Red Book - Chronic Liver Disease

Question 1

Causes of cirrhosis

Answer 1

Infections - Hep B/C

Drugs - Methotrexate, methyldopa, amiodarone

Cholestasis - Primary Billiary Cirrhosis, Sclerosing Cholangitis

Autoimmune hepatitis

Hereditary - Wilsons Disease, Haemochromatosis, alpha 1.

Vascular - BuddChiari, Veno-occlusive disease

NAFLD

Question 2

Scoring systems of Chronic liver disease

Answer 2

Child Pugh score

MELD

SOFA helps to discrimninate survivors and non survivors

Question 3

Features of the Child Score

Answer 3

Scored 1-3
5 parameters = 15 points

Encephalopathy
Ascites
Bilirubin
Albumin
INR

A: 5-6. 100% one year survival
B: 7-9. 81%
C: >10. 45%

Question 4

Features of MELD

Answer 4

Model for End Stage Liver Disease

Bilirubin, INR, Creatinine all put into a formula

UK Model —> UKELD —> helps in selection of liver transplant patients

Question 5

Why do cirrhotics end up in ICU

Answer 5

Bleeding - varices, post OGD etc

Encephalopathy causing low GCS leading to airway support

Sepsis - SBP

AKI

Alcoholic hepatitis

Question 6

Define portal hypertension

Answer 6

Portal pressure > 10mmHg

Question 7

What is the presence of portal hypertension associated with

Answer 7

Develop of porto-systemic collaterol circulation

Ascites

Splenomegaly

Question 8

Diagnosis of portal hypertension

Answer 8

Clinical diagnosis

Pressures can only be measured directly during a TIPSS

Question 9

Complications of portal hypertension

Answer 9

Varices —> massive upper GI bleed

Question 10

Treatment options of variceal bleed

Answer 10

ABCDE etc.

Goals:
Volume resus
Blood products

Vasoconstrict - terlipressin

Endoscopy

Prevent complications —> antibiotics

Question 11

If there is failure to stop bleednig

Answer 11

Sengstaken tube

Further attempts at endoscopy

TIPSS

Orthotopic liver transplant

Question 12

What is a TIPSS

Answer 12

Transjugular Intrahepatic Portosystemic Shunt

Endovascular procedure that shunts a communication between portal vein and hepatic vein (in and out flow)

Reduces the portal pressures when there are complications (variceal bleed, resistant ascites)

Beware encephalopathy - blood from porta vein bypasses liver, not metabolised

Question 13

What is Hepato-renal syndrome

Answer 13

Renal failure in patients wtih fulminant liver failure

A pre-renal AKI

Abnormal autoregulation with renal vasoconstriction and dilated sphlancnic vessels

Low fractional excretion of sodium and rise in creatinine

Question 14

Diagnostic criteria of HRS

Answer 14

Cirrhosis with ascites
Creatnine >133 umol/.

That has not improved with two days of dieuretecs and albumin volume expansion

No shock
No nephrotoxins
No parenchymal disease

Question 15

Types of HRS

Answer 15

1 - Rapid progressive loss of kidney function. (Mortalityy 50%)

2 - indolent, with dieuretic resistance ascites

Question 16

Treatment of HRS

Answer 16

Trial terlispressin
Albumin

TIPSS

Definitive - transplant

Question 17

Diagnosis of SBP

Answer 17

Peritoneal fluid neurophil count >250 cells/mm3

+/- positive fluid culture

Question 18

Define SBP

Answer 18

Ascitic fluid infection without an intra-abdominal, surgically treatable source

Almost always in cirrhotics with ascites

Question 19

What is alcoholic hepatitis

Answer 19

Progressive inflammatory liver injury in long term alcoholics

Acute has mortality >50% in 30 days

Diagnosed with:
	Alcohol intake
	Fever
	Worsening LFTs (bili and transferases)
	Dont have to have cirrhosis

Question 20

Treatment of alocholic hep

Answer 20

Steroids

Transfer to tertiary centre

Patient needs to become abstinent

Pentoxyphylline reduces HRS in alco hep