Liver Disease

Question 1

what does hepatitis mean

Answer 1

inflammation

Question 2

what does steatosis mean

Answer 2

fatty

Question 3

steatohepatitis means

Answer 3

fatty inflamed liver

Question 4

What can cause liver disease?

Answer 4

alcohol excess
viruses - hep B & C
obesity
autoimmune hepatitis
drugs
haematomachrosis - XS iron
wilsons disease - XS copper
cystic fibrosis

Question 5

List complications of liver disease

Answer 5

• jaundice (usually bilirubin > 35) can cause pruritis
• hypoalbuminaemia
• portal hypertension leading to varies and possible vatical bleed
• ascites
• clotting abnormality
• hepatic encephalopathy
• splenomegaly (as a result of portal hypertension. Can cause thrombocytopenia)

Question 6

How does Child-pugh score?

Answer 6

score <6 = grade A
score 7-9 = grade B
Score > 10 = grade C

Question 7

How is jaundice treated?

Answer 7

It is usually only treated for patients who get pruritus. Antihistamines are usually ineffective and can have sedating effect which isn’t good when were looking out if a patient has hepatic encephalopathy.
Cholestyramine binds to bile acids to precent their reabsorption however it also binds to fat soluble drugs which can effect their medicine regime.
Patient will colestatic liver disease e.g. primary biliary cirrhosis may be treated with ursodeoxycholic acid (10-15mg/kg in two divided doses) or rifampicin 300mg BD (unlicensed)

Question 8

How is clotting abnormalities treated?

Answer 8

vitamin K however patients with severe dysfunction may be unable to use vit K to produce closing factors

Question 9

How is portal hypertension treated?

Answer 9

propanolol 20-40mg daily initially. Restricted by low BP and it also undergoes first pass metabolism which would be reduced in these sorts of patients.
Varicies - terlipressin 2mg IV every four hours then every 72 hours

Question 10

How to treat hepatic encephalopathy

Answer 10

lactulose to produce 2-3 soft stools a day. Consultation can be an aggravating factor and lactulose is broken down by the gut bacteria to lactic acid, bacterial conversion of protein to ammonia is reduced.
ABX are sometimes used to reduce the bacteria load in the gut. Neomycin was originally used but has a risk of ototoxicity. Rifampicin can be used but is expensive.

Question 11

How to treat ascites

Answer 11

• sodium restrict to 90mmol/day
• spironolactone 100-400mg.
• aim to lose 0.5-1kg/day. Doses should be reduced if patients are losing more than 1 kg a day
• furosemide in recurrent ascites
• pt aren’t usually fluid restricted unless they have hyponatraemia

Question 12

SBP means?

treatment?

Answer 12

Spontaneous bacterial peritonitis?

ABX to cover gram-ova including E.coli.
Patients would then start on human albumin solution (1.5mg/kg on day 1 followed by 1g/kg on day 3) - This is to kept reduce the risk of renal impairment which happens in 30% of patients.

Following treatment of SBP. Prophylactic ABX such as ciprofloxacin 500mg/day are used.

Question 13

What sort of drugs should we be wary of in patients with liver disease?

Answer 13

hepatically cleared drugs - clearance may be reduced however its hard to know how to reduce these drugs as its not as straight forward like renal meds.

Sedating drugs - encephalopathy

constipating drugs - encephalopathy

NSAID - can cause gastric ulceration - any bleeding from ulcers is likely to be worse in patients with chronic liver disease. They can also cause fluid retention (which can worsen in ascites) and renal impairment.1

Question 14

Which drug can cause gynaecomastia and hyperkalaemia

Answer 14

spironolactone

Question 15

which drug can cause constipation

Answer 15

cholestyramine

Question 16

What drug can cause peripheral vasoconstriction

Answer 16

terlipressin

Question 17

Which drugs should be avoided in liver impairment

Answer 17

NSAIDS

temazepam (sedating)

Question 18

Following paracentesis

Answer 18

patients should be given 100ml of human albumin 20% solution for every 2-3 litres of ascites drained.

Question 19

When patient has an active bleed do they need ABX cover ?

Answer 19

Yes to cover for gram -ve

Tazosin?

Question 20

Liver disease can cause

Answer 20

Jaundice
Ascites
Hypoalbuminaemia

Question 21

Liver disease does not cause

Answer 21

Low INR

Hypercholesterolaemia

Hypertension

Question 22

Raised bilirubin, ALP, GGT

Normal ALT

(Usually INR raises)

means

Answer 22

Cholecystitis

Question 23

Why is INF usually raised in cholecystitis?

Answer 23

Impaired bile flow

Less bile salts

These usually absorb fat soluble vitamins eg vitamins K

Less vitamin K absorbed means high INR. Usually when the vitamin K is absorbed this lowers the INR

Question 24

What can cause cholecystitis

Answer 24

Alcohol

Gallstones

Question 25

Raised ALP, bilirubin, ALT, GGT, INR ALT most significantly raised shows it is an acute picture ALB (albumin) - normal

Answer 25

Acute hepatitis Acute damage that is why the albumin is normal For example para OD

Question 26

``` Raised bilirubin ALP - marginally raised GGT - significantly raised Albumin - low INR - raised ALT - normal ```

Answer 26

Cirrhosis ALT can be normal because there is less healthy liver to damage Low albumin - good indicator of chronic alcohol damage

Question 27

Hepato- renal failure

Answer 27

Terlipressin 1-2g every 4-6 hours plus human albumin 1g/kg for 2 days then 25-50g daily untill terlipressin has stopped

Question 28

Why are bleeds worrying for liver patients

Answer 28

deranged clotting Low platelets Variceal bleeds have 30% mortality