Liver cirrhosis

Question 1

What can happen following increased resistance in the vessels leading to the liver?/

Answer 1

Portal hypertension

Question 2

Common causes of liver cirrhosis?

Answer 2

Alcoholic liver disease
Non-alcoholic fatty liver disease
Hepatitis B
Hepatitis C

Question 3

Rarer causes of liver cirrhosis?

Answer 3

Autoimmune hepatitis
Primary biliary cirrhosis
Haemochromatosis
Wilsons disease
Alpha-1 antitrypsin deficiency
Cystic fibrosis
Drugs (amiodarone, methotrexate, sodium valproate)

Question 4

Abdominal examination signs of cirrhosis?

Answer 4

Spider naevi
Bruising
Ascites
Caput medusae

Question 5

Hand examination signs of cirrhosis?

Answer 5

Palmar erythema
Asterixis (flapping tremor in decompensated liver disease)

Question 6

What is shown via liver biochemistry in liver cirrhosis?

Answer 6

Sometimes normal
If decompensated - ALT, AST, ALP and bilirubin become deranged

Question 7

ALT>AST

Answer 7

Cirrohosis

Question 8

AST>ALT

Answer 8

Acute hepatitis

Question 9

Albumin and prothrombin time in liver cirrhosis?

Answer 9

Albumin drops and PTT increases as synthetic function becomes worse

Question 10

Why measure alpha-fetoprotein?

Answer 10

Tumour marker for hepatocellular carcinoma
Checked every 6 months as screening for patients with cirrhosis

Question 11

What is enhanced liver fibrosis (ELF) blood test?

Answer 11

First line investigation to assess fibrosis in non-alcoholic fatty liver disease.

Measures:
HA, PIIINP, TIMP-1

<7.7 - none to mild fibrosis
>7.7-9.8 - moderate fibrosis
>9.8 - severe fibrosis

Question 12

General management of liver cirrhosis?

Answer 12

USS and alpha-fetoprotein every 6 months for hepatocarcinoma
Endoscopy every 3 years in patients without known varices
High protein, low sodium diet
MELD score every 6 months
Consideration of liver transplant

Question 13

What is the MELD score?

Answer 13

Used every 6 months in patients with compensated cirrhosis
Bilirubin, creatinine, INR, sodium and whether requiring dialysis
Gives percentage estimate of mortality and helps guide liver transplant referral

Question 14

Complications of liver cirrhosis?

Answer 14

Malnutrition
Portal hypertensions
Varices
Variceal bleeding
Ascites
Spontaneous bacterial peritonitis (SBP)
Hepato-renal syndrome
Hepatic encephalopathy
Hepatocellular carcinoma

Question 15

Treatment of stable varices

Answer 15

Propranolol = non-selective beta blocker
Elastic band ligation of varices
Injection of sclerosant (less effective than band ligation)
Last resort = transjugular intra-hepatic portosystemic shunt (TIPS)

Question 16

Resus for bleeding oesophageal varices?

Answer 16

Vasopressin analogues (terlipressin)
Correct coagulopathy with vit K and fresh frozen plasma
Prophylactic broad spectrum antibiotics

Question 17

What is hepatorenal syndrome?

Answer 17

When hypertension leads to dilation of portal veins, leading to loss of blood volume to kidneys. Kidneys sense hypotension so activate the renin-angiotensin system. This leads to vasoconstriction. This combined with the low blood volume to kidneys leads to starvation of blood to the kidneys. This leads to rapidly deteriorating kidneys. It is fatal within a week. Requires liver transplant.

Question 18

What is one of the toxins that causes hepatic encephalopathy?

Answer 18

Ammonia

Question 19

Treatment of hepatic encephalopathy?

Answer 19

Laxatives (lactulose) to promote excretion of ammonia
Antibiotics - reduce number of intestinal bacteria producing ammonia (Rifaximin as stays in GI tract - poorly absorbed)
Nutritional support - NG tube feeding sometimes