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Gastro - Liver Cirrhosis Flashcards

1
Q

What is liver cirrhosis a result of?

A

Chronic inflammation
Damage to hepatocytes

Functional cells replaced with scar tissue

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2
Q

What effect does fibrosis have in the liver?

A

Structural
Blood flow

Leads to an increase in resistance

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3
Q

What effect does increased resistance have on hepatic vasculature?

A

Portal hypertension

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4
Q

What are the common causes of liver cirrhosis?

A

Alcohol-related liver disease
Non-alcoholic fatty liver disease
Hepatitis B
Hepatitis C

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5
Q

What are the rarer causes of liver cirrhosis?

A
  • Autoimmune hepatitis
  • Primary biliary cirrhosis
  • Haemochromatosis
  • Wilson’s disease
  • Alpha-1 antitrypsin deficiency
  • Cystic fibrosis
  • Amiodarone, methotrexate and sodium valproate
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6
Q

What are the examination findings of liver cirrhosis?

A

ALCOHOLICS
Ascites
Liver flap (asterixis)
Cachexia
Oversized spleen
Hand signs - palmar erythema, leukonychia
Oversized liver
Long INR and bruising
Itching
Caput medusae
Spider naevi

Jaundice
Gynaecomastia and testicular atrophy

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7
Q

What causes small nodular liver, splenomegaly and palmar erythema?

A

Small nodular liver
As the liver becomes more cirrhotic and covered in nodules it atrophies

Splenomegaly
Portal hypertension

Palmar erythema
Raised oestrogen levels

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8
Q

What causes gynaecomastia and testicular atrophy?

A

Endocrine dysfunction

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9
Q

What causes bruising, excoriations, caput medusae, leukonychia and asterixis?

A

Bruising
Abnormal clotting

Excoriations
Extreme itching as the liver loses function

Caput medusae
Portal hypertension

Leukonychia
Hypoalbuminaemia

Asterixis
Decompensated liver disease

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10
Q

When is a non-invasive liver screen carried out?

A

Abnormal lfts with no clear cause

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11
Q

What does a non-invasive liver screen involve?

A

Ultrasound liver (diagnose fatty liver)
Hepatitis B and C serology
Autoantibodies
Immunoglobulins
Caeruloplasmin
Alpha-1 antitrypsin levels
Ferritin and transferrin saturation

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12
Q

What autoimmune conditions are looked at in a non-invasive liver screen?

A

Autoimmune hepatitis
Primary biliary cirrhosis
Primary sclerosing cholangitis

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13
Q

What immunoglobulins are looked at in a non-invasive liver screen?

A

Autoimmune hepatitis
Primary biliary cirrhosis

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14
Q

What is caeruloplasmin a marker of?

A

Wilson’s disease

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15
Q

Why do you look at ferritin and transferrin saturation?

A

Hereditary haemochromatosis

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16
Q

What autoantibodies are relevant to liver disease?

A

Antinuclear antibodies (ANA)

Smooth muscle antibodies (SMA)

Antimitochondrial antibodies (AMA)

Antibodies to liver kidney microsome type-1 (LKM-1)

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17
Q

What is the difference between cirrhosis and decompensated cirrhosis?

A

May have normal LFTs cirrhosis

In decompensated all liver markers are deranged with raised
Bilirubin, ALT,AST and ALP

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18
Q

What other blood test results indicate decompensated liver disease?

A

Low albumin
Increased prothrombin time
Thrombocytopenia
Hyponatraemia
Urea and creatinine (hepatorenal syndrome)
Alpha-fetoprotein (hepatocellular carcinoma tumour marker)

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19
Q

What is the enhanced liver fibrosis test used for?

A

First-line for assessing fibrosis in non-alcoholic fatty liver disease

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20
Q

What markers are looked at in enhanced liver fibrosis blood test?

A

HA
P3NP
TIMP-1

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21
Q

What do difference scores in enhanced liver fibrosis test indicate?

A

10.51 or above- advanced fibrosis

Under 10.51- unlikely advanced fibrosis

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22
Q

How often should an enhanced liver fibrosis test be carried out in NAFLD?

A

Every 3 years

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23
Q

How does NAFLD appear on ultrasound?

A

Fatty changes appear as increased echogenicity

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24
Q

In liver cirrhosis what does an ultrasound show?

A
  • Nodularity of liver surface
  • Corkscrew appearance to hepatic arteries with increased flow as they compensate for reduced portal flow
  • Enlarged portal vein with reduced flow
  • Ascites
  • Splenomegaly
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25
What can be used to screen for hepatocellular carcinoma?
Ultrasound Alpha-fetoprotein
26
What is a transient elastography used for?
AKA FibroScan Used to assess stiffness of the liver using high-frequency sound waves Helps determine degree of fibrosis to test for liver cirrhosis
27
**Who** is transient elastrography used for?
Patients at risk of cirrhosis: - Alcoholic-related liver disease - Heavy alcohol drinkers (men drinking over 50 units, women over 35 units) - NAFLD and advanced liver fibrosis (score over 10.51) - Hepatitis C - Chronic hepatitis B
28
What other investigations are used for liver cirrhosis?
**Endoscopy** Assess and treat oesophageal varices when portal hypertension suspected **CT and MRI** Looked for hepatocellular carcinoma **Liver biopsy** Confirm cirrhosis diagnosis
29
What is a MELD score?
Model for End-Stage Liver Disease Use every 6 months in patients with compensated cirrhosis Gives estimated 3-month mortality as a percentage
30
What is the Child-Pugh score?
Uses 5 factors to assess cirrhosis severity and prognosis **A**-Albumin **B**-Bilirubin **C**-Clotting (INR) **D**-Dilatation (ascites) **E**-Encephalopathy
31
What are the principles of general management of liver cirrhosis?
**Treat underlying cause** Monitoring complications Managing complications Liver transplant
32
What does monitoring for complications involve?
- **MELD score** every 6 months - Ultrasound and alpha-fetoprotein every 6 months for hepatocellular carcinoma - Endoscopy every 3 years for oesophageal varices
33
When is liver transplantation considered?
Features of decompensated liver disease **A**- Ascites **H**- Hepatic encephalopathy **O**- Oesophageal varices bleeding **Y**- Yellow (jaundice)
34
What is the 5-year prognosis once cirrhosis has developed?
50%
35
What are the important complications of cirrhosis?
- Malnutrition and muscle wasting - Portal hypertension, oesophageal varices and bleeding varices - Ascites and spontaneous bacterial peritonitis - Hepatorenal syndrome - Hepatic encephalopathy - Hepatocellular carcinoma
36
Why does cirrhosis lead to malnutrition and muscle wasting?
- Loss of appetite - Affected protein metabolism in liver, reduced amount of protein liver produces - Disrupted ability to store glycogen and release it when required - Less protein available for maintaining muscle tissue - Muscle tissue broken down for fuel
37
How is malnutrition managed?
- Regular meals - High protein and calorie intake - Reduced sodium intake to minimise fluid retention - Avoiding alcohol
38
Where does the portal vein come from?
Superior mesenteric vein Splenic veins
39
What is the purpose of the portal vein?
Delivers blood to the liver
40
What happens to the portal vein in cirrhosis?
Increased resistance to blood flow in the liver Increased back-pressure on the portal system Splenomegaly
41
What does back pressure in the portal system cause?
Swollen and tortuous vessels where collaterals form between portal systemic venous systems
42
Where do collaterals form?
Distal oesophagus - Oesophageal varices Anterior abdominal wall - caput medusae
43
What do patients with varices experience?
Asymptomatic until the varices start bleeding Due to high blood flow patients can **exsanguinate** (bleed out) very quickly
44
What prophylaxis can be used for bleeding in stable oesophageal varices?
Non-selective beta blockers, **propranolol**- first line Variceal band ligation (if beta blockers are contraindicated)
45
What does variceal band ligation involve?
Rubber band wrapped around base of the varices Cuts off blood flow through the vessels
46
How are bleeding oesophageal varices managed?
**Life-threatening emergency** - Immediate senior help - Blood transfusion (activate major haemorrhage protocol) - Treat coagulopathy (fresh frozen plasma) - Vasopressin analogues (terlipressin or somatostatin) - Prophylactic broad-spectrum antibiotics - Urgent endoscopy with variceal band ligation - Consider intubation and intesive care
47
What other options to control bleeding are there?
**Sengstaken-Blakemore tube** Inflatable tube inserted into the oesophagus to tamponade bleeding varices **Transjugular intrahepatic portosystemic shunt (TIPS)**
48
What is a transjugular intrahepatic portosystemic shunt (TIPS)?
Wire inserted into jugular vein (under x-ray guidance) Down vena cava into liver via hepatic vein Connection made through liver between hepatic vein and portal vein and stent inserted
49
What does a transjugular intrahepatic portosystemic shunt do?
Allows blood flow directly from portal vein to hepatic vein Relieves pressure in portal system
50
What are the main indications of a transjugular intrahepatic portosystemic shunt?
Bleeding oesophageal varices Refractory ascites
51
What is ascites?
Fluid in the peritoneal cavity
52
What causes ascites?
Increased pressure in portal system causes fluid to leak out of capillaries in liver and other organs into peritoneal cavity
53
Why does blood pressure decrease in the kidneys in ascites?
Drop in circulating volume caused by fluid loss into peritoneal cavity
54
How do the kidneys respond to decreased blood pressure secondary to liver cirrhosis?
Renin release RAAS Causes a transudative ascites
55
What are the management options of ascites?
Low sodium diet Aldosterone antagonists Paracentesis (ascitic tap or ascitic drain) Prophylactic antibiotics (ciprofloxacin) Transjugular intrahepatic portosystemic shunt (refractory ascites) Liver transplant
56
What is spontaneous bacterial peritonitis?
Infection develops in ascitic fluid and peritoneal lining without clear source of infection
57
How often does spontaneous bacterial peritonitis occur?
10-20% of time in patients with ascites Mortality of 10-20%
58
How does spontaneous bacterial peritonitis present?
Fever Abdominal pain Deranged bloods Ileus Hypotension
59
What are the most common causative organisms of spontaneous bacterial peritonitis?
Escherichia coli Klebsiella pneumoniae
60
What does management of spontaneous bacterial peritonitis involve?
Sample of ascitic fluid cultured IV broad-spectrum antibiotics e.g. tazocin
61
What is hepatorenal syndrome?
Impaired kidney function caused by reduced blood flow to the kidney due to liver cirrhosis and portal hypertension Poor prognosis unless patient has liver transplant
62
What causes hepatorenal syndrome?
Portal hypertension causes portal vessels to release vasodilators causing vasodilation in the splanchnic circulation Vasodilation causes reduced blood pressure Kidneys activate RAAS Vasoconstriction of renal vessels, combined with low systemic pressure resulting in kidneys being starved of blood and significantly reduced kidney function
63
What is hepatic encephalopathy?
AKA portosystemic encephalopathy Caused by build up of neurotoxic substances affecting the brain Especially **ammonia**
64
Why does ammonia build up in patients with cirrhosis?
Hepatocyte impairment prevents them from metabolising ammonia into harmless waste products Collateral vessels between portal and systemic circulation mean ammonia bypasses the liver and enters the systemic system directly
65
How does hepatic encephalopathy present?
**Acutely** Reduced consciousness Confusion **Chronically** Personality changes Memory and mood changes
66
What factors trigger or worsen hepatic encephalopathy?
Constipation Dehydration Electrolyte disturbance Infection GI bleeding High protein diet Sedative medications
67
How is hepatic encephalopathy managed?
Lactulose (aim for 2-3 soft stools daily) Antibiotics (rifaximin) reduce number of intestinal bacteria producing ammonia Nutritional support (NG tube)
68
How does lactulose work to reduce ammonia?
Speeds up transit time and reduces constipation - Clearing ammonia before absorption Promotes bacterial uptake of ammonia for protein synthesis Changes pH of intestines contents - More acidic, kills ammonia-producing bacteria
69
Why is Rifaximin the choice of antibiotic for hepatic encephalopathy?
Poorly absorbed, stays in GI tract Neomycin and metronidazole are alternatives

Medicine (111 decks)

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