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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
What does Child Pugh look at [5]
``` Bilirbin Albumin PT Encephalopathy Ascites ```
26
What does MELD look at [3]
Bilirubin Creatinine INR
27
What is autoimmune hepatitis [2] | Epidemiology
AutoAb against hepatocyte surface antigens Causes deranged LFTs Ep: young, middle aged women
28
What Ab's involved [3]
ANA - anti-nuclear LKM1 SMA - smooth muscle
29
What does autoimmune hepatitis present like [7]
``` Teens and early 20s: Constitutional: fever, fatigue, malaise Acute hepatitis: jaundice, abdominal pain Cushingoid (hirsutism, acnes, striae) Amenorrhea Polyarthritis Pulmonary infiltration Pleurisy ```
30
What else can autoimmune hepatitis present with
If post or perimenopausal, CLD of insidious onset
31
What are signs of autoimmune disease [6]
``` Fever Malaise Rash Arthritis GN Pleurisy ```
32
Who is at risk of autoimmune [4]
Female Young / middle age DM / autoimmune thyroid Hyper Ig
33
Autoimmune hepatitis ix [6]
``` FBC: signs of hypersplenism ALT>AST Liver biopsy - lymphocyte Autoantibodies Elevated IgG MRCP to exclude PSC ```
34
What are signs of hypersplenism [3]
Anaemia Thrombocytopenia Decreased WCC
35
How do you treat autoimmune hepatitis [3]
Prednisolone OR Azathioprine - immune suppression Liver transplant if cirrhosis / failure to respond to Rx
36
What are the complications of autoimmune hepatitis
Cirrhosis | Prog: remission in 80% of pts and 10y survival is 80%
37
What are associated conditions [7]
``` DM Autoimmune thyroid PSC GN UC Autoimmune haemolysis Pernicious anaemia ```
38
What causes alcohol liver disease [6]
``` 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
What other factors are involved as not all heavy drinkers progress [3]
Genetics Hep B and C / other liver Malnutrition
40
``` How can alcoholic liver disease present? Hepatic [2] GI [4] CNS [4] CVS [3] Haem [2] What are the features of dependency? ```
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
What does portal hypertension cause [6]
``` Varices - oesophageal and rectal Ascites Splenomegaly Caput medusa Increased JVP Pleural effusion ```
42
How do you Dx alcoholic liver disease [6]
``` AST >ALT Raised GGT Macrocytosis / thrombocytopenia / U+E: low Mg Clotting deranged Low albumin ```
43
Glasgow alcoholic hepatitis score [5] | What indicates a poor prognosis?
``` 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
Management of alcohol withdrawal [2]
BDZ - chlordiazepoxide | Thiamine deficiency - pabrinex
45
What are neurological sequelae of alcoholism
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
What are alcoholics at risk of and why? [3]
DKA Don't eat + malnourished Starvation = ketones Causes acidosis, elevated anion gap, elevated ketones
47
Management of alcoholism [3]
Group therapy and self help Disulphiram- aversion Acamprosate: anticraving
48
Presentation of alcoholic hepatitis Symptoms [5] Signs [5]
Sy: fever, nausea, diarrhoea and vomiting, RUQ pain Si: tender hepatomegaly, jaundice, ascites, oedema, encephalopathy
49
Alcoholic hepatitis bloods [5]
``` AST/ALT >2, raised AST <300 Hyperbilirubinemia Prolonged INR FBC: neutrophilic, MCV up, thrombocytosis ALP raised ```
50
How do you treat alcoholic hepatitis [5]
Oral prednisolone 40mg/d for 2d Pabrinex Manage alcohol withdrawal Manage underlying sepsis, malnutrition
51
When do you consider steroids in alcoholic hepatitis
Maddrey score >32 (PT + bilirubin)
52
``` Alcoholic ketoacidosis Ax Px [3] Presentation [3] ABG [2] Bloods [2] Mx [2] ```
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
What is Budd CHiari Ax [2] Px [3]
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
What are the symptoms of Budd Chiari [5]
Sudden onset RUQ pain (Glissons capsule stretching) Painful ascites Hepatomegaly May have jaundice / AKI Often on background of coagulopathy - preg / polycythaemia etc
55
Budd Chiari Invstigations [6]
``` • Bloods: - FBC and film (+JAK2 mutation) - clotting - LFT - ascitic tap (SAAG >1.1g/dL and protein ++) • USS and hepatic vein doppler ```
56
What is Gilbert syndrome Ax [3] Presentation [3] Ix [2]
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
How do you treat Gilbert
Reassurance
58
What causes ischaemic hepatitis
Hypoperfusion - AKI / MI | Leads to acute risE in ALT
59
What is the ELF test?
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
What is fibroscan?
liver stiffness measurement assessed with transient elastography

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