Liver disease and Cirrhosis

Question 1

What are the general functions of the liver?

Answer 1

Storage,
Breakdown (drugs, toxins, ammonia)
Synthesis (bile, cholesterol, coagulation factors),
Immune function.

Question 2

What are some causes of chronic liver disease/cirrhosis?

Answer 2

Alcohol
Viral hepatitis,
Inherited - Alpha-1 antitrypsin deficiency, Wilson’s disease, Haemochromatosis.
Autoimmune hepatitis,
Metabolic - NAFLD
Biliary - PSC, PBC,
Vascular,
Medication
Think pre-hepatic, hepatic and post hepatic

Question 3

What is the result of long standing liver disease?

Answer 3

Cirrhosis (often synonymous with end stage liver disease) Presents with two clinical states:
Compensated liver disease - Asymptomatic.
Decompensated liver disease - Present with coagulopathy, jaundice, encephalopathy, ascites, GI bleeding

Question 4

What is a scorring system to determine severity of cirrhosis?

Answer 4

Child-Pugh score. It looks at encephalopathy, ascites, bilirubin, albumin and INR

Question 5

What is the clinical presentation of chronic liver disease>

Answer 5

Caput medusa,
Splenomegaly,
Palmar erythema,
Dupytren’s contracture,
Leuconychia (sign of hypoalbuminaemia),
Gyaencomastia ( reduced hepatic clearance of androgens leads to conversion to oestrogen).
Spider naevi (due to excess oestrogen, found in distribution of SVC)

Question 6

What are the features of hepatic decompensation?

Answer 6

A - altered mental state (hepatic encephalopathy)
B - Bleeding (coagulopathy and GI bleeding)
C - colour change (jaundice),
D - distension (ascites)
Ascites,
Encephalopathy,
Jaundice,
GI bleeding,
Coagulopathy.

Question 7

What are the investigations for liver disease/cirrhosis?

Answer 7

Non-invasive liver screen: LFTs, FBC, U&Es, virology, alpha1 antitrypsin, iron studies, AFP, serum copper and caeruloplasmin, auto-antibodies
Imaging: transient elastography to look at fibrosis, ultrasound, endoscopy

Question 8

What antibodies are seen in autoimmune hepatitis?

Answer 8

Antismooth muscle antibodies and ANA

Question 9

What can be seen on imaging in liver cirrhosis?

Answer 9

Nodular liver surface, small liver, ascites, splenomegaly, dilation of portal vein

Question 10

What are the investigations for cirrhosis?

Answer 10

Transient elastrography (fibroscan), measures how stiff the liver is.
Endoscopy,
Liver ultrasound every 6 months to check for hepatocellular cancer.
And if unsure of underlying cause then do liver screen.

Question 11

What are the different classifications of ascites?

Answer 11

By serum ascites albumin gradient. This looks at the albumin concentration in the ascitic fluid vs albumin conc in serum.
Either
< 11 = low SAAG (means peritoneum vessels are more permeable then normal as albumin can pass through).
or > 11= High SAAG (fluid pushed out of vessel, leaving high conc of albumin in blood)

Question 12

What are the causes of a high SAAG ascites?

Answer 12

1. Portal hypertension (pushes fluid our of vessels)
2. Right heart failure or constrictive pericarditis,
3. Cirrhosis,
4. Liver mets,
5. Budd-chiari syndrome

Question 13

What are the causes of a low SAAG ascites?

Answer 13

1. Hypoalbuminaemia (nephrotic syndrome or malnutrition)
2. Peritoneal malignancy,
3. Infections - TB,
4. Pancreatitis,
5. Bowel obstruction,

Question 14

What is the treatment of ascites?

Answer 14

1. Reduce dietary sodium,
2. Aldosterone antagonists +/- loop diuretic
3. Large volume paracentesis if tense ascites + albumin cover

Question 15

How do you diagnose spontaneous bacterial peritonitis?

Answer 15

Clinical features - fever, diffuse abdominal pain, diarrhoea and cirrhosis.
Ultrasound to detect ascites
Do paracentesis - Neutrophil count > 250cells /ul or WCC > 0.5
Culture - often shows e.coli

Question 16

What is the management and prophylaxis of SBP?

Answer 16

Treat - IV cefotaxime.
Prophylaxis - Patients with previous episode, patients with fluid protein < 15g/l andchild push score >9 or hepatorenal syndrome (continued until ascites has resolved). give cipro

Question 17

What are the haemochromatosis symptoms?

Answer 17

Early features = faitgue, erectile dysfuncction and arthralgia.
Bronze pigmentation (reversible),
Diabetes mellitus (irreversible),
Liver disease - hepatomegaly, cirrhosis (irreversible),
Cardiac failure (due to dilated cardiomyopathy - myopathy can be reversible)
Hypogonadism (irreversible),
Arthritis (irreversible),

Question 18

What are the investigations for haemochromatosis?

Answer 18

Transferrin saturation will be high (most useful) but also measure ferritin.
Test family members by testing for the HFE mutation

Question 19

What are some other investigations which should be done once haemochromatosis is confirmed?

Answer 19

LFTs,
Molecular genetic testing,
MRI - quantify liver/cardiac iron.
Liver biopsy if you suspect hepatic cirrhosis

Question 20

What is the management of haemochromatosis?

Answer 20

First line - venesection. Aim to keep transferrin saturation < 50% and ferritin conc <50 ug/l.
Second line - Desferrioxamine

Question 21

Describe features of hepatocellular carcinoma, investigations and treatment?

Answer 21

Most commonly occurs due to cirrhotic liver disease of Hep B.
Investigations - CT/MRI, CT PET, alpha fetoprotein and biopsy
Treatment - surgical rescection is mainstay, medication used = sorafanib

Question 22

Describe features of cholangiocarcinoma, investigations and treatment?

Answer 22

Can present with jaundice, often late stage at this point.
Investigations - obstructive LFTs, positive CA 19-9, CEA and Ca 123. CT/MRI and MRCP for imaging.
Treatment - Surgical resection

Question 23

How can you determine the difference between alcoholic or non alcoholic fatty liver disease

Answer 23

In alcoholic liver disease the AST is raised and so the AST/ALT ratio is above 1.5.
In NAFLD the AST is normal and the ALT can be raised so ratio is below 0.8

Question 24

What is a cause of renal failure in cirrhosis?

Answer 24

Hepatorenal syndrome - AKI diagnosis of exclusion.
Type1 - Rapidly progressive, Cr doubles to > 221 in less than 2 weeks. Poor prognosis.
Type 2 - slowly progressive

Question 25

What is the management of a liver abscess?

Answer 25

Drainage and antibiotics (amox, met and cipro)

Question 26

What is the management of hepatorenal syndrome?

Answer 26

Vasopressin analogues (terlipressin).
Large volume expansion with 20% albumin.
TIPS