Liver Cirrhosis Flashcards
What is liver cirrhosis?
Chronic inflammation and damage to liver cells
Nodules of scar tissue replace functional liver cells
What affect does liver cirrhosis have on circulation and why?
Portal hypertension
Increased resistance and pressure in portal system since a cirrhotic liver is less compliant
What are the most common causes of liver cirrhosis?
Alcohol related liver disease
Non-Alcoholic fatty liver disease
Hepatitis B
Hepatitis C
What are some less common causes of liver cirrhosis?
Autoimmune hepatitis
Primary biliary cirrhosis
Haemochromatosis
Wilsons disease
Alpha-1-antitrypsin deficiency
Cystic fibrosis
Drugs (amiodarone, methotrexate, sodium valproate)
What are some common signs of chronic liver disease?
Specific to chronic:
-Dupuytrens contracture
-Palmar erythema
-Gynaecomastia
-Clubbing
-Spider naevi
Acute or chronic
-jaundice
-hepatomegaly
-ascites
-caput medusae
-astrexis
-caput medusae
How do you investigate a patietn who may have liver cirrhosis?
Ultrasound liver (Fatty liver?)
LFTs
INR
AFP
Urea and creatinine
Hep B and C serology
Autoantibodies (autoimmune hep, primary biliary cirrhosis, primary Sclerosing cholangitis)
Immunoglobulins
Ceruloplasmin (Wilsons)
Alpha-1-antitrypsin levels
Ferritin and transferrin saturation (hereditary Haemochromatosis)
What patients do you do a fibroscan for?
Alcohol related liver disease
Heavy drinkers
Non-alcoholic fatty liver disease advanced fibrosis
Hep C
Chronic hep B
When is liver transplantation considered?
Features of decompensated liver disease:
AHOY
Ascites
Hepatic. Encephalopathy
Oesophageal Varices bleeding
Yellow (Jaundice)
What are the complications of liver cirrhosis?
Malnutrition and muscle wasting
Portal hypertension
Ascites + Spontaneous bacterial peritonitis
Heptaorenal syndrome
Hepatic encephalopathy
Hepatocellular carcinoma
How do you manage malnutrition due to cirrhosis?
Regular meals
High protein and calorie intake
Reduced sodium intake (less fluid retention))
Avoid alcohol
What is the management of portal hypertension and Varices?
Non selective B blockers like propranolol
Variceal band ligation (if cant give beta blockers)
What is the management of bleeding oesophageal Varices?
Escalate
Major haemorrhage protocol
Treat Coagulopathy with fresh frozen plasma
Vasopressin analogues (TERLIPRESSIN vasoconstriction of portal system)
Broad spec abx
Urgent endoscopy + variceal band ligation
Or TIPS
What is TIPS?
Transjugular Intrahepatic portosystemic shunt (stent between portal vein and hepatic vein to relieve portal systems pressure )
What is ascites?
Fluid in the peritoneal cavity
What are the causes of Ascites?
Liver cirrhosis
Heart failure
Nephrotic syndrome
Malignancy
What investigations would you do if a patient has ascites?
LFTs
FBC
Ascitic fluid aspiration (Albumin gradient)
U+Es hepatorenal syndrome
How is the albumin gradient calculated from an abdominal paracentesis of the ascitic fluid?
Serum albumin - ascitic albumin
What is the point of calculating the albumin gradient between the blood and the ascitic fluid?
Used to determine if there’s elevated portal pressure (portal hypertension)
What albumin gradient is considered a normal portal pressure?
What value for albumin gradient is considered elevated portal pressure?
Albumin gradient < 11 is normal portal pressure
Albumin gradient > 11 is portal hypertension
What conditions cause an ascites that has an albumin gradient less than 11? (So not a portal hypertension)
Malignancy
Nephrotic syndrome
Why is the albumin gradient for an ascites caused by nephrotic syndrome less than 11/ not caused by portal hypertension?
Nephrotic syndrome causes hypoalbuminaemia so means the ascites is caused by the lack of oncotic pressure within the blood
What are the causes of ascites with a high albumin gradient >11 / caused by portal hypertension?
Heart failure
Liver cirrhosis
What are you suspecting if a patient has an ascites with a high albumin gradient (>11) / high portal pressure if the patient doesn’t have signs of chronic liver disease?
What are your next steps?
Likely not liver cirrhosis
Potentially malignancy
US abdomen if nt already done
Then CT CAP IV contrast to look for malignancy
What is the pathophysiology behind hepatorenal syndrome?
Portal hypertension leads to ascitic fluid building up and less circulating systemic blood volume. Kidneys receive less blood so activation of RAAS, further increase in pressure worsens portal hypertension and renal perfusion
How do you manage ascites?
Manage underlying cause
Aldosterone antagonists like Spironolactone
Paracentesis/drain
Prophylactic antibiotics (ciprofloxacin) if high protein in ascitic fluid
TIPS
Liver transplant
Why may you give prophylactic antibiotics in a patient with ascites?
High risk of developing spontaneous bacterial peritonitis
Who’s more likely to develop SBP, a patient with liver cirrhotic ascites or malignant ascites?
Liver cirrhotic ascites
Malignant ascites normally have vessel abnormalities where immunoglobulins can leak into the abdomen
Liver cirrhosis has no vessel abnormalities so immunoglobulins cant enter the ascitic fluid
What is considered spontaneous bacterial peritonitis?
Infection of. Ascitic fluid and peritoneal lining without a clear source of infection
How does spontaneous bacterial peritonitis SBP present?
Fever
Abdopain
Deranged bloods
Ileus
Hypotension
What is the most common causative organism of SBP?
E.coli
How is SBP managed?
IV broad spectrum antibiotics
What is the first line therapy used to treat spontaneous bacterial peritonitis?
Cefotaxime IV
+
IV albumin reduce renal impairment
What is the main toxin that can cause hepatic encephalopathy?
Ammonia
How is hepatic encephalopathy treated?
Lactulose
Antibiotics (Rifaximin to reduce number of intestinal bacteria)
NG tubing
What are the stages of alcohol related liver disease?
Alcoholic fatty liver
Alcoholic hepatitis
Cirrhosis
What are some complications of alcohol and liver disease?
Alcohol related liver disease
Cirrhosis
HCC
Alcohol dependance and withdrawal
Wernickes syndrome
Pancreatitis
Alcholic cardiomyopathy
CVA
Cancer
What exam findings can you find with excess alcohol?
Smelling of alcohol
Slurred speech
Bloodshot eyes
Telangiectasia on face
Tremor
What are some investigations that would. Suggest alcohol related liver disease?
High MCV
Elevated ALT AST GGT
Raised bilirubin + jaundice
Reduced albumin
Elevated INR
Deranged U+Es
Fatty changes on USS
Endoscopy = oesophageal Varices
Liver biopsy
What is the management for alcoholic liver disease?
Stop drinking
Psychological interventions
Detox regime
Nutritional support (Vitamins like THiamine = Vit B1 and high protien diet)
Corticosteroids (reduce inflammation in severe alcoholic hepatitis)
What are some medical emergencies. Related to alcohol?
Delirium tremens
Wernicke sydnrome
What is the pathophysiology of delirium tremens?
Alcohol is a depressant stimulating GABA receptors. Alcohol inhibits glutamate/NMDA receptors .
This leads to increased amounts of NMDA/glutamte receptors and decreased amounts of GABA receptors. So when a pateint withdraws there is very high NMDA/glutamate receptor activity leading to high adrenergic activity
How does a patient with delirium tremens present?
Acute confusion
Agitation
Delusions/hallucinations
Tremors
Tachycardia
Hypertension
Hyperthermia
Ataxia
Arrhythmia
What medication do you give to combat the effects of alcohol withdrawal?
Chlordiazepoxide (type of benzodiazepines)
What vitamin becomes deficient with alcohol excess?
Vitmain B1 (Thiamine)
So pateitn should be given high dose B vitamins
What syndrome can be caused by vitamin B1/thiamine deficiency due to alcoholism?
Wernicke-Korsakoff syndrome
What are the features of wernickes encephalopathy?
Confusion
Oculomotort disturbances
Ataxia (coordinated movements)
What are the stages of non-alcoholic fatty liver disease?
Non-alcoholic fatty liver disease
Non-alcoholic Steatohepatitis
Fibrosis
Cirrhosis
What are the risk factors of non-alcoholic fatty liver disease?
Middle age
Obesity
Poor diet and low activity
T2DM
Hypercholesterolemia
HTN
Smoking
What investigations would you do to investigate a non alcoholic fatty liver disease?
ALT
Liver ultrasound
Fibroscan
NAFLD fibrosis score
Liver biopsy
How is non alcoholic fatty liver disease managed?
Weight loss
Healthy diet
Exercise
Avoid alcohol
Stop smoking
Control diabetes, BP and cholesterol
Vit E, pioglitazone , bariatric surgery and liver transplantation
How does a patient with Wilsons disease present?
Neurological symptoms
Kayser-fliescher rings
Blue nails
Renal tubular acidosis
Family history
What is the first line treatment for symptomatic Wilsons disease?
Penicillamine (copper chelating agent)
What blood investigation can determine between an Upper GI bleed and a lower GI bleed?
Urea
If Urea = High its Upper
If urea normal = lower GI bleed
What are the early signs of hereditary haeamochromatosis?
Fatigue
Arthralgia
Erectile dysfunction
Occurs due to chronic deposition of iron in tissues
