Ow: Portal Hypertension, Ascites, HCC +Case 2

Question 1

Hepatitis differential to go through!?!?!?

Answer 1

AH VAN IED

• Autoimmune
• Haemochromotosis
• Viral
• Alcoholic
• Non-alcoholic
• Ischaemic
• Environmenmtal toxins
• Drugs

Question 2

• 25 y/o man with two week flu like illness, vomiting, amorexia and tiredenss?
• Alcohol intake 4-5 beers 2-3x/week (15 units/week)
• No IV drug use or regular medication?

Answer 2

Hepititic Picture (AST and ALT massively raised) - Ischaemic, Viral or Paracetamol

Albumin is low but not low enough to think he has chronic (would be in the 20s) and PR is elevated so likely to be ACUTE!

Unlikely ischaemia, medications are negative, not alcoholic nor non-alcohol as transaminases are too high, haemochromotosis (look at iron studies)

US comes back unremarkable

MOST LIKELY VIRAL! - DO SEROLOGY

Question 3

ACUTE vs CHRONIC HEP B? Transmission?

Answer 3

Acute occurs in adults and chronic occurs when infection is from birth or as a child

Transmission:

1. Perinatal - primary where no universal immunisation - SE asia
2. Horizontal - Primary in africa (close contact)
3. Sexual - in adults mostly
4. Parentral - IV drugs or unscreened blood products

Question 4

4 Phases of Chronic Hep B?

Answer 4

1. Immune tolerant phase - no inflammation w. no damage to liver
2. Immune clearance - Body tries to clear virus (months-years) often unsucessful and referred for treatment to stop inflammation from causing damage
3. Immune control phase - very similar to immune tolerant
4. Immune escape - reactivation of the virus causing repeated inflammation and damage

Question 5

Progression of Acute liver failure from HepB?

Answer 5

Although the Liver Inflammation has died down and the LFTs appear to be normalising the insult has been so massive that the Liver has had no time to regenerate and so continues to fail.

Question 6

What is the Child Pugh score?

Answer 6

A score used to classify the severity of cirrhosis and predicts mortality without transplant using: bilirubuin, albumin, PR, degree of ascites, degree of encephalopathy

Some people live asymptomatically with cirrhosis through to people who are severely ill

Question 7

Complications of Liver Cirrhosis?

Answer 7

Those related to Liver Function:

• encephalopathy
• Jaundice

Those related to Portal hypertension:

• Variceal haemorrhages (oesophageal, caput medusae, haemorrhoids)
• Hypersplenism (Thrombocytpopenia, neutropenia, anaemia)
• Ascites = SBP or Hepatic renal syndrome (HRS)

Question 8

Pathogenesis of Ascites due to cirrhosis?

Answer 8

Cirrhosis → increased resistance to portal flow → portal hypertension

• Increased hydrostatic pressure + Decresed albumin (decreased oncotic pressure) → ascites
• Splanchnic vasodilation → suystemic arterial underfilling → activation of ADH and RAAS → renal Na and H2O retention → Ascites

Question 9

HE development? Treatment?

Answer 9

Ammonia from the gut (from our diet) is failed to be metabolised by the failing liver and so reaches the general circulation.

Here is crosses the BBB and affects the brain function

Treatment:

• Lactulose is a non-absorbable disaccharide that produces osmotic diarrhoea
• It reduces the pH of colonic content and therby prevents NH3 absorption by converting it to NH4 that is excreted

Question 10

HRS?

Answer 10

Hepatorenal syndrome

1. portal hypertension
2. Splanchnic vasodilation
3. Decreased effective circulatory volume
4. Activated RAAS
5. Renal vasoconstriction → HRS

One type occurs in actue event the other in the progeressive ascites

Question 11

HCC screening and diagnosis?

Answer 11

HCC if detected early can be cured

• All patients with cirrhosis need HCC surveillance
• Liver US and Alpha fetoprotein every 6 months