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Liver disease Flashcards

1
Q

Blood borne hepatitis

A

HBV (+HDV) ,HCV (these are also the chronic ones)

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2
Q

Enteric transmission hepatitis

A

HAV,HEV ( these are also acute)

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3
Q

Surface antigen HBsAg

A

active infection (either acute or chronic)

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4
Q

HBeAg

A

a marker of viral replication and infectivity, therefore is positive in acute hepatitis B infection.

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5
Q

Surface antibody (HBsAb) Anti-HBs

A

implies vaccination or past or current infection

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6
Q

Core antibodies HBcAb

A

Anti-HBc implies previous (or current) infection.
IgM implies an active infection and is present for about 6 months.
IgG persists and indicates a past infection

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7
Q

Clinical presentation of acute liver failure

A

Malaise, anorexia and fever
Jaundice
Bleeding
Confusion
Abnormal liver function tests
Abdominal pain
Bruising
oliguria/anuria
Acutely may be asymptomatic and anicteric

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8
Q

Clinical signs of acute liver failure

A

Jaundice
hepatomegaly
Spider naevi
Palmar erythema
Severe RUQ pain
Hepatic encephalopathy
Bruising
Ascites
GI bleeding
Hypotension
Tachycardia
Raised ICP
AKI

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9
Q

Causes of acute liver failure

A

Viruses eg hepatitis
Toxins
Metabolic eg Acute fatty liver of pregnancy
Vascular Events
Wilson disease
Autoimmune hepatitis
Malignancy infiltration

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10
Q

Causes of hepatitis

A

Alcoholic hepatitis
Non alcoholic fatty liver disease
Viral hepatitis
Autoimmune hepatitis
Drug induced hepatitis (e.g. paracetamol overdose)

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11
Q

Drug causes of induced liver injury

A

Paracetamol
Anti-TB medications (Isoniazid)
Ecstasy, cocaine
Chemotherapy (cyclophosphamide, 6MP)
Carbamazepine
Macrolide
Statin
Roziglitazone
flucloxacillin

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12
Q

Hepatitis A

A

most common viral hepatitis worldwide but it is relatively rare in the UK
RNA virus, faecal-oral route
Mx: resolves without treatment in around 1-3 months, analgesia, vaccination available
notifiable disease

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13
Q

Hepatitis B

A

transmitted by direct contact with blood or bodily fluids
DNA virus
Chronic HBV is linked to liver cancer
Vaccination available

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14
Q

Hepatitis C

A

It is spread by blood and body fluids.
RNA virus
the most common blood-borne infection and the leading cause of chronic viral infection
Cx: liver cirrhosis and associated complications and hepatocellular carcinoma

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15
Q

Hepatitis E

A

faecal oral route eg seafood/contaminated pork/sausages/ transmitted by water in endemic areas
RNA virus

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16
Q

Mx Hepatitis B

A

Screen for other blood borne viruses (hepatitis A and B and HIV) and other sexually transmitted diseases
Refer to gastroenterology, hepatology or infectious diseases for specialist management
Notify Public Health (it is a notifiable disease)
Stop smoking and alcohol
Education about reducing transmission and informing potential at risk contacts
Testing for complications: FibroScan for cirrhosis and ultrasound for hepatocellular carcinoma
Antiviral medication can be used to slow the progression of the disease
Liver transplantation for end-stage liver disease

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17
Q

Type 1 Autoimmune hepatitis

A

affects women in their late forties or fifties
most common
fatigue and features of liver disease
30% have concurrent immune diseases,especially autoimmune thyroiditis, synovitis, or ulcerative colitis

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18
Q

Type 2 Autoimmune hepatitis

A

teenage or early twenties present with acute hepatitis with high transaminases and jaundice
commonly have other concurrent autoimmune disorders such as type 1 diabetes, vitiligo

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19
Q

Type 1 Autoimmune hepatitis Autoantibodies

A

Anti-nuclear antibodies (ANA)
Anti-smooth muscle antibodies (anti-actin)

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20
Q

Type 2 Autoimmune hepatitis Autoantibodies

A

Anti-liver kidney microsomes-1 (anti-LKM1)
Anti-liver cytosol antigen type 1 (anti-LC1)

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21
Q

Tx autoimmune hepatits

A

high dose steroids (prednisolone) that are tapered over time as other immunosuppressants, particularly azathioprine, are introduced.

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22
Q

Blood results in alcoholic hepatitis

A

Ratio of AST to ALT >2:1
raised gamma-GT
raised MCV
Low albumin
elevated prothrombin time
U+Es may be deranged in hepatorenal syndrome.
Elevated INR- decline in hepatic function/ dietary vitamin K deficiency.
Thrombocytopenia
Hypoglycaemia

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23
Q

Ix alcoholic hepatitis

A

US/fibroscan- fatty changes , degree of cirrhosis
Endoscopy- asses varices hen portal hypertension is suspected
CT and MRI- fatty infiltration of the liver, hepatocellular carcinoma, hepatosplenomegaly, abnormal blood vessel changes and ascites
Liver biopsy - confirm the diagnosis of alcohol-related hepatitis or cirrhosis

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24
Q

Mx alcoholic liver disease

A

Stop drinking alcohol permanently
Consider a detoxication regime
Nutritional support
Steroids improve short term outcomes (over 1 month) in severe alcoholic hepatitis
Treat complications of cirrhosis
Referral for liver transplant in severe disease however they must abstain from alcohol for 3 months prior to referral

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25
Cx of alcohol
Alcoholic Liver Disease Cirrhosis and the complications of cirrhosis including hepatocellular carcinoma Alcohol Dependence and Withdrawal Wernicke-Korsakoff Syndrome (WKS) Pancreatitis Alcoholic Cardiomyopathy
26
Delirium Tremens
medical emergency associated with alcohol withdrawal 24-72 hours after last alcohol consumption
27
Clinical presentation Delirium tremens
Acute confusion Severe agitation Delusions and hallucinations Tremor Tachycardia Hypertension Hyperthermia Ataxia (difficulties with coordinated movements) Arrhythmias
28
Wernicke-Korsakoff Syndrome (WKS)
due to thiamine vitamin B1 deficiency can be caused by chronic alcohol abuse, malnutrition, bariatric surgery, or hyperemesis gravidarum. treatment is with high-dose intravenous thiamine
29
Clinical features of Wernicke-Korsakoff Syndrome (WKS)
Confusion Oculomotor disturbances (disturbances of eye movements-nystagmus/horizontal or vertical opthalmoplegia) Ataxia
30
Korsakoffs syndrome
follows an episode of Wernicke’s Encephalopathy Memory impairment (retrograde and anterograde) Behavioural changes destruction of the mammillary bodies often irreversible
31
Ix Non alcoholic fatty liver disease
ALT increases more than AST Liver Ultrasound can confirm the diagnosis of hepatic steatosis CT with contrast Liver biopsy ELF/NAFLD fibrosis score / Fibrosis scan
32
Mx Non alcoholic fatty liver disease
Goal is to reverse the factors that contribute to insulin resistance Weight loss Exercise Stop smoking Control of diabetes, blood pressure and cholesterol Avoid alcohol
33
four most common causes of liver cirrhosis.
Alcoholic liver disease Non Alcoholic Fatty Liver Disease Hepatitis B Hepatitis C
34
Features of decompensated liver cirrhosis
Ascites and oedema Jaundice Pruritus Palmar erythema Gynaecomastia and testicular atrophy Easy bruising
35
hepatocellular carcinoma screening
Alpha-fetoprotein can be checked every 6 months as a screening test in patients with cirrhosis along with ultrasound.
36
Screening for cirrhosis
Fibroscan retesting every 2 years in patients at risk of cirrhosis: Hepatitis C Heavy alcohol drinkers (men drinking > 50 units or women drinking > 35 units per week) Diagnosed alcoholic liver disease Non alcoholic fatty liver disease and evidence of fibrosis on the ELF blood test Chronic hepatitis B (although they suggest yearly for hep B)
37
Scoring systems for cirrhosis
Child-Pugh Score for Cirrhosis Model for End-stage Liver Disease (MELD) UK End-stage Liver Disease (UKELD)
38
MELD score
recommended by NICE to be used every 6 months in patients with compensated cirrhosis. It is a formula that takes into account the bilirubin, creatinine, INR and sodium and whether they are requiring dialysis. It gives a percentage estimated 3 month mortality and helps guide referral for liver transplant.
39
Enhanced Liver Fibrosis (ELF) blood test
first line recommended investigation for assessing fibrosis in non-alcoholic fatty liver disease
40
Mx Cirrhosis
Alcohol cessation stop offending med antiviral therapy for viral hepatitis Colestyramine (bile acid sequestrant) can be used to manage pruritus. Ultrasound and alpha-fetoprotein every 6 months for hepatocellular carcinoma Endoscopy every 3 years in patients without known varices High protein, low sodium diet ( low sodium reduces fluid retention) MELD score every 6 months Consideration of a liver transplant Managing complications
41
Cx cirrhosis
Malnutrition Portal Hypertension, Varices and Variceal Bleeding Ascites and Spontaneous Bacterial Peritonitis (SBP) Hepato-renal Syndrome Hepatic Encephalopathy Hepatocellular Carcinoma
42
Ascites
Ascites describes the accumulation of fluid within the peritoneal cavity. involves portal hypertension causing increased hydrostatic pressure leading to transudation of fluid.
43
Serum ascites albumin gradient (SAAG)calculation
is calculated by subtracting the albumin concentration of the ascitic fluid from the serum albumin concentration.
44
Causes of high SAAG (>1.1g/dL)
suggests that the cause of the ascites is due to raised portal pressure.Raised hydrostatic pressure forces water into the peritoneal cavity whilst albumin remains within the vessels causes include: Cirrhosis Heart failure Budd Chiari syndrome Constrictive pericarditis Hepatic failure alcoholic hepatitis portal vein thrombosis massive hepatic metastases
45
Causes of a low SAAG (<1.1g/dL)
indicates that the patient does not have portal hypertension and indicates a peritoneal cause of ascites Cancer of the peritoneum Tuberculosis and other infections Pancreatitis Nephrotic syndrome serositis (including lyphoma), peritoneal carcinomatosis.
46
Mx Ascites
- Address the underlying cause - Salt restricted diet - Fluid restriction - Anti-aldosterone diuretics (spironolactone is first line , if doesnt work furosemide can be added) - Patients with ascites refractory to medical management may require regular therapeutic paracentesis - Prophylactic antibiotics against spontaneous bacterial peritonitis (ciprofloxacin or norfloxacin) in patients with less than 15g/litre of protein in the ascitic fluid - Daily weights
47
Hepatorenal Syndrome
Hypertension in the portal system leads to dilation of the portal blood vessels, stretched by large amounts of blood pooling there. This leads to a loss of blood volume in other areas of the circulation, including the kidneys--> decline in function
48
Mx Hepatorenal syndrome
vasopressin analogues, for example terlipressin, have a growing evidence base supporting their use. They work by causing vasoconstriction of the splanchnic circulation volume expansion with 20% albumin transjugular intrahepatic portosystemic shunt
49
Transjugular Intra-hepatic Portosystemic Shunt (TIPS)
wire inserted under xray into the jugular vein, down the vena cava and into the liver via the hepatic vein. They then make a connection through the liver tissue between the hepatic vein and the portal vein and put a stent in place. This allows blood to flow directly from the portal vein to the hepatic vein and relieves the pressure in the portal system and varices.
50
Hepatic Encephalopathy
build up of toxins/ammonia in the brain, which is produced by intestinal bacteria when they break down proteins and is absorbed in the gut.
51
Precipitating Factors of Hepatic Encephalopathy
Constipation Electrolyte disturbance Infection GI bleed High protein diet Medications (particularly sedative medications eg zopiclone)
52
Clinical presentation hepatic encephalopathy
Four stages of hepatic encephalopathy Altered mood and behaviour, disturbance of sleep pattern and dyspraxia Drowsiness, confusion, slurring of speech and personality change Incoherency, restlessness, asterixis Coma
53
Mx Hepatic encephalopathy.
Septic screen Correct electrolytes Laxatives (i.e. lactulose) promote the excretion of ammonia. Antibiotics (i.e. rifaximin) reduces the number of intestinal bacteria producing ammonia. Nutritional support. Stop diuretics
54
Reye syndrome
An acute encephalopathy with hepatic dysfunction stemming from mitochondrial damage.
55
Reye syndrome presentation
acute onset of profuse vomiting and altered mental status, ranging from a personality change to coma, in children recovering from a recent viral infection.
56
Reye syndrome presentation
acute onset of profuse vomiting and altered mental status, ranging from a personality change to coma, in children recovering from a recent viral infection.
57
Budd chairi syndrome
Hepatic venous outflow obstruction. Classic triad of symptoms is abdominal pain (normally RUQ), ascites, and hepatomegaly.
58
Budd chairi syndrome
Hepatic venous outflow obstruction. Classic triad of symptoms is abdominal pain (normally RUQ), ascites, and hepatomegaly.
59
HELLP syndrome in pregnancy
severe form of pre-eclampsia characterised by haemolysis (H), elevated liver enzymes (EL), and low platelets (LP) in a pregnant or puerperal patient (usually within 7 days of delivery).
60
Complications of acute liver failure :
Hepatic encephalopathy ( signs: altered mental status/ confusion, asterixis) Ascites Sepsis AKI Haemorrhage Cerebral dysfunction due to increased ICP
61
Wilsons disease
- autosomal recessive disease that is due to mutations in the ATP7B gene. - It is a copper transport protein deficiency disease, characterised by excessive copper deposition in the tissues
62
Clinical presentation of Wilsons disease
hepatitis, cirrhosis, akinetic-rigid syndrome, speech, behavioural and psychiatric problems ,Kayser-Fleischer rings,blue nails
63
Clinical signs in Wilson disease
Kayser-Fleischer rings- green-brown rings in the periphery of the iris sunflower cataracts in the lens
64
Wilsons disease Ix
- slit lamp examination for Kayser-Fleischer rings - reduced serum caeruloplasmin, may be normal - reduced total serum copper - increased 24hr urinary copper excretion - genetic analysis of the ATP7B gene - liver biopsy
65
Wilsons disease Mx
penicillamine (chelates copper) trientine hydrochloride is an alternative
66
Causes of Fanconi syndrome
Complication of Wilsons disease,cystinosis (most common cause in children), Sjogren's syndrome, multiple myeloma and nephrotic syndrome
67
Fanconi syndrome
generalised reabsorptive disorder of renal tubular transport in the proximal convoluted tubule resulting in: type 2 (proximal) renal tubular acidosis polyuria aminoaciduria glycosuria phosphaturia osteomalacia
68
Drug-induced liver disease hepatocellular picture
paracetamol sodium valproate, phenytoin MAOIs halothane anti-tuberculosis: isoniazid, rifampicin, pyrazinamide statins alcohol amiodarone methyldopa nitrofurantoin
69
Drug-induced liver disease causing cholestasis (+/- hepatitis):
combined oral contraceptive pill antibiotics: flucloxacillin, co-amoxiclav, erythromycin* anabolic steroids, testosterones phenothiazines: chlorpromazine, prochlorperazine sulphonylureas fibrates rare reported causes: nifedipine
70
Drug-induced liver disease causing cirrhosis
methotrexate methyldopa amiodarone
71
Causes of hepatomegaly
Cirrhosis Malignancy Right heart failure viral hepatitis glandular fever malaria abscess: pyogenic, amoebic hydatid disease haematological malignancies haemochromatosis primary biliary cirrhosis sarcoidosis, amyloidosis
72
Haemochromatosis
multi-system disorder There is increased intestinal iron absorption.
73
Haemachromatosis epidemiology
middle-aged males autosomal recessive
74
Haemachromatosis clinical presentation
lethargy, fatigue loss of libido arthropathy/ arthralgia - 2nd and 3rd MCP joints skin hyperpigmentation - slate/grey/Bronze Hepatomegaly deranged liver function development of diabetes erectile dysfunction Cirrhosis dilated cardiomyopathy osteoporosis
75
Haemachromatosis Ix
Serum iron (↑) and ferritin (↑) TIBC (↓) (relates to the amount of transferrin in your blood that's available to attach to iron) transferrin saturation > 55% in men or > 50% in women MRI brain /heart imaging may show evidence of iron deposition. Liver biopsy- increased iron stores- perls stain
76
Haemachromatosis Cx
skin pigmentation (often decreases after phlebotomy) diabetes Severe myocardial siderosis hepatic cirrhosis→ cancer risk of HCC chondrocalcinosis and arthropathy hypogonadism and pituitary dysfunction
77
Haemachromatosis Mx
Venesection Another option is desferrioxamine, a iron chelating agent
78
Notching of the inferior border of the ribs
Coarctation of the aorta
79
firm, smooth, tender liver edge. May be pulsatile
right heart failure
80
hard, irregular liver edge.
liver mets
81
hepatomegaly if early disease, later liver decreases in size. Associated with a non-tender, firm liver
cirrhosis
82
Amoebic liver abscess
Typical symptoms are malaise, anorexia and weight loss. The associated RUQ pain tends to be mild and jaundice is uncommon.
83
Types of liver cancer
hepatocellular carcinoma (80%) and cholangiocarcinoma (bile duct cancer, 20%)
84
Risk factors for hepatocellular carcinoma
Viral hepatitis (B and C) Alcohol Non alcoholic fatty liver disease Other chronic liver disease haemachromatosis
85
Liver cancer presentation
Weight loss Abdominal pain RUQ Anorexia Nausea and vomiting Jaundice Pruritus Ascites hepato/splenomegaly possible presentation is decompensation in a patient with chronic liver disease
86
Cholangiocarcinoma presentation
painless jaundice in a similar way to pancreatic cancer periumbilical lymphadenopathy (Sister Mary Joseph nodes) and left supraclavicular adenopathy (Virchow node) may be seen
87
2ww US to assess for liver cancer
in people with an upper abdominal mass consistent with an enlarged liver
88
Liver cancer Ix
Alpha-fetoprotein- hepatocellular carcinoma CA19-9 - cholangiocarcinoma liver US CT and MRI ERCP - biopsies in cholangiocarcinoma
89
Hepatocellular Carcinoma Tx
Surgery - resection, transplant Other - radiofrequency ablation, transarterial chemoembolisation, several kinase inhibitors eg sorafenib generally considered resistant to chemo and radiotherapy
90
Cholangiocarcinoma Tx
Surgery - resection, ERCP to place stent for symptom relief generally considered resistant to chemo and radiotherapy.
91
Alcoholic liver disease Ix findings
gamma-GT is characteristically elevated | the ratio of AST:ALT > 3
91
Cancers most likely to metastasise to the liver
colorectal (via the portal circulation which drains the gut), breast and lung.
92
Maddrey's discriminant function
often used during acute alcoholic liver episodes to determine who would benefit from glucocorticoid therapy calculated by a formula using prothrombin time and bilirubin concentration

Medicine (72 decks)

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