Liver Disease Flashcards
What are the symptoms of acute/chronic liver disease?
asymptomatic
cholestatic - jaundice, pruritis, pale stools/dark urine
systemic - cachectic, fatigue, fever, xanthelasma, parotid enlargement, spider naevi, organomegaly, clubbing, Dupuytren’s contracture, telangiectasis
decompensation - ascites, distension, dizzy, drowsy, disorientated, hepatic flap, bleeding
What is Wilson’s disease?
dysregulated Cu2+ autosomal recessive - ATP7B excess copper deposits - especially in liver and brain affects younger ages presents similar to ALF + cirrhosis
What is haemochromatosis?
excess iron absorption in gut –> particularly effects, liver, heart, and endocrine glands
TF saturation and raised ferritin
affects M>W
primary = genetic cause/iatrogenic - autosomal recessive - HFE secondary = from another disease/cause
How does alcohol lead to liver disease?
Metabolic –> alcohol, obesity, insulin resistance –> fat deposits
Inflammatory –> translation of lipid signal in inflammation - chemo/cytokines –> scarring + fibrosis
Genetic –> disturbance of lipid metabolism –> steatosis
PNPLA3
TM6SF2
MBOAT7
What is the AUDIT score?
= Alcohol Use Disorders Indentification Test
There are 3 sections:
hazardous alcohol use
symptoms of dependance
harmful alcohol use
10 questions - ?/40
>20 means concerning alcohol dependence
16-19 indicates hazardous use
8-15 indicates mild intervention required
What is Alcohol Withdrawal Syndrome?
onset of a set of symptoms after last drink
6-36hrs = headache, tremor, anorexia, palpitations, anxiety
6-48hrs = seizures
12-48hrs = alcoholic hallucinosis
48-96hrs = delirium tremens
How do you treat alcohol withdrawal syndrome?
chlordiazepoxide (benzodiazepine)
lorazepam if cirrhosed liver
if severe delirium tremens –> haloperidol
Define alcoholic hepatitis
recent onset of jaundice +/- ascites w/ ongoing alcohol abuse
presents with additional fever, raised WCC, platelets and AST
will show steatosis, hepatocyte ballooning and inflammatory infiltrate on biopsy
How is alcohol hepatitis managed?
sepsis treatment NG feed steroids liver transplant alcohol abstinence
What is NAFLD?
= Non-alcoholic fatty liver disease
caused by:
hepatic triglyceride accumulation –> FFA released –> oxidative stress –> inflammatory mediators –> inflammatory cascade –> progressive fibrosis –> cirrhosis
What is NASH?
= non-alcoholic steatohepatitis
a stage of NAFLD
How does NAFLD present?
abdnormal LFTs - ALT/AST >1, persistent transaminitis
fatigue
RUQ pain
hepatomegaly
What are the risk factors for NAFLD?
obesity T2DM hyperglyceridemia hypertension metabolic syndrome CVS complications TPN haemochromatosis
Which drugs can increase the risk of NAFLD?
steroids
amiodarone
methotrexate
How is NAFLD diagnosed?
exclusion of other causes + metabolic syndrome = impaired glucose tolerance central obesity raised LDLs but low HDLs hypertension
liver bx + fibroscan
How is NAFLD treated?
weight loss
treat metabolic factors eg statins, antihypertensives
Describe the 5 types of viral hepatitis
Hep A - RNA - FO route - can be vaccinated
Hep B - DNA - hepadnavirus - parenteral (28-160 incubation days) - vaccine
Hep C - RNA - flavivirus - parenteral (15-150 incubation days)
Hep D - RNA - parenteral - protected via HBV vaccine
Hep E - RNA - FO route
What can happen as a result of an acute HBV infection?
Futuminant hepatitis
acute hepatitis
recovery
chronicity –> chronic hepatitis –> cirrhosis
What do these mean?
a. HBs Ag
b. HBs Ab
c. HBc Ab
d. HBe Ag
e. HBe Ab
a. HBV surface AntiGen - raised = active infection
b. HBV surface AntiBody - raised = immunisation
c. HBV core AntiBody -
d. HBV E AntiGen - raised = high infectivity
e. HBV E AntiBody - past infection/latent
Where does hep B and hep C most commonly affect?
B - S. America, Africa, Middle East
C - Central Asia, Africa, S. America
How is Hep B treated?
aim is to decrease viral replication
nucleoside/tide analogues (RTi)
eg entercovir or tenofovir
PEG-IFN
How is Hep C diagnosed?
HCV IgG +ve HCV RNA Genotype 1-6 LFTs HCC screen - US + AFP (alpha feto-protein) Bx or fibroscan
How is Hep C treated?
curable!
8-12 weeks
combinations of these drugs depending on genotype + stage of fibrosis: Harvoni Vierkirax + exvira Zepatier Epclusa Mariviret
How is haemochromatosis diagnosed and treated?
fibroscan or bx –> ferriscan of liver
treatment = venesection or Fe chelation therapy
How is Wilson’s disease diagnosed?
low caer raised urinary Cu2+ liver bx MRI brain Kaiser-Fleischer rings movement + psychiatric disorders - due to copper deposits in basal ganglia
How is Wilson’s treated?
Cu chelation therapy
eventually need liver transplant
How is HCC screened for and diagnosed? What is its main RF?
AFP test every 6 months for those with known cirrhosis
diagnosed with CT + MRI
How do you treat HCC?
Curative:
surgical resection
transplant
RFA
Palliative: TACE - transcatheter arterial chemoembolisation SIRT - selective internal radiotherapy RFA - radiofrequency ablation Sorafenib - protein kinase inhibitor
How do you test for HBV?
Screen:
HBcAb - previous infection
HBsAg - active infection
If +ve:
HBeAg - how infective?
HBV DNA - viral load
If solely HBsAb –> vaccinated
What is Autoimmune Hepatitis?
auto-antibodies made attack hepatic cells –> interface inflammation
F>M 3:1
associations: autoimmune thyroid, coeliac, vitiligo
How is AIH diagnosed?
raised ALT
auto-antibodies present - SM, ANA, LKM, ALSA
raised IgG
liver Bx
How is AIH treated?
high dose steroids –> prednisolone, budesonide
immunomodulators –> azathioprine
Liver transplant if nothing helps
What are some clinical features of CLD?
systemic:
weight loss
muscle loss
fatigue
cholestatic: jaundice pruritus pale stools/dark urine otherwise asymptomatic until decompensation
What are the features of decompensated liver disease?
jaundice fluid retention - low albumin drowsiness/confusion/hepatic flap - ammonia build up GI bleed - varices sepsis splenomegaly - pancytopenia
What are signs of compensated liver disease?
xanthelasmata parotid enlargement spider naevi palpable liver clubbing dupuytren's contracture pigmented ulcers gynacomastia palmar erythema
How do you treat a variceal bleed?
ABCDE Abx Terlipressin Endoscopy - banding/glue TIPSS = Transjugular intrahepatic portosystemic shunt
banding + beta-blockers to prevent recurrence
How does liver disease lead to ascites?
low protein production –> low albumin –> low oncotic pressure –> fluid leaves vessles –> ascites
potal hypertension –> splanchnic vasodilation –> decreased effective circulating volume –> upregulation of RAAS –> renal Na+ avidity –> ascites
Spontaneous bacterial peritonitis can occur when ascites is present? How is it diagnosed and treated?
WCC >250
neutrophils
gram -ve rods - E.Coli most common
jaundice
IV abx (cefotaxime) + human albumin solution (HAS)
How is ascites treated?
low sodium diet paracentesis diuretics - spironolactone or furosemide TIPSS liver transplant
What is hepatorenal syndrome?
renal failure in the setting of cirrhosis + hepatic circulatory dysfunction
type 1 = precipitant eg AIH
type 2 = progressive
How is HRS treated?
HAS + terlipressin + liver transplant
What is hepatic encephalopathy?
= altered level of consciousness due to liver failure and accumulation of ammonia graded I (mild confusion) --> IV (comatose)
precipitants inc: constipation sepsis GI bleeding drugs - opioids, diuretics, BDZs dehydration PVT
How is hepatic encephalopathy diagnosed and treated?
hepatic flap + confusion
serum ammonia
EEG
Treat precipitants
lactulose –> flush out NH4+
Rifaximin
liver transplant
How can you tell the difference between hepatic and obstructive jaundice?
hepatic will have normal looking stool + splenomegaly
whereas obstructive will have pale stools + no splenomegaly
What are these Liver Function enzymes?
a. ALT
b. AST
c. ALP
d. GGT
a. alanine aminotransferase - specific to liver
b. aspartate aminotransferase - mitochondrial enzyme released from heart/muscle/kidney/liver
c. alkaline phosphatase - bile cannicular + sinusoidal membranes + bones + placenta
d. gamma-glutamyl transpeptidase - hepatocellular - raised in cholestasis + alcohol
If a person tests positive for ____, they most likely have?
a. AMA, M2M, IgM
b. ANA, SMA, SLA, IgG
c. ANCA
d. IgA
a. Primary Biliary Cholangitis
b. AIH
c. Primary Sclerosing Cholangitis
d. ALD
What does TIPSS do?
decreases portal system pressure
embolises recurrent varices
What is Primary Biliary Cholangitis (PBC)?
small bile duct destruction
F>M 9:1
>40 yrs
What are the S&S of PBC? How is it diagnosed?
xantholasmata
jaundice
pruritis
fatigue
raised ALP + GGT
presence of AMA + M2
fibroscan —> ductopenia
grannuloma on bx
How is PBC treated?
1st line = ursodeoxycholic acid (UDCA)
–> thins bile and makes it flow easier
2nd line = obeticholic acid if that doesn’t work
for itching - cholestyramine or rifampicin
What is Primary Sclerosing Cholangitis (PSC)?
= chronic inflammation and scarring of the bile ducts (in particular, the large bile ducts)
M>F 2:1
>20yrs
65% have an IBD
increased risk of cancer - cholangiocarcinoma + colorectal
What are the symptoms of PSC?
xantholasmata
jaundice
pruritis
fatigue
How is PSC treated?
no treatment
ERCP for strictures
liver transplant
