MEDICINE - GASTROENTEROLOGY Flashcards
Liver cirrhosis
chronic inflammation and damage to liver cells (fibrosis and nodule formation)
4 main causes of liver cirrhosis
Alcohol-related liver disease
Non-alcoholic fatty liver disease (NAFLD)
Hepatitis B
Hepatitis C
signs of liver cirrhosis
Cachexia (wasting of the body and muscles)
Jaundice
Hepatomegaly
Small nodular liver
Splenomegaly
Spider naevi (telangiectasia with a central arteriole and small vessels radiating away)
Palmar erythema caused by elevated oestrogen levels
Gynaecomastia and testicular atrophy in males due to endocrine dysfunction
Bruising due to abnormal clotting
Excoriations (scratches on the skin due to itching)
Ascites (fluid in the peritoneal cavity)
Caput medusae (distended paraumbilical veins due to portal hypertension)
Leukonychia (white fingernails) associated with hypoalbuminaemia
Asterixis (“flapping tremor”) in decompensated liver disease
non invasive liver screen
-US liver (used to diagnose fatty liver)
-Hepatitis B and C serology
-Autoantibodies (autoimmune hepatitis, primary biliary cirrhosis and primary sclerosing cholangitis)
-Immunoglobulins (autoimmune hepatitis and primary biliary cirrhosis)
-Caeruloplasmin (Wilsons disease)
-Alpha-1 antitrypsin levels (alpha-1 antitrypsin deficiency)
-Ferritin and transferrin saturation (hereditary haemochromatosis)
autoantibodies in liver disease
Antinuclear antibodies (ANA)
Smooth muscle antibodies (SMA)
Antimitochondrial antibodies (AMA)
Antibodies to liver kidney microsome type-1 (LKM-1)
decompensated liver cirrhosis LFT
All raised:
-Bilirubin
-Alanine transaminase (ALT)
-Aspartate transferase (AST)
-Alkaline phosphatase (ALP)
how to assess fibrosis in Non alcoholic fatty liver disease?
enhanced liver fibrosis blood test
- three markers (HA, PIIINP and TIMP-1) and score calculation
enhanced liver fibrosis 10.51 or above
advanced fibrosis
US in non alcoholic fatty liver disease
fatty changes, increased echogenicity
liver cirrhosis ultrasound signs
-Nodularity of the surface of the liver
-A “corkscrew” appearance to the hepatic arteries with increased flow as they compensate for reduced portal flow
-Enlarged portal vein with reduced flow
-Ascites
-Splenomegaly
screening for hepatocellular carcinoma
alfa-fetoprotein and US
transient elastography (fibro scan)
assesses stiffness of liver and degree of fibrosis
which pts are at risk of cirrhosis?
-Alcohol-related liver disease
-Heavy alcohol drinkers (men drinking more than 50 units or women drinking more than 35 units per week)
-Non-alcoholic fatty liver disease and advanced liver fibrosis (score 10.51 or more on the ELF blood test)
-Hepatitis C
-Chronic hepatitis B
what to assess when someone has portal hypertension?
oesophageal varices (via endoscopy)
MELD score
% risk of 3 month mortality in pts with compensated cirrhosis
Child Pugh Score
5 factors of severity of cirrhosis (min 5, max 15)
A – Albumin
B – Bilirubin
C – Clotting (INR)
D – Dilation (ascites)
E – Encephalopathy
Monitoring complications of liver cirrhosis
- MELD score every 6 months
- Ultrasound and alpha-fetoprotein every 6 months for hepatocellular carcinoma
- Endoscopy every 3 years for oesophageal varices
decompensated liver cirrhosis features
A – Ascites
H – Hepatic encephalopathy
O – Oesophageal varices bleeding
Y – Yellow (jaundice)
5 year survival in liver cirrhosis
50%
complications of liver cirrhosis?
-Malnutrition and muscle wasting
-Portal hypertension, oesophageal varices and bleeding varices
-Ascites and spontaneous bacterial peritonitis
-Hepatorenal syndrome
-Hepatic encephalopathy
-Hepatocellular carcinoma
portal vein anatomy
comes from superior mesenteric and splenic veins
portal hypertension
increased back pressure on the portal system due to resistance to blood flow in the liver
results in splenomegaly
collaterals between portal and systemic venous systems
Distal oesophagus (oesophageal varices)
Anterior abdominal wall (caput medusae)
prophylaxis of bleeding in stable oesophageal varices
Non-selective beta blockers (e.g., propranolol) first-line
Variceal band ligation (if beta blockers are contraindicated)
Mx of bleeding esophageal varices
- fresh frozen plasma
- blood tranfusion
- vasopressin analogues (terlipressin and somatostatin)
- broad spectrum Abx
- variceal band ligation under endoscopy
- Sengstaken-Blakemore tube
- TIPS
what is TIPS
Transjugular intrahepatic portosystemic shunt - so blood flows directly from portal vein to hepatic vein
what is the protein content of cirrhosis ascites?
low - transudative
mx of ascites
-paracentesis
- tips
- aldosterone antagonists
- prophylactic abx (ciprofloxacin or norfloaxacin) when <15g/L protein in ascitic fluid
most common organisms in spontaneous bacterial peritonitis
-Escherichia coli
-Klebsiella pneumoniae
hepatorenal syndrome
impaired kidney funciton caused by changed in blood flow to the kidneys due to liver cirrhosis and portal hypertension. liver transplant is treatment
Hepatic encephalopathy
(portosystemic encephalopathy)
due to build up of ammonia (as liver metabolism of ammonia is impaired and ammonia bypasses the liver due to collateral vessels)
acute presentation of hepatic encepatholpathy
reduced consciousness and confusion +- changed to personality, memory, mood
Factors that trigger hepatic encepatholpathy
dehydration
constipation
infection
GI bleed
electrolyte disturbance
Mx of hepatic encephalopathy
- lactuose
- Abx (rifaximin or alternatively metronidazole or neomycin)
Alcohol-related liver disease steps
- Alcoholic fatty liver (hepatic steatosis)
- Alcoholic hepatitis
- Cirrhosis
Excessive alcohol consumption
- slurred speech
- bloodshot eyes
- telangiectasia
- tremor
Blood test results in alcohol-related liver disease
- raised MCV
- raised ALT and AST
- AST:ALT ratio >1.5
- raised gamma GT
- raised ALP and bilirubin
- Low albumin
early alcoholic liver disease US
fatty changes and increased echogenicity
Liver biopsy
to confirm alcohol related hepatitis or cirrhosis
Mx of alcohol-related liver disease
- corticosteroids
- liver transplant
- vitamin B
- psychological interventions
CAGE questions
C – CUT DOWN? Do you ever think you should cut down?
A – ANNOYED? Do you get annoyed at others commenting on your drinking?
G – GUILTY? Do you ever feel guilty about drinking?
E – EYE OPENER? Do you ever drink in the morning to help your hangover or nerves?
AUDIT questionnaire
alcohol use disorders identification test (8or more is harmful)
alcohol withdrawal steps
6-12 hours: tremor, sweating, headache, craving and anxiety
12-24 hours: hallucinations
24-48 hours: seizures
24-72 hours: delirium tremens
delirium tremens
alcohol stimulates GABA receptors (relaxing) and inhibits glutamate (NMDA) receptors (excitatory) - when alcohol is removed there is down regulation of gaba and up regulation of NMDA.
delirium tremens presentation
Acute confusion
Severe agitation
Delusions and hallucinations
Tremor
Tachycardia
Hypertension
Hyperthermia
Ataxia (difficulties with coordinated movements)
Arrhythmias
Chlordiazepoxide (librium)
benzodiazepine to combat effects of alcohol withdrawal
diazepam
used to reduce effect of alcohol withdrawal - orally, 10-40mg every 1-4h and reduced over 5-7days
what vitamin is given in delirium tremens?
IM high dose vit B (PABRINEX) and long term oral thiamine - to prevent Wernicke-Korsakoff syndrome
what does thiamine deficiency lead to?
Wernicke’s encephalopathy and Korsakoff syndrome.
features of Wernicke’s encephalopathy
Confusion
Oculomotor disturbances (disturbances of eye movements)
Ataxia (difficulties with coordinated movements)
features of Korsakoff syndrome
Memory impairment (retrograde and anterograde)
Behavioural changes
which one is irreversible? wernickes vs korsakoff
korsakoff syndrome
how many adults have non alcoholic fatty liver disease?
25%
stages of non alcoholic fatty liver disease?
Non-alcoholic fatty liver disease
Non-alcoholic steatohepatitis (NASH)
Fibrosis
Cirrhosis
risk factors for non alcoholic fatty liver disease?
Middle age onwards
Obesity
Poor diet and low activity levels
Type 2 diabetes
High cholesterol
High blood pressure
Smoking
what is non alcoholic fatty liver disease associated with?
metabolic syndrome
what is a metabolic syndrome?
HTN, obesity, and diabetes
non alcoholic fatty liver disease blood tests/ diagnosis
- raised ALT
- enhanced liver fibrosis >10.51
- hepatic steatosis and increased echogenicity on US liver
-Fibroscan - Liver biopsy
- NAFLD fibrosis score
- Fibrosis 4 (FIB4)
AST ALT ratio <1
normal
AST ALT ratio >0.8 in NAFLD
advanced fibrosis
AST ALT ratio >1.5
alcohol related liver disease
Gold standard test to diagnose NAFLD
Liver biopsy
Mx of NAFLD
exercise, stop smoking, reduce BP and cholesterol, limit alcohol, weight loss;
+ vit E, pioglitazone, bariatric surgery, liver transplant
Hep A details
RNA, faecal-oral transmission, vaccine, treatment supportive
Hep B details
DNA, blood/bodily fluids transmission, vaccine, supportive+antiviral treatment
Hep C
RNA, blood transmission, no vaccine, direct acting antivirals treatment
Hep D
RNA, transmision is with Hep B, no vaccine, pegylated interfereon alpha treatment
Hep E
RNA, faecal-oral transmission, no vaccine, supportive treatment
is vital hepatitis a notifiable disease?
yes - UK Health security agency
Other (non viral) causes of hepatitis
Alcoholic hepatitis
Non-alcoholic steatohepatitis (NASH)
Autoimmune hepatitis
Drug induced hepatitis (e.g. paracetamol overdose)
presentation of viral hepatitis
Abdominal pain
Fatigue
Flu-like illness
Pruritus (itching)
Muscle and joint aches
Nausea and vomiting
Jaundice
hepatitic picture on LFTs
high AST and ALT
proportionally less rise in ALP
