Liver disease and Cirrhosis Flashcards
What are the general functions of the liver?
Storage,
Breakdown (drugs, toxins, ammonia)
Synthesis (bile, cholesterol, coagulation factors),
Immune function.
What are some causes of chronic liver disease/cirrhosis?
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
What is the result of long standing liver disease?
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
What is a scorring system to determine severity of cirrhosis?
Child-Pugh score. It looks at encephalopathy, ascites, bilirubin, albumin and INR
What is the clinical presentation of chronic liver disease>
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)
What are the features of hepatic decompensation?
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.
What are the investigations for liver disease/cirrhosis?
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
What antibodies are seen in autoimmune hepatitis?
Antismooth muscle antibodies and ANA
What can be seen on imaging in liver cirrhosis?
Nodular liver surface, small liver, ascites, splenomegaly, dilation of portal vein
What are the investigations for cirrhosis?
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.
What are the different classifications of ascites?
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)
What are the causes of a high SAAG ascites?
- Portal hypertension (pushes fluid our of vessels)
- Right heart failure or constrictive pericarditis,
- Cirrhosis,
- Liver mets,
- Budd-chiari syndrome
What are the causes of a low SAAG ascites?
- Hypoalbuminaemia (nephrotic syndrome or malnutrition)
- Peritoneal malignancy,
- Infections - TB,
- Pancreatitis,
- Bowel obstruction,
What is the treatment of ascites?
- Reduce dietary sodium,
- Aldosterone antagonists +/- loop diuretic
- Large volume paracentesis if tense ascites + albumin cover
How do you diagnose spontaneous bacterial peritonitis?
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
What is the management and prophylaxis of SBP?
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
What are the haemochromatosis symptoms?
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),
What are the investigations for haemochromatosis?
Transferrin saturation will be high (most useful) but also measure ferritin.
Test family members by testing for the HFE mutation
What are some other investigations which should be done once haemochromatosis is confirmed?
LFTs,
Molecular genetic testing,
MRI - quantify liver/cardiac iron.
Liver biopsy if you suspect hepatic cirrhosis
What is the management of haemochromatosis?
First line - venesection. Aim to keep transferrin saturation < 50% and ferritin conc <50 ug/l.
Second line - Desferrioxamine
Describe features of hepatocellular carcinoma, investigations and treatment?
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
Describe features of cholangiocarcinoma, investigations and treatment?
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
How can you determine the difference between alcoholic or non alcoholic fatty liver disease
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
What is a cause of renal failure in cirrhosis?
Hepatorenal syndrome - AKI diagnosis of exclusion.
Type1 - Rapidly progressive, Cr doubles to > 221 in less than 2 weeks. Poor prognosis.
Type 2 - slowly progressive
What is the management of a liver abscess?
Drainage and antibiotics (amox, met and cipro)
What is the management of hepatorenal syndrome?
Vasopressin analogues (terlipressin).
Large volume expansion with 20% albumin.
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