Liver Cirrhosis

Question 1

What is liver cirrhosis?

Answer 1

Chronic inflammation and damage to liver cells

Nodules of scar tissue replace functional liver cells

Question 2

What affect does liver cirrhosis have on circulation and why?

Answer 2

Portal hypertension

Increased resistance and pressure in portal system since a cirrhotic liver is less compliant

Question 3

What are the most common causes of liver cirrhosis?

Answer 3

Alcohol related liver disease
Non-Alcoholic fatty liver disease
Hepatitis B
Hepatitis C

Question 4

What are some less common causes of liver cirrhosis?

Answer 4

Autoimmune hepatitis
Primary biliary cirrhosis
Haemochromatosis
Wilsons disease
Alpha-1-antitrypsin deficiency
Cystic fibrosis
Drugs (amiodarone, methotrexate, sodium valproate)

Question 5

What are some common signs of chronic liver disease?

Answer 5

Specific to chronic:
-Dupuytrens contracture
-Palmar erythema
-Gynaecomastia
-Clubbing
-Spider naevi

Acute or chronic
-jaundice
-hepatomegaly
-ascites
-caput medusae
-astrexis
-caput medusae

Question 6

How do you investigate a patietn who may have liver cirrhosis?

Answer 6

Ultrasound liver (Fatty liver?)
LFTs
INR
AFP
Urea and creatinine
Hep B and C serology
Autoantibodies (autoimmune hep, primary biliary cirrhosis, primary Sclerosing cholangitis)
Immunoglobulins
Ceruloplasmin (Wilsons)
Alpha-1-antitrypsin levels
Ferritin and transferrin saturation (hereditary Haemochromatosis)

Question 7

What patients do you do a fibroscan for?

Answer 7

Alcohol related liver disease
Heavy drinkers
Non-alcoholic fatty liver disease advanced fibrosis
Hep C
Chronic hep B

Question 8

When is liver transplantation considered?

Answer 8

Features of decompensated liver disease:
AHOY

Ascites
Hepatic. Encephalopathy
Oesophageal Varices bleeding
Yellow (Jaundice)

Question 9

What are the complications of liver cirrhosis?

Answer 9

Malnutrition and muscle wasting
Portal hypertension
Ascites + Spontaneous bacterial peritonitis
Heptaorenal syndrome
Hepatic encephalopathy
Hepatocellular carcinoma

Question 10

How do you manage malnutrition due to cirrhosis?

Answer 10

Regular meals
High protein and calorie intake
Reduced sodium intake (less fluid retention))
Avoid alcohol

Question 11

What is the management of portal hypertension and Varices?

Answer 11

Non selective B blockers like propranolol
Variceal band ligation (if cant give beta blockers)

Question 12

What is the management of bleeding oesophageal Varices?

Answer 12

Escalate
Major haemorrhage protocol
Treat Coagulopathy with fresh frozen plasma
Vasopressin analogues (TERLIPRESSIN vasoconstriction of portal system)
Broad spec abx
Urgent endoscopy + variceal band ligation
Or TIPS

Question 13

What is TIPS?

Answer 13

Transjugular Intrahepatic portosystemic shunt (stent between portal vein and hepatic vein to relieve portal systems pressure )

Question 14

What is ascites?

Answer 14

Fluid in the peritoneal cavity

Question 15

What are the causes of Ascites?

Answer 15

Liver cirrhosis
Heart failure
Nephrotic syndrome
Malignancy

Question 16

What investigations would you do if a patient has ascites?

Answer 16

LFTs
FBC
Ascitic fluid aspiration (Albumin gradient)
U+Es hepatorenal syndrome

Question 17

How is the albumin gradient calculated from an abdominal paracentesis of the ascitic fluid?

Answer 17

Serum albumin - ascitic albumin

Question 18

What is the point of calculating the albumin gradient between the blood and the ascitic fluid?

Answer 18

Used to determine if there’s elevated portal pressure (portal hypertension)

Question 19

What albumin gradient is considered a normal portal pressure?

What value for albumin gradient is considered elevated portal pressure?

Answer 19

Albumin gradient < 11 is normal portal pressure

Albumin gradient > 11 is portal hypertension

Question 20

What conditions cause an ascites that has an albumin gradient less than 11? (So not a portal hypertension)

Answer 20

Malignancy
Nephrotic syndrome

Question 21

Why is the albumin gradient for an ascites caused by nephrotic syndrome less than 11/ not caused by portal hypertension?

Answer 21

Nephrotic syndrome causes hypoalbuminaemia so means the ascites is caused by the lack of oncotic pressure within the blood

Question 22

What are the causes of ascites with a high albumin gradient >11 / caused by portal hypertension?

Answer 22

Heart failure
Liver cirrhosis

Question 23

What are you suspecting if a patient has an ascites with a high albumin gradient (>11) / high portal pressure if the patient doesn’t have signs of chronic liver disease?

What are your next steps?

Answer 23

Likely not liver cirrhosis

Potentially heart failure
NT-proBNP
Echo

Question 24

What is the pathophysiology behind hepatorenal syndrome?

Answer 24

Portal hypertension leads to ascitic fluid building up and less circulating systemic blood volume. Kidneys receive less blood so activation of RAAS, further increase in pressure worsens portal hypertension and renal perfusion

Question 25

How do you manage ascites?

Answer 25

Manage underlying cause Aldosterone antagonists like Spironolactone Paracentesis/drain Prophylactic antibiotics (ciprofloxacin) if high protein in ascitic fluid TIPS Liver transplant

Question 26

Why may you give prophylactic antibiotics in a patient with ascites?

Answer 26

High risk of developing spontaneous bacterial peritonitis

Question 27

Who’s more likely to develop SBP, a patient with liver cirrhotic ascites or malignant ascites?

Answer 27

Liver cirrhotic ascites Malignant ascites normally have vessel abnormalities where immunoglobulins can leak into the abdomen Liver cirrhosis has no vessel abnormalities so immunoglobulins cant enter the ascitic fluid

Question 28

What is considered spontaneous bacterial peritonitis?

Answer 28

Infection of. Ascitic fluid and peritoneal lining without a clear source of infection

Question 29

How does spontaneous bacterial peritonitis SBP present?

Answer 29

Fever Abdopain Deranged bloods Ileus Hypotension

Question 30

What is the most common causative organism of SBP?

Answer 30

E.coli

Question 31

How is SBP managed?

Answer 31

IV broad spectrum antibiotics

Question 32

What is the first line therapy used to treat spontaneous bacterial peritonitis?

Answer 32

Cefotaxime IV + IV albumin reduce renal impairment

Question 33

What is the main toxin that can cause hepatic encephalopathy?

Answer 33

Ammonia

Question 34

How is hepatic encephalopathy treated?

Answer 34

Lactulose Antibiotics (Rifaximin to reduce number of intestinal bacteria) NG tubing

Question 35

What are the stages of alcohol related liver disease?

Answer 35

Alcoholic fatty liver Alcoholic hepatitis Cirrhosis

Question 36

What are some complications of alcohol and liver disease?

Answer 36

Alcohol related liver disease Cirrhosis HCC Alcohol dependance and withdrawal Wernickes syndrome Pancreatitis Alcholic cardiomyopathy CVA Cancer

Question 37

What exam findings can you find with excess alcohol?

Answer 37

Smelling of alcohol Slurred speech Bloodshot eyes Telangiectasia on face Tremor

Question 38

What are some investigations that would. Suggest alcohol related liver disease?

Answer 38

High MCV Elevated ALT AST GGT Raised bilirubin + jaundice Reduced albumin Elevated INR Deranged U+Es Fatty changes on USS Endoscopy = oesophageal Varices Liver biopsy

Question 39

What is the management for alcoholic liver disease?

Answer 39

Stop drinking Psychological interventions Detox regime Nutritional support (Vitamins like THiamine = Vit B1 and high protien diet) Corticosteroids (reduce inflammation in severe alcoholic hepatitis)

Question 40

What are some medical emergencies. Related to alcohol?

Answer 40

Delirium tremens Wernicke sydnrome

Question 41

What is the pathophysiology of delirium tremens?

Answer 41

Alcohol is a depressant stimulating GABA receptors. Alcohol inhibits glutamate/NMDA receptors . This leads to increased amounts of NMDA/glutamte receptors and decreased amounts of GABA receptors. So when a pateint withdraws there is very high NMDA/glutamate receptor activity leading to high adrenergic activity

Question 42

How does a patient with delirium tremens present?

Answer 42

Acute confusion Agitation Delusions/hallucinations Tremors Tachycardia Hypertension Hyperthermia Ataxia Arrhythmia

Question 43

What medication do you give to combat the effects of alcohol withdrawal?

Answer 43

Chlordiazepoxide (type of benzodiazepines)

Question 44

What vitamin becomes deficient with alcohol excess?

Answer 44

Vitmain B1 (Thiamine) So pateitn should be given high dose B vitamins

Question 45

What syndrome can be caused by vitamin B1/thiamine deficiency due to alcoholism?

Answer 45

Wernicke-Korsakoff syndrome

Question 46

What are the features of wernickes encephalopathy?

Answer 46

Confusion Oculomotor disturbances (ophthalmoplegia) Ataxia (coordinated movements)

Question 47

What are the stages of non-alcoholic fatty liver disease?

Answer 47

Non-alcoholic fatty liver disease Non-alcoholic Steatohepatitis Fibrosis Cirrhosis

Question 48

What are the risk factors of non-alcoholic fatty liver disease?

Answer 48

Middle age Obesity Poor diet and low activity T2DM Hypercholesterolemia HTN Smoking

Question 49

What investigations would you do to investigate a non alcoholic fatty liver disease?

Answer 49

ALT Liver ultrasound Fibroscan NAFLD fibrosis score Liver biopsy

Question 50

How is non alcoholic fatty liver disease managed?

Answer 50

Weight loss Healthy diet Exercise Avoid alcohol Stop smoking Control diabetes, BP and cholesterol Vit E, pioglitazone , bariatric surgery and liver transplantation

Question 51

How does a patient with Wilsons disease present?

Answer 51

Neurological symptoms Kayser-fliescher rings Blue nails Renal tubular acidosis Family history

Question 52

What is the first line treatment for symptomatic Wilsons disease?

Answer 52

Penicillamine (copper chelating agent)

Question 53

What blood investigation can determine between an Upper GI bleed and a lower GI bleed?

Answer 53

Urea If Urea = High its Upper If urea normal = lower GI bleed

Question 54

What are the early signs of hereditary haeamochromatosis?

Answer 54

Fatigue Arthralgia Erectile dysfunction Occurs due to chronic deposition of iron in tissues

Question 55

What is the first line management/medication for primary biliary cholangitis?

Answer 55

Ursodeoxycholic acid

Question 56

What medication is used to manage Hepato-renal syndrome?

Answer 56

Terlipressin

Question 57

What investigations are key to detecting Primary Billary Cholangitis?

Answer 57

ALP + GGT will be abnormal AMA (Anti Mitochondrial Antibody) will be +ve

Question 58

How does Hereditary Haemochromatosis present?

Answer 58

Fatigue ED Arthralgia (most commonly in the hands) Hypogonadism

Question 59

What investigation is diagnostic for Hereditary Haemochromatosis?

Answer 59

Iron studies

Question 60

What iron study results would indicate hereditary Haemochromatosis?

Answer 60

Ferritin high Low Total Iron Binding Capacity (TIBC) since less transferrin is made by the liver since body has toto much iron around the body already Transferrin saturation high

Question 61

What is the management for hereditary Haemochromatosis?

Answer 61

Venesection