Podcast
Questions and Answers
What characterizes chronic liver disease compared to acute liver injury?
What characterizes chronic liver disease compared to acute liver injury?
- Shorter duration than six months
- Complete recovery is typically expected
- More rapid onset of symptoms
- Progressive deterioration of liver function for over six months (correct)
Which of the following is a known cause of chronic liver disease?
Which of the following is a known cause of chronic liver disease?
- Hepatitis A
- Ischaemic hepatitis
- Paracetamol overdose
- Fatty liver disease (correct)
What process leads to cirrhosis in chronic liver disease?
What process leads to cirrhosis in chronic liver disease?
- Increased bile production
- Acute liver injury
- Chronic inflammation and fibrosis (correct)
- Rapid cell division
Which symptom is NOT typically associated with chronic liver disease?
Which symptom is NOT typically associated with chronic liver disease?
How can chronic liver disease potentially be reversed in its early stages?
How can chronic liver disease potentially be reversed in its early stages?
Which of the following liver diseases can progress from acute to chronic?
Which of the following liver diseases can progress from acute to chronic?
What is the primary focus of investigations in chronic liver disease?
What is the primary focus of investigations in chronic liver disease?
What role does fibrosis play in chronic liver disease?
What role does fibrosis play in chronic liver disease?
What marks the transition point to irreversible fibrosis in liver disease?
What marks the transition point to irreversible fibrosis in liver disease?
Which complication is most commonly associated with cirrhosis?
Which complication is most commonly associated with cirrhosis?
How does portal hypertension affect the hepatic sinusoids?
How does portal hypertension affect the hepatic sinusoids?
Activation of hepatic stellate cells in response to liver injury leads to what change?
Activation of hepatic stellate cells in response to liver injury leads to what change?
Which of the following factors leads to an increase in blood volume in the portal system during portal hypertension?
Which of the following factors leads to an increase in blood volume in the portal system during portal hypertension?
What is the main consequence of the liver's failure to synthesize coagulation factors?
What is the main consequence of the liver's failure to synthesize coagulation factors?
Which of the following describes a significant sign of hepatic encephalopathy?
Which of the following describes a significant sign of hepatic encephalopathy?
What results from the increased resistance to blood flow in the portal circulation during cirrhosis?
What results from the increased resistance to blood flow in the portal circulation during cirrhosis?
Which symptom is indicative of jaundice in a patient with cirrhosis?
Which symptom is indicative of jaundice in a patient with cirrhosis?
What is a potential effect on hormone metabolism in a failing liver?
What is a potential effect on hormone metabolism in a failing liver?
What is the appropriate treatment to address confusion in a patient with chronic liver disease?
What is the appropriate treatment to address confusion in a patient with chronic liver disease?
Why is Lorazepam not suitable for managing confusion in patients with liver disease?
Why is Lorazepam not suitable for managing confusion in patients with liver disease?
Which of the following statements about prednisolone therapy is accurate?
Which of the following statements about prednisolone therapy is accurate?
What is a common side effect of prolonged steroid use like prednisolone?
What is a common side effect of prolonged steroid use like prednisolone?
What condition does lactulose primarily treat in patients with liver disease?
What condition does lactulose primarily treat in patients with liver disease?
What is a concern for patients receiving long-term steroid therapy?
What is a concern for patients receiving long-term steroid therapy?
What is an inappropriate use of Senna in patients with liver disease?
What is an inappropriate use of Senna in patients with liver disease?
What monitoring should be considered for patients on prolonged steroid treatment?
What monitoring should be considered for patients on prolonged steroid treatment?
What neurological symptoms are part of the clinical triad associated with Wernicke's encephalopathy?
What neurological symptoms are part of the clinical triad associated with Wernicke's encephalopathy?
Which treatment is primarily used for managing Wernicke's encephalopathy and Korsakoff Psychosis?
Which treatment is primarily used for managing Wernicke's encephalopathy and Korsakoff Psychosis?
What is the main risk associated with Hepatitis C infections?
What is the main risk associated with Hepatitis C infections?
Which of the following statements is true regarding Hepatitis B?
Which of the following statements is true regarding Hepatitis B?
What symptom can indicate haemochromatosis along with chronic iron overload?
What symptom can indicate haemochromatosis along with chronic iron overload?
What is the primary method used for the management of hereditary haemochromatosis?
What is the primary method used for the management of hereditary haemochromatosis?
Which of the following is a characteristic of Wilson's disease?
Which of the following is a characteristic of Wilson's disease?
What is the common treatment for patients diagnosed with Wilson's disease?
What is the common treatment for patients diagnosed with Wilson's disease?
Primary biliary cholangitis is predominantly found in which demographic?
Primary biliary cholangitis is predominantly found in which demographic?
What laboratory findings are typically associated with primary biliary cholangitis?
What laboratory findings are typically associated with primary biliary cholangitis?
What factor can delay the onset of hereditary haemochromatosis symptoms in women?
What factor can delay the onset of hereditary haemochromatosis symptoms in women?
Which condition is characterized by a T-lymphocyte-mediated attack on bile ducts?
Which condition is characterized by a T-lymphocyte-mediated attack on bile ducts?
What is a common misconception regarding Hepatitis C?
What is a common misconception regarding Hepatitis C?
What is the function of D-penicillamine in Wilson's disease treatment?
What is the function of D-penicillamine in Wilson's disease treatment?
What is the primary cause of confusion in patients with liver disease such as Alcohol-Related Liver Disease?
What is the primary cause of confusion in patients with liver disease such as Alcohol-Related Liver Disease?
Which symptom is caused by excess bilirubin deposition in the skin?
Which symptom is caused by excess bilirubin deposition in the skin?
What condition leads to ascites in chronic liver disease patients?
What condition leads to ascites in chronic liver disease patients?
Which of the following best describes the metabolic syndrome associated with steatotic liver disease?
Which of the following best describes the metabolic syndrome associated with steatotic liver disease?
What is the significant role of thiamine deficiency in alcohol withdrawal?
What is the significant role of thiamine deficiency in alcohol withdrawal?
What is the primary diagnostic feature to differentiate MASLD from other liver diseases?
What is the primary diagnostic feature to differentiate MASLD from other liver diseases?
Which lab finding is typically seen in cases of alcohol-related liver disease?
Which lab finding is typically seen in cases of alcohol-related liver disease?
What is a common cause of jaundice in chronic liver disease?
What is a common cause of jaundice in chronic liver disease?
Which lifestyle change is most recommended for managing chronic liver disease associated with metabolic dysfunction?
Which lifestyle change is most recommended for managing chronic liver disease associated with metabolic dysfunction?
What type of liver disease is associated with the consumption of high saturated calorie fats?
What type of liver disease is associated with the consumption of high saturated calorie fats?
Which condition is a common extra-hepatic manifestation of alcohol-related liver disease?
Which condition is a common extra-hepatic manifestation of alcohol-related liver disease?
Which symptom is primarily associated with portal hypertension?
Which symptom is primarily associated with portal hypertension?
What condition results from hepatic encephalopathy in liver disease patients?
What condition results from hepatic encephalopathy in liver disease patients?
Which statement is true regarding the diagnosis of Non-Alcoholic Fatty Liver Disease (NAFLD)?
Which statement is true regarding the diagnosis of Non-Alcoholic Fatty Liver Disease (NAFLD)?
What is the potential risk associated with chronic alcohol use on brain function?
What is the potential risk associated with chronic alcohol use on brain function?
What is a hallmark histological finding in autoimmune hepatitis?
What is a hallmark histological finding in autoimmune hepatitis?
Which liver function test pattern indicates hepatocellular damage?
Which liver function test pattern indicates hepatocellular damage?
What is a critical diagnostic criterion for alcoholic liver disease?
What is a critical diagnostic criterion for alcoholic liver disease?
Which treatment is considered first-line for autoimmune hepatitis?
Which treatment is considered first-line for autoimmune hepatitis?
What imaging study is most appropriate to evaluate liver morphology for possible cirrhosis?
What imaging study is most appropriate to evaluate liver morphology for possible cirrhosis?
Which condition is characterized by interface hepatitis with lymphocytic infiltration?
Which condition is characterized by interface hepatitis with lymphocytic infiltration?
What does the MELD score predict?
What does the MELD score predict?
Which sign is noted in a physical examination of a patient with chronic liver disease?
Which sign is noted in a physical examination of a patient with chronic liver disease?
What defines a liver biopsy as the 'gold standard' investigation?
What defines a liver biopsy as the 'gold standard' investigation?
What is a common cause of hypergammaglobulinemia in autoimmune hepatitis?
What is a common cause of hypergammaglobulinemia in autoimmune hepatitis?
In diagnosing chronic liver disease, which blood test would most likely be abnormal?
In diagnosing chronic liver disease, which blood test would most likely be abnormal?
What is the purpose of paracentesis in liver disease management?
What is the purpose of paracentesis in liver disease management?
What management strategy is crucial for a patient experiencing variceal hemorrhage?
What management strategy is crucial for a patient experiencing variceal hemorrhage?
Which feature indicates cholestatic liver damage?
Which feature indicates cholestatic liver damage?
What is the primary characteristic of Chronic Liver Disease (CLD)?
What is the primary characteristic of Chronic Liver Disease (CLD)?
Which of the following liver diseases is specifically known to present acutely?
Which of the following liver diseases is specifically known to present acutely?
Which condition is classified under Chronic Alcohol Related Liver Disease (ALD)?
Which condition is classified under Chronic Alcohol Related Liver Disease (ALD)?
Haemochromatosis is an example of a liver disease that can present in which manner?
Haemochromatosis is an example of a liver disease that can present in which manner?
Which of the following is a common cause of Acute Liver Injury?
Which of the following is a common cause of Acute Liver Injury?
Which of the following can progress from an acute to a chronic state?
Which of the following can progress from an acute to a chronic state?
What is fibrosis in the context of liver disease?
What is fibrosis in the context of liver disease?
Which of the following statements about fibrosis is true?
Which of the following statements about fibrosis is true?
What is cirrhosis?
What is cirrhosis?
Which of the following features is associated with cirrhosis?
Which of the following features is associated with cirrhosis?
What is the significance of neo-angiogenesis in cirrhosis?
What is the significance of neo-angiogenesis in cirrhosis?
Which statement best describes the transition from reversible fibrosis to irreversible fibrosis?
Which statement best describes the transition from reversible fibrosis to irreversible fibrosis?
Which of the following best describes the extracellular matrix (ECM) in chronic liver disease?
Which of the following best describes the extracellular matrix (ECM) in chronic liver disease?
Which cells initiate the injury pathway in the liver?
Which cells initiate the injury pathway in the liver?
Where are hepatic stellate cells (HSCs) typically located?
Where are hepatic stellate cells (HSCs) typically located?
What is the primary function of quiescent hepatic stellate cells?
What is the primary function of quiescent hepatic stellate cells?
What occurs in hepatic stellate cells (HSCs) in response to liver injury?
What occurs in hepatic stellate cells (HSCs) in response to liver injury?
What is a significant consequence of the pro-inflammatory phase in liver injury?
What is a significant consequence of the pro-inflammatory phase in liver injury?
What percentage of cardiac output does the liver receive?
What percentage of cardiac output does the liver receive?
What is the primary function of hepatic sinusoids?
What is the primary function of hepatic sinusoids?
In cirrhosis, what do sinusoidal endothelial cells (SECs) produce that leads to vasoconstriction?
In cirrhosis, what do sinusoidal endothelial cells (SECs) produce that leads to vasoconstriction?
What is the result of increased production of nitric oxide (NO) and endothelin-1 (ET-1) in cirrhosis?
What is the result of increased production of nitric oxide (NO) and endothelin-1 (ET-1) in cirrhosis?
What term describes the increased pressure in the portal vein?
What term describes the increased pressure in the portal vein?
How does portal hypertension affect the splanchnic circulation?
How does portal hypertension affect the splanchnic circulation?
Activation of which system is a compensatory response to portal hypertension?
Activation of which system is a compensatory response to portal hypertension?
What is a consequence of activating the renin-angiotensin-aldosterone system (RAAS) in the context of portal hypertension?
What is a consequence of activating the renin-angiotensin-aldosterone system (RAAS) in the context of portal hypertension?
What range of cardiac output does the liver receive?
What range of cardiac output does the liver receive?
What is portal hypertension primarily caused by in the context of cirrhosis?
What is portal hypertension primarily caused by in the context of cirrhosis?
What happens to blood pressure when resistance to blood flow increases in the portal circulation?
What happens to blood pressure when resistance to blood flow increases in the portal circulation?
What condition may develop due to pressure backing up into the gastro-oesophageal veins?
What condition may develop due to pressure backing up into the gastro-oesophageal veins?
What is the clinical consequence of splenic vein hypertension due to portal hypertension?
What is the clinical consequence of splenic vein hypertension due to portal hypertension?
Which condition is characterized by distended veins around the umbilicus due to portal hypertension?
Which condition is characterized by distended veins around the umbilicus due to portal hypertension?
What is a potential risk associated with oesophageal or gastric varices in the context of portal hypertension?
What is a potential risk associated with oesophageal or gastric varices in the context of portal hypertension?
Which of the following proteins is primarily synthesized by the liver and is crucial for maintaining oncotic pressure?
Which of the following proteins is primarily synthesized by the liver and is crucial for maintaining oncotic pressure?
What is the primary role of thrombopoietin, a protein produced by the liver?
What is the primary role of thrombopoietin, a protein produced by the liver?
Which substance is involved in the detoxification of endogenous nitrogenous compounds by the liver?
Which substance is involved in the detoxification of endogenous nitrogenous compounds by the liver?
What is the role of caeruloplasmin in the liver?
What is the role of caeruloplasmin in the liver?
What characterizes the acute deterioration of liver function in a patient with cirrhosis?
What characterizes the acute deterioration of liver function in a patient with cirrhosis?
Which of the following is the most common complication of cirrhosis?
Which of the following is the most common complication of cirrhosis?
What is the underlying cause of jaundice in patients with decompensated cirrhosis?
What is the underlying cause of jaundice in patients with decompensated cirrhosis?
What neurological condition is associated with hepatic encephalopathy in cirrhosis?
What neurological condition is associated with hepatic encephalopathy in cirrhosis?
Which complication of cirrhosis is primarily due to portal hypertension?
Which complication of cirrhosis is primarily due to portal hypertension?
Which of the following describes the term 'decompensation' in the context of liver cirrhosis?
Which of the following describes the term 'decompensation' in the context of liver cirrhosis?
What is the main reason patients with decompensated cirrhosis are at high risk of in-hospital death?
What is the main reason patients with decompensated cirrhosis are at high risk of in-hospital death?
What is the mechanism thought to contribute to hepatic encephalopathy?
What is the mechanism thought to contribute to hepatic encephalopathy?
What is the recently renamed term for Non-Alcoholic Fatty Liver Disease (NAFLD)?
What is the recently renamed term for Non-Alcoholic Fatty Liver Disease (NAFLD)?
Which condition is the most common cause of chronic liver disease in the Western world?
Which condition is the most common cause of chronic liver disease in the Western world?
Which type of liver disease is most strongly associated with diabetes?
Which type of liver disease is most strongly associated with diabetes?
What is a major cause of liver disease and a leading cause of liver-related mortality?
What is a major cause of liver disease and a leading cause of liver-related mortality?
Which viral hepatitis can have a chronic course and potentially lead to cirrhosis?
Which viral hepatitis can have a chronic course and potentially lead to cirrhosis?
Which of the following is classified as an autoimmune liver disease?
Which of the following is classified as an autoimmune liver disease?
Which condition is characterized by copper accumulation in the liver?
Which condition is characterized by copper accumulation in the liver?
What is the primary defect in Alpha-1 Antitrypsin Deficiency?
What is the primary defect in Alpha-1 Antitrypsin Deficiency?
Which autoimmune condition is characterized by the destruction of bile ducts?
Which autoimmune condition is characterized by the destruction of bile ducts?
What is the most common cause of chronic liver disease in Ireland and the Western World?
What is the most common cause of chronic liver disease in Ireland and the Western World?
Which of the following conditions is part of the metabolic syndrome associated with MASLD?
Which of the following conditions is part of the metabolic syndrome associated with MASLD?
Which of the following is NOT associated with Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD)?
Which of the following is NOT associated with Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD)?
Which of the following is a key component in the diagnosis of MASLD?
Which of the following is a key component in the diagnosis of MASLD?
Which of the following is the primary treatment for Metabolic Dysfunction-Associated Steatotic Liver Disease?
Which of the following is the primary treatment for Metabolic Dysfunction-Associated Steatotic Liver Disease?
Which of the following medications is increasingly used for managing MASLD?
Which of the following medications is increasingly used for managing MASLD?
Which of the following is the primary enzyme responsible for ethanol metabolism in hepatocytes?
Which of the following is the primary enzyme responsible for ethanol metabolism in hepatocytes?
Which of the following complications is commonly associated with chronic alcohol use and cerebellar damage?
Which of the following complications is commonly associated with chronic alcohol use and cerebellar damage?
What is the primary toxic byproduct of ethanol metabolism that contributes to liver injury in alcohol-related liver disease?
What is the primary toxic byproduct of ethanol metabolism that contributes to liver injury in alcohol-related liver disease?
Which of the following is a key neurological complication associated with thiamine deficiency in chronic alcoholics?
Which of the following is a key neurological complication associated with thiamine deficiency in chronic alcoholics?
What complication is associated with abrupt alcohol withdrawal and changes to neurotransmitter channels?
What complication is associated with abrupt alcohol withdrawal and changes to neurotransmitter channels?
Which vitamin deficiency is most commonly associated with alcohol use disorder and can lead to Wernicke-Korsakoff syndrome?
Which vitamin deficiency is most commonly associated with alcohol use disorder and can lead to Wernicke-Korsakoff syndrome?
What is the classic triad of symptoms seen in Wernicke's encephalopathy?
What is the classic triad of symptoms seen in Wernicke's encephalopathy?
Korsakoff psychosis, the chronic phase of Wernicke-Korsakoff syndrome, is primarily characterized by which of the following?
Korsakoff psychosis, the chronic phase of Wernicke-Korsakoff syndrome, is primarily characterized by which of the following?
What is the mainstay of treatment for Wernicke's encephalopathy in patients with alcohol use disorder?
What is the mainstay of treatment for Wernicke's encephalopathy in patients with alcohol use disorder?
In alcohol withdrawal, what role does thiamine (Vitamin B1) play in cerebral metabolism?
In alcohol withdrawal, what role does thiamine (Vitamin B1) play in cerebral metabolism?
Which brain structure is most affected by thiamine deficiency, classically seen in Wernicke-Korsakoff syndrome?
Which brain structure is most affected by thiamine deficiency, classically seen in Wernicke-Korsakoff syndrome?
Which of the following is NOT a typical manifestation of Korsakoff psychosis?
Which of the following is NOT a typical manifestation of Korsakoff psychosis?
What is the genetic mutation most commonly responsible for hereditary haemochromatosis (HH)?
What is the genetic mutation most commonly responsible for hereditary haemochromatosis (HH)?
Which of the following is NOT a common organ affected by iron accumulation in hereditary hemochromatosis?
Which of the following is NOT a common organ affected by iron accumulation in hereditary hemochromatosis?
What is the first-line treatment for hereditary hemochromatosis?
What is the first-line treatment for hereditary hemochromatosis?
In Wilson's disease, which organ shows Kayser-Fleischer rings, a diagnostic feature of copper deposition?
In Wilson's disease, which organ shows Kayser-Fleischer rings, a diagnostic feature of copper deposition?
What is the most commonly used medication to promote copper excretion in Wilson's disease?
What is the most commonly used medication to promote copper excretion in Wilson's disease?
Which of the following is a key distinguishing feature of Wilson's disease in neurological presentations?
Which of the following is a key distinguishing feature of Wilson's disease in neurological presentations?
In Wilson's disease, which lab finding would you expect?
In Wilson's disease, which lab finding would you expect?
What is the key distinguishing factor between Wernicke's encephalopathy and Wilson's disease when considering neurological symptoms?
What is the key distinguishing factor between Wernicke's encephalopathy and Wilson's disease when considering neurological symptoms?
What is the hallmark diagnostic antibody for Primary Biliary Cholangitis (PBC)? A) Anti-Smooth Muscle Antibody (SMA) B) Antimitochondrial Antibody (AMA) C) Anti-Liver-Kidney Microsomal Antibody (Anti-LKM) D) Anti-Nuclear Antibody (ANA)
What is the hallmark diagnostic antibody for Primary Biliary Cholangitis (PBC)? A) Anti-Smooth Muscle Antibody (SMA) B) Antimitochondrial Antibody (AMA) C) Anti-Liver-Kidney Microsomal Antibody (Anti-LKM) D) Anti-Nuclear Antibody (ANA)
Which liver enzyme is typically elevated in cholestatic liver diseases like PBC and PSC?
Which liver enzyme is typically elevated in cholestatic liver diseases like PBC and PSC?
Which of the following conditions is most frequently associated with Primary Sclerosing Cholangitis (PSC)?
Which of the following conditions is most frequently associated with Primary Sclerosing Cholangitis (PSC)?
Which imaging modality is typically used to diagnose Primary Sclerosing Cholangitis (PSC) by revealing the characteristic 'beaded' appearance of the bile ducts?
Which imaging modality is typically used to diagnose Primary Sclerosing Cholangitis (PSC) by revealing the characteristic 'beaded' appearance of the bile ducts?
Which of the following is a characteristic feature of Autoimmune Hepatitis on liver biopsy?
Which of the following is a characteristic feature of Autoimmune Hepatitis on liver biopsy?
What is the first-line treatment for Primary Biliary Cholangitis (PBC)?
What is the first-line treatment for Primary Biliary Cholangitis (PBC)?
Which of the following autoimmune liver diseases has a strong association with xanthomas and xanthelasma due to raised cholesterol?
Which of the following autoimmune liver diseases has a strong association with xanthomas and xanthelasma due to raised cholesterol?
Which autoantibodies are commonly positive in Autoimmune Hepatitis (AIH)?
Which autoantibodies are commonly positive in Autoimmune Hepatitis (AIH)?
What is a major long-term complication of Primary Sclerosing Cholangitis (PSC)?
What is a major long-term complication of Primary Sclerosing Cholangitis (PSC)?
What is the main method for diagnosing Autoimmune Hepatitis (AIH)?
What is the main method for diagnosing Autoimmune Hepatitis (AIH)?
What demographic is most commonly affected by chronic inflammatory liver disease?
What demographic is most commonly affected by chronic inflammatory liver disease?
Which symptom is least likely to present in a patient with chronic inflammatory liver disease?
Which symptom is least likely to present in a patient with chronic inflammatory liver disease?
What radiological feature is characteristic of primary sclerosing cholangitis?
What radiological feature is characteristic of primary sclerosing cholangitis?
What is a common risk associated with chronic inflammatory liver disease?
What is a common risk associated with chronic inflammatory liver disease?
What is a common clinical feature of chronic inflammatory liver disease?
What is a common clinical feature of chronic inflammatory liver disease?
Which liver enzyme elevation indicates hepatocyte damage?
Which liver enzyme elevation indicates hepatocyte damage?
What is the major component assessed in the CHILD-PUGH score?
What is the major component assessed in the CHILD-PUGH score?
Which test is considered the gold standard for assessing liver fibrosis?
Which test is considered the gold standard for assessing liver fibrosis?
An AST to ALT ratio greater than 2:1 typically indicates what condition?
An AST to ALT ratio greater than 2:1 typically indicates what condition?
Which imaging technique is best suited for evaluating the biliary tree?
Which imaging technique is best suited for evaluating the biliary tree?
What laboratory finding is most indicative of chronic liver disease regarding synthetic function?
What laboratory finding is most indicative of chronic liver disease regarding synthetic function?
What is the primary role of serum A1AT in liver evaluations?
What is the primary role of serum A1AT in liver evaluations?
What does a raised level of alkaline phosphatase (ALP) primarily indicate?
What does a raised level of alkaline phosphatase (ALP) primarily indicate?
Which medication is primarily used to lower ammonia levels in patients with hepatic encephalopathy?
Which medication is primarily used to lower ammonia levels in patients with hepatic encephalopathy?
What is the recommended target hemoglobin level during resuscitation in cases of variceal hemorrhage?
What is the recommended target hemoglobin level during resuscitation in cases of variceal hemorrhage?
In chronic liver disease, what is a significant role of beta blockers in patient management?
In chronic liver disease, what is a significant role of beta blockers in patient management?
Which sign on a physical examination would be indicative of portal hypertension?
Which sign on a physical examination would be indicative of portal hypertension?
Among the following, which is NOT a pharmacological treatment for portal hypertension?
Among the following, which is NOT a pharmacological treatment for portal hypertension?
What is the primary role of lactulose in the management of hepatic encephalopathy?
What is the primary role of lactulose in the management of hepatic encephalopathy?
Which of the following complications is most concerning with each episode of variceal hemorrhage?
Which of the following complications is most concerning with each episode of variceal hemorrhage?
For a patient receiving long-term prednisolone therapy, which precaution should be emphasized?
For a patient receiving long-term prednisolone therapy, which precaution should be emphasized?
Which of the following represents an inappropriate treatment in the context of hepatic encephalopathy management?
Which of the following represents an inappropriate treatment in the context of hepatic encephalopathy management?
What is a potential benefit of early involvement in palliative care for chronic liver disease patients?
What is a potential benefit of early involvement in palliative care for chronic liver disease patients?
Study Notes
Chronic Liver Disease (CLD) and Cirrhosis
- CLD is a progressive deterioration of liver function lasting more than six months.
- Cirrhosis is the final stage of CLD, leading to irreversible liver damage and disruption of its architecture.
- CLD and Cirrhosis can be caused by alcohol, viral hepatitis, metabolic dysfunction, genetic disorders, and autoimmune diseases.
Pathophysiology of CLD
- Hepatic stellate cells (HSCs), normally dormant, activate in response to liver injury.
- Activated HSCs transform into fibroblasts and produce extracellular matrix (ECM), leading to fibrosis.
- Fibrosis is the deposition of ECM in response to chronic liver injury.
- Fibrosis in the initial stage might be reversible.
- Portal hypertension occurs due to increased resistance to blood flow within the portal circulation.
- Portal hypertension leads to an increase in nitric oxide (NO) and endothelin-1 (ET-1) production, causing blood vessel constriction and high pressure in the liver vascular bed.
- The liver receives 25% of the cardiac output.
Clinical Features of CLD
- Fatigue and weakness are common due to malnutrition, inflammation, and poor diet.
- Nausea and vomiting are common due to poor gastric emptying and ascites.
- Jaundice (yellowing of the skin) is due to the accumulation of bilirubin.
- Ascites (accumulation of fluid in the abdomen) is due to portal hypertension, reduced oncotic pressure, and fluid retention.
- Hepatic encephalopathy is a range of neurological symptoms thought to be caused by a build-up of toxins.
- Variceal hemorrhage is a life-threatening complication of portal hypertension where esophageal varices rupture.
Causes of Chronic Liver Disease
Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD)
- It is the leading cause of chronic liver disease in Ireland and the Western world.
- Steatosis refers to the accumulation of lipid droplets within hepatocytes.
- MASLD can be caused by a combination of factors like insulin resistance, central obesity, hypertension, and hyperlipidaemia.
- Lifestyle modifications, including diet, exercise, and weight loss, are crucial for managing MASLD.
Alcohol-Related Liver Disease (ALD)
- Ethanol is metabolized by alcohol dehydrogenase (ADH) in hepatocytes, creating acetaldehyde, a highly reactive and toxic compound.
- Chronic alcohol use can lead to cerebellar dysfunction, peripheral neuropathy, pancreatitis, and cardiomyopathy.
- Diagnosis of ALD includes documentation of alcohol consumption, clinical or biochemical features of liver injury, and a specific LFT pattern.
Viral Hepatitis
- Hepatitis A (HAV) and E (HEV) are usually acute, while Hepatitis B (HBV) and C (HCV) can become chronic.
- Hepatitis B can be prevented through vaccination.
- Hepatitis C is curable with direct-acting antivirals.
- Hepatitis B is managed by viral suppression with nucleoside analogues.
Haemochromatosis
- It is an autosomal recessive disorder where excessive iron is absorbed via the intestine, leading to total-body iron overload.
- This disorder can lead to cirrhosis, cardiomyopathy, diabetes, pituitary hypogonadism, arthritis, and osteoporosis.
- Symptoms include fatigue, erectile dysfunction, bronze skin hyperpigmentation.
- Treatment involves venesection and iron chelators.
Wilson's Disease
- It is an autosomal recessive disorder of copper metabolism due to ATP7B mutations.
- Impairment of biliary copper excretion leads to copper accumulation, most notably in the liver, brain, and cornea.
- Symptoms include Kayser-Fleischer rings around the cornea, cirrhosis, and neurological symptoms.
- Treatment focuses on promoting copper excretion and interfering with copper uptake from the digestive tract.
Primary Biliary Cholangitis (PBC)
- It is an autoimmune liver disease characterized by T-lymphocyte-mediated attack on small bile ducts, leading to their destruction and cholestasis.
- Associated conditions include Sjogren's syndrome, autoimmune thyroid disease, rheumatoid arthritis, and celiac disease.
- Symptoms include fatigue, pruritis, and signs of CLD.
- It is a progressive disease that can lead to end-stage liver disease.
Autoimmune Hepatitis (AIH)
- It is a clinical diagnosis based on exclusion of other CLD causes, hypergammaglobulinaemia, hepatocellular LFT pattern, positive autoantibodies, and specific liver biopsy findings.
- AIH responds well to corticosteroids and immunosuppressants like azathioprine or mycophenolate mofetil.
Liver Function Tests (LFTs)
- Liver enzymes (ALT, AST, ALP, GGT) indicate damage to different parts of the liver.
- Liver function tests measure bilirubin, albumin, prothrombin time, and platelets.
- Raised ALT/AST: indicate hepatocyte damage.
- Raised GGT/ALP: indicate biliary tree injury.
- Raised bilirubin: visible jaundice when levels exceed 50.
- Alcohol-associated hepatitis: AST>ALT ratio is >2:1.
Investigations - Bloods
- Coagulation profile: Raised INR and reduced coagulation factor production indicate impaired liver synthetic function.
- Albumin: Reduced levels indicate impaired synthetic function.
- FBC:
- Anaemia may be present.
- Thrombocytopenia (low platelets) may be present.
- Viral Hepatitis Screen: Identifies exposure to Hep A, B, C, EBV, CMV, VZV, HIV, and VDRL.
- Autoantibody screen:
- ANA, SMA, Anti-LKM: used to diagnose Autoimmune Hepatitis (AIH).
- Anti Smooth muscle Ab: used to diagnose Primary Sclerosing Cholangitis (PSC).
- AMA: Anti Mitochondrial Ab: used to diagnose Primary Biliary Cholangitis (PBC).
- Iron studies and ferritin:
- Raised Ferritin and T sat %; HFE genotype are suggestive of Haemochromatosis.
- Caeruloplasmin and serum copper: Reduced levels may indicate Wilson's Disease.
- Serum A1AT Level: Reduced levels may indicate Alpha 1 Antitrypsin Deficiency.
Investigations - Imaging
- Liver Ultrasound: Evaluates the liver morphology for nodularity or coarse texture of cirrhosis, ascites, hepatomegaly/splenomegaly, and HCC.
- CT/MRI Liver/MRCP: Provides high-quality images to further evaluate liver tumours, morphology, and the biliary tree to investigate PSC/PBC.
- OGD: To screen for or monitor oesophageal varices.
Special Tests
- Liver elastography (Fibroscan): Can quantify hepatic steatosis and fibrosis.
- Liver Biopsy: Gold standard investigation for liver disease, but invasive and may not always be required.
Scoring Systems in Cirrhosis
- CHILD-PUGH SCORE: Estimates cirrhosis mortality and classifies patients as A, B, or C based on total bilirubin, albumin, INR, ascites, and hepatic encephalopathy.
- MELD (Mayo End-Stage Liver Disease): Predicts 3-month mortality among cirrhotic patients listed for liver transplantation by measuring serum bilirubin, serum creatinine, and INR.
Management
- Prevention:
- Alcohol cessation.
- Avoid hepatotoxic medications (paracetamol, NSAIDs, opiates).
- Weight loss and diet management.
- Optimisation of DM for hepatic steatosis.
- Hep A and B vaccination.
- Pharmacological:
- Alcohol cessation pharmacotherapy.
- GLP1 analogues for metabolic syndrome.
- Beta Blockers for portal hypertension/varices.
- Lactulose for encephalopathy (increases bacterial uptake of ammonia).
- Rifaxamin for encephalopathy.
- Diuretics and low salt diet for ascites and oedema management.
- Procedures:
- Paracentesis to exclude SBP and to drain ascitic fluid.
- OGD banding of varices.
- Trans-jugular Intrahepatic Portosystemic Shunt.
- Surgical: Liver transplant is the definitive management.
- MDT: Involves dietician, physiotherapy, and pharmacy.
- Palliative care: Can be involved early for symptom optimisation and advanced care planning.
Medical Emergency: Variceal Haemorrhage
- Rupture of oesophageal varices.
- Overall mortality per episode is approximately 15-25% at six weeks.
- Sengstaken-Blakemore Tube: A balloon tamponade inserted into the oesophagus to manually apply pressure to the bleeding vessel. Used in rare cases of unstable, uncontrolled haemorrhage when endoscopy is not possible.
- Resuscitation: ABCs, IV fluids, blood transfusion aiming for Hb 7-9g/dL.
- Pharmacological Management:
- Terlipressin.
- Antibiotic prophylaxis (Ceftriaxone). -Source Control:
- Endoscopy.
- Band ligation.
- Sengstaken-Blakemore Tube (if necessary).
-Long-term:
- Prophylaxis: Non-cardioselective beta-blockers: propranolol.
Case Presentation - Planning Management
- Case 1: A 65-year-old gentleman with a history of haemochromatosis and chronic liver disease presents to the emergency department with acute confusion and behavioural disturbance. Physical examination reveals asterixis, distended abdomen with shifting dullness, and caput medusae.
- Answer: Lactulose is an appropriate treatment for this gentleman's confusion, as it lowers ammonia levels and is indicated in the treatment of hepatic encephalopathy. Aim for 3 bowel motions per day.
- Additional information: Rifaximin is also indicated in addition to lactulose. Senna is a stimulant laxative and has no role in ammonia reduction. Lorazepam sedation does not address the underlying cause and will cause encephalopathy. Cefotaxime is an antibiotic used to treat spontaneous bacterial peritonitis.
Case Presentation - Providing Information
- Case 2: A 55-year-old lady presents to the hepatology service with jaundice and hepatocellular derangement of her liver function tests. She is a non-drinker with no metabolic risk factors and a normal ferritin level. Her ANA and SMA antibodies are positive. The hepatology team prescribes a prolonged tapering course of prednisolone.
- Answer: Bone protection should be considered with prolonged steroid use.
- Additional Information: Prolonged steroid use can lead to osteoporosis, gastric ulceration, hypertension, diabetes, and an adrenal crisis if stopped abruptly.
Autoimmune Hepatitis
- Chronic, inflammatory disease of the liver.
- Characterized by circulating autoantibodies and elevated serum globulin levels.
- Challenging to diagnose and manage due to its rarity and heterogeneity.
- More common in females (4:1 ratio).
Clinical Features
- Wide range of symptoms, from asymptomatic to severe liver disease.
- Classically presents in middle-aged women, but can occur at any age in both sexes.
- Common symptoms include fatigue, malaise, weight loss, nausea, itching (pruritis), jaundice, joint pain (polyarthralgia), and irregular periods (oligomenorrhea).
- Can progress to liver cancer (HCC).
Primary Sclerosing Cholangitis (PSC) Diagnosis
- Characterized by distinctive radiological features.
- Multifocal, short, ring-shaped strictures (narrowings) in the bile ducts, alternating with normal or slightly widened segments.
- This creates a "beaded" appearance on imaging.
- Long strictures can also occur and raise concern for bile duct cancer (cholangiocarcinoma).
Liver Function Tests (LFTs)
- Elevated ALT/AST: indicate hepatocyte damage
- Elevated GGT/ALP: indicate biliary tree injury
- Elevated bilirubin: can indicate both hepatocellular and cholestatic/obstructive damage, visible jaundice when >50
- AST>ALT ratio >2:1: may suggest alcohol-associated hepatitis
Investigations
-
Bloods:
- LFTs: assess liver function and damage
- Coagulation profile: Raised INR, reduced coagulation factor production - measure of liver synthetic function
- Albumin: Reduced- measure of synthetic function
- FBC: assess for anemia and thrombocytopenia (low platelets)
- Viral Hepatitis Screen: Hep A, B, C, EBV, CMV, VZV, HIV, VDRL
- Autoantibody screen: ANA, SMA, Anti-LKM- AIH, Anti Smooth muscle Ab- PSC AMA: Anti Mitochondrial Ab-PBC
- Iron studies and ferritin: raised ferritin and T sat %; HFE genotype
- Caeruloplasmin and serum copper: reduced in Wilson's
- Serum A1AT Level: reduced in A1AT deficiency
-
Imaging:
- Liver Ultrasound: evaluate for nodularity, cirrhosis, ascites, hepatomegaly, splenomegaly, HCC
- CT/MRI Liver: higher quality images, evaluate for liver tumors and morphology
- MRCP: evaluate the biliary tree, PSC/PBC
- OGD: screen/surveillance of esophageal varices
-
Special Tests:
- Liver elastography (Fibroscan): evaluate for hepatic steatosis and fibrosis
- Liver Biopsy: gold standard, invasive, may not be required if other investigations suggest CLD/Cirrhosis
Scoring Systems in Cirrhosis
- CHILD-PUGH SCORE: estimates cirrhosis mortality, classified A, B, or C, based on:
- Total bilirubin
- Albumin
- INR
- Ascites
- Hepatic encephalopathy
- MELD Score: Mayo End-Stage Liver Disease (MELD):
- Predictor of 3-month mortality in cirrhotic patients
- Based on serum bilirubin, creatinine, and INR
- Used for liver transplant prioritization
Management
- Prevention:
- Alcohol cessation
- Avoid hepatotoxic medications (paracetamol, NSAIDs, opiates)
- Weight loss and diet management
- Hep A and B vaccination
- Pharmacological:
- Alcohol cessation pharmacotherapy
- GLP1 analogues for metabolic syndrome
- Beta Blockers for portal hypertension/varices
- Lactulose for encephalopathy (increases bacterial uptake of ammonia)
- Rifaximin for encephalopathy
- Diuretics and low salt diet for ascites and edema management
- Procedures:
- Paracentesis to exclude SBP and to drain ascitic fluid
- OGD banding of varices
- Trans-jugular Intrahepatic Portosystemic Shunt
- Surgical: Liver transplant - definitive management
- MDT: Dietician, physiotherapy, pharmacy involvement
- Palliative care: can be involved for symptom optimization and advanced care planning
Medical Emergency: Variceal Haemorrhage
- Rupture of esophageal varices:
- Overall mortality: 15-25% at 6 weeks
- Sengstaken-Blakemore Tube: balloon tamponade, only indicated in rare cases of uncontrolled bleeding when endoscopy is not possible
- Resuscitation: ABCs, IV fluids, blood transfusion
- Pharmacological Management: Terlipressin, antibiotic prophylaxis (Ceftriaxone)
- Source Control: Endoscopy, band ligation, or Sengstaken-Blakemore tube
- Long-term Prophylaxis: Non-cardioselective beta blockers (propranolol)
Case Presentations
- Case 1: Patient with acute confusion, asterixis, distended abdomen, and caput medusae.
- Treatment for confusion: Lactulose
- Other treatment options: Rifaximin
- Lactulose lowers ammonia levels, treating hepatic encephalopathy
- Senna is a stimulant laxative, not indicated
- Lorazepam sedation does not address the underlying cause and can worsen encephalopathy
- Cefotaxime is used for spontaneous bacterial peritonitis
- Case 2: Patient with jaundice, hepatocellular derangement, negative risk factors, positive ANA/SMA antibodies
- Treatment: Prolonged tapering course of prednisolone
- Important information:
- Bone protection is crucial with prolonged steroid use
- Gastric protection is recommended with prednisolone
- Patients can experience hypotension on steroids
- Steroids can increase the risk of diabetes
- Abruptly stopping steroids can be dangerous
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Description
This quiz explores Chronic Liver Disease (CLD) and its progression to cirrhosis. It covers the causes, pathophysiology, and complications associated with liver damage. Test your knowledge on how liver injury leads to fibrosis and portal hypertension.
