Metabolic 1: Introduction to Hepatology

Question 1

Abnormal liver tests: acute

Answer 1

6 weeks

Drugs

Viral hepatitis (A,B,C,E)

Autoimmune hepatitis

Wilson’s disease

Question 2

Abnormal liver tests: subacute

Answer 2

6-28 weeks

Drugs

Viral hepatitis (A,B,C)

Autoimmune hepatitis

Wilson’s disease

Question 3

Abnormal liver tests: chronic

Answer 3

> 26 weeks

Viral hepatitis (B,C)

Alcohol

NAFLD

Autoimmune hepatitis

Wilson’s disease

Hemochromatosis

A1 antitrypsin deficiency

Question 4

Assessment of liver function

Answer 4

Blood tests: basic liver panel

Liver screen for all causes of liver disease

Imaging

Question 5

Liver tests

Answer 5

Bilirubin (17umol/l)

Liver enzymes

• asparate aminotransferase (40io/l)
• alanine aminotransferase (40iu/l)
• alkaline phosphatase (200iu/l)
• gamma GT (50iu/l)

Albumin (40 gm/l)

Prothrombin time

INR

Question 6

Abnormal LFT’s: liver screen

Answer 6

Hepatitis serology: hepatitis A IgM, hepatitis B surface antigen, hepatitis C antibody, hepatitis E IgG and IgM

ANA, SMA LKM (for autoimmune hepatitis)

AMA (for primary biliary cholangitis)

Alpha 1 antitrypsin

Copper, caeruloplasmin (Wilson’s disease)

Ferritin (genetic haemochomatosis)

Ultrasound

Question 7

Abnormal liver tests: hepatic

Answer 7

Viral hepatitis A,B,C,E

Drug induced liver injury

AUtoimmune hepatitis

Question 8

Abnormal liver tests: cholestatic

Answer 8

Biliary obstruction

Viral hepatitis A,B,E

DILI

Autoimmune hepatitis

Primary biliary cirrhosis cholangitis (more women)

Primary sclerosing cholangitis (more men)

Question 9

Cirrhosis

Answer 9

Generally irreversible chronic liver disease

Increase pressure in the portal circulation, also known as portal hypertension

Question 10

Liver failure: development of coagulatory and encephalopathy

Answer 10

Acute: within 4 weeks

Subacute: between 4-12 weeks

Acute on chronic: in setting of underlying chronic liver disease

Question 11

In acute liver failure

Answer 11

No pre-existing liver disease

Coagulopathy

Confusion (hepatic encephalopathy)

Jaundice

Abnormal liver tests

Cerebral oedema

Increased risk of infections

Renal failure (hepatorenal syndrome)

Question 12

In cirrhosis

Answer 12

Portal hypertension

• varices
• ascites
• hepatic encephalopathy

Jaundice

Spiders

Enlarged spleen/ pancytopenis

Renal failure

Hepatocellular cancer

Question 13

Stage 1 cirrhosis

Answer 13

Compensated without varices

Question 14

Stage 2 cirrhosis

Answer 14

Compensated with varices

Question 15

Stage 3 cirrhosis

Answer 15

Decompensated with ascites without variceal hemorrhage

Question 16

Stage 4 cirrhosis

Answer 16

Decompensated with/out ascites with variceal hemorrhage

Question 17

Ascites management in cirrhosis

Answer 17

Salt restriction

Fluid restriction if low sodium

Diuretics (spironolactone and frusemide)

Large volume paracentesis with albumin cover

If refractory ascites

• recurrent LVP
• transjugular intrahepatic portosystemic shunt
• consider liver transplant
• long term drains

Question 18

Variceal bleed

Answer 18

Haemodynamically stable, correct coagulopathy and thrombocytopenia

IV terlipressin and IV antibiotics

Endoscopy in theatre with anaesthetist present- variceal banding

If blood bath- ballon tamponade

Non selective B blockers for secondary prophylaxis

Question 19

Hepatorenal syndrome (AKI)

Answer 19

Functional and fairly rapid renal impairment due to reduced renal perfusion

Increase in serum creatinine by 50% from baseline within 3 months

Type 1 and 2

Treat underlying cause, terlipressin

Liver transplant

Question 20

Hepatic encephalopathy

Answer 20

Elevated ammonia

Diagnosis of exclusion

Treat precipitating cause: constipation, diuretics, infection, sedatives, GI bleed

Lactulose

Non absorbable antibiotics

Question 21

Paracetamol overdose

Answer 21

Present with nausea, vomiting, RUQ pain, confusion

Jaundice and liver failure usually develops after 3-4 days

Very high liver enzymes and prothrombin time

If receive N acetyl cysteine within 16 hours liver failure rare

Some benefit of NAC even up to 36 hours

In severe cases liver transplant only option

Question 22

Severe alcoholic hepatitis

Answer 22

Most serious form of alcohol related injury

Characterised by jaundice and coagulopathy

In patient untreated mortality 40%

Various prognostic scores

Treatment: steroids and pentoxyfilline

Question 23

Risk factors for hepatitis C virus

Answer 23

Recipients of clotting factors made before 1987

Injection drug use

Long term haemodialysis

Individuals with multiple sex partners

Recipients of blood transfusions prior to July 1992

Infants born to infected women

Question 24

Factors associated with disease progression of hepatitis C

Answer 24

Alcohol consumption

• 30g/day in men
• 20g/day in women

Disease acquisition at >40 years

Male gender

HIV coinfection

Hepatitis B virus coinfection

Immunosuppression

Question 25

Hepatitis C: natural history

Answer 25

Normal liver&raquo_space;

Acute infection&raquo_space;

Chronic infection develops in 80%&raquo_space;

Chronic hepatitis&raquo_space;

Cirrhosis develops in 20%&raquo_space;

Risk of carcinoma, 1-4% per year

Question 26

Non alcoholic fatty liver disease

Answer 26

Resemble alcoholic liver disease but occur in absence of alcohol abuse

usually associated with metabolic syndrome: type 2 DM, obesity, HTN, and elevated TG

Underlying mechanism is insulin resistance

Question 27

Indications for liver transplant in cirrhosis

Answer 27

Ascites/ SBP

Variceal bleeding

Hepatic encephalopathy

Hepatocellular cancer