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MSPA- Gastroenterology > Chronic Liver disease > Flashcards

Chronic Liver disease Flashcards

1
Q

What is Alcoholic liver disease ?

A

A range of progressive liver conditions
caused by chronic and excessive alcohol
consumption and is the common cause of liver failure.

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2
Q

what are the three stages of alcoholic liver disease ?

A
  1. Alcoholic Fatty liver (Reversable)
  2. Alcoholic Hepatitis (Mild cases
    reversable)
  3. Alcohol related cirrhosis (Irreversable)
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3
Q

What is the diagnostic criteria for ALD?

A
  • A history of chronic excess alcohol intake that correlates with typical laboratory and imaging findings is diagnostic of alcoholic liver disease.
  • AST > ALT (2:1)
  • ↑ GGT
  • Macrocytic anaemia
  • US: Mild hepatomegaly with increased echogenicity due to steatosis
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4
Q

What is the Tx of ALD?

A
  • Stop drinking
  • Steroids in alcoholic hepatitis
  • Transplantation
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5
Q

What is NAFLD ?

A

It is a synonymous condition to ALD seen in non-heavy drinkers and has a strong association to metabolic syndrome. It is a diagnosis of exclusion as Hepatitis B and C as well as haemochromatosis has to be ruled out.

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6
Q

What is the spectrum of NAFLD?

A

steatosis - NASH - cirrhosis

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7
Q

What are the laboratory findings in NAFLD?

A
  • Ratio of ALT/AST usually <1
  • fatty infiltration on US / CT / MRI
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8
Q

What is the Tx of NAFLD?

A

No good treatment
* Lifestyle modification
* Manage risk factors eg T2DM

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9
Q

What is the diabetic drugs of choice in NAFLD?

A

GLP-1 agonist / SGLT2 inhibitors

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10
Q

What is Alpha -01 Anti-trypsin deficiency ?

A

Inherited genetic disorder characterized by the accumulation of defective alpha-1 antititrypsin. It should be suspected in young patients with emphysema or in smokers who develop emphysema out of proportion to smoking.

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11
Q

What is the pathophysiology of Alpha -01 Anti-trypsin deficiency associated liver disease?

A

It is a protein-folding disorder in which toxic insoluble ATZ proteins aggregate in the ER of hepatocytes leading to inflammation, fibrosis, cirrhosis, and increased risk of hepatocellular carcinoma.

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12
Q

What is the Dx criteria for A1AT?

A
  • Low serum levels of A1AT
  • Abnormal migration in serum phenotype analysis
     M is the normal allele.
     S mutation causes a moderate decrease in AAT production.
     Z mutation causes a significant decrease in AAT production
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13
Q

What is the tx of progressive A1AT ?

A

Liver transplant

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14
Q

What is the pathophysiology of Wilson’s disease ( hepatolenticular degeneration ) ?

A

The age of onset is <35 years and is caused by autosomal recessive mutation in ATP7B gene which leads to defective cooper transport and coper accumulates in organs such as liver, basal ganglia and CNS.

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15
Q

What is the diagnostic work-up in Wilson’s disease ?

A

*Slit lamp examination to rule out corneal involvement and KF ring.
* < serum ceruloplasmin
* > serum coper
* > 24 hr urine coper excretion.

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16
Q

What is the Tx of Wilson’s disease ?

A

Low coper diet and coper chilating agents such as pencilamine, trientine, and Zinc salt

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17
Q

What is the epidemiology of acute liver disease ?

A

Rare critical condition with poor prognosis with a mortality rate of 30 to 40%.

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18
Q

What are the etiology of acute liver disease ?

A
  • Hepatotoxic agents such as acetaminophen, Alfatoxin, mushroom poisoning and alcohol
  • Viral Hep A, B, CMV and EBV or autoimmune hepatitis.
    *Other – Vascular (Budd-Chiari),
    Pregnancy related (HELLP
    syndrome).
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19
Q

What is the diagnostic approach in acute liver disease ?

A
  • Encephalopathy
  • High transaminases sign of liver injury.
  • INR > or = 1.5 sign of coagulopathy.
  • Viral hepatitis panel
20
Q

What is the management of acute liver disease ?

A
  • Immediate hemodynamic and respiratory support.
  • Early intubation
  • Transfer to critical care
  • Liver transplant
21
Q

Why should acute liver disease patients needs to be transfered to critical care?

A
  • Close monitoring
  • neuroprotective measures such as management of encephalopathy and elevated ICP.
  • Metabolic and nutritional support and infection control.
22
Q

What is Chronic hepatitis?

A

It is an insidious condition most patients are asymptomatic and is often an incidental finding on LFT.

23
Q

What are the signs of chronic liver disease ?

A
  • Skin pigmentation, jaundice, and itching
  • Gynecomastia and spider nevi
  • Abdominal swelling, tremor and edema
  • Epigastirc, acute, and chronic abdominal pain.
24
Q

What are the complications of chronic liver disease ?

A
  • Hepatic encephalopathy
  • Ascites
  • Esophageal varices.
25
Q

What is Cirrhosis?

A

It is the leading cause of death worldwide and is the late stage of hepatic fibrosis resulting from
widespread distortion of normal hepatic architecture. It is Characterised by regenerative
nodules surrounded by dense fibrotic tissue. It is 2 times more common in males than females.

26
Q

What are the aetiologies of liver cirrhosis ?

A

ALD, NASH, Hepatitis B, C, and D

27
Q

What is the Dx approach to liver cirrhosis ?

A
  • Liver biopsy is the gold standard (but logistically not done for every case)
    *Initial evaluation:
  • Comprehensive history and clinical examination
  • Routine bloods and screening for the underlying aetiology (viral, autoimmune, metabolic)
  • Abdominal ultrasound (diagnosis and screening)
  • ± Fibroscan
    *Periodically evaluate for complications (HCC, oesophageal varices, etc)
28
Q

What is the tx approach to Liver cirrhosis ?

A
  • Treat the underlying condition (e.g., antivirals for Hep C etc)
  • Screen complications and decompensations
  • Provide supportive care
  • Consider workup for liver transplantation, depending on stage and
    aetiology.
29
Q

What are the elements of supportive care in liver cirrhosis ?

A

 Beta blockers (eg propranolol)
 Vaccinations (eg flu, pneumococcal, COVID19, Hep B/C etc
 Nutritional advice

30
Q

What are the complications of liver cirrhosis induced portal hypertension ?

A
  • Ascites
  • Esophageal varacies
  • Spontaneous bacterial peritonitis
  • Hepatorenal syndrome
  • Hyponatremia
31
Q

What are the complications of liver cirrhosis induced cardiac dysfunction ?

A
  • Hepatopulmonary syndrome
  • Porto-pulmonary HTN
  • Hepatic hydrothroax
  • Cirrhotic cardiomyopathy
32
Q

What are the hemostatic complications of liver cirrhosis ?

A

Increased bleeding, coagulopathy and PVT.

33
Q

What are the metabolic complications of liver cirrhosis ?

A
  • Hepatic encephalopathy
  • jaundice
  • Secondary hyperparathyroidism
  • relative adrenal insufficiency
  • diabetes mellitus and nutritional deficiencies
34
Q

What is the carcingoenic complication of cirrhosis?

A

HCC

35
Q

What is the management fo Variceal bleeding?

A
  • 2 large bore IVCs for fluids and +/- blood transfusion
  • Prophylactic antibiotics
  • IV terlipression or octreotide
  • IV PPI
  • IV B-blocker (propanolol)
  • Endoscopic management consist of Band ligation
    and Sclerotherapy
36
Q

What is the approach to unresponsive Variceal bleeding?

A
  • Transjugular Intrahepatic Portosystemic Stent Shunt
  • Interventional radiology treatment for portal hypertension by creating a direct path between hepatic vein and portal vein diverting portion of flow.
  • Liver transplantation
37
Q

What is the approach to Ascites Tx ?

A
  • Sensitive to diuretics: 1st line – spironolactone and 2nd line – furosemide.
  • Resistant to diuretics- Stop B-blockers / ACEis / ARBs / NSAIDs
  • Serial paracentesis
  • TIPSS
  • Transplant
38
Q

What are the indications for antibiotics in ascites ?

A
  • Temp >37.80C
  • Abdo pain / tenderness
  • Change in mental status
  • Presence of PMNs in ascitic fluid >250 cells/mm3
39
Q

What are the stages of Hepatic Encephalopathy?

A

Stage 0: Minimal HE. Slight changes in memory and concentration.
Stage 1: Mild HE. Mood changes and sleep problems.
Stage 2: Moderate HE. Inappropriate behavior, slurred speech, trouble doing basic math.
Stage 3: Severe HE. Disorientation, extreme sleepiness, or anxiety.
Stage 4: Coma.

40
Q

What is the management of Hepatic Encephalopathy ?

A
  • Avoidance and prevention of precipitating factors.
  • Lactulose: 10 to 3o gm PO / 2 to 4 times / day titrated to 2 to 3 soft stools.
  • Rifaximin- 550 mg PO BD.
  • Maintain protein intake of 1 to 1.5 gm/kg daily.
41
Q

What is the management of severe persistant HE ?

A
  • reduction or clouser of TIPS
  • Occlusion/ embolization of large portosystemic collaterals.
42
Q

What is Child-Trucotte-Pugh Score of HE ?

A

https://pcpc.hku.hk/product/child-pugh-score-en/

43
Q

What is Hepatocellular carcinoma?

A

It is common in East Asia + Sub-Saharan Africa. the signs and symptoms are non-specific.

44
Q

What is the Dx work up in Hepatocellular carcinoma?

A
  • Based on AFP levels
  • Imaging and +/- liver bx
  • Screening for high risk pts (AFP + US)
  • Staging via TNM
45
Q

What is the Tx of Hepatocellular carcinoma?

A
  • Prognosis poor if advanced
  • For small tumours confined to the liver:
  • Abalative therapies are palliative
  • Surgical resection or liver transplantation curative.

MSPA- Gastroenterology (14 decks)

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