Liver Disease Flashcards
Why does ascites start to develop in liver disease?
Portal hypertension and low albumin resulting in blood being pushed out
What drugs should you be careful of in liver disease?
Drugs that are highly metabolised as if the liver is damaged there will be less metabolism so can reach toxic levels. General clue: is the oral dose considerably higher than the IV dose?
Circulation changes in liver disease:
Low ___1____ will result in low plasma levels so the kidneys will produce more renin.
However, aldosterone cannot be metabolised by the damaged liver so will get _____2_______
This results in really low _______ as aldosterone pushes out potassium as it reabsorbs sodium (check this)
Will also get an increase in other hormones such as __________4____________ as these cannot be metabolised
There is also more __5__ produced due to low plasma volume.
Ultimately __________6_____________________
1) Albumin
2) secondary aldosteronism
3) potassium
4) endothelin and oestrogen and other sex hormones
5) ADH
6) there is sodium and water retention and potassium loss as well as lots of vasoconstriction in the kidneys.
What does albumin do?
What are consequences of a low albumin?
It is a plasma protein involved in maintaining oncotic pressure (ie its presence draws in fluid from the capillaries). It also binds many substances to it.
If there is low albumin will get low plasma levels. As many things travel bound to albumin these will also be free in the blood.
What are spider naevi? Why do you get them in liver disease?
Swollen blood vessels beneath the skins surface. They are caused by increased oestrogen, this happens in liver disease as the damaged liver cannot metabolise the oestrogen resulting in an increase.
In practice which drugs can and cannot be prescribed for liver disease?
• Paracetamol 1g twice daily – ‘Lesser of all evils’ – Do not exceed 3 g daily, avoid prolonged use • Codeine 30mg three times daily – Watch out for sedation • Avoid NSAIDs
Why can’t you give NSAIDs?
Renal PGE synthesis is decreased so: – Worsen renal impairment – Further sodium retention – Risk of hepato-renal syndrome – Worsening of CHF
(prostaglandins in the kidney usually cause vasodilation)
Why can’t you give opiates?
Act on brain- with liver disease have a hypersensitive brain
When paracetamol is metabolised the highly reactive intermediate reacts with ____1____. However, glutathione is finite and if you run out of stores ________2____________
1) glutathione
2) you’ll start to damage your liver.
Paracetamol overdose is treated with
Methionine
Most common drug induced hepatitis are caused by?
Amoxicillin and Clavulanic Acid
What is the best diuretic for those with liver disease? Why ?
Spironolactone as this is an aldosterone antagonist
Loop and Thiazide diuretics would increase hypokaelamia. Loop also causes reduced intra-vascular volume.
What drugs can be used for sedation in liver disease?
• Phase II metabolised benzodiazepines
– Lorazepam
– Oxazepam
– Lormetazepam
Antibiotics that may need to be avoided in liver disease?
- Aminoglycosides are nephrotic
- Quinolones are epileptogenic (could cause an epileptic attack)
- Metronidazole reduced metabolism
When is jaundice detectable clinically?
When serum bilirubin is more than 50 micro mol/l
What is the outcome of chronic liver disease?
Cirrhosis. There are liver diseases that affect the liver chronically but if they don’t lead to cirrhosis they are not classed as chronic liver disease.
What is NAFLD?
Non-alcoholic fatty liver disease- a fatty liver/ steatohepatitis in the absence of another cause
Risk factors for NAFLD?
Obesity, hypertension, type 2 diabetes and hyperlipidaemia
Presentation of NAFLD?
Often asymptomatic unless present late with liver fibrosis and failure
Diagnosis of NAFLD and NASH?
NAFLD by ultrasound and NASH by liver biopsy
Main treatment of NAFLD and NASH?
Weight loss and exercise
What is primary biliary cholangitis (cirrhosis)?
An auto-immune disorder that leads to progressive destruction of the small bile ducts leading to cirrhosis
Who classically gets primary biliary cholangitis?
Middle aged women
What antibodies will those is PBC have?
anti-mitochondrial antibodies (AMA)
Presentation of PBC?
May be asymptomatic. Symptoms include fatigue, itch without rash and xanthelasma and xanthoma