Liver disease Flashcards
Name three autoimmune liver diseases.
Autoimmune hepatitis
PBC - primary biliary cholangitis
PSC - primary sclerosing chloangitis
What is the most common autoimmune disease?
PBC
What is the most severe autoimmune condition?
PSC
What is the prevalence of AIH in the UK?
1 in 5,000-1 in 10,000
What causes AIH?
T cell mediated
B cells and plasma cell autoantibodies
Anti-smooth miuscle
Anti-nuclear antigen
Causes ballooning and rosetting of hepatocytes at the interface
How can AIH present?
It can be assymptomatic
Abnormal LFTs
Chronic active hepatitis
Fulminant hepatitis
What are the key features of primary billiary cholangitis?
Most common liver autoimmune condition
>90% in females
Destruction of intrahepatic bile ducts
How is AIH treated?
Steroids for remission
Azathioprine for maintenance
What is the presentation of PBC?
Fatigue
Itchiness
Jaundice
Skin changes
Depression
How is PBC treated?
Urodeoxycholic acid / UDCA
Transplant
Treatment for itching like cholestyramine
What are the key features of PBC?
What are some key features of PSC?
Severe
Stubborn = hard to treat
Strictures in extrahepatic ducts
Systemic disease e.g. episcleritis
Suffering
What is the pathophysiology of PSC?
Autoantibodies
Stricturing of extrahepatic biliary tree
Name a few diseases linked with PSC?
Episcleritis
Pyoderma gangreosum
Erythema nodosum
What percent of PSC cases will recur in under 5 years?
At least 5%
Which autoimmune liver condition is treated with steroids and azathioprine?
AIH
Which liver condition is treated with urodeoxycholic acid?
PBC
What is NAFLD?
An umbrella term for conditions from steatosis, NASH and cirrohosis not caused by alcohol
Give one reason NAFLD is higher in the UK?
Obesity is on the increase as healthy food like fruit and veg is more expensive
What is the pathophysiology of NASH?
NASH involves –> insulin resistance –> increased lipolysis –> increased lipotoxicity and ROS
What happens when hepatocytes are damaged?
Stellate cells become active
Hepatocytes signal to kupffer cells and kupffer cells signal to stellate cells in the space of Disse
What screening tools should be done for people that are overweight/ obese?
Cardiovascular risk
QRISK3
Blood sugar check
HTN
Fibroscan/ ELF
What are the levels of fibrosis?
F1-F4
What are some methods for diagnosing NASH?
- Deranged LFTs
- Rule out EtOH abuse
- ELF - enhanced liver fibrosis blood tests
- Refer to specialist
What are ways of imaging the liver?
Fibroscan
MRI
Liver biopsy for copper
What are treatments for NASH?
No specific treatment
But pioglitazone and vitamine E
What are some provisional treatments for NASH?
No specific treatment
Pioglitazone and vitamine E
How is a liver biopsy taken?
Percutaneous
Laproscopic
Transjugular
What are the signs of liver disease?
Sarcopenia*
Gynecomastia*
Hepatic encephalopathy
Ascites
Pruitis
Hepatorenal syndrome
Cirrhosis
Portal hypertension
Spider angiomas
Capit medusae
Vitamin deficiencies
SBP
What is hepatorenal disease?
Hepatorenal syndrome (often abbreviated HRS) is a life-threatening medical condition that consists of rapid deterioration in kidney function in individuals with cirrhosis or fulminant liver failure.
What is Wernicke’s triad in Wernike’s syndrome?
Ataxia, confusion, opthalmoplegia
What drug/ drugs are used in alcohol withdrawal?
chlordiazepoxide
pabrinex
What is an important screening tool for alcoholism?
Audit C
What are the CAGE questions?
Have you ever felt you ought to cut down on your drinking or drug use?
Have people annoyed you by criticizing your drinking or drug use?
Have you felt bad or guilty about your drinking or drug use?
Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?
What drugs are used in liver transplant?
What are DBDs and DCDs?
DBD - donor after brain death
DCD - donor after cardiac death
What other liver transplants are there?
Graft splitting
Auxillary liver transplant
Domino liver transplant - amyloid
What are the main complications of cirrhosis?
What does SAAG stand for?
Serum-ascitis albumin gradient
What is SAAG?
The serum-ascites albumin gradient or gap ( SAAG) is a calculation used in medicine to help determine the cause of ascites.
>1.1g/dl = heart failure, budd chiari
<1.1g/dl = infection, malignancy
What does SAAG show?
What is transudative vs exudative?
“Transudate” is fluid buildup caused by systemic conditions that alter the pressure in blood vessels, causing fluid to leave the vascular system. “Exudate” is fluid buildup caused by tissue leakage due to inflammation or local cellular damage.
What are four treatments for ascites?
- Salt restriction (20%)
- Spirnolactone (90% effective) - encephalopathy,renal problems
- Paracentesis - hospital visits
- TIPS - surgical issues
What is SBP?
Polymorphs >200cells/mm3 because of jejunal overgrowth and increased permeability
What has reduced need for a transplant?
Hepatitis C treatment
Medication
Antivirals: Drugs which are used for treating viral infections and hepatitis C virus.
Interferon . Ribavirin . Sofosbuvir . Simeprevir . Daclatasvir
Vaccine: There is no vaccination for hepatitis C. Vaccination for hepatitis A and B will be recommended to avoid any further complications caused by these viruses.
Hepatitis A vaccine . Hepatitis B vaccine
What should you do in a clinic for a patient with cirrhosis?
Cirrhosis care bundle first 24h
Decompensated cirrhosis is defined as a patient with cirrhosis who presents with an acute deterioration in liver function that can manifest with the following symptoms: o Jaundice o Increasing ascites o Hepatic encephalopathy o Renal impairment o GI bleeding o Signs of sepsis/hypovolaemia o Frequently there is a precipitant that leads to the decompensation of cirrhosis. Common causes are: o GI bleeding (variceal and non-variceal) o Infection/sepsis (spontaneous bacterial peritonitis, urine, chest, cholangitis etc) o Alcoholic hepatitis o Acute portal vein thrombosis o Development of hepatocellular carcinoma o Drugs (Alcohol, opiates, NSAIDs etc) o Ischaemic liver injury (sepsis or hypotension) o Dehydration o Constipation
What is a medication used in HCC?
Sorafenib
What treatments can be used for ascites?
PAracentesis
Spirnolactone
TIps
Salt restriction
What provides evidence of hepatocyte cell injury?
Evidence of hepatocyte injury in the form of ballooning is required for diagnosis of steatohepatitis. The term ballooning corresponds to swelling of the hepatocyte, rounding of its contour, and alteration of the cytoplasm, which takes on a reticulated, rarified, or flocculant quality.
What is zone 1 of the liver?
periportal zone
What is zone 3 of the liver?
Central veins
Causes of liver cirrhosis?
Hepatotropic viruses
Genetic/ inherited - Wilson’s disease, alpha anti-trypsin deficiency, haemochromatosis (recessive)
Biliary tract disease e.g. PCB, PSB,
Alcohol and toxins
Where are the stem cells of the liver found?
The canal of herring
What is found in the space of Disse?
Stellate cells
What is the difference between micronodular and macronodular cirrhosis?
Micro = <3mm
Macro = >3mm
Which type of hepatitis is mostly lobular?
Acute
What type of hepatitis is chronic|?
Interface hepatitis
What type of liver disease do you get a granulomatous bile duct?
PBC
What type do you get concentric rings?
PSC
