Liver Flashcards
Presentation of alcoholic liver disease
- Generally asymptomatic
- Nausea, vomiting, diarrhoea
- Abdominal pain
- Palmar erythema
- Asterixis
- Jaundice
- Spider naevi
- Gynaecomastia
- Bruising
- Ascites
- Caput medusae (engorged superficial epigastric veins)
- Hepatomegaly
Bloods in alcoholic liver disease
- FBC = raised MCV
- LFTs = elevated ALT and AST, raised gamma-GT, ALP raised (later), low albumin, elevated bilirubin (cirrhosis)
o Ratio of AST:ALT normally >2 - Clotting = elevated prothrombin time
- U+Es = deranged in hepatorenal syndrome
Imaging in alcoholic liver disease
- Ultrasound, MRI or CT = fatty infiltration, hepatocellular carcinoma, hepatosplenomegaly, abnormal blood vessel changes and ascites
- Liver biopsy = alcohol related hepatitis or cirrhosis, Mallory bodies
Management of alcoholic liver disease
- Stop drinking alcohol permanently
- Consider detoxication regime = treat withdrawal Sx with diazepam
- Nutritional support with vitamins (thiamine) and high protein diet
- Prednisolone = improve short term outcomes
o Maddrey’s discriminant function to determine who would benefit from steroids - Referral for liver transplant in severe disease but must abstain from alcohol 3 months prior
Complications of alcoholic liver disease
- Portal hypertension
- Varices
- Hepatic encephalopathy
Factors associated with NAFLD
- Obesity
- Type 2 diabetes
- Hyperlipidaemia
- Jejunoileal bypass
- Sudden weight loss/starvation
Presentation of NAFLD
- Usually asymptomatic
- Hepatomegaly
Investigations of NAFLD
- Abnormal LFT = ALT > AST
- US = increased echogenicity
- Enhanced liver fibrosis (ELF) blood test
Management of NAFLD
- Lifestyle changes weight loss
- Gastric banding
- Insulin-sensitising drugs (metformin, pioglitazone)
Causes of liver cirrhosis
- Alcoholic liver disease
- Non-alcoholic fatty liver disease
- Viral Hepatitis (B/D, C)
- Rarer causes = autoimmune hepatitis, haemochromatosis, Wilson’s disease, alpha-1 antitrypsin deficiency, CF, PBC, drugs (amiodarone, methotrexate)
Presentation of liver cirrhosis
- Abdominal pain
- Bruising
- Ankle swelling and oedema
- Leuconychia
- Clubbing
- Palmar erythema
- Dupuytren’s contracture
- Asterixis
- Spider naevi
- Xanthelasma
- Hepatomegaly + splenomegaly
- Ascites
- Loss of body hair
- Gynaecomastia and testicular atrophy
- Caput medusae
Bloods in liver cirrhosis
- LFTs = normal or deranged (if decompensated)
- Albumin low
- Prothrombin time raised
- Hyponatraemia = fluid retention
- Urea and creatinine = deranged in hepatorenal syndrome
- Enhanced liver fibrosis blood test
- Alpha-fetoprotein = tumour marker for hepatocellular carcinoma
Imaging in liver cirrhosis
- Ultrasound = nodularity of liver surface, corkscrew appearance to arteries, enlarged portal vein with reduced flow, ascites, splenomegaly
- Liver biopsy
- Fibroscan = check elasticity of liver
- Endoscopy = oesophageal varices with portal hypertension
- CT and MRI = hepatocellular carcinoma, hepatosplenomegaly, abnormal blood vessel changes and ascites
Classification of liver cirrhosis
Child-Pugh:
- High Bilirubin
- Low Albumin
- High INR
- Ascites
- Encephalopathy
- Lowest score 5. Highest score 15.
- <7 good. >10 bad prognosis
- Risk of variceal bleeding if >8
Management of liver cirrhosis
- High protein, low sodium diet
- No alcohol
- Avoid NSAIDs and aspirin
- Ultrasound and alpha-fetoprotein every 6 months for hepatocellular carcinoma
- Endoscopy every 3 years for no varices
- Consider liver transplant
Complications of liver cirrhosis
- Malnutrition
- Portal hypertension, varices and variceal bleeding
- Ascites and spontaneous bacterial peritonitis
- Hepato-renal syndrome
- Hepatic encephalopathy
- Hepatocellular carcinoma
What are varices?
Swollen, tortuous vessels at gastro-oesophageal junction, ileocaecal junction, rectum, anterior abdominal wall via umbilical vein
Management of stable varices
o Propranolol (non-selective BB) = reduces portal hypertension
o Elastic band ligation of varices
o Injection of sclerosant
Management of bleeding varices
o Resuscitation
o Vasopressin analogues (terlipressin) = vasoconstriction and slow bleeding
o Coagulopathy with Vit K and fresh frozen plasma
o Prophylactic broad spectrum Abx (cephalosporin)
o Intubation and intensive care
o Urgent endoscopy
o Sengstaken-Blakemore tube if uncontrolled
o Transjugular Intrahepatic Portosystemic Shunt
Causes of liver failure
- Viral = Hep B, C, CMV, cytomegalovirus, EBV, herpes simplex
- Drugs = Paracetamol, alcohol, anti-depressants, NSAIDS, cocaine, Abx
- Hepatocellular carcinoma
- Wilson’s disease or A1A deficiency
- Acute fatty liver of pregnancy
- Budd-chiari syndrome
Presentation of liver failure
- Bruising
- Fever
- Vomiting
- Jaundice
- Signs of hepatic encephalopathy
- Fetor hepaticus = smells like pear drops
- Clubbing
- Dupuytren’s contracture
- Ascites (rare)
- Spasticity and hyper-reflexia
- Plantar response remain flexor until late
- Hypertension
Signs of hepatic encephalopathy
I = altered mood/behaviour, sleep disturbance, dyspraxia
II = increasing drowsiness, confusion, slurred speech, liver flap, inappropriate behaviour/personality change
III = incoherent, restless, liver flap, stupor
IV = coma
Bloods in liver failure
o High serum ALT and AST, bilirubin
o Low levels of coagulation factors and raising prothrombin time
o Low glucose
o Ammonia levels high
o CMV and EBV serology
o Paracetamol levels
Imaging in liver failure
o Abdo Ultrasound = liver size and liver pathology
o Electroencephalogram = grading
o CXR
o Doppler ultrasound to see hepatic vein patency
Management of liver failure
- Treat cause
- Paracetamol poisoning = N-acetyl cysteine
- Monitor glucose levels and administer IV glucose if necessary
- Signs of raised intracranial pressure = IV mannitol
- Mineral supplements = calcium, potassium, phosphate
- Coagulopathy = IV Vit K, platelets, blood/fresh frozen plasma
- Reduce haemorrhage risk = PPI (lansoprazole) to reduce GI bleeds
- Prophylaxis against bacterial and fungal infection
- Urinary and central venous catheters
- Liver transplant
Complications of liver failure
- Sepsis
- Hypoglycaemia
- GI bleeds/varices
- Encephalopathy
- Cerebral oedema
- Ascites
Risk factors for hepatocellular carcinoma
- Chronic hepatitis B and C
- Alcohol cirrhosis
- Non-alcoholic fatty liver disease
- Haemochromatosis
- Primary biliary cirrhosis
- Alpha-1 antitrypsin deficiency
- Hereditary tyronsinosis
- Glycogen storage disease
- Aflatoxin
- Drugs: oral contraceptive pill, anabolic steroids
- Diabetes mellitus
- Metabolic syndrome
Presentation of hepatocellular carcinoma
- Asymptomatic for long time and presents late
- Features of liver cirrhosis jaundice, ascites, RUQ pain, hepatomegaly, pruritus, splenomegaly
- Weight loss
- Anorexia
- Nausea and vomiting
- Fatigue
- Ascites
- Enlarged, irregular, tender liver
Tumour marker for hepatocellular carcinoma
Alpha-fetoprotein (AFP)
Imaging investigations for hepatocellular carcinoma
- Liver ultrasound and biopsy
o Biopsy avoided due to seeding - CT and MRI = diagnosis and staging
Management of hepatocellular carcinoma
- Surgical resection of isolated lesion in early disease
- Liver transplant is only chance for cure
- Radiofrequency ablation
- Transarterial chemoembolisation
- Kinase inhibitors (sorafenib, regorafenib, lenvatinib) = inhibit proliferation of cells
- Palliative care
What is hereditary haemochromatosis?
Inherited disorder (autosomal recessive) of iron metabolism and storage that results in excessive total body iron and deposition of iron in tissues
Risk factors for haemochromatosis
Alcoholic
Presentation of haemochromatosis
- Early Sx fatigue, erectile dysfunction, arthralgia (often hands)
- Memory and mood disturbance
- Bronze/slate-grey skin pigmentation
- Hair loss
- Hepatomegaly
- Hypogonadism = amenorrhoea and erectile dysfunction
Investigations for haemochromatosis
- Raised serum iron and ferritin, Transferrin
- Low total iron binding capacity
- Genetic testing
- MRI = Detects iron overload
- Liver biopsy w/ Perl’s stain establish extent of tissue damage and disease severity
Management of haemochromatosis
- Venesection = regular removal of blood (weekly)
o Monitor serum ferritin and transferritin - Avoid alcohol
- Diet low in iron (Avoid fruit/fruit juice and white wine)
- Desferrioxamine (2nd line)
- Screening = All first-degree relatives
Complications of haemochromatosis
- Type 1 diabetes
- Liver cirrhosis
- Iron deposits in pituitary and gonads = endocrine and sexual problems
- Cardiomyopathy
- Hepatocellular carcinoma
- Hypothyroidism
- Chrondocalcinosis/ pseudogout
What is Wilson’s disease?
Inherited disorder (autosomal recessive) causing excessive accumulation of copper in body and tissues (liver and CNS)
Presentation of Wilson’s disease
- Reduced memory
- Chronic hepatitis cirrhosis
- Dysarthria = speech difficulties
- Dystonia = abnormal muscle tone
- Parkinsonism (tremor, bradykinesia, rigidity)
- Asymmetrical motor symptoms
- Mild depression to full psychosis
- Kayser-Fleischer rings in cornea
- Haemolytic anaemia
- Renal tubular damage renal tubular acidosis
- Osteopenia
- Blue nails
Investigations of Wilson’s disease
- Serum caeruloplasmin = low
- Liver biopsy = increased hepatic copper
- 24 hour urine copper assay elevated
- MRI = basal ganglia and cerebellar degeneration
- Slit lamp examination for kaiser-fleisher rings
- Genetic analysis of ATP7B gene
Management of Wilson’s disease
- Copper chelation (penicillamine/trientene)
- Avoid foods high in copper = chocolate, nuts, mushrooms
- Liver transplant
- Screen siblings
Side effects of copper chelation
skin rashes, fall in WCC/Hb/platelets, haematuria, renal damage
What is alpha-1-antitrypsin deficiency
Inherited autosomal recessive condition where deficiency of A1A causes excess of protease enzymes that attack liver and lung tissue and cause liver cirrhosis and lung disease
Presentation of A1AD
- Liver cirrhosis after 50 years old
- Pulmonary basal emphysema after 30 years old
Investigations of A1AD
- Serum A1A levels low
- Liver biopsy = cirrhosis and acid-Schiff-positive staining globules
- Genetic testing
- High res CT thorax = pulmonary emphysema
Management of A1AD
- Stop smoking
- Symptomatic treatment and monitor complications
- Organ transplant
Complications of A1AD
Hepatocellular carcinoma
Associations of autoimmune hepatitis
- Other autoimmune disorders
- Hypergammaglobulinaemia
- HLA B8
- DR3
Presentation of autoimmune hepatitis
- Signs of chronic liver disease
- Acute hepatitis: fever, jaundice
- Amenorrhoea
Investigations of autoimmune hepatitis
- ANA/SMA/LKM1 antibodies
- Raised IgG levels
- Liver biopsy inflammation extending beyond limiting plate ‘piecemel necrosis’, bridging necrosis
Management of autoimmune hepatitis
- Steroids
- Other immunosuppressants (azathioprine)
- Liver transplantation
Indications for transjugular intrahepatic portosystemic shunt (TIPSS)
Oesophageal variceal bleeding
Refractory ascites
Budd-Chiari syndrome
Complications of TIPSS
Hepatic encephalopathy
