Liver Disease Flashcards
What is chronic hepatitis?
Liver inflammation persisting >6 months
What is acute hepatits?
Acute inflammation of the liver. Can progress to fulminant hepatitis or chronic hepatitis.
What are the signs and symptoms of acute hepatitis?
- Unwell, Jaundice, RUQ pain
- Severe –> confusion (encephalopathy), bruising (coagulopathy)
Where do bloods test show in Acute Hep? (4)
Raised ALT/AST (ALT >1000), raised bilirubin, elongated coagulopathy, renal impairment
What are the symptoms of chronic hep? (3)
Often none, fatigue, possible RUQ
How does chronic hep present? (2)
Liver screening (Abnormal LFTs), cirrhosis
What is fulminant hepatitis?
- Acute hepatitis with liver failure
- The development of encephalopathy within 28 days of jaundice
- Poor prognosis - often needs transplantation
What is cirrhosis?
Fibrosis of the liver and nodular formation. initially, patient can compensate but eventually, patient decompensates leading to Loss of Function and symptoms.
What are loss of function signs? (5)
- Jaundice
- Coagulopathy
- Decreased drug metabolism - watch out benzodiazepines and opiates
- Decreased hormone metabolism - increased oestrogen (signs - spider naevi, palmar erythema, gynaecomastia, loss of secondary body hair, genitalia shrink)
- Increased sepsis risk
What are the variceal sites? (4)
oesophageal varices, rectal varices (piles), varices around umbilicus (Caput medusa), retro-peritoneal varices
What are the signs of portal hypertension? (4)
Varices, ascites, renal failure, encephalopathy
What is the treatment of portal hypertension?
Beta-blockers and shunts
How is Hepatitis A spread?
Faeco-oral
What is Hep A serology? (4)
Hep A IgM - acute infection
Hep A IgG - previous infection
HAV in stool - 1 week post-infection
ALT - acute increase with peak at weak 4
How is hep B spread? (3)
Blood (IVDU, medical), sex, vertical (mother to child)
What are serological markers of an acute Hep B infection? (2)
Anti-HBc IgM - first marker to test for as early rise. Suggests acute infection if raised.
HBsAg (surface antigen) - rises early. Disappears after 24 weeks. +ve means chronic/acute. If core IgM negative and well, then chronic
What is the serology in chronic Hep B? (3)
Persistent HbsAg (Hep B surface antigen), Anti-HBc IgG +ve
HbeAg +ve - immuno-tolerant so high viral loads –> INFECTIOUS
Anti-Hbe +ve - immunoreactive so low viral levels –> less infectious. ALT RAISED.
What is the treatment for chronic Hep B? (2)
Antiviral (entecavir/tenofovir) - life-long
Interferon - 48 week course
How is Hep C transmitted?
Blood, medical, IVDU, sex, vertical
What are tests for Hep c?
Hep C IgG antibodies - +ve means exposure
Hep C RNA -
-ve - exposed but not cleared,
+ve - chronic
How is Hep E transmitted?
Faeco-oral
What are the tests for Hep E?
IgG and IgM
What is delirium tremens?
An acute confusional state which results when someone who drinks excess alcohol daily, suddenly stops drinking. Untreated it results in seizures and even death.
What is the treatment for acute alcohol withdrawal?
Benzodiazepine/carbmazepine
What is treatment for delirium tremens and alcohol withdrawal seizures?
oral lorzepam
What is the cause of wernicke’s encephalopathy?
Organic brain disorder results from damage to the mamillary bodies, dorsomedial nuclei of the thalamus and adjacent areas of periventricular grey matter caused by a deficiency of thiamine (vitamin B1).
What are symptoms of Wernicke’s Encephalopathy?
nystagmus, ophthalmoplegia, ataxia and confusion
What are the symptoms of Korsakoff’s Syndrome?
Severe short-term memory deficits and confabulation
What are the three presentations of Alcoholic liver disease (ALD)?
Alcoholic Fatty Liver Disease (AFLD), alcoholic hepatitis and alcoholic cirrhosis
How does AFLD present?
Elevated transaminases in absence of hepatomegaly. Steatosis usually disappears after 3 months of abstinence.
How does alcoholic hepatitis present?
jaundice and hepatomegaly; complications of portal hypertension may also be present.
How does alcoholic cirrhosis present?
Variceal haemorrhage or ascites
What are the investigations of ALD? (4)
Macroytosis (raised MCV), raised Gamma-GT, jaundice, liver biopsy
What is the test for prognosis of alcoholic hepatitis?
Maddrey score/discriminant function - uses PT and bilirubin
How is ALD managed?
cessation of alcohol consumption, nutrition (via NG tube), corticosteroids (severe hepatitis, DF >32), pentoxifylline (severe), liver transplantation
How is cirrhosis managed?
Treatment of the underlying cause, maintenance of nutrition, treatment of complications
Endoscopy - every 2 years, looking for oesophageal varices
Regular surveillance for hepatocellular carcinoma
Liver transplant
What is ascites?
It is accumulation of free fluid in the peritoneal cavity.
What are the causes ascites? (5)
Splachnic vasodilation, activation of RAAS, portal hypertension, salt and water retention, reduced albumin
How is ascites investigated? (3)
Ultrasonography, paracentesis to obtain fluid, CXR - pleural effusions!
What is the serum serum-ascites albumin gradient (SAAG) and how is it calculated ?
o Measurement of the protein concentration and the serum-ascites albumin gradient (SAAG) are used to distinguish a transudate from an exudate.
Calculate the SAAG by subtracting the concentration of the ascites fluid albumin from the serum albumin.
What is transudative ascites?
SAAG >11g/L (T is later in alphabet, so greater gradient)
Causes include portal hypertension, venous outflow obstruction
What investigations can be carried out on the ascitic fluid?
Total albumin (+ serum) and protein, amylase, neutrophil count, cytology, microscopy and culture
What does the colour of ascitic fluid tell you?
Clear, straw-coloured, light green - cirrhosis Bloody - malignant cloudy - infection bile stained - biliary communication Milky-white - lymphatic obstruction
What is exudative ascites
SAAG <11g/L
Possible the possibility of infection (especially tuberculosis), malignancy, hepatic venous obstruction, pancreatic ascites or, rarely, hypothyroidism.
What does a raised ascites amylase show?
pancreatic ascites
What does low ascitic glucose concentration suggest?
TB or malignant disease
What does cytological exam reveal?
Malignant cells
What do raised Polymorphonuclear leucocyte counts above indicate?
Infection - SBP
How is ascites managed? (4)
Sodium and water restriction, diuretics (spironolactone/amiloride)
Paracentesis - refractory ascites
transjugular intrahepatic portosystemic stent shunt (TIPSS)
peritonea-venous shunt
What are poor prognostic indicators in cirrhosis (5)?
Encephalopathy, ascites, raised bilirubin, prolonged PT time, reduced albumin
What is the child-pugh scoring system?
assess the prognosis of chronic liver disease, mainly cirrhosis.
What is MELD scoring system?
model for end-stage liver disease. Renal function, INR, bilirubin. Prognostic of survival in next couple of months
What is Madley’s scoring system?
A measure of alcoholic hepatitis
What do blood tests show in auto-immune hepatitis (5)?
Raised ALT, raised IgG and +ve ANA (anti-nuclear antibody), anti SMA, anti LKM1.
What is Wilson’s disease?
Copper overload syndrome
How does Wilson’s present?
advance liver disease – cirrhosis
What vaccinations should be offered to patients with chronic hepatitis?
Should be offered both the annual influenza vaccine and the pneumococcal vaccine, which is given one a one-off basis.
What is the main risk factor for developing hepatocellular carcinoma?
liver cirrhosis, for example secondary to e.g. hepatitis B & C, alcohol
