Chronic Liver Disease

Question 1

What are the clinical features of uncomplicated chronic liver disease?

Answer 1

1. Palmar erythema
2. Dupytren’s
3. Loss of axillary hair
4. Gynaecomastia
5. Spider naevii

Question 2

How should CLD be presented?

Answer 2

Signs of CLD
- ? Any sign of portal hypertension
- ?any sign of decompensation
- Size of liver - can be large or small in cirrhosis depending on stage

Question 3

What are the clinical features of portal hypertension? (2)

Answer 3

1. Caput medusa
2. Splenomegaly

Question 4

What are the clinical features of chronic liver disease decompensation? (4)

Answer 4

1. Jaundice
2. Ascites
3. Encephalopathy - constuction dyspraxia (can they draw a 5 point star)
4. Aterixis

Question 5

What are the causes of hepatomegaly/chronic liver disease? 3 Cs 4 Is

Answer 5

Cirrhosis - alcoholic or fatty (body size)
Cancer - HCC (cachexia)
Congestive - congestive cardiac failure or Budd-Chiari (look for fluid overload)

Infective - hepatitis
Immune - PSC, PBC, autoimmune
Infiltrative - amyloid or myeloproliferative
Iron - haemochromatosis (tan or slate grey)

alpa 1
methotrexate
Wilson’s

Question 6

What investigations should be done in CLD/ hepatomegaly? (6)

Answer 6

1. Bloods including:
   - FBC and U&E
   - LFTs (ALT:AST 2:1 - alcohol)
   - Clotting
   - Iron and ferritin
   - Albumin
   - Glucose
   - AFP for HCC
2. Hepatitis and HIV screen
3. USS liver with doppler - fibroscan and portal vein
4. Ascitic tap if iascites
5. Liver biopsy - transjugular if ascites present
6. Endoscopy

Question 7

What tests should be done on ascitic fluid? (4)

Answer 7

1. Protein:creatinine ratio >1.1g/L
   - If raised suggests a systemic cause such as cirrhosis or CCF, Budd Chiari, nephrotic
   - If low suggests malignancy, TB or pancreatitis
2. Cytology can look for malignancy
   - WCC >250 = Spontaneous Bacterial Peritonitis
3. Amylase can look for pancreatitis
4. CS&U for infection

Question 8

What are the 4 categories for causes of ascites?

Answer 8

1. Vascular
2. Low albumin
3. Peritoneal
4. Miscellaneous

Question 9

What are the 4 vascular causes of ascites?

Answer 9

1. Portal hypertension
2. Budd-Chiari
3. CCF
4. Constrictive pericarditis

Question 10

What are the 2 causes of low albumin ascites?

Answer 10

1. Nephrotic syndrome
2. Protein losing enteropathy

Question 11

What are the 3 peritoneal causes of ascites?

Answer 11

1. Meig’s syndrome (benign ovaran tumour + ascites + plueral effusion)
2. Infection e.g. TB, fungal
3. Malignancy (GI, ovarian)

Question 12

How is ascites managed? (5)

Answer 12

1. Fluid restriction
2. Diuresis
3. Drain (discomfort, CVS compromise)
4. TIPs
5. Transplant

Question 13

Which scores can be used to prognositcate cirrhosis? (2)

Answer 13

1. Child-Pugh
2. MELD (Mortality for End-stage Liver Disease)

Question 14

What is included int he Child Pugh score? AABIE

Answer 14

AABIE

Ascites
Albumin
Bilirubin
INR
Encephalopathy

Question 15

What is included in the MELD score?

Answer 15

1. Dialysis (2/7) or CVVHD (1/7)
2. Creatinine >400
3. Bilirubin
4. INR
5. Sodium

Question 16

What is cirrhosis?

Answer 16

Late hepatic fibrosis causing distorition of the hepatic architecture, necorsis, regenerative nodules

Question 17

What are the complications of cirrhosis? (2)

Answer 17

1. Portal hypertension
2. Hepatocellular carcinoma

Question 18

What is primary billiary cirrhosis?

Answer 18

immune system attacks the small bile ducts (canals of hering, interlobar)

Causes cholestasis

Back pressure and disease process leads to fibrosis -> cirrhosis and failure - portal hypertension

Question 19

What are the features of primary billiary cirrhosis? (6)

Answer 19

1. Raised bilirubin - jaundice, pruritis
2. Raised cholesterol - xanthalasmus, corneus arcus, ACS/CVD
3. Malabsorption and steatorrhoea
4. Fatigue
5. Abdo pain
6. Liver failure

Question 20

What risk factors are associated with PBC? (2)

Answer 20

1. Other autoimmune e.g. crohn’s, coeliac, RA,
2. Female, young

Question 21

What are the investigations for PBC? (4)

Answer 21

1. Bloods - raised ALP, later raised bilirubin, ESR, IgM
2. anti-mitochondrial and ANA
3. USS liver
4. Liver biopsy for staging

Question 22

How is PBC managed? (4)

Answer 22

1. Ursodeoxycholic acid reduced cholesterol absorption
2. Colestyramine - bile acid sequestration
3. Liver transplant
4. Immunsupression e.g. steroids

Question 23

What are the complications of cirrhosis?

Answer 23

1. Portal hypertension
2. Hepatocellular carcinoma

Question 24

What is primary sclerosing cholangitis?

Answer 24

The intra hepatic and extra hepatic bile ducts become inflamed, strictured and fibrotic

Cholestasis

Backpressure into the liver hepatitis -> fibrosis -> cirrhosis -> failure

Question 25

What is PSC linked with?

Answer 25

UC Young male Family history

Question 26

What are the features of primary sclerosing cholangitis?

Answer 26

1. Raised bilirubin - jaundice, pruritis 2. Raised cholesterol - xanthalasmus, corneus arcus, ACS/CVD 3. Malabsorption and steatorrhoea 4. Fatigue 5. Abdo pain 6. Liver failure

Question 27

What are the investigations for PSC?

Answer 27

1. Bloods, LFTs - cholestatic, raised ALP 2. Auto-antibodies (not that helpful to diagnose but may guide immunosupression ) p-ANCA, ANA, anti-cardiolipin 3. MRCP ?bile duct lesions/strictures

Question 28

What are the risks of PSC? (5)

Answer 28

1. Cholangitis (infection) 2. Cholangiocarcinoma 3. Colorectal cancer 4. Cirrhosis and liver failure 5. ADEK vitamin deficiency (fat soluble)

Question 29

How is PSC managed? (4)

Answer 29

1. ERCP -> stenting 2. Ursodeoxycolic acid 3. Colestyramine (bile acid sequestration) 4. Transplant only definitive treatment