Lec 2- Liver I Flashcards
1
Q
Signs and symptoms- Specific
NB- usually to see after a period of time of dysfunction
A
- Jaundice (+/- Pruritus)- this can happen a lot quicker than the other changes- jaundice can occur quickly
- Pale Stool & dark urine
- Gynaecomastia
- Spider Naevi
- Ascites-albumin deficiency
- Varices
- Hepatic Encephalopathy- thiamine deficiency
- Dupuytren’s Contracture
- Hepatomegaly
- Splenomegaly
- Palmar erythema
2
Q
Signs and Symptoms- Non-specific
NB- more likely to have
A
- Malnutrition
- Peripheral oedema
- Bruising and bleeding
- Testicular atrophy
- White nail
- Splenomegaly
- Fatigue/Malaise
- Abdominal or RUQ pain
- Muscle cramps
- Finger clubbing
3
Q
Causes of liver disease
A
- Fatty liver- NAFLD (Non-Alcoholic Fatty Liver Disease), NASH (Non-Alcoholic SteatoHepatitis)
- Alcohol
- Viral- hepatitis A,B,C,D,E
- Malignancy- often the 2ndary site of cancer (metastasis)
- Immunological- primary biliary sclerosis/ Billary artemisia
- Biliary tract disorders
- Hereditary and metabolic
- Drug-induced- MTX, Valproate, Anti-TB medicines, Amiodarone
4
Q
Non-Alcoholic Fatty Liver Disease (NAFLD)
A
- Histologically similar to alcoholic liver disease
- Risks: Obesity (central obesity), type 2 diabetes (insulin resistance) or dyslipidaemia, 40-60yrs
- Can progress to cirrhosis and portal HTN
- Asymptomatic or typically fatigue, malaise, ab pain (hardening of the liver)
- Hepatomegaly/Splenomegaly
- Often accidental diagnosis (during routine check-up)
- During irreversible phase= more spleen problems
5
Q
NAFLD- Diagnosis
A
- Presence of risk factors
- Exclude excess alcohol, and viral causes
- Liver ultrasound- check blood flow
- Fibroscan- use to check elasticity= more fibrous (Biopsy- less used now)
- Unexplained elevations in AST/ALT for >6/12- must be for a sustained time
6
Q
NAFLD- Prognosis
A
- Good if no complications
7
Q
NAFLD- Treatment
A
- Eliminate causes and reduce risk factors
- Exercise (give NICE guidance on obesity no matter what BMI)
- Stop any offending drugs
- Optimise treatment for diabetes and dyslipidaemia- (higher risk of diabetes if they don’t have) (also more likely to get arrhythmias/stroke)
- Fibrosis: pioglitazone or Vit E (unlicensed)
8
Q
Alcoholic liver disease
A
- Alcohol damages liver cells- Alcohol metabolised into acetyl aldehyde (formaldehyde)- kill liver cell which is replaced by non-functional fatty cells= decrease in function
- Fatty liver- hepatitis- fibrosis can progress to cirrhosis
- Often cycling in nature
- Need thiamine in order to metabolise alcohol (also needed for brain function= increased encephalopathy)- give oral thiamine
- Depletion of thiamine is called Wernicke’s encephalopathy and can become permanent
- Management
- STOP drinking
- Acute withdrawal can be a big risk- higher risk of epilepsy
- Reducing the regimen of BZ’s
- Support referral
- Steroids (a NICE pathway for criteria- NICE not very good look at specific hospital guidelines)
9
Q
Viral Hepatitis (acute)
A
- Not all hepatitis forms into chronic
- Diffuse liver inflammation caused by a specific but diverse group of virus
- Presentation
- Non-specific: Viral illness, with anorexia, malaise, nausea, ab pain
- Most cases of acute viral hep resolve 4-8 weeks after symptoms onset- most are self-limiting
- Can progress to chronic- >6 months, or acute fulminant hepatitis
- LFTs and viral serology help diagnosis
- Vaccines and immunoglobulins can help pre-exposure and post-exposure
10
Q
Hepatitis A
A
- Most common, esp in children and young adults
- Vaccine for people travelling to underdeveloped countries
- Spread by faecal-oral route- poor hygiene
- Sporadic cases due to person to person contact faecal shedding of virus
- Infectivity occurs before symptoms begin
- Incubation period 15-45 days- foreign travel is a common cause
- Increased liver enzymes and Alk Phos and itching whilst inflammation regresses
- No carrier state, and does not cause chronic hepatitis or cirrhosis
- Resolves spontaneously
11
Q
Hepatitis B
A
- Characteristic and most complex- Wide spectrum of liver disease
- 5-10% of cases progress to chronic
- 2nd most common cause of acute viral hepatitis
- Prevalence <0.5% in US and northern Europe, 10% in far east
- Transmitted via blood or contaminated blood products
- Sexual intercourse, shared needles
- Contact with other bodily fluids by sexual contact
- Screening programmes
- Can be associated with extrahepatic disorders like connective tissue disease, membranous glomerular nephritis (steroid treatment)
- Vertical transmission- from mother to baby (can try and use immunoglobulin to prevent this)
- If you have this for a long time your at higher risk of liver cancer, therefore, start screening
- Chronic treatment: Anti-virals- similar to HIV
12
Q
Hepatitis C
A
- Six subtypes each vary- virulence, geographically and response to treatment
- The highest rate of chronicity with 20-30% progressing to cirrhosis (decades to appear) then possibly HCC
- A chronic state can be benign
- Bloodborne: needle sharing, body piercings, tattooing, donor blood
- Sexual and vertical transmission rare
- Associated with other systematic diseases e.g. cryoglobulinaemia, porphyria and glomerulonephritis
- Synergism to cause liver damage
- Chronic treatment: anti-virals and interferons- very expensive and specialist
13
Q
Hepatitis D, E
A
- Hepatitis D- only replicates in the presence of the Hep B virus. Uncommon co-infection with acute Hep B, or superinfection with chronic Hep B
- Varies in prevalence geographically. IV needle transmission is high risk, but not sexual activity
- Hepatitis E- water-borne linked to faecal contamination in underdeveloped countries. Similar to Hep A, No chronic or carrier state
- Test for E at the same time as A
14
Q
Pruritus (Itching)
A
- Patient-specific
- Accumulation of bile salts causing hyperbilirubinaemia- can’t stop itching
- Management
- Colestyramine (binder- watch the timing of other medication) 2-8g BD. Ineffective in complete biliary obstruction
- Anti-histamine- ineffective and sedating- older, more sedating classes generally more effective
- Sedation can be dangerous- mask regression
- UDCA- cholestasis- often used in pregnancy
- Natural fabrics
- The menthol in Aq cream
- Colestyramine (binder- watch the timing of other medication) 2-8g BD. Ineffective in complete biliary obstruction
15
Q
Portal HTN
A
- Increased portal vein pressure- a back flow of pressure because blood can’t flow through the liver as it should do
- Varices and ascites
- Management
- Propranolol- licensed reduced splenic blood flow (Make sure HR doesn’t drop below 60)
- Can use unlicensed isosorbide mononitrate
- 25% decrease in resting HR
- TIPSS procedure (Transjugular intrahepatic portosystemic shunt)- this reduces first-pass metabolism (effect drug metabolism) also effects breakdown of ammonia compounds (this can lead to hepatic encephalopathy)- bypassing liver
- Propranolol- licensed reduced splenic blood flow (Make sure HR doesn’t drop below 60)
21
Q
Hepatic encephalopathy
A
- Reduced clearing of ammonia compounds
- Means generalised brain dysfunction
- Altered mental and potentially physical state
- Changes can become permanent
