Cirrhosis/ Chonic liver disease Flashcards
What is chronic liver disease?
repeated insults to the liver, which can result in inflammation, fibrosis and ultimately cirrhosis.
Progressive liver dysfunction for six months or longer.
What are the 4 main functions of the liver?
Storage (i.e. glycogen, iron, vitamins (A, B12,D,E,K)
Breakdown (i.e. drugs, toxins, ammonia, bilirubin, excess hormones e.g sex, thyroid, cortisone, other adrenal)
Synthesis (i.e. bile, cholesterol, coagulation factors, growth factors, albumin)
Immune function (i.e. innate immune protein production, resident immune cells, Reticuloendothelial system )
What are the 9 main causes of chronic liver disease?
Alcohol
Viral (Hepatitis A, B, C, D, E)
Inherited (Alpha-1-antitrypsin deficiency, Wilson’s disease,
Hereditary haemochromatosis)
Metabolic (Non-alcohol fatty liver disease / Non-alcoholic steatohepatitis)
Autoimmune (Autoimmune hepatitis)
Biliary (Primary biliary cirrhosis, primary sclerosing cholangitis)
Vascular (Ischaemic hepatitis, Budd-Chiari syndrome, congestive hepatopathy)
Medication (Drug-induced liver injury)
Cryptogenic (no known cause)
What is the difference between compensated and decompensated liver disease?
Compensated - typically asymptomatic as the liver continues to carry out normal function despite extensive damage.
Decompensated - leads to multiple complications due to inadequate liver function. Liver is no longer able to compensate
What are the complications which can arise due to decompensated liver disease? (5)
Coagulopathy (reducing clotting factor synthesis)
Jaundice (impaired breakdown of bilirubin)
Encephalopathy (poor detoxification of harmful substances)
Ascites (poor albumin synthesis and increased portal pressure due to scarring)
Gastrointestinal bleeding (increase portal pressure causing varices)
What are the stigmata’s for chronic liver disease? (7)
State 6 other general symptoms of liver disease
Caput medusa: distended and engorged superficial epigastric veins around the umbilicus.
Splenomegaly
Palmar erythema: particularly over the hypothenar eminence.
Dupuytren’s contracture:
Leuconychia - low albumin
Gynaecomastia
Spider naevie
General
Flappy tremor - encephalopathy
Easy bruising - Liver not producing coagulants
Anaemia - B12 deficiency (B12 produced in the liver)
Oedema - low albumin, loss of oncotic pressure
Pigmentation ulcers
lymphedenopathy
What is Leuconychia a sign of?
hypoalbuminaemia.
What is the first and second line treatment for hepatic encephalopathy?
First line treatments:
Treat precipitating factor
Use laxatives (i.e. lactulose 15-20 mls QDS) to maintain bowel motions.
Second-line treatments: Involves the long-term use of antibiotics (i.e. rifaximin).
May need liver transplant
Which mechanisms contribute to Ascites development?
portal hypertension and loss of oncotic pressure (hypoalbuminaemia).
Due to widespread vasodilatation and underperfusion, the renin-angiotension-aldosterone systems (RAAS) is active leading to excess water and sodium reabsorption that exacerbates ascites.
How is ascites treated?
Aldosterone antagonists (e.g. spironolactone) that can be combined with loop diuretics (i.e. furosemide)
Paracentesis: Patients with tense (grade III) ascites require large volume paracentesis that involves percutaneous drainage of ascites with human albumin solution cover to prevent post-drainage circulatory dysfunction.
100 human albumin solution for every 2l removed
How is Gastrointestinal bleeding treated? (mainly due to oesophageal and gastric varices)
Primary prophylaxis: non-selective beta blockers (i.e. propranolol, carvedilol) to reduce portal pressure in patients with cirrhosis and significant varices
Acute variceal haemorrhage - Medical emergency, ABCDE management, endoscopic variceal band ligation.
Secondary prophylaxis: After the management of an acute bleed patients should be offered enter a banding surveillance programme and offered a non-selective beta blockers (i.e. propranolol, carvedilol),
What is Spontaneous bacterial peritonitis?
SBP refers to infection within ascitic fluid with a predominantly neutrophilic >80% ascitic white cell count (WCC) >550/mm3.
How is Spontaneous bacterial peritonitis treated?
Ascitic tap - first obtained
Antibiotics: Follow local guidance, should not be delayed
Human albumin solution: Helps to prevent the development of acute kidney injury and hepatorenal syndrome.
Prophylaxis: Patients at risk of, or following confirmed, SBP should be managed with long-term prophylactic antibiotics (e.g. rifaximin).
Which 2 chronic liver disease causes are associated with Hepatocellular carcinoma?
cirrhosis or chronic hepatitis B
List 9 causes of Cirrhosis
Alcohol
•
Hepatitis B ± D
•
Hepatitis C
•
Non-alcoholic fatty liver disease (NAFLD)
Primary biliary cholangitis
•
Secondary biliary cirrhosis
•
Autoimmune hepatitis
•
Hereditary haemochromatosis
Drugs
What is Cirrhosis?
implies irreversible liver damage. Histologically, there
is loss of normal hepatic architecture with bridging fibrosis and nodular regeneration.
What are the characteristic features of cirrhosis?
regenerating nodules separated by fibrous septa, and loss of lobular architecture within the nodules
2 types
Micronodular cirrhosis. Regenerating nodules are usually <3 mm in size with uniform involvement of the liver
Macronodular cirrhosis. The nodules are of variable size and normal acini may be seen within larger nodules
State common causes of macro and micro nodular cirrhosis
Micronodular cirrhosis
alcohol
biliary tract disease.
Macronodular cirrhosis
chronic viral hepatitis.
Which investigations are used to assess the type and severity of liver disease?
Liver function test- Serum albumin Prothrombin time (INR) Albumin <28g/l and prolonged prothrombin = worse outcome
Liver Biochemistry-
May be normal depending on severity of disease.
Most cases slight rise in APL, AST and ALT. In decompensated cirrhosis, all biochemistry is deranged.
Serum electrolyte -
A low sodium indicates severe liver disease due to a defect in free water clearance or excess diuretic therapy.
Serum creatinine -
An elevated concentration >130 µmol/L is a marker of poor prognosis.
Biomarkers-
In the Enhanced Liver Fibrosis (ELF™) test, which assesses fibrosis, a value of <7.7 indicates none to mild, 7.7–9.8 moderate, and ≥9.8 severe.
Which raised blood tests is strongly associated with hepatocellular cancer?
Which other FBC findings are assocatied with liver disease? Explain the reason for each
α-fetoprotein of >200 ng/mL
Anaemia (B12 deficiency)
Thrombocytopenia (low platelet count)
Pancytopenia (splenomegaly)
Which investigations are used to assess the type/cause of liver cirrhosis?
viral markers
•
serum autoantibodies
•
serum immunoglobulins
•
iron indices and ferritin
•
copper and caeruloplasmin
α1-antitrypsin
genetic markers.
Which blood tests should be conducted to exclude hereditary haemochromatosis?
Total iron-binding capacity (TIBC) and ferritin
Genetic markers
Which imaging tests are used to investigative liver disease?
Ultrasound - Detects changes in size and shape. Assess fatty and fibrotic changes
Patency of portal and hepatic veins
Transient elastography
- Used instead of liver biopsy
- Assess level of fibrosis
- Can exclude cirrhosis
CT scanning -
show hepatosplenomegaly and the dilated collaterals
Endoscopy
- performed for the detection and treatment of varices and portal hypertensive gastropathy.
Colonoscopy is occasionally carried out for colopathy.
MRI scan
useful in the diagnosis of both malignant and benign tumours such as haemangiomas.
Which patients can Transient elastography not be used on?
patients with ascites or morbid obesity
Which type of CT scans are useful to detect hepatocellular cancer?
Arterial phase-contrast-enhanced scans
What is the gold standard for assessing the type and severity of liver disease?
Liver biopsy
Immunocytochemical stains can identify viruses, bile ducts, angiogenic structures and oncogenic markers.
How is cirrhosis managed?
Manage complications
Which life style changes should people with cirrhosis make? Include drugs which should be avoided
reduce salt intake (≤2 g sodium per day). Alcohol should be avoided, as should aspirin and non-steroidal anti-inflammatory drugs (NSAIDs), which may precipitate gastrointestinal bleeding or renal impairment.
List 3 common bacteria which cause bacterial peritonitis?
E. coli, Klebsiella, and streptococci
How does cirrhosis lead to renal damage?
reduced hepatic clearance of immune complexes leads to trapping in
kidneys ( IgA nephropathy ± hepatic glomerulosclerosis)
Which drug is used to treat Wilsons disease?
Penicillamine
What are the causes of pre-heptic, hepatic and post hepatic jaundice?
Pre hepatic -
- Heamolysis
- Drugs
- Inherited conditions
Hepatic
- Gilberts
- Hepatitis
- NAFLD
- Autoimmune
- Wilsons
- Heamochromatosis
- Viral
- Drug
- Alcohol
- Cirrhosis
Post-heptic
- Sex hormones promazines
- Cancer of the bile ducts
- Gall stones
- Cancer of head of pancreases
Which findings indicate obstructive jaundice?
Itching Jaundice (variable colour) Pale stools Dark urine High bilirubin (not above 600)
Which findings indicate hepatic jaundice?
Jaundice - darkest yellow
-May have itching, normal or pale stools
Yellow urine
bilirubin can get very high
What are the clinical features of portal hypertension?
Splenomegaly
– Pancytopenia
Varices
– Oesophageal
– Gastric
– Rectal
Ascites
Hepatic Encephalopathy
Which investigations for liver disease are used to assess the complications of the disorder?
Septic screen ( MSU (midstream urine), CXR, Cultures )
Anaemia Screen: Haematinics
–
Hepatoma screen : US abd + AFP (alpha-fetoprotein)
Cachexia screen:
Calcium/Phosphate/Magnesium/ Zinc
(at risk of refeeding syndrome!)
People with what deficiencies are at risk of re-feeding syndrome?
High risk and correct the below – BMI< 19 – Hypophosphatemia – Hypokalemia – Hypomagnesemia
What is the difference in treatment between oesophageal varices and gastric varices?
Oesophageal Varices:
- Band if big/bleeding
- B blockers if no contraindication
Gastric Varices: Only treat if bleeding: TIPSS
Transjugular intrahepatic portosystemic shunt (TIPS)
Which Vitamin is prescribed initially in those with Cirrhosis? These prescriptions are a prophylaxis for what?
IV Pabrinex (Vitamin B1) then PO Thiamine (B1)
Prophylaxis for Wernicke’s Encephalopathy
Which fluids and electrolytes imbalances are prescribed and treated in initial Cirrhosis treatment?
- Treat as per sepsis protocol if appropriate
- Do not rush to correct hyponatremia: it is
usually chronic, fluid restriction - Hypokalemia is a potent trigger for hepatic
encephalopathy, correct it - Hypophosphatemia may be fatal esp with
refeeding, correct it!
List the 4 alcoholic withdrawal syndromes, there time of onset and the clinical findings associated/
Minor withdrawal - Tremor, mild anxiety, headache, palpitations, GI upset. - 6-36 hours
Seizures - Single generalized, tonic clonic, short post ictal phase, status epilepticus rare- 6-48h
Alcoholic hallucinosis - visual, aurditory and tactile hallucinations, intact orientation and vital signs normal- 12-48h
Delirium tremens - Delirium, agitation, tachycardia, hypertension, fever, diaphoresis (sweating) - 48-96h
Which drugs are used to treat alcohol withdrawal?
- Chlordiazepoxide
- If cirrhosis: Lorazepam
When treating cirrhosis which dietary requirements should be followed?
1000-1200 calories/d to start with
Daily weight chart if ascites present
Bedtime snack as depleted glycogen reserves
When ascites tap is conducted what type of fluid is obtained (transudate or exudate). Which tests should be done on this fluid?
Transudate
Tests-
WCC
Cytology
What are the precipitants for hepatic encephalopathy? (7)
Constipation
Sepsis
GI Bleeding
Drugs
Opioids
Benzodiazepines
Diuretics
Dehydration
Portal Vein
Thrombosis
What are the treatment for when an oesophago-gastro-duodenoscopy (OGD) with band ligation or injection fails?
Repeat OGD ■ Other options – Sengstaken Blakemore tube – TIPSS ( transjugular intrahepatic portosystemic shunt)
In chronic liver failure 3 things can causes renal failure what are they?
Sepsis related Renal failure (often seen with
spontaneous bacterial peritonitis )
Drug ( diuretic) induced renal failure
Hepatorenal Syndrome (HRS)
What are the Precipitating factors for Hepatorenal Syndrome?
Sepsis esp SBP
GI bleed
How is Hepatorenal Syndrome treated?
IV Glypressin and albumin 20%
