NAFLD, autoimmune, alcohol Flashcards
Why does NAFLD occur [3]
Fat deposit in the liver = steatosis
Unknown cause
Underlying insulin resistance?
How does NAFLD progress [4]
Steatosis
NASH = Steatohepatitis
Fibrosis
Cirrhosis
Who is at risk of NAFLD [7]
Age, Ethnicity, Genetics Obesity, DM Smoking Hyperlipid, High BP Sudden weight loss / starvation Polycystic ovaries Hep B+C
Who is more at risk of progression to cirrhosis [3]
Age
Obesity
DM
What can occur in pregnancy [3]
Acute cholestasis
Abdominal pain
Jaundice
Pruritus = intense
What can cause acute liver injury on top of NAFLD
Drugs so drug review is important
Clinical features of NAFLD [4]
Asymptomatic
Hepatomegaly
ALT > AST
May be picked up on USS - increased fatty hepatocytes and echogenicity
What must you do if diagnosed with NAFLD?
Are the histological changes reversible?
Look for fibrosis
NASH is not reversible
What are the symptoms of NASH [4]
Aching pain
Fatigue
Weight loss
What are the symptoms of cirrhosis [8]
Jaundice HSM Thrombocytopenia = bruising Weight loss Dark urine / pale stool Pruritus Palmar erythema Spider naevi
What is decompensatd liver function / cirrhosis
Symptomatic
Liver unable to do job
What are the symptoms of decompensated disease [5]
Portal hypertension Jaundice Ascites Encephalopathy Varices
How do you Dx NAFLD [2]
Abnormal LFTs - ALT > AST (opposite in alcohol)
USS
Investigations NAFLD [5]
Enhanced Liver Fibrosis - look for fibrosis (expensive) If ELF n/a: - NAFLD fibrosis Score - FIB4 score - Fibroscan Cytokeratin 18 - biomarker for NASH
What imaging options are there for NAFLD [3]
Liver biopsy - not usually needed
MRI / CT if suspect malignancy
Endoscopy for varices
Lifestyle modifications for NAFLD? [5]
Lifestyle = mainstay: Diet and weight, exercise
DM control, BP control, cholesterol control
Avoid alcohol
Vit E may improve fibrosis
Cholestryalmine for cholesterol
When do you refer in NAFLD
If advanced cirrhosis
They will then likely have a liver biopsy to stage the disease more accurately.
Mx NAFLD [4]
Drug review
Anti-coagulate in ANY liver disease
Monitor for complications
Spirnolactone - ascites?
What does cholestyramine do?
Cholestryalmine
Decreased bile acid resorption so more cholesterol
Lowers LDL
What does fib4 look at [4]
ALT
AST
Platelet
Age
What does NAFLD score look at? [6]
Age DM BMI ALT/ AST Platelet - low Albumin - low
When do you refer for fibroscan
When NAFLD score >3 as high risk
What do you do if cirrhotic [3]
HCC surveillance
Routine blood, ALP and USS every 6 months
CT if any suspicion
What grades survival in liver disease / cirrhosis
Child Pugh / MELD score
What does Child Pugh look at [5]
Bilirbin Albumin PT Encephalopathy Ascites
What does MELD look at [3]
Bilirubin
Creatinine
INR
What is autoimmune hepatitis [2]
Epidemiology
AutoAb against hepatocyte surface antigens
Causes deranged LFTs
Ep: young, middle aged women
What Ab’s involved [3]
ANA - anti-nuclear
LKM1
SMA - smooth muscle
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
What else can autoimmune hepatitis present with
If post or perimenopausal, CLD of insidious onset
What are signs of autoimmune disease [6]
Fever Malaise Rash Arthritis GN Pleurisy
Who is at risk of autoimmune [4]
Female
Young / middle age
DM / autoimmune thyroid
Hyper Ig
Autoimmune hepatitis ix [6]
FBC: signs of hypersplenism ALT>AST Liver biopsy - lymphocyte Autoantibodies Elevated IgG MRCP to exclude PSC
What are signs of hypersplenism [3]
Anaemia
Thrombocytopenia
Decreased WCC
How do you treat autoimmune hepatitis [3]
Prednisolone
OR Azathioprine - immune suppression
Liver transplant if cirrhosis / failure to respond to Rx
What are the complications of autoimmune hepatitis
Cirrhosis
Prog: remission in 80% of pts and 10y survival is 80%
What are associated conditions [7]
DM Autoimmune thyroid PSC GN UC Autoimmune haemolysis Pernicious anaemia
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
What other factors are involved as not all heavy drinkers progress [3]
Genetics
Hep B and C / other liver
Malnutrition
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?
What does portal hypertension cause [6]
Varices - oesophageal and rectal Ascites Splenomegaly Caput medusa Increased JVP Pleural effusion
How do you Dx alcoholic liver disease [6]
AST >ALT Raised GGT Macrocytosis / thrombocytopenia / U+E: low Mg Clotting deranged Low albumin
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
Management of alcohol withdrawal [2]
BDZ - chlordiazepoxide
Thiamine deficiency - pabrinex
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
What are alcoholics at risk of and why? [3]
DKA
Don’t eat + malnourished
Starvation = ketones
Causes acidosis, elevated anion gap, elevated ketones
Management of alcoholism [3]
Group therapy and self help
Disulphiram- aversion
Acamprosate: anticraving
Presentation of alcoholic hepatitis
Symptoms [5]
Signs [5]
Sy: fever, nausea, diarrhoea and vomiting, RUQ pain
Si: tender hepatomegaly, jaundice, ascites, oedema, encephalopathy
Alcoholic hepatitis bloods [5]
AST/ALT >2, raised AST <300 Hyperbilirubinemia Prolonged INR FBC: neutrophilic, MCV up, thrombocytosis ALP raised
How do you treat alcoholic hepatitis [5]
Oral prednisolone 40mg/d for 2d
Pabrinex
Manage alcohol withdrawal
Manage underlying sepsis, malnutrition
When do you consider steroids in alcoholic hepatitis
Maddrey score >32 (PT + bilirubin)
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
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
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
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
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
How do you treat Gilbert
Reassurance
What causes ischaemic hepatitis
Hypoperfusion - AKI / MI
Leads to acute risE in ALT
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
What is fibroscan?
liver stiffness measurement assessed with transient elastography
