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NAFLD, autoimmune, alcohol Flashcards

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1
Q

Why does NAFLD occur

A

Fat deposit in the liver = steatosis
Unknown cause
Underlying insulin resistance?

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2
Q

How does NAFLD progress

A

Steatosis
NASH = Steatohepatitis
Fibrosis
Cirrhosis

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3
Q

Who is at risk of NAFLD

A 
Age 
Obesity
DM
Smoking
Hyperlipid / cholesterol
High BP 
Sudden weight loss / starvation 
Ethnicity
Polycystic ovaries
Hep B+C
Genetics - FH
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4
Q

Who is more at risk of progression to cirrhosis

A

Age
Obesity
DM

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5
Q

What can cause acute liver injury on top of NAFLD

A

Drugs so always review

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6
Q

What are the symptoms of NAFLD

A

Asymptomatic

May be picked up on USS or routine LFT - increased fatty hepatocytes and echogenicity

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7
Q

What must you do if diagnosed with NAFLD

A

Look for fibrosis

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8
Q

What are the symptoms of NASH

A

Aching pain
Fatigue
Weight loss
Hepatomegaly

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9
Q

Is NASH reversible

A

NO

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10
Q

What are the symptoms of cirrhosis

A 
Jaundice
HSM
- Hepatomegaly (usually small if chronic) 
- Splenomegaly due to portal HTN 
Thrombocytopenia = bruising
Weight loss
Dark urine / pale stool
Pruritus
Palmar erythema 
Spider naevi
Clubbing 
Leukonychia
Dupytren's 
Parotid gland enlargement 
Decompensated Sx
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11
Q

What is decompensatd liver function

A

Liver unable to do job

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12
Q

What are the symptoms of decompensated disease

A 
Portal hypertension
Jaundice
Ascites
Encephalopathy 
Varices
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13
Q

How do you Dx NAFLD

A

Abnormal LFT - ALT > AST (opposite in alcohol)

USS

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14
Q

What do you do if NAFLD Dx

A

Enhanced Liver Fibrosis - look for fibrosis (expensive)
NAFLD Score if ELF not available
FIB4 score if not available
Cytokeratin 18 - biomarker for NASH
Non invasive liver screen to look for cause

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15
Q

What are imaging if looks like cirrhosis on USS

A

Fibroscan if score suggest high risk
Liver biopsy - not usually needed
MRI / CT if suspect malignancy
Endoscopy for varices

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16
Q

How do you treat NAFLD

What may improve fibrosis

What for symptoms

A 
Lifestyle = mainstay 
Diet and weight
DM control
Exercise
Treat high BP and cholesterol
Avoid alcohol 
Vit E may improve fibrosis - specialist
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17
Q

When do you refer in NAFLD

A

If advanced fibrosis / cirrhosis

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18
Q

What else should you do in NAFLD

A

Look to see if any drugs worsening
Anti-coagulate in ANY liver disease
Monitor for complications

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19
Q

What do you do for hyperlipidaemia

A

Cholestryalmine
Decreased bile acid resorption so more cholesterol
Lowers LDL

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20
Q

What does fib4 look at

A

ALT
AST
Platelet
Age

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21
Q

What does NAFLD score look at

A 
Age
DM
BMI
ALT/ AST
Platelet - low
Albumin - low
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22
Q

When do you refer for fibroscan

A

When NAFLD score >3 as high risk

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23
Q

What do you do if cirrhotic

A 
HCC surveillance
Routine blood, ALP and USS every 6 months
CT if any suspicion
Endoscopy every 3 years if known varies 
MELD score 6 monthly
Manage complications
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24
Q

What grades survival in liver disease / cirrhosis

A

Child Pugh - severity of cirrhosis + predicts prognosis

MELD score - perform every 6 months in compensated cirrhosis

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25
What does Child Pugh look at
``` ABCDE Ascites Bilirubin Coagulation - PT Distension - albumin Encephalopathy ```
26
What does MELD look at
Bilirubin Creatinine INR
27
What is autoimmune hepatitis
Ab against liver | Causes deranged LFT
28
What Ab's involved
ANA - anti-nuclear LKM1 SMA - smooth muscle
29
What does autoimmune hepatitis present like
``` Acute hepatitis + signs of autoimmune Fever Jaundice Abdominal pain Fatigue Anoreixa N+V Pruritus / dark urine / pale stool ``` Features of autoimmune - Amenorrhoea = common - Loose bowel - Excessive hair - Raynaud - Sjogren - Thyroiditis
30
What else can autoimmune hepatitis present with
CLD | Decompensated
31
What are signs of autoimmune
``` Fever Malaise Rash Arthritis GN Pleurisy ```
32
Who is at risk of autimmune
``` Female Young / middle age DM / autoimmune thyroid PSC Hyper Ig ```
33
How do you Dx autoimmune hepatitis
``` History Blood - abnormal LFT Liver biopsy - lymphocyte = confirms Dx Specific Ab's Elevated IgG MRCP to exclude PSC ```
34
What are signs of hypersplenism
Anaemia Thrombocytopenia Decreased WCC
35
How do you treat autoimmune hepatitis
Prednisolone Azathioprine - immune suppression Liver transplant if cirrhosis / failure to respond to Rx
36
What are the complications of autoimmune hepatitis
Cirrhosis
37
What are associated conditions
``` DM PSC Pernicious anaemia Autoimmune thyroid GN UC Autoimmune haemolysis ```
38
What causes alcohol liver disease
Excessive use of alcohol Toxic to liver Acetadehyde builds up Fat deposited due to interruption in lipid metabolism Steatosis (Alcoholic Fatty liver) - reversible Steatohepatitis (Alcoholic Hepatitis) - becomes inflammed Cirrhosis - irreversible
39
What other factors are involved as not all heavy drinkers progress
Genetics Hep B and C / other liver conditions Malnutrition
40
What are the signs of alcoholic liver disease
``` Cirrhotic Sx Jaundice HSM Weight loss Fatigue Abdominal pain Palmar erythema Spider naevi Bruising due to loss of clotting / thrombocytopenia Dark urine / pale stool / pruritus Dupytren's Leukonychia Clubbing ``` Other Hair loss Gynaecomastia Muscle wasting Decompensated Sx
41
What does portal hypertension cause
``` Varices Ascites - oesophageal and rectal Splenomegaly Caput medusa Increased JVP Pleural effusion ```
42
How do you Dx alcoholic liver disease
``` Abnormal LFT - AST >ALT - Raised gamma TG FBC decreased as toxic to bone marrow - Macrocytosis - Thrombocytopenia U+E - may be deranged in hepatorenal Clotting - elevated PT Low albumin Elevated bilirubin in cirrhosis Liver screen to look for other cause ```
43
What imaging
USS = 1st line Fibroscan Biopsy
44
How do you treat alcoholic liver disease
No Rx Fatty liver = reversible if stop drinking Weight loss Exercise Oral thiamine if diet deficient Paprinex if in hospital (thiamine b12 +C to prevent Weirnecke) Liver transplant
45
What are complications of alcohol liver
``` Alcoholic hepatitis Cirrhosis HCC Hepato-renal syndrome Weirnecke's Pancreatitis ```
46
What are alcoholics at risk of
``` Ketoacidosis Suspect in if DKA with low glucose Don't eat + malnourished Starvation = ketones Causes acidosis, elevated anion gap, elevated ketones ```
47
How do you Rx DKA
Saline | Thiamine infusion to prevent Weirnecke's
48
How does alcoholic hepatitis present
``` Often presents on top of CLD Fever Jaundice Hepatomegaly Confusion Fatigue ABdo pain D+V Weight loss Decompensated ```
49
How do you Dx alcoholic hepatitis
Bloods - increased WCC, increased INR, AST, MCV, urea, decreased platelet ALP raised (also in HCC) USS Biopsy
50
How do you treat alcoholic hepatitis
Treat infection if any (often non-infectious) Assess confusion Treat alcohol withdrawal - benzo Paprinex Transplant Steroid but need to treat infection and GI bleed first Ascitic tap if ascites
51
When do you consider steroid in alcoholic hepatitis
Maddrey >32 (PT + bilirubin)
52
What are complications of hepatitis
Hepato-renal syndorme
53
What is Budd CHiari
Hepatic vein occlusion | Rare
54
What are the symptoms of Budd CHiair
RUQ Painful ascites Hepatomegaly May have jaundice / AKI Often on background of coagulopathy - preg / polycythaemia etc
55
How do you Dx Budd chair
USS + doppler
56
What is Gilbert
Absence of UDP glucontransferase
57
What are the symptoms of Gilbert
Unconjugated bilirubin Jaundice - often in stress / illness Urine normal No rise in LFT
58
How do you treat Gilbert
Reassurance
59
What causes ischaemic hepatitis
Hypoperfusion - AKI / MI | Leads to acute risk in ALT
60
What should you do for isolated hyperbilirubin / jaundice
FBC to see if due to haemolyiss or Gilbert

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