Liver symposium Flashcards
What are the major liver diseases?
alcohol related liver disease
viral hepatitis
non-alocholic fatty liver disease
autoimmune liver diseases
which 5 types of viruses cause viral hepatitis?
A, B, C, D and E
A and E are enteric + self-limiting acute infections
B, C and D are parenteral (away from mouth or alimentary canal) - cause chronic disease
Hepatitis A: epidemiology
Mostly in south America, Africa and Asia
Usually lasts under 8 weeks
asymptomatic cases are very common
acute disease diagnosed by IgM antibodies
transmission of Hep A can be through
faecal oral route
Who should Hep A immunisation should be give to?
Travellers
Patients with chronic liver disease
Injecting drug user (especially with HCV or HBV)
Haemophiliacs - people who have impaired blood clotting
Occupational exposure
lab workers
Men who have sex with men (MSM)
Hepatitis B epidemiology
high prevalence in eastern asia, africa/south africa, canada
describe the Hepatitis B virus structure
DNA polymerase
an inner protein core (HBcAg)
HBV DNA
outer lipid envelope containing HB surface antigen
Natural history of chronic hep B
chronic hep B - cirrhosis - Hepatocellular carcinoma or End stage liver disease
treatment options for HBV
pegylated interferon - contains 3 types of drug
oral antiviral drugs - eg lamivudine, adelovirm entecavir
Hepatitis C - info
rarely causes acute liver failure
can be acute or chronic
85% chronic HCV infection
most asymptomatic until cirrhotic
may have normal LFT’s
natural history of Hep C
exposure - chronic - cirrhosis - heptaocellular carcinoma - death
treatment of HCV
Acute HCV:-
either pegylated interferon-α or non-pegylated IFN
for at least 24 weeks
chronic:- antiviral therapy
Hepatitis D/ delta virus info
small RNA virus - doesn’t code for it’s own protein coat - enveloped by HBsAg (hep B surface antigen)
coinfection or super-infection with HBV
Very resistant to treatment
Hepatitis E info
high prev. in places like Mexico, India, China, Iran
Commonest cause of acute hepatitis in Grampian
Self-limiting, no long term sequelae ie doesn’t follow on from acute disease
No specific treatment
No effective vaccine currently available
Previously thought to be limited to tropical countries - caused rapid hepatic failure in pregnancy
Increasingly recognised in UK
What does Epstein-Barr virus (EBV) cause
Causes glandular fever and can generally cause mildly deranges LFTs only in immunocompromised hosts
common virus
What is Herpes simplex
rare severe acute hepatitis
What does the term Non- alcoholic fatty liver disease encompass? (3 things)
simple steatosis
non-alcoholic steatohepatitis
fibrosis and cirrhosis
what other conditions is NAFLD associated with
diabetes
obesity hypertriglyceridemia
hypertension
what genetic factors go into NAFLD?
what about ethnicity?
PNPLA3 gene
hispanics
Natural history of non-alcoholic fatty liver disease
normal liver — steatosis (accumulation of fat in liver) — non-alcoholic steatohepatitis (NASH- more serious form of NAFLD) with or without fibrosis — Cirrhosis of the liver
as it progresses, patient has an increased CV risk
How is NAFLD diagnosed
biochemical tests:- AST/ALT ratio
cytokeratin-18 - biomarker that determines whether NAFLD patient has NASH or no NASH
enhanced liver fibrosis panel (ELF) - blood test to determine severity of liver fibrosis
ultrasound, MR/CT, fibroscan
MR Spectroscopy - analyses molecules such as H2 ions or protons
liver biopsy
NAFLD scoring system: classes and criteria
estimates amount of scarring in the liver if patient answers high risk for 3 or more categories then they have severe liver damage
criteria - age, diabetes or impaired fasting glucose, BMI, AST:ALT, Platelet count, Albumin
Treatment options for non-alcoholic fatty liver disease
Diet and weight reduction + weight reduction surgeries
Exercise
Insulin sensitizers e.g. Metformin, Pioglitazone
Glucagon-like peptide-1 (GLP-1) - lower blood sugar
Farnesoid X nuclear receptor ligand - regulates many genes involved in lipid and glucose metabolism, liver regeneration, inflammation, and liver cancer e.g. Obeticholic acid
Vitamin E
Name some autoimmune liver diseases
Autoimmune hepatitis
Primary biliary cholangitis (PBC)
Primary sclerosing cholangitis (PSC)
Overlap syndromes - inflammatory rheumatic conditions that are linked to a number of diseases
Autoimmune cholangiopathy
IgG 4 disease
Autoimmune hepatitis
female predominant
elevated IgG
three types of antibodies
liver biopsy diagnostic
responds well to steroids
azathioprine long term
Primary biliary cholangitis
F>M
IgM elevated
anti-mitochondrial antibody positive
rash and fatigue common symptoms
Ursodeoxycholic acid - UDCA treatment of choice - dissolves gallstones
Primary sclerosing cholangitis
M>F
pANCA positive
intra and extrahepatic bile ducts involved
stricturing disease
MRCP test of choice
Biliary stents - treatment
Who do they give liver transplants to? (5)
Patients with…
Chronic liver disease with poor predicted survival
Chronic liver disease with associated poor quality of life
Hepatocellular carcinoma
Acute liver failure
Genetic diseases e.g. primary oxaluria, tyrosemia
Contraindications for transplant
Active substance or alcohol abuse
Active extrahepatic malignancy
Hepatic malignancy with macrovascular or diffuse tumor invasion
Severe cardiopulmonary or other comorbid conditions
3 scoring systems for to prioritise patients for liver transplant
Child’s Pugh scoring A, B and C
MELD score
UKELD score
Meaning of MELD score
and UKELD score
Model For End-Stage Liver Disease
United Kingdom Model for End-Stage Liver Disease
what is an orthotopic surgery?
Orthotopic liver transplantation, in which the previous liver is removed and the transplant is placed at that location in the body.
Post liver tranplant op treatment
Post operative ICU care
Multidisciplinary care
Prophylactic antibiotics and anti-fungal drugs
Anti-rejection drugs like steroids, Azathioprine
or Tacrolimus/Cyclosporine
