W30 Clinical management of liver disease Flashcards
-Alcoholic liver disease (ALD) -Non-alcoholic fatty liver disease (NAFLD)
Re-cap; function of the Liver:
- Energy metabolism
- Bile production & bilirubin metabolism
- Fat-soluble vitamin storage and/or metabolism
- Detoxification and clearance
- Drug metabolism (Cyp P450)
- Urea cycle (aa metabolism)
- Ethanol
- RBCs
Other Functions
* Thyroid hormone function - deiodination of T4 to T3
* Synthesis of nearly every plasma protein in the body, some examples include albumin, binding globulins, protein C, protein S, and all the clotting factors of the intrinsic and extrinsic
pathways besides factor VIII.
What can cause liver damage?
- Most common risk factors for liver cirrhosis;
- Alcohol misuse = alcoholic liver disease
- Hepatitis B or C infection
- Obesity or type 2 diabetes (with NAFLD) – if the patient doesn’t have NAFLD = not at
immediate risk at developing cirrhosis
(Note: not everyone with risk factors will develop cirrhosis)
Less common causes of cirrhosis include:
1. Autoimmune liver disease:
* autoimmune hepatitis
* primary biliary cholangitis
* primary sclerosing cholangitis
- Genetic conditions:
* Haemochromatosis
* Wilson’s disease
* Cystic fibrosis
- Medication use, usually over a long period of time e.g. methotrexate
- Recognising risk factors early and managing them effectively may help prevent the development of cirrhosis, or slow its progression
Liver disease progression: What are the stages? (4)
- Healthy
- Fatty
- Fibrotic
- Cirrhotic
What is alcoholic liver disease?
How many stages?
What are they called?
- Refers to liver damage that’s been caused by alcohol
- 4- determine pt symptoms
1. Alcoholic fatty liver disease
2. Alcoholic hepatitis (inflammation- cell death)
3. Fibrosis
4. Cirrhosis
What is Alcoholic fatty liver disease? (stage 1 ALD)
- Build up of fats in the liver usually due to drinking large amounts of alcohol, even if its
just over a few day - Rarely causes any symptoms
- Reversible if you abstain from drinking for a few months /years
What is Alcoholic hepatitis? (stage 2)
inflammation– cell death
- Progresses as a result of alcohol misuse over a longer period of time
- Mild cases - reversible if you stop drinking alcohol permanently
- Severe cases – serious and life threatening illness
- When this develops, usually the first time the patient is made aware they have liver damage
What is Fibrosis (stage 4 ALD)
Continuous inflammation of the liver results in scar tissue forming
* Liver becomes fibrous
* This is known as fibrosis
What are the 2 types of Cirrhosis? (Stage 4 ALD)
symptoms?
Compensated
* The liver can still function effectively
* No or very few noticeable clinical symptoms
Decompensated
* The liver can not effectively function
* Patients experience symptoms and complications of liver cirrhosis
Prognosis of cirrhosis:
What could the prognosis of cirrhosis influenced by?
- Once cirrhosis has occurred, it is usually considered as irreversible
- Patients with cirrhosis are generally well and have no clinical signs or symptoms for a period of time (compensated liver cirrhosis = liver is still able to function)
- When the liver becomes damaged to the point its classified as decompensated, patients will start to develop symptoms and complications
The prognosis of cirrhosis is influenced by a number of factors,
* Underlying cause — successful treatment of the cause may prevent additional liver injury (for example antiviral treatment for hepatitis C)
* Lifestyle changes — obesity and alcohol use have prognostic relevance in people with cirrhosis, regardless of the underlying cause;
* Average survival in the compensated stage is more than 12 years
* Average survival in the decompensated stage it is around 2 years
Diagnosis of ALD (blood tests)
Assess liver function tests = maybe normal at many stages of liver disease
Liver function tests
* Elevated alanine transaminase (ALT)
* Elevated aspartate amino transferase (AST)
* Elevated ALT:AST ratio
* Elevated bilirubin
* Low albumin levels
* Raised Gamma GT = suggestive of alcohol misuse
Full blood count / clotting
* Low platelets
* Prolonged prothrombin time
* Elevated INR
Diagnosis of ALD- History taking:
What to ask?
- Accurate history of alcohol intake
- Identification of other risk factors;
-Viral causes
-Medication history - History of symptoms onset =early stage symptoms are non-specific
Diagnosis of ALD- Physical examination
- Hepatomegaly = palpable left lobe of the liver
- Splenomegaly (enlarged spleen)
Common symptoms in liver cirrhosis:
* Spider Navi
* Palma erytherma (red palms)
* White nails
* Clubbed fingers
* Muscle wasting
Signs and symptoms of decompensated liver disease:
* Ascites / oedema
* Jaundice
* Abnormal bruising
* Variceal bleeding
* Infections
* Encephalopathy
Diagnosis of ALD- Liver imagine / Biopsy
- Ultrasound of the liver
- CT / MRI scan
- Liver biopsy = extent of liver scarring
- Endoscopy = identify oesophageal varices
Liver disease symptoms
What are the Early symptoms? (fatty liver disease)
- Bruise more easily
- Feeling tired / unwell / excessive fatigue
- Abdominal pain (right upper quadrant)
- Loss of appetite
- Weight loss and muscle wasting
- Dark urine
- Pale stools
- Nausea and vomiting
- Spider-like small blood capillaries on the skin above waist level (spider angiomas / spider navi)
- Disturbed sleep patterns
- Red palms
Liver disease symptoms:
What are the Later stage symptoms? = as the liver is struggling to function
(4 main symptoms)
- Jaundice (yellowing of the skin and eyes) = intensely itchy skin
- Ascites = Swelling of the abdomen
-
Coagulopathy = increased bleeding risk:
-Frequent nose bleeds
-Bleeding from the gums
-Vomiting blood - Increased risk of infections;
-Fever and rigors - Encephalopathy
- Forgetfulness
- Memory loss
- Confusion
- Drowsiness
- Increased sensitivity to drugs, both medical and recreational
- Increased sensitivity to alcohol
- Clubbed fingers = ends of fingers become wider/thicker
Symptoms and complications of cirrhosis- Jaundice
What is Jaundice?
What causes it?
Why do cirrhosis pt have jaundice?
1) Jaundice
* Yellowing of the skin, eyes and mucus membrane as a result of an increase in bilirubin (yellow).
* Bilirubin is usually processed in the liver, mixed into bile and excreted via bile ducts into the gallbladder where its eventually released into the small intestine to help digest fats.
* In liver cirrhosis, bilirubin isn’t broken down and hence accumulates leading to jaundice
* Accumulation of bilirubin can also cause intense itchiness
Symptoms and complications of cirrhosis- Encephalopathy
What are the symptoms?
What are the 2 main types? and what do they have a deficiency of?
Hepatic encephalopathy is a dysfunction of the brain = liver insufficiency = results in build-up of nitrogen compounds in the blood (ammonia + glutamine) which INC permeability of BBB
Symptoms:
* Cognitive and behavioural changes (irritability, disorientation)
* Personality changes
* Sleep disturbance
* Motor problems
* Altered level on consciousness
- Two main types that can present either together or in isolation:
1. Wernicke’s encephalopathy; caused by an acute deficiency in thiamine (common in alcoholic patients)
2. Hepatic encephalopathy; caused by excess build-up of toxins in the blood as the liver is unable to clear (e.g. medication)
Symptoms and complications of cirrhosis-
What is Coagulopathy?
- Prolonged clotting time (^ bleeding risk)
- Low platelets (help the blood clot)
- Liver plays a role in hemostasis = synthesis of clotting factors, coagulation inhibitors and fibrinolytic proteins and produces Thrombopoietin which stimulates platelet production
In liver cirrhosis; patients tend to have:
* Low platelets (normal range 150 – 400 x 10 9 /L)
* Prolonged prothrombin time (PT) – blood test used to measure how long it takes your blood to clot (normal range: 10 – 13 seconds)
What is Portal Vein Hypertension?
Why does it occur?
- Portal vein hypertension is one of the earliest signs of liver cirrhosis
WHY DOES IT OCCUR?
* The portal vein carries blood from the digestive system and spleen to the liver
* The pressure in the portal vein can rise for two main reasons in liver cirrhosis:
1. There is a blockage = portal vein clot
2. Increased resistance in blood flow through the liver as a result of scarring
What can portal vein hypertension lead to?
- Ascites
- Spontaneous bacterial peritonitis
- Variceal haemorrhage
- Portal vein thrombus
