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Gastro > NAFLD, autoimmune, alcohol > Flashcards

NAFLD, autoimmune, alcohol Flashcards

1
Q

Why does NAFLD occur [3]

A

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

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2
Q

How does NAFLD progress [4]

A

Steatosis
NASH = Steatohepatitis
Fibrosis
Cirrhosis

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3
Q

Who is at risk of NAFLD [7]

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

Who is more at risk of progression to cirrhosis [3]

A

Age
Obesity
DM

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5
Q

What can occur in pregnancy [3]

A

Acute cholestasis
Abdominal pain
Jaundice
Pruritus = intense

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6
Q

What can cause acute liver injury on top of NAFLD

A

Drugs so drug review is important

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7
Q

Clinical features of NAFLD [4]

A

Asymptomatic
Hepatomegaly
ALT > AST
May be picked up on USS - increased fatty hepatocytes and echogenicity

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8
Q

What must you do if diagnosed with NAFLD?

Are the histological changes reversible?

A

Look for fibrosis

NASH is not reversible

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9
Q

What are the symptoms of NASH [4]

A

Aching pain
Fatigue
Weight loss

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10
Q

What are the symptoms of cirrhosis [8]

A 
Jaundice
HSM
Thrombocytopenia = bruising
Weight loss
Dark urine / pale stool
Pruritus
Palmar erythema 
Spider naevi
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11
Q

What is decompensatd liver function / cirrhosis

A

Symptomatic

Liver unable to do job

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12
Q

What are the symptoms of decompensated disease [5]

A 
Portal hypertension
Jaundice
Ascites
Encephalopathy 
Varices
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13
Q

How do you Dx NAFLD [2]

A

Abnormal LFTs - ALT > AST (opposite in alcohol)

USS

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14
Q

Investigations NAFLD [5]

A 
Enhanced Liver Fibrosis - look for fibrosis (expensive) 
If ELF n/a:
- NAFLD fibrosis Score 
- FIB4 score
- Fibroscan 
Cytokeratin 18 - biomarker for NASH
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15
Q

What imaging options are there for NAFLD [3]

A

Liver biopsy - not usually needed
MRI / CT if suspect malignancy
Endoscopy for varices

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16
Q

Lifestyle modifications for NAFLD? [5]

A

Lifestyle = mainstay: Diet and weight, exercise
DM control, BP control, cholesterol control
Avoid alcohol
Vit E may improve fibrosis
Cholestryalmine for cholesterol

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17
Q

When do you refer in NAFLD

A

If advanced cirrhosis

They will then likely have a liver biopsy to stage the disease more accurately.

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18
Q

Mx NAFLD [4]

A

Drug review
Anti-coagulate in ANY liver disease
Monitor for complications
Spirnolactone - ascites?

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19
Q

What does cholestyramine do?

A

Cholestryalmine
Decreased bile acid resorption so more cholesterol
Lowers LDL

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20
Q

What does fib4 look at [4]

A

ALT
AST
Platelet
Age

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21
Q

What does NAFLD score look at? [6]

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 [3]

A

HCC surveillance
Routine blood, ALP and USS every 6 months
CT if any suspicion

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24
Q

What grades survival in liver disease / cirrhosis

A

Child Pugh / MELD score

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25
Q

What does Child Pugh look at [5]

A 
Bilirbin
Albumin
PT
Encephalopathy
Ascites
26
Q

What does MELD look at [3]

A

Bilirubin
Creatinine
INR

27
Q

What is autoimmune hepatitis [2]

Epidemiology

A

AutoAb against hepatocyte surface antigens
Causes deranged LFTs
Ep: young, middle aged women

28
Q

What Ab’s involved [3]

A

ANA - anti-nuclear
LKM1
SMA - smooth muscle

29
Q

What does autoimmune hepatitis present like [7]

A 
Teens and early 20s:
Constitutional: fever, fatigue, malaise
Acute hepatitis: jaundice, abdominal pain
Cushingoid (hirsutism, acnes, striae)
Amenorrhea
Polyarthritis
Pulmonary infiltration
Pleurisy
30
Q

What else can autoimmune hepatitis present with

A

If post or perimenopausal, CLD of insidious onset

31
Q

What are signs of autoimmune disease [6]

A 
Fever
Malaise
Rash
Arthritis
GN
Pleurisy
32
Q

Who is at risk of autoimmune [4]

A

Female
Young / middle age
DM / autoimmune thyroid
Hyper Ig

33
Q

Autoimmune hepatitis ix [6]

A 
FBC: signs of hypersplenism
ALT>AST
Liver biopsy - lymphocyte 
Autoantibodies
Elevated IgG 
MRCP to exclude PSC
34
Q

What are signs of hypersplenism [3]

A

Anaemia
Thrombocytopenia
Decreased WCC

35
Q

How do you treat autoimmune hepatitis [3]

A

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

36
Q

What are the complications of autoimmune hepatitis

A

Cirrhosis

Prog: remission in 80% of pts and 10y survival is 80%

37
Q

What are associated conditions [7]

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

What causes alcohol liver disease [6]

A 
Excessive use of alcohol 
Toxic to liver
Acetadehyde builds up 
Fat deposited due to interruption in lipid metabolism
Steatosis (Alcoholic Fatty liver) 
Steatohepatitis (Alcoholic Hepatitis)
Cirrhosis
39
Q

What other factors are involved as not all heavy drinkers progress [3]

A

Genetics
Hep B and C / other liver
Malnutrition

40
Q 
How can alcoholic liver disease present? 
Hepatic [2]
GI [4]
CNS [4]
CVS [3]
Haem [2]
What are the features of dependency?
A

Hepatic: alcoholic hepatitis > cirrhosis
GI: gastritis, erosions, peptic ulcer disease, varices, pancreatitis, cancer
CNS: poor memory + cognition, peripheral polyneuropathy, fits, falls
CVS: DCM, AF, HTN
Haem: anaemia, thrombocytopenia
Features of dependency
o Do you feel you should Cut down?
o Have you felt Annoyed when people criticise your drinking?
o Do you feel Guilty?
o Do you need an Eye opener?

41
Q

What does portal hypertension cause [6]

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

How do you Dx alcoholic liver disease [6]

A 
AST >ALT
Raised GGT
Macrocytosis / thrombocytopenia / 
U+E: low Mg
Clotting deranged
Low albumin
43
Q

Glasgow alcoholic hepatitis score [5]

What indicates a poor prognosis?

A 
o	Age: <50 = 1, >50 = 2
o	WCC: <15 = 1, >15 =2 
o	Urea: <5 = 1, >5 = 2
o	INR: <1.5 =1, 1.5-2.0 =1, >2.0 = 2
o	Bilirubin: <125 = 1, 125-250 =2, >250 =3

> 9 poor prognosis

44
Q

Management of alcohol withdrawal [2]

A

BDZ - chlordiazepoxide

Thiamine deficiency - pabrinex

45
Q

What are neurological sequelae of alcoholism

A

o Wernicke’s encephalopathy (thiamine deficiency): triad of nystagmus, ophthalmoplegia and ataxia with confusion and altered GCS
o Korsakoff’s syndrome: untreated Wernicke’s develops into anterograde and retrograde amnesia with confabulation

46
Q

What are alcoholics at risk of and why? [3]

A

DKA
Don’t eat + malnourished
Starvation = ketones
Causes acidosis, elevated anion gap, elevated ketones

47
Q

Management of alcoholism [3]

A

Group therapy and self help
Disulphiram- aversion
Acamprosate: anticraving

48
Q

Presentation of alcoholic hepatitis
Symptoms [5]
Signs [5]

A

Sy: fever, nausea, diarrhoea and vomiting, RUQ pain
Si: tender hepatomegaly, jaundice, ascites, oedema, encephalopathy

49
Q

Alcoholic hepatitis bloods [5]

A 
AST/ALT >2, raised AST <300
Hyperbilirubinemia
Prolonged INR
FBC: neutrophilic, MCV up, thrombocytosis
ALP raised
50
Q

How do you treat alcoholic hepatitis [5]

A

Oral prednisolone 40mg/d for 2d
Pabrinex
Manage alcohol withdrawal
Manage underlying sepsis, malnutrition

51
Q

When do you consider steroids in alcoholic hepatitis

A

Maddrey score >32 (PT + bilirubin)

52
Q 
Alcoholic ketoacidosis
Ax
Px [3]
Presentation [3]
ABG [2]
Bloods [2]
Mx [2]
A

Ax: regular consumption of large amounts of alcohol
Px:
- don’t eat regularly and may vomit food when do eat
- causing episodes of starvation > malnutrition
- after alcohol binge body starts to break down fat producing ketones
Sy/Si:
- ketone smelling breath, reduced GCS, abdo pain
ABG: metabolic acidosis with elevated anion gap
Bloods: raised serum ketones, normal or low Glc
Mx: IV saline, pabrinex

53
Q

What is Budd CHiari
Ax [2]
Px [3]

A

Ax:

  • hypercoagulability (polycythaemia vera and other myeloproliferative disorders)
  • local tumour, congenital (membranous obstruction)

Px:

  • hepatic vein obstruction
  • causes ischaemia and hepatocyte damage
  • leading to liver failure or insidious cirrhosis
54
Q

What are the symptoms of Budd Chiari [5]

A

Sudden onset RUQ pain (Glissons capsule stretching)
Painful ascites
Hepatomegaly
May have jaundice / AKI

Often on background of coagulopathy - preg / polycythaemia etc

55
Q

Budd Chiari Invstigations [6]

A 
•	Bloods: 
- FBC and film (+JAK2 mutation)
- clotting
- LFT
- ascitic tap (SAAG >1.1g/dL and protein ++)
•	USS and hepatic vein doppler
56
Q

What is Gilbert syndrome
Ax [3]
Presentation [3]
Ix [2]

A

Ax:
- autosomal recessive condition of
- defective bilirubin conjugation
- due to UCP glucuronosyltransferase
Sy/Si:
- unconjugated hyperbilirubinemia causing jaundice
- during intercurrent illness, exercise or fasting
Ix: rise in bilirubin post prolonged fasting or IV nicotinic acid

57
Q

How do you treat Gilbert

A

Reassurance

58
Q

What causes ischaemic hepatitis

A

Hypoperfusion - AKI / MI

Leads to acute risE in ALT

59
Q

What is the ELF test?

A

the ELF blood test is a combination of hyaluronic acid + procollagen III + tissue inhibitor of metalloproteinase 1. An algorithm based on these values results in an ELF blood test score, similar to triple testing for Down’s syndrome

60
Q

What is fibroscan?

A

liver stiffness measurement assessed with transient elastography

Gastro (17 decks)

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