Hepatitis and Cirrhosis Flashcards
What is hepatitis?
Inflammation of the liver
What can acute hepatitis lead to?
- Recover
- Chronic hepatitis
- Fulminant hepatitis
What are the typical symptoms of acute hepatitis?
- Malaise
- Jaundice
- RUQ pain
- Pruritis
- Muscle and joint aches
- Fever (if viral)
What are the severe symptoms of acute hepatitis?
- Confusion
- Coagulopathy
- Renal impairment
What do blood tests typically show for acute hepatitis?
- Raised AST and ALT (often<1,000)
- Conjugated hyperbilirubinaemia
- Increased INR
What do blood tests show for severe acute hepatitis?
- Coagulopathy
- Renal impairment
What is chronic hepatits?
Low-grade inflammation of the liver >6 months
What are the symptoms of chronic hepatitis?
- Often none
- Fatigue
- Vague RUQ pain
What tests do you order for chronic hepatitis?
- Screening
Alcoholics, HIV +ve, pregnant women, IV drug users
- LFTs
Abnormal
- INR
- Albumin
- GGT
- Bilirubin
- US/CT
Look for fatty infiltrattionHow do you manage hepatitis?
Treat the causes
What is fulminant hepatitis?
Liver begins to fail very quickly within days or weeks
Defined as developing Encephalopathy within 28 days of jaundice
What is the prognosis for fulminant hepatitis?
Poor prognosis often needs transplantation
What is cirrhosis?
- Fibrosis (scarring) of the liver leading to regenerative nodule formation
- The final state of any chronic liver disease
What are the ‘loss of function’ symptoms of cirrhosis?
- Jaundice
- Coagulopathy and bruising
- Decreased drug metabolism
- Decreased hormone metabolism
- Increased sepsis
What are the ‘portal hypertension’ symptoms of cirrhosis?
- Varices
- Piles
- Encephalopathy
- Renal failure
- Splenomegaly
What causes Coagulopathy and bruising?
Lose ability to make clotting factors
What causes varices?
- Pressure builds up and blood starts to be redirected away from the liver through anastomoses towards systemic circulation.
- Anastomosing veins such as those in the oesophagus enlarge due to high pressure
- 1st bleed + 25% mortality, subsequent bleeds = 10% mortality
What causes ascites?
- Changes in renin-angiotensin axis causing salt and water retention which causes fluid to retain in the abdomen
- Fluid travels down pressure gradient into peritoneal cavity
What causes encephalopathy?
- Blood is bypassing liver though varices, toxins build up in blood, which can lead to brain damage
What causes splenomegaly?
- Fluid backs-up into spleen via splenic vein down the pressure gradient
What is an acsitic tap?
Take small volumes of ascites for analysis
In an ascitic tap if the serum albumin ascites gradient > 1.1 g/dL, what does it show?
Indicates ascites is due to portal hypertension
In an ascitic tap if serum albumin ascites gradient < 1.1 g/dL , what does this show?
Indicates cause is due to peritoneal disease (exudate)
In an ascitic tap if microscopy shows >500 which cells per mm3, what does this show?
Indicated spontaneous bacterial peritonitis
What can cause cirrhosis?
- Alcoholism
- Infection
Chronic hep B and C - NASH
- Autoimmune liver disease
Primary biliary cholangitis - Hereditary
Hemochromatosis
Wilson’s disease - Drug-induced
Medication - amiodarone, methyldopa, methotrexate etc.
Paracetamol OD
What is primary biliary cholangitis?
- Progressive inflammation and fibrosis of the bile ducts in the liver.
- This causes to destruction of intrahepatic bile ducts, leading to cholestatsis, cirrhosis and liver failure
What is cholestasis?
The reduction or stoppage of bile flow
What is hemochromatosis?
- Increased Fe absorption from GI tract, leading to chronic deposition of iron in the tissues
- In the liver, iron-associated lipid peroxidation (“steal” electrons from the lipids in cell membranes, resulting in cell damage) induces hepatocyte apoptosis causing liver fibrosis
What are the signs of cirrhosis?
- Leukonychia (white nails)
- Palmar erythema
- Spider naevi
- Polished nails
- Bruising
- Finger clubbing
- Jaundiced sclera
- Caput medusa
- Abdominal distention
Flanks - Splenomegaly
- Gynaecomastia
- Wilson’s disease
- Chronic obstruction
- Non-palpable liver
What are palmar erythma, spider nasevi and gynaecomastia caused by?
Liver cannot breakdown oestrogen, so there is excess in the blood causing increased vascularity
What blood test would you order for cirrhosis and what do they show?
- FBC
Raised MCV
- LFTs
Raised ALT and AST
Raised GGT
Raised ALP
Raised bilirubin
Low albumin
- Clotting
Increased INRWhat investigations would you order for cirrhosis and what would they potentially show?
- Ultrasound
Fatty changes
- Fibroscan
Elasticity of liver
- Endoscopy
Oesophageal varices
- CT/MRI
Fatty changes
Hepatocellular carcinoma
Hepatosplenomegaly
Abnormal blood vessel changes
Ascites
- Liver biopsyWhat is the difference between compensated and decompensated liver cirrhosis?
- Compensated = asymptomatic stage
- Decompensated = presence or development of overt complications
What may precipitate decompensated liver cirrhosis?
- Infection
- Alcoholic binge
- GI bleed
- Hypoglycaemia
What is the management of liver cirrhosis?
- Good nutrition
- Alcohol abstinence
- Avoid:
NSAIDs, opiates and sedatives - Ultrasound and alpha-fetoprotein every 6 months
Check for hepatocellular carcinoma
What is liver failure?
The development of coagulopathy (INR>1.5) and encephalopathy
What are the stages of alcoholic liver disease?
- Hepatic steatosis (fatty liver)
- Alcoholic hepatitis
- Cirrhosis
What is the treatment for alcoholic liver disease?
- Alcohol abstinence
- Treat complications
Before coticosteroids - Corticosteroids
- Referral for liver transplant in severe disease
MUST abstain from alcohol for 3 months
