Hepatitis and Cirrhosis

Question 1

What is hepatitis?

Answer 1

Inflammation of the liver

Question 2

What can acute hepatitis lead to?

Answer 2

• Recover
• Chronic hepatitis
• Fulminant hepatitis

Question 3

What are the typical symptoms of acute hepatitis?

Answer 3

• Malaise
• Jaundice
• RUQ pain
• Pruritis
• Muscle and joint aches
• Fever (if viral)

Question 4

What are the severe symptoms of acute hepatitis?

Answer 4

• Confusion
• Coagulopathy
• Renal impairment

Question 5

What do blood tests typically show for acute hepatitis?

Answer 5

• Raised AST and ALT (often<1,000)
• Conjugated hyperbilirubinaemia
• Increased INR

Question 6

What do blood tests show for severe acute hepatitis?

Answer 6

• Coagulopathy

- Renal impairment

Question 7

What is chronic hepatits?

Answer 7

Low-grade inflammation of the liver >6 months

Question 8

What are the symptoms of chronic hepatitis?

Answer 8

• Often none
• Fatigue
• Vague RUQ pain

Question 9

What tests do you order for chronic hepatitis?

Answer 9

- Screening
      Alcoholics, HIV +ve, pregnant women, IV drug users
- LFTs
      Abnormal
- INR
- Albumin
- GGT
- Bilirubin
- US/CT
      Look for fatty infiltrattion

Question 10

How do you manage hepatitis?

Answer 10

Treat the causes

Question 11

What is fulminant hepatitis?

Answer 11

Liver begins to fail very quickly within days or weeks

Defined as developing Encephalopathy within 28 days of jaundice

Question 12

What is the prognosis for fulminant hepatitis?

Answer 12

Poor prognosis often needs transplantation

Question 13

What is cirrhosis?

Answer 13

• Fibrosis (scarring) of the liver leading to regenerative nodule formation
• The final state of any chronic liver disease

Question 14

What are the ‘loss of function’ symptoms of cirrhosis?

Answer 14

• Jaundice
• Coagulopathy and bruising
• Decreased drug metabolism
• Decreased hormone metabolism
• Increased sepsis

Question 15

What are the ‘portal hypertension’ symptoms of cirrhosis?

Answer 15

• Varices
• Piles
• Encephalopathy
• Renal failure
• Splenomegaly

Question 16

What causes Coagulopathy and bruising?

Answer 16

Lose ability to make clotting factors

Question 17

What causes varices?

Answer 17

• Pressure builds up and blood starts to be redirected away from the liver through anastomoses towards systemic circulation.
• Anastomosing veins such as those in the oesophagus enlarge due to high pressure
• 1st bleed + 25% mortality, subsequent bleeds = 10% mortality

Question 18

What causes ascites?

Answer 18

• Changes in renin-angiotensin axis causing salt and water retention which causes fluid to retain in the abdomen
• Fluid travels down pressure gradient into peritoneal cavity

Question 19

What causes encephalopathy?

Answer 19

• Blood is bypassing liver though varices, toxins build up in blood, which can lead to brain damage

Question 20

What causes splenomegaly?

Answer 20

• Fluid backs-up into spleen via splenic vein down the pressure gradient

Question 21

What is an acsitic tap?

Answer 21

Take small volumes of ascites for analysis

Question 22

In an ascitic tap if the serum albumin ascites gradient > 1.1 g/dL, what does it show?

Answer 22

Indicates ascites is due to portal hypertension

Question 23

In an ascitic tap if serum albumin ascites gradient < 1.1 g/dL , what does this show?

Answer 23

Indicates cause is due to peritoneal disease (exudate)

Question 24

In an ascitic tap if microscopy shows >500 which cells per mm3, what does this show?

Answer 24

Indicated spontaneous bacterial peritonitis

Question 25

What can cause cirrhosis?

Answer 25

- Alcoholism - Infection Chronic hep B and C - NASH - Autoimmune liver disease Primary biliary cholangitis - Hereditary Hemochromatosis Wilson's disease - Drug-induced Medication - amiodarone, methyldopa, methotrexate etc. Paracetamol OD

Question 26

What is primary biliary cholangitis?

Answer 26

- Progressive inflammation and fibrosis of the bile ducts in the liver. - This causes to destruction of intrahepatic bile ducts, leading to cholestatsis, cirrhosis and liver failure

Question 27

What is cholestasis?

Answer 27

The reduction or stoppage of bile flow

Question 28

What is hemochromatosis?

Answer 28

- Increased Fe absorption from GI tract, leading to chronic deposition of iron in the tissues - In the liver, iron-associated lipid peroxidation ("steal" electrons from the lipids in cell membranes, resulting in cell damage) induces hepatocyte apoptosis causing liver fibrosis

Question 29

What are the signs of cirrhosis?

Answer 29

- Leukonychia (white nails) - Palmar erythema - Spider naevi - Polished nails - Bruising - Finger clubbing - Jaundiced sclera - Caput medusa - Abdominal distention Flanks - Splenomegaly - Gynaecomastia - Wilson's disease - Chronic obstruction - Non-palpable liver

Question 30

What are palmar erythma, spider nasevi and gynaecomastia caused by?

Answer 30

Liver cannot breakdown oestrogen, so there is excess in the blood causing increased vascularity

Question 31

What blood test would you order for cirrhosis and what do they show?

Answer 31

``` - FBC Raised MCV - LFTs Raised ALT and AST Raised GGT Raised ALP Raised bilirubin Low albumin - Clotting Increased INR ```

Question 32

What investigations would you order for cirrhosis and what would they potentially show?

Answer 32

``` - Ultrasound Fatty changes - Fibroscan Elasticity of liver - Endoscopy Oesophageal varices - CT/MRI Fatty changes Hepatocellular carcinoma Hepatosplenomegaly Abnormal blood vessel changes Ascites - Liver biopsy ```

Question 33

What is the difference between compensated and decompensated liver cirrhosis?

Answer 33

- Compensated = asymptomatic stage | - Decompensated = presence or development of overt complications

Question 34

What may precipitate decompensated liver cirrhosis?

Answer 34

- Infection - Alcoholic binge - GI bleed - Hypoglycaemia

Question 35

What is the management of liver cirrhosis?

Answer 35

- Good nutrition - Alcohol abstinence - Avoid: NSAIDs, opiates and sedatives - Ultrasound and alpha-fetoprotein every 6 months Check for hepatocellular carcinoma

Question 36

What is liver failure?

Answer 36

The development of coagulopathy (INR>1.5) and encephalopathy

Question 37

What are the stages of alcoholic liver disease?

Answer 37

1. Hepatic steatosis (fatty liver) 2. Alcoholic hepatitis 3. Cirrhosis

Question 38

What is the treatment for alcoholic liver disease?

Answer 38

- Alcohol abstinence - Treat complications Before coticosteroids - Corticosteroids - Referral for liver transplant in severe disease MUST abstain from alcohol for 3 months