Liver disease Flashcards
What are the liver’s main functions?
Largest single organ
Only organ to have 2 blood supplies
Arterial blood – 20% Hepatic artery
Venous blood – 80% Portal vein
Responsible for numerous functions
Storage - glycogen, fat soluble vitamins
Synthesis - proteins - albumin, clotting factors
Immune system – T cell proliferation, acute phase protein production
Clearance and metabolism etc- drugs, cholesterol (via liver enzymes)
What are the tests to identify liver disease?
Large number of tests and questions Tests related to the functions of the liver (to detect malfunction) and questions to identify possible cause Example questions Recent travel? = infections e.g. Hep A Tattoos? = Hep B Blood transfusions? = Hep B, C Alcohol consumption? = chronic disease (cirrhosis) Social History? = IVDA, poor hygiene Medications? = drug induced
Recent travel?
Infections e.g. HepA
Tattoos?
HepB
Blood transfusions?
HepB, C
Alcohol consumption?
Chronic disease - liver cirrhosis
social history?
IVDA - IV drug abuse, poor hygiene
Medications?
Drug induced
LFTs
Tests are fairly non specific
Can have large rises in enzymes with minimal damage
Liver function tests (LFTs)
-Bilirubin (breakdown product of RBC) – conjugated in liver then excreted in bile
-GGT (gamma-glutamyl transferase) – -
-ALT (alanine aminotransferase), AST (aspartate aminotransferase) – transaminase enzymes
-Alkaline phosphatase
-Albumin
-Prothrombin time
When is GGT raised?
Recent alcohol consumption
ALT and AST increase means?
Hepatocyte injury
Alkaline phosphatase q
not specific to liver
Albumin is a sign of?
Liver’s synthetic function
Prothrombin time?
Clotthing factors
LFT results typical for hepatocellular damage
i.e. damage inside the liver
↑ ALT
↑ AST
↑ gamma GT
↑ Total bilirubin (later in presentation)
LFT results typical for Cholestatic picture (blockage of bile dict etc)
↑ Conjugated bilirubin
↑ Alk phos
↑ Total cholesterol
Pruritis common (severe itching of skin)
Acute liver disease
Usually self limiting
Inflammation or damage to liver cell (hepatocyte)
Inflammation of hepatocyte = hepatitis
Classified on duration – not exceeding 6/12
Majority of cases caused by
Drugs (paracetamol most common)
Acute viral hepatitis – A & B (Europe), E (India)
Symptoms of drug-induced liver disease
Wide range of symptoms from
Reversible alteration in LFTs
Fatal acute hepatic necrosis
Types of reaction (drug-induced liver disease)
Type A
Type B
Type A reaction
Type A - predictable reactions Dose dependent Affect most patients who take sufficient amounts of the drug Examples - paracetamol, methotrexate Latent period – hours to weeks
Type B reaction
Type B - unpredictable reactions Less frequent- ~1% of patients Dose independent Latent period of weeks to months Examples - isoniazid, chlorpromazine
Name two types of acute liver disease
- acute hepatitis
- acute liver failure
Describe acute hepatitis
Present with jaundice
Spontaneous recovery is the norm
Supportive therapy
Describe acute liver failure
can be severe, affecting whole liver
can progress to hepatic failure associated with high mortality
Alternatively become chronic liver disease
? Transplantation
how long does chronic Liver Disease go on for?
Liver disease lasting > 6 months
Common causes of Chronic liver disease?
Other causes?
Common causes
Alcohol
Chronic viral hepatitis (Hepatitis C)
Other causes
Primary biliary cirrhosis
Auto-immune hepatitis - can be drug related
Cancer
Signs and symptoms of chronic liver disease
Patient can present with vague unspecific symptoms - -fatigue
- general malaise
- fever
- nausea and vomiting
Abdominal pain - particularly upper right quadrant
Pruritis (itch) - most common in obstructive disease (bile salts)
Jaundice - yellow skin, pale stools, dark urine ( Bilirubin > 50umol/L)
Common signs and symptoms of chronic liver disease
Common
- Spider naevi
- Gynaecomastia
- Splenomegaly
- Oedema
- Finger clubbing
- Liver palms
- Xanthelasmas
What is spider naevi?
a cluster of minute red blood vessels visible under the skin, occurring typically during pregnancy or as a symptom of certain diseases (e.g. cirrhosis or acne rosacea).
Define gynaecomastia
Enlargement of breasts in men
What is splenomegaly?
Abnormal enlargment of the spleen
Define xanthelasma
demarcated yellowish deposit of fat underneath the skin, usually on or around the eyelids. While they are neither harmful nor painful, these minor growths may be disfiguring and can be removed.
End stage symptoms of chronic liver disease
End Stage Ascites Hepatic flap Dilated abdominal blood vessels Neurological changes Oesophageal varices
Define ascites
the accumulation of fluid in the peritoneal cavity, causing abdominal swelling.
What is hepatic flap?
Asterixis (also called the flapping tremor, or liver flap) is a tremor of the hand when the wrist is extended, sometimes said to resemble a bird flapping its wings
Define oesophageal varices
extremely dilated sub-mucosal veins in the lower third of the esophagus.
Medical emergency due to large blood loss
Aim to stop bleeding and replace lost blood
Colloids, packed red cells
Banding, balloon tamponade, sclerotherapy
What is the most common cause of liver disease in the UK?
Alcoholic liver disease
Alcohol excess can lead to what?
Alcohol excess→Steatosis→fibrosis→cirrohosis
Alcohol excess→fibrosis→cirohosis
Alcohol excess→Hepatitis→Cirrohosis
Normal alcohol excess blood changes?
Elevated GGT
Steatosis definition and blood changes
- infiltration of liver cells with fat, associated with disturbance of the metabolism
- Elevated GGT +/- AST
Cirrhosis definition and blood changes
a chronic disease of the liver marked by degeneration of cells, inflammation, and fibrous thickening of tissue.
High PT
low albumin
Hepatitis blood changes
elevated bilirubin
Describe Pruritis
Patient jaundiced Itching – may see scratch marks More severe in cholestasis Common and distressing Possibly due to bile salts in skin Treatment depends on cause Bile stones – surgical or other removal Medical therapy if cause unknown
Define Cholestasis
defined as a decrease in bile flow due to impaired secretion by hepatocytes or to obstruction of bile flow through intra-or extrahepatic bile ducts.
Pruritis treatment if cause is bile stones
surgical or other removal
Pruritis treatment generally
Tx depends on cause
Bile stones – surgical or other removal
Anion exchange resins
Colestyramine sachets (4g od or bd)
Bind bile acids in the gut
Problems with fat soluble vitamins e.g. Vit K
Antihistamines
Sedating = care needed may be useful nocte
Non sedating = better e.g. Desloratidine 5mg OD
Topical – Calamine, Menthol 2% in aqueous cream
Others e.g. naltrexone, IV ondansetron, rifampicin, urseodeoxycholic acid
Ascites cause
Cause mainly unknown but
Portal hypertension
Activation of Renin Angiotensin System
Decreased oncotic pressure – low albumin
Ascites treatment
Spironolactone => 100–600mg OD (aldosterone antagonist) Furosemide => 40-160mg OD Metolazone in unresponsive cases (care) Aim to lose ~ 0.5 - 1kg body weight/day Others Low sodium diet
Analgesics for ascites
Analgesics for ascitic pain
Paracetamol - caution (max 2g a day)
Tramadol usually okay
NSAIDs / Antiplatelets = risk of bleeding
Opioids = decreased clearance. Extra care needed may cause respiratory depression
Ascities loss aim
0.5-1kg body weight daily
low sodium diet may help
features of hepatic encephalopathy
What is it?
the occurrence of confusion, altered level of consciousness, and coma as a result of liver failure.
Altered mental state
Asterixis (liver flap)
Fetor hepaticus (sweet, pungent breath)
Cause of hepatic encephalopathy
Thought to be caused by
Accumulation of nitrogenous and other toxins
Worsened by GI bleeds, constipation, sedative use (opiates), high protein diet
Treatment of hepatic encephalopathy
Low protein diet
Lactulose – 20-30ml tds po/pr, enough for 2-3 movements/day
Neomycin – 2-4g/ day (peripheral neuropathy)
Rifaxamin- 400mg tds/bd (good evidence) (antibiotic)
Metronidazole – 400-800mg in divided doses
Enemas if can’t swallow
Oesophageal varices drug treatment
Pharmacological – constrict blood flow
Terlipressin IV= 1-2mg bolus, then 4-6 hourly
Octreotide = 50mcg/hour for 48hrs or more
Somatostatin or Vasopressin (2nd line)
Treatment of portal hypertension- propranolol 40mg bd or tds/ carvedilol 6.25mg
Alcohol withdrawal vitamin replacement
Chlordiazepoxide reducing regimen +PRN
Vitamin B co strong + thiamine (vitB1) orally – prevent Wernicke’s encephalopathy (thiamine deficiency)
Can use IV Pabrinex if NBM – care needed in administration
Vitamin K deficiency - use water soluble prep- menandiol 10mg od
Treatment of Hepatitis A
Vaccine?
Hepatitis A – treatment supportive, no therapy to eradicate
Vaccination recommended for travellers
Treatment of hepatitis B
Hepatitis B – Chronic infection tx with
Entecavirortenofovir (antivirals) with
Interferon alfa 2a (boosts immune function)
Vaccination recommended for healthcare workers
Hepatitis C
Treatment
Hepatitis C – world wide health problem
Can lead to chronic hepatitis and cirrhosis and cancer
Tx includes
Ribavirin combined with Interferon alfa 2b
In both chronic hep B & C, pegylated interferon alfa 2b preferred. Less frequent administration due to longer half-life
NICE guidance for Hep B & C treatments
Hepatitis D
Hepatitis D – need Hep B to cause infection
No specific Tx
Hepatitis E
Hepatitis E – self limiting infection that doesn’t cause chronic liver disease
Role of pharmacist in Liver disease
Ensure regular monitoring of LFTs
Counsel patients on side effects of treatments
Being aware of drugs commonly implicated in liver disease (inc herbal)
Taking full drug history in suspected cases
Advise on supportive therapy and ensure appropriately prescribed
