Liver Disease

Question 1

Pathophysiology of alcoholic AFLD

Answer 1

• 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

Question 2

Risk factors for NAFLD

Answer 2

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

Question 3

What are the differences between ALD and NAFLD?

Answer 3

Question 4

Signs and symptoms of liver disease

Answer 4

• 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)

Question 5

Investigation of liver disease

Answer 5

• 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

Question 6

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

Answer 6

• 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

Question 7

What are the elements of the Glasgow Alcoholic Hepatitis Score?

Answer 7

Question 8

What are the stages of chronic liver disease?

Answer 8

• 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

Question 9

Scoring systems for liver disease

Answer 9

• 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.

Question 10

Ascites

Answer 10

• 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

Question 11

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

Answer 11

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

Question 12

General management of alcoholic liver disease

Answer 12

• 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

Question 13

General management of cirrhosis

Answer 13

• 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

Question 14

Complications of cirrhosis

Answer 14

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

Question 15

Malnutrition

Answer 15

• 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

Question 16

Portal hypertension and varices

Answer 16

• 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

Question 17

Spontaneous bacterial peritonitis

Answer 17

• 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

Question 18

General management of NAFLD

Answer 18

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