Liver Disease Flashcards

1
Q

Pathophysiology of alcoholic AFLD

A
  • Stepwise process
    • Alcohol related fatty liver - build-up of fat that reverses in around 2 weeks if drinking ceases
    • Alcoholic hepatitis - long-term drinking leads to liver inflammation, may reverse with permanent abstinence
    • Cirhosis - liver is made of scar tissue, irreversible
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2
Q

Risk factors for NAFLD

A
  • Risk factors
    • Obesity
    • Poor diet and low activity levels
    • T2DM
    • High cholesterol
    • Middle age onwards
    • Smoking
    • High BP
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3
Q

What are the differences between ALD and NAFLD?

A
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4
Q

Signs and symptoms of liver disease

A
  • Jaundice
  • Hepatomegaly
  • Spider naevi
  • Palmer erythema
  • Gynaecomastia
  • Bruising - due to abnormal clotting
  • Ascites
  • Caput medusae - engorger superficial epigastric veins
  • Asterixis - flapping tremor
  • Fetor
  • ‘Synthetic dysfunction’ (prolonged PT, hypoalbuminaemia)
  • Portal hypertension (caput medusa, hypersplenism, thrombocytopenia)
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5
Q

Investigation of liver disease

A
  • Bloods - FBC (raised MCV), LFTs (raised ALT/AST, raised GGT) and clotting (elevated PTT and reduced synthetic function)
  • US
  • Fibroscan - check the elasticity of the liver
  • Endoscopy
  • CT and MRI scans
  • Liver biopsy
  • Enhanced liver fibrosis (ELF) blood test
    • < 7.7 indicates none to mild fibrosis
    • ≥ 7.7 to 9.8 indicates moderate fibrosis
    • ≥ 9.8 indicates severe fibrosis
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6
Q

What are the features are usually seen on investigation of alcoholic hepatitis?

A
  • Recent excess alcohol
  • Bilirubin >80µmol/l
  • Exclusion of other liver disease
  • AST <500 (AST:ALT ratio >1.5)
  • May show hepatomegaly +/- fever +/- leucocytosis +/- hepatic bruit
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7
Q

What are the elements of the Glasgow Alcoholic Hepatitis Score?

A
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8
Q

What are the stages of chronic liver disease?

A
  • Liver disease
    • 0) No fibrosis
    • 1) Portal fibrosis
    • 2) Portal fibrosis with septa
    • 3) Bridging fibrosis (focal, diffuse or marked)
    • 4) Cirrhosis
  • NAFLD
    • NAFLD
    • NASH
    • Fibrosis
    • Cirrhosis
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9
Q

Scoring systems for liver disease

A
  • Childs-Pugh score for cirrhosis
  • MELD Score 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.
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10
Q

Ascites

A
  • Increased pressure in the portal system causes fluid to lead out of the capillaries in the liver and bowel and into the peritoneal cavity - drop in circulating volume lowers BP and so supply to the kidneys activating the RAAS
  • Ascitic tap interpretation:
    • Cell count >500WBC/cm3 and >250 neutrophils/cm3 suggest SBP
    • SAAG/serum albumin minus ascetic albumin >11g/l = portal hypertension
  • Management involves:
    • Low sodium diet
    • Anti-aldosterone diuretics (i.e. spironolactone)
    • Paracentesis (ascitic tap/drain)
    • Prophylactic antibiotics against SBP (i.e. ciprofloxacin)
    • Consider TIPS or transplantation in refractory ascites
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11
Q

What scoring system is used to grade mental state in hepatic encephalopathy?

A
  • Conn score (West Haven Classification)
    • 0) No abnormality
    • 1) Lack of awareness
    • 2) Disorientation
    • 3) Confusion/stupor
    • 4) Coma
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12
Q

General management of alcoholic liver disease

A
  • Stop drinking alcohol permanently
  • Consider a detoxication regime
  • Nutritional support with vitamins (particularly thiamine) and a high protein diet
  • Steroids improve short term outcomes (over 1 month) in severe alcoholic hepatitis but infection and GI bleeding need to be treated first and do not improve outcomes over the long term
  • Treat complications of cirrhosis (portal hypertension, varices, ascites and hepatic encephalopathy)
  • Referral for liver transplant in severe disease however they must abstain from alcohol for 3 months prior to referral
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13
Q

General management of cirrhosis

A
  • Ultrasound and alpha-fetoprotein every 6 months for hepatocellular carcinoma
  • Endoscopy every 3 years in patients without known varices
  • High protein, low sodium diet
  • MELD score every 6 months
  • Consideration of a liver transplant
  • Managing complications
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14
Q

Complications of cirrhosis

A
  • Malnutrition
  • Portal Hypertension, Varices and Variceal Bleeding
  • Ascites and Spontaneous Bacterial Peritonitis (SBP)
  • Hepato-renal Syndrome
  • Hepatic Encephalopathy
  • Hepatocellular Carcinoma
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15
Q

Malnutrition

A
  • Cirrhosis affects the metabolism of proteins in the liver and reduces the amount of proteins produced
  • Cirrhosis also disrupts the livers ability to sotre glucose as glycogen and release it when required
  • Management:
    • Regular meals every 2-3 hours
    • Low sodium (minimise fluid retention)
    • High protein and high calorie diet
    • Avoid alcohol
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16
Q

Portal hypertension and varices

A
  • Portal vein comes from the superior mesenteric vein and the splenic vein and delivers blood to the liver
  • Liver cirrhosis increases the resistance of blood flow in the liver and so there is increased back-pressure into the portal system
  • This causes the vessels at sites where the portal system anastamoses with the systemic venous system to become swollen and tortuous called varices:
    • Gastro-oesophageal junction
    • Ileocaecal junction
    • Rectum
    • Anterior abdominal wall via the umbilical vein (caput medusae)
  • No issue until they start bleeding - very high blood flow
17
Q

Spontaneous bacterial peritonitis

A
  • Most common organisms:
    • E. coli
    • Klebsiella pneumoniae
    • Gram positive cocci (i.e. staphylococcs, enterococcus)
  • Management
    • Ascitic culture prior to antibiotics
    • IV cephalosporin such as cefotaxime
18
Q

General management of NAFLD

A
  • Weight loss
  • Exercise
  • Stop smoking
  • Control of DM, BP and cholesterol
  • Avoid alcohol