Liver Disease and Cirrhosis

Question 1

name a pattern on LFTs that could be used to differentiate between NAFLD and AFLD

Answer 1

AST in alcoholics is normally elevated 1.5 x ALT levels which normally remain normal
In NAFLD the AST is not normally elevated

Question 2

name the characteristic features of alcoholic hepatitis

Answer 2

Hepatomegaly, fever, leucocytosis, hepatic bruit

Question 3

name some clinical features of alcoholic liver disease

Answer 3

• Malaise
• Nausea
• Hepatomegaly
• Fever
• Jaundice
• Sepsis
• Encephalopathy
• Ascites
• Renal Failure
• Death

Question 4

name some signs of chronic liver disease

Answer 4

•	Stigmata: spider naevi, 
•	Fœtor, 
•	Encephalopathy.
•	‘Synthetic dysfunction’:
o	Prolonged prothrombin time
o	Hypoalbuminaemia

Question 5

name some signs of portal hypertension

Answer 5

• Caput medusa
• Hypersplenism:
• Thrombocytopenia
• (pancytopenia)

Question 6

name three reasons that cirrhosis leads to fluid overload

Answer 6

back pressure created by the cirrhosis
Loss of albumin leads to a decline in the oncotic pressure of the blood
hyperaldosteronism results due to the reduced effective circulating volume, resulting in the body retaining even more fluid and sodium.

Question 7

name some causes of acute liver failure

Answer 7

• Infections e.g. viral hepatitis
• Toxins e.g. ETOH, paracetamol
• Vascular e.g. Budd-chiari
• Others e.g. NAFLD, Wilson’s disease, Haemochromatosis, malignancy
• Obstetrics – eclampsia acute fatty liver of pregnancy

Question 8

Define acute liver failure

Answer 8

Defined by rapid decline in hepatic function – recognised by development of coagulopathy, new onset jaundice, and hepatic encephalopathy

Question 9

how would you treat acute liver failure

Answer 9

• IV albumin and terlipressin
• Haemodialysis if renal failure develops
• Liver transplant
o Decide if candidate for a transplant

Question 10

name some complications of acute liver failure

Answer 10

•	Bleeding 
o	Vitamin K, platelets, FFP, blood as needed 
•	Ascites 
o	Fluid restrict and use of diuretics 
•	Sepsis 
•	Hypoglycaemia 
o	Regular BMs, glucose solution if their glucose drops below 2
•	Encephalopathy 
o	Lactulose +/- enemas 
o	Lactulose if catabolised by gut bacteria to short chain fatty acids, decreasing colonic pH and reducing the ammonia in the colon by trapping it 
•	Seizures 
o	Lorazepam 
•	Cerebral oedema – major risk 
o	Mannitol

Question 11

how do you treat acute liver failure and where should the patient be treated?

Answer 11

•	IV albumin  and terlipressin 
•	Haemodialysis if renal failure develops 
•	Liver transplant 
o	Decide if candidate for a transplant 
ITU

Question 12

define hepatorenal syndrome

Answer 12

Cirrhosis + ascites + renal failure = Hepatorenal syndrome when all other causes of renal impairment have been excluded. The cirrhosis causes abnormal haemodynamics which leads to splanchnic arterial vasodilatation, increasing the effective circulatory volume. This activates RAS causing renal vasoconstriction. IF this leads to persistent underfilling of the renal vasculature it eventually leads to renal failure

Question 13

define cirrhosis

Answer 13

Cirrhosis is a diffuse pathological process, characterised by fibrosis and loss of normal liver architecture with formation of nodules

Question 14

name some signs you may see in the face of a person with cirrhosis

Answer 14

o Pallor: ACD
o Xanthelasma: PBC
o Parotid enlargement (esp. ̄c EtOH)

Question 15

Name some abdominal signs of cirrhosis

Answer 15

o Striae
o Hepatomegaly (may be small in late disease)
o Splenomegaly
o Dilated superficial veins (Caput medusa)
o Testicular atrophy

Question 16

name some hand signs of cirrhosis

Answer 16

o	Clubbing (± periostitis) 
o	Leuconychia (↓ albumin) 
o	Terry’s nails (white proximally, red distally) 
o	Palmer erythema 
o	Dupuytron’s contracture

Question 17

name some precipitating factors for hepatic encephalopathy

Answer 17

1. Gastrointestinal bleeding
2. Infections
3. Constipation
4. Electrolyte imbalance

Question 18

name four complications of portal hypertension

Answer 18

a. Splenomegaly
b. Ascites
c. Varices
d. Encephalopathy

Question 19

name some features of decompensated liver disease

Answer 19

a. Jaundice (conjugated)
b. Encephalopathy
c. Hypoglycaemia
d. Hypoalbuminemia

Question 20

if a patient has a conjugated jaundice what colour is their urine and stool likely to be

Answer 20

dark urine

pale stool.

Question 21

what could cause a conjugated jaundice

Answer 21

hepatocellular dysfunction - hepatocyte damage, likely with some level of cholestasis. Causes - viruses, drugs, live mets, cirrhosis
cholestasis - PBC, PSC, CBD gallstons, pancreatic cancer, compression

Question 22

what would cause an unconjugated jaundice

Answer 22

Unconjuagted - not water-soluble.

Causes: haemolysis, drugs (paracetamol), Gilbert’s