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Liver disease TCD Case 3 > Conditions of the Liver > Flashcards

Conditions of the Liver Flashcards

1
Q

How may liver failure be recognised?

A

By the development of coagulopathy (INR > 1.5) and encephalopathy

Sudden = acute liver disease
Background of cirrhosis = chronic liver failure

(Fulminant hepatic failure is a clinical syndrome resulting from massive necrosis of liver cells leading to severe impairment of liver function)

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2
Q

Signs of liver failure?

A

Jaundice, hepatic encephalopathy, fetor hepaticus (smells like pear drops), asterixis/flap

Signs of chronic liver disease suggests acute-on-chronic hepatic failure

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3
Q

What can cause liver failure?

A

Viral hepatitis (esp. B and C), yellow fever, drugs (e.g. paracetamol overdose), alcohol, fatty liver disease, PBC, PSC, haemochromatosis, autoimmune hepatitis, alpha-1-antitrypsin deficiency, Wilson’s disease

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4
Q

What is hepatic encephalopathy?

A

As the liver fails, nitrogenous waste (as ammonia) builds up in the circulation and passes to the brain, where astrocytes clear it (by processes involving the conversion of glutamate to glutamine)

This excess glutamine causes an osmotic imbalance and a shift of fluid into these cells— hence cerebral oedema

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5
Q

What are the 4 stages of hepatic encephalopathy?

A

Grade I: Irritability
Grade II: Confusion, inappropriate behaviour
Grade III: Incoherent, restless
Grade IV: Coma

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6
Q

What is cirrhosis?

A

Liver cirrhosis is the result of chronic inflammation and damage to liver cells. When the liver cells are damaged they are replaced with scar tissue (fibrosis) and nodules of scar tissue form within the liver

IRREVERSIBLE liver damage

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7
Q

What are common causes of liver cirrhosis?

A

Alcoholic liver disease, non-alcoholic liver disease, Hepatitis (B & C)

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8
Q

What are some rarer causes of liver cirrhosis?

A

Autoimmune (primary biliary cholangitis; primary sclerosing cholangitis)
Drugs (e.g. amiodarone, methotrexate, sodium valproate)
Genetic disorders: haemochromatosis; alpha 1-antitrypsin deficiency; Wilson’s disease

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9
Q

What are signs of liver cirrhosis?

A

Jaundice
Hepatomegaly (will actually be small in late stage)
Leuconychia (white nails)
Palmar erythema (due to hyper dynamic circulation)
Spider Naevi
Gynaecomastia + testicular atrophy (due to endocrine dysfunction)
Ascites
Caput medusae (distended periumbilical veins due to portal hypertension)
Asterixis (flapping tremor in decompensated liver disease)

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10
Q

Complications of liver cirrhosis?

A

Hepatic failure:

  • Coagulopathy - bruise more easily (abnormal clotting)
  • Hypoalbuminaemia (oedema)
  • Spontaneous bacterial peritonitis (infection of ascitic fluid)

Portal hypertension:

  • Ascites
  • Splenomegaly
  • Varices (e.g. in oesophagus)
  • Caput medusae
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11
Q

What is seen in the LFTs for cirrhosis?

A

LFTs

  • Raised bilirubin
  • Raised AST, ALT, ALP and gamma-glutamyl transferase (GGT)
  • Albumin (is it low?) - indicates synthetic function worse
  • raised PT/INR

In decompensated cirrhosis

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12
Q

What can be seen in the blood tests in cirrhosis?

A

Low WCC
Low platelets - can indicate hypersplenism
Ferritin
Low Na+ (hyponatraemia - indicates fluid retention in severe liver disease)

Enhanced Liver Fibrosis (ELF) blood test - first line in NAFLD and produces a result to indicate fibrosis of the liver

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13
Q

What would ultrasound show in liver cirrhosis?

A

Ultrasound

  • Hepatomegaly or a small liver
  • Splenomegaly
  • Nodules
  • Ascites
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14
Q

What is the FibroScan and who is it used for?

A

Check the elasticity of the liver by sending high frequency sound waves into the liver. It helps assess the degree of cirrhosis - called ‘transient elastography’

NICE recommends using it in people with:

  • hepatitis C infection
  • men who drink over 50 units of alcohol per week and women who drink over 35 units of alcohol per week
  • diagnosed alcoholic liver disease
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15
Q

What other investigations can be done for liver cirrhosis?

A

Endoscopy - to assess and treat oesophageal varices (when portal HTN is suspected)
CT and MRI scans - to look for hepatocellular carcinoma, abnormal blood vessels and acsites
Liver biopsy - to CONFIRM diagnosis

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16
Q

What is the general management of cirrhosis?

A

Ultrasound and alpha-fetoprotein every 6 months for hepatocellular carcinoma
Endoscopy every 3 years in patients without known varices
High protein, low sodium diet
MELD score every 6 months (gives a percentage estimated 3 month mortality)
Consideration of a liver transplant
Managing complications as below

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17
Q

What does the term hepatitis mean?

A

Hepatitis describes inflammation in the liver

This can vary from a chronic low level inflammation to acute and severe inflammation that leads to large areas of necrosis and liver failure

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18
Q

What can cause hepatitis?

A 
Alcoholic hepatitis
Non alcoholic fatty liver disease
Viral hepatitis (A, B, C, E)
Autoimmune hepatitis
Drug induced hepatitis (e.g. paracetamol overdose)
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19
Q

What is the most common viral hepatitis globally?

A

Hepatitis A - a RNA virus

Not common in the UK but common in the developing world

20
Q

How does Hep A spread?

A

Faeco-oral spread

21
Q

How to treat Hep A?

A

Immunise those at risk

  • Travel
  • Other liver disease

Treatment NOT needed (only needed in those with fulminant liver)

22
Q

In terms of serology what is the significance of IgM and IgG

A

Raised IgM indicates acute infection

Raised IgG indicates chronic infection

23
Q

How is Hepatitis B spread?

A

Blood (IVDU, medical, tattoo)
Sex
Vertical transmission - mother to newborn

24
Q

How is Hep B treated?

A

Vaccination

Chronic - antiviral
Interferon (48 week course) - immune stimulation to develop long term immune response

25
Q

What is the serology in Hep B?

A 
Hepatitis B serology
• Acute - EARLY RISE in anti-core IgM
• Chronic 
	◦ Persistent HbsAg > 6/12 months
	◦ HbeAg positive = immunotolerant
		‣ High viral levels = infectious
		‣ Normal LFTs
		‣ Few liver problems
	◦ HbeAb positive = immunoreactive 
		‣ Low viral levels = less infectious 
		‣ ALT raised
		‣ Often fibrotic/cirrhotic
26
Q

How is Hepatitis C spread?

A 
Blood borne
Medical
IVDU - main cause in UK
Sexual
Vertical transmission
27
Q

What is the disease course of Hep C?

A

1 in 4 fights off the virus and makes a full recovery
3 in 4 it becomes chronic -> increasing fibrosis -> cirrhosis

Complications: liver cirrhosis and associated complications and hepatocellular carcinoma

28
Q

How is Hep C treated?

A

No vaccine

Curable with direct acting antiviral (Ribavirin) medication
Interferon

29
Q

How is Hep C tested for?

A

Hepatitis C antibody is the screening test

Hepatitis C RNA testing is used to confirm the diagnosis of hepatitis C, calculate viral load and assess for the individual genotype

30
Q

Why is Hep D (delta) an imperfect virus?

A

Hepatitis D is an RNA virus

It can only survive in patients who also have a hepatitis B infection
- It attaches itself to the HBsAg to survive and cannot survive without this protein

Worsens prognosis of Hep B

31
Q

How is Hep D treated?

A

Treat hepatitis B - interferon

32
Q

What is Hepatitis E?

A

Hepatitis E is an RNA virus. It is transmitted by the faecal oral route

Normally it produces only a mild illness, the virus is cleared within a month and no treatment is required

Similar to Hep A

33
Q

What is Primary Biliary Cholangitis (PBC)?

A

Primary biliary cirrhosis is a condition where the immune system attacks the small bile ducts within the liver

The first parts to be affected are the intralobar ducts, also known as the Canals of Hering. This causes obstruction of the outflow of bile, which is called cholestasis

The back-pressure of the bile obstruction and the overall disease process ultimately leads to fibrosis, cirrhosis and liver failure

34
Q

How is PBC treated?

A

Ursodeoxycholic acid reduces the intestinal absorption of cholesterol

Colestyramine is a bile acid sequestrate in that it binds to bile acids to prevent absorption in the gut and can help with pruritus due to raised bile acids

35
Q

What is Primary Sclerosing Cholangitis (PSC)?

A

Primary sclerosing cholangitis is a condition where the intrahepatic or extrahepatic ducts become strictured and fibrotic

This causes an obstruction to the flow of bile out of the liver and into the intestines. Sclerosis refers to the stiffening and hardening of the bile ducts, and cholangitis is inflammation of the bile ducts

Chronic bile obstruction eventually leads to liver inflammation (hepatitis), fibrosis and cirrhosis.

36
Q

How is PSC treated?

A

ERCP can be used to dilate and stent any strictures
Ursodeoxycholic acid is used and may slow disease progression
Colestyramine is a bile acid sequestrate in that it binds to bile acids to prevent absorption in the gut and can help with pruritus due to raised bile acids

37
Q

What are the stages of alcoholic liver disease (progression)?

A

1) Alcohol related fatty liver - drinking leads to a build-up of fat in the liver. If drinking stops this process reverses in around 2 weeks
2) Alcoholic hepatitis
3) Cirrhosis

38
Q

What is the CAGE questionnaire?

A

C - cutting down
A - annoyed (Do you get annoyed at others commenting on your drinking?)
G - guilt (ever feel guilty about drinking?)
E - eye opener (ever drink in the morning to help your hangover/nerves?)

39
Q

What are the complications of alcohol consumption?

A 
Alcoholic Liver Disease
Cirrhosis and the complications of cirrhosis including hepatocellular carcinoma
Alcohol Dependence and Withdrawal
Wernicke-Korsakoff Syndrome (WKS)
Pancreatitis
Alcoholic Cardiomyopathy
40
Q

What blood investigations may be done for alcoholic liver disease?

A

FBC – raised MCV
LFTs – elevated ALT and AST (transaminases) and particularly raised gamma-GT
- ALP will be elevated later in the disease
- Low albumin due to reduced “synthetic function” of the liver
- Elevated bilirubin in cirrhosis
Clotting – elevated prothrombin time due to reduced “synthetic function” of the liver
U+Es may be deranged in hepatorenal syndrome.

41
Q

What further investigations can be done for alcoholic liver disease?

A

Ultrasound
FibroScan
Endoscopy - assess for and treat oesophageal varices when portal hypertension is suspected
CT and MRI scans
Liver biopsy - should be considered in those undergoing steroid treatment

42
Q

How may alcoholic liver disease be treated?

A 
Stop drinking alcohol permanently
Corticosteroid treatment (if they have severe alcohol-related hepatitis)
- Only effective in improving survival in short term (1 month)
43
Q

What is ‘delirium tremens’?

A

An acute confusional state which results when someone who drinks excess alcohol daily, suddenly stops drinking

  • Untreated it results in seizures and even death
  • This is why patients are advised to reduce their drinking gradually, which allows receptors in the brain to adapt, or they are started on detoxification regimens.
44
Q

How to pharmacologically manage acute alcohol withdrawal?

A

Offer benzodiazepine (e.g. Chlordiazepoxide) or carbamazepine
Clomethiazole may be offered as an alternative
- CAUTION when used - only in inpatient settings

45
Q

How to manage delirium tremens and alcohol withdrawal seizures?

A

Offer oral lorazepam as 1st line treatment
If symptoms persists off parenteral (non-oral) lorazepam

Seizures: quick-acting benzodiazepines (e.g. lorazepam)

46
Q

What is Wernicke-Korsakoff Syndrome (WKS)?

A

Alcohol excess leads to thiamine (vitamin B1) deficiency. Thiamine is poorly absorbed in the presence of alcohol and alcoholics tend to have poor diets and rely on the alcohol for their calories. Wernicke’s encephalopathy comes before Korsakoffs syndrome. These result from thiamine deficiency

47
Q

What are the features of WKS?

A

Wernickes encephalopathy:

  • Confusion
  • Oculomotor disturbances (disturbances of eye movements)
  • Ataxia (difficulties with coordinated movements)

Korsakoffs syndrome

  • Memory impairment (retrograde and anterograde)
  • Behavioural changes

Liver disease TCD Case 3 (2 decks)

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