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Metabolism 2 > Liver Cirrhosis and Metabolism > Flashcards

Liver Cirrhosis and Metabolism Flashcards

1
Q

how does does the liver respond to injury

A
  • it responds in a stereotypical way

- if you damage the liver over time inflammation and fibrosis results which leads to cirrhosis

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2
Q

name the causes of cirrhosis

A 
•	Alcohol
•	Fat / Metabolic Syndrome
•	Viral Hepatitis
–	HBV / HCV
•	Biliary Disease
–	PBC / PSC
•	Autoimmune
•	Metabolic
–	HC / Wilson’s / A1AT deficiency / amyloid
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3
Q

describe how liver disease progresses

A
  • Primary Injury
  • Inflammation – associated with ongoing liver cell injury and death
  • Liver cell injury / death
  • Fibrosis – liver ability to regenerate liver cells is impaired then you end up with fibrosis
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4
Q

what drives the progression of liver disease

A 
Degree / number of insults
Genetics
Microbiome
Environment
Diet
Drugs
Methotrexate and NAFLD
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5
Q

How can you quantify how much cirrhosis is present

A
  • do a liver biopsy

- use a stain for car tissue then categories it on how much scarring they have

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6
Q

is cirrhosis reversible

A
  • yes
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7
Q

what are the functions of the liver

A

Protein synthesis & metabolism

  • Clotting factors
  • Urea breakdown

Bile production
- Elimination of bilirubin

  • Hormone metabolism
  • Drug metabolism
  • Carbohydrate metabolism
  • Lipid metabolism
  • Immunological function
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8
Q

what is simple definition of liver disease

A
  • this is loss of function of the liver
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9
Q

what do you use to diagnose cirrhosis

A
  • History
  • Symptoms and signs
  • Blood
  • Imaging
  • Histology
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10
Q

what are the symptoms of liver cirrhosis

A 
•	None
•	Systemic
–	Weight loss
–	Tiredness – fatigue and impaired quality of life can be in chronic liver disease 
•	Cholestatic
–	Pruritis
–	Pale stools/dark urine dark urine due to bilirubin increased production 
•	Complications of underlying disease
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11
Q

what would you look for in a history of liver cirrhosis

A
  • Alcohol history
  • Travel – healthcare intervention over seas
  • Illicit drug use
  • Sexual
  • Medication
  • Professional
  • Family history
  • Co-morbidity
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12
Q

what are the signs of chronic liver disease

A
  • Clubbing
  • Gynaesmatic - failure to breakdown oestrogen
  • Leuchonychia - pale nails
  • Palmar erythema
  • Spider naevi
  • Hair loss
  • Proximal wasting
  • Scratch marks
  • Xanthelasma
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13
Q

what two things from signs of chronic liver disease can make you more sure that liver disease is happening

A

palmar erythema and spider naevi

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14
Q

what two factors that assess liver function

A
  • Albumin – low albumin

- INR (prothrombin time) – blood doesn’t clot as well as it should, liver makes Vitmain K clotting factors,

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15
Q

what are the factors that assess the stage of disease of the liver

A
  • Platelet count

- ALT/AST

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16
Q

what is an important factor in assessing the stage of disease in the liver

A
  • As liver disease progressive and the spleen gets bigger the platelet count drops – platelet count is an important test – can get a rough idea of who is at risk of having a more advance disease
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17
Q

name some liver tests that can be used

A
  • bilirubin
  • aspirate aminotransferae (AST)
  • Alanine aminotransferase (ALT)
  • alkaline phosphatase
  • gamma glumly transpeptidase
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18
Q

describe the liver tests that can be used and the things that can cause them to rise independent to the liver

A 
•	Bilirubin
–	Unconjugated vs conjugated
•	Aspartate aminotransferase (AST) – hepatocyte release 
–	Mitochondrial enzyme
–	Heart/muscle/kidney
–	hepatitis

• Alanine aminotransferae (ALT) – hepatocyte release – involved in moving amino groups to make new amino acids from keotacids
– Liver specific

• Alkaline phosphatase
– Bile cannalicular + sinusoidal membranes
– Bone/placenta it is also present in here, can be high in pregnancy
– Cholestasis – intra/extrahepatic

•	Gamma glutamyl transpeptidase (GGT)
–	Hepatocellular
–	Cholestasis
–	Alcohol often associated 
–	Made in liver and biliary cells
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19
Q

If is AST/ALT are high this indicates

A

hepatic damage

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20
Q

if Alkaline phosphate and gamma GT is high this indicates

A

cholestatic

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21
Q

if
- AST > ALT
ALT > AST

A

AST > ALT – alcohol

ALT > AST – eg viruses / NAFLD

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22
Q

alcohol does not put …

A

– Alcohol doesn’t put ALT > 500

  • 500-1500 prephaps due to an autoimmune hepatitis
  • If greater than 1500 acute hepatitis virus/drugs/ischemia
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23
Q

what imaging do you use on the liver

A 
•	Ultrasound
–	Biliary tree
–	Liver lesions
–	Ascites
–	Spleen
–	Veins
–	Other pathology
•	CT
•	MRI
•	ERCP / MRCP – looks at the bile ducts and pancreas
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24
Q

what are the complications of chronic liver disease

A
  • Liver failure – if the liver is damaged it might not work well so we look at function tests of the liver
  • Cirrhosis – leads to portal hypertension
  • Malignancy
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25
Q

What happens f you have raised portal hypertension

A
  • the blood builds up and you end up with pressure in the portal system
    can result in three things
  • dilated abdominal veins - caput medusa
  • ascites
  • splenomegaly
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26
Q

what does a child-turocotte -pugh score determine

A
  • this is a measure of how badly cirrhosis you liver is, helps work out if the liver is compensated or decompensated
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27
Q

what re the 5 points on the child -turoctte- Pugh score

A
  • bilirubin - as the amount of bilirubin increases the score increases
  • albumin - as the amount of albumin increases the score increases
  • prothrombin score as the prothrombin time increases the score increases
  • hepatic encephopahty symptom grade - as this gets more controlled the points increase
  • asicites - as this gets worse the points increase
  • each of the 5 points can be given a mark of 1 to 3 depending on severity
  • the lowest score you can get is 5
  • 5-6 is class A where your. liver is compensated and works normally
  • 7-9 class B and 10-15 class C this is when the liver is decompensated and does not work properly
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28
Q

what are the three things that should you have hepatic decompensation

A

encephalopathy
portal hypertension
bleeding

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29
Q

describe how ascites happens

A

1, portal hyperntesion increases this causes the back up of blood in the splenic vein
2, leads to splanchnic vasodilation
3, this decreases the effectiveness of the circulatory volume
4, this activates the renin-angiontesin-aldosterone system
5, leads to renal sodium remaining in the body
6, this leads to ascites due to an increase in onoctic pressure

or
when the renin angiotensin aldosterone system is activated you could have renal vasoconstriction and this leads to hepatorenal syndrome

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30
Q

what are the treatments of ascites

A

– Low salt diet
– Diuretics
– 50% 2 year mortality
• transplantation

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31
Q

what are varcies

A
  • these can form in the oesophagus and rectum
  • they are big baggy veins that have dilated
  • these can bleed and can cause haemorrhage
32
Q

how do you treat variceal bleeding

A

Resuscitation
Terlipressin and Antibiotics
Banding or injection sclerotherapy
TIPSS

33
Q

what are the primary and secondary prophylaxis for variceal bleeding

A

Propranolol / Carvedilol

Banding

34
Q

what is an hepatic encephalopathy caused by

A
  • sepsis
  • bleeding
  • drugs
  • deteriorating liver function
35
Q

how do you diagnose a hepatic encephalopathy

A

Hepatic flap
Clinical
EEG/MRI changes

36
Q

what are the treatments for hepatic encephalopathy

A

Lactulose
transplantation
- L ornithine and L arginine can be used in acute liver failure to treat this

37
Q

what are the signs of hepatic encephalopathy

A
  • disorientation
  • confusion
  • comma
38
Q

what drives hepatic encephalopathy

A

ammonia

39
Q

describe how hepatic encephalopathy is caused

A
  • usually glutamine is converted to glutamate and ammonia - ammonia then goes to the liver where it is transformed and converted to urea and passed out through the kidney
  • but when the liver is not working ammonia goes to the muscles where it combines back with glutamate and is converted to glutamine this then goes to the brain
40
Q

what are the causes or decompensation of the liver

A 
SEPSIS
- Ascitic Tap
Bleeding
Drugs
-    NSAIDs
Venous occlusion
Hepatocellular carcinoma
41
Q

what are the risk factors for hepatocellular carcinoma

A 
–	Chronic viral hepatitis
–	Cirrhosis
–	Male 
–	Ethnicity (African + Asian)
–	Smoking
–	Family history
42
Q

name a biomarker for hepatocellular carcinoma

A

raised alpha fetoprotein

43
Q

How do you treat hepatocellular carcinoma

A 
–	Ethanol injection)
–	Radiofrequency ablation
–	Transarterial chemoembolisation
–	Antiangiogenic drugs
–	Surgical resection

Liver transplantation
- Criteria depends upon size

44
Q

what is non alcoholic fatty liver (steatosis)

A
  • this is liver caused by the presence of excess fat

- there is no secondary cause for steatosis

45
Q

how much fat in the liver is too much and what happens if the fat in the liver increases by too much

A 
•	Small amount of fat is physiological (2-3%)
•	Increased hepatic fat (>5-10%)
–	Steatosis
–	Inflammation
–	Fibrosis
–	Insulin resistance
46
Q

what are the 5 things that happen when you are insulin resistance

A

• Increased glucose (activates ChREBP)
– De novo lipogenesis (SREBP1)
– Activates PKCe (inhibits IR tyrosine kinase)
• Inappropriate gluconeogenesis
– FOXO1-mediated
• Impaired glycogen synthesis (muscle and liver)
– Akt2-mediated
• Impaired suppression of lipolysis in adipocytes
– Glycerol and FFA

Induction of PPAR-γ (lipogenic)

47
Q

how does hepatic fat accumulation happen

A

1, increased delivery of long chain fatty acids to the liver
– Adipocytokines (adiponectin & resistin)
– ↑ fatty acid translocase
– Central obesity

2, impaired clearance via VLDL formation
– ↓transport into mitochondria (CPT1 saturation)
– Fewer mitochondria for β-oxidation

48
Q

describe the mechanism of injury for hepatic fat accumulation

A 
Multiple hit hypothesis 
•	Hepatic Fat Accumulation
•	Oxidative Stress (lioptoxicity)
•	Inflammation
•	Innate immune activation
49
Q

how many units a week should you have

A

14 units a week

50
Q

how many units a week can cause cirrhosis of the liver

A

-41 u/wk 12 years
• 3%men 4%women
– >42 u/wk
• 6-8%

51
Q

describe what is an alcohol dependence

A
  • Consistent high intake
  • Less able to abstain
  • Increased tolerance
  • Physiological dependence
  • Subjective insight
52
Q

how do you treat alcoholic liver disease

A 
•	Community support
•	Detox / rehab programmes
•	Outpatient appointments	
–	Blood tests / scans / biopsies
•	Emergency admissions
–	Bleeding / fluid retention / kidney failure
–	Expensive treatment – intensive care
•	Transplantation
53
Q

what can result in alcoholic liver disease

A

You can get nutritional deficiencies these can lead to

  • Possible re-feeding risk
  • Thiamine and vitamin deficiencies
  • Replace thiamine early or you will get
    Wericke’s encephalopathy
    Korsakoff’s syndrome
54
Q

what are the causes of chronic liver disease

A 
•	Hepatitis B
–	Major problem worldwide
–	Drugs to control
•	Primary biliary cholangitis
•	Primary sclerosing cholangitis
•	Haemochromatosis
•	Wilson’s
55
Q

describe how HBV can cause liver cirrhosis

A

causes inflammation of the liver this leads to cirrhosis which can cause liver failure and this leads to cancer

56
Q

how do you prevent HBV

A

screening and vaccination

- do it in pregnancy

57
Q

describe Hep B treatment

A

Pegylated interferon

Nucloside + nucleotide analogues

58
Q

what does Hep B treatment do

A

Progression to cirrhosis can be halted

Fibrosis reduced

Reduce risk of HCC

59
Q

what is haemochromatosis

A

iron overload

60
Q

what is the mutation caused in haemochromatosis

A

90% - C282T mutation of HFE gene (Chr 6

61
Q

how do you diagnose haemochromatosis

A

Serum iron > 30

Transferrin saturation >60% / TIBC

Liver biopsy

Genetic analysis

62
Q

what is the treatment for haemochromatosis

A

venesection

63
Q

what are the complications for haemochromatosis

A 
Diabetes
Cardiomyopathy
Impotence
Pigmentation
Arthritis - chondrocalcinosis
30% develop hepatocellular carcinoma
64
Q

what are the types of autoimmune hepatitis

A

Types
Childhood – a-LKM
Adult – a-SMA
Raised globulins (IgG

65
Q

how do you treat autoimmune hepatitis

A

Treat with prednisolone and azathioprine

66
Q

what is primary sclerosing cholangitis

A

Primary sclerosing cholangitis (PSC) is a long-term progressive disease of the liver and gallbladder characterized by inflammation and scarring of the bile ducts which normally allow bile to drain from the gallbladde

67
Q

what are the symptoms of primary sclerosing cholangitis

A

Pruritis
Cholangitis
Dominant strictures leading to jaundice

68
Q

what are the complications of primary sclerosing cholagnitis

A

Increased risk of:
Cholangiocarcinoma
Hepatocellular carcinoma

69
Q

how do you diagnose primary sclerosing cholangitis

A

Positive pANCA / ANA / SMA

70
Q

what are the treatments of primary sclerosing cholangitis

A

Beads on a string at ERCP

Ursodeoxycholic acid

Transplant

71
Q

describe primary biliary cholangitis

A

Symptoms - CLD, pruritis, xanthelasma

Middle aged female
IgM; 96% AMA+ve

Ursodeoxycholic acid and vitamin replacement

Role for fibrates and obeticholic acid

72
Q

what is Wilsons disease

A

Increased copper accumulation:

73
Q

what are the symptoms of Wilson disease

A

Liver – cirrhosis / liver failure
Basal Ganglia – neuropsychiatric
Kidneys – Fanconi’s syndrome
Eyes – Keyser-Fleischer rings

74
Q

how do you diagnose Wilsons disease

A

↑ 24hr[Cu]Ur, ↑ free Cu,

↓ total Cu, ↓ caeruloplasmin

75
Q

how do you treat Wilsons disease

A

Penicillamine
Trientine
Zinc

Metabolism 2 (40 decks)

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