Liver disease Flashcards
What happens in cirrhosis?
- liver gets small and shrunken
- reduced liver blood flow, reduced metabolic function and reduced plasma proteins
What is happening if the oral dose of a drug is much higher than the IV dose?
first-pass metabolism in the liver
How is alcohol metbaolised?
by first-order until a set point then it is by zero order
What happens in liver disease with RAS?
there is an increase in renin
there is a decrease in the metabolism of aldosterone so there is secondary aldosteronism
What can happen to the kidneys in liver disease?
- too much angiotensin 2 (vasoconstrictor), aldosterone, SNS and ADH
- there is potassium loss, sodium retention and water retention
What are the consequences of moderate hepatic impairment?
gut oedema, liver and kidney congestion, gross oedema and ascites and CHF
Why are NSAIDs not used in liver disease?
- get rid of renal prostaglandins
- so harm kidneys and cause ulcers and bleeding
- increase blood pressure
What must always be prescribed with an NSAID?
a PPI
What is the summary of drug metabolism?
- phase 1 is P450 biotransformation
oxidation, reduction and hydrolysis
- phase two is conjugation
How can paracetamol be dangerous?
can make a dangerous substance which is removed by out glutathione stores
What is the rule used to assess drug-induced liver disease severity?
Hy’s Rule
- uses ALT/AST and Bilirubin as parameters
What is the diuretic used in liver disease and how is this administered?
- Spironolactone as it removes secondary aldosteronism
- 1kg/day weight loss of fluid is ideal
What is given to sedate patients with liver disease?
Phase 2 metabolised benzodiazepines eg Lorazepam
What are the features of Hep A?
- faecal-oral spread
- common in gay and IVDUs
- acute not chronic
- peak is in older children and young adults
- confirmed by presence of IgM against Hep A
- vaccine available
- mild illness will usual full recovery
What are the features of Hep B?
- sex, mother to child or by blood
- chronic only if first exposure is in childhood
- adults usually get acute
- confirmed by presence of Hep B surface antigen (HBsAg)
- carriers possible
- antiviral therapy to those with liver inflammation and a high level of Hep B DNA
- treat with vaccine, suppressive antivirals or peginterferon
What are the risk factors for Hep B?
- people who live in affected areas
- have multiple sexual partners
- IVDUs
- children of infected mothers
What are the features of Hep C?
- no vaccine
- transmission is blood or sex
- test for antibody to virus then test for RNA by PCR
- usually chronic
What are the features of Hep D?
only found with Hep B
makes acute or chronic Hep B worse
What are the features of Hep E?
Common in the tropics
Faecal-oral spread
More common than A
Caught from pigs
Genotypes in the tropics cause disease in pregnant women
No vaccine is available
Only chronic infection if there is an abnormal immune system
When is a viral infection classed as chronic?
over 6 months
Which Hep can spontaneously resolve?
Hep B not Hep C
What is the management of acute viral Hep?
monitoring for encephalopathy, resolution and vaccinate those at risk
What is the management of chronic viral Hep?
antivirals, vaccination, infection control, alcohol cessation and awareness and screening for hepatocellular carcinoma
Who is treated with antivirals?
- chronic infection
- inflammation is seen
- if fit for treatment
- HIV co-infection is difficult
What are the common antiviral and their sideffects?
- infterferon alpha
- peginterferon (flu symptoms)
- ribavirin (anaemia)
- sofosbuvir is active against all genotypes
What is compensated cirrhosis?
scarring in the liver without loss of normal functions such as metabolism and removal of toxins
When does liver disease become chronic?
6 months
What drug can cause cirrhosis?
methotrexate which is a treatment or rheumatoid arthritis and psoriasis
What is numerically classed as portal hypertension?
5-8mmHg
What are the clinical features of compensated cirrhosis?
normal from outside, found on imaging or labs, maybe portal hypertension, signs are spider naevi, clubbing, palmar erythema or none
What are the clinical features of decompensated cirrhosis?
liver failure present, end stage liver disease, signs are jaundice, ascites, encephalopathy or bruising
What are the complications of cirrhosis?
ascites, encephalopathy, variceal bleeding and liver failure
What is ascites caused by?
- increased number of vasodilators
- enhanced sensitivity to these
- resistance to vasoconstrictors
What is the diagnosis and management of ascites?
- diagnosis with shifting dullness
- treat with spironolactone, paracentesis or TIPSS
- stop drinking
- sodium must be balanced
What is the diagnosis and treatment of encephalopathy?
- diagnosis is flap, neurology, ammonia
- treat with lactulose, Rifaxamin
What is the treatments for oesophageal varices?
- primary = beta blockers and ligation
- acute = resuscitation, terlipressin, banding and TIPSS
- emergency = balloon tamponade
- secondary treatment = band ligation or beta blockers
What are the main benign liver lesions?
- haemangioma
- focal nodular hyperplasia
- hepatic adenoma
- liver cysts
- polycystic liver disease
- abscess
What are the main malignant liver lesions?
- primary are hepatocellular carcinoma or cholangiocarcinoma
- metastases are common
What are the features of haemangioma?
common females single and small asymptomatic diagnosis is US, CTl, MRI no treatment
What are the features of focal nodular hyperplasia?
- benign nodule of normal liver tissue
- central scar with artery radiating branches to periphery
- young middle aged females
- asymptomatic
- diagnosis is US, CT, MRI or FNA
- no treatment
What are the features of hepatic adenoma?
- proliferation of normal hepatocytes
- females
- associated with contraceptive hormones and anabolic steroids,
- asymptomatic or RUQ pain
- present with rupture or haemorrhage
- diagnosis is US, CT, MRI, stop hormones
- weight loss for treatment and remove in males as malignancy is more common
What are the types of liver cysts?
simple hydatid atypical polycystic lesion pyogenic/amoebic abscess
What are the types of polycystic liver disease?
-Von Meyenburg complexes (benign cystic nodules)
-Polycystic liver disease
-Autosomal dominant PK disease
(treat with somatostatin)
What are the features of liver abscesses?
- high fever
- leukocytosis
- abdominal pain and complex liver lesion
- treat with antibiotics, aspiration, echo then operation
What is the epidemiology, aetiology and presentation of hepatocellular carcinoma?
- men
- most common primary cancer
- risk factor is cirrhosis
- presentation is abdo pain, RUQ, asymptomatic, worsening of chronic liver disease, cirrhosis signs, RUQ mass
Where do hepatocellular carcinoma metastases move to?
liver, portal vein, pymph, lung, bone and brain
What is the diagnosis and treatment of hepatocellular carcinoma?
- AFP is high
- liver transplant, can use RF ablation or chemoembolization
- sorafenib
What parts of the LFT are hepatocellular?
ALT and AST
What parts of the LFT are cholestatic?
ALP
gGT
Bilirubin
What does a raised ALT or AST say?
hepatocellular injury or hepatocellular necrosis
What would the LFTs be in cholestasis?
very raised ALP, gGT and Bilirubin
raised or normal ALT
What would the LFTs be in chronic hepatocellular damage?
normal or raised ALT, ALP, gGT and Bilirubin
What would the LFTs be in acute hepatocellular damage?
very raised ALT
normal or raised ALP and gGT
raised Bilirubin
What is acute liver disease?
- rapid development of liver disease without any previous liver damage which is less than 6 months
- causing encephalopathy and prolonged coagulation
What are the true liver function tests?
- Bilirubin
- Albumin
- Prothrombin time
How does acute liver failure present?
jaundice, lethargy, nausea, anorexia, pain, itch, arthralgia and abnormal LFTs
What are some of the main causes of acute liver disease?
hepatitis drugs shock liver cholangitis alcohol malignancy chronic liver disease
What are some of the rarer causes of acute liver disease?
Budd Chiari, acute fatty liver of pregnancy or cholestasis of pregnancy
What are the main investigations for acute liver disease?
- HISTORY esp drug history
- LFTs
- prothrombin
- examination
- US including vascular
- virology
- investigations of chronic liver disease
What is the treatment for acute liver disease?
rest up to 3 months, fluids, no alcohol, increase calories, observe for FHF
What drugs can cause liver injury?
antibiotics (co-amox or fluclox), paracetamol, NSAIDs or statins
What is fulminate hepatic failure?
- a clinical syndrome resulting from massive necrosis of liver cells leading to severe impairment of liver function
- presents as an acute episode of severe liver dysfunction in a patient with a previous normal liver
What is FHF caused by?
paracetamol, fulminant viral, drugs, HBV or non A-E
What is the treatment for FHF?
supportive
fluids
renal replacement
transplant
