Liver Disease

Question 1

what is liver cirrhosis

Answer 1

Results from chronic inflammation + damage to liver cells - necrosis of liver cells, followed by fibrosis + nodule formation
- this leads to impaired liver function and portal hypertension

Question 2

what are the most common causes of cirrhosis

Answer 2

alcoholic liver disease
non-alcoholic fatty liver disease
hepatitis B +C

Question 3

symptoms of cirrhosis

Answer 3

jaundice 
hepatomegaly
splenomegaly due to portal hypertension 
Spider Naevi
palmar erythema
ascites 
bruising 
caput medusae - may be seen with portal hypertension

Question 4

scoring system used to assess severity of cirrhosis

Answer 4

Child-Pugh score

Question 5

what are the stages of alcoholic liver disease

Answer 5

1. alcohol related fatty liver
   - build up of fat due to drinking, reverses within 2 weeks
2. alcoholic hepatitis
   - long term drinking causes inflammation
3. cirrhosis
   - irreversible changes due to scarring + fibrosis

Question 6

What is NAFLD?

Answer 6

non-alcoholic fatty liver disease

- linked to obesity, HTN, type 2 diabetes, hyperlipidaemia

Question 7

What are the 4 stages of NAFLD?

Answer 7

1. Steatosis: harmless fat buildup
2. NASH: non-alcoholic steatohepatitis
3. Fibrosis
4. Cirrhosis

Question 8

How is steatosis diagnosed?

Answer 8

Ultrasound

Question 9

what test should follow USS in patients with NAFLD

Answer 9

enhanced liver fibrosis blood test (ELF)

Question 10

What drugs can cause cirrhosis

Answer 10

amiodarone
methotrexate
sodium valproate

Question 11

cirrhosis predisposes to what cancer

Answer 11

hepatocellular carcinoma

Question 12

what marker is raised in hepatocellular carcinoma

Answer 12

AFP

- checked 6 monthly in patients with cirrhosis

Question 13

what would blood tests likely show in a patient with cirrhosis

Answer 13

increased PT time

low albumin

Question 14

what is decompensated cirrhosis

Answer 14

cirrhosis with complications of ascites / varices / encephalopathy

Question 15

how does cirrhosis cause portal HTN

Answer 15

cirrhosis increases the resistance of blood flow in the liver – as a result there is increased back pressure in the portal system
– results in swollen, tortuous vessels called varices at sites where portal system anastomoses with systemic venous system

Question 16

which veins form the portal vein?

Answer 16

superior mesenteric vein + splenic vein

Question 17

normal range for portal pressure

Answer 17

5-8 mmHg

Question 18

signs of portal HTN

Answer 18

splenomegaly
ascites
varices
caput medusae

Question 19

what drug can help prevent formation of varies and reduce risk of bleeding

Answer 19

propanolol

Question 20

What is ascites? What is the most common cause?

Answer 20

Fluid in the peritoneal cavity

Portal hypertension due to cirrhosis

Question 21

investigation of ascites

Answer 21

paracentesis

- need to know if fluid is a transudate (low protein) or exudate (high protein)

Question 22

does portal HTN cause a transudate or exudate

Answer 22

transudate

Question 23

tx of ascites

Answer 23

low sodium diet
spironolactone 1st line
paracentesis for tense ascites – ascites that is producing respiratory distress

Question 24

What does an ascites neutrophil count of >250 indicate?

Answer 24

spontaneous bacterial peritonitis

- a complication of ascites

Question 25

what organism usually causes spontaneous bacterial peritonitis

Answer 25

e.coli

Question 26

tx of spontaneous bacterial peritonitis

Answer 26

cefotaxime

Question 27

what is hepatorenal syndrome

Answer 27

kidney failure in context of severe liver disease - AKI does not respond to diuretic withdrawal - diagnosis of exclusion -- no nephrotoxic drug use / shock / structural injury

Question 28

tx of hepatorenal syndrome

Answer 28

terlipressin + albumin infusion

Question 29

what is hepatic encephalopathy

Answer 29

build up of ammonia causes neurological effects

Question 30

symptoms of hepatic encephalopathy

Answer 30

confusion sweet smelling breath (fetter hepaticus) Flap when hand is outstretched (asterixis) Inability to draw a 5 pointed star (constructional apraxia)

Question 31

How is hepatic encephalopathy managed?

Answer 31

``` Oral lactulose (laxative) is given to reduce colonic pH and limit ammonia absorption Antibiotics (Rifaximin/metronidazole) are given to reduce the number of bowel organisms, hence reducing ammonia production ```

Question 32

What is primary biliary cirrhosis?

Answer 32

autoimmune condition where small bile ducts are attacked by immune system -- resulting in obstruction of bile outflow and eventual liver fibrosis + cirrhosis

Question 33

who typically gets primary biliary cirrhosis

Answer 33

middle aged women with other autoimmune conditions e.g. thyroid/ RA/ SLE

Question 34

antibody in primary biliary cirrhosis

Answer 34

AMA

Question 35

presentation of primary biliary cirrhosis

Answer 35

``` pruritis xanthelasma jaundice fatigue GI disturbance ```

Question 36

what investigation diagnoses primary biliary sclerosis

Answer 36

liver biopsy | - lymphocyte infiltration, granulomas, loss of bile ducts, cirrhosis

Question 37

tx primary biliary cirrhosis

Answer 37

ursodeoxycholic acid

Question 38

What is primary sclerosing cholangitis?

Answer 38

Autoimmune destruction of large and medium sized bile ducts

Question 39

what condition is primary sclerosing cholangitis associated with

Answer 39

Ulcerative colitis

Question 40

presentation of primary sclerosing cholangitis

Answer 40

RUQ pain jaundice fatigue itch

Question 41

diagnostic investigation for primary sclerosing cholangitis

Answer 41

MRCP / ERCP | - multiple strictures with beaded appearance

Question 42

what cancer is primary sclerosis cholangitis associated with

Answer 42

cholangiocarcinoma

Question 43

tx of primary sclerosis cholangitis

Answer 43

ERCP to dilate strictures ursodeoxycholic acid cholestyramine

Question 44

how does a cholangiocarcinoma present

Answer 44

jaundice, weight loss, pruritis, persistent biliary colic symptoms

Question 45

ascites with a high SAAG gradient (>11g/L) is caused by what

Answer 45

transudate - liver cirrhosis - hepatic failure - Budd Chiari - alcoholic hepatitis

Question 46

ascites with a low SAAG gradient (<11g/L) is caused by what

Answer 46

exudate - malignancy - infection - nephrotic syndrome - pancreatitis