Liver Disease Flashcards
Acute liver failure describes
the rapid onset of hepatocellular dysfunction leading to a variety of systemic complications.
Acute liver failure causes
paracetamol overdose
alcohol
viral hepatitis
acute fatty liver of pregnancy
Acute liver failure - viral hepatitis usually
A or B
Acute liver failure Features
jaundice
coagulopathy: raised prothrombin time
hypoalbuminaemia
hepatic encephalopathy
renal failure is common ('hepatorenal syndrome')‘liver function tests’ do not always accurately reflect the synthetic function of the liver.
true
This is best assessed by looking at the prothrombin time and albumin level.
Liver cirrhosis remains a significant problem in the developed world, account for 60,000 deaths in the UK each year.
true
Liver cirrhosis - Causes:
alcohol
non-alcoholic fatty liver disease (NAFLD)
viral hepatitis (B and C)
Liver cirrhosis - Diagnosis
NAFLD
enhanced liver fibrosis score to screen for patients who need further testing
Liver cirrhosis liver biopsy is diagnostic
false
enhanced liver fibrosis score to screen for patients who need further testing
Liver cirrhosis reccomended imaging modalities
transient elastography and acoustic radiation force impulse imaging
What is transient elastography?
brand name ‘Fibroscan’
uses a 50-MHz wave is passed into the liver from a small transducer on the end of an ultrasound probe
measures the ‘stiffness’ of the liver which is a proxy for fibrosis
In terms of screening for cirrhosis NICE made a specific recommendation, suggesting to offer transient elastography to:
people with hepatitis C virus infection
men who drink over 50 units of alcohol per week and women who drink over 35 units of alcohol per week and have done so for several months
people diagnosed with alcohol-related liver disease
NICE recommend doing what to check for varices in patient’s with a new diagnosis of cirrhosis
an upper endoscopy
liver ultrasound every ? (+/- alpha-feto protein) to check for hepatocellular cancer
6 months
Hepatitis B serology
what normally implies acute disease (present for 1-6 months)
HBsAg
Hepatitis B serology
if HBsAg is present for > 6 months then this implies
chronic disease (i.e. Infective)
Hepatitis B serology - Anti-HBs implies
immunity (either exposure or immunisation). It is negative in chronic disease
Hepatitis B serology - Anti-HBc
implies previous (or current) infection.
IgM anti-HBc appears
during acute or recent hepatitis B infection and is present for about 6 months.
IgG anti-HBc persists post infection
true
HbeAg is a marker of infectivity
true
results from breakdown of core antigen from infected liver cells
Hepatitis B serology in previous immunisation
anti-HBs positive, all others negative
Hepatitis B serology in previous hepatitis B (> 6 months ago), not a carrier
anti-HBc positive, HBsAg negative
Hepatitis B serology in previous hepatitis B, now a carrier
anti-HBc positive, HBsAg positive
a;colhol The government now recommend the following:
men and women should drink no more than 14 units of alcohol per week
it is best to spread this evenly over 3 days or more
pregnant women should not drink
One unit of alcohol is equal to ? mL of pure ethanol.
One unit of alcohol is equal to 10 mL of pure ethanol.
The ‘strength’ of an alcoholic drink is determined by
‘alcohol by volume’ (ABV).
To calculate the number of units in a drink
multiply the number of millilitres by the ABV and divide by 1,000
Alcoholic liver disease ix
gamma-GT is characteristically elevated
the ratio of AST:ALT is normally > 2, a ratio of > 3 is strongly suggestive of acute alcoholic hepatitis
mx acute episodes of alcoholic hepatitis
glucocorticoids (e.g. prednisolone)
pentoxyphylline is also sometimes used - doesnt improve outcomes
Maddrey’s discriminant function (DF) is?
calculated by a formula using prothrombin time and bilirubin concentration
used during acute episodes to determine who would benefit from glucocorticoid therapy
Alcoholic ketoacidosis arises due to
Often alcoholics will not eat regularly and may vomit food that they do eat, leading to episodes of starvation. Once the person becomes malnourished, after an alcohol binge the body can start to break down body fat, producing ketones. Hence the patient develops a ketoacidosis.
Alcoholic ketoacidosis typical pattern
Metabolic acidosis
Elevated anion gap
Elevated serum ketone levels
Normal or low glucose concentration
Alcoholic ketoacidosis mx
infusion of saline & thiamine. Thiamine is required to avoid Wernicke encephalopathy or Korsakoff psychosis.
most common cause of liver disease in the developed world.
Non-alcoholic fatty liver disease (NAFLD)
Non-alcoholic fatty liver disease (NAFLD) is largely caused by
obesity
NAFLD is a spectrum of disease ranging from
steatosis - fat in the liver
steatohepatitis - fat with inflammation, non-alcoholic steatohepatitis (NASH)
progressive disease may cause fibrosis and liver cirrhosis
key mechanism leading to steatosis.
insulin resistance
Non-alcoholic steatohepatitis (NASH) is a term used to describe
liver changes similar to those seen in alcoholic hepatitis in the absence of a history of alcohol abuse
NASH is relatively common and thought to affect around 3-4% of the general population
true
NAFLD associated factors
obesity type 2 diabetes mellitus hyperlipidaemia jejunoileal bypass sudden weight loss/starvation
NAFLD associated with sudden weight gain
false
suddn weight loss
NAFLD bloods
ALT is typically greater than AST
NAFLD US
increased echogenicity
NAFLD sx
usually asymptomatic
hepatomegaly
incidental finding of NAFLD - typically asymptomatic fatty changes on liver ultrasound mx
enhanced liver fibrosis (ELF) blood test to check for advanced fibrosis
enhanced liver fibrosis (ELF) blood test is?
the ELF blood test is a combination of hyaluronic acid + procollagen III + tissue inhibitor of metalloproteinase 1. An algorithm based on these values results in an ELF blood test score, similar to triple testing for Down’s syndrome
Patients who are likely to have advanced fibrosis should be referred to a liver specialist. They will then likely have a
liver biopsy
NAFLD mx
the mainstay of treatment is lifestyle changes (particularly weight loss) and monitoring
there is ongoing research into the role of gastric banding and insulin-sensitising drugs (e.g. metformin, pioglitazone)
scoring system increasingly used, particularly patient’s who are on a liver transplant waiting list
Model for End-Stage Liver Disease (MELD)
Describe MELD
Uses a combination of a patient’s bilirubin, creatinine, and the international normalized ratio (INR) to predict survival. A formula is used to calculate the score:
MELD = 3.78×ln[serum bilirubin (mg/dL)] + 11.2×ln[INR] + 9.57×ln[serum creatinine (mg/dL)] + 6.43
The 3-month mortality based on MELD scores: 40 or more: 71.3% mortality 30 - 39: 52.6% mortality 20 - 29: 19.6% mortality 10 - 19: 6.0% mortality < 9: 1.9% mortality
Child-Pugh classification describe
Bilirubin (µmol/l) <34 34-50 >50 Albumin (g/l) >35 28-35 <28 Prothrombin time, prolonged by (s) <4 4-6 >6 Encephalopathy none mild marked Ascites none mild marked
Score 1-3 for each factor.
Summation of the scores allows the severity to be graded either A, B or C:
< 7 = A
7-9 = B
> 9 = C
Autoimmune hepatitis is condition of unknown aetiology which is most commonly seen in
young females
Autoimmune hepatitis genetic associations
HLA B8, DR3
Three types of autoimmune hepatitis have been characterised according to the types of circulating antibodies present:
Type I: Anti-nuclear antibodies (ANA) and/or anti-smooth muscle antibodies (SMA)
Type II: Anti-liver/kidney microsomal type 1 antibodies (LKM1)
Type III: Soluble liver-kidney antigen
Three types of autoimmune hepatitis have been characterised according to the types of circulating antibodies present - who do these affect
TI - Affects both adults and children
TII - Affects children only
TIII - Affects adults in middle-age
Autoimmune hepatitis - may present with
signs of chronic liver disease
acute hepatitis: fever, jaundice etc (only 25% present in this way)
amenorrhoea (common)
Autoimmune hepatitis BLOODS
ANA/SMA/LKM1 antibodies, raised IgG levels
Autoimmune hepatitis liver biopsy
liver biopsy: inflammation extending beyond limiting plate ‘piecemeal necrosis’, bridging necrosis
Autoimmune hepatitis mx
steroids, other immunosuppressants e.g. azathioprine
liver transplantation
The most common organisms found in pyogenic liver abscesses are ? in children and ? in adults.
The most common organisms found in pyogenic liver abscesses are Staphylococcus aureus in children and Escherichia coli in adults.
Pyogenic liver abscess mx
drainage (typically percutaneous) and antibiotics
amoxicillin + ciprofloxacin + metronidazole
if penicillin allergic: ciprofloxacin + clindamycin
