Liver Conditions Flashcards
1
Q
What are the major liver diseases?
A
Alcohol related liver disease
Viral hepatitis
NAFLD
Autoimmune diseases
2
Q
What ae the 5 main causative organisms of viral hepatitis?
A
A B C D E
3
Q
What type of viruses are hep A and E?
A
Enteric viruses
4
Q
What type of viruses are hep B, C and D?
A
Parenteral viruses
5
Q
What do hepatitis A and E viruses cause?
A
Self limiting acute infections
6
Q
What hepatitis viruses cause chronic disease?
A
B
C
D
7
Q
Transmission of Hep A
A
Faceal oral
Sexual
Blood
8
Q
Where is Hep A predominant?
A
Poor sanitation
Dirty water
9
Q
Presentation of HAV
A
Asymptomatic very common Jaundice Liver enzymes high Fever Feeling unwell Slowly get better
10
Q
What is the maximum time to get better after HAV?
A
4 months
11
Q
Commonest age group to get Hep A?
A
5 - 14 y / o
12
Q
How is acute disease of HAV diagnosed?
A
IgM antibodies
13
Q
Who gets immunised for HAV?
A
Travellers Patients with chronic liver disease IVDU (especially with HCV or HBV) Haemophiliacs Occupational exposure (lab workers) MSM
14
Q
What does MSM stand for?
A
Men who have sex with men
15
Q
HBV structure
A
Shell covers the virus
Active bit of virus inside
Inside contains core antigen and surface antigen
E antigen protein is secreted out
16
Q
What parts of the HBV can be detected on blood tests?
A
E antigen
Cannot detect core antigen
17
Q
Antigens of HBV
A
Hepatitis surface antigen - HBsAg
Hepatitis e antigen - HBeAg
Hepatitis core antigen - HBcAg - active replication
18
Q
What is a sign of active replication in HBV?
A
HBV DNA
19
Q
Presence of Anti-HB indicates what?
A
Protection from virus (either by immunisation or previous exposure)
20
Q
Presence of IgM anti HBc indicates what? Why?
A
Acute infection
If IgM is present then the virus has been present in the last 6 months
If this is not present then have had the virus for a more chronic length of time
21
Q
Which antibodies are in the core?
A
IgM
IgG
22
Q
Approach to HBV infection
A
If negative - nothing to worry about
If positive - then find out if active or not
Then find out if acute or chronic
23
Q
Progression of pathology of Hep B virus
A
Chronic hep B Can go to either 1. no further progression OR 2. Cirrhosis Cirrhosis can lead to - HCC - ESLD
24
Q
What does HCC stand for?
A
Hepatocellular carcinoma
25
What does ESLD stand for?
End stage liver disease
26
Patients with chronic Hep B who progress to cirrhosis have a higher risk of what?
Hepatic decompression and development of HCC
27
What approx. % of chronic Hep B patients will progress to cirrhosis, HCC or liver failure?
15 - 40%
28
What % of liver transplants are related to Hep B?
5 - 10%
29
Treatment of HBV
Pegylated interferon injection
Oral antiviral drugs
- adefovir
- entecavir
30
What % of the Scottish population is infected with Hep C?
1%
31
What % of patients infected with Hep C have a chronic hep C infection?
85%
32
Presentation of Hep C
10% report acute jaundice
Most asymptomatic until cirrhotic
May have normal LFTs
33
What type of virus is hep C?
RNA
34
Natural history of HCV infection
```
1. exposure
15% will resolve
2. 85% chronic infection
80% will then stabilise
3. 20% Progress to cirrhosis
75% will become slowly progressive after this
4. 25% Progress to HCC or death
```
35
What accelerates the process from cirrhosis to HCC in HCV?
HIV
| Alcohol
36
What % of patients with Hep C get cirrhosis?
20%
37
Diagnostic test for Hep C
Anti HCV antibody
38
Treatment of Hep C
Pegy interferon
39
What type of virus is Hep D?
Small RNA virus
40
What is Hep D enveloped by?
HBsAg
41
What does Hep D coinfect with? Can it survive on its own?
HBV
| Cannot support itself
42
Transmission of HDV
Same as HBV
43
Which hepatitis virus is very resistant to treatment and therefore very difficult to treat?
HDV
44
What type of disease does HEV cause?
Zoonotic disease
45
What does HEV cause in pregnancy?
Fulminant hepatic failure
46
Features of HEV
Self limiting
| No long term sequelae
47
Treatment for HEV
No treatment
48
Is there a vaccine for HEV?
No
49
What is the 3 entities of non alcoholic fatty liver disease?
1. simple steatosis
2. Non alcoholic steatohepatitis
3. Fibrosis and cirrhosis
50
Definition of steatosis
Abnormal retention of lipids in a cell
51
Risk factors of non alcoholic fatty liver disease
```
DM
Obesity
Hypertriglyceridemia
HTN
Age
Hispanic ethnicity
Genetics (PNPLA3 gene)
```
52
What does NAFLD stand for?
Non alcoholic fatty liver disease
53
Pathology / Natural history of NAFLD
1. normal liver
2. 10-35% steatosis
3. 12 - 40% NASH +/- fibrosis
4. 15% cirrhosis
54
What does NASH stand for?
Non alcoholic steatohepatitis
55
Investigations for NAFLD?
```
AST/ALT ratio
Indirect markers- enhanced liver fibrosis panel (ENF)
Cytokeratin-18
USS
Fibiroscan
MRI/CT
MR spectroscopy
Liver biopsy
```
56
What does MR spectroscopy do?
Quantifies fat
57
Criteria for low risk NAFLD
```
Age < 45
DM absent
BMI < 30
AST: ALT <1 (AST150
Albumin normal > 34
```
58
Criteria for high risk NAFLD
```
Age > 45
DM present
BMI > 30
AST:ALT >1 (AST>ALT)
Low < 150
Low < 34
```
59
Treatment of NAFLD
```
Diet
Weight reduction
Exercise
Insulin sensitizers e.g. metformin
GLP-1 analogues e.g. liraglutide
Farnesoid nuclear receptor ligand
Vitamin E
Weight reduction surgeries
```
60
Examples of autoimmune liver diseases
```
Autoimmune hepatitis
Primary biliary cholangitis (PBC)
Primary sclerosing cholangitis (PSC)
Autoimmune cholangiopathy
IgG 4 disease
Overlap syndromes
```
61
What gender gets autoimmune hepatitis more?
Female
62
3 types of antibodies in autoimmune hepatitis
Type 1; ANA, SMA
Type 2; LKM1
Type 3; SLA
63
What antibody is VERY high in autoimmune hepatitis?
IgG
64
Diagnostic test for autoimmune hepatitis
Liver biopsy
65
Treatment of autoimmune hepatitis
Steroids then
| Long term azathioprine
66
Which gender gets primary biliary cholangitis more?
Females (92-95%)
67
What antibody is elevated in PBC?
IgM
68
What is the diagnostic test for PBC?
Anti-mitochondrial antibody positive
69
Treatment of PBC
UDCA
| Bile acid treatment
70
What gender gets PSC more?
M > F
71
Which antibody is found to be positive in PSC?
PANCA
72
What is the investigation of choice for PSC?
MRCP
73
Treatment of PSC
Treatment of liver conditions
| Biliary stents
74
Who gets a liver transplant?
Chronic liver disease with poor predicted survival
Chronic liver disease with associated poor quality of life
Hepatocellular carcinoma
Acute liver failure
Genetic diseases e.g.
- primary oxaluria
- tyrosemia
75
Contraindications to liver transplant
Active extrahepatic malignancy
Hepatic malignancy with macrovascular or diffuse tumour invasion
Active or uncontrolled infection outside of the hepatobiliary system
Active substance or alcohol abuse
Severe Cardiopulmonary or other co morbid conditions
Psychosocial factors that would likely preclude recovery after transplantation
Technical and or anatomical barriers
Brain death
76
How are patients prioritised for liver transplant in acute liver failure?
Acetaminophen-induced ALF
- list if arterial pH < 7.3 or arterial lactate > 3.0 after adequate fluid resus
- strongly recommend if arterial lactate > 3.5 after early fluid resus
- list if all 3 occur < 24 hours
1. Grade 3 or 4 HEC
2. INR > 6.5
3. Creatinine > 300
Nonacetaminophen-induced ALF
- list if INR > 6.5 and encephalopathy present
- If 3 of these present irrespective of grade of encephalopathy
1. < 10 y/o or > 40 y/o
2. Interval from jaundice to encephalopathy of > 7 days
3. INR at least 3.5
4. Serum bilirubin at least 300
5. Unfavourable cause
- seronegative hepatitis
- idiosynactric drug reaction
- wilsons disease
77
How do we prioritise who gets a liver transplant in cirrhosis?
Child Pugh scoring A, B and C
MELD score - decides who gets livers
UKELD - decides who gets livers first
78
What does MELD look at?
Bilirubin
Creatinine
INR
79
What does UKELD look at?
Bilirubin
Sodium
Creatinine
INR
80
Post op care after a liver transplant includes…..
```
ICU care
Prophylactic antibiotics
Prophylactic anti fungal drugs
Anti rejection drugs - a combination of
- steroids
- azathioprine
- tacrolimus/cyclosporin
```
81
Presentation of spontaneous bacterial peritonitis
Ascites
Abdominal pain
Fever
82
Management of SBP
IV Cefotaxime
83
Who with ascites requires antibiotic prophylaxis and what with?
```
Patients who
- have had an episode of SBP
- Fluid protein < 15
- Child pugh score of at least 9
- hepatorenal syndrome
USING CIPROFLOXACIN
```
84
What does HBsAg imply?
Acute disease (present 1 - 6 months)
85
What does anti-HBS imply?
Immunity (either exposure or immunisation)
86
What is anti-HBS negative in?
Chronic disease
87
What does Anti-HBc imply?
Previous or current infection
88
IgM vs IgG Anti-Hbc
IgM acute
| IgG persists
89
Inheritance of haemochromatosis
Autosomal recessive
90
Presentation of haemochoromatosis
```
Early symptoms
- fatigue
- erectile dysfunction
- arthralgia (hands usually)
'Bronze skin' pigmentation
DM
Liver; signs of chronic liver disease
Cardiac failure secondary to cardiomyopathy
Hypogonadism (secondary to cirrhosis and pituitary dysfunction)
Arthritis (esp of hands)
```
91
What is wilsons disease?
Excess copper deposition in the tissues
92
Inheritance of wilsons disease
Autosomal recessive
93
Pathology of wilsons disease
Increased copper absorption from small intestine
| Decreased hepatic copper excretion
94
Gene defect in wilsons disease
10 - 25 y/o
95
Children presentation vs young adult presentation of wilsons disease
Children - present with liver disease
| Adult - Present with neurological disease
96
Presentation of wilsons disease
```
Liver
- hepatitis
- cirrhosis
Neruological
- basal ganglia degeneration
- speech, behavioural and psych problems often the first manifestation
- asterixis, chorea, dementia, parkinsonism
Kayser-Fleischer rings
Renal tubular acidosis
Haemolysis
Blue nails
```
97
Investigations for wilsons disease
Reduced serum caeruloplasmin
Reduced serum copper
Increased 24 hour copper excretion
98
Treatment of wilsons disease
Penicillaemine 1st line
99
Another name for Budd-Chiari syndrome
Hepatic vein thrombosis
100
What is budd-chiari syndrome usually seen in the context of?
Underlying haematological disease
| Another procoagulant condition
101
Causes of Budd-chiari syndrome
Polcythaemia rubra vera
Thrombophilia
Pregnancy
OCP
102
Classic triad of budd chiari syndrome
Abdominal pain - sudden onset and severe
Ascites
Tender hepatomegaly
103
Investigations of budd chiari syndrome
USS with doppler
104
In a patient with NAFLD, what is the test used to aid the diagnosis of liver fibrosis?
Enhanced liver fibrosis testing
105
What would point towards the diagnosis of wilsons disease?
A combination of liver and neurological signs
106
What is the most common cause of HCC worldwide?
Hep B
107
What is the most common cause of HCC in Europe?
Hep C
108
What does PSC look like on ERCP?
Classic 'beaded' strictures
109
What is the investigation of choice for liver cirrhosis?
Transient elastography (fibroscan)
110
Another name for transient elastrography
Fibroscan
111
What can be a useful diagnostic marker for HCC?
Raised AFP
112
What is the mainstay of treatment in haemachromatosis?
Regular Venesection
113
Early signs of haemachromatosis
Fatigue
Erectile dysfunction
Arthralgia
114
Who is autoimmune hepatitis commonly seen in?
Young females
115
How may types of autoimmune hepatitis are there?
3
116
Explain type I autoimmune hepatitis
ANA and/or anti smooth muscle antibodies
| Affects both adults and children
117
Explain type II autoimmune hepatitis
Anti-liver/kidney microsomal type 1 antibodies (LKM1)
| Affects children only
118
Explain type III autoimmune hepatitis
Soluble liver-kidney antigen
| Affects adults in middle age
119
Presentation of autoimmune hepatitis
May present with signs of chronic liver disease
Acute hepatitis (only 25% present like this)
- fever, jaundice etc
Amenorrhea common
120
Investigation of autoimmune hepatitis and what does it show?
Liver biopsy
| Inflammation extending beyond the limiting plate 'piecemeal necrosis', bridging necrosis
121
Management of autoimmune hepatitis
Steriods, other immunosuppressants (e.g. azathioprine)
| Liver transplant
122
What is the triad of acute liver failure?
Encephalopathy
Jaundice
Coagulopathy
123
Most common organism causing SBP
E coli
124
What is the commonest cause of liver failure in the UK?
Paracetamol overdose
125
What is right heart failure associated with (to do with liver)?
Firm, smooth, tender and pulsatile liver edge
126
Blood results on haemachromatosis
Raised transferrin saturation
Raised ferritin
Low TIBC
