Cirrhosis

Question 1

What is cirrhosis?

Answer 1

Result of chronic inflammation + damage to liver cells which are replaced with scar tissue (fibrosis) forming nodules

Question 2

How does portal hypertension result?

Answer 2

Fibrosis causes increased resistance in vessels leading to the liver

Question 3

4 most common causes of cirrhosis?

Answer 3

(1) Alcoholic liver disease (AST x2 ALT)
(2) Non-alcoholic fatty liver disease
(3) Hep B
(4) Hep C

Question 4

Whats drugs can cause cirrhosis?

Answer 4

Amiodarone, methotrexate, sodium valproate

Question 5

Genetic disorders that can cause cirrhosis?

Answer 5

• Wilson’s disease (copper deposition)
• Haemochromatosis (iron overload)
• Alpha-1 antitrypsin deficiency
• Cystic fibrosis

Question 6

Signs of Wilson’s disease?

Answer 6

Copper deposition:

• Kayser-fleischer rings (eyes)
• Osteopenia
• Parkinsonism

Question 7

2x autoimmune conditions causing cirrhosis?

Answer 7

(1) Autoimmune hepatitis

(2) Primary biliary cirrhosis

Question 8

Signs of cirrhosis?

Answer 8

• Jaundice
• Hepatomegaly
• Splenomegaly
• Asterixis
• Gynaecomastia
• Palmar erythema
• Spider naevi
• Easy bruising
• Ascites
• Caput Medusae –> distended paraumbilical veins due to portal hypertension

Question 9

What blood result indicates fluid retention in severe liver disease?

Answer 9

Hyponatraemia

Question 10

What blood test can be checked every 6 months alongside and US and why?

Answer 10

Alpha-fetoprotein - tumour marker for HCC

Question 11

1st line investigation for non-alcoholic fatty liver disease?

Answer 11

Enhanced liver fibrosis (ELF) blood test

Question 12

What does an EFL score of <7.7 indicate?

Answer 12

none to mild fibrosis

Question 13

What does an EFL score of 7.7-9.8 indicate?

Answer 13

moderate fibrosis

Question 14

What does an EFL score of >9.8 indicate?

Answer 14

severe fibrosis

Question 15

Signs of cirrhosis on USS?

Answer 15

(1) Nodular surface
(2) ‘Corkscrew’ appearance to arteries
(3) Enlarged portal vein
(4) Ascites or splenomegaly

Question 16

Which patients would you perform a Fibroscan every 2 years?

Answer 16

Those risk of cirrhosis:

• Hep C/B
• alcoholic liver disease
• heavy alcohol drinkers
• non-alcoholic fatty liver + fibrosis evidence on ELF test

Every year for chronic Hep B

Question 17

Investigation to confirm diagnosis of cirrhosis?

Answer 17

Liver biopsy

Question 18

What score is used for cirrhosis to determine severity?

Answer 18

Child-Pugh Score

Question 19

What score gives an estimated 3 month mortality and helps guide liver transplant referral?

Answer 19

MELD score (every 6 months if compensated cirrhosis)

Question 20

General management

Answer 20

(1) USS + alpha-fetoprotein every 6 months (HCC?)
(2) MELD score every 6 months (liver transplant?)
(3) Endoscopy every 3yrs if varices
(4) High protein, low sodium diet

Question 21

Where does the portal vein come from?

Answer 21

Superior mesenteric vein + splenic vein

Question 22

How do varices develop?

Answer 22

Cirrhosis causes portal hypertension –> back pressure causes sites where the portal system anastamoses w/ the systemic venous system become swollen + tortuous (varices)

Question 23

4 sites of varices?

Answer 23

(1) gastro-oesophageal junction
(2) ileocaecal junction
(3) rectum
(4) caput medusae - ant. abdo wall via umbilical vein

Question 24

Treatment for stable varices?

Answer 24

Medical + endoscopy!

• propanolol
• elastic band ligation
• TIPS

Question 25

Resus for bleeding oesophageal varices?

Answer 25

- terlipressin - vit K + FFP - broad spectrum abx

Question 26

What can be done with endoscopy for bleeding varices?

Answer 26

(1) elastic band ligation | (2) inject sclerosant

Question 27

What can be used if endoscopy fails to stop bleeding in oesophageal varices?

Answer 27

Sengstaken-Blakemore Tube

Question 28

How does ascites form?

Answer 28

High pressure in portal system causes fluid to move from vessels into peritoneal cavity. Drop in BP causes renin release --> aldosterone release --> reabsorption of Na + fluid

Question 29

Management of ascites?

Answer 29

(1) low sodium diet (2) Spironolactone (anti-aldosterone) (3) Paracentesis (tap or drain) (4) Prophylactic antibiotics (ciprofloxacin/norfloxacin) if <15g/L protein in fluid

Question 30

Management of refractory ascites?

Answer 30

- TIPS | - Transplantation

Question 31

Is ascitic fluid low or high in protein if caused by cirrhosis?

Answer 31

low ?

Question 32

When to suspect spontaneous bacterial peritonitis (SBP)?

Answer 32

10% of patients with ascites secondary to cirrhosis: - fever - abdo pain - ileus - hypotension - derranged bloods (raised WCC, CRP, creatinine OR metabolic acidosis)

Question 33

Most common causes of SBP?

Answer 33

(1) E. Coli (2) Klebsiella pneumoniae (3) G +ve cocci (staphylococcus, enterococcus)

Question 34

Management of SBP?

Answer 34

- ascitic culture (before abx) | - IV cephalosporin (cefotaxine)

Question 35

Hepatorenal syndrome is fatal unless what?

Answer 35

Fatal within a week or so unless liver transplant

Question 36

How might hepatic encephalopathy present?

Answer 36

Cirrhosis patient! Acute - reduced LOC, confusion Chronic - changes in personality, mood, memory

Question 37

Precipitating factors of hepatic encephalopathy?

Answer 37

(1) constipation (2) electrolyte disturbance (3) infection (4) GI bleed (5) high protein diet (6) sedatives

Question 38

Management of hepatic encephalopathy?

Answer 38

- LACTULOSE (laxatives) get rid of ammonia before absorbed | - ABX (RIFAXIMIN)

Question 39

Diagnosis of cirrhosis?

Answer 39

Tranditionally liver biospy | FIbroscan now used (transient elastography)

Question 40

AST, ALT blood result to mark degree of necoinflammatory activity in patients with cirrhosis?

Answer 40

AST 2.5x raised as ALT | AST 10x raised as ALT if chronic hepatitis

Question 41

Best blood test to investigate cirrhosis in patient with chronic liver disease?

Answer 41

Platelets! (<150,000mm3)

Question 42

Domains of child-pugh score (useful things to indicate severity of cirrhosis)?

Answer 42

(1) Bilirubin - increases (2) Albumin - decreases (3) PT - prolonges (4) Encephalopathy (5) Ascites

Question 43

Domains of MELD score?

Answer 43

(1) bilirubin (2) creatinine (3) INR