Liver disease

Question 1

Symptoms of liver disease

Answer 1

Jaundice
Ascites
Pruritis 
Fat in faeces
Changes in colour of urine and faeces
Irregularities in clotting

Question 2

What tests can be done to indicate liver disease?

Answer 2

Liver function tests - testing liver enzymes & proteins.

Question 3

What enzymes/proteins etc are measured in LFTs?

Answer 3

Enzymes: ALT 
AST 
ALP 
GGT 
- Bilirubin 
- Albumin 
- Prothrombin (clotting) - INR

Question 4

What are the AST/ALT?

Answer 4

Inflammation markers - damaged hepatocytes release these into the blood. ALT is more specific to the liver (AST may indicate muscle damage too).
Ratio >2 alcoholic liver disease indicator
Ratio <1 NAFLD indicator

Question 5

If a AST/ALT ratio is >2 or <1 what liver diseases do they indicate?

Answer 5

> 2 alcoholic

<1 NAFLD

Question 6

What do ALP and GGT indicate?

Answer 6

A blockage of the bile ducts. They help confirm that the liver is the source of the raised ALT. GGT is useful for detecting alcohol damage but be aware high GGT can indicate any form of liver disease.

Question 7

What is INR? and why can it be used to detect liver disease?

Answer 7

Time taken for he blood to clot. “Prothrombin time”. The liver is responsible for producing prothrombin/clotting factors. So a longer PT (higher INR) may suggest a reduction in clotting factors/liver not working properly/ Vitamin K deficiency due to block of bile extraction/malnutrition

Question 8

Why might a vitamin K injection be given following a high INR score?

Answer 8

Given to see if it affects clotting time because vitamin K is deficient in liver disease - block of bile extraction/malnutrition

Question 9

In acute liver damage - how do these parameters change:

1. Bilirubin
2. ALT/AST
3. ALP
4. Albumin
5. INR

Answer 9

Bilirubin normal or increased 
ALT/AST greatly increased (ALT >AST) 
ALP normal or slightly increased
Albumin is normal
INR is usually normal//increase

Question 10

How does bilirubin indicate liver disease?

Answer 10

Protein - it is a breakdown of haemoglobin - measure of liver function as liver usually conjugates bilirubin - so bilirubin in blood predicts LD. Can also indicate blockage of bile ducts

Question 11

How does albumin indicate liver disease

Answer 11

Albumin is produced by liver and responsible for oncotic pressure, transport/binding of nutrients and drugs.
Reduced albumin means not enough being produced by liver - results in fluid retention (note - total protein is usually normal in liver disease but changes may indicate malnutrition).

Question 12

What is liver disease classified based on?

Answer 12

Duration - acute/ chronic

Damage type - Cholestatic/hepatocellular

Question 13

Differentiate acute and chronic liver disease

Answer 13

Acute: self limiting, history <6 months e.g paracetamol overdose, viral infection

Chronic: Long term liver damage >6mnth. Could lead to permenant structural changes e.g due to alcoholic cirrhosis, NAFLD, non alcohol steatohepatitis, viral infection, hereditory

Question 14

Differnentiate cholestatic and hepatocellular LD

Answer 14

Cholestatic - Bile flow reduced/blocked. Increased ALP, GGT, Bilirubin, bile acids, cholesterol

Hepatocellular - damage to hepatocytes - ALT and AST increase as released from damaged hepatocytes. Serum levels increased. - something outside liver is affecting function?

Both types lead to fibrosis - larger, whiter liver

Question 15

What are the 5 main complications associated with severe liver disease?

Answer 15

fluid retention 
Ascites
Portal hypertension 
Jaundice 
Hepatic encephalopathy

Question 16

What is the most common cause of cirrhosis

Answer 16

Alcoholic liver disease

Question 17

What is produced in alcoholic LD that causes inflammation/damage

Answer 17

Production of reactive oxygen species at every point in the metabolism of alcohol

Question 18

Stages of alcoholic LD?

Answer 18

1. Alcoholic fatty LD - asymptomatic, rapid, reversible
2. Alcoholic hepatitis - chronic use, can slow progression by stopping drinking
3. Cirrhosis - Unlikely to survive <5 years unless permentantly stop drinking

Question 19

What is the management of alcoholic Fatty LD?

Answer 19

Stop drinking alcoholic - behaviour and support services
Treat the symptoms of alcohol withdrawal - Delirium Tremens (DTs), diazepam
- Treat the thiamine deficiency and malnutrition - can get wernickes encephalopathy so give IV thiamine and vitamins

Question 20

What is non alcoholic fatty liver disease?

Answer 20

Largest increase in fatty globules in NAFLD & changes in hormonal signalling around liver - inflammation forming sar tissue

Question 21

Stages of NAFLD

Answer 21

1. fatty liver - asymptomatic, may be detected by LFts
2. NASH - non alcoholic steatohepatitis - inflammation & pain
3. fibrosis
4. cirrhosis

Question 22

What are the risks of NAFLD

Answer 22

Type 2 diabetes
obesity 
Hypertension 
Hypercholesterolaemia 
Smokers
>50 y/o

Question 23

Treatment for NAFLD?

Answer 23

Increase exercise and diet.
Treat underlying cause eg diabetes, hypertension,
Avoid alcohol
If on statins for high lipids - stay on unless LFTs double within 3 months of starting

Question 24

name 3 types of viral hepatitis and transmission routes

Answer 24

Hep A - faecal oral route e.g contaminated foods, can also be sex, anal, sharing needles
Hep B - infected blood products / sexual intercourse unprotected Mainly
Hep C - infected blood products e.g IV drug users (rarely sex)

Question 25

Duration of Hep A and treatment?

Answer 25

Self limiting 3-6 weeks, no treatment but avoid alcohol, vaccination if high risk or travelling to high risk areas

Question 26

Does Hep C have symptoms?

Answer 26

Asymptomatic until et chronic liver disease - only really diagnosed at this stage via Hep C blood test.

Question 27

Hep C treatments?

Answer 27

Achieve sustained viral clearance and antiviral drugs - Ribavarin - but does not give immunity

Question 28

Symptoms of Hep B

Answer 28

May take 2-3 months to present, self limiting, diagnose using Hep B blood test.

Question 29

What is viral hepatitis?

Answer 29

Inflammation of the lier and increased ALT due to virus.
A generally contaminated foods
B sexual contact unprotected
C infected blood products mainly IV drug users

Question 30

What is the leading cause of acute liver failure?

Answer 30

Paracetamol poisoning

Question 31

In the case of paracetamol overdose, why is it important to know exactly how many tablets were consumed and when they were taken? (4)

Answer 31

Because after 24hours - there will be irreversible severe liver damage

• Liver failure will occur 48-96 hours after OD.
• If within 1 hour - can give activated charcoal which will absorb the drug in the GIT.
• Acetylcysteine IV can be given if on or above treatment line and is 100% effective if given within 8 hours or less.
• if its been 24hours from the OD to 1st presentation then must alert poisons authority.

Question 32

What happens in paracetamol overdose

Answer 32

usually metablised by conjugation - small % via CYP450 route to form NAPqI which is toxic, but usually conjugated by glutathione (GSH). In overdose, conjugation is saturated as more NAPQI forms which means it cannot be broken down.

Question 33

Treatment of paracetamol overdose

Answer 33

N-acetylcysteine - spares GSH glutathione

Question 34

What drugs should be avoided inliver damage - why?

Answer 34

Rifampicin
Liver damage
They are excreted unchanged by liver,

Also - NSAIDS, warfarin, sedative drugs (action could be increased so may mask hepatic encephalopathy)

Question 35

What happens to bioavailability of drugs in liver damage?

Answer 35

Hepatic blood flow is reduced so bioavailability of drugs undergoing first pass metabolism is increased.