Liver Cirrhosis Flashcards
What is liver cirrhosis?
Scarring of the liver caused by chronic inflammation. Healthy cells are replaced by scar tissue - this process is known as fibrosis
1) What are the 4 commonest causes of cirrhosis?
2) Name 2 other causes
1) ALD, NAFLD, hepatitis B, hepatitis C
2) Autoimmune hepatitis, primary biliary cirrhosis, haemochromatosis, Wilson’s Disease, alpha-1 antitrypsin deficiency, cystic fibrosis, drugs (e.g. amiodarone, methotrexate, sodium valproate)
Name 5 signs of liver cirrhosis
- Jaundice
- Hepatomegaly/small liver in late disease
- Splenomegaly
- Spider naevi
- Palmar Erythema
- Gynaecomastia and testicular atrophy in males
- Bruising
- Ascites
- Caput Medusae
- Asterixis
- Dupuytren’s contracture
1) How does cirrhosis cause splenomegaly?
2) How does cirrhosis cause gynaecomastia and testicular atrophy in males?
3) What is caput medusae and what causes it?
4) What is asterixis and when does it occur?
5) What is spider naevi?
1) Causes portal hypertension which causes splenomegaly
2) Endocrine dysfunction
3) Distended paraumbilical veins due to portal hypertension
4) “flapping tremor” in decompensated liver disease
5) Central arteriole from which numerous vessels radiate
1) In patients with cirrhosis, what 2 investigations are used for screening for hepatocellular carcinoma every 6 months?
2) What investigation is most useful for the diagnosis and monitoring of liver cirrhosis?
3) Name 3 other investigations in liver cirrhosis that may be used
1) Ultrasound, alpha fetoprotein in a blood test
2) Fibroscan - transient elastography
3) Blood tests, enhanced liver fibrosis (ELF) blood test, endoscopy, CT, MRI, liver biopsy
1) What is the Child-Pugh score used to assess?
2) What are the 5 features considered when generating the Child-Pugh score?
3) The MELD score is used in which patients?
4) What 5 things does the MELD score take into consideration?
5) What does the MELD score provide information about (2)?
1) Severity of the cirrhosis and the prognosis
2) Bilirubin, INR, encephalopathy, albumin, ascites
3) Patients with compensated cirrhosis
4) Bilirubin, creatinine, INR, sodium and whether they are requiring dialysis.
5) Percentage estimated 3 month mortality and helps guide referral for liver transplant
Name 4 aspects of the management of liver cirrhosis
- Ultrasound and alpha-fetoprotein every 6 months for hepatocellular carcinoma
- Endoscopy every 3 years in patients without known varices
- High protein, low sodium diet
- MELD score every 6 months
- Consideration of a liver transplant
- Managing complications
- Alcohol abstinence
- Diuretic for ascites (spironolactone)
What is the only definitive treatment for cirrhosis?
Liver transplant
Complications of cirrhosis - malnutrition and muscle wasting
1) How does cirrhosis cause malnutrition and muscle wasting?
2) Name 2 ways this can be managed
1) Cirrhosis increases use of muscle tissue for fuel as it reduces the metabolism of proteins in the liver, reduces the amount of protein produced and disrupts the liver’s ability to store glucose as glycogen and release it when required. Consequently, the body requires alternative sources for fuel (muscle tissue) which results in muscle wasting and malnutrition
2) Regular meals (every 2-3 hours), low sodium. high protein, high calorie and avoid alcohol
Complications of cirrhosis - portal hypertension and varices (1)
1) How does cirrhosis cause portal hypertension?
2) What are varices and how are they formed?
3) Name 2 locations where they commonly occur
1) It increases the resistance of blood flow through the liver which increases back pressure into the portal system
2) Enlarged and swollen vessels at the sites where the portal system anastomoses with the systemic venous system due to backlog of pressure
3) Gastro-oesophageal junction, ileocaecal junction, eectum, anterior abdominal wall via the umbilical vein
Complications of cirrhosis - portal hypertension and varices (2)
1) What are the 2 main ways that stable varices are treated?
2) Name a medication that may be given in the case of bleeding oesophageal varices
3) Name another way it might be treated
1) Non-selective beta blocker (portal hypertension treatment) and elastic band ligation of varices
2) Vasopressin analogue, IV broad spectrum antibiotics
3) Correct any coagulopathy, injection of sclerosant, elastic band ligation of varices
Complications of cirrhosis - ascites
1) What is ascites?
2) How does cirrhosis cause ascites?
3) Is ascites caused by cirrhosis high or low in protein?
4) Name 2 aspects of ascites management
1) Accumulation of fluid in the peritoneal cavity
2) Increased pressure in the portal system causes fluid to leak out of the capillaries in the liver and bowel and into the peritoneal cavity
3) Low
4) Low sodium in the diet, anti-aldosterone diuretics (spironolactone), paracentesis (ascitic tap or ascitic drain. If large volume, albumin cover required), prophylactic antibiotics against spontaneous bacterial peritonitis ( oral ciprofloxacin) in patients with less than 15g/litre of protein in the ascitic fluid, TIPS procedure in refractory ascites, transplantation in refractory ascites
Complication of cirrhosis - spontaneous bacterial peritonitis
1) What is this?
2) Name 2 ways it may present
3) Name a common causative agent
4) How is it usually treated, and give an example of a drug
1) Infection developing in the ascitic fluid and peritoneal lining without any clear cause
2) Can be asymptomatic, fever, abdominal pain, deranged bloods (raised WBC, CRP, creatinine or metabolic acidosis), hypotension
3) Escherichia coli, klebsiella pneumoniae and gram positive cocci (such as staphylococcus and enterococcus)
4) IV cephalosporin such as cefotaxime
Complications of cirrhosis - hepatorenal syndrome
1) What is hepatorenal syndrome?
2) What drug can be used for it’s management?
3) Name another management option
1) Deteriorating renal function due to lack of blood supply to the kidneys. Lack of blood supply to kidneys is due to splanchnic vasodilation. Lack of blood supply to the kidneys also stimulates RAS which causes renal vasoconstriction, furthermore decreasing blood supply
2) Vasopressin analogue - terlipressin
3) Transjugular intrahepatic porto-systemic shunt, volume expansion with 20% albumin
Complications of cirrhosis - hepatic encephalopathy (1)
1) What is hepatic encephalopathy?
2) What are the 2 mechanisms by which this occurs?
3) What is the main toxin associated with hepatic encephalopathy?
1) Buildup of toxins that affect the brain due to liver insufficiency
2) The functional impairment of the liver cells prevents them metabolising toxins and the opening of portosystemic shunts allows toxins to bypass the liver.
3) Ammonia
