Liver Flashcards
1
Q
What are the 4 most common causes of liver cirrhosis?
A
- Alcohol-related liver disease
- Non-alcoholic fatty liver disease (NAFLD)
- Hepatitis B
- Hepatitis C
2
Q
What 2 scores are used as as prognostic tools in liver cirrhosis? What information does each provide?
A
- MELD score (Model for End-Stage Liver Disease): gives an estimated 3-month mortality as a percentage, should be calculated every 6 months in patients with compensated cirrhosis
- Child-Pugh score: assesses the severity of cirrhosis and the prognosis
3
Q
What are complications of liver cirrhosis?
A
- Malnutrition and muscle wasting
- Portal hypertension -> oesophageal varices -> bleeding varices
- Ascites -> spontaneous bacterial peritonitis
- Hepatorenal syndrome
- Hepatic encephalopathy
- Hepatocellular carcinoma
4
Q
How does cirrhosis lead to malnutrition and muscle wasting?
A
- Patients often have a LOA resulting in reduced intake
- Cirrhosis affects protein metabolism in the liver -> reduces the amount the liver produces -> less protein available to maintain muscle tissue
5
Q
What is used for bleeding prophylaxis in stable oesophageal varices?
A
- Beta blockers (e.g. propranolol) first-line
- Variceal band ligation (if BB are contraindicated)
6
Q
What is the management of bleeding oesophageal varices?
A
- Immediate senior help
- Consider blood transfusion (activate the major haemorrhage protocol)
- Treat any coagulopathy (e.g. with fresh frozen plasma)
- Vasopressin analogues (e.g. terlipressin or somatostatin) cause vasoconstriction and slow bleeding
- Prophylactic broad-spectrum antibiotics (shown to reduce mortality)
- Urgent endoscopy with variceal band ligation
- Consider intubation and intensive care
7
Q
What is ascites?
A
Abnormal accumulation of fluid in the abdomen
8
Q
How can ascitic fluid be classified?
A
According to serum-ascites albumin gradient (SAAG)
9
Q
How do you calculate serum-ascites albumin gradient?
A
Serum albumin - ascitic fluid albumin = SAAG
10
Q
How do you interpret SAAG?
A
- High SAAG (>11g/L) = transudate
- Low SAAG (<11g/L) = exudate
11
Q
What are causes of a high serum-ascites albumin gradient?
A
High SAAG indicates portal hypertension (fluid pushes out, albumin remains)
- Liver disorders - cirrhosis, ALD, acute LF, liver mets
- Cardiac - RHF, constrictive pericarditis
- Other - Budd-Chiari syndrome
12
Q
What are causes of a low serum-ascites albumin gradient?
A
Low SAAG implies an aetiology that causes increased vascular permeability of the portal system
- Malignancy
- Infections - tb peritonitis
- Hypoalbuminamia - nephrotic syndrome, severe malnutrition
- Other - pancreatitis, bowel obstruction, biliary ascites
13
Q
What is the management of ascites?
A
- Low sodium diet
- Aldosterone antagonists (spironolactone)
- Paracentesis
- Prophylactic antibiotics (ciprofloxacin) when there is <15 g/litre of protein in the ascitic fluid
14
Q
Why are aldosterone antagonists given in ascites?
A
- Fluid loss into the peritoneal cavity decreases circulating volume
- This decreases renal blood pressure, triggering renin release
- Aldosterone is secreted which causes fluid and sodium reabsorption in the kidneys
- This results in fluid and sodium retention
15
Q
What is a complication of ascites?
A
Spontaneous bacterial peritonitis
16
Q
How do you diagnose SBP?
A
- Paracentesis - neutrophil >250 cells/ul
- Ascitic fluid culture
17
Q
What are the most common causative organisms of SBP?
A
- E. Coli
- Klebsiella pneumoniae
18
Q
What is the management of SBP?
A
IV abx (normally cefotaxime)
19
Q
What is one toxin that can build up in patients with liver cirrhosis and cause hepatic encephalopathy?
A
Ammonia
20
Q
How does hepatic encephalopathy present acutely and chornically?
A
Acutely - reduced consciousness, confusion
Chronically - changes to personality, memory and mood
21
Q
What is the management of hepatic encephalopathy?
A
- Lactulose (aiming for 2-3 soft stools daily)
- Antibiotics
22
Q
What is the role of antibiotics in the management of hepatic encephalopathy? What is the first line antibiotic?
A
- Ammonia is produced in the intestinal bacteria when they break down proteins and is (normally) metabolised and excreted by the liver
- Antibiotics are used to reduce the number of intestinal bacteria producing ammonia
Rifaximin is used as it is poorly absorbed and stays in the GI tract
23
Q
What is the step-wise progression of alcohol-related liver disease?
A
- Hepatic steatosis
- Alcoholic hepatitis
- Cirrhosis
24
Q
What can be used to quickly screen for harmful alcohol use?
A
CAGE questions:
C – CUT DOWN? Do you ever think you should cut down?
A – ANNOYED? Do you get annoyed at others commenting on your drinking?
G – GUILTY? Do you ever feel guilty about drinking?
E – EYE OPENER? Do you ever drink in the morning to help your hangover or nerves?
25
What withdrawal symptoms 6-12 hrs after alcohol consumption ceases?
- Tremor
- Sweating
- Headache
- Craving
- Anxiety
26
What withdrawal symptoms 12-24 hrs after alcohol consumption ceases?
Hallucinations
27
What withdrawal symptoms 24-48 hrs after alcohol consumption ceases?
Seizures
28
What withdrawal symptoms 24-72 hrs after alcohol consumption ceases?
Delirium tremens
29
What 2 medications are used in alcohol withdrawal? What are their roles?
- Chlordiazepoxide - combat the effects of alcohol withdrawal
- Pabrinex followed by long-term oral thiamine - used to prevent Wernicke-Korsakoff syndrome
30
What causes Wernicke-Korsakoff Syndrome?
- Thiamine deficiency (vit B1) due to excess alcohol
- Thiamine is poorly absorbed in the presence of alcohol
- Alcoholics typically have poor diets -> decreased intake
31
What are features of Wernicke's encephalopathy?
- Confusion
- Oculomotor disturbances (disturbances of eye movements)
- Ataxia
32
What are features of Korsakoff's syndrome?
- Memory impairment (retrograde and anterograde)
- Behavioural changes
33
What is Non-alcoholic fatty liver disease (NAFLD)?
Excess fat (namely triglycerides) in liver cells. These fat deposits interfere with the functioning of liver cells. NAFLD can progress to hepatitis and cirrhosis
34
NAFLD is associated with metabolic syndrome. What is this?
A combination of HTN, obesity and diabetes
35
NAFLD has stages of disease. What investigation findings indicate each stage? What investigation is diagnostic?
1. NAFLD
- Raised ALT is often the first indication of NAFLD
2. Non-alcoholic steatohepatitis (NASH)
- Liver USS confirms hepatic steatosis (seen as increased echogenicity)
3. Fibrosis
- Enhanced liver fibrosis (ELF) blood test indicates advanced liver fibrosis
4. Cirrhosis
- Transient elastography (“FibroScan”) determines the degree of fibrosis to test for liver cirrhosis
Liver biopsy is diagnostic
36
What two scores can be used to assess liver fibrosis in NAFLD? What do they use? What result would indicate advanced fibrosis? What would indicate an alternate diagnosis?
- NAFLD Fibrosis Score (NFS) and Fibrosis 4 (FIB-4) score
- Both use AST:ALT ratio to assess severity of fibrosis
- Ratio > 0.8 suggests advanced fibrosis
- Ratio greater than 1.5 indicates ALD rather than NAFLD
37
What does NAFLD management entail?
- Lifestyle changes
- Managing co-morbidities
- If scoring test indicate fibrosis, refer to specialist
38
When is liver transplantation considered?
- Acute liver failure
- Decompensated liver disease (?same as chronic liver failure)
39
What is acute liver failure?
The rapid onset of hepatocellular dysfunction leading to a variety of systemic complications
40
What are the causes of acute liver failure?
- Paracetamol overdose
- Viral hepatitis (usually A/B)
- Alcohol
- Acute fatty liver of pregnancy
41
What are features of acute liver failure?
- Jaundice
- Hepatic encephalopathy
- Renal failure
42
What investigations indicate acute liver failure?
- Coagulopathy - raised PTT
- Hypoalbuminaemia
LFTs do not always accurately the synthetic function of the liver
43
Which pts benefit from activated charcoal following paracetamol overdose?
- Pts who present within 1 hr of overdose
- May reduce absorption of the drug
44
What is a complication of acetylcysteine treatment for paracetamol overdose? What is the management?
- Anaphylactic reaction
- Stop infusions, restart at a slower rate
45
What is the King's College Hospital criteria for liver transplantation (in paracetamol overdose)?
Arterial pH <7.3 (24 hrs after ingestion)
Or all of:
- Raised PTT
- Raised Cr
- Encephalopathy
46
What features indicate decompensated liver disease?
A – Ascites
H – Hepatic encephalopathy
O – Oesophageal varices bleeding
Y – Yellow (jaundice)
47
Give 3 complications of gallstones
- Acute cholecystitis
- Acute cholangitis
- Pancreatitis
48
What is biliary colic?
Intermittent RUQ pain caused by gallstones irritating bile ducts
49
Biliary tract disease definitions:
1. Cholestasis
2. Cholelithiasis
3. Cholecystitis
4. Gallbladder empyema
5. Cholecystectomy
6. Cholecystostomy
1. Blockage to flow of bile
2. Gallstones present
3. Inflammation of the gallbladder
4. Pus in gallbladder
5. Removal of gallbladder
6. Drain inserted into gallbladder
50
What are the risk factors for gallstones?
- Fat
- Fair
- Female
- Forty
51
Why are patients with gallstones and biliary colic advised to avoid fatty foods?
- Fat entering the digestive system triggered CCK secretion from the duodenum
- CCK triggers contraction of the gallbladder
- This exacerbates symptoms
52
What is the first line Ix for gallstones? What is second line if this fails to show stones but is still suggestive of disease?
- USS
- MRCP
53
What is the main indication for endoscopic retrograde cholangio-pancreatography? What else is ERCP used for?
To clear stones in the bile ducts
Other roles:
- Insert stents to improve bile drainage
- Take biopsies of tumours
- Inject contrast and take XR to visualise the biliary system
54
What is the management of gallstones in asymptomatic and symptomatic patients?
- Asymptomatic: no intervention required
- Symptomatic: cholecystectomy
55
What is the main cause of acute cholecystitis?
Gallstones in the head of the gallbladder or cystic duct, preventing the gallbladder from draining
56
How does acute cholecystitis present?
- RUQ pain
- Fever
- N+V
- Tachycardia
57
What is a key examination finding in acute cholecystitis?
Murphy's sign
58
What is the first line investigation for acute cholecystitis? What will it show?
- USS
- Thicken gallbladder wall
- Stones/sledge in gallbladder
- Fluid around gallbladder
59
What is the management of acute cholecystitis?
- Admit
- IV fluids
- Abx
- ERCP/cholecystectomy
60
What are possible complications of acute cholecystitis?
- Sepsis
- Gallbladder empyema
- Gangrenous gallbladder
- Perforation
61
What is acute cholangitis?
Infection and inflammation in the bile ducts
62
What are the 2 main causes of acute cholangitis?
- Obstruction in the bile ducts e.g. gallstones
- Infection introduced during an ERCP procedure
63
What are the common causative organisms of acute cholangitis?
- E coli
- Klebsiella species
- Enterococcus species
64
How does acute cholangitis present?
- RUQ pain
- Fever
- Jaundice
65
What is the name for the triad of symptoms seen in acute cholangitis?
Charcot's triad
66
What is the management of acute cholangitis?
- Admit
- IV fluids
- Blood cultures
- IV abx
- ERCP/percutaneous transhepatic cholangiogram (PTC)
PTC is an option where ERCP has failed, it involves inserting a drain through the skin and liver into bile ducts and relieves the immediate obstruction
67
What are the top 3 causes of pancreatitis?
- Gallstones
- Alcohol
- Post-ERCP
68
What drugs can cause pancreatitis?
- Steriods
- Furosemide
- Thiazide diuretics
- Azathioprine
69
How does acute pancreatitis present?
- Severe epigastric pain
- Radiates to back
- Vomiting
- Systemically unwell
70
What investigations are useful in pancreatitis?
- Amylase - raised >3x upper limit of normal in acute pancreatitis, can be normal in chronic
- Lipase - more sensitive and specific than amylase
- CRP - useful for monitoring inflammation
- USS - first line for assessing gallstones
- CT abdo - not required unless suspect complications of pancreatitis
71
What score can be used to assess the severity of pancreatitis? What are the criteria?
Glasgow score
Criteria --> PANCREAS (1 point per criteria)
- PaO2 <8 KPa
- Age >55
- Neutrophils (WBC >15)
- Calcium <2
- uRea >16
- Enzymes (LDH >600 or AST/ALT >200)
- Albumin <32
- Sugar (Glucose >10)
Scores:
- 0-1 = mild pancreatitis
- 2 = moderate
- 3 or more = severe
72
What is the management of acute pancreatitis?
- ABCDE
- IV fluids
- Analgesia
- Treatment of cause e.g. gallstones
- Abx if evidence of specific infections
- Treatment of complications
73
What are potential complications of acute pancreatitis?
- Necrosis of pancreas
- Abscess formation
- Acute peripancreatic fluid collections
- Pseudocyst (collections of pancreatic juice that can develop 4 wks after acute pancreatitis)
- Chronic pancreatitis
74
What are potential complications of chronic pancreatitis?
- Chronic epigastric pain
- Loss of exocrine function
- Loss of endocrine function -> lack of insulin production -> diabetes
- Damage and strictures in the duct system -> obstruction in excretion of pancreatic juice and bile
- Pseudocysts and abscesses
75
What is involved in the management of chronic pancreatitis?
- Analgesia if required
Management of complications:
- Replacement of pancreatic enzymes (Creon) if lose of enzymes (reduced exocrine function)
- Insulin regime if diabetes
- ERCP with stenting to treat strictures and obstruction
- Surgery to manage cysts, abscesses, obstruction
76
What is the most common site of pancreatic tumour?
The head of the pancreas
77
How does pancreatic cancer present?
- Painless obstructive jaundice
- Wt loss
- Non-specific abdo pain/back pain
- Palpable epigastric mass
- N+V
- Loss of endocrine function - new onset diabetes/worsening of T2DM (in exam if pt has worsening glycaemic control despite good lifestyle measures and medication)
- Loss of exocrine function - steatorrhoea
78
What are the referral guidelines for pancreatic cancer?
- >40 with jaundice = 2ww
- >60 with wt loss plus an additional symptoms = GP can refer directly for a CT abdo (suspected pancreatic cancer is the only situation GPs can do this)
79
What is a differential to pancreatic cancer?
Cholangiocarcinoma
80
What does Courvoisier's law state?
- A palpable gallbladder along with jaundice is unlikely to be gallstones
- Cause is usually cholangiocarcinoma/pancreatic cancer
81
How do you investigate pancreatic cancer?
- USS
- High resolution CT is Ix of choice if diagnosis is suspected
- Imaging may demonstrate 'double duct' sign - presence of simultaneous dilation of the common bile and pancreatic ducts
- MRCP to assess the billiard system
- ERCP to put a stent in and relieve obstruction and to obtain a biopsy
- Biopsy under US/CT guidance or during ERCP
82
What is the tumour marker of pancreatic cancer?
- CA19-9 (carbohydrate antigen)
- Also raised in cholangiocarcinoma and other malignant/non-malignant conditions
83
What is the management if pancreatic cancer
- Less than 20% are suitable for surgery at diagnosis
- Whipple's resection (pancreaticoduodenectomy) for resectable lesions at the head of the pancreas
- Chemo
- ERCP with stunting is used for palliation
84
What are causes of hepatitis?
- Viral hepatitis
- Autoimmune hepatitis
- Alcoholic hepatitis
- Non-alcoholic steatohepatitis (NASH)
- Drug induced hepatitis (e.g. paracetamol overdose)
85
What are the 5 types of viral hepatitis? Which have vaccines?
- Hep A (vaccine)
- Hep B (vaccine)
- Hep C
- Hep D
- Hep E
86
Which viral hepatitis is a DNA virus?
- Hep B
- Double stranded DNA virus
- Rest are all RNA
87
Which types of viral hepatitis have faecal-oral transmission?
- Hep A
- Hep E
88
How is Hep B transmitted?
Blood/bodily fluids
89
How is Hep C transmitted?
Blood
90
How is Hep D transmitted?
Always with Hep B
91
What is the most common viral hepatitis worldwide?
Hep A
92
How is Hep A diagnosed?
IgM antibodies
93
Which types of viral hepatitis are managed supportively?
- Hep A
- Hep E
94
How does hepatitis present?
- Abdo pain
- Fatigue
- Flu like illness
- Pruritis
- Muscle/joint aches
- N+V
- Jaundice
95
How do you screen for Hep B?
- HBcAb (vaccination/past/current infection)
- HBsAg (active infection)
96
How do you confirm a diagnosis of Hep B?
If positive screening tests:
- HbeAg (marker of viral replication and implies high infectivity)
- HBV DNA (viral load)
97
What is the management of Hep B?
- Refer to gastro/hepatology/ID
- Screen for other viral infections
- Avoid alcohol
- Contact tracing
- Testing for complications (FibroScan for cirrhosis and USS for hepatocellular carcinoma)
- Antiviral meds to slow progression of disease and reduce infectivity
- Transplant for liver failure
98
How do you test for Hep C?
- Hep C antibody (screening test)
- Hep C RNA testing (confirm diagnosis)
99
What is the management of Hep C?
Same general principles as for Hep B
100
Is Hep C curable?
- Yes - with direct-acting antiviral meds
- Without treatment 1 in 4 make a full recovery and 3 in 4 develop chronic Hep C
101
What are complications of Hep C?
- Liver cirrhosis and associated complications of cirrhosis
- Hepatocellular carcinoma
?same for Hep B
102
Why id Hep D always associated with Hep B?
Hep D attaches itself to HBsAg and cannot survive without it
103
How is Hep D treated?
- Pegylated interferon alpha for > 48 weeks
- Tx is not very effective = has sig side effects
104
What is autoimmune hepatitis?
A rare cause of chronic hepatitis due to a combination of genetic and environmental factors
105
What are the two types of autoimmune hepatitis? Who do they affect? How do they present?
Type 1:
- Women in their late 40s/50s
- Presents around menopause with fatigue and features of liver disease
- Less acute than type 2
Type 2:
- Children/young people
- F>M
- Presents with acute hepatitis with high transaminases and jaundice
106
How do you investigate autoimmune hepatitis?
- LFTs - hepatic picture
- Raised IgG
- Autoantibodies
- Liver biopsy (showing interface hepatitis and plasma cell infiltration)
107
What autoantibodies are present in Type 1 autoimmune hepatitis?
- Anti-nuclear antibodies
- Anti-smooth muscle antibodies
- Anti-soluble liver antigen
108
What autoantibodies are present in Type 2 autoimmune hepatitis?
- Anti-liver kidney microsomes-1
- Anti-liver cytosol antigen type 1
109
What is the management of autoimmune hepatitis?
- Immunosuppressants (usually successful in inducing remission) - high dose steroids, azathioprine
- Liver transplant - required in end-stage liver disease
