Hepatobiliary Disease Flashcards by Holly Pettitt

Biliary system

Main = liver

Other - pancreas, stomach, gallbladder, common bile duct…

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Liver functions (4)

Synthesis - proteins, cytokines, TAG, haem, bile salt
Storage - folate, glycogen, Vit A,D,E,K, B12
Metabolism - fat, CHO
Degradation - detoxification, inactivation of hormones, destruction of RBC

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Chronic liver disease (3)

Compensated liver disease
Decompensated liver disease
Cirrhosis

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Chronic liver disease:

Complications reflect degree of damage

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Chronic liver disease:

Compensated

Asymptomatic

Can occur with up to 80% of liver damage

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Chronic liver disease:

Decompensated liver disease

Syptomatic
Child-pugh classification system

Symptoms - ascites, jaundice, variceal bleeding, encephalopathy

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Chronic liver disease:

Cirrhosis

Irreversible damage to liver
Hepatocyte replaced by fibrosis
Changes flow of blood through liver => portal hypertension -> ascites or varices
Metabolic changes - glucose intolerance, malnutrition

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Types of liver disease

Infections
Toxic
Cholestatic
Metabolic 
Vascular
Other (CF related)
Acute or chronic

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Non-alcoholic fatty liver disease

May progress to CLD

Occurrence linked with - genetics, low P.A, high energy intake, overweight/obesity, insulin resistance

Symptoms - generally those considered harmless, e.g. fatigue, weight loss, weakness

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Liver function tests:

Bilirubin

Pigment
Excretory product of haemoglobin
>17mmol/L = greater severity of damage

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Liver function tests:

Aminotransferases

ALT/AST
Enzymes sensitive to liver damage
High levels can suggest obstruction or hepatitis

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Liver function tests:

ALP

High in cholestatic liver disease

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Liver function tests:

GGT

Sensitive marker of liver cell damage
High serum levels due to liver/biliary disease
Interpret with ALP to confirm liver damage

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Liver function tests:

INR

Blood clot time
Produces + clears coagulating factors

Increase may be due to

low serum vit K
poor vit K utilisation
increased risk of bleeding

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Liver function tests:

Alpha fetoprotein

Malignancy marker

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Liver function tests:

Immunoglobins

Liver degraded antigen
Poor liver function = high circulatory antigens
Activated immune response (IgG, IgM, IgA)

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CLD:

Symptoms

Spider angiomas
Blotchy red skin
Easy bruising 
Very itchy skin
Hair loss

CLD - symptoms:

Jaundice

Yellowing of eyes and/or skin

Accumulation of bilirubin

CLD - symptoms

Hepatic encephalopathy

Neuropsychiatric signs of cerebral irritation
Unclear pathogenesis

To treat

bowel cleansing
remove precipitants

CLD - symptoms

Steatorrhoea

Faecal matter full of fat
Impaired bile secretion
Decreased lipase action

CLD - symptoms

Ascites

Excessive ECF in peritoneal cavity
80% cases due to liver cirrhosis
Most common cirrhosis complication
Diagnosis - swollen abdo or ultrasound (small vol)
Leads to - SOB, abdo pain, decreased mobility

Nutritional assessment

Require v detailed
A - weight, height, MUAC, handgrip
B - albumin, transport proteins
C - observation, history
D - consider reliability

Calculating requirements

Use estimated dry weight if pt fluid overloaded

2 methods

energy/kg body weight
Henry equation for BMR + stress factor

Malnutrition
More common in…
Contributing factors…

More common in decompensated

Contributing factors

clinical symptoms: steatorrhoea, odema
dietary: restrictions, unpalatable diet
treatment related: fluid restrictions, altered taste

Dietetic aims

Symptom management Increasing energy + protein intake improves - liver function, nutritional status, survival Acute/end stage - minimise protein loss by meeting increased requirements w/o overfeeding Early stage/post-transplant - recovery phase, increase or maintain bosy stores

Early onset starvation

Cirrhosis prevents storage + release of glycogen Even induced by 2hr fast Prevention - regular meals - late night snack to shorten nocturnal fasting - study 2011: 50g CHO eve snack maintains lean muscle stores by sparing N utilisation overnight

Nutritional support

Enteral feeding Gastrostomy + jejunostomy contraindicated (e.g. impaired coagulation)

Steatorrhoea treatment

Restriction of fat intake only if symptomatic (decrease to tolerance level to limit deficiencies) Replace with CHO + protein foods (consider supplements) May need to supplement with fat soluble vitamins

Varices

Dilated veins in lower end of oesophagus Medical/surgical - NBM until resolves, variceal banding Dietetic - establish oral intake ASAP, NG tube with fine bore tube is safe

Ascites treatment Aims (4)

Aims - 500ml net fluid loss/day + watch for dehydration Sodium restriction - less Na available to be reabsorbed so less fluid retained, severe may promote malnutrition Fluid restriction - 750-1500ml, only used when previous treatment ineffective Diuretic therapy - blocks Na conserving mechanisms in kidney to result in increased urinary Na excretion (monitor for rapid weight loss) Paracentesis - catheter inserted into peritoneal cavity to drain fluid, increased protein requirements, albumin loss

Liver transplant

Treatment for end stage liver disease

Liver transplant: | Malnutrition

Increased - infection rates - mortality - operative blood loss

Liver transplant: | Obesity

Increased - wound infection rates - mortality

Liver transplant: | Post-transplant

Metabolic response to injury Early (12-14h) post-op feeding beneficial Complications - hypertension (62-69% pts) - hyperlipidaemia (45-85% pts) - obesity (increased QoL + no restrictions) - drug-nutrient interactions - food bourne illness - bone disease

Gallstones

May arise due to rapid weight loss (limit to 1.5kg loss/wk) May cause cholecystitis or obstruction (pyrexia, nausea, poor appetite) No evidence for low fat diet beyond healthy diet Recommend healthy diet + weight loss if req

Gallstones: | Cholecystectomy

Surgical removal of gallbladder Diarrhoea may present post op CHO rich drink prior surgery associated with decreased post op N+V

Gallstones: | Dietary factors

Refined CHO Dietary fibre Alcohol (protective)

Gallstones: | Symptoms

Asymptomatic Pain Jaundice

Primary biliary cirrhosis (PBC)

Autoimmune disease Chronic inflammation + destruction of intrahepatic bile ducts Predominately females affected Symptoms - jaundice, dark urine, steatorrhoea, increased lethargy

Primary sclerosing cholangitis (PSC)

Inflammation + fibrosis bile ducts -> cirrhosis -> portal hypertension -> liver failure

Treating PBC + PSC

``` Treat cirrhosis as in CLD Dietary advice for malnutrition May need advice regarding fat malabsorption Lifestyle advice Consider Ca + vit D supplements ```