6. Liver Disease Notes Flashcards
(124 cards)
1
Q
Which condition(s) is/are jaundice more common in?
- PBC
- Steatotic cholangitis
- Cirrhosis
A
PBC and Steatotic Cholangitis ( but jaundice may be present in Cirrhosis)
2
Q
Signs of cirrhosis on the hands and legs
A
- Clubbing
- Luekonychia
- Duputryen’s contracture (ALD in particular)
- Palmar erythema
- Flapping tremor ( encephalopathy)
- Bruising
- Ankle oedema
- Leg bruising
3
Q
What clotting factor does the liver not make?
A
VII
4
Q
Signs of cirrhosis on the trunk
A
- Axillary hair loss
- Gynaecomastia
- Spider naevi
5
Q
What drugs can cause gynaecomastia
A
Spironolactone, digoxin, metronidazole
6
Q
Signs of cirrhosis on the abdomen
A
- Hepatomegaly
- Splenomegaly
- Ascites
- Dilated veins
- Testicular atrophy
- Umbilical hernia
7
Q
What drug can be used for ascites ( caused by portal hypertension?)
A
Carvedilol
8
Q
What is the treatment for bleeding oesophageal varices
A
- Resusc
- Endoscopic therapy with Band ligation
- Terlipressin ( vasoconstrictor)
- Balloon tamponade if aboce doesnt work
- TIPSS if all else fails
9
Q
Primary and Secondary prophylaxis for variceal bleeds
A
Primary - Non selective B blocker (prop) and variceal band ligation
Secondary - Band ligation and propanolol/carvedilol
10
Q
Treatment for ascites
A
- Sodium restriction
- Spironolactone (NOT loop diuretics - too strong)
- Paracentesis (resistant ascites). Need albumin cover
- Prohylatic abx to reduce risk of SBP- cirpo oral
11
Q
How to dx SBP
A
Neutrophil>250 on PARACENTESIS
12
Q
Most common organism in SBP
A
E. coli
13
Q
Treatment of SBP
A
Intravenous Cetofaxime
14
Q
What does SAAG>11gL mean
A
To separate Ascites:
High:
Portal hypertension, could be due to liver diseases
Cardiac - RHF, constrictive pericarditis
Loww:
Hypoalbuminea, malignancy, infections
15
Q
When in AST high when ALT may be normal ( ratio >2)
A
Alcoholic liver injury
16
Q
When does ALT and not AST increase
A
HCV, fatty liver ( unless very serious)
17
Q
In what non-pathological state is ALP increased
A
Last trimester
18
Q
In what group of people is GGT increased
A
Heaver drinkers ( esp those with liver disease)
Those on enzyme-inducing meds like carbamazapine or phenytoin, alcohol
19
Q
How is unconjugated bilirubin transported in blood?
How does it get conjugated and where?
How does bilirubin get into the SI
What does conjugated bilirubin get excreted as?
A
- With albumin
- In the liver, with glucronic acid
- Through the biliary system
- Urobilinogen, after conversion by bacterial proteases
20
Q
Which Hep viruses
- are transmitted faeco-orally
- commonly result in chronic infection
- are blood borne
- have vaccine
A
- A and E
- B and C
- B and C
- A and B
21
Q
Sx of HAV and complications
A
- Jaundice
-flu-like prodrome
abdominal pain: typically right upper quadrant
tender hepatomegaly
-deranged LFT
Complications: - Fulminant hepatitis
- Cholestatic hepatitis
22
Q
Incubation period of HAV
A
30 (15-50)
23
Q
What are HEV epidemics assoc with
A
Contaminated drinking water
24
Q
How is HEV commonly transmitted
A
- Foodborne, through uncooked meat such as pork, or molluscs
- Contaminated water
- Blood transfusion and transplanted organs
- Vertical transmission
25
Most common cause of acute hep in UK
HEV
26
How is HCV commonlly transmitted
Blood borne through shared needles
27
Which Hep Viruses are likely to cause cirrhosis
HCV, HBV
28
Can HCV be cured, and if so, with what?
Yes, with combination therapies
29
What can cause HBV to be reactivated
Iatrogenic causes
Oncological causes
30
What defines Hep B as being chronic?
HBsAg +ve > 6 mo
31
Are anti HBe and Hbs present in chronic Hep B
No
32
What is an indicator to acute HBV infection
HBsAg main indicator
IgM Anti-HBc- highest in acute infn, and in acute LF HBsAg may be negative but IgM may be present
33
Is HBe Ag present in chronic HBV infection
No,negative in certain infections, HBV DNA usually lower in these pts. HbeAg results from breakdown of core antigen from infected liver cells as is, therefore, a marker of infectivity
34
IgM anti-HBc vs IgG anti-HBc
IgM anti-HBc appears during acute or recent hepatitis B infection and is present for about 6 months. IgG anti-HBc persists- can imply PREVIOUS infection
35
Complications of Hep B infection
Chronic hepatitis (5-10%)
'Ground-glass' hepatocytes may be seen on light microscopy
Fulminant liver failure (1%)
hepatocellular carcinoma
glomerulonephritis
polyarteritis nodosa
cryoglobulinaemia
36
Can HBV be cured, and if so, with what?
Pegylated interferon
Oral antivirals
37
Which HEV genotypes are more common in developing countries compared to developed countries? Difference in transmission
1 and 2 - Faeco-oral vis infected water
vs 3 and 4 - Faeco-oral via infected pig meat, direct exposure to pigs or infected water`
38
Age at infection of HEV (1,2 vs 3,4)
15-30yo vs >50
39
Is HEV self-limiting
Yes
40
Does HEV cause chronic hep
Yes in genotype 3
41
HEV treatment
Ribavarin in immunocompetent, although rarely used.
Interferon a and ribavarin in chronic HEV infxn in immunosuppressed
42
Ribavarin for ?
HCV in decompensated cirrhosis, HEV in immunosuppressed and sometimes in immunocompetent
43
which group is more liely to get chronic HEV infxn?
Solid organ transplant individuals
44
Main serology when acute hepatitis has resolved?
HBsAg negative
45
Risk of reactivation is HBsAg positive compared to HBsAg negative but core Ab positive
Higher if HBsAg +ve
46
What to treat HBV in pregnancy
Tenovir if viral load>200000 IU in third trimester
47
48
Sexually transmitted Hep Viruses
B and D mainly
49
Features of viral hep
headache, myalgia, arthralgia, nausea and anorexia usually precedes the development of jaundice by a few days to 2 weeks.
50
Which viral heps are more likely to cause cirrhosis
B and C
51
ALT in Viral Hep
200-2000
52
Vehicles of transmission of HAV in occassional outbreaks
Shellfish and water
53
What is diagnostic of HAV infxn
HAV IgM
54
How to provide immediate protection soon after exposure to HBV
Give IMMUNISATION or immune serum globulin ( esp in >60yo or immunocompromised indiv)
55
If vaccination to HBV is given, will anti HBc and HBs present?
HBs yes, HBc no
56
What does seroconversion to e ag in HBV suggest
Seroconversion to e antigen (i.e. loss of HBeAg and development of anti-HBe antibody) indicates a partial immune control of the virus and is associated with a significant drop in viral load
57
Is chronic HBV infxn more common in children or adults
children
58
What does HBeAg negativity in chronic hep mean
HBV mutants that escape from immune regulation
59
Who gets antiviral therapy for Hep B
Those with sever liver injury and INR >1.5, or protracted course with persistent sx >4 weeks
60
LFT in HCV
LFTs may be normal or show fluctuating serum transaminases between 50 and 200 U/L
61
Diagnosis of acute HEV infection
Diagnosis of acute infection is usually based on detection of anti-HEV IgM antibodies
62
In which groups can HEV be more serious
nfection with genotype 1 or 2 virus during pregnancy carries a high risk of acute liver failure, which has a high mortality. Hepatitis E also causes more severe disease in those with underlying cirrhosis, resulting in decompensation or acute-on-chronic liver failure.
63
Which patiens are at higher risk of HCC
Viral Hep and Haemachromatosis patients
64
NASH CRN Scoring System for fibrosis stages:
Centrilobular peri-sinusoidal fibrosis
+ Periportal fibrosis
+ bridging fibrosis
cirrhosis
65
What inherited metabolic disorders can cause fibrosis
Hemachromatosis, wilsons, a1-antitrypsin
66
What drug can cause liver fibrosis
Methothrexate
67
Liver enzymes in MASLD
AST and GGT elevated, ALT normal , ferritin slightly elevated
68
What is MetALD
MASLD + Increased alcohol intake
69
How to risk stratify pt with MASLD/MASH?
FIB-4
70
Ix for NAFLD
- FIB-4
- Fibroscan
- USS
- Liver Biopsy : Can give NAS score and fibrosis stage
71
Possible surgical tx for NAFLD and side effects
Laparoscopic sleeve gastroscopy, chronic diarrheoa
72
Blood Tests for ALD
Elevated AST, ferritin and GGT ( higher than for NAFLD)
73
Ferritin and transferrin level in haemachromatosis
Ferritin and transferrin both high
74
Investigations in cirrhosis of the liver
Fibroscan aka transient elastography (stiffness) - esp for those with indeterminate firbosis scores(Fib4) esp for NAFLD
- USS (fat) ,
biopsy - GOLD STANDARD
- Ascitic tap if ascites present, to culture fluid
- UGIE for varices in pts with new dx of cirrhosis
75
Clinical features of NAFLD
Often aSx but may have assoc RUQ discomfort
hepatomegaly
ALT is typically greater than AST
increased echogenicity on ultrasound
76
What drugs cause fatty liver
tamoxifen, amiodarone and corticosteroids.
77
Is ALT or AST higher in advanced NAFLD
AST
78
Expected liver biopsy obs for NAFLD
- steatosis, hepatocellular injury and inflammationwith mainly centrilobular, acinar zone 3 distribution
- perisinusoidal fibrosis is characteristic feature of NAFLD
79
How to determine Tx for NAFLD
Based on FIB-4, and TE if indeterminate risk
- Low risk, lifestyle advice (GP)
- High risk, address CV risks and assess for portal HT and HCC (hep clinic)
80
81
How to differentiate cholecystitis from cholangitis
Murphy's sign positive for cholecystitis and fever and raided inflammatory markers
Charcot's triad for cholangitis - RUQ pain, jaundice and fever
82
Difference between Liver cancer and PBC in terms of jaundice
Higher bilibrubin for liver cancer
83
Drugs that can cause hepatocellular picutre
paracetamol
sodium valproate, phenytoin
MAOIs
halothane
anti-tuberculosis: isoniazid, rifampicin, pyrazinamide
statins
alcohol
amiodarone
methyldopa
nitrofurantoin
84
drugs tend to cause cholestasis (+/- hepatitis):
combined oral contraceptive pill
antibiotics: flucloxacillin, co-amoxiclav, erythromycin*
anabolic steroids, testosterones
phenothiazines: chlorpromazine, prochlorperazine
sulphonylureas
fibrates
85
Acute mx of alcoholic hepatitis
glucocorticoids (e.g. prednisolone) are often used during acute episodes of alcoholic hepatitis
pentoxyphylline is also sometimes used
86
How to treat Wernicke encephalopathy or Korsakiff psychosis
THIAMINE/ Pabrinex
87
Features of Wernicke's encephalopathy
oculomotor dysfunction
nystagmus (the most common ocular sign)
ophthalmoplegia: lateral rectus palsy, conjugate gaze palsy
gait ataxia
encephalopathy: confusion, disorientation, indifference, and inattentiveness
peripheral sensory neuropathy
88
What is Korsakoff sx
Antero and retrogade amnesia and confabulation in addition to Wernicke's
89
Risk factors for NAFLD include
Associated factors
obesity
type 2 diabetes mellitus
hyperlipidaemia
jejunoileal bypass
sudden weight loss/starvation
90
What is AIH assoc with
- Autoimmune thyroiditis
- Systemic lupus erythematosus
- Rheumatoid arthrits
- Primary sclerosing cholangitis
- Coeliac disease
- Type 1 diabetes
- Dermatomyositis
- Coombs-positive haemolytic anaemia
- Ulcerative colitis
91
What drug can induce AIH
Nitrofurantoin
92
Px of AIH
may present with signs of chronic liver disease
acute hepatitis: fever, jaundice etc (only 25% present in this way)
amenorrhoea (common)
ANA/SMA/LKM1 antibodies, raised IgG levels
liver biopsy: inflammation extending beyond limiting plate 'piecemeal necrosis', bridging necrosis
93
Mx of AIh
Steroids or Aza
Liver transplant if severe
94
PBC assoc
Sjogren's syndrome (seen in up to 80% of patients)
rheumatoid arthritis
systemic sclerosis
thyroid disease
Coeliac
95
Features of PBC
early: may be asymptomatic (e.g. raised ALP on routine LFTs) or fatigue, pruritus
cholestatic jaundice
hyperpigmentation, especially over pressure points
around 10% of patients have right upper quadrant pain
xanthelasmas, xanthomata
also: clubbing, hepatosplenomegaly
late: may progress to liver failure
96
How to diagnose PBC
Middle aged women, raised IgM, AMA present in most patients
97
Ix for PBC and what to exclude
Exclude extrahepatic biliary obstruction, using MRCP- ducts should appear normal
98
Treatment of PBC
Urso first line, cholestyramine for pruritus, fat-soluble vit supp
Liver transplantation if bilirubin >100
99
Complications of PBC
Causes fibrosis/ cirrhosis, Portal hyperT, ascites, variceal haemorrhage
increased risk of HCC
100
PSC dx
Dx→Beading and stenosis of biliary system on MRCP
101
How is PSC usually discovered incidentally
raised serum ALP is discovered in an individual with ulcerative colitis.
102
Presentation of PSC
Patients may present with episodes of biliary obstruction, or with symptoms of cirrhosis or portal hypertension.
103
What abs are detected in majority of pts with PSC
ANCA
104
what disease is PSC closely assoc with
UC
105
Common sx of PSC
Fatigue, intermittent jaundice, weight loss, right upper quadrant abdominal pain and pruritus. Attacks of acute cholangitis are uncommon and usually follow biliary instrumentation.
106
Is fatigue more prominent in PSC or PBC
PBC
107
Treatment for PSC
Cipro for acute attacks, ERCP to relieve obstruction causes by stricture
108
Haemochromatosis fx
fatigue, erectile dysfunction and arthralgia (often of the hands)
bronze skin pigmentation
May have CLD
109
What mutation can be tested for haemachromatosis
HFE
110
Is TIBC high or low in haemachromatosis
Low
111
Treatment of haemachromatosis
Venesection
112
Most common causes of liver cirrhosis are:
Alcohol
non-alcoholic fatty liver disease (NAFLD)
viral hepatitis (B and C)
113
Complications of Cirrhosis
Ascites,
114
Treatment of ascites
Carvedilol
115
What is duputryen's a sign of
alcohol misuse
116
Cirrhosis complications
High blood pressure in the veins that supply the liver (portal hypertension)
Swelling in the legs and abdomen (edema and ascites)
Enlargement of the spleen
Bleeding
Infections
Malnutrition
Buildup of toxins in the brain
Jaundice
Liver cancer
117
Fx of HCC
tends to present late
features of liver cirrhosis or failure may be seen: jaundice, ascites, RUQ pain, hepatomegaly, pruritus, splenomegaly
possible presentation is decompensation in a patient with chronic liver disease
raised AFP
118
How to screen for HCC and in which groups
ltrasound (+/- alpha-fetoprotein) should be considered for high risk groups such as:
patients liver cirrhosis secondary to hepatitis B & C or haemochromatosis
men with liver cirrhosis secondary to alcohol
119
Mx of HCC
early disease: surgical resection
liver transplantation
radiofrequency ablation
transarterial chemoembolisation
sorafenib: a multikinase inhibitor
120
Common causes of liver metastases
Colorectal, lung, ooesophageal, breast
121
What drugs increase risk of developing hepatotoxicity from paracetamol overdose
liver enzyme-inducing drugs (rifampicin, phenytoin, carbamazepine, chronic alcohol excess, St John's Wort)
122
Management of paracetamol ocerddose
Acetylcysteine infusion
Liver transplantation if serious
123
Features of acute liver failure
jaundice
coagulopathy: raised prothrombin time
hypoalbuminaemia
hepatic encephalopathy
renal failure is common ('hepatorenal syndrome')
124
