Davidson - Liver and Biliary Tract Disease Flashcards
What do we look for in the hands during examination for liver and biliary disease?
- Clubbing
- Dupuytren’s contracture
- Leuconychia
- Bruising
- Flapping tremor (hepatic encephalopathy)
- Palmar erythema
What do we look for in the face during examination for liver and biliary disease?
- Jaundice
- Spider naevi
- Parotid swelling
- Xanthelasma and jaundiced sclera in a patient with chronic cholestasis.
- Kayser-Fleischer rings in Wilson’s disease.
What do we look for in the chest during examination for liver and biliary disease?
- Loss of body hair
- Gynecomastia
- Spider naevi
What do we look for in the abdomen during examination for liver and biliary disease?
- Scars
- Distention
- Veins
- Testicular atrophy
What do we find through palpation/percussion/auscaltation of the abdomen during examination for liver and biliary disease?
- Hepatomegaly
- Splenomegaly
- Ascites
- Palpable gallbladder
- Hepatic bruit (rare)
- Tumor
What do we look for in the legs during examination for liver and biliary disease?
- Bruising
2. Edema
What are the presenting features of liver disease that indicate impairment of liver function?
- Jaundice –> Failure of bilirubin clearance.
- Encephalopathy –> Failure of clearance of by-products of metabolism.
- Bleeding
- Hypoglycemia
What are the presenting clinical features of liver disease that indicate ongoing presence of aetiological factors (e.g. alcohol)?
- Effects of aetiological agent, e.g. intoxication, withdrawal, cognitive impairment vs
- Effects of liver injury from agent, e.g. encephalopathy.
What are the presenting clinical features of liver disease that indicate effects of chronic liver injury (>6months)?
- Catabolic status (+/- poor nutrition) –> Skin thinning (paper-money skin), loss of muscle bulk, leuconychia.
- Impaired albumin synthesis.
- Reduced aldosterone clearance.
- Reduced estrogen clearance.
How do we assess encephalopathy?
FLAPPING TREMOR:
Jerky forward movements every 5-10sec when arms are outstretched and hands are dorsiflexed suggest hepatic encephalopathy.
COARSER movement than those of tremor.
How do we assess clinically hepatomegaly?
- Start in the right iliac fossa.
- Process up the abdomen 2cm with each breath (through open mouth).
- Confirm the lower border of the liver by percussion.
- Detect if smooth or irregular, tender or non tender, ascertain shape.
- Identify the upper border by percussion.
What are the causes of EXUDATIVE ascites?
- Carcinoma –> Weight loss + hepatomegaly.
2. TB –> Weight loss + fever.
What are the causes of transudative ascites?
- Cirrhosis
- Renal failure (incl. nephrotic syndrome) –> Generalized and peripheral edema.
- Congestive heart failure (elevated jugular venous pressure).
How much does the liver weigh?
1.2-1.5 kg.
In how many segments is the liver divided according to subdivisions of the hepatic and portal veins?
8
What are the main features of zone 1 hepatocytes (periportal)?
- Good oxygen supply
- Gluconeogenesis
- Bile salt formation
What are the main features of zone 3 hepatocytes?
- Mono-oxygenation
- Glycolysis
- Lipolysis
- Glucuronidation
What is the space of Disse?
The space between the hepatocytes and leaky sinusoids.
What does the space of Disse contain?
Stellate cells that store vitA and play an important role in regulating liver blood flow.
What is the portal venous contribution to the liver blood supply?
50-90%.
What are the dimensions of the common bile duct?
Approx:
5cm long + 4-6mm wide.
What is the EXACT location of the gallbladder?
Pear-shaped sac typically lying under the right hemiliver, with its fundus located anteriorly behind the tip of the 9th COSTAL CARTILAGE.
What is characteristic of the cystic duct mucosa?
Has prominent crescentic folds - Valces of Heister - giving it a beaded appearance on cholangiography.
Mention some general important functions of the liver.
- Nutrient metabolism
- Protein synthesis
- Immune functions
- Excretion
- Storage
What protein does the liver synthesize?
- Albumin
- Coagulation factors
- Complement factors
- Haptoglobin
- Ceruloplasmin
- Transferrin
- Protease inhibitors (alpha-1 antitrypsin)
What does the liver excrete?
- Bile salts
- Bilirubin
- Drugs
- Phospholipid
- Cholesterol
How much albumin does the liver produce each day?
8-14g.
What is now recognized to play a key part in the pathogenesis of hep C?
Lipids - facilitating viral entry into hepatocytes.
What is important to keep in mind about deranged PT or INR seen in liver disease?
May not directly equate to increased bleeding risk –> these tests do NOT capture the concurrent reduced synthesis of anticoagulant factors including protein C and S.
How much unconjugated bilirubin is produced from the catabolism of heme daily?
250-300mg.
How much bile does the liver secrete daily?
1-2L.
Which vitamins are storaged in the liver in large amounts?
A, D, B12 –> Folate and vitK in smaller amounts.
What percentage of normal liver is composed of immune cells?
9%.
What immune cells do we find in the liver?
- Kupffer cells
- B and T cells
- Liver macrophages
- NK cells
- Atypical lymphocytes - phenotype between NK and T cells.
What do Kupffer cells constitute?
The largest single mass of tissue-resident macrophages in the body and account for 80% of the phagocytic capacity of this system.
What is the importance of investigation in the management of liver disease?
- Identification of the presence of liver disease.
- Establishing etiology
- Understanding disease severity (identification of cirrhosis with its complications).
What are the aims of investigations in patients with suspected liver disease?
- Detect hepatic abnormality
- Measure the severity of liver damage
- Detect pattern of liver function test abnormality: hepatitic, or obstructive/cholestatic.
- Identify the specific cause
- Investigate possible complications
What is the plasma half-life of albumin?
About 2 weeks - Albumin levels may be normal in ACUTE liver failure but are almost always reduced in CHRONIC liver failure.
ALT or AST is more specific for hepatocellular damage?
ALT.
What is basically the ALP?
The collective name given to several different enzymes that hydrolyze phosphate esters at alkaline pH.
What are the main sites of production of ALP in the body?
- The liver
- GI
- Bone
- Placenta
- Kidney
What is GGT?
A microsomal enzyme found in many cells and tissues of the body.
Where do we find the highest concentrations of GGT?
In the liver where it is produced by hepatocytes and by the epithelium lining small bile ducts.
What is the function of GGT?
To transfer glutamyl groups from gamma-glutamyl peptides to other peptides and amino acids.
What does isolated elevation of the serum GGT indicate?
Relatively common - May occur during ingestion of microsomal enzyme-inducing drugs, including alcohol, but also in NAFLD.
What other biochemical abnormalities may be found in patients with liver disease?
- Hyponatremia –> severe liver disease due to production of ADH.
- Serum UREA may be REDUCED. (Incr. in GI hemorrhage).
- High urea + raised bilirubin + high Cr + low urinary sodium –> Hepatorenal syndrome.
- Very high ferritin –> hemochromatosis.
Which drugs may increase levels of GGT?
- Barbiturates
- Carbamazepine
- Ethanol
- Griseofulvin
- Isoniazid
- Rifampicin
- Phenytoin
What abnormalities may be found in the peripheral blood count?
- Normocytic normochromic anemia –> Recent GI hemorrhage.
- Macrocytosis –> Alcohol misuse + target cells in any jaundice patient also result in macrocytosis.
- Leukopenia
- Leukocytosis with cholangitis, alcoholic hep, hepatic abscesses.
- Thrombocytopenia –> Both from hypersplenism + reduced prod. of thrombopoietin.
Can thrombocytosis occur in patients with liver disease?
It is unusual but may occur in those with active GI hemorrhage and, rarely, in hepatocellular carcinoma.
What is the normal half-life of vitK-dependent coagulation factors?
5-72h.
What are the main screening tests for chronic liver disease?
- Hep B surface antigen
- Hep C antibody
- Liver autoantibodies
- Immunoglobulins
- Ferritin
- Alpha-1 antitrypsin
- Ceruloplasmin
What is the clinical clue of alcoholic liver disease?
History
What is the initial test for alcoholic liver disease?
- LFTs –> AST>ALT
2. High MCV.
What additional test for alcoholic liver disease may be ordered?
Random blood alcohol.
What is the clinical clue for NAFLD?
Metabolic syndrome (central obesity, diabetes, HTN).
What is the initial test in NAFLD?
LFTs.
What additional tests may be ordered in NAFLD?
Liver biopsy.
What is the initial test for chronic hep B/C?
HBsAg and HCV antibody.
What additional tests may be ordered in chronic hep B/C?
HBeAg
HBeAb
HBV-DNA
HCV-RNA
What is the clinical clue for PBC?
Itching - raised ALP.
What is the initial test for PBC?
Antimitochondrial antibody (AMA).
What additional tests may be ordered in PBC?
Liver biopsy.
What is the clinical clue in PSC?
IBD
What is the initial test for PSC?
MRCP
What additional tests may be ordered for PSC?
ANCA
What is the clinical clue for autoimmune hepatitis?
Other autoimmune diseases.
What is the initial test for autoimmune hepatitis?
ASMA, ANA, LKM, immunoglobulin.
What additional tests may be ordered in autoimmun hepatitis?
Liver biopsy.
What is the clinical clue for hemochromatosis?
Diabetes/ joint pain.
What is the initial test for hemochromatosis?
Transferrin sat and ferritin.
What additional test may be ordered for hemochromatosis?
HFE gene test.
What is the clinical clue of Wilson disease?
Neurological signs and hemolysis.
What is the initial test for Wilson disease?
Ceruloplasmin.
What additional tests may be ordered for Wilson disease?
24h urinary copper.
What is the clinical clue for alpha-1 antitrypsin deficiency?
Lung disease.
How is US-guided liver biopsy performed?
Percutaneously with Trucut or Menghini needle, usually through an intercostal space under local anesthesia, or radiologically using a transjugular approach.
What are the conditions required for a safe percutaneous liver biopsy?
- Cooperative patient
- PT 80x10^9/L
- Exclusion of bile duct obstruction, localised skin infection, advanced COPD, marked ascites + severe anemia.
What are the main complications of percutaneous liver biopsy?
- Abdominal and/or shoulder pain.
- Bleeding
- Biliary peritonitis
When can liver biopsies be carried out in patients with defective hemostasis?
IF:
- The defect is corrected with fresh frozen plasma and platelet transfusion.
- Biopsy is obtained by the transjugular route.
- The procedure is conducted percutaneously under US control and the needle track is then plugged with procoagulant material.
In what patients should we ALSO avoid liver biopsies?
In patients with potentially resectable malignancy –> potential risk of tumor dissemination.
Operative or laparoscopic liver biopsy may sometimes be valuable.
Non-invasive markers of liver fibrosis have been developed and can reduce the need for liver biopsy to assess the extent of fibrosis in some settings. Mention some of them.
- Alpha-2 macroglobulin
- Haptoglobin
- Routine clinical biochemistry tests
Used in the Fibrotest.
More recently newer classifications have been developed to reflect differences in presentation and outcome of acute liver failure. Mention one of them.
Divides acute liver failure into hyperacute, acute, and subacute:
Hyperacute –> Jaundice to encephalopathy in Jaundice to encephalopathy in 8-28d.
Subacute –> Jaundice to encephalopathy in 29d-12wks.
In hyperacute, acute, or subacute ALF is cerebral edema common?
In hyperacute + acute.
What percentage of ALF remains the cause unknown?
10% –> Cryptogenic or Non A-E viral hepatitis.
What is the cardinal manifestation of ALF?
Cerebral disturbance –> Hepatic encephalopathy and/or cerebral edema).
But in the early stages this can be mild and episodic and so its absence does not exclude a significant acute liver injury.
What are the initial features of ALF?
Often subtle:
- Reduced alertness
- Poor concentration
- Progressing through behavioral abnormalities –> restlessness and aggressive outbursts, to drowsiness and coma.
- Cerebral edema may occur –> with its complications.
- General features –> Weakness, nausea, vomiting.
- OCCASIONALLY –> right hypochondrial discomfort.
In ALF can death occur before jaundice?
Yes –> Jauncide may not be present at the outset and sometimes it is rare (Reye’s).
How do we assess clinical grade of hepatic encephalopathy?
Through 4 grades.
What are the clinical signs of grade 1 hepatic encephalopathy?
- Poor concentration
- Slurred speech
- Slow mentation
- Disordered sleep rhythm
What are the clinical signs in grade 2 hepatic encephalopathy?
- Drowsy but easily rousable.
- Occasional aggressive behavior.
- Lethargic
What are the clinical signs of grade 3 hepatic encephalopathy?
- Marked confusion
- Drowsy
- Sleepy but responds to pain and voice
- Gross disorientation
What are the clinical signs of grade 4 hepatic encephalopathy?
- Unresponsive to voice
- May or may not respond to painful stimuli
- Unconscious
What are the causes of ALF?
Drugs –> 70-80%
Cryptogenic –> 5-10%
Viral infections –> 5%
Poisons –> <5%
Which drugs may cause ALF?
- Paracetamol
- Halothane
- Antituberculous drugs
- Ecstasy
- Herbal remedies
Mention some miscellaneous causes of ALF?
- Wilson disease
- Acute fatty liver of pregnancy
- Shock and cardiac failure
- Budd-Chiari syndrome
- Leptospirosis
- Liver metastases
- Lymphoma
What is the best screening test for acute hep B infection?
Hep B core IgM antibody –> Liver damage is due to the immunological response to the virus, which has often been eliminated, and the test for HBsAg may be negative.
What is the test of greatest prognostic value in ALF?
PT - should be carried out at least twice daily.
Mention some major investigations to determine the cause of ALF?
- Toxicology screen of blood and urine.
- HBsAg, IgM anti-HBc.
- IgM anti-HAV
- Anti-HEV, HCV, CMV, HSV, EBV
- Ceruloplasmin, serum copper, urinary copper, slit-lamp eye examination.
- Autoantibodies: ANA, ASMA, LKM, SLA (soluble liver antigen).
- Immunoglobulins
- US of liver and Doppler of hepatic veins.
Mention some adverse prognostic criteria in ALF due to paracetamol toxicity? (mortality >90% –> referral for possible liver transplantation).
H>50nmol/L (pH3.38mg/dL +
- PT >100 secs +
- Grade 3 or 4 encephalopathy.
Mention some adverse prognostic criteria in ALF in non-paracetamol cases? (mortality >90% –> referral for possible liver transplantation).
PT>100secs OR ANY three of the following: 1. Jaundice to encephalopathy in >7d. 2. Age 40. 3. Indeterminate or drug-induced causes. 4. Bilirubin >17.6mg/dL 5. PT>50secs. OR Factor V level <15% and encephalopathy grade 3 or 4.
What does the cardiorespiratory monitoring in ALF involve?
- Pulse
- BP
- Central venous pressure
- Respiratory rate
What does the neurological monitoring in ALF involve?
- Intracranial pressure monitoring
2. Conscious level
What does the fluid balance monitoring in ALF involve?
- Hourly output (urine, vomiting, diarrhea).
2. Input: oral, IV.
What does the blood analyses monitoring in ALF involve?
- Arterial blood gases
- Peripheral blood count (incl. platelets
- Na, K, HCO3, Ca, Mg
- Creatinine, urea
- Glucose (2hourly in acute phase)
- PT
What does the infection surveillance monitoring in acute liver failure involve?
- Cultures: Blood, urine, throat, sputum, cannula sites.
- CXR
- Temperature
What are the possible complications of ALF?
- Encephalopathy + cerebral edema.
- Hypoglycemia
- Metabolic acidosis
- Infection (bacterial, fungal)
- Renal failure
- Multi-organ failure (hypotension and respiratory failure)
What is the 1-year survival following liver transplantation for ALF?
About 60% and improving.
What must be done when abnormal LFTs are detected?
- Thorough history should be compiled.
- Determine patients alcohol consumption.
- Drug use (prescribed drugs or otherwise).
- Risk factors for viral hepatitis (blood transfusions, injecting drug use, tattoos).
- Presence of autoimmune diseases
- Family history
- Neurological symptoms
- Features of metabolic syndrome
What must be done when we find incr. bilirubin ONLY in an asymptomatic patient?
Recheck with conjugated bilirubin –> exclude hemolysis –> Reassure, as likely Gilbert’s syndrome.
What must be done if increased GGT ONLY is found in asymptomatic patients?
Determine whether:
- NAFLD/incr. BMI –> Stage disease –> Lifestyle modifications.
- Enzyme induction from drugs –> Review current medication.
- Alcohol –> Alcohol abstinence.
What must be done when abnormal ALP or serum transaminases <2x upper limit are found in an asymptomatic patient?
- Check GGT if raised ALP –> Alcohol abstinence, stop hepatotoxic drugs, advise weight loss if BMI>25.
- Recheck LFT in 3-6months.
What must be done if LFTs are persistently abnormal or we have an abnormal ALP and serum transaminases >2x upper limit in an asymptomatic patient?
Liver screen, i.e.
- Full history
- Chronic liver disease screen
- US abdomen
- HBsAg
- HCV Ab
- Alpha-1 AT
- Autoimmune profile
- Ferritin
- Ceruloplasmin
- Immunoglobulins
Mention some causes of mild elevation of serum transaminases (<100U/L)?
- Chronic hep C
- Chronic hep B
- Hemochromatosis
- Fatty liver disease
Mention some causes of moderate elevation of serum transaminases (100-300 U/L).
As with mild elevation plus:
- Alcoholic hepatitis
- Non-alcoholic hepatitis
- Autoimmune hepatitis
- Wilson’s disease
Mention some causes of major elevation of serum transaminases (>300U/L).
- Drugs
- Acute viral hep
- Autoimmune liver disease
- Ischemic liver
- Toxins (e.g. Amanita phalloides poisoing)
- Flare of chronic hep B.
Mention some causes of INTRAHEPATIC cholestatic jaundice.
- PBC
- PSC
- Alcohol
- Drugs
- Hepatic infiltrations (lymphoma, granuloma, amyloid, metastases)
- Cystic fibrosis
- Severe bacterial infections
- Pregnancy
- Inherited cholestatic liver disease, e.g. benign recurrent intrahepatic cholestasis
- Chronic right heart failure
Mention causes of EXTRAHEPATIC cholestatic jaundice.
- Carcinoma –> Ampullary, pancreatic, bile duct (cholangiocarcinoma), liver metastases.
- Choledocholithiasis
- Parasitic infection
- Traumatic biliary strictures
- Chronic pancreatitis
What symptoms may be key history points in patients with jaundice?
- Itching PRECEDING jaundice
- Abdominal pain (suggests stones)
- Weight loss (chronic liver disease or malignancy)
- Dark urine and pale stools
- Fever+/- rigors
- Dry eyes, dry mouth
- Fatigue
When is jaundice usually clinically detectable?
When the plasma bilirubin exceeds 2.5mg/dL.
What happens in pre-hepatic jaundice?
Cause by either hemolysis or by congenital hyperbilirubinemia and is characterized by an isolated raised bilirubin level.
What is the most common form of non-hemolytic hyperbilirubinemia?
Gilbert syndrome.
What happens in hepatocellular jaundice?
The concentrations of BOTH unconjugated and conjugated bilirubin increase –> Due to acute or chronic liver disease.
Besides viral infection and drugs, what else can elevate the ALT >1000?
Hepatic ischemia.
What can cause cholestatic (obstructive) jaundice?
- Failure of hepatocytes to initiate bile flow.
- Obstruction of the bile ducts or portal tracts.
- Obstruction of bile flow in the extrahepatic bile ducts between the porta hepatis and the papilla of Vater.
What are the early features of cholestasis?
- Jaundice
- Dark urine
- Pale stools
- Pruritus
What are the late features of cholestasis?
- Malabsorption (ADEK)
- Weight loss
- Steatorrhea
- Osteomalacia
- Bleeding tendency
- Xanthelasma and xanthomas
What are the clinical features of cholangitis?
- Fever
- Rigors
- Pain (if gallstones present)
What is likely the cause of static or increasing jaundice?
- Carcinoma
- PBC
- PSC
What is the most likely cause of fluctuating jaundice?
- Choledocholithiasis
- Stricture
- Pancreatitis
- Choledochal cyst
- PSC
What is the most likely cause if we have cholestatic jaundice with abdominal pain?
- Choledocholithiasis
- Pancreatitis
- Choledochal cyst
What is the most likely cause if we have cholestatic jaundice with cholangitis?
- Stone
- Stricture
- Choledochal cyst
What is the most likely cause if we have cholestatic jaundice with abdominal scar?
- Stone
2. Stricture
What is the most likely cause if we have cholestatic jaundice with irregular hepatomegaly?
HCC
What is the most likely cause if we have cholestatic jaundice with palpable gallbladder?
Carcinoma below the cystic duct (usually pancreas).
What is the most likely cause if we have cholestatic jaundice with abdominal mass?
- Carcinoma
- Pancreatitis (cyst)
- Choledochal cyst
What is the most likely cause if we have cholestatic jaundice with occult blood in stools?
Ampullary tumor.
What does the Courvoisier’s law suggest?
Jaundice due to a malignant biliary obstruction (e.g., pancreatic cancer).
What is the Charcot triad?
Characterizes cholangitis:
- Jaundice
- RUQ pain
- Fever
Mention some causes of hepatomegaly.
- Liver metastases
- Multiple or large hepatic cysts
- Cirrhosis (early): NAFLD, alcohol, hemochromatosis.
- Hepatic vein outflow obstruction.
- Infiltration: amyloid.
Mention some common causes of ascites.
- Malignant disease (hepatic, peritoneal).
- Cardiac failure
- Hepatic cirrhosis
Mention some other causes of ascites.
- Hypoproteinemia –> Nephrotic syndrome, protein-losing enteropathy, malnutrition.
- Pancreatitis.
- Lymphatic obstruction
- Hepatic venous occlusion (Budd-Chiari, veno-occlusive disease)
- Infection (TB)
Mention some rare causes of ascites.
- Meigs syndrome
2. Hypothyroidism
What happens in Meigs syndrome?
Right pleural effusion with or without ascites and a benign ovarian tumor –> Ascites resolves on removal of the tumor.
What is though to be the main factor leading to ascites in cirrhosis?
Splanchnic vasodilation.
Mediated by vasodilators (mainly NO) that are released when portal hypertension causing shunting of blood into the systemic circulation.
What is the appearance of the ascitic fluid in cirrhosis?
Clear, straw-coloured or light green.
What is the appearance of the ascitic fluid in malignant disease?
Bloody.
What is the appearance of the ascitic fluid in infection?
Cloudy.
What is the appearance of the ascitic fluid in biliary communication?
Heavy bile staining.
What is the appearance of the ascitic fluid in lymphatic obstruction?
Milky-white (chylous).
Mention some useful investigations regarding the ascitic fluid.
- Total albumin (plus serum albumin) and protein –> to calculate the serum-ascites albumin gradient (SAAG).
- Amylase
- Neutrophil count
- Cytology
- Microscopy and culture
What is the hepatic hydrothorax?
In 10% of patients with ascites, a RIGHT pleural effusion is found –> Most are small and only identified on CXR.
What is 96% predictive that ascites is due to portal HTN?
A gradient of more than 11g/L.
What is the main difference between transudate ascites caused by venous outflow obstruction due to cardiac failure and the one cause by cirrhosis?
Unlike cirrhosis, the TOTAL PROTEIN CONTENT is usually above 25g/L.
What identifies pancreatic ascites?
Ascites amylase activity above 1000U/L.
What does the management of ascites involve?
- Restricting Na and H2O intake.
- Diuretics –> No more than 1L/day removal.
- Paracentesis
- Patient should be weighed regularly.
Mention some drugs with high Na content that should be avoided in ascites.
- Alginates
- Antacids
- Antibiotics
- Phenytoin
- Sodium valproate
- Effervescent preparations (e.g. aspirin, Ca, paracetamol)
Mention some drugs that promote sodium retention and should be avoided in ascites.
- Carbenoxolone
- Corticosteroids
- Metoclopramide
- NSAIDs
- Estrogens
What is the 1st line diuretic for ascites?
Spironolactone (100-400mg/d).
It can cause painful gynecomastia and hyperK –> substitute with amiloride (5-10mg/d).
What may improve diuresis?
Bed rest –> More renal blood flow in the horizontal position.
Mention some complications of ascites.
- Renal failure
- Hepatorenal syndrome
- Spontaneous bacterial peritonitis
In what percentage of patients with advanced cirrhosis and ascites do we see hepatorenal syndrome?
10%.
How many types of hepatorenal syndrome do we have?
2 types.
What are the clinical features of type I hepatorenal syndrome?
- Progressive oliguria
- Rapid rise in serum Cr
- Very poor prognosis (death in less than 1 month without treatment).
- Usually NO proteinuria
What are the clinical features of type II hepatorenal syndrome?
- In patients with refractory ascites.
- Moderate and stable increase in serum Cr.
- Better prognosis than type 1.
Recurrence of spontaneous bacterial peritonitis is common. What may reduce this?
Prophylactic quinolones such as norfloxacin or ciprofloxacin.
What is the prognosis of ascites?
Only 10-20% of patients survive 5 years from the 1st appearance of ascites due to cirrhosis.
Mortality at 1 year is 50% following first episode of bacterial peritonitis.
What is basically hepatic encephalopathy?
A neuropsychiatric syndrome caused by liver disease.
What is the differential diagnosis of hepatic encephalopathy?
- Intracranial bleed (subdural, or extradural hematoma).
- Drug or alcohol intoxication.
- Delirium tremens/alcohol withdrawal.
- Wernicke’s encephalopathy.
- Primary psychiatric disorders
- Hypoglycemia
- Neurological Wilson disease
- Post-ictal state
Mention some factor that precipitate hepatic encephalopathy.
- Drugs (especially sedatives, antidepressants)
- Dehydration (including diuretics, paracentesis)
- Portosystemic shunt
- Infection
- Hypokalemia
- Constipation
- Increased protein load (including gi bleeding)
Are focal neurologic signs features of hepatic encephalopathy?
No - if present other causes must be sought.
What is the hepatocerebral degeneration?
CHRONIC hepatic encephalopathy –> Combination of symptoms: Cerebellar dysfunction, Parkinsonian syndromes, spastic paraplegia, and dementia.
What is the basis of the Pathophysiology of hepatic encephalopathy?
Disturbance of brain function provoked by circulating neurotoxins that are normally metabolized by the liver.
What do most patients with hepatic encephalopathy have?
Some degree of hepatic failure and portosystemic shunt.
Mention some substances that are considered important factors in hepatic encephalopathy.
- Ammonia
- Other nitrogenous substances produced in the gut by bacteria.
- GABA
- Octopamine
- Amino acids
- Mercaptans
- Fatty acids that act as neurotransmitters