Liver disease – treatment

Question 1

What are the 4 principles of treatment for liver disease?

Answer 1

1. Eliminate causative agent
2. Suppress ongoing disease
3. Optimise regenerative capacity
4. Control complications

Question 2

How can therapy for liver disease be tailored to the clinical picture?

Answer 2

• Dietary modification
• Ursodeoxycholic acid (UDCA)
• Anti-oxidant drugs & glutathione donors
• Treatment of complications

Question 3

How can therapy for liver disease be tailored to biopsy results?

Answer 3

Inflammatory cells = antibiotics, immunosuppressive
Fibrosis = anti-fibrotic drugs
Copper accumulation = decoppering drugs
Positive bacterial culture = appropriate antibiotic

Question 4

Describe how you would use dietary management to treat hepatic encephalopathy

Answer 4

Aim = Minimise Ammonia production
Protein restriction ± modification
Restrict if shunt present
High biological value
- Dairy
- Vegetable

Question 5

Describe how you would use dietary management to treat chronic active inflammation

Answer 5

Aims:
-> Reduce inflammation
- >Prevent copper accumulation
- Alter mineral balance: Low copper and high zinc
- Fat-soluble vitamins: A,D,E,K
- Taurine & L-carnitine for cats
- Protein restriction rarely required

Question 6

Would you use antibacterial therapy for hepatic encephalopathy?

Answer 6

Use empirically based on clinical picture
Ampicillin or metronidazole

Question 7

Would you use antibacterial therapy for bacterial cholangiohepatitis

Answer 7

Documented (proven bacterial) infection e.g. cholangiohepatitis
Need culture and sensitivity (bile and tissue)

Question 8

What would be seen on the biopsy of chronic active inflammation to indicate glucocorticoid therapy?

Answer 8

Lymphocytes and plasma cells

Question 9

What would be seen on the biopsy of hepatic fibrosis to indicate glucocorticoid therapy?

Answer 9

Fibrosis/cirrhosis

Question 10

What are the advantages of glucocorticoid therapy in liver disease cases?

Answer 10

Improved well-being
Appetite stimulation
Anti-inflammatory
Immunosuppression
Anti-fibrotic

Question 11

What are the disadvantages of glucocorticoid therapy in liver disease cases?

Answer 11

Steroid hepatopathy
Predispose to infection
Fluid retention
Catabolic

Question 12

List the breeds affected by copper associated hepatopathies. Why are these breeds affcted?

Answer 12

Bedlington terrier
WHWT
Skye terrier
Dalmatian
Labrador
Doberman
- Can’t excrete copper as they normally should leading to a massive levels accumulating in the liver

Question 13

Same some decoppering agents

Answer 13

Copper chelators
- D-penicillamine
- 2,2,2-tetramine
Copper absorption blockers
- Oral zinc
Reducing copper in the diet

Question 14

What are the pros of adjunctive therapy?

Answer 14

Can be tailored to the clinical picture
Do not need biopsy results
Broad spectrum of activity
Wide safety margin
Combination therapy used

Question 15

List 4 adjunctive therapies used with liver disease

Answer 15

Ursodeoxycholic acid (UDCA)
S-Adenosyl methionine (SAMe)
Milk thistle
Vitamin E

Question 16

Describe how Ursodeoxycholic acid works as an adjunctive therapy

Answer 16

Hydrophilic (water soluble), ‘beneficial’ bile salt
- Alters bile composition: Decreases hydrophobic bile acids
- Stimulates bile flow: Contraindicated if complete biliary obstruction
- Modulates inflammatory/immune response

Question 17

Describe how S-Adenosyl methionine works as an adjunctive therapy

Answer 17

Glutathione (GSH) donor E.g. a precursor for GSH production
GSH = endogenous molecule central to: Hepatic metabolism and Detoxification

Question 18

Silymarin is another name for?

Answer 18

Milk thistle

Question 19

What are the actions of milk thistle?

Answer 19

Free-radical scavenger
Inhibits inflammation
Inhibit lipid peroxidase
Inhibit collagen deposition
Increase glutathionine

Question 20

What are the advantages of milk thistle?

Answer 20

Wide safety margin
No absolute contraindications
Broad spectrum of activity

Question 21

What are the disadvantages of milk thistle?

Answer 21

Cost
Evidence for efficacy?
Does not reduce mortality
Does not improve histology picture
Does not improve biochemical markers

Question 22

Protein restriction is used to dietary manage which condition?

Answer 22

Hepatic encephalopathy

Question 23

Describe the diet used for liver disease due to chronic active inflammation

Answer 23

Low Copper
High zinc
High protein quality
Anti-oxidants

Question 24

What are the main complications of liver disease

Answer 24

Hepatic encephalopathy & coma
Ascites and oedema
Haemorrhage and anaemia

Question 25

How can you reduce ammonia concentrations in cases of hepatic encephalopathy?

Answer 25

Low protein diet
Lactulose
Antibiotics (ampicillin or metronidazole)

Question 26

How can ascites and oedema due to liver disease be treated?

Answer 26

1. Low sodium diet
2. Diuretics
   - Spironolactone first choice
   - Occasionally add in furosemide
3. Paracentesis
   - Drain a minimal volume for patient comfort
   - Could worsen bodywide protein status

Question 27

How can haemorrhage and anaemia due to liver disease be treated?

Answer 27

Vitamin K injections
Fresh blood transfusions
B vitamin injections