Liver and Biliary System Diseases II Flashcards
Hepatobiliary diseases, Acute liver failure and Cirrhosis
Symptoms of liver disease occur late and are characterised by:
i. Jaundice
or features of hepatic decompensation, such as:
ii. Ascites
iii. Peripheral oedema
iv. Portal hypertensive GI bleeding
v. Encephalopathy
JAPEP
Mention 4 examples of Liver disease
i. Acute liver disease
ii. Chronic liver disease
iii. Cirrhosis
iv. Viral hepatitis (A, B, C, D, E, G)
What are the symptoms that characterise biliary disorders?
i. Upper abdominal pain
ii. Jaundice
iii. Fever
iv. Weight loss
Mention 4 examples of Biliary disorders.
i. Gallstone disease
ii. Cholecystitis: inflammation of the gallbladder, often due to gallstones blocking the cystic duct
iii. Mirizzi syndrome: a rare condition where a gallstone becomes impacted in the cystic duct or neck of the gallbladder, causing compression of the common bile duct.
iv. Cholangitis: an infection of the bile ducts, often due to bile duct obstruction, commonly by gallstones
v. Biliary tract malignancies, cysts and others.
Mention 3 examples of pancreatic disorder.
i. Pancreatitis
ii. Pancreatic cancer
iii. Exocrine pancreatic insufficiency (EPI)
What is Acute Liver Failure (ALF)?
This is an uncommon condition characterised by rapid deterioration of liver function, resulting in coagulopathy (with INR greater than 1.5) and encephalopathy (altered mental status ) in previously healthy individuals.
What are the symptoms of ALF?
i. Encephalopathy
ii. Cerebral edema / signs Increased intracranial pressure e.g. papilledema, hypertension, bradycardia
iii. Jaundice
iv. Ascites
v. Tenderness of the abdominal upper right quadrant
vi. Change in liver size:
shrinking due to liver necrosis or enlargement due to heart failure, viral hepatitis
vii. Hematemesis or melena
viii. Hypotension and tachycardia: due to reduced systemic vascular resistance
The most important step in assessing patients with ALF is _________.
Identifying the cause
What evaluations should be carried out on patients with laboratory evidence of moderate or severe hepatitis?
Immediate measurement of Prothrombin time (PT) and careful evaluation of mental status.
The presence of PT prolongation or mental status change is not enough grounds for hospitalisation.
True or False.
False.
The presence of these two is in fact grounds for hospitalisation.
Mention 8 laboratory tests that are conducted in the investigation of ALF.
- Complete blood count: to reveal thrombocytopenia
- Coagulation studies: PT time or INR
- Liver function tests:
i. AST
ii. Serum glutamic-oxaloacetic transaminase (SGOT)
iii. ALT
iv. Serum glutamic-pyruvic transaminase (SGPT)
v. ALP - Serum bilirubin level: Elevated
- Acetaminophen and acetaminophen-protein adducts levels
- Drug screening
- Blood cultures: For patients with suspected infection
- Viral serologies: hepatitis A, B, C, D, E
What medications may be used in emergency response to ALF?
- Antidotes
- Osmotic diuretics (e.g. mannitol) to decrease cerebral edema
- Barbiturates (e.g. pentobarbital, thiopental) to check unresponsive intracranial hypertension
- Benzodiazepines (e.g. midazolam) used during intubation
- Anesthetics (e.g. propofol) decreases cerebral blood flow and intracranial hypertension
What are the antidotes for acetaminophen poisoning?
i. N-acetylcysteine
ii. Activated charcoal (if less than 4 hrs)
What would you use as an antidote for mushroom (Amanita phalloides) poisoning?
Activated charcoal
Penicillin G
_________ possesses antioxidant properties that benefit liver disease management and is used as an antidote.
Silymarin
What is Cirrhosis?
It is a diffuse hepatic process characterised by fibrosis and the conversion of normal liver architecture into structurally abnormal nodules.
In most patient, cirrhosis is not a reversible process.
With appropriate examples, mention the causes of cirrhosis.
- Drugs and Toxins e.g. Alcohol, Methotrexate, Isoniazid, Methyldopa, Amiodarone.
- Infections e.g. Hepatitis B and C, Schistosomiasis.
- Immune-mediated e.g. Autoimmune hepatitis, Primary sclerosing cholangitis.
- Metabolic e.g. Hemochromatosis, Porphyria, α1-antitrypsin deficiency, Wilson’s disease
- Biliary Obstruction e.g. Cystic fibrosis, Strictures, Gallstones.
- Cardiovascular e.g. Chronic Right-sided Heart Failure, Budd-Chiari syndrome, Veno-occlusive disease.
- Cryptogenic
Cirrhosis results in the elevation of portal blood pressure. How does this occur?
i. Fibrotic changes with the hepatic sinusoids
ii. Increased vascular resistance in the liver as a result of a change in the level of vasodilatory (e.g. Nitrous oxide) and vasoconstrictive mediators .
iii. Increase in systemic artery vasodilation or in blood flow to the splanchnic vasculature
List 7 signs and symptoms (complications) of cirrhosis?
- Portal hypertension
- Ascites: pathological accumulation of lymph fluid in the peritoneal cavity. Progressive systemic vasodilation results in decreased arterial blood volume, triggering baroreceptors in the kidney and activation of RAAS, resulting in plasma volume expansion, which is translocated from the liver sinusoids and splanchnic capillaries to the peritoneum.
- Hepatic encephalopathy
- Hepatic fibrosis: caused by the activation of stellate cells into collagen-forming cells by paracrine factors.
- Hepatorenal syndrome: constriction of renal arteries and impaired perfusion that occurs in patients with cirrhosis and ascites
- Coagulopathy: reduction in the synthesis of coagulation factors and the clearance of activated clotting factors due to cirrhosis. Vitamin K–dependent clotting factors, including factor VII, are affected early.
- Oesophageal varices: the pressure build-up in the liver results in blood drainage from alternative routes, which manifest as varices. Oesophageal varices can only be identified by endoscopy.
- Hepatopulmonary Syndrome
- Endocrine dysfunction
- Other signs and symptoms include: anorexia, fatigue, jaundice, weight loss, muscle wasting, pruritus, spider angioma, skin telangiectasis, finger clubbing etc.
American Association for the study of Liver Diseases (AASLD) suggested that measurement of _________ is the gold-standard method to assess the presence of clinically significant portal hypertension (CSPH) - defined as an HVPG of ___________
hepatic venous pressure gradient (HVPG)
at least 10 mm Hg
The primary strategy for the treatment of esophageal varices is __________.
the reduction of portal hypertension
The major complications of cirrhosis that require therapeutic intervention include:
i. Portal hypertension and variceal bleeding
ii. Ascites and spontaneous bacterial peritonitis
iii. Hepatic encephalopathy
iv. Other systemic complications
In patients with cirrhosis, the goal of treatment is to:
i. Prevent the development of clinically significant portal hypertension (CSPH), decompensation and even to achieve regression of cirrhosis.
ii. Eliminate the etiologic agent (the current mainstay of therapy)
What is the general approach to treatment of cirrhosis?
- Identify and eliminate, where possible, the causes of cirrhosis (e.g., alcohol abuse).
- Assess the risk for variceal bleeding and begin pharmacologic prophylaxis when indicated.
- Evaluate the patient for clinical signs of ascites and manage with pharmacologic and non-pharmacological therapy (e.g., diuretics and paracentesis).
- Careful monitoring for spontaneous bacterial peritonitis should be employed in patients with ascites who undergo acute deterioration.
- Clinical vigilance and treatment with dietary restriction, elimination of central nervous system depressants, and therapy to lower ammonia, to counter encephalopathy
