MET3 Revision: Hepatology I Flashcards
A 55-year-old male alcoholic with known cirrhotic liver disease is admitted to the Gastroenterology Ward with a distended abdomen, jaundice and confusion. On examination, he is clinically jaundiced and has a massively distended abdomen with evidence of a fluid level on percussion. An aspirate of fluid is taken from his abdomen and sent for analysis. Results indicate the fluid is an exudate.
Which of the following is an exudative cause of ascites?
Portal hypertension
Cardiac failure
Fulminant hepatic failure
Budd–Chiari syndrome
Malignancy
A 55-year-old male alcoholic with known cirrhotic liver disease is admitted to the Gastroenterology Ward with a distended abdomen, jaundice and confusion. On examination, he is clinically jaundiced and has a massively distended abdomen with evidence of a fluid level on percussion. An aspirate of fluid is taken from his abdomen and sent for analysis. Results indicate the fluid is an exudate.
Which of the following is an exudative cause of ascites?
Malignancy
Ascites is defined as an accumulation of fluid within the peritoneal cavity. The causes can be classified according to the protein content of the fluid: < 30 g/l transudate, >30 g/l exudate. The most common causes of an exudative ascites are infection or malignancy. The above patient scenario would be more in keeping with a malignant cause.
Alcohol withdrawal sydrome serverity is determined using a scoring system from which chart? [1]
CIWA-Ar Chart
If a patient is scoring > [] on a CIWA-Ar then they are given a [] to help control symptoms
If a patient is scoring > 10 on a CIWA-Ar then they are given a benzodiazapene to help control symptoms
State the first and second line benzodiazepenes used to treat AWS [2]
1st line: Chlordiazepoxide
2nd line: Lorazepam - First line if cirrhotic.
Which drugs are used if seizures [1] and pyschotic symptoms [1] develop from AWS?
Seizures: IV Lorazepam
Pyschotic symptoms: Haloperidol (blocks D2 receptors)
Which drug is used to prevent Wernicke’s encephalopathy or Korsakoffs? [1]
What is given as continuing supplementation after ^? [1]
Prevent WE & Korsakoffs: Pabrinex: high strength Vit B & C
After completin pabrinex: Thiamine 100mg 3XD}
Why is Lorazepam prescribed for AWS in Ptx w cirrhosis? [2]
Short acting: liver function is already impaired, so if give long acting chlordiazepoxide then could get accumulation & cause toxicity (like resp. depression)
What is the treatment dose for pabrinex in treating AWS? [1]
What is the prophylatic dose for pabrinex in treating AWS? [1]
TD: 2 pairs IV pabrinex 3xday for 3-5 days
Prophylatic dose: 1 pair 3xD}
Name an AE of pabrinex [2]
- Risk of anaphylaxis
- Risk of glucose infusions in diabetic or low blood sugars: may deplete thiamine stores and precipate Wernickes
Describe and explain treatment plan for hepatic encephalopathy [3]
1. Lactulose:
- Increases faecal bulk & peristalsis
- Also reduces colonic pH: reduces absorption of NH3
- dose varies from 15-50ml TDS
2. Phosphate enemas:
- fast acting osmotic laxative
- STAT if Ptx encephalopathic; after passing stools PRN BD
3. Rifaximin
- antibiotic: diminishes deaminating enteric bacteria to decrease production of nitrogenous compounds
- 550mg BD
When is rifaximin prescribed in HE? [1]
Only in recurrent HE
Treatment of ascites? [2]
Fuoresemide:
- loop diuretic: binds to Na-K-2Cl; inhibits Na+ reabsorption
- 40mg OM
- IV in ascitic patients due to risk of AKI
Spironolactone:
- aldosterone antagonist at DCT
- 100mg OM; increased to 400mg if need
Which patients does terlipressin prescription need to be cautious with? [2]
Cardiac conditions:
Causes increase in BP; atherosclerosis; cardiac dysrythmia or coronary insufficiency
Tx for gastro-oesophageal varices? [2]
Terlipressin:
- contracts smooth oesophageal muscles; compression of the varices
- 1-2 mg for 4-6hrs until bleeding controlled
- Continue for 5day
Carvedilol:
- preffered due to mild anti-alpha 1 adrenergic activity (historically propanolol)
- used as prophylaxis
Tx for paracetamol OD? [1]
Describe MoA [1]
N-acytlcysteine (NAC) IV infusion:
- restores gluthathione levels or acts as alternate substrate for conjugation
- antioxidant
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Describe IV NAC infusion regime in paracetamol OD [3]
First infusion:
- 150mg/kg: one hour
Second infusion:
- 50mg/kg: 4 hours
Third infusion (can repeat if need)
- 100mg/kg: 16 hours
Tx for Hep B? [2]
Tenofocir
- competitive inhibition: replaces the deoxyribonucleitde substrate in HBV DNA
- faster acting than entecavir
- safe in pregancy
Entecavir
- inhibits RT of Hep B DNA
- toxicity in pregnancy
Describe the aim of Hep B treatment? [1]
Describe treatment aim of HCV? [1]
HBV: Suppress but DO NOT cure virus: undetectable viral load
HCV: CURE of virus
What monitoring should be given for HBV treatment? [1]
Why? [2]
Renal monitoring: nephrotoxicity due to lactic acidosis and may decrease bone mineral density
- Monitor phosphate and creatinine levels
HCV treatment? [1]
Describe what is meant by Korsakoff syndrome [1]
Korsakoff syndrome is a chronic amnesia resulting from unrecognized or undertreated Wernicke encephalopathy and is caused by thiamine (vitamin B1) deficiency.
Name three scoring systems used to assess NAFLD [3]
NICErecommends considering the use of which test to assess the risk of advanced liver fibrosis in people with suspected non-alcoholic fatty liver disease (NAFLD), prior to the other two? [1]
NAFLD Fibrosis Score (NFS)
Enhanced Liver Fibrosis (EFS) - NICE rec. as first line score
FIB-4
Which pathology would these nails indicate? [1]
Wilsons disease
Why does Wilsons disease lead to haemolysis? [1]
The hemolysis in Wilson’s disease is due to deficiency of ceruloplasmin, the copper transport protein which results in exessive inorganic copper in the the blood circulation, much of it accumulates in red blood cells.
State two haemodynamic conseqeunces of:
- Acute liver failure [2]
- Chronic liver failure [5]
Acute liver failure:
* Cerebral oedema;
* Renal failure
Chronic liver failure:
Portal HTN:
* i) Ascites
* ii) Splenomegaly
* iii) Varices
* iv) Hepatic encephalopathy
Explain specific change in blood flow from portal hypertension contributes to hepatic encephalopathy [1]
Collaterals between splenic and renal veins: spleno-renal shunts: allow blood from bowel to bypass the liver and leak into systemic circulation, ammonia included (instead of being converted to urea and excreted). Goes to brain
What effect does portal HTN have on cell count? [1]
Why? [1]
Causes pancytopenia (red blood cells, white blood cells and platelets decreased) due to splenomegaly
How does portal hypertension lead to ascites? [5]
- Increased pressure in portal system causes fluid to leak out of the capillaries in the liver and into peritoneal cavity. Increase in pressure also causes release of splachnic vasodilators.
- Drop in circulating volume due to vasodilators on splachnic vessels and fluid forced out causes reduced pressure in kidneys
- Renin is released
- Aldosterone is secreted via RAAS
- Increased aldosterone increase Na+ and therefore fluid reabsorption
- Cirrhosis is causes low albumin levels, which decreases oncotic pressure
What are the two reasons that ammonia builds up in the blood in patients with cirrhosis? [2]
- liver cells’ functional impairment prevents them from metabolising the ammonia into harmless waste products
- collateral vessels between the portal and systemic circulation mean that the ammonia bypasses the liver and enters the systemic system directly
State 5 triggers for decompensated cirrhosis
State the cause of jaundice
Upon ultrasound imaging of non-alcoholic fatty liver disease, how would fatty changes appear? [1]
increased echogenicity.
Describe the process of TIPS [2]
- shunt inserted into portal vein & into hepatic circulation
- reduces portal pressure
What is Budd-chiari syndrome? [1]
Budd-Chiari syndrome is a vascular liver disorder due to obstruction of hepatic venous outflow:
Describes a condition characterised by occlusion or partial occlusion of any, or all, the three major hepatic veins. This may occur with or without occlusion of the IVC.
Define Gilbert’s syndrome [1]
Gilbert’s syndrome is an autosomal recessive condition associated with intermittent raised unconjugated bilirubinaemia, resulting from a defective glucuronyl transferase. This is the enzyme involved in conjugation of bilirubin, and so the ability of patients to conjugate bilirubin is significantly reduced.
