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NUR5801G > Gastro-Liver disease > Flashcards

Gastro-Liver disease Flashcards

1
Q

What are the components of LFT

A

Albumin, Total Bilirubin
ALT (Alanine aminotransferase (SGPT))
AST(Aspartate aminotransferase (SGOT))
ALP (Alkaline Phosphatase)
GGT (Gamma
Glutamyl Transpeptidase)
Coagulation profile (PT/INR)

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2
Q

Which component of LFT will determine the liver function?

A
  1. PT/INR
  2. Bilirubin
  3. Albumin
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3
Q

Which component of LFT will determine hepatocellular damage?

A
  1. ALT
  2. AST
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4
Q

Which component of LFT will determine intra or extra hepatic biliary disease?

A
  1. ALP
  2. GGT
  3. Bilirubin
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5
Q

What can AST/ALT ratio tell about the etiology of liver injury

A

(a) > 2: Alcoholic hepatitis, space occupying lesion
(b) 1-2: cirrhosis, drugs
(c) < 1: viral hepatitis

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6
Q

A raise in GGT indicates

A

alcohol or drugs (anti-epileptic) use

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7
Q

What picture does predominantly raised ALT/AST paint?

A

Hepatitic picture

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8
Q

What picture does predominantly raised ALP and GGT paints?

A

Cholestatic picture
(but ddx if isolated raised ALP)

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9
Q

what does a mild raise in ALT and AST signify

A

Fatty liver, drug induced, chronic hepatitis

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10
Q

How would you investigate a mildly raise AST/ALT?

A

HBsAg, Anti HBs, Anti HCV, U/S HBS
2nd line: ANA, ASMA, AMA, Globulin, IgG, Ceruloplasmi

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11
Q

How would you investigate a raised ALP and GGT?

A

U/S HBS then MRCP to look for choledocholithiasis

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12
Q

What presents with isolated hyperbilirubinemia?

A

Gilbert’s syndrome

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13
Q

What are intrahepatic causes of cholestasis?

A
  1. Hepatitis (viral/alcohol)
  2. Idiopathic adult ductopenia
  3. Genetic
  4. Malignancy
  5. Pregnancy
  6. Prolonged TPN
  7. Primary biliary cirrhosis
  8. Postoperative state
  9. Primary sclerosing cholangitis
  10. Sepsis
  11. Granulomatous disease
  12. Autoimmune cholangitis
  13. Infiltrative
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14
Q

What is liver cirrhosis?

A

*Liver cirrhosis is the result of many
years of repeated damage to the liver
*Leads to formation of scar tissue in
the liver
*This results in hardening of the liver
(cirrhosis) and liver dysfunction
*Cirrhosis is considered to be
irreversible and leads to liver failure,
liver cancer and death

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15
Q

What is liver fibrosis?

A

Fibrosis or scarring in the liver is a generic wound healing response to chronic
liver disease that occurs regardless of etiology of the underlying disease

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16
Q

Diagnosis of liver fibrosis

A
  1. Serum tests eg. FibroTEST but low accuracy
  2. Fibroscan
  3. Liver biopsy (gold standard)
  4. MRI elastography (not widely available
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17
Q

What are the most common etiology of liver cirrhosis in Singapore

A
  1. Chronic hepatitis B,
  2. alcoholic liver disease
  3. NAFLD
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18
Q

What is the definition of liver cirrhosis?

A

A late stage of progressive
hepatic fibrosis characterized by distortion of hepatic
architecture and formation of regenerative nodules

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19
Q

How do you diagnose liver cirrhosis?

A
  1. liver biopsy is the most accurate but invasive
  2. Fibroscan most accurate for early diagnosis of subclinical cirrhosis (70-80% accuracy)
  3. Biochemical (LFT)
  4. Clinical S/S (ascites, jandice, dark urine, splenomegaly, spider naevi, palmar erythema, hemetemesis/malena stool, encephalopathy, liver Ca)
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20
Q

How to assess severity of liver cirrhosis?

A
  1. Compensated vs. decompensated
  2. Child’s Score – Child’s A(compensated) / B(early decompensated) / C(late decompensated)
  3. MELD score (for transplant)
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21
Q

Advice to patients with liver cirrhosis

A
  1. All cirrhotics should be on regular follow-up with a specialist
  2. Regular blood tests to assess liver function
  3. Regular alfafetoprotein (AFP) blood test and liver ultrasound at
    least every 6 months to monitor for liver cancer
  4. Maintain a healthy and balanced diet
  5. Avoid alcohol intake
  6. Avoid excessive salt intake (low-salt diet)
  7. All cirrhotics should
    undergo gastroscopy for
    evaluation for varices
  8. If you have cirrhosis due to
    hepatitis B, you should be
    treated for hepatitis B to
    reduce the amount of virus
    in the blood
  9. Avoid drugs and herbal remedies that
    may potentially be toxic to the liver
  10. Avoid Non-steroidal anti-inflammatory
    drugs (NSAIDs) which can cause kidney problems in patients with advanced
    cirrhosis
  11. Do not take more than the
    recommended dosages of medications, including Panadol
22
Q

What is the treatment for hepatic varices?

A
  1. Propranolol or Carvedilol to reduce
    portal hypertension
  2. Endoscopic banding (ligation) for
    treatment of varices
23
Q

What is the treatment for ascites in liver cirrhosis?

A
  1. low salt diet
  2. Diuretics (spironolactone and frusemide) to
    increase clearance of water from the body
    —– (if severe)
  3. Abdominal paracentesis
  4. TIPS shunt
  5. Liver transplant
24
Q

Treatment for Hepatic Encephalopathy

A
  • clear bowel regularly to reduce toxins (BO 2-3x/day)
  • lactulose to prevent constipation
  • fleet enema to clear retained stools
  • Rifaximin to kill gut bacteria
25
What is the treatment for acute variceal bleed?
1. Start IV somatostatin / terlipressin / midodrine as soon as possible 2. Blood volume restitution using plasma expanders should be done cautiously with an aim to maintain Hb at 8 g/dL 3. Antibiotic prophylaxis should be instituted from admission (3rd generation cephalosporins or quinolones) 4. Early intubation if encephalopathic 5. Early endoscopy (w/n 12 hours) 6. Band ligation is the recommended form of endoscopic therapy for bleeding esophageal varices 7. Balloon tamponade should only be used in massive bleeding as a temporary bridge until definitive treatment can be instituted (maximum of 24h)
26
What is Transjugular Intrahepatic Porto-Systemic Shunt (TIPS)?
- radiological procedure whereby a metallic shunt is inserted from the hepatic vein to the portal vein - via the internal jugular vein - divert portal blood flow from the portal vein directly into the hepatic vein and back to the heart
27
What is the indication for TIPs
1. Acute variceal bleed 2. Refractory ascites 3. Refractory ascites with hydrothorax (pleural effusion) Hypatic hydrothorax without ascites 4. Budd-chiari syndrome (obstruction in hepatic vein preventing outflow of blood from liver)
28
What are some complications of TIPS
Hepatic encephalopathy - due to increased shunting of blood to the heart bypassing the liver Cardiac failure - from increased volume of venous return to the heart Hepatic ischemia / infarct - from obstruction of hepatic venous flow by the TIPS Re-stenosis 70 - due to blockage or blood clot forming within the shunt
29
What is the significance of the Hepatic venous pressure gradient (HVPG)mmHg?
The HVPG provides a quantitative assessment of the severity of portal hypertension 0-5 normal 5-10 Clinically nonsignificant PHT >=10 Clnically significant PHT (varices, ascites) >12 variceal bleed Reduce HPVG to <12 to reduce risk of variceal bleed
30
How would you evaluate new onset ascites in cirrhosis
Diagnostic paracentesis Peritoneal fluid should be sent for * FEME * Albumin, specific gravity, total protein, glucose * Culture & Sensitivity (aerobic/anaerobic) * Cytology (positive only in peritoneal carcinomatosis) * Serum ascites albumin gradient (SAAG), if SAAG ≥ 11 g/L = patient has portal hypertension (97% accuracy)
31
Definition of chronic Liver failure
Progressive deterioration in liver function injury and cirrhosis
32
Definition of acute liver failure
Rapid deterioration of liver function resulting in altered mentation and coagulopathy in individuals with previously normal livers
33
Definition of Acute on Chronic Liver Failure (ACLF)
Acute deterioration of liver function in patients with pre-existing liver disease
34
What is the definition of hepatitis
Inflammation of the liver that can be due to multiple causes. The causes are the diagnosis eg. Viral hepatitis
35
What is transaminitis?
An abnormal liver function test that indicate underlying biliary pancreatic and hepatology disease.
36
How is hepatitis A/E transmitted?
Oral – fecal route by contaminated food/water
37
How is hepatitis B transmitted?
Blood transmission by drug use and unprotected sexual contacts
38
How is hepatitis C transmitted?
Blood transmission by drug use, or by healthcare worker, improper sterilized equipment
39
How is hepatitis D transmitted?
Coinfection usually with HBV and is transmitted by drug use
40
What is the incubation period of hepatitis A?
14-28 days
41
What antibodies tests for Hepatitis A?
IgM: First antibody the body makes when it fights a new infection. IgG: take time to form after an infection or immunization (permanent antibody)
42
How is hepatitis A treated?
Avoid Hepatotoxicity or drugs clear by liver, Supportive care. Vaccination for prevention Postexposure prophylaxis is recommended for all unvaccinated individuals with significant exposure in the previous two weeks, including sex partners, household contacts, or known contaminated food sources *Hep A only spread via sex with an active Hep A carrier
43
What is the incubation period for hepatitis B?
1-4 months
44
Which serological markers would indicate an active Hep B infection?
HBsAg (Hepatitis B surface antigen)
45
Which serological markers would indicate immunity from infection
Anti-HBs (hepatitis B surface antibody)
46
What is a sample adult hepatitis B vaccination schedule
2 dose: 0/1 month Heplisav B 3 dose: 0/2/6 month Engerix-B, Recombivax B 3 dose: 0/1/6 month Twinrix
47
Hepatitis B Post Exposure Prophylaxis (PEP) is available for Hep B (True/false)
True
48
Perinatal Exposure is required for hepatitis B (True/false)
True
49
The chronicity rate of hepatitis C is low (True/False)
False. It is high at 60-85% regardless of age. As opposed to 5% in adult hepatitis B or 1% of liver failure in hepatitis A
50
What is the incubation period of hepatitis C?
2-20weeks
51
All hepatitis C should be treated (True/false)
True
52
What is a treatment to initiate for hepatitis C treatment?
Genotype 1-6 - Glecaprevir/pibrentasvir 3tab/day for 8 weeks Sofosbuvir/velpatasvir 1 tab/day for 12 weeks

NUR5801G (15 decks)

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