Hepatology Flashcards
Age group most affected by cholangiocarcinoma
Mostly in those aged over 60
Risk factors for cholangiocarcinoma
Patients with chronic ulcerative colitis who develop sclerosing cholangitis
Infection with liver flukes
Chemical exposure
Congenital abnormalities
Hep C, HIV, cirrhosis and diabetes
Presentation of cholangiocarcinoma
Jaundice(early feature)
Hepatomegaly
Abdo pain(localised to RUQ)
Weight loss
Pale-coloured stools, passage of dark urine
Splenomegaly if prolonged biliary obstruction
Courvoisier’s sign
What is courvoisier’s sign
Palpable gallbladder may occur with tumours distal to the cystic duct
IX for cholangiocarcinoma
LFTs(Elevated conjugated bilirubin, cholestatic picture)
Prothrombin and INR prolonged
Tumour markers(CA 19-9 and CEA)
Ultrasound and CT
Contrast MRI for diagnosis
Surgical management of cholangiocarcinoma
Complete surgical resection
Liver resection for intrahepatic tumours
Non-surgical management of cholangiocarcinoma
Stenting of bile duct to relieve symptoms using ERCP
Palliative chemotherapy
Radiotherapy
Complications of cholangiocarcinoma
Biliary tract sepsis
Secondary biliary cirrhosis
What is primary sclerosing cholangitis
Intrahepatic or extra hepatic ducts become structured and fibrotic causing obstruction to bile flow out of liver and into the intestines
Chronic bile obstruction eventually leads to liver inflammation(hepatitis), fibrosis and cirrhosis
Which condition is associated with primary sclerosing cholangitis
Ulcerative colitis
Risk factors for PSC
Male
Aged 30-40
Ulcerative colitis
Family history
Presentation of PSC
Jaundice Chronic RUQ pain Pruritus Fatigue Hepatomegaly
What do liver function tests show in PSC
Cholestatic picture - Elevated ALP
May be a rise in bilirubin as strictures become severe and prevents bilirubin from being excreted through bile duct
Other LFTs can also be deranged as disease progresses to hepatitis
What autoantibodies may indicate an autoimmune element to PSC
Antineutrophil cytoplasmic antibody (p-ANCA) in up to 94% Antinuclear antibodies (ANA) in up to 77% Anticardiolipin antibodies (aCL) in up to 63%
Diagnosis of PSC
MRCP - shows bile duct lesions or strictures
Complications of PSC
Acute bacterial cholangitis Cholangiocarcinoma develops in 10-20% of cases Colorectal cancer Cirrhosis and liver failure Biliary strictures Fat soluble vitamin deficiencies
Management of PSC
Liver transplant
ERCP to dilate and stent strictures
Colestyramine
Monitor for complications
What is colestyramine
Bile acid sequestrate in that it binds to bile acids to prevent absorption in the gut and can help with pruritus due to raised bile acids
Causes of hepatitis
Alcoholic hepatitis Non alcoholic fatty liver disease Viral hepatitis Autoimmune hepatitis Drug induced hepatitis (e.g. paracetamol overdose)
Hepatitis presentation
Abdominal pain Fatigue Pruritis (itching) Muscle and joint aches Nausea and vomiting Jaundice Fever (viral hepatitis)
Typical LFTs in hepatitis
High transaminases(AST/ALT) with proportionally less of a rise in ALP
Bilirubin can also rise as a result of inflammation of the liver cells.
Most common viral hepatitis
Hep A
How is Hep A transmitted
faecal-oral route usually by contaminated water or food
Presentation of hep A
nausea, vomiting, anorexia and jaundice. It can cause cholestasis (slowing of bile flow through the biliary system) with dark urine and pale stools and moderate hepatomegaly.
Disease progression of hep A
Resolves without treatment in around 1-3 months
Management of Hep A
Basic analgesia
Notable disease
What type of virus is Hep B
DNA virus
How is hep B transmitted
Direct contact with blood or bodily fluids, such as during sexual intercourse or sharing needles (i.e. IV drug users or tattoos).
It can also be passed through sharing contaminated household products such as toothbrushes or contact between minor cuts or abrasions.
It can also be passed from mother to child during pregnancy and delivery (known as “vertical transmission”).
Disease course of hep B
Most people fully recover from the infection within 2 months, however 10% go on to become chronic hepatitis B carriers.
In these patients the virus DNA has integrated into their own DNA and so they will continue to produce the viral proteins.
Test for active hepatitis b infection
HBsAg
Test for previous hep b infection
HBcAb
What should be tested if HBsAg and HBcAb are positive
Further testing for HBeAg and viral load
How can Hep B c antibodies be used to distinguish acute, chronic and past infections
IgM implies an active infection and will give a high titre with an acute infection and a low titre with a chronic infection.
IgG indicates a past infection where the HBsAg is negative.
Importance of Hep B e antigen test
Where the HBeAg is present it implies the patient is in an acute phase of the infection where the virus is actively replicating.
The level of HBeAg correlates with their infectivity.
When the HBeAg is negative but the hepatitis B e antibody is positive this implies they have been through a phase where the virus was replicating and but the virus has now stopped replicating
What is the Hep B vaccination
involves injecting the hepatitis B surface antigen. Vaccinated patients are tested for HBsAb to confirm their response to the vaccine
Management of hep B
Screen for other blood born viruses (hepatitis A and B and HIV) and other sexually transmitted diseases Refer to gastroenterology Notify public health Smoking and alcohol cessation Antiviral meds Liver transplantation
What type of virus is hep C
RNA virus
How is hep c transmitted
Spread by blood and body fluids
Complications of hep B
Cirrhosis
HCC
Disease course of hep c
1 in 4 fights off the virus and makes a full recovery
3 in 4 it becomes chronic
Complications of hep c
liver cirrhosis
HCC
Test for hep c
Hepatitis C antibody is the screening test
Hepatitis C RNA testing is used to confirm the diagnosis of hepatitis C, calculate viral load and assess for the individual genotype
Management of hep c
Screen for other blood born viruses Notify Public Health Smoking and alcohol cessation Antiviral treatment with direct acting antivirals Liver transplant
Features of hep d
RNA virus
Can only survive in patients who have hep b
Attaches itself to HBsAg
Increases complications and disease severity of hep B
Management of hep D
No specific treatment for hep D
Notifiable disease
What is Hep E
RNA virus
How is Hep E transmitted
Faecal oral route
Disease course of Hep E
Produces only a mild illness, the virus is cleared within a month and no treatment is required.
Rarely it can progress to chronic hepatitis and liver failure, more so in patients that are immunocompromised.
What is autoimmune hepatitis associated with
Can be associated with a genetic predisposition and triggered by environmental factors such as viral infection that causes a T cell-mediated response against liver cells
What are the two types of autoimmune hepatitis
Type 1: occurs in adults
Type 2: occurs in children
Features of type 1 autoimmune hepatitis
Typically affects women in their late forties or fifties.
It presents around or after the menopause with fatigue and features of liver disease on examination.
It takes a less acute course than type 2.
Features of type 2 autoimmune hepatitis
In type 2, patients in their teenage or early twenties present with acute hepatitis with high transaminases and jaundice.
General IX for type 1 and type 2 autoimmune hepatitis
Raised transaminases (ALT and AST), IgG levels and it is associated with many autoantibodies.
Specific autoantibodies associated with type 1 autoimmune hepatitis
Anti-nuclear antibodies (ANA)
Anti-smooth muscle antibodies (anti-actin)
Anti-soluble liver antigen (anti-SLA/LP)
Specific autoantibodies associated with type 2 autoimmune hepatitis
Anti-liver kidney microsomes-1 (anti-LKM1)
Anti-liver cytosol antigen type 1 (anti-LC1)
Diagnosis of autoimmune hepatitis
Liver biopsy
Treatment for autoimmune hepatitis
High dose steroids(prednisolone) Immunosuppressants(azathioprine) Liver transplant(autoimmune hepatitis can recur)
Aetiology of hepatic encephalopathy
Not fully understood but is thought to include excess absorption of ammonia and glutamine from bacterial breakdown of proteins in the gut.
what is hepatic encephalopathy associated with
Often associated with acute liver failure it may also be seen with chronic disease
Which procedure can precipitate encephalopathy
transjugular intrahepatic portosystemic shunting (TIPSS) may precipitate encephalopathy
Features of hepatic encephalopathy
confusion, altered GCS (see below)
asterix: ‘liver flap’, arrhythmic negative myoclonus with a frequency of 3-5 Hz
constructional apraxia: inability to draw a 5-pointed star
raised ammonia level (not commonly measured anymore)
EEG features - hepatic encephalopathy
triphasic slow waves on EEG
Grading of hepatic encephalopathy
Grade I: Irritability
Grade II: Confusion, inappropriate behaviour
Grade III: Incoherent, restless
Grade IV: Coma
precipitating factors in hepatic encephalopathy
infection e.g. spontaneous bacterial peritonitis GI bleed TIPPS constipation hypokalaemia renal failure increased dietary protein (uncommon)
Drugs implicated in hepatic encephalopathy
Sedative
Diuretics
Mx of hepatic encephalopathy
treat any underlying precipitating cause
NICE recommend lactulose first-line, with the addition of rifaximin for the secondary prophylaxis of hepatic encephalopathy
How does lactulose work in hepatic encephalopathy
lactulose is thought to work by promoting the excretion of ammonia and increasing the metabolism of ammonia by gut bacteria
How do antibiotics work in hepatic encephalopathy
antibiotics such as rifaximin are thought to modulate the gut flora resulting in decreased ammonia production
Types of drug-induced liver disease
Hepatocellular
Cholestatic
Mixed
Causes of hepatocellular drug-induced liver disease
paracetamol sodium valproate, phenytoin MAOIs halothane anti-tuberculosis meds statins alcohol
Causes of cholestatic/mixed drug-i induced liver disease
COCP Abx anabolic steroids chlorpromazine, prochlorperazine sulphonylureas fibrates
Drugs which can cause liver cirrhosis
Methotrexate
Methyldopa
Amiodarone
Risk factors for HCC
Liver cirrhosis due to:
Viral hep(B and C)
Alcohol
NAFLD
Tumour marker associated with HCC
Alpha-fetoprotein
Drugs associated with HCC
COCP
Anabolic steroids
Features of HCC
tends to present late
features of liver cirrhosis or failure may be seen: jaundice, ascites, RUQ pain, hepatomegaly, pruritus, splenomegaly
possible presentation is decompensation in a patient with chronic liver disease
When should screening be considered for HCC
Screening with ultrasound (+/- alpha-fetoprotein) should be considered for high risk groups such as:
patients liver cirrhosis secondary to hepatitis B & C or haemochromatosis
men with liver cirrhosis secondary to alcohol
Mx of HCC
early disease: surgical resection
liver transplantation
radiofrequency ablation
transarterial chemoembolisation
What might be seen on light microscopy in chronic hep B
Ground-glass hepatocytes
Definition of chronic hep c
persistence of HCV RNA in the blood for 6 months.
Eye problem associated with chronic hep c
Sjogren’s syndrome
