Liver Flashcards
What is the most common cause of chronic liver disease
Non Alcoholic fatty liver disease - hepatic steatosis
What are the risk factors for NAFLD
- Dyslipidaemia
- Insulin resistant DM
- HTN
- Obesity
- TPN
- Hepatotoxic meds
- Rapid weight loss
- Metabolic syndrome
What are the Sx of NAFLD
- RUQ pain
- Jaundice
- Puritis
- Truncal obesity
- Fatigue
- Organomegaly
What is the management of NAFLD
- Diet and exercise
- Insulin sensitizer
- Vit E
- Lipid lowering drugs
- Liver transplant
- gastric bypass
What are the 3 stages of alcoholic liver disease
- steatosis
- alcoholic hepatitis - inflamation and necrosis
- Alcoholic citthosis
What is the management for Alcoholic liver disease
- STOP DRINKING
- corticosteroids
- Sodium restriction
- Nutrition and multivit
- lower weight and stop smoking
- Liver transplant
- Immunisations
What are the complications of Alcoholic liver disease
- Hepatocellular Ca
- Hepatic encephalopathy
- Sepsis
- Hepatorenal syndrome
- coagulopathy
- GI bleed
- Portal HTN
What are the Sx of alcoholic liver disease
- abdo pain
- anorexia
- fatigue
- confusion
- puritis
What are the signs of alcoholic liver disease
- Ascites
- Weight loss/gain
- Muscle wasting/malnutrition
Haematemesis/malaena - Jaundice
- venous collaterals
What drugs can cause hepatocellular insult
- Statins
- Epilepsy meds
- paracetamol
- Amiodarone
- TB meds
- Nitrofurantoin
What is given in a paraccetamol overdose
Acetlycysteine
What are the causes of liver ischaemia
- Hypoperfusion
- Heat stroke
- burns
- clots
- vasculitus
What types of hypoperfusion may lead to liver Ischaemia
- HF
- arrythmias
- Sepsis
- GI bleed
- Dehydration
What are the signs and Sc of liver ischaemia
- Decrease in appetite
- Jaundice
- general discomfort
What serum marker do you look for in Liver Ca
AFP
Where does hepatocellular ca arise from
Hepatocytes
What are the risk factors for hepatocellular CA
- Hep B/C
- chronic heavy alcohol
- cirrhosis
- FH
- Obesity
- DM
What are the signs and symptoms of Cirrhosis
- Peripheral oedema
- consitutional symptoms
- Hepatic fator
- mm wasting
- Jaundice and puritis
- distention - ascites/hepatomegaly
- malaena
- Hand and nail signs
What does ascites indicate in liver disease
Portal HTN
What are the RF of cirrhosis
- IVDU
- Unprotected sex
- Obesity
- Blood transfusion
- tattoos
- Alcohol
What is the management of Cirrhosis of the liver
- treat underlying cause
- liver transplant
- sodium restriction
- monitor for complications
What are the complications of liver cirrhosis
- Portopulmonary HTN
- Gastro-oesophageal varcies
- Hepatic hydrothorax
- Hepatocellular Ca
- Hepatopulmonary syndrome
- Ascites
- hepatorenal syndrome
- Spontaneous bacterial peritonitis
- portosystemic encephalopathy
What are the precipitating factors for portosystemic encephalopathy?
- Constipation
- GI bleed
- Hypocalcaemia
- drugs
- electrolyte imbalances
- excess protein intake
what % of people with cirrhosis will develop portosystemic encephalopathy per year
2-3%
What signs/symptoms may indicate portosystemic encephalopathy
- increased drowsiness
- changes in personality - aggression
- disorientation/confusion
- asterixis
- slurred speech
What investigation should be done if suspecting portosystemic encephalopathy
- serum ammonia - usually raised
What is the management of portosystemic encephalopathy
- treat underlying cause
- May require rifaxmin - Abx
What is portosystemic encephalopathy
neuropsychiatric syndrome associated with hepatocellular failure or portosystemic venous shunting
What is spontaneous bacterial peritonitis
infection of ascitic fluid that cannot be attributed to any intra-abdominal, ongoing inflammatory, or surgically correctable condition
What are the symptoms of SBP
- abdominal pain & tenderness
- fever
- malaise
- D&V
- altered mental state
- GI bleed
- hyperthermia
- tachycardia
RF for SBP
- cirrhosis
- low ascitic protein complement
- GI bleeding
- sclerosis/oesophageal varices
Investigations for SBP
- FBC
- CRP
- ascitic tap
- blood cultures
- LFTs
- INR and Coags
What may you see in an ascitic tap in SBP
- polymorphonuclear count >250
- hazy/cloudy/blood stained
- pH <7.35
What is the management of SBP
- IV cefotaxime/quinolone
- Lifelong secondary prophylactic Abx
- IV albumin if renal dysfunction
- large volume paracentesis if large amounts of fluid
What is hepatopulmonary syndome
Complication from portal HTN whereby the vessels in the lungs vasolidate causing hypoxaemia
How to you manage hepatopulmonaary syndrome
liver transplant - 5-10% of patients awaiting liver transplant have this
What is hepatorenal syndrome
progressive kidney failure seen in people with severe liver damage, most often caused by cirrhosis
What is type 1 hepatorenal syndrome
- rapidly progressive
- createnine doubles within 2 wks
What is the management of type 1 hepatorenal syndrome
- Albumin infusion
- Abx
- octreotide
- list for transplant
What is type 2 hepatorenal syndrome
- slowly progressive renal failure
- refractory ascites
What medication MUST be avoided in hepatorenal syndrome
NSAIDs
What hand and nail signs can be seen in liver problems
- leuconychia
- Palmar erythema
- duputryns contracture
- Clubbing
- hepatic failure
What facial signs can be seen in liver problems
- Jaundiced sclera
- Xanthalasma
- telangectasia
- Spider angiomata
- bruising
- Parotid gland swellign
What signs can be seen on viewing the abdomen in liver problems
- distention
- bruising
- caput medussa
- testicular atrophy
- loss of secondary sexual hair
What signs can be felt/heard on abdominal examination in liver problems
- shifting dullness
- organomegaly
- hepatic bruit
What are common causes of chronic liver problems
- chronic infection
- NAFLD
- Alcoholic fatty liver disease
- CIrrhosis
- Primary billiary cirrhosis
What are some uncommon causes of chronic liver problems
- alpha 1 antitrypsin defiency
- Wilson’s disease
- Haemochromatosis
What causes acute hepatocellular injury
- Poisoning
- Infection
- Liver ischaemia
What are the functions of the liver
- Synthesis of albumin
- Synthesis of coagulation factors
- Gluconeogenesis
- conjugate and eliminate billirubin
What LFTs may indicate a hepatocellular injury
raised ALT and AST
In acute hepatocellular injury what may the LFTs show
ALT < AST
In chronic hepatocellular injury what may the LFTs show
ALT > AST
what colour is unconjugated billirubin in the urine
Unconjugated is water soluble so doesn’t change the colour of the urine
What colour is conjugated billirubin in the urine
conjugated billirubin passes to the urine as urobilogen causing dark urine
What impact does pre hepatic jaundice have on urine and stool
Normal urine and stool
What impact does hepatic jaundice have on urine and stool
Dark urine
Normal stool
What impact does post hepatic jaundice on urine and stools
Dark urine
Pale stools
What causes prehepatic jaundice - unconjugated hyperbillirubinaemia
- Gilberts
- Haemolysis: haemolytic anaemia
- Impaired hepatic uptake: Drugs
What causes post-hepatic jaundice
- obstruction: cholestasis, head of panc ca
What is hepatitis A
- Most common viral infection worldwide (rare UK)
- RNA virus
- Faecal-oral route: contaminated food or water
What is the presentation of hepatitis A
- Nausea and vomiting
- Anorexia
- Jaundice
- Cholestasis
- dark urine, pale stools
- hepatomegaly
What is the treatment of hepatitis A
- Resolves on own in 1-3 months
- analgesia
- vaccination
- notifiable disease
What is hepatitis B
- DNA virus
- Transmitted via direct contact with bodily fluids, toothbrush, pregnancy
Why do people become chronic hepatitis B carriers
- the virus DNA has integrated into their own DNA and so they will continue to produce the viral proteins. (10%)
- most people recover in 1-2 months
What does a Surface antigen (HBsAg) mean
active infection
what does E antigen (HBeAg) mean
marker of viral replication and implies high infectivity
What do Core antibodies (HBcAb) suggest?
implies past or current infection
what do Surface antibody (HBsAb) suggest
implies vaccination or past or current infection
What isHepatitis B virus DNA (HBV DNA)
Direct count of viral load
What investigations should you do for suspected viral hepatitis
- test HBcAb (for previous infection) and HBsAg (for active infection)
- If these are positive then do further testing for HBeAg and viral load.
How can you distinguish between acute, chronic or past infection?
- IgM and IgG versions of the HBcAb.
- IgM: active infection, high titre = acute infection and a low titre = chronic infection
- IgG indicates a past infection where the HBsAg is negative.
Wha tis the Hep B vaccination
- injects the hepatitis B surface antigen
- tested for HBsAb to confirm their response
- 3 doses at different intervals
- Included as part of the UK routine vaccination schedule (as part of the 6 in 1 vaccine).
What is the management of hepatitis B or C
- low threshold for screening those at risk of hepatitis B.
- Screen for other blood born viruses & STIs
- Refer to gastroenterology, hepatology or infectious diseases for specialist management
- Notify Public Health (it is a notifiable disease)
- Stop smoking and alcohol
- Education about reducing transmission and informing potential at risk contacts
- Testing for complications
- Antiviral medication
- Liver transplantation for end-stage liver disease
What is the invstigations for complications of hepatitis B
FibroScan for cirrhosis and ultrasound for hepatocellular carcinoma
What is the role of antiviral medication in hepatitis B
slow the progression of the disease and reduce infectivity
What is hepatitis C
- RNA virus
- spread by blood and body fluids
- No vaccine is available
What is the disease course of hepatitis C
1 in 4 fights off the virus and makes a full recovery
3 in 4 it becomes chronic
What are the complications of hepatitis C
- liver cirrhosis
- hepatocelluar carcinoma
What investigations are done for ? hepatitis C
- Hepatitis C antibody is the screening test
- Hepatitis C RNA testing: confirm the diagnosis of hepatitis C, calculate viral load and assess for the individual genotype
What is hepatitis D
- RNA virus
- Requires hepatitis B co-infection
- low rates in the UK
- Increases the complications and disease severity of hepatitis B.
- No treatment
- Notifiable disease
What is hepatitis E
- RNA virus
- faecal oral rout
- Very rare in the UK.
- mild illness, the virus is cleared within a month and no treatment is required.
- Rarely it can progress to chronic hepatitis and liver failure, if immunocompromised
- no vaccination.
- Notifiable disease
What is auto-immune hepatitis
- Rare cause of chronic hepatitis, not sure of cause
- genetic predisposition
- triggered by environmental factors such as a viral infection that causes a T cell-mediated response against the liver cells
- T cells of the immune system recognise the liver cells as being harmful and alert the rest of the immune system to attack these cells.
What is type 1 autoimmune hepatitis
- women in late 40s-50.
- It presents around or after the menopause with fatigue and features of liver disease on examination
- less acute course than type 2.
What is type 1 autoimmune hepatitis
patients in their teenage or early twenties present with acute hepatitis with high transaminases and jaundice.
What auto-antibodies are associated with type 1
Anti-nuclear antibodies (ANA)
Anti-smooth muscle antibodies (anti-actin)
Anti-soluble liver antigen (anti-SLA/LP)
What auto-antibodies are associated with type 2
Anti-liver kidney microsomes-1 (anti-LKM1)
Anti-liver cytosol antigen type 1 (anti-LC1)
How do you confirm diagnosis of autoimmune hepatitis
liver biopsy
What is the treatment of autoimmune hepatitis
- high dose steroids (prednisolone)
- immunosuppression: azothiaprine (usually life long)
- Liver transplants ( can still recur)
What factors make you unsuitable for a liver transplant
Significant co-morbidities (e.g. severe kidney or heart disease)
Excessive weight loss and malnutrition
Active hep B or C or other infection
End stage HIV
Active alcohol use (generally 6 months of abstinence is required)
How do you monitor for evidence of liver rejection
Abnormal LFTs
Fatigue
Fever
Jaundice
What advice is given to patients post organ donation
Avoid alcohol and smoking
Treating opportunistic infections
Monitoring for disease recurrence (i.e. of hepatitis or primary biliary cirrhosis)
Monitoring for cancer as there is a significantly higher risk in immunosuppressed patients
Common Causes of hepatomegaly
Cirrhosis (in early stages) Malignancy Right heart failure Viral hepatitis Haematological malignancies Glandular fever Malaria
