Liver Disease Flashcards
What is haemochromatosis?
excessive iron absorption- treat by venesection
What is haemosiderosis?
an iron overload disorder resulting from transfusion
What is Wilson’s Disease?
Copper accumulation
What are the causes of hepatic injury?
accumulation of toxins infection immune mediated bile retention amyloid sarcoidosis diabetes
What is cirrhosis of the liver?
nodules of hepatocytes separated by bands of fibrous tissue
Explain the development of chronic liver injury
injury–>fibrous expansion–>bridging (fibrotic areas start to join)–>cirrhosis–>liver failure–>death/cancer–>death/transplant
What are the features of decompensated cirrhosis?
Jaundice (pre-hepatic, intra-hepatic and post-hepatic) Ascites Encephalopathy Palmar erythema Spider naevi Caput medusa Gynaecomastia GI bleeding Sepsis
What is steatosis?
Fatty liver disease
Explain the progression from steatosis to liver cancer
steatosis–>fatty hepatitis–>fibrosis–>cirrhosis (irreversible)–>liver cancer
What are some causes of fatty liver disease (steatosis)?
Alcohol
Obesity
Hep C
T2DM
What are the complications of liver cirrhosis?
Liver failure- poor exchange between hepatocytes and blood (decreased plasma protein conc reduces oncotic pressure leading to ascites)
Portal hypertension- from the increase vascular resistance
Nodule formation leading to hepatocellular carcinoma (liver cancer)
Explain the role of albumin
Albumin in produced by the liver so in liver disease it is reduced. it transports fatty acts and is important in maintaining oncotic pressure
What are the biomarkers for liver damage?
decreased clotting and platelets increased ammonia and amino acids decreased albumin increased bilirubin-->jaundice hypoglycaemia due to decreased gluconeogenesis increased ALT, AST and ALP
What are the causes of liver failure?
Viral infections e.g. Hep B, C, CMV, yellow fever, leptospirosis Paracetamol OD Alcohol fatty liver disease primary biliary cholangitis primary sclerosing cholangitis hamochromatosis autoimmune hepatitis wilsons disease alpha 1 antitrypsin deficiency
What would you expect in liver failure?
coagulopathy (INR>1.5)
Encephalopathy
jaundice
asterixis/flap
What tests would you order if you suspected liver failure?
Bloods- FBCs, U&Es, LFTs, Clotting (increase PT/INR), glucose, paracetamol levels, ferritin, alpha 1 antitrypsin Blood culture, urine culture Ascitic tap- are there neutrophils CXR abdo US EEG
Explain the management of liver failure
ABCDE monitor bloods and abs 10% glucose IV 1L/12hrs- to avoid hypoglycaemia treat cause if known treat malnutrition treat seizures with phenytoin about drugs metabolised by the liver liaise with transplant team
What are the signs of liver cirrhosis?
leuconychia, dupytrens contracture, clubbing, spidernaevi, xanthelasma, gynaecomastia, loss of body hair, hepatomegaly, ascites, splenomegaly, atrophic testes
How would you manage liver cirrhosis?
Stop drinking alcohol
avoid NSAIDs, sedatives and opiates
if ascites- fluid restriction, spironolactone (100mg/24hr)- can add furosemide if needed
Liver transplant
what marker in the blood can be used to monitor hepatocellular carcinoma recurrence?
AFP
What is SAAG used for?
used to determine if ascites is due to portal HTN or not.(if raised, the ascites is caused by portal HTN.
does budd chiari cause portal hypertension?
Yes
does liver cirrhosis cause portal hypertension?
Yes
What is the most common cause of acute liver failure in the UK?
paracetamol OD
What is the most common cause of liver failure worldwide?
Viral hepatitis
what are some clinical features of liver failure?
ascites, hepatomegaly, infections (decreased immunoglobulins), hepatic encephalopathy, jaundice, hypoglycaemia, bruising and haemorrhage, fetor hepaticus
why is it important to check U+Es in liver failure?
to assess for the presence of hepatorenal syndrome
why do you give lactulose in liver failure?
to minimise nitrogenous substance absorption by the gastrointestinal tract.
what drugs can you give in liver failure if encephalopathy is present?
lactulose
rifaximin (abx)
list 5 hepatotoxic drugs
methotrexate, paracetamol, isoniazid, tetracyclines, salicylates
what are some prognostic factors in liver failure?
grade 3/4 hepatic encephalopathy age >40 albumin <30g/L increased INR drug induced liver failure
it is 8 hrs after a patient has taken a large paracetamol OD what is the most appropriate management?
Start NAC
it has been 4-6hrs since a patient has taken a large paracetamol OD- what is the appropriate management?
Take bloods ASAP- paracetamol level, U and Es, LFTs, INR and PT, BM, ABG
a patient presents within 1hr of taking a large paracetamol overdose what is the most appropriate management?
give activated charcoal
a patient presents within 1hr of taking a <75mg/kg paracetamol overdose what is the most appropriate management?
delay bloods until 4hrs after ingestion
a patient presents within 8hr of taking a <75mg/kg paracetamol overdose what is the most appropriate management?
Do bloods ASAP- paracetamol level, U and Es, LFTs, INR and PT, BM, ABG
what are some complications of liver cirrhosis?
compensated liver failure–>ascites, coagulopathy etc
portal HTN–>splenomegaly, ascites, varices, encephalopathy
Spontaneous bacterial peritonitis
increased risk of HCC
hepatorenal syndrome
What specific treatment would you give in hep C virus liver cirrhosis?
interferon alpha
What specific treatment would you give in primary biliary cirrhosis liver cirrhosis?
ursodeoxycholic acid
What specific treatment would you give in wilson’s disease liver cirrhosis?
Penicillamine
how should patients with liver cirrhosis be followed up?
regularly with imaging and AFP testing- due to high risk of HCC
what grading tool do you use in liver cirrhosis?
Child-Pugh Grading- it predicts the risk of bleeding, mortality and the need for treatment
A- albumin
B- Bilirubin
C- clotting
D- distension ascites
E- encephalopathy
a score >8 indicates a significant bleeding risk
What is hepatorenal syndrome?
renal failure in a patient with chronic liver disease
what is the underfill theory of how chronic liver failure leads to hepatorenal syndrome?
cirrhosis causes splanchnic arterial vasodilation leading to RAAS activation and renal artery vasoconstriction. persistence underselling of the renal circulation leads to renal failure
how would you manage hepatorenal syndrome?
colloids and vasopressor analogues
IV albumin+Splanchnic vasoconstriction (terlipressin)
haemodyalysis (if severe metabolic acidosis and hyperkalaemia)
liver transplant is treatment of choice
What is the most common cause of portal HTN in the UK?
Cirrhosis
what is the most common cause of portal HTN worldwide?
Schistosomiasis
What are some possible presentations of portal HTN?
oesophageal varices
anorectal varices
Caput medusae
why do you get encephalopathy in hepatic problems?
the liver’s metabolic function is impaired therefore toxins from the liver are diverted into the systemic circulation. ammonia accumulates and passes into the brain. as a result glutamate is converted to glutamine which when it increases causes an osmotic imbalance and cerebral oedema
what features make up hepatic encephalopathy?
asterixis, ataxia, confusion, instructional apraxia and seizures
how do you manage hepatic encephalopathy?
nurse with head at 20 degrees
lactulose +/- phosphate enema to remove nitrogen forming bacteria from the bowel
consider rifaximin
correct any precipitants
what is a useful investigation in hepatic encephalopathy?
plasma NH4 levels
what is the mechanism of ascites formation?
activation of RAAS (increased renin release and therefore salt and water retention), increased vascular resistance due to portal HTN and decreased albumin leading to less oncotic pressure
what are the conservative management options for ascites?
bed rest which reduced RAAS activation
daily wt aiming for <0.5kg/day reduction
fluid restriction <1.5L/d and a low sodium diet
what are some medical management options for ascites?
Spironolactone (1st line)
Frusomide (if poor response)
therapeutic paracentesis with albumin infusion (give 100ml of 20% albumin per litre drained)- the colloid maintains intravascular volume
what are the surgical management options for ascites?
refractory ascites: TIPSS- producing a shunt with the liver from portal vein to hepatic vein.
consider for liver transplant.
what are 3 complications of ascites?
Intractable ascites (ie ascites that doesn’t respond to retractable diuretic use)
Spontaneous bacterial peritonitis (SBP) (treat with Tazocin or cefotaxime until sensitivities known)
Splenomegaly due to splenic congestion
what is Wernickes encephalopathy?
neuropsychiatric disorder caused by thiamine deficiency which is most commonly seen in alcoholics.
what are the features of wernicke’s encephalopathy?
Features nystagmus (the most common ocular sign) ophthalmoplegia ataxia confusion, altered GCS peripheral sensory neuropathy
how do you treat wernicke’s encephalopathy?
urgent thiamine replacement
what would happen if wernicke’s encephalopathy is not treated?
If not treated Korsakoff’s syndrome may develop as well. This is termed Wernicke-Korsakoff syndrome and is characterised by the addition of antero- and retrograde amnesia and confabulation in addition to the above symptoms.
what is the management of alcohol withdrawal?
chlordiazepoxide (a BDZ) helps with the withdrawal symptoms
pabrinex (replace thiamine)
describe the mechanism behind alcohol withdrawal
Mechanism
chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors
alcohol withdrawal is thought to be lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission)
how does alcoholic hepatitis present?
anorexia Diarrhoea and vomiting tender hepatomegaly ascites if severe: jaundice, bleeding, encephalopathy
what is the maangement of alcoholic hepatitis?
stop drinking alcohol treat withdrawal (chlordiazepoxide) give pabrinex optimise nutrition daily wt, LFTs, U+Es and INR manage and complications of liver failure
what score predicts mortality in alcoholic hepatitis?
The maddrey score
painless jaundice in an elderly patient is what until proven otherwise?
obstructive malignancy e.g. cholangiocarcinoma, cancer of the head of the pancreas
dark urine, pale stools- what sort of jaundice have they got?
intrahepatic jaundice e.g. due to hepatitis
what does leukonychia indicate?
hypoalbuminaemia
- not enough in - malabsorption and malnutrition
- not enough produced in the liver- chronic liver disease
- increased excretion- nephrotic syndrome (kidneys), protein losing enteropathy
what causes koilonychia? (spoon shaped nails)
iron deficiency anaemia
what are some GI causes of clubbing?
alcoholic chronic liver disease
IBD
GI malignancy (upper GI from hepatic and pancreatic to stomach and oesophageal etc)
4 causes of palmar erythema?
thyrotoxicosis
pregnancy
chronic liver disease
hyper dynamic circulation (Pagets and high output cardiac states)
What are some causes of dupytrens contracture?
idiopathic (familial) alcoholic liver disease ?DM phenytoin/epilepsy vibrating tools e.g pneumatic jack hammer trauma
3 causes for asterixis
hepatic flap (encephalopathy )
CO2 retention
uraemia
what are some risk factors for primary liver tumours?
HBV, HCV, smoking, alcohol, obesity, DM
true of false
90% of liver tumours are secondary metastases
true
what is tehmost common type of primary liver tumour?
hepatocellular carcinoma
name 3 types of benign liver tumours
haemangioma, hepatocellular adenomas and cysts
what investigation must you never do if you suspect a patient has liver haemangiomas?
never biopsy due you risk of bleeding (NB risk blood supply)
what is the most common organism to be found in the peritoneal fluid in spontaneous bacterial peritonitis ?
Spontaneous bacterial peritonitis: most common organism found on ascitic fluid culture is E. coli
what does Courvoisier’s sign state?
states that in a patient with a painless, enlarged gallbladder and mild jaundice the cause is unlikely to be gallstones. Furthermore, it is more likely to be a malignancy of the pancreas or biliary tree.
