Week 2 - Liver disease Flashcards
What are the main functions of the liver
Liver is able to repair + regenerate new liver cells (hepatocytes)
FUNCTION:
1. Metabolism (drugs, bilirubin, protein, fat, etc.)
2. Clearance (drugs, bilirubin, toxins)
3. Produces bile
4. Synthesis (proteins, fibrinogen, cholesterol, clotting factors etc.)
5. Storage (of fat soluble vitamins + folic acid)
6. Homeostasis
7. Immunological
What are the common causes of liver disease (alcohol-related)
- Alcohol is most common cause for liver disease
- High alcohol intake (>14 units a week)
- approx. 50-70% cirrhosis is alcohol related
What are the common causes of liver disease (non-alcoholic fatty liver disease - NAFLD)
- Metabolic condition
- linked with CVD and diabetes
Other Causes:
- Viral hepatitis
- Infections
- Medicines + toxins
- Immune disease of the liver
- Inherited and metabolic disorders
- Cancer
- Biliary tract disorders
How is liver disease classified (time period - 2 types)
Classified according to time period it occurs over + pattern of the damage
Acute OR Chronic
- Acute
- rapid onset of symptoms which doesn’t exceed 6 months
- most common cause is medicines or viral hepatitis
- acute hepatitis is self-limiting (will recover)
- can develop into acute liver failure (ALF), acute liver dysfunction or chronic liver disease
SYMPTOMS: jaundice to encephalopath
= yellowing of eyes/ skin and + brain function affected i.e. confusion
- HYPERACUTE = symptoms last 0-7 days
- ACUTE = symptoms last 8-28 days
- SUBACUTE = symptoms last 29-84 days - Chronic
- symptoms last longer than 6 months
- most common cause alcohol or chronic viral hepatitis
- progressive + permanent structural damage
- patient is decompensated = can’t preform normal function
MANAGEMNET:
- treat underlying condition
- treat symptoms + complications
- liver transplant if needed
How is liver disease classified (pattern of damage - 2 types)
Classified according to time period it occurs over + pattern of the damage
Cholestatic or Hepatocellular
- Cholestatic / Cholestasis
- is disruption of bile flow (bile doest move in bile ducts) - Hepatocellular
- is injury to hepatocytes (liver cells)
- injury can be steatosis (fatty infiltration) and hepatitis (inflammation)
- injury can lead to fibrosis (liver scarring) + cirrhosis (permanent structural change to liver)
Fibrosis / Cirrhosis
- usually liver cells can repair themselves but ongoing damage to liver / hepatocytes = no repair = scarring develops (fibrosis) = blood flow is disrupted
- ongoing damage can cause cells to grow in wrong places = nodules form = cirrhosis
2 Types of cirrhosis
1. Compensated cirrhosis
- have enough hepatocytes for liver to carry out function
2. Decompenstated cirrhosis
- don’t have enough hepatocyte required for lover function (liver is extensively damaged)
What are the common signs and symptoms of liver disease
- Jaundice (yellowing of eyes, skin)
- buildup / high levels of bilirubin (>50) - Pale stools
- indicate biliary obstruction / bile excretion reduction (as binary is converted into faecal pigment when excreted) - Dark urine
- indicates obstruction
- conjugated bilirubin is excreted renally - Pruritus (itching)
- accumulation of bile under skin - Ascites
- swelling in abdomen (accumulation of / excess fluid) - Enchephalopathy
- changes in brain function e.g. confusion, coma - Varices + portal hypertension
- diabetes vessels due to increased portal vein pressure - Finger clubbing
- Red palms
- Spider nave (vascular changes)
- Bruising + bleeding
- Enlargement of male breast tissue
How is the severity of liver disease assessed (specifically for cirrhosis)
Assed by using “Child Pugh Scoring System”
- points are given for certain factors
Have 3 classes:
- Class A = <6 points
- have cirrhosis but fall into compensated category
- Class B = 7-9 points
- Class C = >10 points
- severe cirrhosis, fall into decompensated category need to consider medicine dose
List & explain the types of liver blood tests (5 Liver Function Tests ~ LFT)
Blood tests are used to assed liver function
- biochemical markers can be indicators that there is liver disease
- Bilirubin
- its a product of RBC breakdown
- when there’s liver damage bilirubin won’t be metabolised or excreted well = ↑ levels of bilirubin
- excreted via bile
- causes jaundice when levels >50 micromol/L
- bilirubin levels are ↑ by RBC breakdown, hepatocellular damage, cholestasis (disrupted bile flow) - Albumin
- a protein synthesised by liver
- albumin level ↓ in chronic liver disease (can’t be synthesised)
- ↓ albumin level causes oedema - Transaminases
- are enzyme in liver cells
- damaged liver cells release this enzyme = ↑ in levels
- not always present in liver damage, liver may be so damaged it doesn’t produce enzyme anymore
- transaminase levels ↑ in hepatitis, medicines, sepsis
- AST and ALT (ALT preferred as it is liver specific enzyme) - ALP and y-GT
Alkaline Phosphatase – ALP
- found in liver
- levels ↑ in cholestasis and damage to biliary tree
γ-Glutamyltransferase – GGT
- found in liver + biliary epithelial cells
- levels ↑ by enzyme inducers e.g. alcohol, medicined, cholestasis - PT/INR
PT = prothrombin time | INR = international normalised ratio
- clotting factors are synthesised by liver
- measuring clotting gives indication of how well liver is working
- levels ↑ if person has acute / chronic liver disease (as it should be synthesised quickly in healthy liver)
Explain how liver blood tests are used in practice
- If results are 2-3x above normal range = abnormal results
- At least 2 of the tests will be abnormal if have liver dysfunction
- Blood tests aren’t always abnormal in liver dysfunction e.g. transaminases
- Abnormal results aren’t always because of liver dysfunction
- Need to check medicines recommendation for hepatic impairment / function
- they may specific which liver blood test to monitor e.g. albumin or bilirubin
List other ways liver function can be assessed (NOT blood tests)
- Liver biopsy
- take samples of liver + examination pattern of damage - Imaging
- e.g. CT scan, MRI scan, liver ultrasound - Fibroscan
- assesses liver stiffness (the stiffer it is the more likely there is damage to liver)
- quick, non-invasive and not painful
List the complications that can occur from liver disease
- Ascites
- Hepatic encephalopathy
- Spontaneous bacterial peritonitis
- Portal hypertension and Varices
- Pruritus (itching)
How do you manage ascites (a complication)
- Diuretics
- help by shifting excess fluid from abdomen
- by inducing -ive fluid balance = amount of free fluid in abdomen is reduced
- e.g. Spironolactone (aldosterone inhibitor) = 1st line
- liver disease patients have ↑ aldosterone levels as liver can’t break it down (aldosterone causes H2o retention)
- e.g. Furosemide (loop diuretic)
- see effects through measuring weight daily (weight loss is related to fluid loss) - Fluid / Sodium Restriction
- fluid restriction - patient is more careful about amount of fluids consumed / avoid drinking too much
- given a set volume per day to prevent accumulation of excess fluid
- sodium restriction - reduce salt intake in diet
- salt leads to water retention = fluids buildup - Paracentesis
- draining fluid from stomach (if have large volume of ascites)
- used alongside diuretic
How do you manage hepatic encephalopathy (a complication)
Hepatic encephalopathy is acute confusion caused by changes in brain
- can cause confusion, mood changes, behavioural changed, coma
- drugs, infection, toxin accumulation (e.g. ammonia) can make this worse
TREATMENT:
1. Laxatives
- inhibit intestinal ammonia production by;
- changing pH of gut lumen (= ↓ ammonia absorption)
- ↓ colonic bacteria load = ↓ ammonia production
- AIM: increase bowel movement to ↓ ammonia levels through excretion
- e.g. lactulose liquid (1-3x daily)
2. Antibiotics
- kills naturally occurring gut bacteria (which produces ammonia) = ↓ ammonia levels
- e.g. Rifaxamin (550mg 2x daily)
3. L-ornithine L-aspartate Sachets
- amino acid supplements
- thes amino acids make body more efficient at removing ammonia
How do you manage spontaneous bacterial peritonitis (SBP - a complication)
SBP is a bacterial infection of the ascitic fluid
- causes severe pian, raised temp., raised WBC count
- usually caused by gram -ive but can be caused by gram +ive bacteria too
TREATMENT:
- Initially treat with broad spectrum IV antibiotics e.g. cephalosporins
- treat for 5 days then review
- If improved after 5 days can stop treatment, if not continue treatment
- For prevention can give oral antibiotics e.g. Norfloxacin / Ciprofloxacin
How do you manage portal hypertension and varices (a complication)
Portal hypertension caused by ↑ resistance to blood flow due to;
- compression of hepatic venues from regenerating nodules
Varices are weak blood vessels that form when pressure around liver builds up (from restricted blood flow)
- body produces new vessels to try reduce pressure
- new vessels may burst as they’re weak - variceal bleed (GI bleed)
MANAGEMENT of variceal bleed:
- May need resuscitation
- May need fluids, blood transfusion etc.
- Endoscopy (camera put inside to see if bleeding can be stopped)
- Give terlipressin (1-2mg) IV every 4-6 hours
- potent vasoconstrictor to try stop bleeding
- Give antibiotic (broad spectrum for 5 days)
- to prevent infection
- Give PPI
- to protect stomach
PREVENTION of 2nd bleed:
- Propranolol tablets (20-40mg, x2 daily)
- reduce pressure around liver
- B2 blocker and B1 blockers
How do you manage pruritus (itching - a complication)
Pruritus is caused by build up of bile salts
TREATMENT:
1. Antihistamine - provides symptomatic relied from itching
- e.g. cetirizine, loratadine
2. Topical creams - provide symptomatic relief
- e.g. calamine lotion
3. Colestyramine
- binds to bile acids + helps body remove them
4. UCDA (ursodeoxycholic acid)
- works on bile breakdown to help remove excessive buildup of bile
Explain the treatments for liver disesse
MANAGEMNET:
- treat underlying condition
- treat symptoms + complications
- liver transplant if needed
What is alcohol withdrawal
- when someone who previously drunk a lot of alcohol stops suddenly
- sudden stops can cause withdrawal symptoms ranging from mild to severe
SYMPTOMS:
- delirium, tremor
- fear and delusions
- restlessness
- agitation
- fever
- rapid pulse
- dehydration
- seizures
How is alcohol withdrawal managed
With sedatives and vitamin supplements
- Chlordiazepoxide
- a sedative that prevents withdrawal symptoms like agitation + seizures
- helps patients ween off alcohol
- stimulates GABA=A process which helps manage withdrawal process
- 1st line, given orally, has low potency (= can’t be abused)
- given for 5 days, start with high dose then gradually reduce - Vitamin Supplements
- given as may be deficient due to poor diet + alcohol prevents thiamine absorption
- e.g. pabrinex
- is a combination of vitamin B and C
- given IV, 2-3x a day
- e.g. thiamine + vitamin B
- given orally to treat thiamine deficiency
List the types of viral hepatitis
Isch hepatitis
Chronic viral hepatitis (cause of chronic liver disease)
List the significance of viral hepatitis
It causes chronic inflammation of the liver + causes liver damage
Explain the principles of safe medicine use in people with liver impairment
Use BNF (Hepatic impairment section) when deciding dosage + what medication to prescribe
