small nodular liver as it becomes more cirrhotic
Splenomegaly due to portal hypertension
Spider naevi (telangiectasia with a central arteriole and small vessels radiating away)
Palmar erythema caused by elevated oestrogen levels
Gynaecomastia and testicular atrophy in males due to endocrine dysfunction
Bruising due to abnormal clotting
Excoriations (scratches on the skin due to itching)
Ascites (fluid in the peritoneal cavity)
Caput medusae (distended paraumbilical veins due to portal hypertension)
Leukonychia (white fingernails) associated with hypoalbuminaemia
Asterixis (“flapping tremor”) in decompensated liver disease
what are some of the non-invasive liver screenings
Ultrasound liver (used to diagnose fatty liver)
Hepatitis B and C serology
Autoantibodies (autoimmune hepatitis, primary biliary cirrhosis and primary sclerosing cholangitis)
Immunoglobulins (autoimmune hepatitis and primary biliary cirrhosis)
Caeruloplasmin (Wilsons disease)
Alpha-1 antitrypsin levels (alpha-1 antitrypsin deficiency)
Ferritin and transferrin saturation (hereditary haemochromatosis)
name relevant autoantibodies associated with liver diseases
Antinuclear antibodies (ANA)
Smooth muscle antibodies (SMA)
Antimitochondrial antibodies (AMA)
Antibodies to liver kidney microsome type-1 (LKM-1)
liver function tests may be normal in cirrhosis, however in decompensated cirrhosis all the liver markers come deranged. True or false?
True
name some finding in the blood tests for cirrhosis
Bilirubin
Alanine transaminase (ALT)
Aspartate transferase (AST)
Alkaline phosphatase (ALP)
Low albumin due to reduced synthetic function of the liver
Increased prothrombin time due to reduced synthetic function of the liver (reduced production of clotting factors)
Thrombocytopenia (low platelets) is a common finding and indicates more advanced disease
Hyponatraemia (low sodium) occurs with fluid retention in severe liver disease
Urea and creatinine become deranged in hepatorenal syndrome
Alpha-fetoprotein is a tumour marker for hepatocellular carcinoma
what is the first-line investigation for assessing fibrosis in non-alcoholic fatty liver disease.
ELF TEST: 10.51 OR ABOVE- ADVANCED FIBROSIS
UNDER 10.51- UNLIKELY AF (NICE RECOMMNEDS RECHECKING EVERY 3 YEARS IN NAFLD)
ELF Blood tests can be used to investigate fibrosis in patients with other causes of liver diseases. True or False?
False. Can only be used to assess fibrosis in NAFLD.
Ultrasound is used to diagnose non-alcoholic fatty liver disease (once other causes are excluded). True or False
True
In liver cirrhosis, an ultrasound may show:
Nodularity of the surface of the liver
A “corkscrew” appearance to the hepatic arteries with increased flow as they compensate for reduced portal flow
Enlarged portal vein with reduced flow
Ascites
Splenomegaly
Nodularity,
A “corkscrew” appearance
Enlarged portal vein
Ascites
Splenomegaly
may indicate:
Liver cirrhosis
what are the Ultrasound findings for hepatocellular carcinoma
alpha-fetoprotein
name the investigation used to assess the stiffness of liver using high-frequency sound waves. What does the test show?
what group of patients does this test aim at?
Transient Elastography (‘FibroScan’)
It helps determine the degree of fibrosis (scarring) to test for liver cirrhosis. It is used in patients at risk of cirrhosis:
Alcohol-related liver disease
Heavy alcohol drinkers (men drinking more than 50 units or women drinking more than 35 units per week)
Non-alcoholic fatty liver disease and advanced liver fibrosis (score 10.51 or more on the ELF blood test)
Hepatitis C
Chronic hepatitis B
what test can be used to confirm the diagnosis of cirrhosis
Liver biopsy
what other investigations are used in liver disease
Endoscopy can be used to assess for and treat oesophageal varices when portal hypertension is suspected.
CT and MRI can be used to look for hepatocellular carcinoma, hepatosplenomegaly, abnormal blood vessel changes and ascites.
Liver biopsy can be used to confirm the diagnosis of cirrhosis.
which investigation is to look for hepatocellular carcinoma, hepatosplenomegaly, abnormal blood vessel changes and ascites.
CT AND MRI
which investigation is used to assess and treat oesophageal varices when portal hypertension is suspected?
Endoscopy.
what Tool is used to monitor patients with compensated cirrhosis and how often is it investigated. what are the criteria ?
NICE recommend using the MELD (Model for End-Stage Liver Disease) score every 6 months in patients with compensated cirrhosis. The formula considers the bilirubin, creatinine, INR and sodium and whether they require dialysis, giving an estimated 3-month mortality as a percentage.
what tool is used to assess the severity and prognosis of cirrhosis? Name the factors included.
The Child-Pugh scores uses 5 factors to assess the severity of cirrhosis and the prognosis. Each factor is considered and scored 1, 2 or 3. The minimum overall score is 5 (scoring 1 for each factor), and the maximum is 15 (scoring 3 for each factor). You can remember the features with the “ABCDE” mnemonic:
A – Albumin
B – Bilirubin
C – Clotting (INR)
D – Dilation (ascites)
E – Encephalopathy
what are the principles of management for cirrhosis
Treating the underlying cause
Monitoring for complications
Managing complications
Liver transplant
Stop drinking alcohol
Lifestyle changes for non-alcohol fatty liver disease
Antiviral drugs for hepatitis C
Immunosuppressants for autoimmune hepatitis
what tools are used to monitor complications of cirrhosis?
MELD score every 6 months
Ultrasound and alpha-fetoprotein every 6 months for hepatocellular carcinoma
Endoscopy every 3 years for oesophageal varices
what tool can be used to for compensated cirrhosis?
MELD score
when is liver transplant considered for decompensated liver disease
A– Ascites
H – Hepatic encephalopathy
O – Oesophageal varices bleeding
Y – Yellow (jaundice)
name some complications and prognosis of cirrhosis. What tools can be used (2)
MELD- every 6 months
Child-Pugh score
Malnutrition and muscle wasting
Portal hypertension, oesophageal varices and bleeding varices
Ascites and spontaneous bacterial peritonitis
Hepatorenal syndrome
Hepatic encephalopathy
Hepatocellular carcinoma
How does malnutrition affect cirrhosis?
name the management.
Muscle wasting- due to loss of appetite.
protein metabolism is affected.
liver is unable to store glycogen
inadequate ability for maintaining muscle tissue and muscle tissue is broken down for use as fuel.
- regular meals
- high protein and calorie intake
reduced sodium intake to minimise fluid retention
avoiding alcohol
name the veins involved in delivering blood to the liver
superior mesenteric and splenic veins (portal veins)
what is portal hypertension
liver cirrhosis can increase the resistance of blood flow into the liver and as a result there is increase pressure on the portal system and the back pressure of blood may result in splenomegaly.
back pressure in the portal system can affect which site.
where collaterals form between the portal and systemic venous systems. These collaterals can occur at several locations, notably the:
Distal oesophagus (oesophageal varices)
Anterior abdominal wall (caput medusae)
Varices are asymptomatic until they start bleeding. True or false
True
what are varices
enlarged or dilated blood vessels in the oesophagus connecting the portal and systemic circulations. they form due to poor hypertension as a result of cirrhosis, resistance to portal blood flow and increased portal venous blood flow.
stable oesophagus varices require vasopressins, prohylactic boras-spectrum ABX.
True or false
False.
Prophylaxis of bleeding in stable oesophageal varices involves:
Non-selective beta blockers (e.g., propranolol) first-line
Variceal band ligation (if beta blockers are contraindicated)
what are the prophylaxis used for bleeding in stable O.Varices
Non-selective beta blockers (e.g., propranolol) first-line
Variceal band ligation (if beta blockers are contraindicated)
name the management for bleeding Oesophageal Varices
Immediate senior help
Consider blood transfusion (activate the major haemorrhage protocol)
Treat any coagulopathy (e.g., with fresh frozen plasma)
Vasopressin analogues (e.g., terlipressin or somatostatin) cause vasoconstriction and slow bleeding
Prophylactic broad-spectrum antibiotics (shown to reduce mortality)
Urgent endoscopy with variceal band ligation
Consider intubation and intensive care
Other options to control the bleeding include:
Sengstaken-Blakemore tube (an inflatable tube inserted into the oesophagus to tamponade the bleeding varices)
Transjugular intrahepatic portosystemic shunt (TIPS)
Describe the process of TIPS. what are the indications (2)
A wire under x-ray is inserted into the jugular vein down the vena cava and into the liver via the hepatic vein. A bypass is made from the hepatic vein and portal vein so the blood flow directly to relieve the pressure in the portal system.
- Bleeding oeasophageal Varices
- Refractory Ascites
Describe the process of ascites in cirrhosis.
- Fluid in the peritoneal cavity. Increased pressure in the portal system causes fluid to leak out of the capillaries in the liver and abdo organs into the peritoneal cavity.
- The drop in the circulating volume results in a lower blood pressure in the kidneys. RAAS is activated therefore more absorption of fluid in the kidney and sodium retention.
Ascites is exudative in liver diseases. True or false.
Explain
False.
Ascites is the leakage of fluid from the capilaries into the peritoneal cavity as a result of increased pressure in portal system. damaged liver means there is inadequate protein synthesis like albumin therefore oncotic pressure decreases, leading to fluid in the abdomen.
Name the management for Ascites (6)
Low sodium diet
Aldosterone antagonists (e.g., spironolactone)
Paracentesis (ascitic tap or ascitic drain)
Prophylactic antibiotics (ciprofloxacin or norfloxacin) when there is <15 g/litre of protein in the ascitic fluid
Transjugular intrahepatic portosystemic shunt (TIPS) is considered in refractory ascites
Liver transplantation is considered in refractory ascites
Explain spontaneous Bacterial peritonitis
Spontaneous bacterial peritonitis (SBP) occurs in 10-20% of patients with ascites. It has a mortality of 10-20%. It involves an infection developing in the ascitic fluid and peritoneal lining without a clear source of infection (e.g., an ascitic drain or bowel perforation).
Spontaneous bacterial peritonitis can be asymptomatic. what are the presenting features: (5)
Fever
Abdominal pain
Deranged bloods (raised WBC, CRP, creatinine or metabolic acidosis)
Ileus (reduced movement in the intestines)
Hypotension
IN spontaneous bacterial peritonitis is the BP low or high
low.
The infection can cause systemic inflammatory response where it can lead to vasodilation and increased vascular permeability resulting in decreased blood pressure.
septic shock: overwhelms the body’s ability to regulate BP.
cirrhosis itself can cause vasodilation and reduced systemic vascular resistance leading to hypo.
name two organism associates with Spontaneous Bacterial Peritonitis
Escherichia coli
Klebsiella pneumoniae
what is the management for Spontaneous Bacterial Peritonitis
Taking a sample of ascitic fluid for culture before giving antibiotics
Intravenous broad-spectrum antibiotics according to local policies (e.g., piperacillin with tazobactam)
Describe Hepatorenal syndrome associated with cirrhosis
Impaired kidney function caused by changes in the blood flow to the kidney relating to liver cirrhosis and portal hypertension.
The exact pathophysiology is still being debated. A simplified version is that portal hypertension causes the portal vessels to release vasodilators, which cause significant vasodilation in the splanchnic circulation (the vessels supplying the gastrointestinal organs). Vasodilation leads to reduced blood pressure. The kidneys respond to the reduced pressure by activating the renin-angiotensin-aldosterone system, which leads to vasoconstriction of the renal vessels. Renal vasoconstriction combined with low systemic pressure results in the kidneys being starved of blood and significantly reduced kidney function.
Hepatorenal syndrome has a poor prognosis unless the patient has a liver transplant.
Describe Hepatic Encephalopathy associated with cirrhosis
Hepatic encephalopathy is also known as portosystemic encephalopathy. It is thought to be caused by the build-up of neurotoxic substances that affect the brain.
when proteins are broken down by intestinal bacteria it releases ammonia which is absorbed by the intestine.
what are the two reason for ammonia to build up in blood of patients with cirrhosis
Firstly, the liver cells’ functional impairment prevents them from metabolising the ammonia into harmless waste products. Secondly, collateral vessels between the portal and systemic circulation mean that the ammonia bypasses the liver and enters the systemic system directly.
