Clinical Aspects of Liver Disease

Question 1

How should you investigate a patient that comes in with acute liver injury (days/weeks)? [4]

Answer 1

1. ultrasound
   
   • look for evidence of cancer
   • look at bile ducts and blood vessels
2. consider acute viral hepatitis
   
   • HAV, HBV, (HCV), HEV, CMV, EBV (other infections)
3. consider autoimmune liver disease
   
   • ANA/SMA/LKM
   • check immunoglobulins
4. check paracetamol levels

Question 2

How should you investigate a patient who comes in with chronic liver disease (>6months)? [6]

Answer 2

1. ultrasound
   
   • look for evidence of cancer
   • look at bile ducts and blood vessels
   • look for evidence of portal hypertension
2. +/- CT or MRCP
3. liver “screen”
   
   • chronic viral hepatitis: HBV, HCV
   • autoimmune liver disease
   • metabolic liver disease
     
     • check ferritin levels (haemochromatosis)
     • caeruloplasmin (Wilson’s diseae)
     • α1 anti-trypsin deficiency

Question 3

What are the common causes of abnormal liver blood tests? [6]

Answer 3

1. Fatty liver
   
   • alcoholic liver disease
   • non-alcoholic fatty liver disease (NAFLD)
2. Chronic viral hepatitis
   
   • chronic hepatitis C
3. Autoimmune liver disease
   
   • primary biliary cirrhosis
   • autoimmune hepatitis
4. Haemochromatosis

Question 4

Describe the histological features seen in each of the following images:

1. top image? [2]
2. middle image? [3]
3. bottom image? [2]

Answer 4

1. macrovesicular steatosis with lipid vaculoe filling the hepatocyte cytoplasm
2. steatohepatitis:
   
   • neutrophils and lymphocytes surrounding hepatocytes with Mallory hyaline
3. pericellular fibrosis as well as bands of fibrous tracts between portal tracts

Question 5

How does alcoholic liver disease (ALD) progress? [3]

Answer 5

alcoholic steatosis → alcoholic hepatitis → alcoholic cirrhosis

Question 6

How does non-alcoholic fatty liver disease (NAFLD) progress? [3]

Answer 6

steatosis → non-alcoholic steatohepatitis (NASH) → NAFLD cirrhosis

Question 7

Compare NAFLD with ALD under the following headings:

1. weight
2. fasting plasma glucose/HbA1c
3. daily alcohol intake
4. ALT
5. AST
6. AST/ALT ratio
7. GGT
8. Triglycerides
9. HDL-cholesterol
10. Mean corpuscular volume

Answer 7

1. elevated weight in non-alcoholic (variable in ALD)
2. often elevated fasting plasma glucose/HbA1c in non-alcoholic
3. high daily alcohol intake in ALD
4. elevated or normal ALT in both ALD & NAFLD
5. elevated AST in ALD
6. high AST/ALT ratio in ALD
7. markedly elevated GGT in ALD
8. elevated triglycerides in non-alcoholic (variable in ALD)
9. elevated HDL-cholesterol in ALD
10. elevated mean corpuscular volume in ALD

Question 8

What is the differential diagnosis of:

1. ↑ALP [1]
2. ↑AST [1]
3. ↑isolated bilirubin [1]

Answer 8

1. bone abnormality (if normal GGT)
2. potential muscle abnormality
3. haemolysis

Question 9

What are the clinical patterns of alcoholic liver disease on LFTs? [4]

Answer 9

1. raised AST:ALT ratio
2. AST not >500
3. ALT usually <300
4. alcoholic hepatitis may appear cholestatic

Question 10

What are the clinical features of a newly jaundiced ALD patient with alcoholic hepatitis? [8]

Answer 10

1. recent excess alcohol
2. bilirubin >80
3. AST <500
4. AST:ALT ratio >1.5
5. hepatomegaly +/- fever +/- leucocytosis +/- hepatic bruit

Question 11

What are the risk factors of Hepatitis C viral liver disease? [6]

Answer 11

1. male sex
2. age >40yrs
3. alcohol >50g/week
4. IVDU
5. sexual transmission
6. needle-stick transmission

Question 12

What are the signs of decompensated liver cirrhosis? [7]

Answer 12

1. jaundice (on background of cirrhosis)
2. ascites (spontaneous bacterial peritonitis)
3. encephalopathy
4. hepatic flap
5. bleeding varices
6. hepatocellular cancer
7. deteriorating synthetic function
   
   • high bilirubin
   • low albumin
   • high PT

Question 13

What are the clinical signs of chronic liver disease? [8]

Answer 13

• stigmata:
  
  1. spider naevi
  2. palmar erythema
  3. loss of male hair pattern
  4. gynaecomastia
  5. foetor
  6. encephalpathy
• signs of synthetic dysfunction:
  
  1. prolonged prothrombin time → bruising
  2. hypoalbuminaemia

Question 14

What are the clinical signs of portal hypertension? [4]

Answer 14

1. caput medusa
2. hypersplenism
3. thrombocytopenia
4. (pancytopenia)

Question 15

What is the Childs-Turcotte-Pugh Score? [1]

Answer 15

used to assess severity of chronic liver disease:

• separates into:
  
  • Grade A [5-6: mild] ,
  • Grade B [7-9: moderate]
  • Grade C [10-15: severe]

Question 16

Describe the pathophysiology of portal hypertension

Answer 16

Question 17

Describe the 2 types of hepatorenal syndrome [2]

Answer 17

Type 1 → rapid decline function (often triggered by spontaneous bacterial peritonitis (SBP))

Type 2 → moderate/stable decline

Question 18

What are the precipitating factors for hepatic encephalopathy? [5]

Answer 18

1. GI bleeding,
2. infections,
3. constipation,
4. electrolyte imbalance,
5. excess dietary esp. protein

Question 19

What is the treatment for hepatic encephalopathy? [1]

Answer 19

laxatives e.g. lactulose