hepatology

Question 1

name some functions of the liver.

Answer 1

nutrition/metabolic

• stores glycogen
• releases glucose
• absorbs fats, fat soluble vitamins and iron
• manufactures cholesterol

clotting factors

detoxification

• drug excretion (and activation)
• alcohol breakdown

immune function
- Kupfer cells engulf antigens

bile salts
- dissolves dietary fats

bilirubin

manufactures proteins

• albumin
• binding proteins

Question 2

what risk factors would you ask for in a patient with liver disease?

Answer 2

• Blood transfusions prior to 1990 in the UK
• IVDU
• operations/vaccinations with dubious sterile procedures
• sexual exposure
• medications
• FH of liver disease, diabetes, IBD
• obesity/features of metabolic syndrome
• travel

Question 3

what are the key features of acute liver injury/disease?

Answer 3

no pre existing liver disease

resolves in six months

• Hep A, E, CMV, EBV
• drug induced liver injury (DILI)

Question 4

what are the key features of chronic liver disease?

Answer 4

• starts with acute liver disease (often asymptomatic)
• on going effects beyond 6 months
• may lead to cirrhosis and its complications (genetics important)
  1) alcohol
  2) hep c
  3) non alcoholic steatohepatitis (NASH)
  4) autoimmune (primary billiard cholangitis, primary sclerosing cholangitis, Autoimmune hepatitis)

Question 5

when examining a patient for liver disease, what can you do to look for evidence of chronicity?

Answer 5

check for stigmata of chronic liver disease

• spider naevi
• clubbing
• palmar erythema
• ascites

as well as signs of complications of liver disease

Question 6

give some examples of complications of liver disease

Answer 6

• portal hypertension
• splenomegaly
• hepatic encephalopathy
• jaundice
• ascites
• oedema
• itchy skin
• gynacomastia
• amenorrhoea

Question 7

what does grade 1 of hepatic encephalopathy consist of?

Answer 7

• psychomotor slowing
• constructional apraxia
• poor memory
• reversed sleep pattern

Question 8

what does grade 2 of hepatic encephalopathy consist of?

Answer 8

• lethargy
• disorientation
• agitation/ irritability
• asterixis

Question 9

what does grade 3 hepatic encephalopathy consist of?

Answer 9

drowsiness

Question 10

what does grade 4 hepatic encephalopathy consist of?

Answer 10

coma

Question 11

what investigations are done in liver disease?

Answer 11

similar in both acute and chronic liver disease

• thrombocytopenia is a sensitive marker for liver fibrosis
• LFTs will indicate where damage is
  (ALT rise= hepatocytes, ALP rise = the ducts)/ If cholestatic change is suspected, USS to asses if ducts are dilated (obstructive jaundice). May be USS findings that suggest cirrhosis also
• bilirubin, albumin and prothrombin time/INR are markers of synthetic function and in acute abnormalities, should raise concern

Question 12

what are the USS features of liver cirrhosis?

Answer 12

• coarse texture
• nodularity
• splenomegaly
• ascites

Question 13

what are the cholestatic (dilated ducts) causes of liver disease?

Answer 13

• gallstones

- malignancy

Question 14

what are the cholestatic (non dilated ducts) causes of liver disease?

Answer 14

• alcoholic hepatitis
• cirrhosis (primary billiard cholangitis, primary sclerosing cholangitis)
• drug induced liver injury

Question 15

what can cause ALT >500?

Answer 15

• viral
• ischaemia
• toxic (paracetamol is common)
• autoimmune

Question 16

what can cause ALT to be between 100-200?

Answer 16

• NASH
• autoimmune hepatitis
• chronic viral hepatitis

Question 17

what does the liver screen consist of?

Answer 17

• hepatitis B&C serology (in acute liver disease, consider Hep A and E if ALT rise)
• iron studies (ferritin and transferrin)
• autoantibodies (AMA and SMA) and immunoglobulins
• consider caeuruloplasmin if under 30
• alpha a antitrypsin
• coeliac serology
• TFT, lipids and glucose

Question 18

what are the commonest causes of cirrhosis?

Answer 18

• Alcoholic liver disease
• NASH
• viral hepatitis (B and C)

Question 19

what causes of cirrhosis are commoner in women?

Answer 19

• autoimmune hepatitis

- primary billiard cholangitis

Question 20

what causes of cirrhosis are commoner in men?

Answer 20

• primary sclerosing cholangitis, associated with IBD

- earlier in men = haemachromatosis

Question 21

what is the treatment of chronic liver disease?

Answer 21

its based on removing the underlying aetiology (stopping drinking, weight loss, antivirals, venesection, etc) to prevent further liver damage and progress to cirrhosis

Question 22

when should cirrhosis be suspected?

Answer 22

• thrombocytopenia
• clinical stigmata of chronic liver disease
• imaging can be suggestive (splenomegaly, course texture and nodularity)
• presence of varices on endoscopy in a patient with chronicler disease would be diagnostic of cirrhosis

Question 23

why is it important to screen for varices in patients with cirrhosis?

Answer 23

as primary prophylaxis can decrease the risk of bleeding significantly

Question 24

what is used to treat ascites in cirrhosis?

Answer 24

spironolactone or, if tense, paracentesis

Question 25

what can be done if a patient with cirrhosis is at risk of osteoporosis?

Answer 25

DEXA scan

bone density scan

Question 26

what is a hepatocellular carcinoma?

Answer 26

a type of primary liver tumour that can develop in patients with cirrhosis

patients should be screened using alpha fetoprotein and USS every 6 months for early diagnosis and good prognosis

Question 27

When should a diagnostic ascitic tap (cell count and MC&S)be done?

Answer 27

in all patients with ascites who are admitted to hospital to look for spontaneous bacterial peritonitis (SBP)