Clinical Assessment of Liver Disease
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Questions and Answers

What is the most likely diagnosis given the patient's symptoms and examination findings?

  • Liver cirrhosis (correct)
  • Chronic pancreatitis
  • Acute hepatitis
  • Biliary obstruction

    • Which laboratory finding is most indicative of spontaneous bacterial peritonitis in this patient?

  • WBC count of 1500/cmm with 90% neutrophils (correct)
  • Enlarged liver with coarse texture
  • Ascitic fluid albumin of 0.4 g/dl
  • PCR for HCV RNA viral load of 2654000 iu/ml

    • Which treatment is recommended while awaiting bacterial culture results for spontaneous bacterial peritonitis?

  • Intravenous cephalosporins (correct)
  • Steroids
  • Oral antibiotics only
  • Increased dietary protein

    • What should be done if the patient cannot take lactulose orally due to reduced conscious level?

    <p>Administer phosphate enemas (B)</p> Signup and view all the answers

    Which examination should be performed to check for varices in this patient?

    <p>Upper gastrointestinal endoscopy (C)</p> Signup and view all the answers

    What complication is associated with the patient’s low ascitic fluid albumin level?

    <p>Infection risk (C)</p> Signup and view all the answers

    The presence of spider naevi in this patient is indicative of which condition?

    <p>Chronic liver disease (A)</p> Signup and view all the answers

    Which statement about the patient’s history is significant in assessing his liver condition?

    <p>He used intravenous drugs as a youth (A)</p> Signup and view all the answers

    What is the primary consequence of the transformation of the normal liver architecture in cirrhosis?

    <p>Impaired hepatic function (D)</p> Signup and view all the answers

    Which classification of cirrhosis encompasses both uniform and varied nodular formations?

    <p>Mixed cirrhosis (C)</p> Signup and view all the answers

    What is one of the most common causes of cirrhosis due to rising lifestyle factors?

    <p>Non-alcoholic steatohepatitis (NASH) (D)</p> Signup and view all the answers

    What characterizes micronodular cirrhosis?

    <p>Uniform nodules smaller than 3 mm in diameter (A)</p> Signup and view all the answers

    Which symptom is NOT typically associated with liver cirrhosis?

    <p>Increased urination (B)</p> Signup and view all the answers

    Which statement accurately reflects the process leading to fibrosis in the liver?

    <p>Activation of stellate cells and cytokine release (C)</p> Signup and view all the answers

    What is a consequence of capillarization of the hepatic sinusoids?

    <p>Impaired sinusoidal blood flow (D)</p> Signup and view all the answers

    Which factor plays a key role in increasing intrahepatic resistance in liver cirrhosis?

    <p>Increased stellate cell contractility (A)</p> Signup and view all the answers

    What is one of the primary features of hepatopulmonary syndrome?

    <p>Intrapulmonary shunting (C)</p> Signup and view all the answers

    Which gastrointestinal complication can arise due to portal hypertension?

    <p>Gastrointestinal bleeding (C)</p> Signup and view all the answers

    What is a hematological consequence of liver dysfunction?

    <p>Thrombocytopenia (D)</p> Signup and view all the answers

    Which of the following is NOT typically associated with hepatic encephalopathy?

    <p>Enhanced reflexes (C)</p> Signup and view all the answers

    Which symptom is likely a dermatological manifestation of liver disease?

    <p>Clubbing (A)</p> Signup and view all the answers

    What is a common endocrine symptom in male patients with liver dysfunction?

    <p>Testicular atrophy (B)</p> Signup and view all the answers

    Which condition is characterized by muscle cramping and reduction in muscle mass?

    <p>Hepatic osteodystrophy (A)</p> Signup and view all the answers

    What is the 10-year survival rate for compensated cirrhosis?

    <p>47% (B)</p> Signup and view all the answers

    What defines Type B hepatic encephalopathy?

    <p>It is caused by portal-systemic shunting without intrinsic liver disease. (A)</p> Signup and view all the answers

    Which precipitant is NOT commonly associated with hepatic encephalopathy?

    <p>Diabetic ketoacidosis (D)</p> Signup and view all the answers

    What causes an increase in portal pressure in cirrhosis?

    <p>Decreased hepatic blood flow (D)</p> Signup and view all the answers

    What is the primary pathophysiological trigger in hepatic encephalopathy?

    <p>Increased levels of ammonia (D)</p> Signup and view all the answers

    Which neurohormonal system is activated due to baroreceptors sensing arterial underfilling?

    <p>All of the above (D)</p> Signup and view all the answers

    What condition can result from prolonged renal vasoconstriction due to cirrhosis?

    <p>Hepatorenal syndrome (D)</p> Signup and view all the answers

    Which condition is characterized by minimal hepatic encephalopathy?

    <p>Cirrhosis with no symptoms (B)</p> Signup and view all the answers

    What is a gross examination finding of a liver affected by cirrhosis?

    <p>Multiple yellowish nodules (D)</p> Signup and view all the answers

    What is the mainstay of treatment in managing hepatic encephalopathy?

    <p>Disaccharides like lactulose (D)</p> Signup and view all the answers

    Which clinical feature may indicate the presence of cirrhosis?

    <p>High serum bilirubin (D)</p> Signup and view all the answers

    Which grading system is used to assess the severity of hepatic encephalopathy?

    <p>West Haven criteria (C)</p> Signup and view all the answers

    Which of the following statements about ammonia levels in hepatic encephalopathy is accurate?

    <p>Ammonia levels vary widely without consistent relation to HE severity. (A)</p> Signup and view all the answers

    Which of the following is NOT a complication of decompensated cirrhosis?

    <p>Heart failure (A)</p> Signup and view all the answers

    What should be the focus of laboratory evaluation in diagnosing hepatic encephalopathy?

    <p>Ruling out electrolyte abnormalities and infections. (B)</p> Signup and view all the answers

    What type of examination is crucial for determining the presence and cause of cirrhosis?

    <p>Liver biopsy (B)</p> Signup and view all the answers

    What change in laboratory results may signify hepatic synthetic dysfunction in cirrhosis?

    <p>Prolonged prothrombin time (B)</p> Signup and view all the answers

    What percentage of patients typically develop varices annually in decompensated cirrhosis?

    <p>5% to 10% (C)</p> Signup and view all the answers

    Which of the following is a feature of portal hypertension?

    <p>Ascites (C)</p> Signup and view all the answers

    What is the significance of an AST/ALT ratio greater than 1 in patients with chronic hepatitis progressing to cirrhosis?

    <p>Indicates alcoholic hepatitis (A)</p> Signup and view all the answers

    Which diagnostic test for hepatocellular injury is characterized by elevated prothrombin time?

    <p>Coagulation factors (II, V, VII, X) (C)</p> Signup and view all the answers

    Which imaging modality is most reliable for assessing hepatic vasculature without using nephrotoxic contrast?

    <p>Magnetic resonance imaging (A)</p> Signup and view all the answers

    Which of the following tests is specifically used as a tumor marker for hepatocellular carcinoma (HCC)?

    <p>Serum alpha fetoprotein (AFP) (C)</p> Signup and view all the answers

    What percentage of patients with decompensated cirrhosis are likely to develop ascites within five years?

    <p>35% to 50% (A)</p> Signup and view all the answers

    What radiological investigation is often used to confirm a diagnosis of hepatocellular carcinoma?

    <p>Computed tomography (A)</p> Signup and view all the answers

    Flashcards

    Liver Cirrhosis

    A diffuse process characterized by fibrosis and the conversion of normal liver architecture into structurally abnormal nodules, leading to impaired hepatic function.

    Ascites

    The abnormal accumulation of fluid in the peritoneal cavity, often a consequence of portal hypertension.

    Varices

    Enlarged and tortuous veins, primarily in the esophagus, that form due to portal hypertension.

    Portal Hypertension

    The development of high pressure in the portal vein system, often due to cirrhosis.

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    Progressive Hepatic Failure

    A severe complication of cirrhosis, characterized by a range of effects including jaundice, ascites, and encephalopathy.

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    Alcoholic Liver Disease

    Inflammation of the liver caused by excessive alcohol consumption, leading to fibrosis and cirrhosis.

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    Non-Alcoholic Fatty Liver Disease (NAFLD)

    A type of liver damage characterized by fat accumulation, inflammation, and fibrosis, often associated with obesity and diabetes.

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    Viral Hepatitis

    A type of liver damage due to viral infection, primarily Hepatitis B and C.

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    Hepatitis

    Inflammation of the liver, often caused by viruses like Hepatitis C.

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    Cirrhosis

    A severe form of liver disease where the liver is scarred and damaged, leading to impaired function.

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    Asterixis

    A type of tremor characterized by rapid, irregular flapping movements of the hands often seen in patients with liver failure.

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    Spider naevi

    Small, spider-shaped blood vessels that appear on the skin, frequently associated with liver disease.

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    Splenomegaly

    Enlargement of the spleen, often seen in patients with liver diseases and other disorders.

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    Spontaneous bacterial peritonitis (SBP)

    A serious infection of the abdominal lining that can occur in patients with ascites and liver failure.

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    Hepatitis C antibody test

    A screening test used to detect the presence of antibodies against the Hepatitis C virus.

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    Hepatopulmonary Syndrome

    A specific form of hepatic hydrothorax that is characterized by dyspnea (shortness of breath), platypnea (shortness of breath when sitting upright), orthodeoxia (lower blood oxygen when sitting upright), digital clubbing, and severe hypoxemia.

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    Hepatic hydrothorax

    The buildup of fluid in the space between your lung and the chest wall (pleural space), which often accompanies cirrhosis.

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    Parotid gland enlargement

    Enlargement of the parotid glands, located near the ears, which can occur as a symptom of advanced liver disease.

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    Gastrointestinal Bleeding in Cirrhosis

    A complication of portal hypertension where there is bleeding from enlarged and weakened veins in the digestive tract.

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    Impaired Coagulation

    Reduced blood clotting ability, often seen in advanced liver disease.

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    Hepatic Encephalopathy

    A condition where the liver is unable to remove waste substances from the blood, leading to a buildup of toxins and a decline in brain function.

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    Thrombocytopenia

    A decrease in blood platelets, which can increase the risk of bleeding.

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    Gastroesophageal Varices

    Enlarged and twisted veins, usually in the esophagus, caused by increased pressure in the portal vein.

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    Hepatocyte Regeneration

    Abnormal proliferation of liver cells, leading to the formation of nodules and impaired liver function.

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    Hepatic Synthetic Function

    A measure of how well the liver is functioning, assessed by levels of bilirubin, albumin, and clotting factors.

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    Liver Fibrosis

    The process where the liver's architecture is replaced by scar tissue, leading to impaired function.

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    Liver Biopsy

    A microscopic examination of a liver tissue sample to assess the extent of damage and determine the cause of cirrhosis.

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    Decompensated Cirrhosis

    A condition where the liver's ability to function is significantly impaired due to widespread scarring and damage. This leads to complications like ascites, varices, and increased mortality.

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    Prothrombin Time

    A test of liver function that measures the time it takes for blood to clot, indicating how well the liver is producing clotting factors.

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    Abdominal Ultrasonography (US)

    A noninvasive imaging technique that uses sound waves to visualize the liver, particularly the size, texture, and presence of masses or fluid.

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    Serum Albumin

    A blood test that measures the level of albumin, a protein produced by the liver, which is important for fluid regulation and transporting substances in the blood.

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    Bilirubin

    A blood test that measures the level of bilirubin, a yellow pigment produced when red blood cells break down, reflecting liver's ability to process it.

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    Hepatic Encephalopathy (HE)

    A neuropsychiatric disorder associated with severe liver disease, manifested by altered mental status, asterixis, and hypo- or hyperreflexia.

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    Type A HE

    Classification of HE according to the condition that triggers it. This type is associated with acute liver failure.

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    Type B HE

    Classification of HE according to the condition that triggers it. This type is caused by abnormal blood flow bypassing the liver, without underlying liver disease.

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    Type C HE

    Classification of HE according to the condition that triggers it .This type occurs specifically in individuals with cirrhosis, defined as ongoing liver damage.

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    Cerebral Edema

    A serious complication of HE, where excessive brain swelling can lead to herniation and death, particularly in Type A HE, though possibly seen in Type C.

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    HE Treatment - Identifying and Treating the Precipitant

    The primary treatment strategy for HE focuses on identifying and addressing the underlying cause or precipitating factor.

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    Lactulose - HE Treatment

    A common treatment for HE that works by lowering ammonia levels in the gut.

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    Study Notes

    Liver Cirrhosis

    • A diffuse process characterized by fibrosis and the conversion of normal liver architecture into abnormal nodules
    • Results in impairment of hepatic function manifesting as jaundice, portal hypertension, varices, ascites, and spontaneous bacterial peritonitis
    • Associated with hepato-renal syndrome, hepatic encephalopathy, and progressive hepatic failure

    Case Presentation

    • A 50-year-old male was admitted with a 4-week history of increasing abdominal distension, anorexia, and 2 weeks of jaundice
    • No change in bowel habits or vomiting, denies weight loss
    • His wife noticed confusion over the previous 24 hours
    • Used intravenous drugs at age 20
    • 5-6 spider naevi on upper chest wall
    • Asterixis (flapping tremor) observed
    • Firm, sharp-bordered, non-tender liver palpable 6 cm below right costal margin at midclavicular line
    • Ascites confirmed by abdominal examination (shifting dullness)

    Clinical Signs

    • Jaundice: Yellowing of the eyes and skin
    • Ascites: Fluid buildup in the abdomen
    • Spider naevi: Vascular birthmark on the skin
    • Bilateral pitting oedema LL: Swelling of the legs

    Investigations

    • Initial Investigations:
      • Sodium: 130 mmol/L
      • Potassium: 3.8 mmol/L
      • Urea: 0.9 mmol/L
      • Creatinine: 89 µmol/L
      • Albumin: 25 g/L
      • Bilirubin: 90 µmol/L
      • Alkaline phosphatase: 400 U/L
      • ALT: 150 U/L
      • AST: 180 U/L
      • Hemoglobin: 110 g/dL
      • WCC: 8x109/L
      • Platelets: 70x109/L
      • Prothrombin time: 20 s
    • Ultrasound Examination: Enlarged liver with coarse texture, enlarged spleen, no intrahepatic/common bile duct dilatation, main portal vein patent and dilated (16mm), and moderate ascites
    • Virology screening: Positive for Hepatitis C antibody
    • PCR for HCV RNA viral load: 2654000 iu/ml
    • Ascitic fluid analysis: WBC count 1500/cmm, 90% neutrophils, ascitic fluid albumin 0.4 g/dl

    Treatment

    • Spontaneous Bacterial Peritonitis (SBP) diagnosed
    • Intravenous cephalosporins or oral quinolones
    • Secondary prophylaxis needed to reduce risk of further infections
    • Lactulose given orally, if reduced conscious level, then phosphate enemas
    • Beta-blocker prophylaxis to reduce risk of bleeding from asymptomatic varices
    • Hepatitis C treatment to be considered when liver function improves

    Liver Cirrhosis Definition/Pathology

    • A diffuse process characterized by fibrosis and the conversion of normal liver architecture into structurally abnormal nodules
    • Leads to impaired hepatic function
    • Gross examination often shows irregular surface with multiple yellowish nodules; enlarged liver may shrink in later stages
    • Microscopic examination reveals nodularity (regenerative nodules), fibrosis, abnormal hepatic architecture, and abnormal hepatocytes
    • Importance of histologic examination for establishment of cirrhosis, grading histologic activity, degree of liver fibrosis, and cause of cirrhosis in some cases

    Clinical Features

    • General: Fatigue, anorexia, malaise, sleep-wake reversal, weight loss, muscle wasting
    • Gastrointestinal: Parotitid gland enlargement, diarrhea, cholelithiasis, gastrointestinal bleeding (due to ruptured esophageal, gastric, duodenal, rectal, and/or stomal varices)
    • Hematological: Anemia, thrombocytopenia, leukopenia, impaired coagulation, disseminated intravascular coagulation, portal vein thrombosis
    • Pulmonary: Hepatopulmonary syndrome
    • Cardiac: Hyperdynamic circulation, diastolic dysfunction
    • Renal: Secondary hyperaldosteronism

    Clinical Features -Continued

    • Endocrinological: Hypogonadism, Feminization, diabetes mellitus
    • Neurological: Hepatic encephalopathy, peripheral neuropathy, asterixis
    • Musculoskeletal: Reduction in muscle mass, hepatic osteodystrophy, muscle cramping, umbilical herniation
    • Dermatological: Spider naevi, palmar erythema, jaundice, pruritus, Dupuytren contractures, clubbing, paper-money skin, caput medusa, easy bruising
    • Infections: Spontaneous bacterial peritonitis, urinary tract infection, respiratory tract infection, bacteremia, cellulitis
    • Cirrhotic features on physical exam: Spider naevi, palmar erythema, Dupuytren contractures, gynecomastia, testicular atrophy, ascites, splenomegaly, caput medusa, resting tachycardia, water hammer pulse, venous hum, hepatic encephalopathy, jaundice, parotid gland enlargement, scanty suprapubic and axillary hair

    Diagnosis

    • Clinical exam: Presence of stigmata of cirrhosis, features of portal hypertension (ascites, splenomegaly, caput medusa, etc.), and features of hepatic encephalopathy
    • Lab evaluation:
      • Tests of hepatocellular injury (AST, ALT)
      • Tests of cholestasis (bilirubin, ALP, GGT)
      • Tests of synthetic function (albumin, prothrombin time)
      • Tests for cause (e.g., viral markers, autoimmune antibodies)
      • Tumor markers
    • Radiological investigations: Abdominlal ultrasonography (assessing liver echotexture, border irregularities, size, detecting ascites, biliary dilatation, Doppler ultrasonography assess hepatic and portal vein patency, diameter, and blood flow), Computed tomography (CT, more expensive, requires administration of potentially nephrotoxic contrast to confirm HCC diagnosis), Magnetic resonance imaging (MRI, hepatic masses, hepatic vasculature), Magnetic resonance cholangio-pancreaticography (MRCP, biliary tract imaging)
    • Endoscopic investigations: Esophagogastroduodenoscopy (EGD, for gastro-esophageal varices screening)
    • Noninvasive markers of fibrosis/cirrhosis: APRI score, FIB-4 score, transient elastography (Fibroscan)
    • Liver biopsy: Useful in rare cases to diagnose cause of cirrhosis (e.g., Wilson's disease, autoimmune hepatitis, hemochromatosis). Usually performed percutaneously, sometimes transjugular or during laparoscopy.

    Prognostic Scores

    • Child-Turcotte-Pugh (CTP) score and class: Classifies severity of cirrhosis based on clinical and lab criteria (encephalopathy, ascites, bilirubin, albumin, prothrombin time).
    • Model for End-stage Liver Disease (MELD) score: Predicts 90-day mortality and guides organ allocation policies. Scores can range from 6-40; higher number indicates more severe liver impairment. Formula: MELD = 9.57 × loge (creatinine) + 3.78 × Loge (total bilirubin) + 11.2 × Loge (INR) + 6.43

    Hepatic Encephalopathy

    • A neuropsychiatric disorder associated with severe liver disease
    • Classified according to the condition during which manifestations appear and graded by the West Haven criteria
    • Types include acute (type A), bypass (type B) and cirrhotic (type C)
    • Common precipitating factors include gastrointestinal bleeding, post-transjugular intrahepatic portosystemic shunts (TIPS), constipation, spontaneous bacterial peritonitis, narcotics, benzodiazepines, hepatocellular carcinoma

    Treatment

    • Treatment of cirrhosis aims at addressing the underlying cause:
    • Lifestyle modifications: Avoiding alcohol, weight management
    • Medications: Antivirals for chronic hepatitis C or B, glucocorticoids/azathioprine for autoimmune hepatitis, D-penicillamine/trientine for Wilson disease, Ursodeoxycholic acid and/or obeticholic acid for primary biliary cholangitis (PBC)
    • Treatment for complications: Hemorrhage, hepatic encephalopathy, ascites, spontaneous bacterial peritonitis, cirrhosis surveillance for HCC (ultrasound, AFP)
    • Vaccination: Against hepatitis A and B
    • Avoiding hepatotoxins: alcohol and other hepatotoxins
    • Liver transplantation: indicated in end-stage cirrhosis (CTP class B/C or MELD score ≥15)

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    Liver Cirrhosis PDF

    Description

    This quiz evaluates your understanding of key aspects related to liver disease, including diagnoses, laboratory findings, treatments, and complications. Questions will focus on spontaneous bacterial peritonitis, liver examination techniques, and significant historical factors impacting liver conditions.

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