Liver disease

Question 1

What are the common causes of liver cirrhosis?

Answer 1

• Alcohol-related liver disease
• Non-alcoholic fatty liver disease (NAFLD)
• Hep B
• Hep C

Question 2

What are the signs of liver cirrhosis?

Answer 2

• Cachexia
• Jaundice
• Hepatomegaly
• Small nodular liver
• Splenomegaly due to portal hypertension
• Spider naevi
• Palmar erythema (increased oestrogen)
• Gynaecomastia and testicular atrophy
• Bruising, excoriations, ascites
• Caput medusae - portal hypertension
• Leukonychia - hypoalbuminaemia
• Asterixis

Question 3

What is included in a liver screen?

Answer 3

• USS liver (fatty liver)
• Hep B and C serology
• Autoantibodies - autoimmune hepatitis, PBC, PSC (ANA, SMA, AMA, LKM-1)
• Immunoglobulins (autoimmune hepatitis and PBC)
• Ceruloplasmin (Wilson’s disease)
• Alpha-1-antitrypsin levels
• Ferritin and transferrin saturation (hereditary haemochromatosis.

Question 4

What will blood tests show in decompensated cirrhosis?

Answer 4

• Normal in cirrhosis
• Decompensated cirrhosis - raised bilirubin, ALT, AST, ALP
• Low albumin
• Increased PTT
• Thrombocytopenia
• Hyponatraemia - fluid retention in severe liver disease
• Alpha-fetoprotein is a tumour marker for hepatocellular carcinoma

Question 5

What investigations are used in liver disease?

Answer 5

• Transient elastography for those at risk of cirrhosis, determines degree of fibrosis
• Endoscopy - assess and treat oesophageal varcies
• CT and MRI for hepatocellular carcinoma, hepatosplenomegaly, abnormal blood vessel changes and ascites
• Liver biopsy to confirm cirrhosis

Question 6

What scores are used in liver cirrhosis?

Answer 6

• MELD score every 6 months for compensated cirrhosis - estimates if they require dialysis and 3 month mortality as %.
• Child-Pugh score - severity of cirrhosis and prognosis (A-E pneumonic)

Question 7

What are the principles of management for liver cirrhosis?

Answer 7

• Treat underlying cause e.g. stop alcohol, antiviral drugs for hepC
• Monitor for complications - MELD score, USS and alpha fetoprotein for hepatocellular carcinoma, endoscopy every 3yrs
• Managing complications
• Liver transplant

Question 8

When is liver transplantation considered?

Answer 8

When there are features of decompensated liver disease (AHOY)
- Ascites
- Hepatic encephalopathy
- Oesophageal varices bleeding
- Yellow (jaundice)

Question 9

What are the complications of liver cirrhosis?

Answer 9

• Malnutrition and muscle wasting
• Portal hypertension, oesophageal varices and bleeding varices
• Ascites and spontaneous bacterial peritonitis
• Hepatorenal syndrome
• Hepatic encephalopathy
• Hepatocellular carcinoma

Question 10

How do you manage stable oesophageal varices?

Answer 10

Prophylaxis of bleeding in stable oesophageal varices:
- Non-selective beta blockers e.g. propanolol
- Variceal band ligation (if beta blockers contraindicated)

Question 11

How do you manage bleeding oesophageal varices?

Answer 11

• Senior help
• Consider blood transfusion - activate major haemorrhage protocol
• Treat any coagulopathy e.g. with FFP
• Vasopressin analogues e.g. terlipressin or somatostatin, cause vasoconstriction and slow bleeding
• Prophylactic broad-spectrum abx
• Urgent endoscopy with variceal band ligation
• Consider intubation and intensive care
• Sengstaken-Blakemore tube or TIPS

Question 12

What is the management for ascites?

Answer 12

• Low sodium diet
• Aldosterone antagonists e.g. spironolactone
• Paracentesis (ascitic tap or ascitic drain)
• Prophylactic abx (ciprofloxacin or norfloxacin) when there is <15g/l of protein in ascitic fluid
• TIPS in refractory ascites
• Liver transplant in refractory ascites

Question 13

What are the symptoms of spontaneous bacterial peritonitis?

Answer 13

• Can be asymptomatic
• Fever
• Abdominal pain
• Deranged bloods raised WBC, CRP, creatinine or metabolic acidosis)
• Ileus (reduced movement in intestines)
• Hypotension
• Most common is E.coli or Klebsiella pneumoniae

Question 14

What is hepatic encephalopathy?

Answer 14

• Build-up of neurotoxic substances that affect the brain e.g. ammonia
• Presents with reduced consciousness and confusion acutely
• Chronically can cause changes to personality, mood and memory

Question 15

What is the management for hepatic encephalopathy?

Answer 15

• Lactulose (aiming for 2-3 soft stools daily) - can reduce ammonia
• Abx e.g. rifaximin to reduce the number of intestinal bacteria producing ammonia
• Nutritional support (potentially NG tube)