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Year Two - Gastroenterology System > Liver Cirrhosis > Flashcards

Liver Cirrhosis Flashcards

1
Q

What is liver cirrhosis?

A

It is defined as an irreversible, chronic condition in which there is fibrosis of the liver due to long-term damage

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2
Q

Describe the pathophysiology of liver cirrhosis

A

In liver cirrhosis, there is chronic hepatic inflammation, which causes damage to hepatic cells

The damaged hepatic cells are replaced by nodules of scar tissue, in a process known as fibrosis

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3
Q

What is the pathophysiological consequence of liver cirrhosis? How?

A

Portal hypertension

The fibrosis results in alterations to liver structure, causing an increased resistance in the blood vessels supplying the liver

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4
Q

What are the eleven causes of liver cirrhosis?

A

Alcoholic Liver Disease

Non-Alcoholic Fatty Liver Disease

Viral Hepatitis B

Viral Hepatitis C

Autoimmune Hepatitis

Primary Biliary Cirrhosis

Haemochromatosis

Wilson’s Disease

Alpha-1 Antitrypsin Deficiency

Cystic Fibrosis

Drug Administration

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5
Q

Which three drugs are associated with liver cirrhosis?

A

Amiodarone

Methotrexate

Sodium valproate

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6
Q

What are the four main causes of liver cirrhosis?

A

Alcoholic Liver Disease

Non-Alcoholic Fatty Liver Disease

Viral Hepatitis B

Viral Hepatitis C

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7
Q

What is a trigger for decompensation in liver cirrhosis?

A

Constipation

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8
Q

What are the nine clinical features of liver cirrhosis?

A

Jaundice

Palmar Erythema

Spider Naevi

Caput Medusa

Ascites

Asterixis

Hepatomegaly

Splenomegaly

Gynaecomastia

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9
Q

What are the three investigations used to diagnose liver cirrhosis?

A

Blood Tests

Ultrasound Scan

Liver Biopsy

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10
Q

What nine blood test results indicate liver cirrhosis?

A

Decreased Sodium Levels

Increased Urea Levels

Increased Creatinine Levels

Increased ALT Levels

Increased AST Levels

Increased ALP Levels

Increased Bilirubin Levels

Decreased Albumin Levels

Increased Prothrombin Time

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11
Q

In chronic liver disease, which blood test result is the most sensitive finding for diagnosis of liver cirrhosis?

A

Decreased Platelet Count < 150,000mm3

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12
Q

What specific blood test is used to investigate liver cirrhosis?

A

Enhanced liver fibrosis (ELF) blood test

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13
Q

When is the ELF blood test used?

A

It is the first line investigation used to classify the severity of liver cirrhosis related to non-alcoholic fatty liver disease

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14
Q

What is the ELF test?

A

It measures three markers: HA, PIIINP and TIMP-1, which are then used in an algorithm to provide a result that indicates the severity of liver cirrhosis

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15
Q

What ELF score indicates mild liver cirrhosis?

A

< 7.7

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16
Q

What ELF score indicates moderate liver cirrhosis?

A

7.7 - 9.8

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17
Q

What ELF score indicates severe liver cirrhosis?

A

> 9.8

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18
Q

What are the six features of liver cirrhosis on ultrasound scan?

A

Nodular Hepatic Surface

Corkscrew Appearance of Hepatic Arteries

Enlarged Portal Vein

Ascites

Hepatomegaly

Splenomegaly

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19
Q

What specialised ultrasound scan is used to investigate liver cirrhosis?

A

Fibroscan

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20
Q

What is a Fibroscan?

A

It involves sending high frequency sound waves into the liver and measuring the transmission back to the sound wave probe – a process known as transient elastography

This enables a measure of liver elasticity

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21
Q

How is a Fibroscan used to investigate liver cirrhosis?

A

It is used to assess the degree of liver cirrhosis, and therefore to classify the severity of disease

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22
Q

When are Fibroscans used to investigate liver cirrhosis?

A

They are used as a screening technique, which is conducted every two years in high risk patient groups

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23
Q

What five patient groups receive screening of liver cirrhosis via Fibroscans?

A

Alcoholics

Alcoholic Liver Disease

Non-Alcoholic Fatty Liver Disease

Chronic Hepatitis B

Hepatitis C

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24
Q

In terms of liver cirrhosis screening, what is the criteria required for alcoholics to be screened?

A

Men > 50 units per week

Women > 35 units per week

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25
Q

Which patient group receive annual screening of liver cirrhosis?

A

Chronic hepatitis B

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26
Q

What is the feature of liver cirrhosis on liver biopsy?

A

Regenerative nodules surrounded by fibrotic tissue

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27
Q

Which two scoring systems are used in liver cirrhosis?

A

Child-Pugh Classification

Model for End-Stage Liver Disease (MELD) Score

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28
Q

What is the function of the Child-Pugh classification system?

A

To assess the severity of liver cirrhosis

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29
Q

What are the five criteria used in the Child-Pugh classification system?

A

Bilirubin

Albumin

INR

Encephalopathy

Ascites

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30
Q

Which Child-Pugh score indicates Grade A liver cirrhosis?

A

< 7

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31
Q

Which Child-Pugh score indicates Grade B liver cirrhosis?

A

7 - 9

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32
Q

Which Child-Pugh score indicates Grade C liver cirrhosis?

A

> 9

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33
Q

What is the function of the MELD score?

A

It is used to obtain a percentage estimated 3 month mortality rate of liver cirrhosis

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34
Q

When is the MELD score used?

A

It is recommended every six months in individuals with compensated cirrhosis

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35
Q

How do we calculate the MELD score?

A

A formula is applied which takes into account the patient’s bilirubin levels, creatinine levels, INR, sodium levels and whether they receive dialysis

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36
Q

What are the six conservative management options used in liver cirrhosis?

A

Alcohol Cessation

High Protein, Low Sodium Diet

MELD Score 6 Monthly

Alpha-Fetoprotein Level 6 Monthly

Ultrasound 6 Monthly

Endoscopy Every 3 Years

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37
Q

Why do we conduct alpha-fetoprotein level and ultrasound monitoring to manage liver cirrhosis?

A

This allows us to monitor for hepatocellular carcinoma development

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38
Q

Why do we conduct endoscopy to manage liver cirrhosis?

A

This allows us to monitor for oesophageal variceal development

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39
Q

What surgical management option is used in liver cirrhosis?

A

Liver Transplant

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40
Q

What is a liver transplant?

A

It involves surgical removal of the whole liver, with replacement of a donor liver

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41
Q

What is the only curative management option for liver cirrhosis?

A

Liver transplant

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42
Q

When is liver transplant used to manage liver cirrhosis?

A

It is only considered in those with severe disease and complication developmen

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43
Q

What are the seven complications associated with liver cirrhosis?

A

Malnutrition

Variceal Haemorrhage

Ascites

Spontaneous Bacterial Peritonitis

Hepatorenal Syndrome

Hepatic Encephalopathy

Hepatocellular Carcinoma

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44
Q

Describe how malnutrition can develop as a complication of liver cirrhosis

A

In liver cirrhosis, there is dysfunctional protein metabolism and glycogen storage within the liver

This results in the use of muscle tissue to provide energy, leading to muscle wasting and weight loss

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45
Q

What are the four conservative management options of malnutrition?

A

Low Sodium Diet

High Protein Diet

Regular Meal Consumption

Alcohol Cessation

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46
Q

What is variceal haemorrhage?

A

It is defined as a condition in which blood leaks from blood vessels due to portal hypertension

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47
Q

Describe how variceal haemorrhage can develop as a complication of liver cirrhosis

A

Portal hypertension results in the vessels at the sites where the portal system anastomoses with the systemic venous system to become swollen and tortuous

These vessels are referred to as varices.

Due to the high blood flow through varices, they can burst and start to bleed

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48
Q

Name the five locations in which varices form

A

Oesophagus

Gastro-oesophageal junction

Ileocaecal junction

Rectum

Anterior abdominal wall

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49
Q

What is the pharmacological management of stable varices?

A

Beta-blockers

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50
Q

Name a beta-blocker used to manage variceal haemorrhage

A

Propanolol

51
Q

How are beta-blockers used to manage stable varices?

A

They can be used to reduce portal hypertension and therefore prophylactically prevent variceal haemorrhage

52
Q

What are the three pharmacological management options for variceal haemorrhage?

A

Vasopressin Analogues

Blood Transfusion

Prophylactic IV Antibiotics

53
Q

Name a vasopressin analogue used to manage variceal haemorrhage

A

Terlipressin

54
Q

How are vasopressin analogues used to manage variceal haemorrhage?

A

They can be used to cause vasoconstriction of the splanchnic vessels, therefore reducing bleeding in the varices

55
Q

What three blood transfusions are used to manage variceal haemorrhage?

A

Vitamin K

Fresh frozen plasma

Platelets

56
Q

Why are prophylactic antibiotics used to manage variceal haemorrhage?

A

They are used to reduce mortality

57
Q

Name a prophylactic IV antibiotic used to manage variceal haemorrhage

A

Quinolones

58
Q

When should vasopressin analogues and prophylactic antibiotics be administered in variceal haemorrhage?

A

BEFORE endoscopy

59
Q

What are the four surgical management options for variceal haemorrhage?

A

Band Ligation

Sclerotherapy

Sengstaken-Blakemore Tube

Transjugular Intra-Hepatic Portosystemic Shunt (TIPS)

60
Q

What is band ligation?

A

It involves securing an elastic band around the variceal to cut off the blood supply, thus stopping haemorrhage

61
Q

When is band ligation used to manage variceal haemorrhage?

A

It is the first line surgical management option

It is also a prophylactic management option in medium to large varices. It is conducted at two-weekly intervals until all varices have been eradicated.

62
Q

What is sclerotherapy?

A

It involves endoscopic injection of a solution directly into a vein

This solution causes the vein to scar, forcing blood to reroute through healthier veins

63
Q

What is a Sengstaken-Blakemore tube?

A

It is an inflatable tube inserted into the oesophagus to tamponade the bleeding varies

64
Q

When is a Sengstaken-Blakemore tube used to manage variceal haemorrhage?

A

In cases of uncontrolled haemorrhage

65
Q

What is TIPS?

A

It involves insertion of a wire under x-ray guidance into the jugular vein, down the vena cava and into the liver via the hepatic vein

There is then anastomosis of the hepatic vein and the portal vein, which a stent is inserted into

This enables blood to flow directly from the portal vein to the hepatic vein – relieving pressure in the portal system and varices

66
Q

When is TIPS used to manage variceal haemorrhage?

A

It is the last management option

It is also a prophylactic management option in medium to large varices

67
Q

What is a complication of TIPS?

A

Hepatic encephalopathy exacerbation

68
Q

What is ascites?

A

It is defined as a condition in which there is an abnormal collection of fluid in the peritoneal cavity – > 25ml

69
Q

Describe how ascites can develop as a complication of liver cirrhosis

A

Portal hypertension causes fluid to leak out of the capillaries within the liver and bowel and into the peritoneal cavity

The decrease in circulating volume causes a reduction in blood pressure entering the kidneys

This leads to activation of the renin-angiotensin-aldosterone system, in which the kidneys release renin to stimulate increased aldosterone secretion

This increased aldosterone secretion causes reabsorption of fluid and sodium in the kidneys, leading to fluid and sodium overload

70
Q

In liver cirrhosis, is ascites exudative or transudative? What does this mean?

A

Transudative

The ascites fluid consists of a high protein count > 11g/L

71
Q

What are the two conservative management options of ascites?

A

Low Sodium Diet

Restrict Fluid Intake

72
Q

When is fluid restriction recommended in ascites?

A

Na < 125 mmol/L

73
Q

What are the two pharmacological management options of ascites?

A

Anti-Aldosterone Diuretics

Prophylactic Antibiotics

74
Q

Name an anti-aldosterone diuretic used to manage ascites

A

Spironolactone

75
Q

How are anti-aldosterone diuretics used to manage ascites?

A

They inhibit aldosterone to in turn inhibit water and sodium absorption in the kidneys

76
Q

Name two prophylactic antibiotics used to manage ascites

A

Ciprofloxacin

Norfloxacin

77
Q

Why do we administer prophylactic antibiotics in ascites?

A

To reduce the risk of spontaneous bacterial peritonitis

78
Q

In which three patient groups do we administer prophylactic antibiotics to manage ascites?

A

Individuals with < 15g/L of protein in ascitic fluid

Those with hepatorenal syndrome

Those with a Child-Pugh score > 9

79
Q

What are the two surgical management options of ascites?

A

Paracentesis

Transjugular Intra-Hepatic Portosystemic Shunt (TIPS)

80
Q

What is paracentesis?

A

It involves the insertion of a needle into the peritoneal cavity to drain ascitic fluid

81
Q

Following large volume (5L) paracentestis, what do we administer? Why?

A

Albumin cover

This is due to the fact that it reduced paracentesis-induced circulatory dysfunction and mortality

82
Q

What is spontaneous bacterial peritonitis (SBP)?

A

It is defined as condition in which there is infection within the ascitic fluid and peritoneal lining without any clear cause

83
Q

What are the three causative organisms of ascites?

A

E.Coli

Klebsiella Pneumoniae

Gram positive cocci

84
Q

What is the most common causative organism associated with spontaneous bacterial peritonitis?

A

E.Coli

85
Q

What are the five clinical features of spontaneous bacterial peritonitis?

A

Ascites

Abdominal Pain

Fever

Ileus

Hypotension

86
Q

What are the two investigations used to diagnose spontaneous bacterial peritonitis?

A

Blood Tests

Paracentesis

87
Q

What are the three blood test results indicative of spontaneous bacterial peritonitis?

A

Increased WBC Levels

Increased CRP Levels

Increased Creatinine Levels

88
Q

What is the feature of spontaneous bacterial peritonitis on paracentesis?

A

An increased neutrophil counts > 250 cells/ul

89
Q

How can paracentesis be used to investigate spontaneous bacterial peritonitis?

A

It can be used to obtain a bacterial culture

90
Q

What is the pharmacological management option for spontaneous bacterial peritonitis?

A

IV antibiotics

91
Q

Name an IV antibiotic used to manage spontaneous bacterial peritonitis

A

Cefotaxime

92
Q

What is a poor progonostic marker of spontaneous bacterial peritonitis?

A

Alcoholic liver disease

93
Q

What is hepatorenal syndrome?

A

It is defined as a condition in which renal failure develops due to severe liver damage

94
Q

Describe how hepatorenal syndrome can develop as a complication of liver cirrhosis

A

Portal hypertension causes portal vein dilation, which leads to a loss of blood volume in other areas of the circulation – including the kidneys

This renal hypotension leads to activation of the renin-angiotensin system, which leads to renal vasoconstriction

Therefore, there is reduced blood flow to the kidneys, which leads to a rapidly deteriorating renal function

95
Q

What are the two classifications of hepatorenal syndrome?

A

Type one hepatorenal syndrome

Type two hepatorenal syndrome

96
Q

What is type one hepatorenal syndrome?

A

Doubling of serum creatinine to > 221 µmol/L over a period of less than 2 weeks

OR

A halving of the creatinine clearance to less than 20 ml/min over a period of less than 2 weeks

97
Q

What is type two hepatorenal syndrome?

A

It is a slowly progressive form of hepatorenal syndrome

98
Q

What is the pharmacological management option of hepatorenal syndrome?

A

Vasopressin Analogues

99
Q

Name two vasopressin analogues used to manage hepatorenal syndrome

A

Terlipressin

Octreotide

100
Q

How are vasopressin analogues used to manage hepatorenal syndrome?

A

They can be used to cause vasoconstriction of the splanchnic vessels, therefore reducing portal hypertension

101
Q

What are the two surgical management options of hepatorenal syndrome?

A

Liver transplant

Transjugular Intra-Hepatic Portosystemic Shunt (TIPS)

102
Q

How soon after a hepatorenal syndrome diagnosis should a liver transplant be conducted?

A

A week

103
Q

When is TIPS used to manage hepatorenal syndrome?

A

It is recommended when individuals are unfit for liver transplant surgical management

104
Q

What is hepatic encephalopathy?

A

It which is defined as a neurological condition which is related to the liver being unable to remove toxins from the blood

105
Q

Name two toxins that build up in hepatic encephalopathy

A

Ammonia

Glutamine

106
Q

What is the main toxin that builds up in hepatic encephalopathy?

A

Ammonia

107
Q

Describe how hepatic encephalopathy can develop as a complication of liver cirrhosis

A

In liver cirrhosis, raised levels of ammonia and glutamine are related to functional impairment of hepatic cells preventing appropriate metabolism of these toxins into harmful waste products

In addition, the collateral vessels between the portal and systemic circulation results in these toxins bypassing the liver altogether and entering the systemic circulation directly

108
Q

What are the seven causes of hepatic encephalopathy?

A

Infection

Gastrointestinal Bleeding

Constipation

Post TIPS Procedure

Renal Failure

Hypokalaemia

Drug Administration

109
Q

Name two drugs associated with hepatic encephalopathy?

A

Diuretics

Sedatives

110
Q

What are the five clinical features of hepatic encephalopathy?

A

Confusion

Asterix

Seizures

Personality Changes

Mood Changes

111
Q

What asterix frequency is associated with hepatic encephalopathy?

A

3 - 5 Hz

112
Q

What clinical features indicate grade I hepatic encephalopathy?

A

Irritable

113
Q

What clinical features indicate grade II hepatic encephalopathy?

A

Confusion

Inappropriate behaviour

114
Q

What clinical features indicate grade III hepatic encephalopathy?

A

Incoherent

Restless

115
Q

What clinical features indicate grade IV hepatic encephalopathy?

A

Coma

116
Q

What are the two pharmacological management options of hepatic encephalopathy?

A

Laxatives

Antibiotics

117
Q

How are laxatives used to manage hepatic encephalopathy?

A

They promote the excretion and metabolism of ammonia from the gut

118
Q

What is the first line management option of hepatic encephalopathy?

A

Laxatives

119
Q

Name a laxative used to manage hepatic encephalopathy

A

Lactulose

120
Q

Name an antibiotic used to manage hepatic encephalopathy

A

Rifaximin

121
Q

How are antibiotics used to manage hepatic encephalopathy?

A

They reduce the number of intestinal bacteria producing ammonia

122
Q

What is the surgical management option is used for hepatic encephalopathy?

A

Portosystemic Shunt Embolisation

123
Q

When is portosystemic shunt embolisation used to manage hepatic encephalopathy?

A

When hepatic encephalopathy is related to post transjugular intrahepatic portosystemic shunting

Year Two - Gastroenterology System (33 decks)

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