Cirrhosis

Question 1

What are the most common causes of liver cirrhosis?

Answer 1

Alcohol related liver disease
NAFLD
Hepatitis B
Hepatitis C

Question 2

What are the rarer causes of cirrhosis?

Answer 2

Autoimmune hepatitis
Primary biliary cirrhosis
Haemochromatosis
Wilsons disease
Alpha-1 antitrypsin deficiency
Cystic fibrosis

Question 3

What medications can cause cirrhosis?

Answer 3

Methotrexate
Isoniazid
Methyldopa
Amiodarone

Question 4

What clinical signs may be seen in cirrhosis?

Answer 4

Cachexia
Jaundice
Hepatomegaly
Splenomegaly due to portal hypertension
Spider naevi
Palmar erythema
Gynaecomastia
Bruising due to abnormal clotting
Ascites
Caput medusae
Asterixis

Question 5

What is part of a non-invasive liver screen?

Answer 5

Ultrasound liver
Hepatitis B and C serology
Autoantibodies
Immunoglobulins
Caeruloplasmin (Wilson’s disease)
Alpha-1 antitrypsin levels
Ferritin and transferrin saturation

Question 6

What autoantibodies are relevant to liver disease?

Answer 6

Antinuclear antibodies (ANA)
Smooth muscle antibodies (SMA)
Antimitochondrial antibodies (AMA) - primary biliary cirrhosis
Antibodies to liver kidney microsome type 1 (LKM-1)

Question 7

What other blood results might be seen in cirrhosis?

Answer 7

Deranged LFTs
- Bilirubin, ALT, AST, ALP
Low albumin
Increased PTT
Thrombocytopenia
Hyponatraemia due to fluid retention
Alpha-fetoprotein - hepatocellular carcinoma

Question 8

What is the enhanced liver fibrosis test?

Answer 8

First line investigation for assessing cirrhosis in NAFLD. It uses three markers to determine the degree of fibrosis:
- 10.51 or above - advanced fibrosis
- Under 10.51 - unlikely advanced fibrosis

Question 9

What might an ultrasound show in liver cirrhosis?

Answer 9

Nodularity of the surface of the liver
Corkscrew appearance of the hepatic arteries
Enlarged portal vein
Ascites
Splenomegaly

Question 10

What is transient elastography?

Answer 10

High frequency sound waves help to determine the degree of fibrosis to test for cirrhosis.

Used in the following patients:
- Alcohol related liver disease
- Heavy alcohol drinkers
- NAFLD and advanced liver cirrhosis on ELF blood test
- Hepatitis C
- Chronic hepatitis B

Question 11

What is the Child-Pugh score?

Answer 11

Used 5 factors to assess the degree of fibrosis - each is scored on a scale of 1-3
- A - albumin
- B - bilirubin
- C - clotting
- D - dilation
- E - encephalopathy

Question 12

What monitoring do patients with cirrhosis have?

Answer 12

MELD score every 6 months
Ultrasound and alpha-fetoprotein every 6 months
Endoscopy every 3 years

Question 13

What features would suggest the need for liver transplantation?

Answer 13

A - ascites
H - hepatic encephalopathy
O - oeseophageal varices bleeding
Y - yellow (jaundice)

Question 14

What are the complications of liver cirrhosis?

Answer 14

Malnutrition
Portal hypertension
Oesophageal varices and bleeding varices
Ascites
Spontaneous bacterial peritonitis
Hepatorenal syndrome
Hepatic encephalopathy
Hepatocellular carcinoma

Question 15

How does portal hypertension occur in cirrhosis?

Answer 15

Liver cirrhosis increases resistance to blood flow in the liver
- There is then increased back pressure on the portal system
- The back pressure of blood can result in splenomegaly

Question 16

What are the other complications of portal hypertension?

Answer 16

Splenomegaly
Oesophageal varices
Caput medusae - dilated vessels in the anterior abdominal wall

Question 17

What is the prophylaxis of bleeding of oeseophageal varices?

Answer 17

Non-selective beta blockers - propranolol
Variceal band ligation - if beta blockers are contraindicated

Question 18

What is spontaneous bacterial peritonitis?

Answer 18

Infection developing in the ascitic fluid and peritoneal lining, without a clear source of infection

Question 19

What are the presenting features of spontaneous bacterial peritonitis?

Answer 19

Fever
Abdominal pain
Ileus
Hypotension

Question 20

What organisms commonly cause spontaneous bacterial peritonitis?

Answer 20

E. coli
Klebsiella pneumoniae

Question 21

What is the management of spontaneous bacterial peritonitis?

Answer 21

Ascitic fluid sample and culture before antibiotics
IV broad-spectrum antibiotics - piperacillin with tazobactam

Question 22

What is the pathophysiology of hepatorenal syndrome?

Answer 22

• Portal hypertension causes the portal vessels to release vasodilators
• Vasodilation leads to reduced blood pressure in the abdominal blood vessels
• Kidneys activate RAAS in response to reduced blood pressure
• This leads to vasoconstriction of the renal vessels, and renal hypoperfusion

Question 23

What is hepatic encephalopathy?

Answer 23

Ammonia, which is neurotoxic, is unable to be metabolised into waste products

Question 24

What are the risk factors for hepatic encephalopathy?

Answer 24

Constipation
Dehydration
Electrolyte disturbance
Infection
GI bleeding
High protein diet

Question 25

What is the management of hepatic encephalopathy?

Answer 25

Lactulose
Antibiotics e.g rifaximin, to reduce the number of intestinal bacteria producing ammonia
Nutritional support