Hepatology

Question 1

Describe acute liver failure

Answer 1

Development of coagulopathy (INR>1.5) and encephalopathy suddenly in a previously healthy liver (8-21 days)

Question 2

List common causes of acute liver failure

Answer 2

Paracetamol overdose
Hepatitis A & E
Alcoholic poisoning

Question 3

List the investigations for suspected liver failure

Answer 3

Bloods – FBC, U&Es, LFT, clotting, glucose
Microbiology – blood culture, urine culture, ascitic tap for ascites
CXR
Abdominal ultrasound

Question 4

Describe the management of liver failure

Answer 4

Treat the underlying cause if known
Protect airway with intubation and insert an NG tube to avoid aspiration
Monitor observations
Glucose IV to avoid hypoglycaemia

Question 5

Describe the clinical features of paracetamol poisoning

Answer 5

None initially, or vomiting +/- RUQ pain
Jaundice and encephalopathy from liver damage +/- AKI

Question 6

Describe management of paracetamol overdose

Answer 6

GI decontamination is recommended in those presenting <4 hours = activated charcoal
IVI acetylcysteine
Next day – INR, U&E, LFT

Question 7

Describe the management of alcoholic liver disease

Answer 7

Stop drinking alcohol permanently
Consider a detox regime
Nutritional support with vitamins (particularly thiamine) and a high protein diet
Steroids – improve short term outcomes in severe alcoholic hepatitis
Treat complications of cirrhosis
Refer for liver transplant in severe disease

Question 8

Describe the management of non-alcoholic fatty liver disease

Answer 8

Weight loss
Exercise
Stop smoking
Control of diabetes, blood pressure and cholesterol
Avoid alcohol
Refer patients with liver fibrosis to a liver specialist – they may treat with vitamin E or pioglitazone

Question 9

Describe the management of viral hepatitis

Answer 9

Hepatitis B – antivirals, screen for other blood born viruses, refer to gastro/hepatology/infectious diseases for specialist management, liver transplantation for end-stage liver disease
Hepatitis C – antiviral treatment with direct acting antivirals (DAAs) is tailored to the specific viral genotype -> successfully cure the infection in over 90% of patients (8-12 weeks)

Question 10

Describe the management of haemochromatosis

Answer 10

Venesection – weekly protocol of removing blood to decrease total iron
Monitoring serum ferritin
Avoid alcohol
Genetic counselling
Monitoring and treatment of complications

Question 11

Describe the management of autoimmune liver disease

Answer 11

Autoimmune hepatitis – high dose steroids (prednisolone) that are tapered over time as other immunosuppressants, particularly azathioprine, are introduced; immunosuppressant treatment is usually successful in inducing remission but required life long

Question 12

List complications of chronic liver disease

Answer 12

Malnutrition
Portal hypertension, varices and variceal bleeding
Ascites & SBP
Hepatorenal syndrome
Hepatic encephalopathy
Hepatocellular carcinoma

Question 13

Describe the management of malnutrition as a complication of cirrhosis

Answer 13

Regular meals
Low sodium
High protein and high calorie
Avoid alcohol

Question 14

Describe the management of portal hypertension and varices as a complication of cirrhosis

Answer 14

Stable varices – propranolol, elastic band ligation of varices, injection of sclerosant, TIPS
Bleeding oesophageal varices:
1) Resus – vasopressin analogues, correct coagulopathy with vit K and fresh frozen plasma, prophylactic blood spectrum abx
2) Urgent endoscopy – injection of sclerosant, elastic band ligation

Question 15

Describe the management of ascites as a complication of cirrhosis

Answer 15

Low sodium diet
Anti-aldosterone diuretics
Paracentesis
Prophylactic abx against SBP

Question 16

Describe the management of SBP as a complication of cirrhosis

Answer 16

Take an ascitic culture prior to giving antibiotics
Usually treated with IV cephalosporin such as cefotaxime

Question 17

Describe the management of hepatorenal syndrome and hepatic encephalopathy as a complication of cirrhosis

Answer 17

Hepatorenal syndrome – fatal within a week or so unless liver transplant is performed
Hepatic encephalopathy:
1) Laxatives promote the excretion of ammonia
2) Antibiotics reduce the no. of intestinal bacterial producing ammonia
3) Nutritional support