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Pharmacy Year 2 Semester 2 > Liver disease > Flashcards

Liver disease Flashcards

1
Q

What are the liver’s main functions?

A

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)

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2
Q

What are the tests to identify liver disease?

A 
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
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3
Q

Recent travel?

A

Infections e.g. HepA

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4
Q

Tattoos?

A

HepB

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5
Q

Blood transfusions?

A

HepB, C

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6
Q

Alcohol consumption?

A

Chronic disease - liver cirrhosis

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7
Q

social history?

A

IVDA - IV drug abuse, poor hygiene

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8
Q

Medications?

A

Drug induced

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9
Q

LFTs

A

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

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10
Q

When is GGT raised?

A

Recent alcohol consumption

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11
Q

ALT and AST increase means?

A

Hepatocyte injury

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12
Q

Alkaline phosphatase q

A

not specific to liver

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13
Q

Albumin is a sign of?

A

Liver’s synthetic function

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14
Q

Prothrombin time?

A

Clotthing factors

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15
Q

LFT results typical for hepatocellular damage

i.e. damage inside the liver

A

↑ ALT
↑ AST
↑ gamma GT
↑ Total bilirubin (later in presentation)

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16
Q

LFT results typical for Cholestatic picture (blockage of bile dict etc)

A

↑ Conjugated bilirubin
↑ Alk phos
↑ Total cholesterol
Pruritis common (severe itching of skin)

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17
Q

Acute liver disease

A

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)

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18
Q

Symptoms of drug-induced liver disease

A

Wide range of symptoms from
Reversible alteration in LFTs
Fatal acute hepatic necrosis

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19
Q

Types of reaction (drug-induced liver disease)

A

Type A

Type B

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20
Q

Type A reaction

A 
Type A - predictable reactions
Dose dependent
Affect most patients who take sufficient amounts of the drug
Examples - paracetamol, methotrexate
Latent period – hours to weeks
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21
Q

Type B reaction

A 
Type B - unpredictable reactions
Less frequent- ~1% of patients
Dose independent
Latent period of weeks to months
Examples - isoniazid, chlorpromazine
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22
Q

Name two types of acute liver disease

A
  • acute hepatitis

- acute liver failure

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23
Q

Describe acute hepatitis

A

Present with jaundice
Spontaneous recovery is the norm
Supportive therapy

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24
Q

Describe acute liver failure

A

can be severe, affecting whole liver
can progress to hepatic failure associated with high mortality
Alternatively become chronic liver disease
? Transplantation

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25
Q

how long does chronic Liver Disease go on for?

A

Liver disease lasting > 6 months

26
Q

Common causes of Chronic liver disease?

Other causes?

A

Common causes
Alcohol
Chronic viral hepatitis (Hepatitis C)

Other causes
Primary biliary cirrhosis
Auto-immune hepatitis - can be drug related
Cancer

27
Q

Signs and symptoms of chronic liver disease

A

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)

28
Q

Common signs and symptoms of chronic liver disease

A

Common

  • Spider naevi
  • Gynaecomastia
  • Splenomegaly
  • Oedema
  • Finger clubbing
  • Liver palms
  • Xanthelasmas
29
Q

What is spider naevi?

A

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).

30
Q

Define gynaecomastia

A

Enlargement of breasts in men

31
Q

What is splenomegaly?

A

Abnormal enlargment of the spleen

32
Q

Define xanthelasma

A

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.

33
Q

End stage symptoms of chronic liver disease

A 
End Stage
Ascites 
Hepatic flap
Dilated abdominal blood vessels
Neurological changes
Oesophageal varices
34
Q

Define ascites

A

the accumulation of fluid in the peritoneal cavity, causing abdominal swelling.

35
Q

What is hepatic flap?

A

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

36
Q

Define oesophageal varices

A

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

37
Q

What is the most common cause of liver disease in the UK?

A

Alcoholic liver disease

38
Q

Alcohol excess can lead to what?

A

Alcohol excess→Steatosis→fibrosis→cirrohosis
Alcohol excess→fibrosis→cirohosis
Alcohol excess→Hepatitis→Cirrohosis

39
Q

Normal alcohol excess blood changes?

A

Elevated GGT

40
Q

Steatosis definition and blood changes

A
  • infiltration of liver cells with fat, associated with disturbance of the metabolism
  • Elevated GGT +/- AST
41
Q

Cirrhosis definition and blood changes

A

a chronic disease of the liver marked by degeneration of cells, inflammation, and fibrous thickening of tissue.
High PT
low albumin

42
Q

Hepatitis blood changes

A

elevated bilirubin

43
Q

Describe Pruritis

A 
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
44
Q

Define Cholestasis

A

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.

45
Q

Pruritis treatment if cause is bile stones

A

surgical or other removal

46
Q

Pruritis treatment generally

A

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

47
Q

Ascites cause

A

Cause mainly unknown but
Portal hypertension
Activation of Renin Angiotensin System
Decreased oncotic pressure – low albumin

48
Q

Ascites treatment

A 
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
49
Q

Analgesics for ascites

A

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

50
Q

Ascities loss aim

A

0.5-1kg body weight daily

low sodium diet may help

51
Q

features of hepatic encephalopathy

What is it?

A

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)

52
Q

Cause of hepatic encephalopathy

A

Thought to be caused by
Accumulation of nitrogenous and other toxins
Worsened by GI bleeds, constipation, sedative use (opiates), high protein diet

53
Q

Treatment of hepatic encephalopathy

A

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

54
Q

Oesophageal varices drug treatment

A

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

55
Q

Alcohol withdrawal vitamin replacement

A

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

56
Q

Treatment of Hepatitis A

Vaccine?

A

Hepatitis A – treatment supportive, no therapy to eradicate

Vaccination recommended for travellers

57
Q

Treatment of hepatitis B

A

Hepatitis B – Chronic infection tx with
Entecavirortenofovir (antivirals) with
Interferon alfa 2a (boosts immune function)
Vaccination recommended for healthcare workers

58
Q

Hepatitis C

Treatment

A

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

59
Q

Hepatitis D

A

Hepatitis D – need Hep B to cause infection

No specific Tx

60
Q

Hepatitis E

A

Hepatitis E – self limiting infection that doesn’t cause chronic liver disease

61
Q

Role of pharmacist in Liver disease

A

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

Pharmacy Year 2 Semester 2 (33 decks)

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