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
2
Q
What drugs are likely to lead to cirrhosis
A
Methotrexate Methyldopa Amidarone Izonazid Sodium valproate
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
4
Q
What is the most sensitive marker of CLD
A
Thrombocytopenia
5
Q
What increases risk of decompensation
A
Dehydration Infection Alcohol Constipation Occult GI bleed
6
Q
How do you Dx cirrhosis
A
Blood
Fibroscan - transient elastogrpahy = 1st line
Liver USS and doppler
Liver biopsy
7
Q
Who gets fibroscan to asses
A
Scores suggest need
All Dx of alcoholic liver disease
All Dx of Hep B and C
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)
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
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
11
Q
What causes acute liver failure
A
Drug overdose
Alcohol
Viral hepatitis - any cause
Acute fatty liver of pregnancy
12
Q
What is chronic liver failure
A
> 6 months
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
14
Q
What is the most precipitating factor for liver failure
A
Cirrhosis
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
16
Q
What does chronic liver failure have and what are they
A
Decompensated Sx
- Jaundice
- Portal hypertension
- Ascites
- Varices
- Encephalopathy
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
18
Q
How do you differentiate from chronic stable liver failure
A
Encephalopathy
High bilirubin
High PT
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
20
Q
What are the complications of liver failure
A
Hepatorenal syndrome Oedema Ascites Bleeding Infection Decreased glucose Encephalopathy
21
Q
What suggests poor prognosis in liver failure
A
Grade 4 encephalopthy
Albumin <30
INR increased
Drug induced
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
23
Q
When is encephalopathy seen
A
More in acute liver but can be seen in chronic
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
25
What worsens / precipitates encephalopathy
```
Infection
GI bleed
Constipation / dehydration
Drugs - diuretic/. sedative
Hypokalaemia
Renal failure
Post TIPS
```
26
How do you treat and what must you exclude
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
Ddx of encephalopathy
Sepsis
Hypoglycaemia
Trauma
28
What is hepatorenal syndrome
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
How do you treat hepatorenal
Fatal within a week unless transplant performed
Terlipressin (vasopressin) = constriction
Volume expansion with 20% albumin
Shunt
Haemodialysis
TIPS
Transplant (often too unwell)
30
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)
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
What causes ascites <11
Exuate
Epithelial damage so albumin leaks out
```
Periotneal cause
Bowel obstruction
Lymphatic leak
Pancreatic malignancy or pancreatitis
TB
Peritoneal cancer
```
32
How do you Dx ascites and other investigations you would do
```
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
How do you treat ascites
```
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
What antibiotic
Ciprofloxacin to ascites resolves
| Ceftaxime if SPB
35
How does malignancy cause ascites
Decreased resorption and increased fluid
36
What is the differential of ascites
Secondary peritonitis
Bowel obstruction
Haemoperitoneum - trauma
37
What is SPB
Inflammation of ascites
High neutrophil >25 (Calculate % of WCC)
Low protein <25
38
What organisms common in SPB
E.coli = most common
Klebsiella
Strep pneumonia if gram V+e
39
When should you consider SPB
```
Any patient with ascites who deteriorates suddenly even if no Hx ascites
Fever
Abdo pain / guarding
Increased WCC, CRP, metabolic acidosis
Ileys
Hypotension
```
40
Who is most at risk of SPB
Liver cirrhosis
Alcohol = poor
Portal hypertension
41
How do you Dx SPB
Ascitic tap - appear cloudy
| High neutrophil and low protein = dx
42
How do you Rx
```
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
How does SPB present
```
Ascites
Sudden abdominal pain
Fever
N+V
Rigors
Sepsis
Renal impairment
No urine
Altered mental
Liver not palpable
```
44
When do you give prophylaticx Ax - ciprofloxacin
Previous SPB
Child-pugh >9
Hepatorenal syndrome
Low protein <15g
45
What categories can liver transplant be broken into
Acute liver failure
| Chronic liver
46
What causes acute
Acute viral hepatitis
Paracetamol overdose
Go to top of transplant list
47
What factors suggest unsuitable for transplant
```
Significant co-morbid
Excessive weight loss / malnutrition
Active hep B or C
End stage HIV
Active alcohol use - need 6 months abstinence
```
48
What suggest transplant rejection
Abnormal LFT
JAundice
Fever
Fatigue
49
What will patient require
Life long immunosuppression
50
Types of transplant
Orthotopic if whole liver transplant
| Split donation if liver split and transplanted to two people as liver regenerates
51
What does bloody ascitic fluid suggest
Malignancy
| Haemorrhagic pancreatitis
52
What does milk colour suggest
Lymphoma
TB
Malignancy
53
What does cloudy suggest
SBP
Perforated bowel
Pancreatitis
54
What does clear/. straw suggest
Liver cirossis
55
How does ascites present
Abdominal distension / discomfort
Weight gain
SOB if pressing on diaphragm
Reduced appetite
56
Ascites
Accumulation of ascitic fluid in peritoneal cavity
57
What is biggest risk of TIPS
Hepatic encephalopathy
58
What does TIPS do
Connect portal vein to hepatic vein to reduce pressure
| - Will also reduce risk of varicose
59
What is criteria for transplant in acute liver failure due to paracetamol
Arteria pH <7.3 OR 3+ of
PT >100s
Creatinine >300
IV encephalopathy
60
What is non-paracetamol criteria
```
PT >100 or 3+ of
Age <10 or >40
1 week from jaundice -> encephalopathy
PT >50s
Bilirubin >300
```
61
What should you always monitor in acute liver failure
```
LFT
Clotting
Creatinine
VBG
Conscious
```
