Medicine- gastroenterology Flashcards
The three stages of alcoholic liver disease
- Alcohol related fatty liver Drinking leads to a build-up of fat in the liver. If drinking stops this process reverses in around 2 weeks.
- Alcoholic hepatitis Drinking alcohol over a long period causes inflammation in the liver sites. Binge drinking is associated with the same effect. Mild alcoholic hepatitis is usually reversible with permanent abstinence.
- Cirrhosis Scar tissue replaces normal tissue. Irreversible. Stopping drinking can prevent further damage. Continued drinking has v poor prognosis.
Treatment of non alcoholic fatty liver disease
Mainstay is gradual weight loss (0.5-1 kg/wk) as rapid weight loss can worsen liver disease. Aim to lose at least 7-10% of body weight • some evidence for vitamin E (800 U daily) if there is hepatic inflammation • some evidence for benefits of coffee drinking (3 cups/d) and vitamin D Pioglitazone
Deranged AST and ALT suggests what?
Hepatocellular injury
Deranged ALP and bilirubin suggests what?
Cholestasis
Features of Wernicke’s encephalopathy
Confusion Oculomotor disturbances (disturbances of eye movements) Ataxia (difficulties with coordinated movements)
Stages of non-alcoholic fatty liver disease
- Non-alcoholic Fatty Liver Disease
- Non-Alcoholic Steatohepatitis (NASH)
- Fibrosis
- Cirrhosis
Risk factors non alcoholic fatty liver disease
Obesity Poor diet and low activity levels Type 2 diabetes High cholesterol Middle age onwards Smoking High blood pressure
Gold standard for diagnosis of cirrhosis
Liver biopsy Show bridging fibrosis and nodular regeneration
Progress of lab abnormalities in cirrhosis
Fall in platelet count <150 is the earliest finding, followed many years later with rise in INR, fall in albumin, rise in bilirubin, fall in glucose level (pre-terminal event)
Signs of cirrhosis
- Jaundice – caused by raised bilirubin
- Hepatomegaly – however the liver can shrink as it becomes more cirrhotic
- Splenomegaly – due to portal hypertension
- Spider Naevi – these are telangiectasia with a central arteriole and small vessels radiating away
- Palmar Erythema – caused by hyperdynamic cirulation
- Gynaecomastia and testicular atrophy in males due to endocrine dysfunction
- Bruising – due to abnormal clotting
- Ascites
- Caput Medusae – distended paraumbilical veins due to portal hypertension
- Asterixis – “flapping tremor” in decompensated liver disease
What is the MELD score in cirrhosis?
• Predicts 3 mo survival and used to stratify patients on transplant list • Based on creatinine, INR, total bilirubin, and serum sodium concentration
General management of cirrhosis patients
- Ultrasound and alpha-fetoprotein every 6 months for hepatocellular carcinoma
- Endoscopy every 3 years in patients without known varices
- High protein, low sodium diet
- MELD score every 6 months
- Consideration of a liver transplant
Management of ascites
-Sodium restriction -Diuretics (frusemide + spironolactone) -Prophylactic antibiotics against spontaneous bacterial peritonitis -Large volume paracentesis -TIPS
What can present with fever, abdominal pain, vomiting chills and nausea in a cirrhosis patient?
Spontaneous bacterial peritonitis. V bad prognosis
The mechanism for the development of ascites
Ascites is fluid in the peritoneal cavity. Increased pressure in the portal system causes fluid to leak from capillaries in the liver and bowel and in to the peritoneal cavity. The drop in circulating volume caused by fluid loss into the peritoneal space causes a reduction in blood pressure entering the kidneys. The kidneys sense this lower pressure and release renin, which leads to increased aldosterone secretion (via the renin-angiotensin-aldosterone system) and reabsorption of fluid and sodium in the kidneys. Cirrhosis causes a transudative, meaning low protein content, ascites. Ascites marks the start of decompensated liver disease.
Management of spontaneous bacterial peritonitis.
Take an ascitic culture prior to giving antibiotics Usually treated with an IV cephalosporin such as cefotaxime
Sites of varices
Gastro oesophageal junction
Ileocaecal junction
Rectum
Anterior abdominal wall via the umbilical vein (caput medusae
Treatment of stable varices
- Propranolol reduces portal hypertension by acting as a non-selective beta blocker
- Elastic band ligation of varices
- Injection of sclerosant (less effective than band ligation)
Treatment of bleeding oesophageal varices
- Resuscitation
- Vasopressin analogues (i.e. terlipressin) cause vasoconstriction + slow bleeding in varices
- Correct any coagulopathy with vitamin K + FFP (which is full of clotting factors)
- Giving prophylactic broad spectrum antibiotics has been shown to reduce mortality
- Consider intubation and intensive care as they can bleed very quickly and become life threateningly unwell
- Urgent endoscopy
- Injection of sclerosant into varices can be used to cause “inflammatory obliteration” of vessel
- Elastic band ligation of varices
- Sengstaken-Blakemore Tube = inflatable tube inserted into the oesophagus to tamponade bleeding varices. Used when endoscopy fails.
Most useful lab test to diagnose hepatic encephalopathy
Ammonia
Mode of inheritance, gene and chromosome for Wilson’s disease
Autosomal recessive defect in copper elimination (gene ATP7B) chromosome 13
Typical bacteria in spontaneous bacterial peritonitis
Gram-negatives compose 70% of pathogens: E. coli (most common), Streptococcus, Klebsiella
Copper deposition in the liver leads to what?
Chronic hepatitis and eventually liver cirrhosis
In Wilson’s disease copper deposits in the brain lead to what?
Deposits in the basal ganglia lead to Parkinsonism
Eye sign in Wilson’s disease + proper method of examination
Kayser-Fleischer rings in cornea (deposition of copper in Descemet’s corneal membrane)
Examine via slit lamp
Initial investigation of choice in Wilson’s disease
Serum caeruloplasmin.
May be low in Wilson’s Note it’s not specific and can be affected by cancer or inflammatory conditions
The definitive gold standard test for diagnosis Wilson’s disease
Liver biopsy for liver copper content
Rx Wilson’s disease
Copper chelation using:
- Penicillamine
- Trientene
Liver biopsy showing acid-Schiff-positive staining globules in hepatocytes is associated with what?
Alpha-1 antitrypsin
Liver biopsy with Perl’s stain to diagnose what?
Haemochromatosis
Haemochromatosis complications
- Type 1 Diabetes
- Liver Cirrhosis
- Iron deposits in the pituitary and gonads lead to endocrine and sexual problems (hypogonadism, impotence, amenorrhea, infertility)
- Cardiomyopathy (iron deposits in the heart)
- Hepatocellular Carcinoma
- Hypothyroidism (iron deposits in the thyroid)
- Chrondocalcinosis / pseudogout (calcium deposits in joints) causing arthritis
An antibody specific to primary biliary cirrhosis which forms part of the diagnostic criteria
Anti-mitochondrial antibodies
Investigation to confirm diagnosis of primary biliary cirrhosis
Liver biopsy
Who gets primary biliary cirrhosis?
mainly middle-aged women (M:F = 1:9)
Antibodies in coeliac disease
- Anti-tissue transglutaminase (anti-TTG)
- Anti-endomysial (anti-EMA).
- Also Deaminated gliadin peptides antibodies (anti-DGPs)
These antibodies relate to disease activity and will rise with more active disease and may disappear with effective treatment.