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Year Two - Gastroenterology System > Liver Cirrhosis > Flashcards

Liver Cirrhosis Flashcards

1
Q

What is liver cirrhosis?

A

It is defined as an irreversible, chronic condition in which there is fibrosis of the liver due to long-term damage

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2
Q

Describe the pathophysiology of liver cirrhosis

A

In liver cirrhosis, there is chronic hepatic inflammation, which causes damage to hepatic cells

The damaged hepatic cells are replaced by nodules of scar tissue, in a process known as fibrosis

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3
Q

What is the pathophysiological consequence of liver cirrhosis? How?

A

Portal hypertension

The fibrosis results in alterations to liver structure, causing an increased resistance in the blood vessels supplying the liver

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4
Q

What are the eleven causes of liver cirrhosis?

A

Alcoholic Liver Disease

Non-Alcoholic Fatty Liver Disease

Viral Hepatitis B

Viral Hepatitis C

Autoimmune Hepatitis

Primary Biliary Cirrhosis

Haemochromatosis

Wilson’s Disease

Alpha-1 Antitrypsin Deficiency

Cystic Fibrosis

Drug Administration

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5
Q

Which three drugs are associated with liver cirrhosis?

A

Amiodarone

Methotrexate

Sodium valproate

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6
Q

What are the four main causes of liver cirrhosis?

A

Alcoholic Liver Disease

Non-Alcoholic Fatty Liver Disease

Viral Hepatitis B

Viral Hepatitis C

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7
Q

What is a trigger for decompensation in liver cirrhosis?

A

Constipation

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8
Q

What are the nine clinical features of liver cirrhosis?

A

Jaundice

Palmar Erythema

Spider Naevi

Caput Medusa

Ascites

Asterixis

Hepatomegaly

Splenomegaly

Gynaecomastia

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9
Q

What are the three investigations used to diagnose liver cirrhosis?

A

Blood Tests

Ultrasound Scan

Liver Biopsy

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10
Q

What nine blood test results indicate liver cirrhosis?

A

Decreased Sodium Levels

Increased Urea Levels

Increased Creatinine Levels

Increased ALT Levels

Increased AST Levels

Increased ALP Levels

Increased Bilirubin Levels

Decreased Albumin Levels

Increased Prothrombin Time

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11
Q

In chronic liver disease, which blood test result is the most sensitive finding for diagnosis of liver cirrhosis?

A

Decreased Platelet Count < 150,000mm3

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12
Q

What specific blood test is used to investigate liver cirrhosis?

A

Enhanced liver fibrosis (ELF) blood test

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13
Q

When is the ELF blood test used?

A

It is the first line investigation used to classify the severity of liver cirrhosis related to non-alcoholic fatty liver disease

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14
Q

What is the ELF test?

A

It measures three markers: HA, PIIINP and TIMP-1, which are then used in an algorithm to provide a result that indicates the severity of liver cirrhosis

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15
Q

What ELF score indicates mild liver cirrhosis?

A

< 7.7

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16
Q

What ELF score indicates moderate liver cirrhosis?

A

7.7 - 9.8

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17
Q

What ELF score indicates severe liver cirrhosis?

A

> 9.8

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18
Q

What are the six features of liver cirrhosis on ultrasound scan?

A

Nodular Hepatic Surface

Corkscrew Appearance of Hepatic Arteries

Enlarged Portal Vein

Ascites

Hepatomegaly

Splenomegaly

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19
Q

What specialised ultrasound scan is used to investigate liver cirrhosis?

A

Fibroscan

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20
Q

What is a Fibroscan?

A

It involves sending high frequency sound waves into the liver and measuring the transmission back to the sound wave probe – a process known as transient elastography

This enables a measure of liver elasticity

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21
Q

How is a Fibroscan used to investigate liver cirrhosis?

A

It is used to assess the degree of liver cirrhosis, and therefore to classify the severity of disease

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22
Q

When are Fibroscans used to investigate liver cirrhosis?

A

They are used as a screening technique, which is conducted every two years in high risk patient groups

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23
Q

What five patient groups receive screening of liver cirrhosis via Fibroscans?

A

Alcoholics

Alcoholic Liver Disease

Non-Alcoholic Fatty Liver Disease

Chronic Hepatitis B

Hepatitis C

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24
Q

In terms of liver cirrhosis screening, what is the criteria required for alcoholics to be screened?

A

Men > 50 units per week

Women > 35 units per week

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25
Which patient group receive annual screening of liver cirrhosis?
Chronic hepatitis B
26
What is the feature of liver cirrhosis on liver biopsy?
Regenerative nodules surrounded by fibrotic tissue
27
Which two scoring systems are used in liver cirrhosis?
Child-Pugh Classification Model for End-Stage Liver Disease (MELD) Score
28
What is the function of the Child-Pugh classification system?
To assess the severity of liver cirrhosis
29
What are the five criteria used in the Child-Pugh classification system?
Bilirubin Albumin INR Encephalopathy Ascites
30
Which Child-Pugh score indicates Grade A liver cirrhosis?
< 7
31
Which Child-Pugh score indicates Grade B liver cirrhosis?
7 - 9
32
Which Child-Pugh score indicates Grade C liver cirrhosis?
> 9
33
What is the function of the MELD score?
It is used to obtain a percentage estimated 3 month mortality rate of liver cirrhosis
34
When is the MELD score used?
It is recommended every six months in individuals with compensated cirrhosis
35
How do we calculate the MELD score?
A formula is applied which takes into account the patient’s bilirubin levels, creatinine levels, INR, sodium levels and whether they receive dialysis
36
What are the six conservative management options used in liver cirrhosis?
Alcohol Cessation High Protein, Low Sodium Diet MELD Score 6 Monthly Alpha-Fetoprotein Level 6 Monthly Ultrasound 6 Monthly Endoscopy Every 3 Years
37
Why do we conduct alpha-fetoprotein level and ultrasound monitoring to manage liver cirrhosis?
This allows us to monitor for hepatocellular carcinoma development
38
Why do we conduct endoscopy to manage liver cirrhosis?
This allows us to monitor for oesophageal variceal development
39
What surgical management option is used in liver cirrhosis?
Liver Transplant
40
What is a liver transplant?
It involves surgical removal of the whole liver, with replacement of a donor liver
41
What is the only curative management option for liver cirrhosis?
Liver transplant
42
When is liver transplant used to manage liver cirrhosis?
It is only considered in those with severe disease and complication developmen
43
What are the seven complications associated with liver cirrhosis?
Malnutrition Variceal Haemorrhage Ascites Spontaneous Bacterial Peritonitis Hepatorenal Syndrome Hepatic Encephalopathy Hepatocellular Carcinoma
44
Describe how malnutrition can develop as a complication of liver cirrhosis
In liver cirrhosis, there is dysfunctional protein metabolism and glycogen storage within the liver This results in the use of muscle tissue to provide energy, leading to muscle wasting and weight loss
45
What are the four conservative management options of malnutrition?
Low Sodium Diet High Protein Diet Regular Meal Consumption Alcohol Cessation
46
What is variceal haemorrhage?
It is defined as a condition in which blood leaks from blood vessels due to portal hypertension
47
Describe how variceal haemorrhage can develop as a complication of liver cirrhosis
Portal hypertension results in the vessels at the sites where the portal system anastomoses with the systemic venous system to become swollen and tortuous These vessels are referred to as varices. Due to the high blood flow through varices, they can burst and start to bleed
48
Name the five locations in which varices form
Oesophagus Gastro-oesophageal junction Ileocaecal junction Rectum Anterior abdominal wall
49
What is the pharmacological management of stable varices?
Beta-blockers
50
Name a beta-blocker used to manage variceal haemorrhage
Propanolol
51
How are beta-blockers used to manage stable varices?
They can be used to reduce portal hypertension and therefore prophylactically prevent variceal haemorrhage
52
What are the three pharmacological management options for variceal haemorrhage?
Vasopressin Analogues Blood Transfusion Prophylactic IV Antibiotics
53
Name a vasopressin analogue used to manage variceal haemorrhage
Terlipressin
54
How are vasopressin analogues used to manage variceal haemorrhage?
They can be used to cause vasoconstriction of the splanchnic vessels, therefore reducing bleeding in the varices
55
What three blood transfusions are used to manage variceal haemorrhage?
Vitamin K Fresh frozen plasma Platelets
56
Why are prophylactic antibiotics used to manage variceal haemorrhage?
They are used to reduce mortality
57
Name a prophylactic IV antibiotic used to manage variceal haemorrhage
Quinolones
58
When should vasopressin analogues and prophylactic antibiotics be administered in variceal haemorrhage?
BEFORE endoscopy
59
What are the four surgical management options for variceal haemorrhage?
Band Ligation Sclerotherapy Sengstaken-Blakemore Tube Transjugular Intra-Hepatic Portosystemic Shunt (TIPS)
60
What is band ligation?
It involves securing an elastic band around the variceal to cut off the blood supply, thus stopping haemorrhage
61
When is band ligation used to manage variceal haemorrhage?
It is the first line surgical management option It is also a prophylactic management option in medium to large varices. It is conducted at two-weekly intervals until all varices have been eradicated.
62
What is sclerotherapy?
It involves endoscopic injection of a solution directly into a vein This solution causes the vein to scar, forcing blood to reroute through healthier veins
63
What is a Sengstaken-Blakemore tube?
It is an inflatable tube inserted into the oesophagus to tamponade the bleeding varies
64
When is a Sengstaken-Blakemore tube used to manage variceal haemorrhage?
In cases of uncontrolled haemorrhage
65
What is TIPS?
It involves insertion of a wire under x-ray guidance into the jugular vein, down the vena cava and into the liver via the hepatic vein There is then anastomosis of the hepatic vein and the portal vein, which a stent is inserted into This enables blood to flow directly from the portal vein to the hepatic vein – relieving pressure in the portal system and varices
66
When is TIPS used to manage variceal haemorrhage?
It is the last management option It is also a prophylactic management option in medium to large varices
67
What is a complication of TIPS?
Hepatic encephalopathy exacerbation
68
What is ascites?
It is defined as a condition in which there is an abnormal collection of fluid in the peritoneal cavity – > 25ml
69
Describe how ascites can develop as a complication of liver cirrhosis
Portal hypertension causes fluid to leak out of the capillaries within the liver and bowel and into the peritoneal cavity The decrease in circulating volume causes a reduction in blood pressure entering the kidneys This leads to activation of the renin-angiotensin-aldosterone system, in which the kidneys release renin to stimulate increased aldosterone secretion This increased aldosterone secretion causes reabsorption of fluid and sodium in the kidneys, leading to fluid and sodium overload
70
In liver cirrhosis, is ascites exudative or transudative? What does this mean?
Transudative The ascites fluid consists of a high protein count > 11g/L
71
What are the two conservative management options of ascites?
Low Sodium Diet Restrict Fluid Intake
72
When is fluid restriction recommended in ascites?
Na < 125 mmol/L
73
What are the two pharmacological management options of ascites?
Anti-Aldosterone Diuretics Prophylactic Antibiotics
74
Name an anti-aldosterone diuretic used to manage ascites
Spironolactone
75
How are anti-aldosterone diuretics used to manage ascites?
They inhibit aldosterone to in turn inhibit water and sodium absorption in the kidneys
76
Name two prophylactic antibiotics used to manage ascites
Ciprofloxacin Norfloxacin
77
Why do we administer prophylactic antibiotics in ascites?
To reduce the risk of spontaneous bacterial peritonitis
78
In which three patient groups do we administer prophylactic antibiotics to manage ascites?
Individuals with < 15g/L of protein in ascitic fluid Those with hepatorenal syndrome Those with a Child-Pugh score > 9
79
What are the two surgical management options of ascites?
Paracentesis Transjugular Intra-Hepatic Portosystemic Shunt (TIPS)
80
What is paracentesis?
It involves the insertion of a needle into the peritoneal cavity to drain ascitic fluid
81
Following large volume (5L) paracentestis, what do we administer? Why?
Albumin cover This is due to the fact that it reduced paracentesis-induced circulatory dysfunction and mortality
82
What is spontaneous bacterial peritonitis (SBP)?
It is defined as condition in which there is infection within the ascitic fluid and peritoneal lining without any clear cause
83
What are the three causative organisms of ascites?
E.Coli Klebsiella Pneumoniae Gram positive cocci
84
What is the most common causative organism associated with spontaneous bacterial peritonitis?
E.Coli
85
What are the five clinical features of spontaneous bacterial peritonitis?
Ascites Abdominal Pain Fever Ileus Hypotension
86
What are the two investigations used to diagnose spontaneous bacterial peritonitis?
Blood Tests Paracentesis
87
What are the three blood test results indicative of spontaneous bacterial peritonitis?
Increased WBC Levels Increased CRP Levels Increased Creatinine Levels
88
What is the feature of spontaneous bacterial peritonitis on paracentesis?
An increased neutrophil counts > 250 cells/ul
89
How can paracentesis be used to investigate spontaneous bacterial peritonitis?
It can be used to obtain a bacterial culture
90
What is the pharmacological management option for spontaneous bacterial peritonitis?
IV antibiotics
91
Name an IV antibiotic used to manage spontaneous bacterial peritonitis
Cefotaxime
92
What is a poor progonostic marker of spontaneous bacterial peritonitis?
Alcoholic liver disease
93
What is hepatorenal syndrome?
It is defined as a condition in which renal failure develops due to severe liver damage
94
Describe how hepatorenal syndrome can develop as a complication of liver cirrhosis
Portal hypertension causes portal vein dilation, which leads to a loss of blood volume in other areas of the circulation – including the kidneys This renal hypotension leads to activation of the renin-angiotensin system, which leads to renal vasoconstriction Therefore, there is reduced blood flow to the kidneys, which leads to a rapidly deteriorating renal function
95
What are the two classifications of hepatorenal syndrome?
Type one hepatorenal syndrome Type two hepatorenal syndrome
96
What is type one hepatorenal syndrome?
Doubling of serum creatinine to > 221 µmol/L over a period of less than 2 weeks OR A halving of the creatinine clearance to less than 20 ml/min over a period of less than 2 weeks
97
What is type two hepatorenal syndrome?
It is a slowly progressive form of hepatorenal syndrome
98
What is the pharmacological management option of hepatorenal syndrome?
Vasopressin Analogues
99
Name two vasopressin analogues used to manage hepatorenal syndrome
Terlipressin Octreotide
100
How are vasopressin analogues used to manage hepatorenal syndrome?
They can be used to cause vasoconstriction of the splanchnic vessels, therefore reducing portal hypertension
101
What are the two surgical management options of hepatorenal syndrome?
Liver transplant Transjugular Intra-Hepatic Portosystemic Shunt (TIPS)
102
How soon after a hepatorenal syndrome diagnosis should a liver transplant be conducted?
A week
103
When is TIPS used to manage hepatorenal syndrome?
It is recommended when individuals are unfit for liver transplant surgical management
104
What is hepatic encephalopathy?
It which is defined as a neurological condition which is related to the liver being unable to remove toxins from the blood
105
Name two toxins that build up in hepatic encephalopathy
Ammonia Glutamine
106
What is the main toxin that builds up in hepatic encephalopathy?
Ammonia
107
Describe how hepatic encephalopathy can develop as a complication of liver cirrhosis
In liver cirrhosis, raised levels of ammonia and glutamine are related to functional impairment of hepatic cells preventing appropriate metabolism of these toxins into harmful waste products In addition, the collateral vessels between the portal and systemic circulation results in these toxins bypassing the liver altogether and entering the systemic circulation directly
108
What are the seven causes of hepatic encephalopathy?
Infection Gastrointestinal Bleeding Constipation Post TIPS Procedure Renal Failure Hypokalaemia Drug Administration
109
Name two drugs associated with hepatic encephalopathy?
Diuretics Sedatives
110
What are the five clinical features of hepatic encephalopathy?
Confusion Asterix Seizures Personality Changes Mood Changes
111
What asterix frequency is associated with hepatic encephalopathy?
3 - 5 Hz
112
What clinical features indicate grade I hepatic encephalopathy?
Irritable
113
What clinical features indicate grade II hepatic encephalopathy?
Confusion Inappropriate behaviour
114
What clinical features indicate grade III hepatic encephalopathy?
Incoherent Restless
115
What clinical features indicate grade IV hepatic encephalopathy?
Coma
116
What are the two pharmacological management options of hepatic encephalopathy?
Laxatives Antibiotics
117
How are laxatives used to manage hepatic encephalopathy?
They promote the excretion and metabolism of ammonia from the gut
118
What is the first line management option of hepatic encephalopathy?
Laxatives
119
Name a laxative used to manage hepatic encephalopathy
Lactulose
120
Name an antibiotic used to manage hepatic encephalopathy
Rifaximin
121
How are antibiotics used to manage hepatic encephalopathy?
They reduce the number of intestinal bacteria producing ammonia
122
What is the surgical management option is used for hepatic encephalopathy?
Portosystemic Shunt Embolisation
123
When is portosystemic shunt embolisation used to manage hepatic encephalopathy?
When hepatic encephalopathy is related to post transjugular intrahepatic portosystemic shunting

Year Two - Gastroenterology System (33 decks)

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