Liver Disease Flashcards
what are the 9 subtypes of liver disease?
hepatitis cirrhosis alcoholic liver disease drug toxicity storage disease chronic liver disease autoimmune structural disease liver lesions
prevalence of viral hepatitis?
dec in HepC, inc in E & B
hep A is caused by the ___ ___ virus
Ebstein-Barre Virus
epidemiology of HepA?
faecal-oral spread, common in young
is HepA chronic?
no- mild illness with full recovery
ix for diagnosing HepA?
bloods (HepA IgM)
HepE is caused by _______ virus
cytomegalovirus
true/false…
HepE is clinically same as HepA
true
HepB is caused by _____ ____ virus
yellow fever virus
Hep E & A spread faecal-orally, what about HepB?
hepB spreads by blood, sexually, mother to child
is the incubation period for hep B long or short?
long
true/false…
the hep B virus causes direct damage to liver
False…
it is the antiviral immune response that causes the damage to the liver
if disease presents during childhood then it is more likely to be…
chronic
HBsAg antigen…
present for > 6 months in chronic infection
HBeAg…
present in highly infectious individuals (as is viral DNA)
HepB IgM…
present soon after becoming infected
HepB IgG…
present after a while of infection
anti-HBe antibody…
present in immunity
how to control spread of HepB?
minimise exposure, screening of pregnant women, vaccines
outcomes of hepB?
chronic hepatitis, cirrhosis, hepatocellular carcinoma,
what is important about HepD?
only found with hepB and exacerbates it (parasite of a parasite)
HepC is caused by the ____ _____ virus
herpes simplex virus
True/False…
HepC’s spread is similar to HepA & HepE
False…
HepA & E spread via faecal-oral
HepC (like HepB) spreads via blood & blood products
HepC is often asymptomatic but tends to do what?
waxes and wanes but tends to become chronic
ix for HepC?
test for antibody to HepC. if +ve do PCR for HepC RNA= if this is +ve then definitive dx of active HepC can be made
true/false…
there is no vaccine for HepC?
true
more than __ months means hepatitis is chronic
6 months
pathophysiology of acute & chronic hepatitis?
acute hepatitis can.. resolve, become chronic
chronic can.. become cirrhosis, cancer, liver failure or resolve
what is Mx for acute infection?
- monitor for complications
- notify public health
- immunisation of contacts
main complications of hepatitis?
cirrhosis, liver failure (acute or chronic), liver cancer
which 2 hepatitis infections may become chronic?
hepB & C
HepB & C chronic infection cure?
HepB= spontaneous cure HepC= once chronic infection is established so no cure
general timeline of complications following chronic hepatitis?
cirrhosis after 20 years, carcinoma after 30 years
tx for chronic hep?
- antivirals
- hepB: interferon alfa (peginterferon injection)
- hepC: oral course of 2/3 antivirals - vaccines
- infection control
- hepatocellular carcinoma screening
when should antivirals be given in chronic hepatitis?
HepC= always HepB= if high HBV DNA present in serology
common causes of acute liver failure?
viruses, alcohol/drugs, bile duct obstruction
what is cirrhosis?
bands of fibrosis separating regenerative nodules of hepatocytes & alteration of hepatic micro-vasculature so loss of hepatic function
aetiology of cirrhosis?
alcohol, HBV & C, haemochromatosis, AI disease, gallstones, NASH? NAFLD
common complications of cirrhosis?
portal HT, ascites, encephalopathy, vatical bleeding
pathophysiology of ascites?
- portal circulation disrupted by cirrhosis
- inc in portal pressure
- lack of portal blood flow causes liver to inc production of vasodilators
- inc in CO but low SVR so low MAP
- baroreceptors activated to inc MAP
- sympathetic system activated & renin-angiotensin pathway to inc SVR
- inc CO & high H2O retention
space to store extra water ran out to ascites
Dx for ascites
shifting dullness on examination and USS
Tx for ascites
low Na diet, no NSAIDs, diuretics*, paracentesis/TIPSS/ transplant
what diuretic is given in ascites?
spironolactone
what is TIPSS?
stenting of hepatic vein
complication of ascites??
spontaneous bacterial peritonitis- dx with ascites tap and tx is Antibiotics
what are symptoms of encephalopathy?
mental confusion hand flap, slow tremor when grasping 2 fingers
pathogenesis of encephalopathy?
microglial inflammation 2y to ammonia metabolism
tx for encephalopathy?
lactulose (clear gut), maintain nutritional status, if spontaneous consider transplantation
variceal bleeding is most common at…?
oesophagus
what score is used in variceal bleed assessment?
CHILD’s score
A= normal, C= jaundiced
tx for variceal bleed?
b blockers and variceal ligation
acute tx for upper GI bleed due to variceal bleed?
resuscitate, terlipressin (reduces portal pressure), endoscopy & TIPS
- if bleeding can’t be controlled perform a balloon tamponade
what type of drug is terlipressin?
vasoconstrictor
common complication of varicese in cirrhotic patients?
thrombosis
2 classes of cirrhosis?
compensated: image abnormalities but no s/s
decompensated: acute liver failure- usually caused by infection or end stage liver disease
signs for decompensated cirrhosis?
jaundice, ascites, encephalopathy, rising, leukonychia
what is leukonychia?
white discolouration of nails
tx for cirrhosis?
remove/ treat underlying cause
nutrition: high energy intake and vitB supplements, fed state maintenance
transplant
what score is used to assess ability to receive transplant?
UKELD
what condition may cause cardiac cirrhosis?
constrictive pericarditis
ix for any alcoholic liver disease?
biopsy
pathology of alcoholic liver disease?
fatty liver (reversible) > hepatitis (reversible, wks of abuse) > fibrosis (irreversible, mnths) > cirrhosis (end stage, yrs)
histological pathology of alcoholic hepatitis
hepatocyte necrosis, mallory bodies, pericellular fibrosis
what grading system is used for alcoholic hepatitis?
Turcotte-Pugh Grading
- bilirubin >80
- AST < 500
- AST:ALT > 1.5
hepatomegaly & fever *
outcomes of alcoholic liver disease ?
cirrhosis, Portal HT, malnutrition, hepcel carcinoma
what does NASH stand for?
Non-alcoholic Steatohepatitis
pathology of NASH?
identical to alcoholic liver disease
risk factors/ aetiology for NASH?
diabetes, obesity, hyperlipidaemia
what can drug toxicity cause?
hepatitis, granulomas, fibrosis, necrosis, failure, cholestasis, cirrhosis
what drug is commonly responsible for drug toxicity?
methotrexate
what is methotrexate given for?
psoriasis & RA
what does methotrexate cause?
fibrosis
true/false…
methotrexate toxicity presents with a rash and ascites
false…
no clinical signs
all storage diseases of the liver are…
genetic and are autosomal recessive
what are the 3 storage diseases of the liver?
haemochromatosis, Wilson’s disease, alpha-1-antitrypsin deficiency
epidemiology of haemochromatosis?
worse in homozygotes & men
how does haemochromatosis present commonly in men?
no erections
what is haemochromatosis?
excess iron in liver
aetiology of haemochromatosis?
1y: genetic
2y: iron overload from diet, transfusion or iron therapy
what gene mutations causes 1y haemochromatosis?
C282Y mutation on HFE gene
ix for haemochromatosis?
LFTs (inc in ferritin), liver MRI, liver biopsy
when should an ECG/Echo be carried out as a full work up of haemochromatosis?
if cardiomyopathy suspected
tx for haemochromatosis?
venesection
main complication of haemochromatosis?
cardiomyopathy
what are other haemochromatosis complications?
cirrhosis > hepatocellular carcinoma
diabetes
what is Wilson’s disease?
excess of copper which deposits in liver and brain due to loss of function of ceruloplasmin
presentation of Wilson’s?
neurological deficits (confusion, parkinsons, depression, personality changes etc), hepatic (cirrhosis)
main signs of Wilson’s?
Kaiser-Fleisher rings at corneal limbus
ix for Wilsons?
U&Es (assesses kidney function), LFTs, eugenic tests, MRI
Tx for Wilsons?
copper chelation drugs
what are some copper chelation drugs?
Trientine, Depencillamine
what is alpha-1-antitrypsin deficiency
disorder of production of an enzyme inhibitor
aetiology of A-1-A def?
A1AT gene mutation resulting in excess tryptic activity
pathology of A-1-A?
blocks neutrophil elastase (blocking collagen breakdown) but lack of A-1-A causes inc breakdown
presentation of A-1-A def?
lungs (emphysema)
liver (cirrhosis)
tx for A-1-A def?
supportive
what is classed as chronic liver disease?
disease for > 6 months
what is the usual outcome for chronic liver disease?
cirrhosis
aetiology for chronic liver disease?
alcohol, NAFLD, HepC, 1y Billiary Cholangitis, autoimmune hepatitis, HepB
what rare conditions may also cause chronic liver disease?
haemochromatosis, 1y sclerosis cholangitis, Wilson’s, A1AT, Budd-Chiari
pathophysiology for non-alcoholic fatty liver disease (NAFLD)?
steatosis > steatohepatitis (NASH) > steatohepatitis w fibrosis > cirrhosis
what is the aetiology of NAFLD?
metabolic syndromes e.g. hypertension, obesity, NASH, T2 Diabetes
ix for NAFLD?
liver biopsy
tx for NAFLD?
wt loss & exercise
what are the 3 autoimmune diseases of the liver
1y Biliary cholangitis
1y sclerosing cholangitis
autoimmune hepatitis
what is 1y biliary cholangitis
chronic inflammation of intrahepatic bile ducts
epidemiology of 1y biliary cholangitis
middle aged women
aetiology for 1y biliary cholangitis?
anti mitochondrial antibodies (M2 specifically)
presentation of PBC?
asymptomatic, itch, xanthelasma & xanthomas (high cholesterol), dark urine (high bilirubin)
Ix for PBC?
serology- AMA, LFTs, liver biopsy
Dx for PBC?
+ve AMA serology
LFTs= alt fossa (ALP) & gamma GT (GGT) elevated
Biopsy= granuloma & bile duct loss
tx fo PBC?
Urseo deoxycholic acid
2nd line= obeticholic acid
last resort= transplant
outcomes of PBC?
cholestasis or cirrhosis
what is 1y sclerosing cholangitis?
chronic inflammation of extra +/- intrahepatic bile ducts
epidemiology of PSC?
males w/wo UC, common in Scandinavia
pathophysiology of PSC?
inflammation of bile ducts > periductal ‘onion-skinning’ fibrosis & stricture formation > jaundice
s/s of PSC?
asymptomatic or itch/rigors
Ix for PSC?
imaging, LFTs, serology
dx for PSC?
serology AMA= -ve
LFTs= inc ALP, inc bilirubin, hypergammaglobulinemia
Tx for PSC?
maintain bile flow e.g. ERCP
monitor for colorectal cancer
transplant
prognosis for PSC?
poor- 10 years
what is autoimmune hepatitis (AIH)?
attack on the liver causing chronic inflammation
are women or men affected more by AIH?
women
classes of AIH?
T1: adult female, more common, SMA +ve, associated with other AI diseases e.g. thyroiditis
T2: children, harder to treat, LKM-1 Antibody (SMA -ve)
what are SMAs
smooth muscle antibodies
presentation of AIH?
jaundice, hepatomegaly, splenomegaly, elevated prothrombin time, non-specific symptoms (malaise, fatigue, nausea, anorexia)
dx for AIH?
LFTs= elevated AST & ALT serology= elevated IgG, AMA liver biopsy (to rule out other causes)
histology of AIH?
interface hepatitis w marked piecemeal necrosis
aetiology of AIH?
genetic predisposition & environmental triggers
tx for AIH?
corticosteroids
remission: azathioprine
last resort: transplant
what condition falls under structural disease for liver?
Budd Chiari
what is Budd Chiari?
thrombosis of hepatic vein
clinical presentation of Budd-Chiari?
acutely jaundiced, tender hepatomegaly, ascites
dx for BC?
USS of hepatic vein
tx for BC?
recanalization, TIPS
1y liver cancer is more common in…
chronic liver disease pts
what are the 5 benign liver lesions?
- Haemangioma
- Focal Nodular Hyperplasia (FNH)
- Hepatic Adenoma
- Cysts
- Liver Abscess
haemangiomas occur in…
females
pathological appearance of haemangioma?
hyper vascular, single, small, well demarcated capsule
s/s of Haemangioma?
asymptomatic
Dx for haemangioma?
USS, CT, MRI
Tx for haemangioma?
no tx needed
epidemiology of focal nodular hyperplasia (FNH)?
young & middle aged women
pathology of FNH?
nodule formation resulting from hyperplastic response to congenital vascular abnormality
CT appearance of FNH?
central scar in liver containing large artery
s/s of FNH?
asymptomatic
Dx for FNH?
CT*, USS, MRI, FNA
True/False…
tx for FNH is radiofrequency ablation?
False..
no tx for FNH
hepatic adenomas are largely associated with ____ because…
women due to contraceptive hormones
what is a hepatic adenoma?
solitary fat containing lesions in right lobe
s/s of hepatic adenoma?
asymptomatic or sometimes RUQ pain
what is acute presentation of hepatic adenoma due to?
rupture, haemorrhage malignant tranformation (rare)
Dx for Hepatic Adenoma?
USS, CT, MRI, FNA
Tx for hepatic adenoma?
stop oral contraceptives, wt loss, monitor for malignant transformation, surgical excision if no regression
what are the 3 types of cysts that exist?
- simple cyst
- hydatid cyst
- polycystic liver disease
what is the pathogenesis of a simple cyst?
liquid collection lined by epithelium,
are simple cysts solitary or grouped?
solitary
s/s of simple cysts?
asymptomatic but symptoms may present if ruptures, compressed or due to infection
tx for simple cysts?
imaging in 3-6months, consider surgical excision
what are hydatid cysts?
disseminated disease or erosion of cysts
what organisms causes hydatid cysts?
echinococcus granulosus
dx for hydatid cysts?
hx appearance, serology (Anti E.granulosus Antibodies)
tx for hydatid cysts?
surgery (cystectomy or radical- lobectomy)
drainage= PAIR
Rx= Albendazole
what is the cause for polycystic liver disease?
embryonic ductal plate malformation of intrahepatic biliary tree
what is polycystic liver disease?
numerous cysts throughout liver parenchyma
what are the 3 types of polycystic liver disease?
- Von Meyenburg Complexes
- Polycystic Liver Disease
- Autosomal dominant polycystic kidney disease
von meyenburg complexes are…
incidental benign cystic nodules throughout liver
in polycystic liver disease, liver function is…?
preserved
in autosomal dominant polycystic kidney disease, kidney function…?
fails
tx for autosomal dominant polycystic kidney disease?
conservative
rare- aspiration, liver transplant
rx: somatostatin
what is the clinical presentation of a liver abscess?
pyrexia, leucocytosis, abdominal pain
hx for liver abscess?
abdominal or biliary infection? dental procedure?
tx for liver abscess?
broad spec antibiotic e.g. co-amoxiclav for 4 weeks
aspiration/drainage
echo- check for infective pericarditis
surgical
what is 1y liver cancer called?
hepatocellular carcinoma or hepatoma
is hepatocellular carcinoma commoner in males or females?
males
risk factors for hepatocellular carcinoma?
HBV, HCV, cirrhosis, alcohol excess, any chronic liver disease
presentation of hepatocellular carcinoma?
mass in RUQ, RUQ pain, obstruction so cholestasis- jaundice, high bilirubin, ascites, non-specific- wt loss, worsening of chronic liver disease
ix for Hepc carcinoma?
AFP (alpha fetoprotein)*, USS, CT, MRI, biopsy
Dx for hepc carcinoma?
AFP values >100ng suggestive of HCC
tx for HCC?
liver transplant*, resection but recurrence is high
local ablation w radio or ethanol
TACE: chemo in hepatic artery
prognosis of HCC?
poor- usually late finding and mets common to rest of liver
fibrolamellar carcinoma presents commonly in..
young
true/false…
people with chronic liver disease or cirrhosis have high risk of developing fibrolamellar carcinoma
false..
fibrolamellar carcinoma not related to end stage liver disease, HCC is
ix for fibrolamellar carcinoma?
AFP is normal
CT
Dx for fibrolamellar carcinoma?
CT- stellate scar with radial septa showing persistent enhancement
Tx for fibrolamellar carcinoma?
surgical resection, transplant, TACE
metastases from liver cancer are commonly to…?
colon, pancreas, stomach, breast, lung, skin
how would liver mets present?
mild cholestatic picture with preserved liver function
due to the central stellate scar on CT (thick fibrosis bands) what is a possible Ddx for fibrolamellar carcinoma?
focal nodular hyperplasia