GI- the last hurdle

Question 1

define acute hepatic failure

Answer 1

severe lver injury for fewer than 26 weeks duration. + encephalopathy + impaired synthetic function (inr > 1.5) - in a patient without chirrosis or preexisting liver disease.

high morbid + mortality but getting better as ICU gets better

Question 2

causes of acute hepatic failure + signs and symptoms

Answer 2

hepatitis (viral OR drug induced)hypoxia induced liver injury, budd-chiari syndrome, veno-occlusive disease, mushroom ingestion etc etc etc - long list .

paracetamol toxicity is the most comon cause. A+E are the most common viruses

S+S: jaundice, fetor hepaticus- strong sweet breath
asterixis
drowsy + confused + slurred speech.

Question 3

pathology of hepatic encephalopoathy

Answer 3

accumulation of glutammine 2’ to ammonia crossing the BBB.
accumulation of oxidative stress
depletion of ATP and GTP meaning astrocites swell and edema formation.

Question 4

investigation and treatment of acute hepatic failure

Answer 4

Ix:
INR > 1.5
elevated bili, aminotransferases, thrombocytopenia + anaemia, hypoglycaemia, inc ammonia

could also show acute renal injury.

CT chest abdo pelvis.
USS +/- doppler can be considred if vascular concern.
Brain CT/MRI to rule out chronic aetiology of neuro manifestations.

Rx: supportive care + management of complications untill cause known.

if paracetamol- NAC of activated charcoal (if within 4 hrs)

rising aminotransferases + or worsening + coaulopathy indicates hepatic nercosis.

consider liver transplantation.

if grade 3 encephalopothy- intubate and sedate with minimal suctioning and stimulation.

Question 5

discuss alcoholic hepatitis

Answer 5

inflmmation of the liver due to excessive intake of alcohol.- probably about 10 years worth (8-10 a day)

found in association with fatty liver.

can present acutely- after big binge - or chronically. - but within 60 days of a big one.

important- alcoholic steatohepatitis- is a histological diagnosis
alcoholic hepatitis is a clinical diag.

Question 6

signs and symptoms + Ixof alcoholic hepatitis

Answer 6

mild- fever, RUQ pain, elevates aminotransferases- normalising with sobriety,

severe- jaundice, ascites, hepatic encephalopathy, coagulopathy.

Ix:
should have imaging to rule out obstruction + other liver disease.—–> USS

LFTs- inc AST: ALT 2:1 (opposite of other liver disorder)
Carbohydrate-deficient transferrin- most reliable marker for chronic alcoholism.
CRP is a good marker of alcoholic hepatitis.

Question 7

management of alcoholic hepatitis

Answer 7

classify using child-pugh score.

abstinance + adequate nutritional support

short course pred 40mg/day 28 days.
- if no response in a week stop.
pentoxifylline
NAC
transplantation

Question 8

discuss child-pugh score

Answer 8

measures bili
albumin
inr
ascites
encephalopathy

scores them all-
5-6 points- 100% one year survival- 85% 2 year

7-9- 80% one year survival- 60% 2 year

10-15- 45% one year- 35% 2 year

Question 9

discuss chirrosis

Answer 9

chronic- irreversable liver damage.

hepatocites replaced with fibrosis/ scar tissue.

nodules of fibrosis form shrinking the liver.
structural change affects flow through the liver- increacing resistance in vessels + portal hypertension

ccauses: booze, drugs. inflammation (thiink Hep A + B etc)
metabolic (NAFLD, A1 antitrypsin)

Question 10

signs and symptoms of Chirrosis + invstigations

Answer 10

hepatic jaundice
hepatomegaly
splenomealy
spider naevi- sign of inc oestrogen
palmer erythaema
gynecomastia + testicular atrophy.
bruising
ascites
asterixis (ammonia build up)

Ix:
LFT- raised ALT, AST, ALP
coagulation- raised prothrombin
fibroscan- helps assess the elasticitty of the liver. - ax degree of fibrosis

Question 11

how to examine the extent of fibrosis in chirrosis and NAFLD

Answer 11

FIB4 score

age X AST/PLT X root ALT

less than 1.45- no chirrohsis
abover 3.25- chirrosis

between is inconclusive.

Question 12

management of chirrosis + list some complications

Answer 12

meals every 2-3 hours
low sodium- minimise fluid retention
avoid alcohol
steroids in severe disease

in ascited- reduce sodium before giving spironolactone + then loop diuretics.

Complications-
malnutrition- no ability to store glycogen
cannot metabolise proteins
portal htn + splenomegaly

hepatocellular carcinoma
spontaneous bacterial peritoniti- caused by E.Coli —> ciproflaxin mx.

Question 13

discuss chronic liver disease

Answer 13

progressive deterioration of liver function over more than 6 months.

chirrosis is the final stage of liver function decline.

continuous cycle of inflammation, destruction, regeneration- fibrosis and chirrosis.

caued by alcohol, NAFLD, genetic causes, autoimmune etc etc.

Question 14

pathology of liver fibrosis

Answer 14

hepatic stellate cells - activated by liver injury, rtransform into myofibroblast like cells. – lay down extracellular matrix- collagen.

General signs and symptoms-
fatigue, anorexia, weight loss– or condition dependant

Question 15

stages of hepatic encephalopathy

Answer 15

0- sub clinical with normal mental status

1- trivial lack of awareness- euphoria/ anxiety + shortenend attention span. impaied additino + subtraction

2- letargy, apathy, disorientation to time, inappropriate behaviour

3- semi stupor- responsive to stimuli, confusion + gross disorientation

4- coma

Question 16

investigations of chronic liver disease + staging of chronic liver disease + preventative care.

Answer 16

CT/ USS

elastography. biopsy

Lab findings:
inc AST, ALT, ALP, GGT,– 2-3 x normal limit

bili conjugated > non conjugated

raised PT/INR

Stages:
hepatitis/ steatosis
fibrosis
chirrhosis
hepatocellular carcinoma

preventative care in CLD:
no alcohol
screen for Hep B+C
vaccinate A+B
avoid iron supplimentation
avoid over thr counter painkillers
maintain good lipid profile.

Question 17

discuss Non alcoholic fatty liver disease + its stages.

Answer 17

an umbrella term- covers liver disease without classical causes (alcohol, drug)

often diagnosed incidentally.
20-30% prevalence in western countries.

– generally the liver manifestation of metabolid syndrome

simple steatosis
statohepatitis
fibrosis
chirrosis
carcinoma

Question 18

risk factors for NAFLD + pathologenesis

Answer 18

obesity, diabetus, insulin resistance, metabolic syndrome.
1st degree relly with it.
arsenic exposure

accumulation of fat droplets due to insulin resistance in cytoplasm of hepatocites

excess delivery of free fatty acid and triglycerides to the liver + decreaced excretion leading to accumulation.
excess carbs is also a stimuus for denovo fatty acid synth in the liver.

multifactoral 2nd hit.
some infflammatory xdative stress is then applied to the already prone to injury liver.

hepatocites- baloon, aggregation, aPOPtosie and necrose.

Question 19

investigation of NAFLD

Answer 19

biopsy- more than 10% of hepatocites with fat droplets on biopsy- gold standard.
mildly elevated aminotransferases AST:ALT less than 1.

USS abdo

S+S: nausea, vom, jaundice, prrirotis, ascites, memory impairment, easy bleed, loss of appetite.
mild – moderate hepatomegaly.

Question 20

Rx of NAFLD + staging

Answer 20

lifestyle changes
3-5% weight loss, or 7-10% in NASH

survey for carcinoma
treat complications

Staging::
Grade1: steatosis up to 66%, occasional balooning zone 3 (most hypoxic) - mild/ no portal inflam

Grade 2: any degree of steatosis + obvious balooning, inflammation with polymorphs

Grade 3: panacinar steatosis, balooning, disarray inflam, polymorphs, chronic moderate portal inflam.