GI - Hepatomegaly, Cirrhosis, Ascites and Hepatocellular Carcinoma

Question 1

List the most common causes of hepatomegaly

Answer 1

• Cirrhosis: if early disease, later on decreases in size (non-tender, firm liver)
• Malignancy: metastatic spread or primary hepatoma (hard, irregular liver edge)
• Right heart failure: firm, smooth, tender liver edge- may be pulsatile

Question 2

List other less common causes of hepatomegaly

Answer 2

• Viral hepatitis
• glandular fever
• malaria
• abscess: pyogenic/amoebic
• hyatid disease
• haematological malignancies
• haemochromatosis
• sarcoidosis/amyloidosis

Question 3

Name 3 causes of liver cirrhosis

Answer 3

• Alcohol
• non-alcoholic fatty liver disease
• viral hepatitis (B and C)

Question 4

How do you diagnose liver cirrhosis? What other Ix should you do for newly diagnosed cirrhosis pts?

Answer 4

• Traditionally: liver biopsies - C/I b/c of bleeding/pain now
• Now: transient elastography - ‘Fibroscan’ - measures stiffness of liver with a probe - proxy for fibrosis

Other Ix

• Upper endoscopy to check for varies in pts with new cirrhosis diagnosis
• liver ultrasound (+/- alpha-feto protein to check for Hepatocellular carcinoma)

Question 5

According to NICE, which patients should be offered transient elastography ‘fibroscans’?

Answer 5

• People with hepatitis C virus infection
• men who drink >50 units alcohol/week or women who drink >35 units alcohol/week for several months
• People diagnosed with alcohol related liver disease

Question 6

Ascites: what does the serum-Ascites albumin gradient (SAAG) tell you about the cause?

Answer 6

SAAG > 11g/L = portal hypertension problem
-Eg: Cirrhosis, alcoholic hepatitis, cardiac Ascites, massive liver mets, Budd-Chiari syndrome, portal vein thrombosis, fatty liver of pregnancy

SAAG < 11g/L = malignancy or TB problem
-Eg: peritoneal carcinomatosis, tuberculous peritonitis,

Question 7

What is the management of Ascites?

Answer 7

• reduce diet sodium
• fluid restriction
• aldoestone antagonists: spironolactine
• drainage if tense Ascites - therapeutic abdo paracentesis
• prophylactic ABX to reduce risk of spontaneous bacterial peritonitis - oral Ciprofloxacin
• some pts may need TIPS - transjugular intrahepatic portosystemic shunt

Question 8

What is the most common cause of Hepatocellular carcinoma (HCC) worldwide? In Europe?

Answer 8

• world-wide: Chronic hep B

- Europe: chronic hep C

Question 9

What are some risk factors for developing HCC?

Answer 9

-Main risk factor: cirrhosis (eg secondary to hep B/C, alcohol, haemochromatosis, primary biliary cholangitis)

Others

• alpha 1 antitrypsin deficiency
• glycogen storage disease
• drugs: OCP, anabolic steroids
• DM/metabolic syndrome

Question 10

What are the features of HCC?

Answer 10

• Tends to present late
• features of liver cirrhosis may be seen: jaundice, Ascites, RUQ pain, hepatomegaly, pruritus, splenogemaly
• Possible presentation: decompensation in a pt with chronic liver disease

Question 11

In which groups should we consider screening for HCC? What test is useful?

Answer 11

Ultrasound +/- alpha-fetoprotein should be used in high risk groups:

• Pts with liver cirrhosis 2ndary to hepatitis B/C or haemochromatosis
• men with liver cirrhosis 2ndary to alcohol

Question 12

What are the Mx options for pts with HCC?

Answer 12

• Early disease: surgical resection
• liver transplant
• Radiofrequency ablation
• transarterial chemoembolisation
• sorafenib: multikinase inhibitor