Liver symposium ( - hepatitis )

Question 1

Non-alcoholic fatty liver disease encompasses 3 different entities

What are these?

Answer 1

Simple steatosis
Non alcoholic steatohepatitis
Fibrosis and cirrhosis

Question 2

Risk factors for NAFLD?

Answer 2

Obesity
Hypertension
Type 2 diabetes
Hyperlipidaemia

Age
Ethnicity (e.g. Hispanics)
Genetic factors (e.g. PNPLA3 gene)

Question 3

Describe the natural history / progression of the liver in NAFLD

Answer 3

Normal liver –> Steatosis –> NASH (+/- fibrosis) –> Cirrhotic liver

Question 4

How is NAFLD diagnosed?

Answer 4

Ultrasound - demonstration of steatosis without h/o alcohol abuse etc
+/- MR/CT

Liver biopsy - allows staging

AST/ALT ratio (with AST>ALT in NAFLD)

Question 5

What are the different aspects of the NAFLD score’s criteria?

What score is needed for a patient to be ‘high risk’

Answer 5

3 or more of:

Age > 45
Diabetes or IFG (impaired fasting glucose >7) 
BMI > 30
AST : ALT (AST>ALT)
Albumin < 34
Platelet count < 150

Question 6

What age is ‘high risk’ in the NAFLD score?

Answer 6

> 45

Question 7

What IFG score is high risk in the NAFLD score?

Answer 7

> or = 7 mmol/L

Question 8

What BMI is classed as high risk for NAFLD

Answer 8

> 30

Question 9

What AST : ALT ratio is high risk for NAFLD?

Answer 9

> 1

AST > ALT

Question 10

A platelet count of _______ is classed as high risk for NAFLD

Answer 10

< 150 (low)

Question 11

An albumin level of ________ is classed as high risk for NAFLD

Answer 11

< 34 (low)

Question 12

Highlight the treatment for NAFLD

Answer 12

Diet, weight reduction and exercise are the most important parts

Insulin sensitizers e.g. Metformin, Pioglitazone
Glucagon-like peptide-1 (GLP-1) analogues e.g. Liraglutide
Farnesoid X nuclear receptor ligand e.g. Obeticholic acid
Vitamin E
Weight reduction surgeries

Question 13

What are the types of automimmune liver diseases?

Answer 13

Autoimmune hepatitis
Primary biliary cholangitis (PBC)
Primary sclerosing cholangitis (PSC)
Overlap syndromes
Autoimmune cholangiopathy
IgG 4 disease

Question 14

What is autoimmune hepatitis?

Answer 14

Autoimmune attack on Hepatocytes causing chronic inflammation of the liver

Characterised by elevated levels of IgG and is more common in women

Question 15

What Immunoglobulin is elevated in autoimmune hepatitis?

Answer 15

IgG

Question 16

what are the 3 types of antibodies found in autoimmune hepatitis?

Answer 16

Type 1) ANA, SMA

Type 2) LKM1

Type 3) SLA

Question 17

How is autoimmune hepatitis diagnosed?

Answer 17

Liver biopsy

Question 18

How is autoimmune hepatitis managed?

Answer 18

Long term azathioprine

Question 19

What is primary biliary cholangitis?

Answer 19

Autoimmune disease in which there is a slow, progressive destruction of the intrahepatic bile ducts

Question 20

Primary biliary cholangitis causes elevated levels of what?

Answer 20

IgM antibodies

Question 21

What clinical signs/symptoms are there for primary biliary cholangitis?

Answer 21

Asymptomatic patients often found with:

• hepatomegaly
• elevated serum alkaline phosphatase
• elevated serum autoantibodies

Symptoms:

• pruritis (itchy skin) ± scratch marks?
• fatigue (often disabling)

Symptomatic patients may also have:

• jaundice
• xanthelasma
• cholesterol deposits on hand creases

Question 22

How is biliary cholangitis treated?

Answer 22

UDCA - Ursodeoxycholic acid
(basically supplements one of the secondary bile acids)

Others:
- Fat-soluble vitamin supplements (A,D,K) as these may be malabsorbed

Question 23

What is primary sclerosing cholangitis (PSC)?

What damage does it do?

Answer 23

Autoimmune disease in which there is scarring and fibrosis of both intrahepatic and extrahepatic bile ducts

Involves stricturing (narrowing) of these ducts which means that stuff cant drain as its meant to

Question 24

What are the risk factors for PSC?

Answer 24

INFLAMMATORY BOWEL DISEASE

Male > female

Question 25

How is Primary sclerosing cholangitis tested for?

Answer 25

Magnetic resonance cholangiopancreatography (MRCP)

just a spicy MRI

Question 26

What are the clinical signs of PSC?

Answer 26

Jaundice, recurrent cholangitis

Question 27

How is PSC treated?

Answer 27

Liver transplant

Biliary stents

Question 28

Who should be considered for liver transplantation?

Answer 28

Chronic liver disease with poor prognosis or poor quality of life

Hepatocellular carcinoma (HCC)

Acute liver failure

Certain genetic diseases - primary oxaluria, tyrosemia etc

Question 29

What are the contraindications for liver transplant?

Answer 29

Active substance or alcohol abuse*

Active extrahepatic malignancy

Hepatic malignancy with macrovascular or diffuse tumor invasion

Active and uncontrolled infection outside of the hepatobiliary system

Severe cardiopulmonary or other comorbid conditions

Psychosocial factors that would likely preclude recovery after transplantation

Technical and/or anatomical barriers

Brain death

Question 30

Highlight the post operative measures after a liver transplant

Answer 30

Post operative ICU care

Multidisciplinary care

Prophylactic antibiotics and anti-fungal drugs

Anti-rejection drugs:

• Steroids
• Azathioprine
• Tacrolimus/Cyclosporine

Question 31

What scoring systems are used to determine what patient receives a liver transplant with cirrhosis?

Answer 31

Child’s Pugh scoring A, B and C

MELD score ( Bilirubin, Creatinine and INR)*

UKELD( Bilirubin, Sodium, Creatinine and INR)