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GI > NAFLD, autoimmune, alcohol > Flashcards

NAFLD, autoimmune, alcohol Flashcards

1
Q

Why does NAFLD occur

A

Fat deposit in the liver = steatosis
Unknown cause
Underlying insulin resistance?

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2
Q

How does NAFLD progress

A

Steatosis
NASH = Steatohepatitis
Fibrosis
Cirrhosis

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3
Q

Who is at risk of NAFLD

A 
Age 
Obesity
DM
Smoking
Hyperlipid / cholesterol
High BP 
Sudden weight loss / starvation 
Ethnicity
Polycystic ovaries
Hep B+C
Genetics - FH
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4
Q

Who is more at risk of progression to cirrhosis

A

Age
Obesity
DM

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5
Q

What can cause acute liver injury on top of NAFLD

A

Drugs so always review

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6
Q

What are the symptoms of NAFLD

A

Asymptomatic

May be picked up on USS or routine LFT - increased fatty hepatocytes and echogenicity

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7
Q

What must you do if diagnosed with NAFLD

A

Look for fibrosis

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8
Q

What are the symptoms of NASH

A

Aching pain
Fatigue
Weight loss
Hepatomegaly

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9
Q

Is NASH reversible

A

NO

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10
Q

What are the symptoms of cirrhosis

A 
Jaundice
HSM
- Hepatomegaly (usually small if chronic) 
- Splenomegaly due to portal HTN 
Thrombocytopenia = bruising
Weight loss
Dark urine / pale stool
Pruritus
Palmar erythema 
Spider naevi
Clubbing 
Leukonychia
Dupytren's 
Parotid gland enlargement 
Decompensated Sx
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11
Q

What is decompensatd liver function

A

Liver unable to do job

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12
Q

What are the symptoms of decompensated disease

A 
Portal hypertension
Jaundice
Ascites
Encephalopathy 
Varices
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13
Q

How do you Dx NAFLD

A

Abnormal LFT - ALT > AST (opposite in alcohol)

USS

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14
Q

What do you do if NAFLD Dx

A

Enhanced Liver Fibrosis - look for fibrosis (expensive)
NAFLD Score if ELF not available
FIB4 score if not available
Cytokeratin 18 - biomarker for NASH
Non invasive liver screen to look for cause

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15
Q

What are imaging if looks like cirrhosis on USS

A

Fibroscan if score suggest high risk
Liver biopsy - not usually needed
MRI / CT if suspect malignancy
Endoscopy for varices

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16
Q

How do you treat NAFLD

What may improve fibrosis

What for symptoms

A 
Lifestyle = mainstay 
Diet and weight
DM control
Exercise
Treat high BP and cholesterol
Avoid alcohol 
Vit E may improve fibrosis - specialist
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17
Q

When do you refer in NAFLD

A

If advanced fibrosis / cirrhosis

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18
Q

What else should you do in NAFLD

A

Look to see if any drugs worsening
Anti-coagulate in ANY liver disease
Monitor for complications

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19
Q

What do you do for hyperlipidaemia

A

Cholestryalmine
Decreased bile acid resorption so more cholesterol
Lowers LDL

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20
Q

What does fib4 look at

A

ALT
AST
Platelet
Age

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21
Q

What does NAFLD score look at

A 
Age
DM
BMI
ALT/ AST
Platelet - low
Albumin - low
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22
Q

When do you refer for fibroscan

A

When NAFLD score >3 as high risk

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23
Q

What do you do if cirrhotic

A 
HCC surveillance
Routine blood, ALP and USS every 6 months
CT if any suspicion
Endoscopy every 3 years if known varies 
MELD score 6 monthly
Manage complications
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24
Q

What grades survival in liver disease / cirrhosis

A

Child Pugh - severity of cirrhosis + predicts prognosis

MELD score - perform every 6 months in compensated cirrhosis

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25
Q

What does Child Pugh look at

A 
ABCDE 
Ascites
Bilirubin
Coagulation - PT
Distension - albumin 
Encephalopathy
26
Q

What does MELD look at

A

Bilirubin
Creatinine
INR

27
Q

What is autoimmune hepatitis

A

Ab against liver

Causes deranged LFT

28
Q

What Ab’s involved

A

ANA - anti-nuclear
LKM1
SMA - smooth muscle

29
Q

What does autoimmune hepatitis present like

A 
Acute hepatitis + signs of autoimmune
Fever
Jaundice
Abdominal pain
Fatigue
Anoreixa 
N+V
Pruritus / dark urine / pale stool

Features of autoimmune

  • Amenorrhoea = common
  • Loose bowel
  • Excessive hair
  • Raynaud
  • Sjogren
  • Thyroiditis
30
Q

What else can autoimmune hepatitis present with

A

CLD

Decompensated

31
Q

What are signs of autoimmune

A 
Fever
Malaise
Rash
Arthritis
GN
Pleurisy
32
Q

Who is at risk of autimmune

A 
Female
Young / middle age 
DM / autoimmune thyroid 
PSC 
Hyper Ig
33
Q

How do you Dx autoimmune hepatitis

A 
History
Blood - abnormal LFT
Liver biopsy - lymphocyte = confirms Dx 
Specific Ab's
Elevated IgG 
MRCP to exclude PSC
34
Q

What are signs of hypersplenism

A

Anaemia
Thrombocytopenia
Decreased WCC

35
Q

How do you treat autoimmune hepatitis

A

Prednisolone
Azathioprine - immune suppression
Liver transplant if cirrhosis / failure to respond to Rx

36
Q

What are the complications of autoimmune hepatitis

A

Cirrhosis

37
Q

What are associated conditions

A 
DM
PSC
Pernicious anaemia
Autoimmune thyroid 
GN
UC
Autoimmune haemolysis
38
Q

What causes alcohol liver disease

A

Excessive use of alcohol
Toxic to liver
Acetadehyde builds up
Fat deposited due to interruption in lipid metabolism
Steatosis (Alcoholic Fatty liver) - reversible
Steatohepatitis (Alcoholic Hepatitis) - becomes inflammed
Cirrhosis - irreversible

39
Q

What other factors are involved as not all heavy drinkers progress

A

Genetics
Hep B and C / other liver conditions
Malnutrition

40
Q

What are the signs of alcoholic liver disease

A 
Cirrhotic Sx 
Jaundice
HSM
Weight loss
Fatigue
Abdominal pain
Palmar erythema
Spider naevi
Bruising due to loss of clotting / thrombocytopenia 
Dark urine / pale stool / pruritus
Dupytren's 
Leukonychia 
Clubbing

Other
Hair loss
Gynaecomastia
Muscle wasting

Decompensated Sx

41
Q

What does portal hypertension cause

A 
Varices
Ascites - oesophageal and rectal 
Splenomegaly 
Caput medusa
Increased JVP
Pleural effusion
42
Q

How do you Dx alcoholic liver disease

A 
Abnormal LFT
- AST >ALT
- Raised gamma TG
FBC decreased as toxic to bone marrow 
- Macrocytosis 
- Thrombocytopenia 
U+E  - may be deranged in hepatorenal
Clotting - elevated PT
Low albumin
Elevated bilirubin in cirrhosis 
Liver screen to look for other cause
43
Q

What imaging

A

USS = 1st line
Fibroscan
Biopsy

44
Q

How do you treat alcoholic liver disease

A

No Rx
Fatty liver = reversible if stop drinking
Weight loss
Exercise
Oral thiamine if diet deficient
Paprinex if in hospital (thiamine b12 +C to prevent Weirnecke)
Liver transplant

45
Q

What are complications of alcohol liver

A 
Alcoholic hepatitis
Cirrhosis
HCC
Hepato-renal syndrome
Weirnecke's
Pancreatitis
46
Q

What are alcoholics at risk of

A 
Ketoacidosis 
Suspect in if DKA with low glucose 
Don't eat + malnourished
Starvation = ketones
Causes acidosis, elevated anion gap, elevated ketones
47
Q

How do you Rx DKA

A

Saline

Thiamine infusion to prevent Weirnecke’s

48
Q

How does alcoholic hepatitis present

A 
Often presents on top of CLD 
Fever
Jaundice
Hepatomegaly
Confusion 
Fatigue
ABdo pain
D+V
Weight loss
Decompensated
49
Q

How do you Dx alcoholic hepatitis

A

Bloods - increased WCC, increased INR, AST, MCV, urea, decreased platelet
ALP raised (also in HCC)
USS
Biopsy

50
Q

How do you treat alcoholic hepatitis

A

Treat infection if any (often non-infectious)
Assess confusion
Treat alcohol withdrawal - benzo
Paprinex
Transplant
Steroid but need to treat infection and GI bleed first
Ascitic tap if ascites

51
Q

When do you consider steroid in alcoholic hepatitis

A

Maddrey >32 (PT + bilirubin)

52
Q

What are complications of hepatitis

A

Hepato-renal syndorme

53
Q

What is Budd CHiari

A

Hepatic vein occlusion

Rare

54
Q

What are the symptoms of Budd CHiair

A

RUQ
Painful ascites
Hepatomegaly
May have jaundice / AKI

Often on background of coagulopathy - preg / polycythaemia etc

55
Q

How do you Dx Budd chair

A

USS + doppler

56
Q

What is Gilbert

A

Absence of UDP glucontransferase

57
Q

What are the symptoms of Gilbert

A

Unconjugated bilirubin
Jaundice - often in stress / illness
Urine normal
No rise in LFT

58
Q

How do you treat Gilbert

A

Reassurance

59
Q

What causes ischaemic hepatitis

A

Hypoperfusion - AKI / MI

Leads to acute risk in ALT

60
Q

What should you do for isolated hyperbilirubin / jaundice

A

FBC to see if due to haemolyiss or Gilbert

GI (29 decks)

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