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MPharm 2 - PH2113 > Unit 4 - The Liver 2 > Flashcards

Unit 4 - The Liver 2 Flashcards

1
Q

What sexual characteristics are affected by liver disease?

A

Endocrine changes most common in alcoholic liver disease

- poor metabolism of oestrogen

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2
Q

How are males affected by liver disease?

A

Testicular atrophy
Female body hair
Gynaecomastia
- increased breast tissue

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3
Q

How are females affected by liver disease?

A

Menstrual irregularity

Reduced fertility

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4
Q

How can liver disease be tested biochemically?

A 
Simple, inexpensive, easy to perform
Useful to monitor disease progression or response to therapy
Enzymes
- hepatocellular
- AST
- ALT
Bilirubin
Synthetic function
- PT and INR
- albumin
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5
Q

Apart from biochemical liver tests, how else can liver disease be investigated?

A 
Laboratory investigations
- hepatitis A
- hepatitis B
- hepatitis C
- immunoglobulins
- lipid profile
Imaging
- ultrasound - preliminary assessment
- CT and MRI - precise definition of abnormalities
Biopsy
- gold standard for establishing diagnosis and assessing severity
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6
Q

What is the treatment for pruritis?

A

Anion exchange resins

- bind bile acids and prevent reabsorption

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7
Q

What are the side effects of anion exchange resins?

A 
GI issues
- constipation
- diarrhoea
- flatulance
Fat and vitamin malabsorption
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8
Q

Why is the poor adherence of anion exchange resins?

A

Poor palatability

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9
Q

What counselling points should be given for treating pruritis?

A

Take interacting drugs 1 hour before or 4 hours after colestyramine
Benefits may take up to one week to become apparent

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10
Q

Give two examples of anion exchange resins used to treat pruritis

A

Colestyamine

Colestipol

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11
Q

Apart from anion exchange resins, what else can be used to treat pruritis?

A 
Antihistamines
- sedating properties useful if pruritis affects sleep
Ursodeoxycholic acid
- treats cholestatic disease
Rifampicin
- inhibits hepatocyte uptake of bile salts
- decreases reabsorption
Opiod antagonists
- itching due to increased endogenous opiate tone
Topical therapies
- calamine lotion
menthol 2% in aqueous cream
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12
Q

What is the aim of treating ascites?

A

Mobilise intra-abdominal fluid

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13
Q

What non-pharmacological treatments are there for ascites?

A 
Simple measures:
- reduce sodium intake
- fluid restriction
Moderate to severe measures
- diuresis (increase urine output)
- paracentesis (sucked out with a needle)
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14
Q

What pharmacological treatments are there for ascites?

A

Diuretics
- increase diuresis
Spironalactone is first line agent
- blocks sodium reabsorption in kidney tubules
- dose range 50 - 400 mg daily
- titrate slowly
- side effects
- gynaecomastia (potassium sparing diuretic)
- hyperkalaemia (potassium sparing diruetic)
Add furosemide if severe
Care to avoid excessive diuresis

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15
Q

How is paracentesis used to treat ascites?

A

Use in refractory ascites
Combined with albumin administration
Does not affect mechanisms responsible for fluid accumulation
- transient effect
Repeated every 2 - 4 weeks in outpatient setting

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16
Q

What is TIPS?

A

Transjugular Intrahepatic Portosystemic Shunt

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17
Q

Where is the shunt placed in TIPS?

What is a shunt ?

A

Between hepatic portal vein and systemic circulation
In medicine, a shunt is a hole or a small passage which moves, or allows movement of, fluid from one part of the body to another

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18
Q

What are the drawbacks of TIPS?

A

Prevents recurrence in refractory ascites

Shunt stenosis is common

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19
Q

What percentage of patients with cirrhosis develop encephalopathy?

A

40%

More than half die within a year

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20
Q

What are the symptoms of encephalopathy caused by cirrhosis?

A

Reversible neuropsychiatric condition

  • lack of awareness
  • altered mental state
  • disorientation
21
Q

What are the causes of encephalopathy in cirrhosis?

A 
Portosystemic shunting
Metabolic dysfunction
Alteration of Blood Brain Barrier
Ammonia heavily implicated
- accumulation in CNS
22
Q

What is encephalopathy precipitated by?

A

GI bleeding
Spontaneous Bacterial Peritonitis (SBP)
Drugs

23
Q

What is the treatment for encephalopathy?

A

Lactulose

Antibiotics

24
Q

How is lactulose used to treat encephalopathy?

A

Acidifies colonic contents
- leading to ionisation of nitrogenous products and therefore a reduction in absorption
30 - 40 ml/day titrated to achieve 2 - 3 soft stools per day
Side effects
- bloating
- diarrhoea

25
Q

How are antibiotics used to treat encephalopathy?

A

Metronidazole reduces ammonia production by GI bacteria

26
Q

What is used to treat clotting abnormality caused by liver disease?

A

Phytomenadione IV (vitamin K)

  • 10mg daily for 3 days
  • oral not as effective as IV (therefore not used)

Not effective in patients with significant disease

27
Q

What medications should patients with a clotting abnormality avoid?

A

NSAIDs
Aspirin
Anticoagulants

28
Q

What are varices?

A

Development of weak and leaky vessels

29
Q

What is the treatment for varices?

A

Shunting of portal blood to systemic circulation

  • pre-existing vessels dilate
  • active angiogenesis
30
Q

What is the initial treatment for varices?

A

Stop immediate bleeding
Treat hypovolaemic shock
- increase blood volume
Aim to prevent recurrent bleeding

31
Q

What medication should be given immediately to treat varices?

A

Terlipressin (vasopressin analogue)

  • systemic vasoconstrictor
  • infused for 2 - 5 days
32
Q

How can varices be prevented?

A 
Band ligation
Long term non-selective beta-blockers
- propanolol
- reduced portal hypertension by splenic vasoconstriction
- reduced portal blood flow
33
Q

What is Acute Liver Failure (ALF)?

A

Rapid deterioration in liver function in a previously healthy individual

34
Q

What is the most common cause for Acute Liver Failure in the UK?

A

Paracetamol overdose

35
Q

Why is Acute Liver Failure complicated to manage?

A 
Multiple organ systems affected
- central nervous system
- cardiovascular
- renal systems affected
Infection and bleeding can be life threatening
36
Q

How many paracetamol tablets consumed within 24 hours can result in severe harm?

A

20 - 30 tablets

37
Q

Why is paracetamol overdose hard to metabolise?

A

Saturation of glutathione pathway

38
Q

Which chemical is produced in the metabolism of paracetamol when glutathione is exhausted?

A

NAPQI

39
Q

When does NAPQI cause necrosis of liver and kidney?

A

When glutathione reserves are less than 30%

40
Q

What is the timeline after paracetamol overdose?

A 
0 - 24 hours
- asymptomatic
- non-specific signs
24 - 48 hours
- right upper quadrant pain
- jaundice
- deranged bloods
- coagulopathy
> 72 hours
- jaundice
- somnolence
- liver failure
41
Q

What is the result of paracetamol overdose?

A

Cerebral oedema
Shock
Sepsis
Renal failure

42
Q

What is the treatment for paracetamol overdose in the first 4 hours?

A

Activated charcoal
- mop up GI tract

Do not treat with N-ac
- wait for paracetamol to be absorbed into the blood to find single paracetamol concentration related to time of ingestion

43
Q

What is the treatment for paracetamol overdose between 4 and 36 hours after ingestion?

A

N-actylcysteine

  • almost 100% effective if given within 8 hours
  • increases glutathione concentration
44
Q

When was legislation introduced to restrict the sale of paracetamol?

A

1998

  • pack size
  • packaging
45
Q

What was the effect of restricting the sale of paracetamol?

A

Significant decrease in paracetamol overdose

- Heath hospital still admits 1 patient a week

46
Q

Why do prescribers need to be aware of liver disease in patients?

A

Impaired drug metabolism

  • main route of elimination for many drugs
  • hepatic reserve is large
  • liver disease must be severe for clinically relevant changes occur
  • care with rifampicin and fusidic acid
47
Q

What is hypoproteinaemia?

A

Low levels of protein in the blood

- albumin

48
Q

What are the implications of hypoproteinaemia?

A 
Albumin is produced in the liver
Affects highly protein bound drugs
- low albumin
- less albumin binding
- increased free drug concentration
- exposure to drug increased
49
Q

What prescribing considerations are there in patients with liver disease?

A 
Impaired clotting
- clotting factors synthesised in liver
- increased sensitivity to oral anticoagulants
Hepatic encephalopathy
- many drugs can impair cerebral function
- lower awareness
- care with
- sedative drugs
- opioids
- diuretics that reduce potassium levels
Fluid overload
- oedema/ascites exacerbated by drugs that cause fluid retention
- NSAIDs
- corticosteroids
Hepatotoxic drugs
- dose related or idiosyncratic
- avoid
- use with extreme caution

MPharm 2 - PH2113 (50 decks)

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