HPB Flashcards
What are the screening questionnaires for alcohol consumption?
CAGE
AUDIT
What are the signs of alcoholic liver disease?
Jaundice + scleral jaundice Palmar erythema Hepatomegaly Spider naevi Caput medusa Flapping tremor (asterixis) Ascites Gynaecomastia Unexplained bruising
How is alcoholic liver disease diagnosed?
Careful history taking and examination
LFTs: Raised AST/ALT, normal/mild raised ALP, raised gamma gt, low albumin, raised bilirubin
Clotting: prolonged PT
USS abdo: may show enlarged/fatty liver in acute inflammation or small, sclerotic liver
CT abdomen
Liver biopsy
OGD can be done to look for varices
What is the management of alcoholic liver disease?
- Stop drinking / detox programme
- Calorie and nutrition support- incl thiamine
- Consider suitability for transplant
- Symptomatic treatment
What are the stages of alcohol withdrawal?
- 6-12 hrs: tremors, sweating, headache, cravings and anxiety
- 12-24 hrs: hallucinations and tactile disturbance - characteristically insects crawling
- 24-48hrs: seizures
- 48-36 hrs: delirium tremens
What is delirium tremens?
Alcohol withdrawal syndrome - 48-36hr into withdrawal
Downregulation of GABA, up regulation of glutamate -> brain excitability and adrenergic overactivity
Sx: confusion, agitation, delusions and hallucinations
tremor, ataxia, tachycardia, hyperthermia, arrhythmia
What classification system is used in alcohol withdrawal?
CIWA-AR tool
How should you manage acute alcohol withdrawal?
Benzodiazepine e.g. chlordiazepoxide (librium) titrated regimen
Thiamine: IV pabrinex followed by oral thiamine
Manage any seizures/other symptoms
What are the 3 features of Wernicke’s encephalopathy?
Confusion
Ataxia
Occulomotor disturbance
What are the three features of Korsakoff’s syndrome?
- Amnesia- anterograde and retrograde
- Confabulation
- Behavioural change: lack of insight, apathy
What are the causes of liver cirrhosis?
Common:
- Alcoholic liver disease
- Non-alcoholic steatohepatitis
- Chronic viral hepatitis
- Drug causes
Less common
- a1-antitripsin deficiency
- Wilson’s disease
- Haemochromatosis
- Primary biliary cirrhosis
- Autoimmune hepatitis
- Cystic fibrosis
Which drugs most commonly cause liver cirrhosis?
- Methotrexate
- Amiodarone
- Sodium valproate
- Chemotherapy agents
TPN is also associated with liver injury and fibrosis.
What are the signs of liver cirrhosis?
Palmar erythema Asterixis Jaundice Spider naevi, caput medusa Ascites and oedema Bruising and bleeding Pale stool and dark urine Splenomegaly Gynaecomastia
What investigations should be done in liver cirrhosis?
- LFTs: raised AST/ALT, raised ALP, low albumin, high bilirubin, ?gamma gt
- Coagulation: prolong PT
- AFP: marker for HCC
- U&E: can cause deranged urea and creatinine, hyponatraemia due to dilution
- Hepatitis viral screen and autoantibody testing
- USS abdomen and Fibroscan
- CT scan and biopsy
- Endoscopy looking for varies
Enhanced liver fibrosis blood test= new test, not available in all centres
What are the scoring systems for liver cirrhosis?
Child-Pugh score - indicated severity
MELD score- done 6 monthly in those with compensated cirrhosis to estimate mortality and need for transplant
How should patients with liver cirrhosis be managed?
Avoid alcohol!
- Vitamin and nutrition replacement - high protein, low sodium, vitamin supplements
- Coagulopathy management
- Diuretics for ascites
- BP control for hepatorenal syndrome
- Consideration for transplant
What are the complications of cirrhosis?
Ascites + SBP Portal hypertension Varices + variceal bleeding Hepatorenal syndrome Encephalopathy Bleeding/bruising Malnutrition HCC
What is the blood marker for HCC?
AFP
How are stable varices managed?
- Stop drinking if alcohol-related / abstain either way
- Propranolol to reduce BP
- Elective banding procedure
- TIPS procedure
How are unstable varices managed?
A-E
Bloods: FBC, U&E, LFT, CRP, coagulation, group and save
Resuscitation if necessary
Correct any coagulopathy
IV terlipressin + IV Abx
if stable enough for endoscopy- endoscopic banding
Sengstaken-Blakemore tube / balloon tamponade in less stable patients
How does ascites form?
Less albumin produced by the liver -> lower osmotic pull of the bloodstream
Fluid loss into extracellular space
Reduced blood volume -> reduced renal perfusion -> activation of RAAS
Fluid and sodium retention
How should ascites be managed?
- Low sodium diet
- Spironolactone
- Ascitic tap / drain
- > Sample should always be sent for analysis
- > for every litre of fluid drained, a certain amount of albumin should be given to the patient to prevent immediate recurrence.
What are the most common organisms causing SBP?
Ecoli
Klebsiella
Gram positive cocci
What are the symptoms of SBP?
May be asymptomatic Ascites Abdominal pain Fever Sepsis Ileus
How is SBP diagnosed?
Record all vital signs
Bloods: FBC, CRP, U&E, LFT, coagulation
Ascitic tap: send for MC&S, pH, glucose, protein, LDH
Full infection work-up
How is SBP managed?
IV antibiotics - usually cefotaxime
Ascitic drain - albumin replacement for each L of fluid drained
What is hepatorenal syndrome?
In portal hypertension, due to the increased blood volume in the portal system there is dilation of the vessels to cope with the increased pressure and pooling of blood.
This leads to reduced blood supply to the kidneys, activation of the RAAS as a result and renal vasoconstriction as a result.
This constriction with the addition of blood pooling elsewhere leads to reduced renal blood supply and reduced function as a result.
This is a fatal complication of cirrhosis if liver transplant is not obtained ASAP.
What is the cause of hepatic encephalopathy?
Increased ammonia in circulation due to reduced hepatic metabolism and increased collateral blood flow bypassing the liver. This ammonia is produced by intestinal bacteria and absorbed into circulation, crosses BBB to cause encephalopathy.
What are the symptoms of hepatic encephalopathy?
Flapping tremor
Reduced GCS
Confusion, change in behaviour/personality
How do you manage hepatic encephalopathy?
Laxatives to increase excretion of intestinal ammonia
Enemas
Oral rifampicin to kill bacteria and reduce ammonia production
Nutritional support
What can precipitate hepatic encephalopathy?
- Constipation
- Renal impairment
- Infection
- GI bleed
- Excess protein
How is non-alcoholic fatty liver disease diagnosed?
Often incidental
LFT derangement
Non-invasive liver screen: USS, hep B&C serology, autoantibodies, immunoglobulins, coeruloplasmin, a1 antitrypsin, ferritin + transferrin
-> rules out other causes of hepatic disease
Liver USS
Enhanced liver fibrosis test / NAFLD fibrosis score / fibroscan
What is the management for non-alcoholic fatty liver disease?
Weight loss and nutrition support
Stop smoking, control other RFs e.g. diabetes, BP, cholesterol
Alcohol avoidance
Vitamin E or pioglitazone for anti-oxidant/anti-fibrotic action
What is the inheritance pattern for a1-antitrypsin deficiency?
Autosomal recessive
How is hepatitis A diagnosed?
Symptom profile= N&V, anorexia, jaundice, cholestasis, hepatomegaly, fever
HAV IgM
What percentage of HBV and HCV become chronic infections?
HBV: 10%
HCV: 75%
What do each of the serology factors mean in HBV?
HBsAg, HBeAg, Anti-HBc, Anti-HBs, HBV DNA
HBsAG= presence of infection HBeAg= indication of viral replication and infectivity Anti-HBc= Current or past infection Anti-HBs= resolution of infection
What would you expect to see on serology in acute HBV infection?
- HBsAg +ve
- HBeAg +ve
- Anti-HbC IgM
- HBV DNA +ve
Raised ALT
What would you expect to see on serology in chronic HBV infection?
- HBsAg +ve
- HBeAg +ve or -ve
- Anti-HbC IgG
- HBV DNA +ve
Elevated ALT
What would you expect to see on serology in somebody who has recovered from HBV infection?
Anti-HBs
Anti-HBc IgG
Normal ALT
No Antigens or DNA
What would you expect to see on serology for somebody who has been vaccinated against HBV?
Anti-HBs
Normal ALT
No antigens or DNA
