Liver GI Flashcards
When would you start calling it a chronic liver failure?
The onset of liver failure on a background of cirrhosis.
What are the FOUR STAGES OF HEPATIC ENCEPHALOPATHY?
(1) Altered mood and behaviour. Disturbance of sleep pattern and dyspraxia
(2) Drowsiness, confusion, slurring of speech and personality change
(3) Incoherency, restlessness, asterixis
(4) Coma
INR test is used when?
To establish a diagnosis of liver failure
What are the King’s College Criteria for liver transplant for paracetamol-induced?
Arterial pH <7.3, 24h after ingestion (eg, overdose)
OR
Pro-thrombin time >100s
AND creatinine >300µmol/L
AND grade III or IV encephalopathy.
What are the King’s College Criteria for liver transplant for non-paracetamol-liver failure?
Prothrombin time >100s (INR >6.5)
OR
Any three of:
Drug-induced liver failure
Age under 10 or over 40 years
1 week from 1st jaundice to encephalopathy
Prothrombin time >50s
Bilirubin ≥300µmol/L.
The most Commonest causes of liver cirrhosis are?
Alcohol
Hepatitis B and C
Non-alcoholic fatty liver disease (NAFLD)
Chronic hepatitis symptoms are what?
Patient presents with fatigue, malaise, low-grade fever, and hepatomegaly
Congestive heart failure symptoms are what?
The patient has symptoms of;
Dyspnoea
Fatigue
Fluid retention
Peripheral oedema.
Explain the Child-Pugh Score
The severity of liver cirrhosis
=
Score: 1 2 3
Bilirubin (umol/l): <34 34-51 >51
Albumin (g/l): >35 28-35 <28
Prothrombin time (seconds prolonged): <4 4-6 >6
Encephalopathy: none mild marked
Ascites: none mild marked
A MELD score of 6-9 indicates what?
Low risk of mortality; Class I (less than 10%)
A MELD score of 10-19 indicates what?
Intermediate risk of mortality; Class II (19%)
A MELD score of 20-29 indicates what?
High risk of mortality; Class III (52%)
A MELD score of 30-39 indicates what?
Severe risk of mortality; Class IV (71%)
A MELD score of ≥ 40 indicates what?
Very severe risk of mortality; Class V (95%)
A 59-year-old woman is admitted to the hospital with alcohol withdrawal. She is noticed to have deranged liver function and clotting results, so she undergoes an abdominal ultrasound scan and fib4 testing and is found to have liver cirrhosis. Despite completing treatment for alcohol withdrawal and being declared medically fit for discharge, she becomes increasingly confused whilst awaiting transport home. On assessment, her vital signs are all within normal ranges. What is the most appropriate medication to prescribe while further investigations are pending?
Explain why you have chosen this medication.
Lactulose
= Patients with new confusion on a background of liver cirrhosis should raise suspicion for hepatic encephalopathy.
This occurs due to a build-up of ammonia, and an ammonia blood test can be used to aid diagnosis.
Lactulose can help to prevent and treat this because it encourages the excretion of ammonia through the digestive system in faeces.
Patients with new-onset confusion in liver cirrhosis should be started on lactulose and aim for two to three loose stools per day
A 52-year-old man attends the Gastroenterology Clinic for review. He complains that his breasts appear to have enlarged slightly over the past few years. What is the cause of gynaecomastia in cirrhosis?
Altered oestrogen metabolism
What is the most common complication of acute liver failure?
Bacterial infections
What are other complications that may arise in a person who has acute liver failure?
(1) Cerebral oedema ± raised intracranial pressure
(2) Bleeding
(3) Hypoglycaemia (easily treated with glucose)
(4) Multi-organ failure.
What helps reduce encephalopathy?
Lactuolse
What is used to reduce cerebral oedema in hepatic encephalopathy?
Intravenous mannitol
When would you prescribe Spironolactone
In oedema or ascites in liver cirrhosis
A 64-year-old man was recently diagnosed with alcohol-related liver cirrhosis. He presents to the emergency department feeling generally unwell with worsening abdominal swelling. On examination, there is evidence of asterixis, abdominal distension with shifting dullness and some generalised abdominal tenderness. An ascitic tap is performed and demonstrates a white cell count of 300/mm3, predominantly neutrophils. Lactulose and spironolactone have already been commenced.
Which of the following is the best next step in the management of this patient?
Commence broad-spectrum antibiotics
What happens to Prothrombin time during liver cirrhosis?
Increases
What is the leading cause of acute hepatitis?
Hepatitis E
What is Hepatitis C associated with? (strongly)
Hepatocellular carcinoma
+Ve HBsAG is what?
Hepatitis B
= Currently Infected
+Ve HBeAG is what?
Hepatitis B
= Highly Infected
+Ve Hep B IgM is what?
Hepatitis B
= Recently Infected
+Ve Hep B IgG is what?
Hepatitis B
= Chronically Infected
+Ve Anti-HBs is what?
Hepatitis B
= Vaccine or previous infection
+Ve Anti-HBc is what?
Hepatitis B
= Previous Infection
(+) serology but (-) PCR Indicates what?
Hepatitis C
= Past Infection
(+) serology and (+) PCR Indictaes what?
Hepatitis C
= Current Infection
What is Hep D treated with?
Pegylated interferon for 48 weeks
Chronic hep B is treated with what?
Tenofovir, Entecavir, Pegylated Inferon
When and who can get a vaccination to treat their hepatitis
- Vaccine available for hepatitis B – requires 3 doses
- Recommended for certain groups
What causes an increase in cardiovascular risk?
NAFLD
Weight loss and exercise in those with NAFLD with the aim of doing what?
Preventing the progression to NASH
Weight loss and exercise in those with NASH with the aim of doing what?
Prevent the progression to cirrhosis
Explain what is Type 1 Autoimmune Hepatitis
ANA positive, with anti-smooth muscle antibodies
More common in females
Explain what Type 2 Autoimmune Hepatitis is
Anti-liver/kidney mitochondrial type 1 antibodies (LKM1)
Children and young adults
What would the blood results show for a patient suffering from alcoholic liver disease hepatitis?
LFTs - AST > ALT
↑ GGT
Prolonged PT
↓ albumin
↑ bilirubin suggests end-stage ALD (cirrhosis)
Is Primary sclerosing cholangitis T cell or B cell mediated?
T cell - CD4+ cells react against antibodies
What is the second line after Ursodeoxycholic acid for Primary sclerosing cholangitis?
Obeticholic acid
How would you investigate ascites?
Do a tap in all ascites and cell count - Neutrophil count >250 cells/mm3
(1) Ultrasound - Darkness (fluid)
What is the management of ascites in order?
(1) Diuretics
Spironolactone - first line - blocks aldosterone (RAAS)
In recurrent ascites - dual step-wise increments of spironolactone and loop diuretic-furosemide
U+Es should be monitored frequently
(2) Paracentesis
Drain inserted into the abdomen
- For patients with large volumes of ascites or if their kidneys will not tolerate drainage via diuretics
(3) Trans-jugular intra-hepatic portosystemic shunt (TIPSS)
If paracentesis has to occur too frequently
A tract was created between the hepatic vein and the portal vein within the liver and a stent was inserted to keep it open
Removes portal hypertension so removes drive towards ascites
(4) Liver transplantation
Last line
Describe Prehepatic portal hypertension
Obstruction
Blockage of the portal vein before the liver due to portal vein thrombosis or occlusion secondary to congenital portal venous abnormalities
Describe Intrahepatic portal hypertension
Cirrhosis
Due to distortion of the liver architecture
- Presinusoidal e.g. schistosomiasis
- Post sinusoidal e.g. cirrhosis - most common cause
Describe Post hepatic portal hypertension
- Budd Chiari
- Veno-occlusive
What is the clinical presentation of Hepatic Encephalopathy?
(1) Slow flapping tremor
(2) Confusion
(3) Presents similarly to alcohol withdrawal
Describe the management for Hepatic Encephalopathy.
- Lactulose
- Antibiotic e.g. rifaximin - changes pH
- If spontaneous consider transplantation - sign of advancing liver failure
What is the management for haemochromatosis?
Venesection
= A procedure to reduce red blood cells
What is the management for Wilson’s disease?
Penicillamine
Explain what is Alpha-1 Antitrypsin Deficiency
Genetic disorder that may result in lung disease or liver disease
What is the clinical presentation of Alpha-1 Antitrypsin Deficiency?
Pulmonary symptoms - cough, wheeze, dyspnoea
Hepatic symptoms - hepatitis, cirrhosis
What are the 2 bacteria most commonly associated with spontaneous bacterial peritonitis?
Escherichia coli and Klebsiella pneumoniae
A 25-year-old man is brought into A&E by his partner. She is concerned as for the past 24 hours he has ‘not been himself’ – she reports that he is confused, drowsy and is slurring his speech. On examination, he is tender in the right upper abdominal quadrant and has a scleral icterus. When asked, he is unable to draw a simple five-pointed star. He has a past medical history of severe depression.
Which of the following blood tests would be of most use in establishing a diagnosis of acute liver failure (ALF)?
INR
A 32-year-old Afro-Carribean woman presents to the respiratory clinic with a 2-month history of dry cough.
On examination, there are several abdominal spider naevi and evidence of hepatomegaly. There are several red nodules on the patient’s shins bilaterally.
She is diagnosed with liver cirrhosis. Which of the following is the most likely underlying cause?
Sarcoidosis
A 50-year-old man presents to his GP. He has suffered for many years with recurrent episodes of shortness of breath and wheezing. He denies any smoking history. His GP has prescribed him Salbutamol and Ipratropium inhalers but to no benefit. This morning while looking in the mirror, he noticed that the whites of his eyes appeared yellow.
Which investigation is more likely to confirm the underlying diagnosis?
Serum alpha-1 antitrypsin
A friend brings a 29-year-old man into the Emergency Department. He is incoherent and drowsy. His friend tells you that he has not been himself all day. His medical notes show that he is an HCV-positive intravenous drug abuser and an alcoholic. He is jaundiced, with stigmata of chronic liver disease, no palpable liver, but a spleen tip and a small amount of ascites. What would be your first investigation?
Capillary blood glucose
Asterixis is also known as what?
Hepatic flap
A 65-year-old woman who has recently been diagnosed with polycythaemia rubra vera is admitted to the Emergency Department with sudden onset abdominal pain and swelling. On examination, she had a tender, palpable liver, with moderate abdominal distension and shifting dullness. What is the most likely diagnosis
Budd-Chiari Syndrome
A 52-year-old female with a history of hepatitis C and chronic liver disease is brought in by ambulance, having been found collapsed in the street. She seems very confused and is unable to give a clear history. On examination, she has a grossly distended abdomen with evidence of shifting dullness.
An ascitic tap confirms the diagnosis of spontaneous bacterial peritonitis. What is the most appropriate treatment to prescribe?
Ceftriaxone, Cefotaxime, or Ciprofloxacin
A 69-year-old gentleman with a past medical history of cirrhosis secondary to alcohol-related liver disease is scheduled to have an abdominal ultrasound scan and his alpha-fetoprotein (AFP) measured as part of the screening programme for hepatocellular carcinoma. He was previously admitted to intensive care earlier this year due to spontaneous bacterial peritonitis. On examination, his vitals are within normal range, with few physical signs of cirrhosis.
Which is associated with increased oestrogen in the context of liver cirrhosis?
Palmar erythema
A 25-year-old female presents with vomiting and abdominal pain after taking a paracetamol overdose. Her plasma paracetamol concentration is above the treatment line. What is the most appropriate next step in the management of this patient?
N-acetylcysteine (NAC) infusion
Ingestion less than 1 hour ago + dose >150mg/kg
Paracetamol overdose
activated charcoal
Ingestion <4 hours ago
Paracetamol overdose
Wait until 4 hours to take a level and treat with N-acetylcysteine based on level
Ingestion within 4-8 hours + dose >150mg/kg
Paracetamol overdose
Start N-acetylcysteine immediately if there is going to be a delay of ≥8 hours in obtaining the paracetamol level
Ingestion within 8-24 hours + dose >150mg/kg
Paracetamol overdose
Start N-acetylcysteine immediately
Ingestion >24 hours ago
Paracetamol overdose
Start N-acetylcysteine immediately if the patient has jaundice, right upper quadrant tenderness, elevated ALT, INR >1.3 or the paracetamol concentration is detectable
Staggered overdose
Paracetamol Overdose
Start N-acetylcysteine immediately
Accumulation of excess fluid in the peritoneal cavity
Ascites > Liver cirrhoris
The Serum-Ascites Albumin Gradient (SAAG) is calculated by what?
A high SAAG > 1.1g/dL indicates the ascites is due to what?
Plasma [albumin] - ascitic [albumin] in g/dL
Portal hypertension
A 23-year-old woman presents to her GP with a 2-month history of fatigue and intermittent abdominal discomfort. She denies any yellowing or itchiness of the skin or pale stool. Blood tests show a normal full blood count and thyroid function tests; however, she has a raised alanine aminotransferase (ALT) and IgG.
Which autoantibodies are expected to be positive based on the most likely diagnosis?
Anti-smooth muscle antibody
When is Alpha-feto-protein (AFP) marker used?
hepatocellular carcinoma (HCC) and testicular cancer
Anti-mitochondrial antibodies are found where?
Primary biliary cirrhosis
A 26-year-old gentleman attends the Emergency Department complaining of a 6-month history of worsening tremors in his both hands and increased clumsiness. His partner also notes that he has been short-tempered and more forgetful recently as well. On examination, he has a postural tremor affecting both upper limbs, but otherwise, the examination is unremarkable. Routine blood show deranged liver function tests. A diagnosis of Wilson’s disease is suspected.
Which blood test would aid diagnosis?
Caeruloplasmin - serum
Azathioprine is a first line drug for what?
Autoimmune hepatisis
Abnormal liver function tests (LFTs) or hepatomegaly
Jaundice
Right upper quadrant pain
Fatigue, weight loss, fevers, and sweats
Associated with ulcerative colitis
Suggests what?
primary sclerosing cholangitis
Characterized by elevated transaminases, hypergammaglobulinemia, and positive autoantibodies
Suggests what?
Autoimmune hepatitis
Investigations of primary sclerosing cholangitis
Deranged LFTs, showing a cholestatic picture
Positive anti-smooth muscle and antinuclear antibodies and myeloperoxidase antineutrophil cytoplasmic antibody (ANCA)
(MRCP) or (ERCP)
The ratio of AST: ALT is usually 2:1 or greater. Indicates what condition?
Alcoholic hepatitis
A 54-year-old woman is referred to outpatient clinic with pruritis, lethargy and jaundice.
What is the likely diagnosis?
Primary biliary cholangitis
Liver cirrhosis main test to confirm diagnosis
Serum alpha-1 antitrypsin
A high SAAG (>1.1g/dL) would suggest what conditions?
Heart failure
cirrhosis
Budd-Chiari syndrome
constrictive pericarditis
Liver failure
A low SAAG (<1.1g/dL) would suggest what conditions?
malignancys / infections.
Extreme fatigue
Pruritus (itching)
Xerosis (dry skin)
Sicca syndrome (dry eyes)
Jaundice
Suggests what disease?
Primary biliary cholangitis
What is the diagnosis of Primary biliary cholangitis?
Abnormal liver function tests
Positive Anti-mitochondrial antibodies (AMAs) in >90% of individuals
Raised serum IgM
Abdominal ultrasound to visualize the liver
MRCP
Liver biopsy showing inflammation and scarring
What are the indications for the TIPSS procedure?
(1) Ascites
(2) Secondary prophylaxis of variceal haemorrhage that does not respond to medical management
Hepatitis A management control plan
Advice on infection control and supportive management
Sofosbuvir is a medication for what hepatitis?
C
Anti-mitochondrial antibody levels are the diagnostic test for what?
Primary Biliary Cholangitis
A 65-year-old gentleman with cirrhosis secondary to alcoholic liver disease has had multiple admissions with ascites requiring regular abdominal paracentesis. He is planned to have a transjugular intrahepatic portosystemic shunt (TIPSS) procedure for his refractory ascites. Which of the following is he most at risk of following the TIPSS?
Hepatic encephalopathy
A 67-year-old man is being investigated for abnormal liver function tests. He is due to undergo a liver biopsy. What test results would be a contraindication to the procedure going ahead?
INR is >1.5
Causes of a high SAAG (>11g/L) include what?
Cirrhosis
Heart failure
Budd Chiari syndrome
Constrictive pericarditis
Hepatic failure
Causes of a low SAAG (<11g/L) include what?
Cancer of the peritoneum, metastatic disease
Tuberculosis, peritonitis and other infections
Pancreatitis
Hypoalbuminaemia
Gallstones can cause cholestatic jaundice but what has to be present?
Pain
Whats most likely cause of Jaundice- antibiotic?
Co-amoxiclav
Causes and signs of pre-hapatic jaundice include;
Causes;
(1) Conjugation disorders, such as Gilbert’s disease and Crigler-Najjar
(2) Haemolysis (such as malaria or haemolytic anaemia)
(3) Drugs, such as contrast or rifampicin
Signs;
haemolysis, anaemia (fatigue, chest pain, palpitations, lightheadedness)
Causes and signs of hepatocellular dysfunction/ hapatic include;
Causes;
(1) Viruses (hepatitis, CMV, EBV)
(2) Drugs, including paracetamol overdose
(3) Tuberculosis antibiotics
(4) Alcohol
(5) Cirrhosis
(6) Liver mass (abscess or malignancy)
(7) Haemochromatosis
(8) Autoimmune hepatitis
(9) Alpha-1 antitrypsin deficiency
(10) Budd-Chiari
(11) Wilson’s disease
(12) Failure to excrete conjugated bilirubin (Rotor and Dubin-Johnson syndromes)
Signs;
RUQ pain, fever, viral illness, risk factors include: IVDU/tattoo, UPSI
Post-hepatic causes and signs include:
Causes;
(1) Primary biliary cirrhosis
(2) Primary sclerosing cholangitis
(3) Common bile duct gallstones or
(4) Mirrizi’s syndrome
(5) Drugs, including co-amoxiclav, flucloxacillin, steroids, sulfonylureas
(6) Malignancy, such as head of the pancreas adenocarcinoma, cholangiocarcinoma
(7) Caroli’s disease
(8) Biliary atresia
Signs;
dark urine, pale stools, itch
A 47-year-old patient presents to your clinic with newly diagnosed chronic hepatitis C. What is the most appropriate management strategy for this patient?
Direct-acting antiviral (DAA) therapy
A 56-year-old man with alcoholic liver disease presents to the Emergency Department with a distended, painful abdomen and feeling generally unwell. On examination, he is generally tender, and percussion reveals shifting dullness. Bloods show deranged liver function tests and raised inflammatory markers. His doctor suspects spontaneous bacterial peritonitis (SBP).
What is the most appropriate next step in this patient’s management?
Ascitic tap
Ischaemic hepatitis presents usually with what ALT?
Severly raised = >1000u/L
Hepatocellular liver function tests
(1) ALT and AST are higher than ALP.
(2) This indicates damage to liver cells (hepatocytes).
= Commonly seen in conditions like viral hepatitis or liver damage due to alcohol
Cholestasis liver function tests
(1) ALP is higher than ALT and AST.
(2) This suggests a blockage in the bile ducts, impairing the flow of bile from the liver.
= Conditions like gallstones or tumours can cause this
The raised anti-mitochondrial antibody (AMA), right upper quadrant pain and increased ALP point towards a diagnosis of what?
primary biliary cholangitis
In patients with PBC there’s a significant risk of developing what condition?
Hepatocellular carcinoma
Type 1 diabetes young female indicates what
autoimmune
