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Clinical > Liver > Flashcards

Liver Flashcards

1
Q

How does alcohol damage the liver?

A
  • induces hepatic steatosis
  • increases gut permeability ( to toxins)
  • alcohol metabolism causes oxidative stress
  • alcohol metabolism produces acetaldehyde.
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2
Q

How would you diagnose someone having alcoholic hepatitis?

A

Need a liver biopsy for definitive diagnosis but very expensive

  • ballooning degeneration of hepatocytes
  • neutrophil infiltrate
  • pericellular fibrosis
  • perivenular distribution
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3
Q

What can be used for prognosis of liver failure?

A

Maddrey’s Discriminant Function score used for severity + prognosis
DF>32 is severe and would benefit from steroids

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4
Q

Most important thing to do in patient with alcohol liver disease

A

Treat the addiction

  • Help them engage w/ addiction support in the community
  • Treat w/ support, counselling ( 60mins/wk for 12 wks ) + pharmacotherapy
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5
Q

What are the pharmacoptherapy options for alcohol addiction?

A
  • Naltrexone to help with alcohol withdrawal. Use for 6 months but discontinue after 6 weeks if no benefit
  • Baclofen is a GABA b agonist that can be sued in decompensated cirrhosis.
  • Disulfiram must be started at least 24hrs after last drink
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6
Q

What are the causes of acute liver failure?

A

Infection - Hep A,B, EBV
Toxins - Alcohol, paracetamol, isoniazid
Vascular - Budd Chiari
In pregnancy - eclampsia and AFL of pregnancy
Autoimmune - Wilson’s, AIH

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7
Q

What are the signs of Acute Liver Failure?

A

Jaundice
Oedema + ascites
Bruising
Asterixis + constructional apraxia ->Encephalopathy
Fetor hepaticus - breath smell
could be acute on chronic so may be signs of chronic liver disease.

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8
Q

What are the signs of chronic liver disease?

A 
Clubbing
Leuconychia ( due to hypoalbuminaemia)
Palmer erythema ( less oestrogen clearance)
Duputron's contracture
Xanthelasma - in PBC
Spider Naevi
Gynacomastia
Striae 
Dilated superficial veins - acute medusa
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9
Q

What investigations would you do if suspected liver failure?

A

*FBC - infection, anaemia ( low MCV due to alcohol or normal but possible GI bleed)
*blood glucose
*U+E - urea may be low because it synthesised in liver, Cr may be higher than normal if hepatorenal syndrome
*LFTs
- check AST and ALT
- low albumin in Chronic
PT - increased in acute liver liver failure
* Also check INR -increased if there is a clotting factor issue
* do bloods to look for the cause
> paracetamol levels,
> ferritin
>urine copper levels high, serum copper and caeruloplasmin low )
> a1 AT deficient

radiology - CXR, PFA, doppler of portal vein and hepatic vein if Budd Chiara suspected

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10
Q

Why might caeruloplasmin be low?

Why might it be falsely high?

A

Wilson’s disease
falsely low in protein deficiency states e.g. nephrotic synd, malabsorption.
Falsely high because it is an acute phase reactant high in inflammation - infection, pregnancy

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11
Q

What screening tests can be done in a patient with Chronic liver disease of unknown cause?

A
  • Hep B and C virology
  • Iron studies for haemochromatosis ( high ferritin and iron but low TIBC)
  • a1AT deficiency
  • Wilson’s - low serum Cu and Caeruloplasmin
  • Anti mitochondrial anitbodies- PBC
  • ANA, ANCA, SMA - PSC
  • increased a fetoprotein in HCC
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12
Q

How should a patient with liver failure be managed?

A 
Manage in HDU
Treat the underlying cause
Thiamine supplements
PPI prophylaxis for stress ulcers
Monitor 
 - fluids 
 - FBC, LFTs, U+E daily
 - glucose every 4hrs + give glucose if it goes to low (<2mM)
- give rifaximin and lactulose to prevent encephalopathy
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13
Q

What are complications of liver disease?

A

Bleeding - give fit K, platelets, blood
Sepsis - avoid gentamicin due to nephrotoxicity ( try tazacin)
Ascites - fluid and salt restriction, furosemide, tap
Hypoglycaemia - reg blood check, IV glucose if needed
Encephalopathy - avoid constipation + give rifaximin
Seizures - lorazepam
Cerebral oedema - mannitol

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14
Q

What must be considered when prescribing in patient with liver failure?

A

*Avoid hepatotoxic drugs e.g. paracetamol, methotrexate, isoniazid, tetracycline
*Avoid opiates, oral hypoglycaemic,
Effect of warfarin is increased

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15
Q

Anaemia w/ high LDH, low haptoglobin, slow healing ( low platelets), AST and ALT elevated?

A

HELLP syndrome

associated with pre-eclampsia

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16
Q

What are the causes of liver cirrhosis?

A
  • alcohol liver disease
  • NAFLD
  • Chronic hep C and B
  • Genetic - Wilsons, haemochromatosis,
  • Autoimmune - PBC, PSC, AIH
  • Drugs - Methotrexate, amiodarone
  • Vascular - budd chiari
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17
Q

What are the complications of cirrhosis?

A 
Jaundice
Encephalopathy 
Hypoalbuminaemia
Coagulopathy - high INR - easy bruising
Hypoglycaemia
Systemic Bacterial Peritonitis
Portal Hypertension
higher risk of HCC
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18
Q

What are the signs of portal hypertension?

A

Splenomegaly
Ascites
Varices
Encephalopathy

19
Q

What are the causes of portal hypertension?

A

Pre-hepatic = Portal vein thrombosis
Hepatic - cirrhosis, schistosomiasis, sarcoid
Post-hepatic - Budd chiaria, RHF, constrictive pericarditis

20
Q

What is the child Pugh grading system?

A

grading of cirrhosis to predict risk of bleeding, mortality and need for tx
Graded A-C, A =5-6, B=7-9, C10 or above
Score calculated on the severity of 5 factors
- Albumin, Bilirubin, (Clotting), PT ( how many seconds more than normal is it), (Distension) Ascites, Encephalopathy
The risk of variceal bleeding is much higher with a score of 8 or higher

note - poor prognostic indicators include encephalopathy, Hyponatremia <110mmol/L and serum albumin <25g/L

21
Q

What would your workup be of a patient with Liver disease?

A 
FBC 
LFTs - hepatic deranged ( AST + ALT elevated)
U+E - if encephalopathic
PT or INR - increased
Blood glucose

HBV and HCV serology
look at possible alcohol cause - high MCV and GGT
look for hyperlipidaemia in NAFLD

Look at genetic causes - Check ferritin levels for HH, check a1AT, low caeruloplasmin in Wilson’s
autoimmune look at antibodies
- AMA in PBC, ANCA and ANA in PSC

radiological -Abdo US + PV duplex looking at size of liver, focal lesions, evidence of reversed portal vein flow

complications
OGD - if appears decomp ->variceal bleed
Ascitic tap if decomp concern of SBP

22
Q

What is the management of a patient with cirrhosis?

A
  • good nutrition
  • alcohol absitinence
    *screen for HCC with US and AlpahaFetaProtein levels
    OGD for oesophageal varices

if varices are present - can do OGD screening + banding of varices

if the patient has decompensated
- ascites - fluid + salt restrict, furusomide, tap if concerned + give tazocin if SBP
- coagulopathy -> vitK, Fresh frozen plasma
- encephalopathy - lactulose+ rifaximin
- Sepsis / SBP - tazacin ( sepsis 6)
Hepatorenal syndrome - albumin + terlipressin

23
Q

How would you stage encephalopathy?

A

1-4
1 confused - irritable, mild confusion, sleep inversion
2 drowsy - disorientated, slurred speech, asterixis
3 stupor - rousable, incoherent
4 coma - unrousable

24
Q

What signs would signal encephalopathy?

A 
ACDCs
Asterixis, ataxia
Confusion
Dysarthria
Constructional apraxia
Seizures
25
Q

What can precipitate encephalopathy?

A 
HEPATICS
Haemorrhage - varices
Electrolytes - hypo kal, nat
Poisons - diuretics, sedatives, anaesthesia
Alcohol
Tumor - HCC
Infection - SBP, pneumonia, UTI, HDV
Constipation - most common 
Sugar - low calorie diet
26
Q

Investigation for encephalopathy?

A

elevated serum ammonium NH4

27
Q

Why do patients with liver failure and cirrhosis become encephalopathic?

A
  • reduced hepatic metabolic function
  • diversion of toxins from the GI tract and liver directly into the systemic system
  • ammonia accumulates and goes to brain where astrocytes clear it causing glutamine formation
  • the increased glutamine causes osmotic imbalance and cerebral oedema
28
Q

How should you give rifaximin for a patient with encephalopathy?

A

PO

because you want it to act within the intestines

29
Q

What could you give to a patient with liver disease who has had recurrent SBP?

A

Ciprofloxacin long term as prophylaxis

30
Q

What is the Maddrey score?

A

Predicts mortality in patients with alcoholic heptatitis
mild
severe 50% 30day mortality

31
Q

How might a patient with alcoholic hepatitis present?

A

Anorexia
Diarrhoea or vomitting
tender hepatomegaly ( assuming not yet cirrhoses)
ascites
if severe - they may be jaundiced, GI bleed, encephalopathy

*patient with alcohol hepatitis and hx of alcoholism are at risk of GI bleed both b/c of varices and PUD ulceration + bleeding

32
Q

What is Budd Chiari syndrome?

A

Hepatic vein obstruction which leads to ischaemia and hepatocyte damage. ultimately it can cause liver failure or cirrhosis

33
Q

What are the possible causes of Bud-Chiari syndrome?

A

Hypercoaguable states - Polycythemia vera, OCP
Local tumor - HCC
Congenital - membranous obstruction of IVC

34
Q

What blood results would you expect in a patient with Hereditary haemochromatosis?

A

Elevated LFTs
elevated ferritin and iron levels
low TIBC

35
Q

What tests could show the severity of liver disease in patient with Haemochromatosis?

A

MRI can estimate the iron loading
liver biopsy with pearl’s stain to quantify the amount of iron and severity of liver disease.
should do ECHO because could have dilated cardiomyopathy

36
Q

a 45-year-old woman presents with fatigue and pruritus. Blood tests show a raised bilirubin, ALP and IgM level

A

Primary biliary cirrhosis aka primary biliary cholangitis

37
Q

a 20-year-old woman with a history of emotional lability and depression presents with an asymmetrical tremor. On examination she has early stigmata of chronic liver disease

A

wilson’s

38
Q

a 35-year-old man presents with fatigue, erectile dysfunction and arthralgia. On examination he ‘bronze’ pigmentation of his skin and some early stigmata of chronic liver disease

A

Haemochromatosis

39
Q

Strong family history of colorectal and endometrial cancer in a question is most likely to indicate:

A

Hereditary non-polyposis colorectal carcinoma

40
Q

Anti mitochondrial antibodies

A

Primary biliary cirrhosis aka prim bil cholangitis

41
Q

1st line medication for primary biliary cholangitis

A

Ursodeoxycholic acid is the first-line medication for primary biliary cholangitis

42
Q

consequence of Gilbert’s syndrome

A

Gilbert’s syndrome is a benign condition causing a mild rise in bilirubin - no treatment needed

43
Q

iron study results with haemochromatosis

A

high ferritin, high iron, low TIBC

transferrin saturation >80%

Clinical (45 decks)

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