Cirrhosis

Question 1

What are the four most common causes of cirrhosis?

Answer 1

ALD

Non-Alcoholic fatty liver disease

Hep B

Hep C

Question 2

What are the less common causes of cirrhosis?

Answer 2

Autoimmune hepatitis 
Primary biliary cirrhosis 
Haemochromatosis
Wilson’s disease 
Alpha 1 antitrypsin deficiency 
CF
Meds e.g amioderone, methotrexate, sodium valproate

Question 3

What are the signs of cirrhosis?

Answer 3

Jaundice 
Hepatomegaly 
Splenomegaly 
Spider Naevi
Palmar erythema
Gynaecomastia
Bruising
Ascites
Caput medusae
Asterixis

Question 4

What basic bloods are done for cirrhosis?

Answer 4

LFT’s can be normal, but if decompensated then deranged markers

Albumin and PTT

U+E shows hyponatraemia, deranged urea and creatinine (hepatorenal syndrome)

Alpha fetoprotein to check for hepatocellular carcinoma

Question 5

What specific blood test not available in all areas can detect degree of fibrosis?

Answer 5

Enhanced liver fibrosis blood test

From 7.7-mild fibrosis

To over 9.8 which is severe fibrosis

Question 6

What is the Child-Pugh score used for and what are the score ranges?

Answer 6

Indicates severity of cirrhosis and prognosis

Minimum score is 5, maximum 15

Question 7

What is the general maintenance management of cirrhosis?

Answer 7

US and AFP every 6 months for HCC

Endoscopy every 3 years in patients without varices

High protein low sodium diet

MELD score every 6 months

Consideration for liver transplant

Managing complications

Question 8

Complications of cirrhosis?

Answer 8

Malnutrition

Portal hypertension, varices, varices bleeding

Ascites and spontaneous bacterial peritonitis

Hepato-renal syndrome

Hepatic encephalopathy

Hepatocellular carcinoma

Question 9

What is the treatment for stable varices?

Answer 9

Propanol

Elastic band ligation

Injection of sclerosant

TIPS (last resort to divert pressure away from portal system)

Question 10

What is the treatment for bleeding varices?

Answer 10

Vasopressin analogues (Terlipressin)

Vitamin k and FFP to correct coagulopathy

Prophylactic broad spectrum antibiotics

Consider intubation and intensive care

Urgent endoscopy (injection of sclerosant)

Sengstaken-Blakemore tube when endoscopy fails

Question 11

What is the management of ascites?

Answer 11

Low sodium diet

Anti-Aldosterone diuretics (spironolactone)

Paracentesis

Prophylactic antibiotics (cipro or norfloxacin)

Consider TIPS in refractory ascites

Consider transplantation in refractory ascites

Question 12

What is the presentation of spontaneous bacterial peritonitis (SBP)?

Answer 12

Can be asymptotic

Fever

Abdo pain

Deranged bloods (wbc, CRP, creatinine or metabolic acidosis)

Ileus

Hypotension

Question 13

What are the most common organisms that cause SBP?

Answer 13

E. coli

Klebsiella pneumoniae

Gram positive cocci (staphylococcus and enterococcus)

Question 14

What is the management of SBP?

Answer 14

Take an ascitic culture prior to giving antibiotics

Usually treated with IV cephalosporin such as cefotaxime

Question 15

How does hepatic encephalopathy present?

Answer 15

Reduced consciousness

Confusion

Chronically presents with changes to personality, memory and mood

Question 16

What are the precipitating factors to hepatic encephalopathy?

Answer 16

Constipation

Electrolyte disturbances

Infection

GI bleed

High protein diet

Medications (particularly sedatives)

Question 17

What is the management of hepatic encephalopathy?

Answer 17

Laxatives (to clear ammonia producing bacteria from the gut)

Antibiotics (rifaximin) reduces number of ammonia producing bacteria in gut, rifaximin stays in gut for a long time so good

Nutritional support through an NG tube

Question 18

When analysing ascitic fluid, the serum-ascites albumin gradient (SAAG) can be measured. Over what value should the gradient be to indicate the cause of the ascites as portal hypertension?

Answer 18

Over 11g/L