Liver Disease Flashcards
1
Q
What is haemochromatosis?
A
excessive iron absorption- treat by venesection
2
Q
What is haemosiderosis?
A
an iron overload disorder resulting from transfusion
3
Q
What is Wilson’s Disease?
A
Copper accumulation
4
Q
What are the causes of hepatic injury?
A
accumulation of toxins infection immune mediated bile retention amyloid sarcoidosis diabetes
5
Q
What is cirrhosis of the liver?
A
nodules of hepatocytes separated by bands of fibrous tissue
6
Q
Explain the development of chronic liver injury
A
injury–>fibrous expansion–>bridging (fibrotic areas start to join)–>cirrhosis–>liver failure–>death/cancer–>death/transplant
7
Q
What are the features of decompensated cirrhosis?
A
Jaundice (pre-hepatic, intra-hepatic and post-hepatic) Ascites Encephalopathy Palmar erythema Spider naevi Caput medusa Gynaecomastia GI bleeding Sepsis
8
Q
What is steatosis?
A
Fatty liver disease
9
Q
Explain the progression from steatosis to liver cancer
A
steatosis–>fatty hepatitis–>fibrosis–>cirrhosis (irreversible)–>liver cancer
10
Q
What are some causes of fatty liver disease (steatosis)?
A
Alcohol
Obesity
Hep C
T2DM
11
Q
What are the complications of liver cirrhosis?
A
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)
12
Q
Explain the role of albumin
A
Albumin in produced by the liver so in liver disease it is reduced. it transports fatty acts and is important in maintaining oncotic pressure
13
Q
What are the biomarkers for liver damage?
A
decreased clotting and platelets increased ammonia and amino acids decreased albumin increased bilirubin-->jaundice hypoglycaemia due to decreased gluconeogenesis increased ALT, AST and ALP
14
Q
What are the causes of liver failure?
A
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
15
Q
What would you expect in liver failure?
A
coagulopathy (INR>1.5)
Encephalopathy
jaundice
asterixis/flap
16
Q
What tests would you order if you suspected liver failure?
A
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
17
Q
Explain the management of liver failure
A
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
18
Q
What are the signs of liver cirrhosis?
A
leuconychia, dupytrens contracture, clubbing, spidernaevi, xanthelasma, gynaecomastia, loss of body hair, hepatomegaly, ascites, splenomegaly, atrophic testes
19
Q
How would you manage liver cirrhosis?
A
Stop drinking alcohol
avoid NSAIDs, sedatives and opiates
if ascites- fluid restriction, spironolactone (100mg/24hr)- can add furosemide if needed
Liver transplant
20
Q
what marker in the blood can be used to monitor hepatocellular carcinoma recurrence?
A
AFP
21
Q
What is SAAG used for?
A
used to determine if ascites is due to portal HTN or not.(if raised, the ascites is caused by portal HTN.
22
Q
does budd chiari cause portal hypertension?
A
Yes
23
Q
does liver cirrhosis cause portal hypertension?
A
Yes
24
Q
What is the most common cause of acute liver failure in the UK?
A
paracetamol OD
25
What is the most common cause of liver failure worldwide?
Viral hepatitis
26
what are some clinical features of liver failure?
ascites, hepatomegaly, infections (decreased immunoglobulins), hepatic encephalopathy, jaundice, hypoglycaemia, bruising and haemorrhage, fetor hepaticus
27
why is it important to check U+Es in liver failure?
to assess for the presence of hepatorenal syndrome
28
why do you give lactulose in liver failure?
to minimise nitrogenous substance absorption by the gastrointestinal tract.
29
what drugs can you give in liver failure if encephalopathy is present?
lactulose
| rifaximin (abx)
30
list 5 hepatotoxic drugs
methotrexate, paracetamol, isoniazid, tetracyclines, salicylates
31
what are some prognostic factors in liver failure?
```
grade 3/4 hepatic encephalopathy
age >40
albumin <30g/L
increased INR
drug induced liver failure
```
32
it is 8 hrs after a patient has taken a large paracetamol OD what is the most appropriate management?
Start NAC
33
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
34
a patient presents within 1hr of taking a large paracetamol overdose what is the most appropriate management?
give activated charcoal
35
a patient presents within 1hr of taking a <75mg/kg paracetamol overdose what is the most appropriate management?
delay bloods until 4hrs after ingestion
36
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
37
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
38
What specific treatment would you give in hep C virus liver cirrhosis?
interferon alpha
39
What specific treatment would you give in primary biliary cirrhosis liver cirrhosis?
ursodeoxycholic acid
40
What specific treatment would you give in wilson's disease liver cirrhosis?
Penicillamine
41
how should patients with liver cirrhosis be followed up?
regularly with imaging and AFP testing- due to high risk of HCC
42
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
43
What is hepatorenal syndrome?
renal failure in a patient with chronic liver disease
44
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
45
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
46
What is the most common cause of portal HTN in the UK?
Cirrhosis
47
what is the most common cause of portal HTN worldwide?
Schistosomiasis
48
What are some possible presentations of portal HTN?
oesophageal varices
anorectal varices
Caput medusae
49
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
50
what features make up hepatic encephalopathy?
asterixis, ataxia, confusion, instructional apraxia and seizures
51
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
52
what is a useful investigation in hepatic encephalopathy?
plasma NH4 levels
53
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
54
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
55
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
56
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.
57
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
58
what is Wernickes encephalopathy?
neuropsychiatric disorder caused by thiamine deficiency which is most commonly seen in alcoholics.
59
what are the features of wernicke's encephalopathy?
```
Features
nystagmus (the most common ocular sign)
ophthalmoplegia
ataxia
confusion, altered GCS
peripheral sensory neuropathy
```
60
how do you treat wernicke's encephalopathy?
urgent thiamine replacement
61
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.
62
what is the management of alcohol withdrawal?
chlordiazepoxide (a BDZ) helps with the withdrawal symptoms
| pabrinex (replace thiamine)
63
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)
64
how does alcoholic hepatitis present?
```
anorexia
Diarrhoea and vomiting
tender hepatomegaly
ascites
if severe: jaundice, bleeding, encephalopathy
```
65
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
```
66
what score predicts mortality in alcoholic hepatitis?
The maddrey score
67
painless jaundice in an elderly patient is what until proven otherwise?
obstructive malignancy e.g. cholangiocarcinoma, cancer of the head of the pancreas
68
dark urine, pale stools- what sort of jaundice have they got?
intrahepatic jaundice e.g. due to hepatitis
69
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
70
what causes koilonychia? (spoon shaped nails)
iron deficiency anaemia
71
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)
72
4 causes of palmar erythema?
thyrotoxicosis
pregnancy
chronic liver disease
hyper dynamic circulation (Pagets and high output cardiac states)
73
What are some causes of dupytrens contracture?
```
idiopathic (familial)
alcoholic liver disease
?DM
phenytoin/epilepsy
vibrating tools e.g pneumatic jack hammer
trauma
```
74
3 causes for asterixis
hepatic flap (encephalopathy )
CO2 retention
uraemia
75
what are some risk factors for primary liver tumours?
HBV, HCV, smoking, alcohol, obesity, DM
76
true of false
| 90% of liver tumours are secondary metastases
true
77
what is tehmost common type of primary liver tumour?
hepatocellular carcinoma
78
name 3 types of benign liver tumours
haemangioma, hepatocellular adenomas and cysts
79
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)
80
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
81
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.
