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Y3M - Gastro > Cirrhosis > Flashcards

Cirrhosis Flashcards

1
Q

What is cirrhosis?

A

Irreversible liver damage.

There is histological loss of normal architecture with bridging fibrosis and nodular regeneration.

There are many causes of liver cirrhosis, however the end result is always the same.

This means that treatment and complications will be the same regardless of aetiology.

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2
Q

Causes of cirrhosis.

A

Most often due to chronic alcohol abuse, HBV or HCV infection.

Can also be;

Genetics - haemochromatosis, alpha1-antitrypsin def., Wilson’s disease

Hepatic vein evet (Budd-Chiari)

Non-alcoholic steatohepatitis

Autoimmune - PBC, PSC

Drugs like amiodarone, methyldopa and methotrexate

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3
Q

Signs of cirrhosis.

A

Ascites

Splenomegaly

Leuconychia - due to hypoalbuminaemia

Terry’s nails - white proximally but distal 1/3 reddened by telangiectasias

Clubbing

Palmar erythema

Dupuytren’s contracture

Spider naevi

Xanthelasma

Gynaecomastia

Atrophic testes

Loss of body hair

Parotid enlargement

Hepatomegaly

Small liver in late disease

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4
Q

Blood investigations in cirrhosis.

A

LFTs

Albumin

PT/INR

WCC

Platelets

Ferritin

Iron

Serology for hepatitis

Immunoglobulins

Autoantibodies (ANA, AMA, SMA)

Alpha-feto protein

Ceruloplasmin if less than 40 yo

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5
Q

Other investigations of liver cirrhosis.

A

Liver ultrasound+duplex

MRI

Ascitic tap

Liver biopsy

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6
Q

When should you suspect cirrhosis?

A

In any patient with chronic liver disease who has thrombocytopenia or clinical stigmata of chronic liver disease.

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7
Q

Findings on liver ultrasound and duplex.

A

May show a small liver or hepatomegaly depending on how far gone the disease is.

Splenomegaly

Coarse texture of liver

Nodularity

Focal liver lesions

Hepatic vein thrombus

Reversed flow in the portal vein

Ascites

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8
Q

Findings on MRI.

A

Increased caudate lobe size

Smaller islands of regenerating nodules

Presence of the right posterior hepatic notch are more frequent in alcoholic cirrhosis than in virus-induced.

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9
Q

What is sometimes preferred instead of imaging?

A

Fibroscan.

It is quicker and more specific and can be performed in the clinic room.

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10
Q

Diagnostis of cirrhosis.

A

Clinical history

History of chronic liver disease

Findings on USS and fibroscan

Evidence of varices on endoscopy.

Liver biopsy is definitive but usually not needed because at this time it is unlikely that this will give you any clue as to the underlying pathology.

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11
Q

What should be screened for in cirrhosis?

A

Varices

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12
Q

Why is it important to screen for varices in cirrhosis?

A

So prophylaxis can be introduced in order to decrease the risk of bleeding

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13
Q

Complications of cirrhosis.

A

Can be divided into hepatic failure and portal hypertension.

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14
Q

Complications of cirrhosis in regards to hepatic failure.

A

Coagulopathy

Encephalopathy

Hypoalbuminaemia leading to oedema

Sepsis

Spontaneous bacterial peritonitis

Hypoglycaemia

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15
Q

Complications of cirrhosis in regards to portal hypertension.

A

Ascites

Splenomegaly

Portosystemic shunt including oesophageal varices, caput medusae and anorectal varices.

Cirrhosis (not related to portal HTN) can also lead to hepatocellular carcinoma.

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16
Q

When should an ascitic tap be done?

A

If there is suspicion of peritonitics.

>250/mm3 of neutrophils indicates SBP.

17
Q

General management of cirrhosis.

A

Good nutrition

Alcohol abstinence

Avoid NSAIDs, sedatives and opiates

Colestyramine can help pruritus

18
Q

Screening of hepatocellular carcinoma in cirrhosis.

A

Ultrasound +/- alpha-fetoprotein every 6 months.

19
Q

Treatment of ascites in cirrhosis.

A

Fluid restriction ( < 1.5L/d)

Low salt diet

Spironolactone

Chart daily weight and aim for weight loss of half a kg or less a day.

Therapeutic paracentesis with concomitant albumin infusion may be required if the ascites is resistant.

20
Q

Treatment of SBP in cirrhosis.

A

Must be considered in any patient with ascites who deteriorates suddenly.

The common organisms are E. coli, Klesbiella and streptococci.

Piperacillin with tazobactam 4.5g/8h for 5d should be given until sensitvities are known.

Give prophylaxis for high-risk patients e.g. ciprofloxacin 500mg PO daily.

21
Q

Treatment of encephalopathy in cirrhosis.

A

Lactulose and rifaximin can be given as prophylaxis.

22
Q

Prognsosis of cirrhosis.

A

5 yr survival is around 50%

Poor prognostic indicators include encephalopathy, hyponatremia and hypoalbuminaemia as well as increased INR.

23
Q

What is the only definitive treatment for cirrhosis?

A

Liver transplantation.

24
Q

Acute indications of liver transplant.

A

Acute liver failure meeting King’s College Criteria

25
Q

Chronic indication of liver transplant.

A

Advanced cirrhosis of any cause

Hepatocellular cancer

26
Q

What is the first line recommended investigation in assessing fibrosis in non-alcoholic fatty liver disease?

A

Enhanced Liver Fibrosis (ELF) blood test

It measures three markers;

HA

PIIINP

TIMP-1

Gives a scoring that indicates fibrosis of the liver.

27
Q

What is fibroscan?

A

Checks the elasticity of the liver by sending high frequency sound waves into the liver.

It helps assess the degree of cirrhosis. This is called “transient elastography” and should be used to test for cirrhosis.

28
Q

What patients should be scanned with fibroscan every 2 years?

A

NICE recommend retesting every 2 years in patients at risk of cirrhosis:

Hep C

Heavy alcohol drinkers (men drinking > 50 units or women drinking > 35 units per week)

Diagnosed alcoholic liver disease

Non alcoholic fatty liver disease and evidence of fibrosis on the ELF blood test

Chronic hepatitis B (although they suggest yearly for hep B)

29
Q

What scoring systems are used in liver cirrhosis

A

Child-Pugh score

MELD score

30
Q

Explain Child-Pugh score

A

Indicates severity of disease and prognosis

31
Q

Explain MELD score

A

Suggested by NICE to be done every 6 months in patients with compensated liver cirrhosis.

It takes into account bilirubin, INR and sodium.

It tries to figure out whether the patient needs dialysis or not.

It gives a percentage of 3 month mortality and helps guide referral for liver transplant.

32
Q

General management of liver cirrhosis

A

Ultrasound and alpha-fetoprotein every 6 months for hepatocellular carcinoma

Endoscopy every 3 years in patients without known varices

High protein, low sodium diet

MELD score every 6 months

Consideration of a liver transplant

Managing complications

33
Q

Treatment of stable varices

A

Propranolol reduces portal hypertension by acting as a non-selective beta blocker

Elastic band ligation of varices

Injection of sclerosant (less effective than band ligation)

TIPSS

34
Q

Management of bleeding oesophageal varices

A

Resuscitation

Terlipressin cause vasoconstriction and slow bleeding in varices

Correct any coagulopathy with vitamin K and fresh frozen plasma (which is full of clotting factors)

Giving prophylactic broad spectrum antibiotics has been shown to reduce mortality

Consider intubation and intensive care as they can bleed very quickly and become life threateningly unwell

Urgent endoscopy

Injection of sclerosant into the varices can be used to cause “inflammatory obliteration” of the vessel

Elastic band ligation of varices

Sengstaken-Blakemore Tube is an inflatable tube inserted into the oesophagus to tamponade the bleeding varices. This is used when endoscopy fails.

35
Q

What is an orthotopic liver transplant

A

When an entire liver is transplanted from a deceased patient to a recipient it is known as an orthotopic transplant.

36
Q

Factors suggesting unsuitability for liver transplantation.

A

Significant co-morbidities (e.g. severe kidney or heart disease)

Excessive weight loss and malnutrition (suggesting they won’t tolerate surgery)

Active hepatitis B, hepatitis C or other infection

End-stage HIV

Active alcohol use (generally 6 months of abstinence is required)

37
Q

Post-transplantation care.

A

Patients will require lifelong immunosuppression (e.g. steroids, azathioprine and tacrolimus)

Avoid alcohol and smoking

Treating opportunistic infections

Monitoring for disease recurrence (i.e. of hepatitis or primary biliary cirrhosis)

Monitoring for cancer as there is a significantly higher risk in immunosuppressed patients

38
Q

Monitoring for evidence of liver transplant rejection.

A

Abnormal LFTs

Fatigue

Fever

Jaundice

Y3M - Gastro (21 decks)

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