Liver Pathology and Alcohol Flashcards
What factors precipitate hepatic encephalopathy?
Drugs
- sedatives
Dehydration
Infection
Hypokalemia
Constipation
High protein load
G.I bleeding
What serious effect may encephalopathy lead to in the brain and why?
cerebral oedema
- disruption/ dysregulation to the BBB
Name 2 physiological causes of palmar erythema:
Pregnancy
Hyperdynamic vascular states
What is the general management of cirrhosis:
Treat underlying cause
Maintain good nutritional status
Treat complications such as:
- ascites
- hepatic encephalopathy
- portal hypertension
- varices
Endoscopic analysis of varices
Hepatocellular carcinoma screening
- 6 monthly alpha fetal protein
Liver transplant
- need to meet the King’s college criteria
What scoring system can be used for the prognosis of cirrhosis?
Child - Pugh Classification
Which of the hepatitis viruses is DNA?
Hepatitis B
it is the only one
What are the viral infections other than hepatitis A-E that can infect the liver?
CMV
EBV
HSV
Yellow fever
What are the standard symptoms of any hepatitis?
Prodromal illness
- flu
- headache
- myalgia
Vomiting and diarrhea
Followed by:
- Jaundice
- Upper abdominal discomfort/ pain
Lymphadenopathy and splenomegaly in EBV
If needed what is the treated of Hepatitis A:
Immune serum globulin - usually reserved for those with liver disease already, elderly and pregnant women.
Vaccine is available.
What are the complications of Hepatitis B?
Cirrhosis
Hepatocellular carcinoma
What is HbSAg an indicator of?
Active infection
What does HbSAb demonstrate?
Immunity with either:
- previous infection
- Immunisation (Anti HBc will be present)
What does HBeAg represent?
Active replication of the virus in the blood
How can the response to antivirals in Hepatitis B be monitored?
PCR of viral load
What may cause a high viral load but a low HBeAg and HBeAb?
Mutation in the pre-core protein which results in the inability to secrete e antigen, thus no antigen (suggesting to active replication) but a high viral load which does suggest active viral replication
What are the two drug types used to treat hepatitis B?
Direct acting nucleosides/ nucleotides
- reverse transcriptase inhibitors
- Tenofovir
- Entecavir
Interferon alpha
- causes a rise in transaminases - contraindicated in cirrhosis
- bone marrow suppression
- autoimmune thyroid disease
What are the risk factors for hepatitis C infection?
IV drug use
Unscreened blood products
Vertical transmission
Needle stick injury
How long does Hepatitis C RNA take to appear in the blood?
2 weeks
Antibodies take 6-12 weeks
*think needlestick injury testing
What percent of Hepatitis C patient will develop liver cirrhosis?
20%
2-5% of them will develop carcinoma
What is the treatment of Hepatitis C?
Direct acting antivirals
- proteas inhibitors
What type of hepatitis is very dangerous to pregnant woman and what can it cause?
Hepatitis E
Guillain Barre syndrome
What are some signs and symptoms of alcohol withdrawal?
Tachycardia Low BP Tremor and confusion Seizures Hallucinations
Delirium Tremens
- shaking
- agitation
- Hallucinations
What is the treatment for Wilson’s disease?
Penicillamine
Why does renal failure occur in Cirrhosis?
Reduced Circulating volume
Lack of clearance of immune complexes
What things would inhibit someone getting a liver transplant, according the king’s college criteria?
extrahepatic malignancy
non compliance with drug therapy
on going alcohol consumption
How is prioritisation for liver transplants measured?
UK end stage liver disease score
What things can lead to cirrhosis being decompensated?
Dehydration Constipation Alcohol use Infection Opioid use G.I bleed
What do the bloods usually show in alcohol hepatitis and how is it management of alcohol liver disease?
Bloods show:
- increased white cell count
- Reduced platelets (splenomegaly)
- increased INR
- High AST
- High MVC
- High urea
Management:
- screen for infection / ascitic tap
- stop alcohol - chlordiazepoxide
- optimise nutrition
- give Vit K
- daily weights
- Steroids *based on the Maddrey discrimination factor (>31)`
How would you manage SBP?
Diagnostic tap:
- Microbiology
- Biochemistry
- Cytology
sepsis 6 management
Antibiotics:
- Tazocin
How does Wernicke’s present? and how is it treated and why?
Ataxia
Ophthalmoplegia (nystagmus)
Confusion
Treated with:
- thiamine - Pabrinex
+
- Glucose
Essential to treat thiamine first as build up of glucose can cause metabolic acidosis
Which drugs cause a Hepatocellular derangement in enzymes and which cause a cholestasis derangement?
Hepatocellular (ALT high, ALP normal):
- Paracetamol
- sodium valproate
- Nitrofurantoin
- statins
Cholestasis:
- Co-amoxiclav
- Erythromycin
- flucloxacillin
- Oral contraceptive
- Steroids
What is the presentation and complications of PBC?
Jaundice Xanthelasma Fatigue Pruritus Inflammatory Arthropathy
Complications:
- cirrhosis
- Coagulopathy
- Osteoporosis - unable to absorb fat soluble vitamins
What scoring system is used to stage hepatocellular carcinoma?
Barcelona Clinic Liver Cancer
What scoring systems can be used to assess mortality from Liver cirrhosis?
Child Pugh scoring system
What criteria must be met for liver transplantation?
Milan criteria:
- < 5 cm
- < 3 cm for 3 tumours
- no metastasis
- No vascular infiltration
What are the non - surgical options for treatment of liver cancer?
Image guided ablation
- using ultrasound to induce necrosis
Trans-arterial Chemoembolisation
- where chemo is injected into the main arterial branch supply the tumour and then is embolized cutting off blood supply
What Antibodies are associated with Autoimmune Hepatitis?
Type 1 -
- soluble liver antigen
- ANA
Type 2
- Anti liver and kidney microsomal
List some causes of a low SAAG ratio:
Peritoneal carcinoma TB Biliary Ascites Pancreatic ascites Obstruction
What biliary tract disorder gives a beaded appearance on MRCP?
PSC
In the setting of alcohol withdrawal, what screening tool can be used to assess the most appropriate management? regarding discharge, referral or drug intervetion?
Fast Alcohol Screening Tool
- FAST
What screening tool can be used to assess the severity of withdrawal?
Clinical Institute withdrawal assessment of alcohol scale
What scoring system can be used in Alcoholic hepatitis?
Glasgow Alcoholic hepatitis score
What are the contraindications to a liver transplant?
Metastasis Extra-hepatic cancer Poor anatomy Cardiovascular disease - extensive Poor compliance
What are the clinical signs of haemochromatosis?
MEALS
Myocardial
- cardiomyopathy
Endocrine
- Diabetes
- Hypopituitarism
Arthritis
Liver
- cirrhosis
Skin
- tanning
- grey colouring
What drugs can be used preventively in alcohol abuse?
Acamprosate
- GABA receptor agonist
Disulfiram
- promotes unpleasant nausea when combined with alcohol
What in the management of alcoholic hepatitis?
Stop alcohol
Treat withdrawal
Pabrinex
Vitamin K
Steroids
- need daily weights
- *monitor urine output
What will the ABG show in liver failure?
Metabolic acidosis
What antibodies are associated with PSC?
Anti ANA
p-ANCA
*should be screened for in post hepatic jaundice
What are the typical symptoms associated with Budd Chiari Syndrome?
Severe sudden onset Abdominal Pain
Tender hepatomegaly - as gleason’s capsule is being stretched
Ascites
- usually in the background of:
- polycythemia rubra vera - most common cause
- coagulopathy
- contraceptive pill
Why might someone with alcoholic liver disease develop abnormal sensation in their peripheries?
Due to alcoholic neuropathy
What Antibody type is raised in autoimmune hepatitis?
IgG
What infection can give rise to symptoms of fever, jaundice, renal failure and conjunctivitis following swimming in dirty/ contaminated water?
Leptospirosis
- associated with contaminated water that animals have urinated into.
**tested by dark field microscopy of the urine
Which antibody may be raised in PSC?
p- ANCA
How does metastasis to the liver present?
Hepatomegaly which is craggy in nature.
- usually liver will be smoothly hepatomegaly
What are the symptoms associated with autoimmune hepatitis and how is it treated?
Jaundice
Fatigue
Polyarthralgia
Associated autoimmune conditions
Treatment:
Steroids
Azathioprine
Liver Transplant
What are the LFT results in PBC?
Obstructive
- increased Alkaline phosphatase
Later transaminases will defect
What is the treatment for PBC?
Cholestyramine
- for pruritus
Bisphosphonates
Liver specific:
- Ursodeoxycholic acid
- liver transplant
What is the diagnosis of choice for PSC?
MRCP
What scoring system can be used to assess need for liver transplantation?
Model of end-stage liver disease - MELD
>20
Child Pugh classification
grade C
What are some symptoms of encephalopathy?
Reversal of sleep pattern Reduced attention span Dyspraxia Reduced conscious level Flapping tremor
What are the definitive symptoms of acute liver failure:and what investigations are wanted?
Encephalopathy
Increased PT/ INR time
Investigations:
- coagulation
- LFTs
- Blood glucose
- U&Es - renal disturbance is a big issue
- ABG - lactic acid - metabolic acidosis
- Toxicology screen
