Liver Disorders

Question 1

What is Liver cirrhosis?

Answer 1

Liver cirrhosis is a chronic, progressive liver disease characterized by fibrosis (scarring) and the formation of regenerative nodules that replace healthy liver tissue. This scarring disrupts the normal structure and function of the liver.

Question 2

What is the pathophysiology of Liver cirrhosis?

Answer 2

Ongoing liver injury → inflammation → fibrosis

1. The liver attempts to regenerate, but the new tissue is disorganized, leading to nodule formation and impaired function
2. Normal liver architecture is replaced by scar tissue and nodules
3. Blood flow through the liver becomes impaired, leading to portal hypertension and liver dysfunction (Impaired metabolism of toxins, clotting factors, and proteins)

Question 3

What are the causes of liver cirrhosis?

Answer 3

Alcohol-related liver disease (ARLD):
Chronic alcohol abuse

Non-alcoholic fatty liver
disease (NAFLD):
Obesity, diabetes, metabolic syndrome

Viral hepatitis:
Hepatitis B and C

Autoimmune liver disease:
Autoimmune hepatitis, primary biliary cholangitis (PBC), primary sclerosing cholangitis (PSC)

Genetic/metabolic disorders:
Haemochromatosis, Wilson’s disease, Alpha-1 antitrypsin deficiency

Drug-induced liver injury:
Methotrexate, amiodarone, isoniazid

Question 4

What are the clinical features of cirrhosis?

Answer 4

General:
Fatigue, weight loss, muscle wasting, anorexia

Skin:
Jaundice, spider naevi, palmar erythema, bruising
Gastrointestinal:
Ascites, hepatomegaly, splenomegaly

Endocrine:
Gynecomastia, testicular atrophy (due to oestrogen excess)

Neurological:
Hepatic encephalopathy (confusion, asterixis, coma)

Question 5

What is cirrhosis classified into?

Answer 5

Compensated: Asymptomatic and no complications.

Decompensated: Symptomatic with complications such as jaundice, vatical bleeding and encephalopathy.

Question 6

How is liver cirrhosis diagnosed?

Answer 6

Imaging:

First line is ultrasound which will show a nodular liver, splenomegaly and ascites.

Elastography can be used to measure the liver stiffness to assess fibrosis severity.

CT/MRI to detect complications such as portal hypertension.

Blood tests:
Liver function tests: Raised ALT, AST, ALP, and GGT (early); low albumin and raised bilirubin (late)

Clotting tests: Prolonged prothrombin time (PT) due to reduced clotting factors

Full blood count: Low platelets (due to splenic sequestration), anemia

Other tests:
Liver biopsy is gold standard but rarely every needed.

Question 7

What is the management of liver cirrhosis?

Answer 7

Treat underlying cause:
- Alcohol cessation (ARLD)
- Antiviral therapy (Hepatitis B, C)
- Weight loss (NAFLD)

Liver protective measures:
- Avoid NSAIDS, hepatatoxic drugs
- vaccinations ( hep A, B)

Monitor for complications:
Regular ultrasound and AFP (alpha-fetoprotein) for hepatocellular carcinoma screening

Question 8

What is the management of the complications of liver cirrhosis?

Answer 8

Ascites: Sodium restriction, diuretics (spironolactone ± furosemide), paracentesis, albumin infusion.

Spontaneous bacterial peritonitis (SBP): IV antibiotics (ceftriaxone), prophylaxis with norfloxacin.

Variceal Bleeding: Endoscopic band ligation, beta-blockers (propranolol), IV terlipressin.

Hepatic Encephalopathy:
Lactulose, rifaximin

Hepatocellular Carcinoma (HCC): Regular screening; treatment depends on stage (resection, liver transplant, TACE)

Question 9

What is the scoring system in Liver cirrhosis?

Answer 9

Child-Pugh Score which predicts cirrhosis severity and mortality based on 5 parameters which is albumin, bilirubin, INR, ascites, encephalopathy. Cirrhosis is then graded into Class A (mild), Class B (moderate) and class C (Severe).

A MELD score (Model for End-Stage Liver Disease) is used for liver transplant allocation. A score greater than 15 suggests need for liver transplant evaluation.

Question 10

What is Hepatitis?

Answer 10

Hepatitis refers toinflammation of the liver, caused by viruses, toxins, autoimmune conditions, or metabolic disorders.
The most common types are:
1. Viral hepatitis (A, B, C, D, E)
2. Alcoholic
3. Autoimmune
4. Drug-induced hepatitis

Question 11

What are the different types of Hepatitis:

Answer 11

A & E: eating or drinking contaminated food or water.
B: Through contact with bodily fluids of infected person.
C: blood to blood contact
D: contact with infected blood( only occurs in people already infected with hep B)

Question 12

What is hepatitis A and its management?

Answer 12

Cause:RNA virus (picornavirus)

Transmission:Fecal-oral (contaminated food/water)

Incubation:2-6 weeks

Symptoms:Fatigue, nausea, vomiting, jaundice, dark urine, pale stools, hepatomegaly

Diagnosis:Anti-HAV IgM (for acute infection)

Management:Supportive care (self-limiting disease)

Prevention:Good hygiene, vaccination, avoiding contaminated water

Question 13

Hepatits B

Answer 13

Cause:DNA virus (hepadnavirus)

Transmission:Blood, sexual contact, perinatal (mother-to-child)

Symptoms:flu like symptoms, joint pain, jaundice

Acute vs Chronic:90% clear it, but 10% develop chronic HBV

Diagnosis:
HBsAg
Active infection
Anti-HBc IgM
Recent infection
Anti-HBc IgG
Past or chronic infection
Anti-HBs
Immunity/vaccination
HBeAg
High infectivity

Management:
Acute: Supportive care
Chronic: Antivirals (tenofovir, entecavir)

Prevention:Vaccination

Question 14

Hepatitis C

Answer 14

Cause:RNA virus (flavivirus)

Transmission:Blood (IV drug use, transfusions, unsafe procedures)

Incubation:2-26 weeks

Silent progression:Asymptomatic until cirrhosis develops

Chronicity:85% develop chronic infection

Diagnosis:Anti-HCV antibodies, HCV RNA

Management:Direct-acting antivirals (sofosbuvir, ledipasvir)
No vaccine available

Question 14

Hep D

Answer 14

Cause:RNA virus (defective virus requiring HBV)

Transmission:Blood (same as HBV)

Superinfection:More severe liver disease in HBV carriers

Diagnosis:Anti-HDV, HDV RNA

Management:Treat HBV (interferon therapy)

Prevention:HBV vaccination

More rapid progression to cirrhosis

Question 15

Hep E

Answer 15

Cause:RNA virus (hepevirus)

Transmission:Fecal-oral (contaminated water, undercooked pork)

Symptoms: Flu-like illness, jaundice and nausea.

High risk in pregnancy:20-30% maternal mortality in the third trimester

Diagnosis:Anti-HEV IgM

Management:Supportive care
Vaccine available only in China

Question 16

What are the nonviral hepatitis types of disease?

Answer 16

Alcoholic hepatitis which is due to alcohol use leading to fatty liver, fibrosis and cirrhosis.

Autoimmune hepatitis which is caused by immune system attacking liver cells which is more common in young women associated with ANA and SMA antibodies. Can lead to liver failure.

Drug induced hepatitis which is caused by medications (NSAIDs, antibiotics, paracetamol overdose) which can cause acute liver failure.

Metabolic hepatitis which is caused by Wilson’s disease or hemochromatosis. Normally there’s copper/iron accumulation in the liver.

Question 17

What are the early symptoms of hepatitis?

Answer 17

Early (Prodromal) Symptoms:
Fatigue
Nausea & vomiting
Fever (especially in viral hepatitis)
Loss of appetite
Abdominal discomfort (right upper quadrant pain)
Muscle and joint pain (common in viral hepatitis)

Question 18

What are the later symptoms of hepatitis?

Answer 18

Later Symptoms (Indicative of Liver Dysfunction):
Jaundice(yellowing of skin and sclera due to bilirubin buildup)
Dark urine(bilirubin excretion in urine)
Pale/clay-coloured stools(reduced bile secretion)
Pruritus (itching)(bile salt accumulation in skin)
Hepatomegaly(enlarged liver, tender on palpation)
Splenomegaly(enlarged spleen in advanced disease)

Question 19

What are the severe symptoms of hepatitis?

Answer 19

Severe Symptoms (Seen in Advanced Hepatitis):
- Ascites(fluid accumulation in the abdomen)
- Peripheral oedema(fluid retention in legs)
- Easy bruising/bleeding(coagulopathy due to reduced clotting factors)
- Hepatic encephalopathy(confusion, asterixis, coma due to ammonia buildup)

Question 20

What are the red flags to look out for?

Answer 20

Encephalopathy

Severe coagulopathy ( prolonged bleeding, easily bruised)

Massive ascites with respiratory distress

Sudden severe jaundice in a previously stable patient

Severe abdominal pain with fever (suggests liver abscess or secondary infection)

Question 21

What are hepatic neoplasms?

Answer 21

Hepatic neoplasms includebenignandmalignanttumors of the liver.
Malignant neoplasms can beprimary (originating in the liver)orsecondary (metastatic, spread from another site).

Question 22

What are some benign hepatic tumours?

Answer 22

(a) Hepatic Hemangioma(Most common benign liver tumor)
(b) Focal Nodular Hyperplasia (FNH)
(c) Hepatic Adenoma

Question 23

What is a Hepatic Hemangioma?

Answer 23

Definition:Vascular tumor made of blood vessels.

Risk Factors:More common in women, associated with estrogen (may grow in pregnancy or with OCP use).

Symptoms:Usually asymptomatic, but large hemangiomas may cause RUQ pain or mass effect.

Diagnosis:Incidental finding onultrasound (hyperechoic lesion), confirmed byMRI or CT with contrast.
No tumor markers

Management:
No treatment if asymptomatic.
Surgery if large and causing symptoms.

Question 24

What is Focal Nodular Hyperplasia (FNH)?

Answer 24

Definition: Benign liver hyperplasia with normal hepatocytes. Risk Factors: More common in young women, linked to hormones but not as much as hemangiomas. Symptoms: Usually asymptomatic, rarely causes pain. Diagnosis: MRI with contrast (central scar seen). No tumour markers Management: No treatment needed unless symptomatic.

Question 25

What is a Hepatic Adenoma?

Answer 25

(c) Hepatic Adenoma Definition: Benign tumor of hepatocytes, but has a risk of malignant transformation or rupture. Risk Factors: Oral contraceptive pills, anabolic steroids, glycogen storage diseases. Symptoms: RUQ pain (if large or ruptured). Diagnosis: CT or MRI with contrast. Well-circumscribed lesion, risk of bleeding. No Tumor markers Management: Small adenomas (<5 cm): Stop OCPs and monitor. Large adenomas (>5 cm): Surgical resection due to risk of rupture and malignancy

Question 26

What are some examples of common malignant tumours?

Answer 26

(a) Hepatocellular Carcinoma (HCC) - Most Common Primary Liver Cancer (b) Cholangiocarcinoma (Bile Duct Cancer) (c) Secondary (Metastatic) Liver Cancer

Question 27

What is Hepatocellular Carcinoma (HCC)?

Answer 27

Definition: Malignant tumor of hepatocytes, often arising from cirrhosis. Risk Factors: Cirrhosis (major risk factor) – from HBV, HCV, alcohol, NAFLD. Chronic HBV infection (even without cirrhosis!). Aflatoxin exposure (from contaminated food, common in Africa/Asia). Symptoms: Early: Often asymptomatic. Late: RUQ pain, weight loss, jaundice, hepatomegaly, ascites. Diagnosis: Alpha-fetoprotein (AFP) – Tumor marker for HCC. Ultrasound (first-line for surveillance). MRI or CT (characteristic arterial enhancement with washout in venous stage). Liver biopsy (rarely needed if imaging is diagnostic). Management: Curative options (only for early-stage HCC) → Surgical resection or liver transplant. Locoregional therapy (if not surgical candidate): Radiofrequency ablation (RFA), transarterial chemoembolization (TACE). Systemic therapy for advanced disease: Sorafenib (tyrosine kinase inhibitor). Palliative care for end-stage disease.

Question 28

What is Cholangiocarcinoma?

Answer 28

Definition: Adenocarcinoma of the bile ducts, highly aggressive. Risk Factors: Primary sclerosing cholangitis (PSC, associated with ulcerative colitis). Liver flukes (Opisthorchis, Clonorchis – common in SE Asia). Biliary tract diseases (choledochal cysts, chronic biliary inflammation). Symptoms: Painless jaundice (like pancreatic cancer!). Weight loss, pruritus, RUQ pain. Courvoisier’s sign (palpable, non-tender gallbladder with jaundice). Diagnosis: Tumor markers: CA 19-9 (also seen in pancreatic cancer). Imaging: MRCP, CT, or ERCP (endoscopic biopsy possible). Biliary dilation, mass in bile ducts. Management: Surgical resection (only curative option but often not feasible due to late presentation). Palliative biliary stenting for symptom relief. Chemotherapy (e.g., gemcitabine/cisplatin) for advanced disease.

Question 29

What is Secondary (Metastatic) Liver Cancer?

Answer 29

Definition: Most common liver malignancy (more common than primary tumors!). Common Primary Sources: GI cancers (colorectal is the most common). Breast, lung, pancreas. Symptoms: Similar to HCC – RUQ pain, weight loss, hepatomegaly. Diagnosis: CT/MRI (multiple liver lesions suggest metastases). Tumor markers (CEA for colorectal, CA 19-9 for pancreas). Management: Depends on the primary tumor. Colorectal cancer with liver metastases may be treated with liver resection. Palliative chemotherapy for widespread disease.

Question 30

What are the red flags for liver cancer?

Answer 30

Unexplained weight loss Painless jaundice Sudden worsening of cirrhosis symptoms New ascites or rapidly growing liver mass