Clinical Topic 8: Chronic Liver Disease Flashcards
Give the name of a parasitic organism which can cause a rise in portal hypertension. Is commonly found in Asia, South America, Africa, or the Caribbean
Schistosomiasis
What is the most common cause of Liver Cirrhosis?
Alcohol
What is the most common electrolyte abnormality associated with Liver Cirrhosis?
Hyponatraemia
Why is bruising a common feature in Liver Cirrhosis?
Due to thrombocytopenia, which is caused by splenomegaly
Liver cirrhosis causes a raise in Oestrogen levels. What effect does this have?
Gynaecomastia (also due to spironolactone use)
Spider naevi
What is the best investigation to confirm Cirrhosis of the Liver?
Transient Elastrography (Fibroscan)
A value of what SAAG is diagnostic for portal hypertension?
> 11g/L
What is the reason for encephalopathy? What is used to treat Hepatic encephalopathy? What is second-line?
Encephalopathy is caused by a build up of ammonium, and is treated by Lactulose.
If Lactulose is not tolerated, give Phosphate Enema
What is the best medication used to treat Ascities?
Spironolactone (often given with Furosemide)
What antibiotics are used to treat spontaneous bacterial peritonitis?
Cephalosporins i.e. Cefotaxime, Cetriaxone
What beta-blockers are used to reduce portal pressure in patients with Liver Cirrhosis?
Carvediolol
Propanolol
Why is albumin administered to patients who are undergoing therapeutic paracentesis for ascites?
To cover the risk of circulatory dysfunction and thus avoid an AKI
NAFLD is a spectrum of conditions; what are they?
- Steatosis
- Fibrosis
- Cirrhosis
What are risk factors for NAFLD?
Hypertension
diabetes
hypercholesterolaemia hypertriglyceridaemia
obesity
Older age
Smoking
Poor activity and diet
How does the liver appear in Cirrhosis?
Shrunken, non-palpable liver with regenerative nodules
How does the liver appear in NAFLD?
Large, yellow with steatosis
What are the investigations for NAFLD?
BLOODS
FBC - platelets
LFTs - raised ALT, raised AST
Enhanced Liver Fibrosis (ELF) test
IMAGING
Transient elastography
Ultrasound
Liver biopsy
Why do patients with NAFLD have Acanthosis Nigricans?
Acanthosis Nigricans is a sign of insulin resistance, and one risk factor for NAFLD is diabetes
What can be done for patients with variceal bleeding that cannot be controlled on Endoscopy?
Sengstaken tube is inserted
What is the stepwise progression of alcoholic - related liver disease? Which ones are reversible?
- Steatosis (reversible)
- Hepatitis (reversible if mild)
- Cirrhosis (irreversible)
- Recommended alcoholic consumption per week
- What is binge drinking
- No more than 14 units, and spread over 3 or more days
- 6 units for women, 8 units for men in a single session
Why should alcohol be avoided in pregnancy?
Leads to:
- miscarriage
- Small for dates
- preterm delivery
- fetal alcohol syndrome
Complications of alcohol consumption
Alcohol related liver disease
Hepatocellular carcinoma
Wernicke Korsakoff syndrome
Pancreatitis
Alcohol cardiomyopathy
Alcoholic myopathy
Stroke/MI
Breast, mouth, throat cancer
Men: impotence, testicular atrophy
Women: ovarian disruption, menstrual cycle changes
Dementia
Epilepsy
Bipolar
Signs of excessive alcohol consumption
Smelling of alcohol
Slurred speech
Bloodshot eyes
Tremor
Facial telengectasia
Investigations for alcohol related liver disease
FBC - high MCV
LFTs - high AST, ALT, GGT, bilirubin if cirrhos, ALP if later stage of disease
AST:ALT ratio above 1.5
Low albumin
Prothrombin time - raised
Deranged U&Es
IMAGING
- Liver US -fatty changes with increased echogeneity and screen for HCC
- Transient Elastography - determine fibrosis severity
- if Portal hypertension suspected -> do endoscopy for oesophageal varices
- CT / MRI of liver
Liver biopsy
How to quickly screen for harmful alcohol use?
CAGE mnenomic
- Do you ever think you should CUT DOWN?
- Do you get ANNOYED when others comment on your drinking?
- Do you ever feel GUILTY about drinking?
- Do you drink in the morning to help your hangover or your nerves?
Management of ARLD
- Stop drinking
- CBT/motivational interviewing
Detox regime - Nutrition support - thiamine and high protein diet
- Corticosteroids to reduce inflammation
- treat complications
Liver transplant if severe disease
What is required for a liver transplant
Atleast 6 months of alcohol abstinence
Severe ARLD
Complications of liver cirrhosis
Portal hypertension
Oesophageal varices
Ascites
Hepatic encephalopathy
HCC
Malnutrition
Muscle wasting
- What is delirium tremens?
- Mortality rate?
- Pathophysiology of DT?
- Symptoms?
- Management?
- Medical emergency caused by alcohol withdrawal ( 24-72 hours after last intake)
- 35% mortality rate if untreated
- Alcohol’s effects on GABA stimulation and inhibition of glutamate receptors lead to down regulation of GABA and upregulation of glutamate receptors in absence of it causing extreme excitability of brain and adrenergic activity
- Confusion
Delusions
Hallucinations
Tremor
Ataxia
Tachycardia, hypertension, hyperthermia, arrythmia - CIWA-R tool to assess severity of DT
Librium
Pabrinex (B vitamins) IM/IV to prevent Wernicke-Korsakoff syndrome
What is Wernicke Korsakoff syndrome
Wernicke’s encephalopathy (confusion, oculuomotor disturbance, ataxia) and Korsakoff syndrome (retrograde/anterograde memory impairment and behaviour changes) caused by deficiency in vitamin B1
Signs of liver cirrhosis
Cachexia
Jaundice
Leukonychia
Asterixis
Hepatomegaly
Splenomegaly
Spider naevi
Palmar erythema
Gynaecomastia and testicular atrophy
Bruising
Excoriations
Ascites
Caput medusae
What’s leukonychia caused by
Trauma or hypoalbuminaemia
Main causes of liver cirrhosis
AFLD
NAFLD
Hepatitis C
Hepatitis B
What to do if you have abnormal LFTs without a clear cause?
Non invasive liver screen:
- USS liver
- Hep B and C serology
- Autoantibodies
- Immunoglobulins
- Ceruloplasmin
- Alpha 1 antitrypsin
- ferritin and transferrin saturation
Autoantibodies relevant to liver disease?
Antinuclear antibodies (ANA)
Smooth muscle antibodies (SMA)
Antimitochondrial antibodies (AMA)
Antibodies to liver kidney microsome type 1 (LKM-1)
What’s the tumour marker in HCC
Alpha fetoprotein
Indications for liver transplant
Signs of decompensated liver disease (AHOY):
Ascites
Hepatic encephalopathy
Oesophageal varices
Yellow
Prognosis of liver cirrhosis
Once cirrhosis has developed, 5 year survival is 50% likely
How does cirrhosis lead to malnutrition? How to manage malnutrition
Cirrhosis leads to reduced ability of liver to metabolise and make protein -> body breaks down muscle to use as protein source
High protein and calorie diet
Regular meals
Limit sodium intake
- Management of oesophageal varices
- Prophylaxis of oesophageal varices
- Call senior
Major haemorrhage protocol
Treat coagulopathy with FFP
Terlipressin/somatostatin
Prophylactic broad spectrum abx
Urgent endoscopy with variceal band ligation OR sengstaken Blakemore tube OR transjugular intrahepatic portosystemic shunt (TIPS)
Consider intubation and ICU
- Propranolol
Band ligation
What does ascites lead to?
Fluid and sodium retention
What is spontaneous bacterial peritonitis?
What bacteria commonly causes it?
How to treat it?
Infection in ascitic fluid without a clear cause (eg bowel perforation, ascitic drain)
E coli and klebsiella pneumoniae
Sample ascitic fluid for culture
Iv broad spectrum abx
