Liver Diseases

Question 1

What you know about autoimmune hepatitis?

Answer 1

In young females, associated with other autoimmune diseases.
Progress to fibrosis and cirrhosis
Ix- ^ALT AST
hypergamaglobulinaemia
Mild normochromic normocytic anemia with thrombocytopenia and leucopenia
3 types - type 1 (ANA, anti smooth muscle ab)
Type 2 - (anti liver kidney microsomal ab, anti liver cytosole ab) affect children only.
Type 3- soluble liver kidney ag ab. Affects adults in middle age. Now a part of type 1

Mx- perdnisolone,azathioprine, liver transplant

Question 2

NASH mechanism

Answer 2

Osmosis

Question 3

NASH Mx and Ix?

Answer 3

Ix- USS , CT, MRI , Elastography, biopsy
Mx- weight loss, strict control of HTN DM and lipid, regular followup, vit E, pioglitazone, liver transplant in end stage

Question 4

Etiology of hemachromatosis

Answer 4

1. Primary - HFE gene mutation on chromosome 6. Enterocytes absorb iron even when there’s no need.
2. Frequent blood transfusions

Question 5

Clinical features of hemachromatosis

Answer 5

1. triad- hepatomegaly, bronze skin, DM ( also malabsorption due to destruction of exocrine glands)
2. Cardiomyopathy,arrhythmia
3. hypogonadism and other pituitary hormones (amenorrhea,testicular atrophy)
4. calcium pyrophosphate deposition of large and small joints, chondrocalcinosis

Question 6

Ix and Mx of hemachromatosis

Answer 6

Ix-
High serum iron 
High transferrin saturation 
Low transferrin production
Low TIBC 
High ferritin 
LFT often normal 
Biopsy (diagnostic) 

Mx- venesection
Chelation
Desferioxamine

Question 7

Ix and Mx for alcoholic liver disease

Answer 7

Ix- 
High MCV 
AST>ALT
High gamma GT 
elastography
Low albumin
^PT 

Mx- 
Stop drinking 
Tx complications 
Prednisolone (severity measure by maddrey score) 
Transportation in end stage

Question 8

What is the pathophysiology of Wilson’s disease?

Answer 8

Osmosis

Question 9

Clinical features of Wilson’s disease?

Answer 9

Children- often present with hepatic prob
Young adults- more neurological problems, tremors, dysarthria, involuntary movements, dementia,chorea
Acute/chronic hepatitis,cirrhosis
KF rings

Question 10

Ix and Mx of Wilson’s disease?

Answer 10

Ix-
Reduced serum copper and caeruloplamin
Increased urinary copper

Tx-
Life time penicillamine/trientine
SE- skin rash, leucopenia, skin changes, renal damage.

Question 11

Pathophysiology of cirrhosis?

Answer 11

Osmosis

Question 12

Aetiological criteria of cirrhosis?

Answer 12

Alcohol
Metabolic 
Infective 
Immune
Biliary
Genetic 
Venoocclusive disease

Question 13

Complications of cirrhosis?

Answer 13

Portal HTN 
asites and SBP
Congestive spleenomegaly 
Portosystemic shunt 
Hepatic encephalopathy 
Hepatorenal failure 
hepatopulmonary syndrome 
Decrease liver function 
Increase estrogen in blood 
Jaundice 
Hypoalbuminemia
Decreased coagulation

Question 14

Features of decompensated liver disease?

Answer 14

Hepatic encephalopathy 
Ascites
Bleeding 
Portal HTN 
new onset jaundice

Question 15

Prognostic indicators of cirrhosis?

Answer 15

Low albumin
Low serum sodium
Prolonged PT >_6s
Increased creatinine

Question 16

What are the Ix of cirrhosis?

Answer 16

Uss abd 
FBC 
LFT 
serum bilirubin 
Serum albumin, PT/INR 
RFT 
Serum alpha feto protein 

Aetiology- 
Hep B and C serology 
ANA, ASMA
serum caeruloplasmin, 24hr urinary cu excretion, serum Fe studies 
Anti mitochondrial ab 

Liver biopsy

Severity of cirrhosis-
Modified child Pugh classification
Model of endstage liver disease (MELD)

Question 17

Mx of cirrhosis?

Answer 17

General Mx-
Treat causative agent
Adequate diet ( correct deficiencies, veg protein 1g/kg/day, adequate calorie 25-35 kcal/kg/day, vit and mineral supplements, salt restrictions)
Avoid physical exertion,dehydration
Vaccines
Avoid ppt factors of HE ( dehydration, constipation, hypokalemia, hyponatremia, drugs, infection, surgery, UGI bleeding, hypovolemia)

Question 18

Mx of haematemesis?

Answer 18

Resuscitation
Left lateral
2 wide bore
Blood for FBC DT grouping
IV NS 20ml/kg
FFP or packed red cells if needed
IV omeprazole
IV vassopresin , octreotide, terlipressin
Prophylactic antibiotic (3rd gen cephalosporin)
Urgent endoscopic but doing injection sclerotherapy or banding
Balloon tamponade with a sengstaken-blakemore tube
Drugs to mx HE
prophylactic non selective beta blocker (o propranolol)
Follow up endoscopy
TIPS

Question 19

Mx of ascites?

Answer 19

IP OP chart and daily weight chart 
Salt restricted diet (<2g/d) 
Diuretics 
Large volume paracentesis (with or without albumin 10g/L) 
Watch out for HE and pre renal ARF

Question 20

Mx of spontaneous bacterial peritonitis?

Answer 20

Exclude the DDs
Empirical broad spectrum antibiotics
IV albumin (1.5 g/kg initially, 1g/kg 48hrs later)
Correct adrenal insufficiency

Question 21

Mx of HE?

Answer 21

Grade 
Elevate the head end 
IP OP chart and proper fluid Mx 
Tx the underlying cause 
Nutrition- veg protein 
Maintain electrolyte balance 
Tx infection 
Reduce N load from gut (lactulose 30ml 3-4 times a day) 
Metronidazole 200mg tds /rifaximine
Branched amino acid 
Mannitol in cerebral edema

Question 22

Precipitating factors of HE

Answer 22

GI- haemorrhage,constipation,high protein diet
Infection-SBP,pneumonia,UTI
Electrolyte imbalance-hypokalemia,hyponatremia,dehydration, uraemia
Drugs- benzodiazepine,sedatives,K loosing diuretics
Surgery-TIPS
superimposed acute liver disease(acute hep), hep ca