Liver Disease Overview
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Questions and Answers

What condition is characterized by inflammation secondary to fatty infiltration?

  • Chronic Hepatitis
  • Cirrhosis
  • Alcoholic Liver Disease
  • Non-Alcoholic Steatohepatitis (correct)

    • Which of the following is NOT a requirement for diagnosing MASLD?

  • Fatty liver on ultrasound
  • Signs of liver cirrhosis (correct)
  • Features of metabolic syndrome
  • Absence of alcohol excess

    • What is a common CNS effect of low-level ethanol intoxication?

  • Nervousness
  • Euphoria (correct)
  • Seizures
  • Stupor

    • What substance is generated during the metabolism of ethanol by ADH in the liver?

    <p>Acetaldehyde</p> Signup and view all the answers

    Which of the following is considered an extra-hepatic manifestation of Alcoholic Liver Disease?

    <p>Symmetric peripheral neuropathy</p> Signup and view all the answers

    Chronic alcohol use can result in which of the following cerebellar issues?

    <p>Cerebellar atrophy</p> Signup and view all the answers

    Which treatment is primarily recommended for managing liver diseases related to fatty liver?

    <p>Lifestyle modification</p> Signup and view all the answers

    What change can abrupt alcohol withdrawal induce due to neurotransmitter channel modifications?

    <p>Seizures</p> Signup and view all the answers

    What type of virus causes Hepatitis B?

    <p>DNA virus</p> Signup and view all the answers

    Which of the following hepatitis types has a vaccine available?

    <p>Hepatitis A</p> Signup and view all the answers

    Which Hepatitis virus primarily causes chronic infections?

    <p>Hepatitis C</p> Signup and view all the answers

    What is a key risk factor for Hepatitis C transmission?

    <p>Intravenous drug use</p> Signup and view all the answers

    How long can Hepatitis C remain active on surfaces?

    <p>1 week</p> Signup and view all the answers

    Which of the following statements about Hepatitis E is true?

    <p>It usually causes acute infections</p> Signup and view all the answers

    What is the main treatment strategy for Hepatitis C?

    <p>Direct Acting Antivirals</p> Signup and view all the answers

    Which of the following groups is at higher risk for Hepatitis B infection?

    <p>Healthcare workers</p> Signup and view all the answers

    Which laboratory finding is commonly associated with alcoholic liver disease?

    <p>Elevated GGT</p> Signup and view all the answers

    What is a clinical feature of Wernicke's encephalopathy?

    <p>Ophthalmoplegia with nystagmus</p> Signup and view all the answers

    Which of the following is NOT a component of the management for alcoholic liver disease?

    <p>Regular physical activity</p> Signup and view all the answers

    Which of these is a classic symptom of Korsakoff syndrome?

    <p>Confabulation</p> Signup and view all the answers

    What role does thiamine play in the brain?

    <p>Key role in cerebral metabolism</p> Signup and view all the answers

    Which of these findings would suggest thiamine deficiency?

    <p>Neuronal cell death in the mammillary bodies</p> Signup and view all the answers

    What is the purpose of thiamine supplementation in the context of alcohol withdrawal?

    <p>To prevent Wernicke's encephalopathy</p> Signup and view all the answers

    What is a common cause for thiamine deficiency among individuals with alcohol use disorder?

    <p>Impaired intestinal absorption</p> Signup and view all the answers

    What is the primary purpose of administering lactulose in cirrhotic patients?

    <p>To reduce ammonia absorption</p> Signup and view all the answers

    What is the recommended aim for hemoglobin levels during resuscitation in variceal hemorrhage?

    <p>7-9 g/dL</p> Signup and view all the answers

    Which medication is used as long-term prophylaxis against variceal hemorrhage?

    <p>Propranolol</p> Signup and view all the answers

    What is the main treatment modality for definitive management of liver cirrhosis?

    <p>Liver transplantation</p> Signup and view all the answers

    In the event of ruptured oesophageal varices, what is a primary pharmacological option for management?

    <p>Somatostatin</p> Signup and view all the answers

    What is the role of paracentesis in managing cirrhotic patients?

    <p>To drain ascitic fluid</p> Signup and view all the answers

    Which of the following is a key preventive measure for acute liver failure in cirrhotic patients?

    <p>Obesity management</p> Signup and view all the answers

    What is the aim of using a Sengstaken-Blakemore tube during variceal hemorrhage?

    <p>To apply manual pressure to bleeding vessels</p> Signup and view all the answers

    What is the primary goal of therapy for managing viral hepatitis?

    <p>To prevent disease progression to cirrhosis or HCC</p> Signup and view all the answers

    What is hereditary haemochromatosis primarily caused by?

    <p>Homozygous mutations in the HFE gene</p> Signup and view all the answers

    Which of the following symptoms is NOT associated with excess iron deposition in haemochromatosis?

    <p>Increased appetite</p> Signup and view all the answers

    What is a common diagnostic criterion for men or post-menopausal women for hereditary haemochromatosis?

    <p>Transferrin saturation &gt;50%</p> Signup and view all the answers

    In which organ does excess iron primarily accumulate in patients with haemochromatosis that can lead to cardiomyopathy?

    <p>Heart</p> Signup and view all the answers

    Which condition could potentially mitigate the onset of symptoms in premenopausal women with haemochromatosis?

    <p>Menstrual loss of blood</p> Signup and view all the answers

    Which of the following HFE gene mutations is associated with the majority of hereditary haemochromatosis cases?

    <p>C282Y</p> Signup and view all the answers

    What percentage of people in Ireland are believed to be carriers of the hereditary haemochromatosis gene?

    <p>1 in 5</p> Signup and view all the answers

    What is the most appropriate treatment for a patient with hepatic encephalopathy?

    <p>Lactulose</p> Signup and view all the answers

    What is the underlying issue that causes the confusion in patients with a history of chronic liver disease?

    <p>Elevated ammonia levels</p> Signup and view all the answers

    In a patient requiring lactulose for hepatic encephalopathy, what is the target number of bowel movements to aim for each day?

    <p>3-4 bowel movements</p> Signup and view all the answers

    Which of the following medications is an antibiotic used for spontaneous bacterial peritonitis in liver disease patients?

    <p>Cefotaxime</p> Signup and view all the answers

    What role does rifaximin have in the management of hepatic encephalopathy?

    <p>It reduces intestinal ammonia production.</p> Signup and view all the answers

    During the management of hepatic encephalopathy, which medication should be avoided due to its sedative effects?

    <p>Lorazepam</p> Signup and view all the answers

    Which treatment option has no role in ammonia reduction for a patient with hepatic encephalopathy?

    <p>Senna</p> Signup and view all the answers

    What is the likely consequence if ammonia levels are not addressed in a patient with hepatic encephalopathy?

    <p>Worsening confusion and lethargy</p> Signup and view all the answers

    What is a consequence of chronic liver disease if the underlying cause is not addressed?

    <p>Fibrosis and cirrhosis</p> Signup and view all the answers

    What role do hepatic stellate cells (HSC) play in the liver's response to injury?

    <p>They transform into fibroblasts and upregulate inflammatory receptors.</p> Signup and view all the answers

    Which of the following statements about fibrosis in chronic liver disease is true?

    <p>Initial stages of fibrosis can be reversible.</p> Signup and view all the answers

    What physiological change occurs in the liver during cirrhosis that contributes to portal hypertension?

    <p>Enhanced nitric oxide production and endothelin-1 activity</p> Signup and view all the answers

    In chronic liver disease, what is the primary consequence of HSC activation?

    <p>Accumulation of extracellular matrix and fibrosis</p> Signup and view all the answers

    What is the final architectural change in the liver associated with cirrhosis?

    <p>Formation of widespread nodules</p> Signup and view all the answers

    What is the role of sinusoidal endothelial cells (SECs) in portal hypertension?

    <p>Production of excess nitric oxide and endothelin-1</p> Signup and view all the answers

    Which statement is true regarding the transition of fibrosis to cirrhosis?

    <p>The transition from reversible to irreversible fibrosis is not fully understood.</p> Signup and view all the answers

    What is the primary risk associated with iron overload in patients with hereditary haemochromatosis?

    <p>Cirrhosis and hepatocellular carcinoma (HCC)</p> Signup and view all the answers

    Which mechanism contributes to the delay in symptom onset of haemochromatosis in premenopausal women?

    <p>Menstrual blood loss</p> Signup and view all the answers

    How is hereditary haemochromatosis primarily inherited?

    <p>Autosomal recessive</p> Signup and view all the answers

    What is the consequence of C282Y homozygosity in individuals with hereditary haemochromatosis?

    <p>Heightened iron absorption</p> Signup and view all the answers

    What percentage of hereditary haemochromatosis cases in Ireland is attributed to C282Y mutations?

    <p>85%</p> Signup and view all the answers

    Which of the following symptoms is directly associated with excess iron deposition in haemochromatosis?

    <p>Erectile dysfunction</p> Signup and view all the answers

    What laboratory findings are typical in diagnosing hereditary haemochromatosis in post-menopausal women?

    <p>Transferrin saturation &gt;50%, ferritin &gt;300 µg/L</p> Signup and view all the answers

    What is the primary goal in managing hepatitis B infections?

    <p>Preventing disease progression to cirrhosis or liver cancer</p> Signup and view all the answers

    What is the primary difference between Hepatitis B and Hepatitis C in terms of chronicity?

    <p>Hepatitis C primarily causes chronic infections</p> Signup and view all the answers

    Which hepatitis virus is known to have a vaccine available?

    <p>Hepatitis A and B</p> Signup and view all the answers

    Which of the following statements regarding Hepatitis C is false?

    <p>It always leads to cirrhosis</p> Signup and view all the answers

    In which scenario is Hepatitis E most commonly asymptomatic?

    <p>In immunocompetent individuals</p> Signup and view all the answers

    What characteristic of Hepatitis C contributes to its high infection rate?

    <p>It remains stable on surfaces for long durations</p> Signup and view all the answers

    Which mode of transmission is specific to Hepatitis B that is not typically associated with Hepatitis C?

    <p>Vertical transmission</p> Signup and view all the answers

    What is a key distinguishing feature of Hepatitis D in relation to Hepatitis B?

    <p>Hepatitis D can only exist in the presence of Hepatitis B</p> Signup and view all the answers

    Which treatment is specifically associated with a high cure rate for Hepatitis C?

    <p>Direct Acting Antivirals</p> Signup and view all the answers

    What is a primary cause of weight gain in patients with chronic liver disease?

    <p>Fluid retention and third spacing</p> Signup and view all the answers

    Which symptom indicates a possible cause of chronic inflammation when present in patients with ALD?

    <p>Fatigue and weakness from malnutrition</p> Signup and view all the answers

    Which cause is directly linked to the symptom of pruritis in liver disease?

    <p>Excess bilirubin deposited in skin</p> Signup and view all the answers

    What condition might cause ascites in patients with portal hypertension?

    <p>Activation of the RAA system</p> Signup and view all the answers

    Which symptom is linked to hepatic encephalopathy in liver disease?

    <p>Reduced GCS/Asterixis from ammonia accumulation</p> Signup and view all the answers

    Which sign indicates reduced production of clotting factors in chronic liver disease?

    <p>Bruising and petechiae from consumptive thrombocytopenia</p> Signup and view all the answers

    What complication can arise from an upper GI bleed in patients with portal hypertension?

    <p>Oesophageal varices leading to haematemesis</p> Signup and view all the answers

    Which mechanism contributes to nausea and vomiting in patients with chronic liver disease?

    <p>Poor gastric emptying due to ascites</p> Signup and view all the answers

    Study Notes

    Liver Disease

    • Non-Alcoholic Fatty Liver Disease (NAFLD) is the leading cause of chronic liver disease in Ireland and the Western world.
    • NAFLD is a diagnosis of exclusion:
      • Ultrasound shows fatty liver.
      • No history of excessive alcohol consumption.
      • Features of metabolic syndrome are present.
      • All other potential causes of liver disease must be ruled out.
    • Treatment for NAFLD: lifestyle modification, including diet, exercise, and weight management.

    Alcoholic Liver Disease

    • Major Public Health Issue in Ireland and Worldwide.
    • Impact of Alcohol on the Liver
      • Ethanol is metabolized by alcohol dehydrogenase (ADH) in hepatocytes.
      • ADH-catalyzed ethanol oxidation uses NAD+ as a cofactor and generates reduced NADH and acetaldehyde, which is highly reactive and toxic.
    • Clinical features of Alcoholic Liver Disease:
      • Features of chronic liver disease.
      • Extrahepatic manifestations, including:
        • Nervous system:
          • Symmetric peripheral neuropathy.
          • Thiamine deficiency complications: Wernicke's encephalopathy, Korsakoff's psychosis.
        • Pancreatitis.
        • Cardiomyopathy.
    • Diagnosis of Alcoholic Liver Disease:
      • Documentation of regular alcohol consumption.
      • Clinical or biochemical features suggestive of liver injury.
      • Liver function tests (LFT) pattern:
        • AST: ALT ratio >1.5
        • Elevated GGT.
      • Exclusion of alternative causes of liver disease.
      • Liver biopsy: histology shows steatosis, hepatocellular injury, fibrosis or cirrhosis.
    • Management of Alcoholic Liver Disease:
      • Alcohol cessation and avoidance of risks (alcohol withdrawal seizures, Wernicke's, Korsakoff's).
      • Addiction support.
      • Screening for and management of cirrhosis complications (variceal bleeding, ascites, spontaneous bacterial peritonitis (SBP), hepatic encephalopathy, hepatocellular carcinoma (HCC)).
      • Nutritional support.
      • Avoidance of other causes of liver injury.

    Alcoholic Withdrawal

    • Thiamine (vitamin B1) plays a key role in cerebral metabolism.
    • Thiamine Deficiency can cause neuronal cell death, classically seen in the mammillary bodies.
    • Thiamine Deficiency is associated with alcohol use disorder, poor dietary intake, impaired intestinal absorption, and reduced hepatic stores.
    • Wernicke-Korsakoff Syndrome is a disease spectrum.
      • Wernicke's encephalopathy is the acute, life-threatening neurological condition caused by thiamine deficiency, characterized by the triad of ophthalmoplegia with nystagmus, ataxia, and confusion.
      • Korsakoff psychosis is the neuropsychiatric disorder associated with memory disturbances, confabulation, and emotional disturbances.
    • Management: Thiamine supplementation: intravenous pabrinex (vitamin B and C), switching to oral thiamine tablets for long-term management.

    Viral Hepatitis

    • Hepatitis A (HAV): RNA virus.
    • Hepatitis B (HBV): DNA virus.
    • Hepatitis C (HCV): RNA virus.
    • Hepatitis E (HEV): RNA virus.
    • Incubation Period (days):
      • HAV: 15-50.
      • HBV: 50-180.
      • HCV: 14-84.
      • HEV: 15-60.
    • Acute vs. Chronic Liver Disease:
      • HAV: Acute.
      • HBV: Acute, chronic.
      • HCV: Chronic.
      • HEV: Acute, rarely chronic in immunocompromised individuals.
    • Can Cause Cirrhosis and Primary Hepatocellular Carcinoma:
      • HAV: No.
      • HBV: Yes.
      • HCV: Yes.
      • HEV: No.
    • Vaccine Available:
      • HAV: Yes.
      • HBV: Yes.
      • HCV: No.
      • HEV: No.

    Hepatitis C

    • Risk factors: IV drug users, multiple sexual partners, unprotected sex, tattoos, blood transfusions, hemodialysis, vertical transmission (mother to baby), travel to endemic areas, health care workers.
    • Curable: Yes, with direct-acting antivirals (DAAs).
      • 99% chance of cure with an 8-week course of DAA tablets.

    Hepatitis B

    • Modes of transmission: Similar to HCV.
    • Highly infectious.
    • Environmentally stable: Can remain active on surfaces for up to a week.
    • Preventable: Yes, vaccination exists.
    • Curable: No, managed by viral suppression with nucleoside analogues (e.g., entecavir, lamivudine).
    • Goals of therapy:
      • Prevent disease progression to cirrhosis or HCC.
      • Prevent mother-to-child transmission.
      • Prevent reactivation.
      • Prevent HBV-associated extrahepatic manifestations.

    Haemochromatosis

    • 'Bronzed Diabetes': Named in the 1800s, referring to the skin pigmentation due to iron overload.
    • Excess iron absorption via the intestines leads to total body iron overload.
    • Iron accumulation in multiple organs, including:
      • Liver (cirrhosis and HCC).
      • Heart (cardiomyopathy).
      • Pancreas (diabetes).
      • Pituitary (pituitary hypogonadism).
      • Skeletal (arthralgias/arthritis/osteoporosis).
    • Chronic picture: Manifests years later after significant iron deposition.
    • Onset in premenopausal women can be delayed by menstrual blood loss.
    • Symptoms:
      • Cirrhosis.
      • Diabetes.
      • Arthralgias/arthritis/osteoporosis.
      • Fatigue.
      • Erectile dysfunction/loss of libido/amenorrhea.
      • ECG abnormalities.
      • Bronze skin hyperpigmentation (epidermal iron deposition).
    • Ireland has the highest prevalence of hereditary haemochromatosis in the world.
    • 1 in 5 people in Ireland are gene carriers.
    • Hereditary haemochromatosis is an autosomal recessive condition caused by homozygous mutations in the HFE gene on chromosome 6:
      • C282Y (Cysteine to Tyrosine at the 282nd amino acid).
      • H63D (Histidine to Aspartic Acid at the 63rd amino acid).
    • 85% of HH is due to C282Y homozygosity.
    • Diagnosis:
      • Iron studies:
        • Premenopausal women: transferrin saturation >45%, ferritin >200 µg/L.
        • Men/postmenopausal women: transferrin saturation >50%, ferritin >300 µg/L.
      • Model for End-Stage Liver Disease (MELD) score is an excellent predictor of 3-month mortality among cirrhotic patients listed for liver transplantation.
    • King's College Criteria: Used to diagnose acute liver failure.

    Management of Liver Disease

    • Prevention:
      • Alcohol cessation.
      • Avoid hepatotoxic medications e.g., paracetamol/NSAIDs.
      • Weight loss and diet management.
      • Optimize diabetes management for hepatic steatosis.
      • Hepatitis A and B vaccination.
    • Pharmacological:
      • Beta blockers for varices.
      • Lactulose for encephalopathy (increases bacterial uptake of ammonia).
      • Rifaxamin for encephalopathy.
      • Diuretics and low salt diet for ascites and edema management.
    • Procedures:
      • Paracentesis to drain ascitic fluid.
      • Oesophagogastroduodenoscopy (OGD) banding of varices.
      • Transjugular intrahepatic portosystemic shunt (TIPS).
    • Surgical:
      • Liver transplant - definitive management.
    • Palliative care: Can be involved early for symptom optimization and advanced care planning.

    Medical Emergency: Variceal Haemorrhage

    • Rupture of oesophageal varices.
    • Mortality: Overall mortality with each episode of variceal haemorrhage remains around 15% to 25% at six weeks.
    • Management:
      • Resuscitation: ABC; intravenous crystalloid fluids, blood transfusion aiming for Hb 7-9 g/dL.
      • Pharmacological:
        • Somatostatin.
        • Terlipressin.
        • Antibiotic prophylaxis (Ceftriaxone).
      • Source Control:
        • Endoscopy.
        • Band ligation.
        • Sengstaken-Blakemore tube - balloon tamponade, inserted into the oesophagus and inflated to apply manual pressure to the bleeding vessel. Indicated only in rare cases of very unstable, uncontrolled bleeding.
      • Long-term prophylaxis: Non-cardioselective beta blockers (propranolol).

    Chronic Liver Disease

    • A continuous process of inflammation, destruction, and regeneration of liver parenchyma
    • Can lead to fibrosis and cirrhosis if underlying cause not addressed
    • Fibrosis is deposition of extracellular matrix (ECM) in response to chronic liver injury
    • Fibrosis can be reversible in the initial stage
    • The transition point to irreversible fibrosis is not fully understood
    • Cirrhosis is the final stage of chronic liver disease resulting in disruption of liver architecture, widespread nodules, vascular reorganization, neo-angiogenesis, and ECM deposition

    Pathophysiology

    • Injury pathway initiated by hepatic stellate cells (HSC)
    • HSC are usually dormant cells found in the space between sinusoids and hepatocytes
    • Quiescent HSC play a role in Vitamin A metabolism
    • In response to liver injury, HSCs are activated and transform into fibroblasts
    • Activated HSC upregulate the expression of inflammatory receptors
    • This pro-inflammatory phase makes liver cells responsive to inflammatory cytokines
    • Progressive activation of more HSC cells results in ECM accumulation and fibrosis

    Portal Hypertension

    • Liver receives 25% of the cardiac output (800-1200mls/min)
    • Hepatic sinusoids are specialized capillaries that receive this blood volume
    • In cirrhosis, sinusoidal endothelial cells (SECs) produce excess nitric oxide (NO) and endothelin-1 (ET-1), leading to blood vessel constriction and high pressure within the liver vascular bed
    • This is termed portal hypertension

    Symptoms & Causes

    • Fatigue and weakness: Catabolic state, malnutrition, poor diet of ALD
    • Nausea and vomiting: Poor gastric emptying, increased acid production, ascites causing mechanical nausea
    • Pruritis: Excess bilirubin deposited in skin
    • Jaundice: Circulating unconjugated bilirubin
    • Bleeding: Reduced clotting factors produced, platelets consumed due to splenomegaly
    • Weight gain: Fluid retention and third spacing due to a hyperdynamic state, reduced albumin production
    • Confusion: Encephalopathy due to reduced ammonia excretion, B12 deficiency due to alcohol (Wernicke's)
    • Fever/Abdominal pain: Subacute bacterial peritonitis due to ascites
    • Upper GI Bleed (Haematemesis, Malaena): Oesophageal varices due to portal hypertension

    Signs & Causes

    • Reduced GCS/Asterixis: Hepatic encephalopathy due to reduced excretion of ammonia
    • Jaundice: Hepatocyte damage reducing conjugation of bilirubin
    • Bruising/Petechiae: Reduced clotting factor synthesis, consumptive thrombocytopaenia
    • Ascites: Due to RAA system activation, salt and fluid retention, splanchnic arterial dilation, portal hypertension, reduced oncotic pressure due to reduced albumin synthesis
    • Splenomegaly/Caput medusae: Portal hypertension
    • Peripheral oedema: Reduced albumin production
    • Pallor: Anaemia of chronic disease, B12 deficiency, iron deficiency

    Causes of Chronic Liver Disease

    • Overlapping causes are common
    • Viral Hepatitis: HAV, HBV, HCV, HEV
      • HAV: RNA virus, incubation 15-50 days, acute liver disease, no cirrhosis, vaccine available
      • HBV: DNA virus, incubation 50-180 days, acute and chronic liver disease, can cause cirrhosis and HCC, vaccine available
      • HCV: RNA virus, incubation 14-84 days, usually chronic liver disease, can cause cirrhosis and HCC, curable, no vaccine available
      • HEV: RNA virus, incubation 15-60 days, acute liver disease, rarely chronic (immunocompromised), no cirrhosis, no vaccine available

    Hepatitis C

    • Risk Factors: IV drug injectors, sexually transmitted (multiple partners/unprotected sex), tattoos, blood transfusion, haemodialysis, vertical transmission, travel to endemic areas (Egypt), healthcare workers
    • ssRNA virus
    • 80-90% of infections become chronic
    • Risk of cirrhosis and HCC
    • Curable with direct acting antivirals (DAAs) - 99% chance of cure with an 8-week course

    Hepatitis B

    • Modes of transmission similar to HCV
    • Highly infectious
    • Very environmentally stable (up to one week on surfaces)
    • Preventable with vaccination
    • Curable: No, managed by viral suppression with nucleoside analogues (e.g., Entecavir, Lamivudine)
    • Goals of therapy: prevent disease progression, prevent mother-to-child transmission, prevent reactivation, prevent HBV-associated extra-hepatic manifestations

    Haemochromatosis ('Bronzed Diabetes')

    • Excess iron absorbed via the intestine leads to total-body iron overload
    • Iron accumulates in multiple organs: liver (cirrhosis, HCC), heart (cardiomyopathy), pancreas (diabetes), pituitary (pituitary hypogonadism), skeleton (arthralgias, arthritis, osteoporosis)
    • Chronic picture manifests years later after significant iron deposition
    • Onset in premenopausal women can be delayed by menstrual blood loss
    • Symptoms: cirrhosis, diabetes, arthralgias/arthritis/osteoporosis, fatigue, erectile dysfunction, loss of libido, amenorrhoea, ECG abnormalities, bronze skin hyperpigmentation (epidermal iron deposition)
    • Ireland has the highest prevalence of hereditary haemochromatosis (HH) in the world
    • 1/5 people in Ireland are gene carriers
    • Hereditary Haemochromatosis is an autosomal recessive condition due to homozygous mutations in the HFE gene on chromosome 6
      • C282Y (Cysteine to Tyrosine at 282nd amino acid)
      • H63D (Histidine to Aspartic Acid at amino acid 63)
    • 85% of HH due to C282Y homozygosity

    Diagnosis of Haemochromatosis

    • Iron Studies:
      • Pre-menopausal women: Transferrin saturation >45%, ferritin >200 µg/L
      • Men/post-menopausal women: Transferrin saturation >50%, ferritin >300 µg/L
    • Physical examination: Asterixis, distended abdomen with shifting dullness, caput medusae

    Case Presentation: Management of Hepatic Encephalopathy

    • A 65-year-old male presents with acute confusion and behavioural disturbance.
    • Past medical history includes chronic liver disease.
    • Physical examination reveals asterixis, distended abdomen with shifting dullness, caput medusae.
    • Appropriate treatment: Lactulose
      • Lactulose lowers ammonia levels
      • Indicated for treatment of hepatic encephalopathy
      • Aim for 3 bowel motions per day
      • Rifaxamin (not rifampicin) is also indicated in addition to lactulose
      • Senna is a stimulant laxative with no role in ammonia reduction
      • Lorazepam sedation will not address the underlying cause
      • Cefotaxime is an antibiotic used for spontaneous bacterial peritonitis

    Case Presentation: Management of Autoimmune Hepatitis

    • A 55-year-old female is referred for jaundice and hepatocellular derangement of liver function tests.
    • Non-drinker, no metabolic risk factors, normal ferritin.
    • AMA and SMA antibodies are positive.
    • Hepatology team prescribes a prolonged tapering course of prednisolone.
    • Most appropriate information to discuss: Bone protection should be considered with prolonged steroid use
      • Prolonged steroid use can increase the risk of osteoporosis
      • Gastric protection is not required with prednisolone
      • Hypotension is not a primary risk of steroid therapy
      • Steroids can increase the risk of diabetes

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