Gastro: Chronic Liver Disease and Cirrhosis Flashcards
there are 3 places where stigmata for chronic liver disease
- hands
- chest
- abdomen
what type of stigmata can you find on the hands?
- clubbing
- leuconychia
- palmar erythema
- dupuytren’s contracture
what type of stigmata can you find on the chest?
- spider naevi
- gynaecomastia
- loss of body hair
what type of stigmata can you find on the abdomen?
- caput medusae
- nodular hepatomegaly
- splenomegaly
what are the 3 signs of decompensation
- jaundice
- fluid overload
- encephalopathy
what are signs of fluid overload?
- ankle oedema
- ascites
what are signs of encephalopathy?
- flapping tremor
- confusion
- drowsiness
- coma
what are the causes of cirrhosis?
- non-alcoholic steatohepatitis (NASH)
- alcohol abuse
- viral hepatitis
- autoimmunity (chronic active hepatitis)
- primary biliary cholangitis
- haemochromatosis
what does the hepatic screen consist of?
- HCV antibody
- HBsAg
- ASMA
- ANA
- ALKMA
- AMA
- Ferritin
what are rarer causes of cirrhosis?
- wilson’s disease
- primary sclerosing cholangitis
- alpha1-anti-trypsin deficiency
- drugs: amiodarone, methotrexate
- budd-chiari syndrome
- rare metabolic conditions
how do you check for PSC?
- MRI/ERCP
- liver biopsy
how do you assess the severity of cirrhosis?
Child-Pugh score (grades A to C - C is the worst prognosis)
what does the child-pugh score take into consideration?
- encephalopathy
- ascites
- bilirubin
- albumin
- INR
who should be considered for a liver transplant?
patients going from a Grade B to Grade C
what are the complications of cirrhosis?
- effective hypovolaemia
- GI bleeding
- hepatic encephalopathy
- hepatocellular carcinoma
- osteoporosis and muscle wasting
what happens with effective hypovolaemia
cardiac output does not compensate well, leading to activation of the renin-angiotensin system, sympathetic system and ADH
what happens with worsening renal hypoperfusion?
- salt retention leads to ascites
- hyponatremia
- rise in creatinine
what do you check in ascites?
- WCC
- biochemistry
- cytology
- culture
management of ascites
- salt restriction
- diuretics (spironolactone: bumetanide)
- therapeutic ascitic drainage in tense ascites
investigations in secondary bacterial peritonitis
- high neutrophils
- high leucocytes
- culture results in monomicrobial/negative result
how you do manage secondary bacterial peritonitis?
- plasma expansion with albumin
- norfloxacin, ceftriaxone, carbipenems/tazocin
- norfloxacin 400mg daily life-long
which criteria are considered to diagnose secondary bacterial peritonitis?
Runyan’s criteria
- total protein
- glucose
- LDH
- ULN serum
which additional tests are specific for secondary bacterial peritonitis?
- CEA
- ALP
management of hepatorenal syndrome
- albumin
- terlipressin IV
- eventually, they need a transplant
what are the common causes of upper GI bleeding?
- oesophageal varices
- gastric varices
- portal hypertensive gastropathy
- gastric and duodenal ulcers
what should you ask about in cases of upper GI bleeding?
- haematemesis
- melaena
- rectal bleeding
acute management of GI bleeding
- ABC
- correct hypovolaemia
- cross-match
- urgent gastroscopy to diagnose and stop the bleeding
- FFP and platelet transfusion depending on the INR and platelet count
- IV cefotaxime 2g TDS
- IV terlipressin 2mg/4hr
- lactulose PO/NG/enema
- ITU/HDU support
treatment of oesophageal varices using gastroscopy
sclerotherapy +/- banding
treatment of gastric varices using gastroscopy
glue injection
treatment of ulcers using gastroscopy
adrenaline injection and clips
what methods should you use if bleeding is not controlled by gastroscopy?
- sengstaken tube
- oesophageal stent
- transjugular intrahepatic portosystemic shunting
- surgery: oesophageal transection, portocaval shunt
stages of hepatic encephalopathy
Grade 0: no encephalopathy
Grade 1: short attention span; reversed sleep cycle; mood changes
Grade 2: mild confusion and drowsiness; asterixis
Grade 3: moderate confusion and drowsiness
Grade 4: unarousable
can the patient recover from hepatic encephalopathy?
yes, this is a completely reversible thing
what can trigger hepatic encephalopathy?
- GI bleeding
- sepsis without secondary bacterial peritonitis
- alcoholic binge
- surgery
- electrolyte imbalances
- constipation
- drugs: NSAIDs, diuretics, codeine, sedatives
how can you manage hepatic encephalopathy?
- ABC
- admit Grade 3/4 patients into ITU
- correct the trigger factors
- lactulose via PO, NG or enema
- ensure adequate nutrition
- protein restriction leads to malnutrition is thus, not useful
what is rifaximin?
- non-absorbed oral antibiotic used against gram positive and negative, aerobes and anaerobes
- licensed for use in hepatic encephalopathy
- dose: 550mg BD/400mg TDS
what does the prognosis and treatment of HCC depend on?
- size of the lesion/s
- hepatic function
which radiological techniques are used in HCC lesions?
- contrast enhanced US
- triphasic spiral CT scan
- MRI scan
less likely:
- PET/CT
- hepatic angiography
- liver biopsy
how can you detect HCC early?
- US and AFP screening every 6 months
- annual screening for HBV and HCV carriers
- suspect if there is a unexplained deterioration in cirrhotic patients
how do you treat HCC?
- surgery: resection, liver transplantation
- percutaneous techniques: ethanol injection, radiofrequency ablation, transarterial chemoembolisation, systemic therapy
