Metabolic 1: Introduction to Hepatology Flashcards
Abnormal liver tests: acute
6 weeks
Drugs
Viral hepatitis (A,B,C,E)
Autoimmune hepatitis
Wilson’s disease
Abnormal liver tests: subacute
6-28 weeks
Drugs
Viral hepatitis (A,B,C)
Autoimmune hepatitis
Wilson’s disease
Abnormal liver tests: chronic
> 26 weeks
Viral hepatitis (B,C)
Alcohol
NAFLD
Autoimmune hepatitis
Wilson’s disease
Hemochromatosis
A1 antitrypsin deficiency
Assessment of liver function
Blood tests: basic liver panel
Liver screen for all causes of liver disease
Imaging
Liver tests
Bilirubin (17umol/l)
Liver enzymes
- asparate aminotransferase (40io/l)
- alanine aminotransferase (40iu/l)
- alkaline phosphatase (200iu/l)
- gamma GT (50iu/l)
Albumin (40 gm/l)
Prothrombin time
INR
Abnormal LFT’s: liver screen
Hepatitis serology: hepatitis A IgM, hepatitis B surface antigen, hepatitis C antibody, hepatitis E IgG and IgM
ANA, SMA LKM (for autoimmune hepatitis)
AMA (for primary biliary cholangitis)
Alpha 1 antitrypsin
Copper, caeruloplasmin (Wilson’s disease)
Ferritin (genetic haemochomatosis)
Ultrasound
Abnormal liver tests: hepatic
Viral hepatitis A,B,C,E
Drug induced liver injury
AUtoimmune hepatitis
Abnormal liver tests: cholestatic
Biliary obstruction
Viral hepatitis A,B,E
DILI
Autoimmune hepatitis
Primary biliary cirrhosis cholangitis (more women)
Primary sclerosing cholangitis (more men)
Cirrhosis
Generally irreversible chronic liver disease
Increase pressure in the portal circulation, also known as portal hypertension
Liver failure: development of coagulatory and encephalopathy
Acute: within 4 weeks
Subacute: between 4-12 weeks
Acute on chronic: in setting of underlying chronic liver disease
In acute liver failure
No pre-existing liver disease
Coagulopathy
Confusion (hepatic encephalopathy)
Jaundice
Abnormal liver tests
Cerebral oedema
Increased risk of infections
Renal failure (hepatorenal syndrome)
In cirrhosis
Portal hypertension
- varices
- ascites
- hepatic encephalopathy
Jaundice
Spiders
Enlarged spleen/ pancytopenis
Renal failure
Hepatocellular cancer
Stage 1 cirrhosis
Compensated without varices
Stage 2 cirrhosis
Compensated with varices
Stage 3 cirrhosis
Decompensated with ascites without variceal hemorrhage
Stage 4 cirrhosis
Decompensated with/out ascites with variceal hemorrhage
Ascites management in cirrhosis
Salt restriction
Fluid restriction if low sodium
Diuretics (spironolactone and frusemide)
Large volume paracentesis with albumin cover
If refractory ascites
- recurrent LVP
- transjugular intrahepatic portosystemic shunt
- consider liver transplant
- long term drains
Variceal bleed
Haemodynamically stable, correct coagulopathy and thrombocytopenia
IV terlipressin and IV antibiotics
Endoscopy in theatre with anaesthetist present- variceal banding
If blood bath- ballon tamponade
Non selective B blockers for secondary prophylaxis
Hepatorenal syndrome (AKI)
Functional and fairly rapid renal impairment due to reduced renal perfusion
Increase in serum creatinine by 50% from baseline within 3 months
Type 1 and 2
Treat underlying cause, terlipressin
Liver transplant
Hepatic encephalopathy
Elevated ammonia
Diagnosis of exclusion
Treat precipitating cause: constipation, diuretics, infection, sedatives, GI bleed
Lactulose
Non absorbable antibiotics
Paracetamol overdose
Present with nausea, vomiting, RUQ pain, confusion
Jaundice and liver failure usually develops after 3-4 days
Very high liver enzymes and prothrombin time
If receive N acetyl cysteine within 16 hours liver failure rare
Some benefit of NAC even up to 36 hours
In severe cases liver transplant only option
Severe alcoholic hepatitis
Most serious form of alcohol related injury
Characterised by jaundice and coagulopathy
In patient untreated mortality 40%
Various prognostic scores
Treatment: steroids and pentoxyfilline
Risk factors for hepatitis C virus
Recipients of clotting factors made before 1987
Injection drug use
Long term haemodialysis
Individuals with multiple sex partners
Recipients of blood transfusions prior to July 1992
Infants born to infected women
Factors associated with disease progression of hepatitis C
Alcohol consumption
- 30g/day in men
- 20g/day in women
Disease acquisition at >40 years
Male gender
HIV coinfection
Hepatitis B virus coinfection
Immunosuppression
Hepatitis C: natural history
Normal liver»_space;
Acute infection»_space;
Chronic infection develops in 80%»_space;
Chronic hepatitis»_space;
Cirrhosis develops in 20%»_space;
Risk of carcinoma, 1-4% per year
Non alcoholic fatty liver disease
Resemble alcoholic liver disease but occur in absence of alcohol abuse
usually associated with metabolic syndrome: type 2 DM, obesity, HTN, and elevated TG
Underlying mechanism is insulin resistance
Indications for liver transplant in cirrhosis
Ascites/ SBP
Variceal bleeding
Hepatic encephalopathy
Hepatocellular cancer
