Gastro - Chronic Liver Failure

Question 1

common causes of liver cirrhosis?

Answer 1

1. non-alcoholic fatty liver disease
2. alcoholic liver disease
3. viral hepatitis (B or C)
4. other: haemochromatosis, autoimmune hepatitis, a1-antitrypsin deficiency, Budd-Chiari syndrome, primary sclerosing cholangitis, primary biliary cholangitis

Question 2

pathophysiology of liver cirrhosis

Answer 2

Hepatic stellate/ito cells lose vitamin A storage capacity and differentiate into myofibroblasts - deposit collagen into perisinusoidal space causing liver fibrosis.

1. Distortion of hepatic vasculature… portal HTN causing: ascites, oesophageal varices, haemorrhoids, caput medusa, renal hypoperfusion and RAAS activation, portosystemic shunting.
2. Hepatocyte damage… decreased albumin and clotting factor synthesis and decreased detoxification function.

Question 3

explain why cirrhotic pts may be malnourished

Answer 3

1. decreased intake: anorexia, ascites-related early satiety
2. impaired digestion: decreased bile salt solubilisation
3. malabsorption: portal HTN causing intestinal mucosa congestion
4. impaired nutrient storage, esp. water soluble vitamins
5. impaired protein metabolism

Question 4

describe the common symptoms of liver cirrhosis

Answer 4

1. fatigue, malaise
2. anorexia, nausea, bloating and weight loss
3. pruritis, jaundice
4. easy brusing and bleeding, oesophageal varices
5. poor concentration and memory

Question 5

describe possible physical signs of liver cirrhosis

Answer 5

1. ascites, caput medusae, splenomegaly (portal HTN)
2. peripheral oedema
3. jaundice
4. spider naevi, telangiectasia
5. bruising, petechiae or purpura
6. palmar erythema
7. hair loss and gynaecomastia
8. leukonychia
9. finger clubbing
10. dupuytren’s contracture
11. hepatomegaly and nodular liver

Question 6

which blood tests would you request in a pt with ?liver cirrhosis?

Answer 6

Assess liver function:

1. LFTs: AST and ALT raised due to hepatocyte damage, y-GT high in active alcoholics
2. albumin: hypoalbuminaemia in advanced cirrhosis
3. coagulation screen: PT reduced in advanced cirrhosis

Assess effects of cirrhosis:

4. FBC: occult bleeding can cause anaemia, hypersplenism can cause thrombocytopenia, macrocytosis can suggest alcoholism
5. ferritin: if low may indicate iron deficiency from diet or blood loss; raised in haemochromatosis
6. UandEs: hyponatraemia may be present due to increased activity of ADH, poor renal function may represent hepatorenal syndrome

Determine cause:

7. viral antibody screen: hepB or C?
8. fasting glucose/insulin/triglycerides and uric acid levels: measured if NASH suspected
9. autoantibody screen: anti-mitochondrial antibodies associated with primary biliary cholangitis
10. a1-antitrypsin: ?deficiency
11. fasting transferrin saturation and HFE mutation: ?haemochromatosis

Question 7

how should Dx of liver cirrhosis be confirmed?

Answer 7

1. transient elastography (fibroscan)
2. +/- liver biopsy

USS, CT and MRI may be used to detect cirrhosis complications such as splenomegaly, ascites or hepatocellular carcinoma