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GI > Cirrhosis and Liver Failure > Flashcards

Cirrhosis and Liver Failure Flashcards

1
Q

What causes cirrhosis

A

Common
Chronic Alcohol
NAFLD
Hep B+C

Rarer
Autoimmune 
Genetic - A1, haematochromatosis, Wison
PBC
PSC
CF
Drugs
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2
Q

What drugs are likely to lead to cirrhosis

A 
Methotrexate
Methyldopa
Amidarone
Izonazid 
Sodium valproate
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3
Q

What are the signs of a cirrhotic liver

A 
Fatigue
Anorexia
Nausea 
Abdo pain 
Clubbing
Spider naevi
Palmar erythema
Leukonychia
Dupuytren
Gynaecomastia
Loss body hair
Parotid enlargement
Hepatomegaly (usually small in late disease)
Splenomegaly due to portal  
Decompensated liver
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4
Q

What is the most sensitive marker of CLD

A

Thrombocytopenia

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5
Q

What increases risk of decompensation

A 
Dehydration
Infection
Alcohol
Constipation 
Occult GI bleed
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6
Q

How do you Dx cirrhosis

A

Blood
Fibroscan - transient elastogrpahy = 1st line
Liver USS and doppler
Liver biopsy

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7
Q

Who gets fibroscan to asses

A

Scores suggest need
All Dx of alcoholic liver disease
All Dx of Hep B and C

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8
Q

How do you treat cirrhosis

A 
Treat cause 
Nutrition
Stop alcohol
Avoid bad drugs
Cholestraymine to bind bile acid to reducer itch 
Treat complications
Monitor 
Transplant is only definite Rx (advanced or HCC)
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9
Q

How do you screen cirrhotic

A

Blood, ALP and USS every 6 months
CT if suspect
Endoscopy for varices if Dx and also every 3 years

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10
Q

What are complications of cirrhosis / signs of decompensation

Decompensation when liver no longer able to do. job

A 
Liver failure
Jaundice 
Ascites
Varices 
Splenomegaly
Pruritus 
Bruising due to clotting 
Encephalopathy 
SPB
Hepatorenal
HCC
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11
Q

What causes acute liver failure

A

Drug overdose
Alcohol
Viral hepatitis - any cause
Acute fatty liver of pregnancy

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12
Q

What is chronic liver failure

A

> 6 months

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13
Q

What drugs cause liver failure

A 
Hepatitis Pattern 
Paracetamol
Methotrexate
Methydopa 
Amidarone
Azathioprine
Alcohol
Anti-TB
Statin - regular LFT 
MAOI

Obstructive
OCP
Ax - tetracycline
Steroid

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14
Q

What is the most precipitating factor for liver failure

A

Cirrhosis

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15
Q

What does acute liver failure present with

A

Jaundice due to bilirubin
Encephalopathy - flap (Astrexis) / confusion / fetor hepaticus
Coagulopathy
KEY TO DX

Abdominal pain
Pruritus
Hypoalbumin  - oedema
Sepsis
SBP
Seizures
Hepatorenal = very common
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16
Q

What does chronic liver failure have and what are they

A

Decompensated Sx

  • Jaundice
  • Portal hypertension
  • Ascites
  • Varices
  • Encephalopathy
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17
Q

How do you Dx Liver failure

A 
FBC, U+E, LFT, clotting, glucose, albumin 
Liver screen
Assess drugs
Blood / urine culture 
Ascitic tap
USS
CXR
Doppler
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18
Q

How do you differentiate from chronic stable liver failure

A

Encephalopathy
High bilirubin
High PT

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19
Q

How do you treat acute liver failure

A 
Beware of sepsis / hypoglycaemia / bleed / encephalopathy
Monitor for this
Monitor vital sign
Catheter for fluid output
Daily blood
PPI for stress ulceration
Avoid drugs that can worsen
Paprinxes / nutrition
Vit K / platelet / FFP and RBC as needed
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20
Q

What are the complications of liver failure

A 
Hepatorenal syndrome
Oedema
Ascites
Bleeding
Infection
Decreased glucose
Encephalopathy
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21
Q

What suggests poor prognosis in liver failure

A

Grade 4 encephalopthy
Albumin <30
INR increased
Drug induced

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22
Q

What causes encephalopathy

A 
Ammonia builds up as can't be cleared
Passes into brain 
Converted to glutamine by atrocytes
Osmotic shift
Oedema
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23
Q

When is encephalopathy seen

A

More in acute liver but can be seen in chronic

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24
Q

What are the symptoms of encephalopathy

A 
Grade 1 
Mood / sleep 
Confusion - may present subtle with this in chronic 
Poor concentration
Dyspraxia

Grade 2
Drowsy / decreased GCS
Slurred speech
Atrexis - liver flap

Grade 3
Seizures
Fetar hepaticas
Stupor
Apraxia

Grade 4
Coma

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25
Q

What worsens / precipitates encephalopathy

A 
Infection
GI bleed
Constipation / dehydration
Drugs - diuretic/. sedative 
Hypokalaemia 
Renal failure
Post TIPS
26
Q

How do you treat and what must you exclude

A

Treat cause
Exclude bleed / infection / hypoglycaemia
Avoid sedative
Raise head
Correct electrolyte
LACTULOSE = traps NH4 and clears from gut before it is absorbed
Ax - Rifaximin - decrease NH4 forming bacteria
Nutritional support
IV mannitol to reduce oedema
Liver transplant in selected

27
Q

Ddx of encephalopathy

A

Sepsis
Hypoglycaemia
Trauma

28
Q

What is hepatorenal syndrome

A

Chronic liver failure / cirrhosis leads to acute renal failure due to
Abnormal haemodynamic response
Splancnic and systemic vasodilation = hypotension
Renal constriction due to activation of RAAS
Type 1
- Acute process e.g. GI bleed
- <2 weeks
Type 2
- Slower process, gradual decline in renal
- Usually in combination with refractory ascites

Leads to
Renal failure / rapid rise in creatinine
Cirrhosis
Ascites

29
Q

How do you treat hepatorenal

A

Fatal within a week unless transplant performed
Terlipressin (vasopressin) = constriction
Volume expansion with 20% albumin
Shunt
Haemodialysis
TIPS
Transplant (often too unwell)

30
Q

What causes ascites with SAAG (serum albumin ascites gradient) >11

SAAG = (Serum albumin) - (ascites albumin)

> 11

  • Transudate
  • Due to pressure pushing fluid through capillary so only fluid in ascites so big difference)
A

Indicates portal hypertension of different causes
Cirrhosis - leads to fluid leaking out, drop in BP leads to activation of renin and aldosterone
Hepatitis
CCF
Liver met
Portal vein thrombosis
Venous occlusion - Budd chiari

31
Q

What causes ascites <11

Exuate
Epithelial damage so albumin leaks out

A 
Periotneal cause 
Bowel obstruction
Lymphatic leak
Pancreatic malignancy or pancreatitis 
TB
Peritoneal cancer
32
Q

How do you Dx ascites and other investigations you would do

A 
FBC, U+E, LFT, CRP, TB
May do tumour marker - Ca-125, Ca19-19 
USS abdo 
Ascitic tap of fluid - cytology, culture, albumin 
- Cell count - WCC (high in SBP and TB) 
- Glucose 
= Low in TB / malignancy 
- Amylase 
= High in pancreatitis 
- Biochemistry - inc albumin + protein
 = Protein low in SBP / TB 
- C+S, gram stain 
- Cytology

Can do CT /MRI

33
Q

How do you treat ascites

A 
Reduce Na
Fluid restrict if Na low 
Spirnolactone - aldosterone antagonist (MASSIVE DOSE) to counteract the deranged renin-angiotensin  
Paracentesis 
Albumin infusion after (prevent shift) 
Prophylactic Ax to redue SPB if protein <15g or previous SBP / high child-pugh 
TIPS / transplant if refractory 
Other diuretics if unresponsive
34
Q

What antibiotic

A

Ciprofloxacin to ascites resolves

Ceftaxime if SPB

35
Q

How does malignancy cause ascites

A

Decreased resorption and increased fluid

36
Q

What is the differential of ascites

A

Secondary peritonitis
Bowel obstruction
Haemoperitoneum - trauma

37
Q

What is SPB

A

Inflammation of ascites
High neutrophil >25 (Calculate % of WCC)
Low protein <25

38
Q

What organisms common in SPB

A

E.coli = most common
Klebsiella
Strep pneumonia if gram V+e

39
Q

When should you consider SPB

A 
Any patient with ascites who deteriorates suddenly even if no Hx ascites 
Fever
Abdo pain  / guarding 
Increased WCC, CRP, metabolic acidosis
Ileys
Hypotension
40
Q

Who is most at risk of SPB

A

Liver cirrhosis
Alcohol = poor
Portal hypertension

41
Q

How do you Dx SPB

A

Ascitic tap - appear cloudy

High neutrophil and low protein = dx

42
Q

How do you Rx

A 
Discontinue fluid retention drugs - steroid / Na
Sodium and fluid restriction
Spirnolactone
Ax - ceftaxime
Anti-fungal
Surgery to repair peritoneum
Paracentesis
TIPS
Furesmide if still unresponsive
43
Q

How does SPB present

A 
Ascites
Sudden abdominal pain
Fever
N+V
Rigors
Sepsis
Renal impairment
No urine
Altered mental 
Liver not palpable
44
Q

When do you give prophylaticx Ax - ciprofloxacin

A

Previous SPB
Child-pugh >9
Hepatorenal syndrome
Low protein <15g

45
Q

What categories can liver transplant be broken into

A

Acute liver failure

Chronic liver

46
Q

What causes acute

A

Acute viral hepatitis
Paracetamol overdose
Go to top of transplant list

47
Q

What factors suggest unsuitable for transplant

A 
Significant co-morbid
Excessive weight loss / malnutrition
Active hep B or C
End stage HIV
Active alcohol use - need 6 months abstinence
48
Q

What suggest transplant rejection

A

Abnormal LFT
JAundice
Fever
Fatigue

49
Q

What will patient require

A

Life long immunosuppression

50
Q

Types of transplant

A

Orthotopic if whole liver transplant

Split donation if liver split and transplanted to two people as liver regenerates

51
Q

What does bloody ascitic fluid suggest

A

Malignancy

Haemorrhagic pancreatitis

52
Q

What does milk colour suggest

A

Lymphoma
TB
Malignancy

53
Q

What does cloudy suggest

A

SBP
Perforated bowel
Pancreatitis

54
Q

What does clear/. straw suggest

A

Liver cirossis

55
Q

How does ascites present

A

Abdominal distension / discomfort
Weight gain
SOB if pressing on diaphragm
Reduced appetite

56
Q

Ascites

A

Accumulation of ascitic fluid in peritoneal cavity

57
Q

What is biggest risk of TIPS

A

Hepatic encephalopathy

58
Q

What does TIPS do

A

Connect portal vein to hepatic vein to reduce pressure

- Will also reduce risk of varicose

59
Q

What is criteria for transplant in acute liver failure due to paracetamol

A

Arteria pH <7.3 OR 3+ of
PT >100s
Creatinine >300
IV encephalopathy

60
Q

What is non-paracetamol criteria

A 
PT >100 or 3+ of 
Age <10 or >40
1 week from jaundice -> encephalopathy
PT >50s
Bilirubin >300
61
Q

What should you always monitor in acute liver failure

A 
LFT
Clotting
Creatinine
VBG
Conscious

GI (29 decks)

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