Liver cirrhosis

Question 1

Cirrhosis

• Definition
• Causes
• Diagnosis

Answer 1

Definition
- Fibrosis (scarring) of the liver, that is mainly irreversible

Cause

• Alcoholic liver disease
• NAFLD
• Viral hepatitis B, C
• Genetic: haemochromatosis, Wilson’s disease
• Autoimmune hepatitis

Diagnosis

• Physical signs of cirrhosis: jaundice, hepatosplenomegaly, encephalopathy, ascites.
• Bloods: Low albumin, increased bilirubin, increased INR increased AST/ALT
• Imaging: Ultrasound of liver, CT of liver.

Question 2

Hereditary haemochromatosis

• Definition
• Cause
• Signs and symptoms

Answer 2

Inherited condition that leads to increased absorption of iron from the gut.

Cause

• Mutation in proteins involved in iron absorption
• Polygenic inheritance
• C28Y and H63D genes mutated
• Heterozygous for those genes or homozygous for C28Y.

Signs and symptoms

• Bronzed skin
• Diabetes
• Cirrhosis
• Joint and bone pain
• Cardiomyopathy

Question 3

Hereditary haemochromatosis

- Diagnosis

Answer 3

Serum ferritin
- Raised

Serum transferrin concentration
- >45%

Genetic screen

• Heterozygous for C28Y and H63D
• Homozygous for C28Y

Liver

• MRI scan= reduced signal intensity
• Biopsy show raise iron content
• Raised ALT

Question 4

Hereditary haemochromatosis

- Treatment

Answer 4

Conservative
- Monitor for signs of organ disease and regular blood tests

Lifestyle changes
- Avoid high iron, vitamin C containing foods and supplement

Hep A, B vaccination

Phelbotomy

Iron chelation therapy if phlebotomy is contraindicated.

Question 5

Wilson’s disease

• Definition
• Cause
• Signs and symptoms

Answer 5

Genetic condition that leads to build up of cooper in the body

• Especially in liver and brain
• Autosomal recessive

Cause
- Mutation in Wilson’s disease protein (ATP7B)

Signs and symptoms

• Liver cirrhosis/ hepatitis
• Neurological deficits: Parkinsonism, ataxia, dystonia
• Behavioural abnormalities: mood disorders, psychosis, cognitive dysfunction
• Kayser-Fleischer rings due to cooper deposits in eyes

Question 6

Wilson’s disease

- diagnosis

Answer 6

Liver function tests

• Raised AST, ALT, bilirubin
• Decreased albumin when cirrhosis decompensates

Serum ceruloplasmin (carries copper)
- Low

Serum copper
- Low

Urine copper 24 hrs
- Raised

Genetic screen
- ATP7B gene mutation

Question 7

Wilson’s disease

- Treatment

Answer 7

Mild-moderate hepatic failure

• Treintine= increases urinary excretion
• Zinc= blocks copper absorption
• Restrict copper diet

Severe liver failure= liver transplant

Question 8

NAFLD

- management

Answer 8

Lifestyle modifications

• NO alcohol
• Healthy, balanced diet
• Lose 10-15% body weight
• Reduce salt intake if ascites is present

Good glycaemic control if diabetic

Route screen for varices if cirrhosis may be present

Open bowels to remove liver toxins if liver function is failing

Question 9

NAFLD

• Definition
• Causes

Answer 9

Non-alcoholic fatty liver disease
- Fat cells in liver that can eventually progress to fibrosis/ cirrhosis.

Causes
- Metabolic syndrome is high risk factor: diabetes/ insulin resistance, hypertension, high BMI, central obesity, Dyslipidaemia

Question 10

Ascites

• Definition
• Most common causes
• Complications

Answer 10

Build up of peritoneal fluid, >25 mls

Most common causes

• Portal hypertension (commonly caused by liver cirrhosis)
• Malignancy
• Heart failure

Complications

• Spontaneous bacterial peritonitis (due to bacterial translocation).
• Hyponatraemia
• Hepatorenal syndrome

Question 11

Ascites

- Diagnosis

Answer 11

1. Ultrasound
   - Sensitive to fluid in abdomen
2. CT will also show ascites

Sample of ascitic fluid

• Test WCC and bacteria for SBP
• Albumin levels
• SAAG (ascites albumin gradient). >11= transudate