Viva - Chronic Liver Disease

Question 1

Causes of chronic liver disease

Answer 1

Alcohol

Infective - Hep B and C

Drugs - Methotrextate, Methyldopa, Amiodarone

Cholestasis - Primary biliary cirrhosis, sclerosing cholangitis

Autoimmune hepatitis

Hereditary - Wilson, Haemachromatosis, a1 deficiency

Vascular - Budd -Chiari, veno- occlusive disease

Non Alcoholic Fatty Liver Disease NAFLD

Question 2

Scoring systems in the prognostication of CLD

Answer 2

Child-Pugh Score

Model of End Stage Liver Disease (MELD)

SOFA can be used to discriminate survivors from non

UK Model for End Stage Liver Disease (UKELD) to aid selection of transplant candidate

Question 3

Waht is the Child Pugh Score

Answer 3

Scored 1-3, 5 catergories

Encephalopathy –> None, Grade 1-2, Grade 3-4
Ascites None, Mild, severe (refractory)
Bilirubin <34, 34-50, >50
Albumin >35, 28-35, less than 28
INR <1.7, 1.7.- 23, >2.3

Grade A 5-6 points
B 7-9
C 10-15

Question 4

Survival based on child pugh grades

Answer 4

A (5-6) 100% at 1 year, 85% at 2
B (7-9) 81% at 1, 57% at 2
C (10-15), 45% at 1, 35% at 2

Question 5

MELD score

Answer 5

Predicts mortality in hospitalised patients with cirrhosis

MELD, taken from bilirubin, INR, creatinine

MELD = (3.78 x ln{bili])+(11.2x ln [INR}) + 9.57 (ln creatinine) + 6.43

Question 6

Why do cirrhotic patients come to ICU

Answer 6

Management of bleeding varices
Management of coagulopathy
Alchoholic hepatitis
AKI
Severe sepsis

Question 7

What is portal hypertension

Answer 7

Portal pressure > 10mmHg and is associated with :

porto-systemic collateral venous circulation
ascites
splenomegaly

Clinical diagnosis as portal pressure can only be diagnoised directly via a TIPSS

Question 8

Main complication of portal hypertension

Answer 8

Varices leading to massive upper GI bleed

Question 9

Treatment of variceal bleed

Answer 9

ABCDE treat as found

Specific:
Volume - transfuse blood and blood products
Vasoconstrictors - terlipressin (or?somatostatin)
Endoscopy within 24 hours using variceal band ligation

Prevent complication - antibiotics

Question 10

and if you cants control bleed via OGD

Answer 10

Balloon tampanade via Sengstaken blakemore

Further endocscopy

TIPPS
Surgery

Consider TIPPS or transplant to prevent rebleeds

Question 11

What is a TIPPS

Answer 11

Transjugular Intrahepatic Portosystemic Stent Shunt

Question 12

What does a TIPPS do

Answer 12

Endovacular procedure

Makes a communication between the inflow portal vein and the outflow hepatic vein, using a stent.

Reduces portal pressure in patients with complications related to portal hypertension (bleeding, dieuretic resistant ascites)

Divert blood from hepatic vein, to reduce pressure gradient between portal and systemic circulations.

Also useful in encephalopathy to divert blood from liver

Question 13

What is HepatoRenal Syndrome

Answer 13

Type of renal failure in patients with cirrhosis or fulminant liver failure.

It is a PRE-RENAL AKI that does not respond to fluids

Abnormal autoregulation with renal vasoconstircion due to sympathetic stimulation and dilation of splanchnic vessels.

Question 14

What is the characteristic feature

Answer 14

Low fractional excretion of sodium with progressive rise in plasma creatinine in patient with CLD

Question 15

Diagnostic criteria of HRS

Answer 15

Cirrhosis with ascites
Creatinie above 133
No improvement in creatinine after 2 days of dieurteitc withdrawel and volume expansion with albumin

No shock
No nephrotoxins
No renal parenchnymal disease

Question 16

Types of HRS

Answer 16

2

Type 1- Rapidly progressive decline in kidney function with mortality > 50%

Type 2- More indolent course with dieuretic resistant ascites

Question 17

Tx options for HRS

Answer 17

Trial of terlipressin and plasma expansion with albumin

TIPPS may improve renal function

Definative - tranplant

Question 18

What is SBP

Answer 18

Ascitiv fluid infection without an evident intra-abdominal surgically treatable source

Almost always occurs in paitents with cirrhosis and ascites

Question 19

Presenting features of SBP

Answer 19

non specific

Fever, hypotension, abdo pain, altered mental status

Question 20

Fluid wcc?

Answer 20

Neutrophil greater than 250 cells/mm3 and / or positive periotoneal fluid cultures

Question 21

Treatment of SBP

Answer 21

Empriic abx and local sensitivitys

Smal study shower terlipressin improved haemodynamics

Question 22

Features of hepato-pulmonary syndrome

Answer 22

Poorly understood, with intrapulmonary shunting and hypoxia in patients with cirrhosis

Dyspnoea, hypoxia that are worse upright (platypnoea and orthodeoxia)

Poor prognosis

Indication for orthotopic liver transplant

Question 23

What is alcholic hep

Answer 23

Syndrome of progressive inflammatory liver injury with long term alcohol use.

Severe alcoholic hep –> mortality of 50% in 30 days

Question 24

How to diagnose alco hep

Answer 24

Hx of alcohol intake
Fever
worsening LFTs (inc raised bili and aminotransferases)

May not have cirrhosis

Question 25

Tx of alco hep

Answer 25

Supportive Steroid in severe cases --> reduce inflammation Transfer to tertiary centre in severe cases Pentoxyphyline reduces incidence of HRS in alco hep. Abstinance in long term

Question 26

Define chronic liver failure

Answer 26

Deterioration in hepatic synthetic and metabolic function of grater the 26 weeks duration WITHOUT ENCEPHALOPATHY

Question 27

Define acute on chronic liver failure

Answer 27

chronic liver disease who develops acute deterioration in liver function and organ dysfunction

Question 28

Systemic manifestations of CLD

Answer 28

CVS - CAD, Cardiomyopathy, Cardiac Failure Resp - Pulmonary Hypertension, fibrosis, VQ mismatch Neuro - polyneuropathy, autonomic dysfunction, encepph Endocrine _ DM, Thyroid Disease, hyper lipid Haem - anaemia, hypersplenism, neutropenia, thrombocytopenia, coagulapathy GI - portal gastropathy, varices, Panc and biliary Ca Renal - glomerularnephritis from hep virus nephropathy HRS Skin - pruritis, palmar erythema, spider naevia, porphyria curtanea tarda

Question 29

Grading of encephalopathy

Answer 29

West Haven 1 - behaviour change without change in conciousness 2- drowsiness, disorintated 3 - Rousable to voice, confused, incoherent 4 - Coma, decorticate posturing

Question 30

Scoring systems

Answer 30

MELD | Child Pugh

Question 31

Features of Child Pugh

Answer 31

``` Bilrubin Albumin Ascites INR Enceph ```

Question 32

Grades of Child pugh

Answer 32

A - 5-6 B - 7-9 C 10-15

Question 33

Life expectancy by childs score

Answer 33

A - 15-20 years B - 4 - 15 years C - 1-2 years Peri op motality rises ( 10%, 30%, 80% for laporotomy)

Question 34

Meld features

Answer 34

INR plus bilirubin plus albumin BUT Add sodium if MELD > 12

Question 35

MELD score points

Answer 35

>9 refers to transplant centre >24 consider for transplant

Question 36

What causes acute on chronic failure

Answer 36

Infection (bacterial, viral, funalg) Alcolic hep Trauma (surgery) In 40%, no cause found

Question 37

Predictors of mortality in acute on chronic

Answer 37

Age, WCC Degree of organ dysfunction

Question 38

Critical care manamagent of acute on chronic

Answer 38

Supportive ABCDE Find the precipitating cause Restore the circulating volume, maintain organ perfusion wiht vasoactives ?cardiac output monitor Early Abx Invasive fungaemia is rare --> fungal colonisers are not Albumin Adrenocortical failure is common but steroids do not improve mortality HF to remove ammonia Liver transplant - HOWEVER, no provision for emergency transplant in chronic failures