Chronic Liver Disease

Question 1

What are the causes of chronic liver disease?

Answer 1

• Common:
  
  • Chronic ETOH
  • Chronic Hep C (and B) infection
  • Non-alcoholic fatty liver disease/non-alcoholic steatohepatitis
• Other
  
  • Congenital: Wilsons, alpha-1 anti-trypsin deficiency, CF
  • Autoimmune: Autoimmune hepatitis, PBC, PSC
  • Drugs: Methotrexate, amiodarone, isoniazid
  • Neoplasm: HCC, mets
  • Vascular: RHF, Budd-Chiari syndrome,

Question 2

What are the complications of CLD?

Answer 2

• Liver failure/decompensation
• Spontaneous bacterial peritonitis
• Portal HTN
• HCC

Question 3

What are the precipitants of decompensated chronic liver disease?

Answer 3

HEPATICS:

Haemorrhage: E.g. varices

Electrolytes: Low K, Na

Poisons: Diuretics, sedatives, anaesthetics

Alcohol

Tumour: HSS

Infection: SBP, pneumonia, UTI

Constipation: Most common cause

Sugar: Hypoglycaemia e.g. low calorie diet

Question 4

How would you manage decompensated liver disease?

Answer 4

General:

• HDU or ITU
• Treat precipitant
• Good nutrition: NGT, high carb
• Thiamine supplement
• Prophylactic PPIs vs stress ulcers

Monitor:

• Fluids: Urinary and central venous catheters
• Bloods: Daily FBC, UsEs, LFTs, INR
• Glucose: 1-4hourly + 10% dextrose IV 1L/12 hours

Complications:

• Ascites:
  
  • Daily weight, fluid and Na restriction, diuretics, tap
• Coagulopathy:
  
  • Vitamin K, FFP, platelets
• Encephalopathy:
  
  • Avoid sedatives
  • Lactulose, refaximin
• Sepsis/SBP:
  
  • Tazocin or cefotaxime
• Hypoglycaemia:
  
  • Dextrose
• Hepatorenal syndrome:
  
  • IV albumin + terlipressin

Question 5

Why does encephalopathy occur?

Answer 5

Decreased liver metabolic function –> toxins diverted from liver into the systemic blood stream

Accumulation of ammonia –> breaches brain where it is converted to glutamine –> cerebral oedema

Question 6

How does encephalopathy present?

Answer 6

• Asterixis
• Ataxia
• Confusion
• Constructional apraxia
• Dysarthria
• Seizures

Question 7

How would you investigate encephalopathy?

Answer 7

Plasma ammonia levels -would be increased

Question 8

How would you manage encephalopathy?

Answer 8

Conservative:

• Well lit, calm environment
• One to one/close surveillance from nurse
• Correct any precipitants
• Avoid sedatives

Medical:

• Lactulose: Reduces ammonia production (by reducing numbers of nitrogen forming bacteria)
• Rifaximin PO: Kill intestinal microflora

Question 9

What is spontaneous bacterial peritonitis?

Answer 9

A patient with ascites and peritonitic abdomen

Question 10

What are the complications of SBP?

Answer 10

Hepatorenal syndrome- 30%

Recurrence- require prophylactic abx

Question 11

What are common causative organisms of SBP?

Answer 11

E. coli, klebsiella, streps

Question 12

What investigations would be required to diagnose SBP?

Answer 12

Ascitic tap- Polymorphonucleocytes >250mm3

MC&S

Question 13

How would you treat SBP?

Answer 13

Tazocin or cefotaxime- until sensitivities known

Question 14

What would indicate a poor prognosis in SBP?

Answer 14

Worsening enceph

Older

Low albumin

High INR