Liver Cirrhosis Flashcards
What is liver cirrhosis?
It is defined as an irreversible, chronic condition in which there is fibrosis of the liver due to long-term damage
Describe the pathophysiology of liver cirrhosis
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
What is the pathophysiological consequence of liver cirrhosis? How?
Portal hypertension
The fibrosis results in alterations to liver structure, causing an increased resistance in the blood vessels supplying the liver
What are the eleven causes of liver cirrhosis?
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
Which three drugs are associated with liver cirrhosis?
Amiodarone
Methotrexate
Sodium valproate
What are the four main causes of liver cirrhosis?
Alcoholic Liver Disease
Non-Alcoholic Fatty Liver Disease
Viral Hepatitis B
Viral Hepatitis C
What is a trigger for decompensation in liver cirrhosis?
Constipation
What are the nine clinical features of liver cirrhosis?
Jaundice
Palmar Erythema
Spider Naevi
Caput Medusa
Ascites
Asterixis
Hepatomegaly
Splenomegaly
Gynaecomastia
What are the three investigations used to diagnose liver cirrhosis?
Blood Tests
Ultrasound Scan
Liver Biopsy
What nine blood test results indicate liver cirrhosis?
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
In chronic liver disease, which blood test result is the most sensitive finding for diagnosis of liver cirrhosis?
Decreased Platelet Count < 150,000mm3
What specific blood test is used to investigate liver cirrhosis?
Enhanced liver fibrosis (ELF) blood test
When is the ELF blood test used?
It is the first line investigation used to classify the severity of liver cirrhosis related to non-alcoholic fatty liver disease
What is the ELF test?
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
What ELF score indicates mild liver cirrhosis?
< 7.7
What ELF score indicates moderate liver cirrhosis?
7.7 - 9.8
What ELF score indicates severe liver cirrhosis?
> 9.8
What are the six features of liver cirrhosis on ultrasound scan?
Nodular Hepatic Surface
Corkscrew Appearance of Hepatic Arteries
Enlarged Portal Vein
Ascites
Hepatomegaly
Splenomegaly
What specialised ultrasound scan is used to investigate liver cirrhosis?
Fibroscan
What is a Fibroscan?
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
How is a Fibroscan used to investigate liver cirrhosis?
It is used to assess the degree of liver cirrhosis, and therefore to classify the severity of disease
When are Fibroscans used to investigate liver cirrhosis?
They are used as a screening technique, which is conducted every two years in high risk patient groups
What five patient groups receive screening of liver cirrhosis via Fibroscans?
Alcoholics
Alcoholic Liver Disease
Non-Alcoholic Fatty Liver Disease
Chronic Hepatitis B
Hepatitis C
In terms of liver cirrhosis screening, what is the criteria required for alcoholics to be screened?
Men > 50 units per week
Women > 35 units per week
Which patient group receive annual screening of liver cirrhosis?
Chronic hepatitis B
What is the feature of liver cirrhosis on liver biopsy?
Regenerative nodules surrounded by fibrotic tissue
Which two scoring systems are used in liver cirrhosis?
Child-Pugh Classification
Model for End-Stage Liver Disease (MELD) Score
What is the function of the Child-Pugh classification system?
To assess the severity of liver cirrhosis
What are the five criteria used in the Child-Pugh classification system?
Bilirubin
Albumin
INR
Encephalopathy
Ascites
Which Child-Pugh score indicates Grade A liver cirrhosis?
< 7
Which Child-Pugh score indicates Grade B liver cirrhosis?
7 - 9
Which Child-Pugh score indicates Grade C liver cirrhosis?
> 9
What is the function of the MELD score?
It is used to obtain a percentage estimated 3 month mortality rate of liver cirrhosis
When is the MELD score used?
It is recommended every six months in individuals with compensated cirrhosis
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
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
Why do we conduct alpha-fetoprotein level and ultrasound monitoring to manage liver cirrhosis?
This allows us to monitor for hepatocellular carcinoma development
Why do we conduct endoscopy to manage liver cirrhosis?
This allows us to monitor for oesophageal variceal development
What surgical management option is used in liver cirrhosis?
Liver Transplant
What is a liver transplant?
It involves surgical removal of the whole liver, with replacement of a donor liver
What is the only curative management option for liver cirrhosis?
Liver transplant
When is liver transplant used to manage liver cirrhosis?
It is only considered in those with severe disease and complication developmen
What are the seven complications associated with liver cirrhosis?
Malnutrition
Variceal Haemorrhage
Ascites
Spontaneous Bacterial Peritonitis
Hepatorenal Syndrome
Hepatic Encephalopathy
Hepatocellular Carcinoma
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
What are the four conservative management options of malnutrition?
Low Sodium Diet
High Protein Diet
Regular Meal Consumption
Alcohol Cessation
What is variceal haemorrhage?
It is defined as a condition in which blood leaks from blood vessels due to portal hypertension
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
Name the five locations in which varices form
Oesophagus
Gastro-oesophageal junction
Ileocaecal junction
Rectum
Anterior abdominal wall
What is the pharmacological management of stable varices?
Beta-blockers
Name a beta-blocker used to manage variceal haemorrhage
Propanolol
How are beta-blockers used to manage stable varices?
They can be used to reduce portal hypertension and therefore prophylactically prevent variceal haemorrhage
What are the three pharmacological management options for variceal haemorrhage?
Vasopressin Analogues
Blood Transfusion
Prophylactic IV Antibiotics
Name a vasopressin analogue used to manage variceal haemorrhage
Terlipressin
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
What three blood transfusions are used to manage variceal haemorrhage?
Vitamin K
Fresh frozen plasma
Platelets
Why are prophylactic antibiotics used to manage variceal haemorrhage?
They are used to reduce mortality
Name a prophylactic IV antibiotic used to manage variceal haemorrhage
Quinolones
When should vasopressin analogues and prophylactic antibiotics be administered in variceal haemorrhage?
BEFORE endoscopy
What are the four surgical management options for variceal haemorrhage?
Band Ligation
Sclerotherapy
Sengstaken-Blakemore Tube
Transjugular Intra-Hepatic Portosystemic Shunt (TIPS)
What is band ligation?
It involves securing an elastic band around the variceal to cut off the blood supply, thus stopping haemorrhage
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.
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
What is a Sengstaken-Blakemore tube?
It is an inflatable tube inserted into the oesophagus to tamponade the bleeding varies
When is a Sengstaken-Blakemore tube used to manage variceal haemorrhage?
In cases of uncontrolled haemorrhage
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
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
What is a complication of TIPS?
Hepatic encephalopathy exacerbation
What is ascites?
It is defined as a condition in which there is an abnormal collection of fluid in the peritoneal cavity – > 25ml
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
In liver cirrhosis, is ascites exudative or transudative? What does this mean?
Transudative
The ascites fluid consists of a high protein count > 11g/L
What are the two conservative management options of ascites?
Low Sodium Diet
Restrict Fluid Intake
When is fluid restriction recommended in ascites?
Na < 125 mmol/L
What are the two pharmacological management options of ascites?
Anti-Aldosterone Diuretics
Prophylactic Antibiotics
Name an anti-aldosterone diuretic used to manage ascites
Spironolactone
How are anti-aldosterone diuretics used to manage ascites?
They inhibit aldosterone to in turn inhibit water and sodium absorption in the kidneys
Name two prophylactic antibiotics used to manage ascites
Ciprofloxacin
Norfloxacin
Why do we administer prophylactic antibiotics in ascites?
To reduce the risk of spontaneous bacterial peritonitis
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
What are the two surgical management options of ascites?
Paracentesis
Transjugular Intra-Hepatic Portosystemic Shunt (TIPS)
What is paracentesis?
It involves the insertion of a needle into the peritoneal cavity to drain ascitic fluid
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
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
What are the three causative organisms of ascites?
E.Coli
Klebsiella Pneumoniae
Gram positive cocci
What is the most common causative organism associated with spontaneous bacterial peritonitis?
E.Coli
What are the five clinical features of spontaneous bacterial peritonitis?
Ascites
Abdominal Pain
Fever
Ileus
Hypotension
What are the two investigations used to diagnose spontaneous bacterial peritonitis?
Blood Tests
Paracentesis
What are the three blood test results indicative of spontaneous bacterial peritonitis?
Increased WBC Levels
Increased CRP Levels
Increased Creatinine Levels
What is the feature of spontaneous bacterial peritonitis on paracentesis?
An increased neutrophil counts > 250 cells/ul
How can paracentesis be used to investigate spontaneous bacterial peritonitis?
It can be used to obtain a bacterial culture
What is the pharmacological management option for spontaneous bacterial peritonitis?
IV antibiotics
Name an IV antibiotic used to manage spontaneous bacterial peritonitis
Cefotaxime
What is a poor progonostic marker of spontaneous bacterial peritonitis?
Alcoholic liver disease
What is hepatorenal syndrome?
It is defined as a condition in which renal failure develops due to severe liver damage
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
What are the two classifications of hepatorenal syndrome?
Type one hepatorenal syndrome
Type two hepatorenal syndrome
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
What is type two hepatorenal syndrome?
It is a slowly progressive form of hepatorenal syndrome
What is the pharmacological management option of hepatorenal syndrome?
Vasopressin Analogues
Name two vasopressin analogues used to manage hepatorenal syndrome
Terlipressin
Octreotide
How are vasopressin analogues used to manage hepatorenal syndrome?
They can be used to cause vasoconstriction of the splanchnic vessels, therefore reducing portal hypertension
What are the two surgical management options of hepatorenal syndrome?
Liver transplant
Transjugular Intra-Hepatic Portosystemic Shunt (TIPS)
How soon after a hepatorenal syndrome diagnosis should a liver transplant be conducted?
A week
When is TIPS used to manage hepatorenal syndrome?
It is recommended when individuals are unfit for liver transplant surgical management
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
Name two toxins that build up in hepatic encephalopathy
Ammonia
Glutamine
What is the main toxin that builds up in hepatic encephalopathy?
Ammonia
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
What are the seven causes of hepatic encephalopathy?
Infection
Gastrointestinal Bleeding
Constipation
Post TIPS Procedure
Renal Failure
Hypokalaemia
Drug Administration
Name two drugs associated with hepatic encephalopathy?
Diuretics
Sedatives
What are the five clinical features of hepatic encephalopathy?
Confusion
Asterix
Seizures
Personality Changes
Mood Changes
What asterix frequency is associated with hepatic encephalopathy?
3 - 5 Hz
What clinical features indicate grade I hepatic encephalopathy?
Irritable
What clinical features indicate grade II hepatic encephalopathy?
Confusion
Inappropriate behaviour
What clinical features indicate grade III hepatic encephalopathy?
Incoherent
Restless
What clinical features indicate grade IV hepatic encephalopathy?
Coma
What are the two pharmacological management options of hepatic encephalopathy?
Laxatives
Antibiotics
How are laxatives used to manage hepatic encephalopathy?
They promote the excretion and metabolism of ammonia from the gut
What is the first line management option of hepatic encephalopathy?
Laxatives
Name a laxative used to manage hepatic encephalopathy
Lactulose
Name an antibiotic used to manage hepatic encephalopathy
Rifaximin
How are antibiotics used to manage hepatic encephalopathy?
They reduce the number of intestinal bacteria producing ammonia
What is the surgical management option is used for hepatic encephalopathy?
Portosystemic Shunt Embolisation
When is portosystemic shunt embolisation used to manage hepatic encephalopathy?
When hepatic encephalopathy is related to post transjugular intrahepatic portosystemic shunting
