Liver symposium ( - hepatitis ) Flashcards
Non-alcoholic fatty liver disease encompasses 3 different entities
What are these?
Simple steatosis
Non alcoholic steatohepatitis
Fibrosis and cirrhosis
Risk factors for NAFLD?
Obesity
Hypertension
Type 2 diabetes
Hyperlipidaemia
Age
Ethnicity (e.g. Hispanics)
Genetic factors (e.g. PNPLA3 gene)
Describe the natural history / progression of the liver in NAFLD
Normal liver –> Steatosis –> NASH (+/- fibrosis) –> Cirrhotic liver
How is NAFLD diagnosed?
Ultrasound - demonstration of steatosis without h/o alcohol abuse etc
+/- MR/CT
Liver biopsy - allows staging
AST/ALT ratio (with AST>ALT in NAFLD)
What are the different aspects of the NAFLD score’s criteria?
What score is needed for a patient to be ‘high risk’
3 or more of:
Age > 45 Diabetes or IFG (impaired fasting glucose >7) BMI > 30 AST : ALT (AST>ALT) Albumin < 34 Platelet count < 150
What age is ‘high risk’ in the NAFLD score?
> 45
What IFG score is high risk in the NAFLD score?
> or = 7 mmol/L
What BMI is classed as high risk for NAFLD
> 30
What AST : ALT ratio is high risk for NAFLD?
> 1
AST > ALT
A platelet count of _______ is classed as high risk for NAFLD
< 150 (low)
An albumin level of ________ is classed as high risk for NAFLD
< 34 (low)
Highlight the treatment for NAFLD
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
What are the types of automimmune liver diseases?
Autoimmune hepatitis Primary biliary cholangitis (PBC) Primary sclerosing cholangitis (PSC) Overlap syndromes Autoimmune cholangiopathy IgG 4 disease
What is autoimmune hepatitis?
Autoimmune attack on Hepatocytes causing chronic inflammation of the liver
Characterised by elevated levels of IgG and is more common in women
What Immunoglobulin is elevated in autoimmune hepatitis?
IgG
what are the 3 types of antibodies found in autoimmune hepatitis?
Type 1) ANA, SMA
Type 2) LKM1
Type 3) SLA
How is autoimmune hepatitis diagnosed?
Liver biopsy
How is autoimmune hepatitis managed?
Long term azathioprine
What is primary biliary cholangitis?
Autoimmune disease in which there is a slow, progressive destruction of the intrahepatic bile ducts
Primary biliary cholangitis causes elevated levels of what?
IgM antibodies
What clinical signs/symptoms are there for primary biliary cholangitis?
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
How is biliary cholangitis treated?
UDCA - Ursodeoxycholic acid
(basically supplements one of the secondary bile acids)
Others:
- Fat-soluble vitamin supplements (A,D,K) as these may be malabsorbed
What is primary sclerosing cholangitis (PSC)?
What damage does it do?
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
What are the risk factors for PSC?
INFLAMMATORY BOWEL DISEASE
Male > female
How is Primary sclerosing cholangitis tested for?
Magnetic resonance cholangiopancreatography (MRCP)
just a spicy MRI
What are the clinical signs of PSC?
Jaundice, recurrent cholangitis
How is PSC treated?
Liver transplant
Biliary stents
Who should be considered for liver transplantation?
Chronic liver disease with poor prognosis or poor quality of life
Hepatocellular carcinoma (HCC)
Acute liver failure
Certain genetic diseases - primary oxaluria, tyrosemia etc
What are the contraindications for liver transplant?
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
Highlight the post operative measures after a liver transplant
Post operative ICU care
Multidisciplinary care
Prophylactic antibiotics and anti-fungal drugs
Anti-rejection drugs:
- Steroids
- Azathioprine
- Tacrolimus/Cyclosporine
What scoring systems are used to determine what patient receives a liver transplant with cirrhosis?
Child’s Pugh scoring A, B and C
MELD score ( Bilirubin, Creatinine and INR)*
UKELD( Bilirubin, Sodium, Creatinine and INR)
