Nikita Goyal; Hepatobiliary
Info History/RF Examination Investigation Management
Acute Liver Ax – Hep A/E, CMV, EBV, HSV, drugs, alcoholic hepatitis,
Disease paracetomol
Chronic Liver Disease
Info History/RF Examination Investigation Management
Cirrhosis Ax – hepatotoxicity (chronic alcohol use disorder), inflammation Compensated Compensated Bedside – ECG Non-pharm – Anti-viral drugs – HCV infection
Pathological end- (commonly hep C), metabolic disorder (haemochromatosis, Largely asymptomatic Spider naevi, gynaecomastia Avoid hepatotoxic substances – alcohol, meds
stage of any Wilson disease, α1 antitrypsin deficiency), hepatic vein Fatigue, weakness, LOW Hepatomegaly or small liver Bloods – such as NSAIDs
chronic liver congestion or vascular anomalies (Budd-Chiari syndrome), Recurrent infections Splenomegaly FBE – thrombocytopenia Routine vacc – pneumococcal, hep A/B, flu
disease most cryptogenic cirrhosis Decreased libido -testicular Dupuytren’s contracture UEC - ↓Na from ascites High protein, low salt intake; HCC screening;
commonly results Pathophys – degeneration + necrosis of hepatocytes → fibrotic atrophy Bruising/bleeding LFTs – AST>ALT; low variceal screening
from chronic hep B, tissue + regenerative nodules (from stellate cells) replace liver Muscle atrophy serum alb Treat underlying Ax of cirrhosis
C, alcohol-related parenchyma → loss of liver function Extra Exam stuff Peripheral oedema – low Alb Coags – ↑PT HCC screening – 6 monthly liver US + serum
liver disease & Micronodular – Alcohol, NASH/NAFLD, haemochromatosis, Clubbing Portal HTN w/o ascites, ? AFP + Variceal screening
non-alcoholic fatty PBC/PSC Leukonychia varices
Imaging –
liver disease Macronodular – Infectious hepatitis, Wilson’s, A1AT Confusion Pharm – non-selective BB – propranolol
Endoscopy –
Xanthelasma Decompensated gastrooesophageal Spironolactone + frusemide – manages ascites
Child-Pugh Score Compensated – Pathological, but preservation of hepatic Cyanosis Ascites – shifting dullness + varices + oedema
– bilirubin, albumin, synthetic function; NO ascites, varices, variceal bleeding, Loss of secondary sexual abdo distention USS – evaluation + Surg + intervention – paracentesis –
INR, ascites, encephalopathy or jaundice hair in males Varices – oesophageal, HCC screening decompress abdo due to ascites
encephalopathy Decompensated – evidence of comps from fibrosis (HTN) & loss haemorrhoids, caput Biopsy – trichome strain TIPSS – lowers portal pressure + manages Cx
of liver function medusae; Bleeding – for fibrous tissue
Ax - ↑alcohol, infection, constipation, drugs, GIT bleed, haematemesis or melaena Bone mineral density for Surgery – liver transplant is the only curative
dehydration, Ca Encephalopathy – hepatic bone disease option
Comps – ascites, hepatic encephalopathy, bacterial peritonitis, flap, ASC, fetor hepaticus
hepatorenal syndrome, portal HTN, hepatopulmonary syndrome Jaundice – itch
Hepatic Encephalopathy Mx – protein
Oedema
restriction, lactulose, phosphate enemas,
rifaximin
Alcoholic Liver 1st stage – asymptomatic + reversible alcoholic fatty liver Asymptomatic Jaundice Bedside – BSL + Urine Lifestyle – alcohol abstinence + reduction
Disease (steatosis); 2nd stage – alcoholic hepatitis (inflammation + Fatigue Hepatomegaly dipstick Medication review – avoid hepatotoxic meds
Progressive liver necrosis); 3rd stage – alcohol cirrhosis RUQ pain (dull) Splenomegaly Bloods – Smoking cessation, flu + pneumococcal +
conditions caused Ax – chronic excessive alcohol intake; not just a few binges; Nausea/vomiting BMI>30 FBE (leukocytosis, ↓ hepatitis A/B vacc
by chronic and >2std drinks/day; F – lower alcohol Jaundice Ascites Plts) Good nutritional intake – calories, low salt, high
excessive alcohol Pathophys – hepatic degradation of ethanol to acetyl co-A by Anorexia Malnutrition LFTs (↑AST>↑ALT; 2:1; protein
consumption alcohol dehydrogenase → ↑ NADH → ↑G3P + fatty acids → Haematemesis/melaena Atrophy ↑bilirubin, ↓albumin) Medical –
steatohepatitis → chronic inflammation leads to hepatic fibrosis + LOW/weight gain Parotidmegaly – EtOH use Coags – ↑ INR/APTT T2DM – Metformin + all the other drugs
sclerosis → portal HTN, cirrhosis RF – amount of alcohol, Bruising, leukonychia, UEC/CMP Weight loss – orlistat
Epi – M>F, BUT women more susceptible, 5 yr survival rate FHx, NAFLD things, clubbing, palmar erythema, Iron studies –
>50% if abstinent from alcohol hepatitis infection, spider naevi, haemachromatosis ?corticosteroids – suppress immune system
Comps – oesophageal or gastric variceal bleeding, ascites, haemochromatosis, hep C gynaecomastia, testicular Hep serology Sedatives + anticoags contraindicated in those
coagulopathy, hepatic encephalopathy, HCC, SBP, sepsis atrophy CRP/ESR w/ decompensation
Dupuytren contracture Imaging –
US (Fibroscan)
Abdo CT/MRI +/- biopsy
(?HCC)
Non-alcoholic Ax – part of metabolic syndrome (central obesity, HTN, Absence of significant Hepatosplenomegaly Bedside –
, Nikita Goyal; Hepatobiliary
fatty liver disease ^glycaemia, dyslipidaemia) alcohol use Truncal obesity
Simple fatty Pathophys – fat accumulation within the liver (more circulating Fatigue, malaise Bloods – FBE –
infiltration TAG’s (obesity) and hence gets taken up by the liver, reversible RUQ abdo discomfort anaemia, ↓ Plts
NASH – presence process; can involve inflammation and fibrosis LFT – (↑ AST, ↑ALT;
of fat leading to ?insulin resistance appears to be the key mechanism leading to AST:ALT<1, ↑bilirubin,
lipotoxicity and triglyceride accumulation in the liver ALP, GGT can also be
RF – obesity, diabetes,
inflammatory elevated, ↓alb)
^lipidaemia, ^tension,
damage to Epi – chronic liver disease in the Western world; prevalence is CMP - ↓Na
metabolic syndrome, rapid
hepatocytes 30% of adults Lipid panel
LOW, medications, total
parenteral nutrition, FHx Coags - ↑INR/APTT
Dx based on exclusion of other Ax e.g alcohol
Portal HTN Portal v – formed by SMV + splenic v; drains blood from the abdo Malaena Caput medusae Same as cirrhosis Primary – variceal screening; Non-selective
Pathological GI tract, spleen and pancreas into the liver Haematemesis (sudden) Anorectal varices BB (propranolol) – splanchnic vasoconstriction
evidence of Ax – pre-hepatic (portal/splenic vein thrombosis), intrahepatic Haematochezia – frank PR Haemorrhoids Would also lead to ECG + banding
elevated portal (cirrhosis), post-hepatic (Budd-Chiari syndrome, RHF, constrictive bleed Oesophageal + epigastric – RVH, pericarditis Ax
venous pressure pericarditis) varices G&H – variceal TIPSS – shunts portal v to vena cava; some
resulting from Pathophys - ↑blood flow via portosystemic anastomoses – RF – HF, alcohol intake, ↑ Splenomegaly – bleeding, haemorrhage risk of encephalopathy as GIT blood is not
obstructions in Paraumbilical + epigastric v – caput medusae; rectal v – BMI, Hx of HBV, HCV – bruising passing the liver
portal flow haemorrhoidal or anorectal varices; veins of gastric fundus + IVDU, sex, etc, thrombotic Upper GI bleeding
distal oesophagus – oesophageal/gastric varices Hx Ascites
Ascites –
Congestive splenomegaly → hypersplenism (thrombocytopenia);
1 Salt restriction <100mmol/day
transudative ascites
2 Diuretic therapy - Spironolactone +/-
Epi – 55% have oesophageal varices when diagnosed w/
frusemide
cirrhosis; Alcohol > NAFLD > Viral; oesophageal varices lethal in
3 Paracentesis – protein + MCS on first
20-30%; cirrhosis 2-5% annual risk of HCC
presentation; therapeutic on presentations
Comps – acute haemorrhage, gastropathy from pressure, HCC,
after; + albumin 20% IV during or soon after the
SBP
drain
4 TIPSS (bypass procedure) or Liver
Transplant
Variceal Bleed –
1 Haemodynamic Resus – IV/Central line
access, fluid resus to raise BP; conservate
blood transfusion to increase Hb to 70-80g/L
2 Airway protection – endotracheal intubation
if mandatory
3 Pharm – Abx – 3-5 days of IV ceftriaxone,
pip-taz or oral fluroquinolone; vaso-active meds
i.e terlipressin or octreotide for 3-5 days +
before endoscopy
4 Endoscopic therapy – Endoscopic variceal
ligation (oesophageal); endoscopic injection of
tissue adhesives (gastric)
5 Salvage therapy – balloon tamponade w/ a
Minnesota tube or TIPSS
Genetic and
Info History/RF Examination Investigation Management
Acute Liver Ax – Hep A/E, CMV, EBV, HSV, drugs, alcoholic hepatitis,
Disease paracetomol
Chronic Liver Disease
Info History/RF Examination Investigation Management
Cirrhosis Ax – hepatotoxicity (chronic alcohol use disorder), inflammation Compensated Compensated Bedside – ECG Non-pharm – Anti-viral drugs – HCV infection
Pathological end- (commonly hep C), metabolic disorder (haemochromatosis, Largely asymptomatic Spider naevi, gynaecomastia Avoid hepatotoxic substances – alcohol, meds
stage of any Wilson disease, α1 antitrypsin deficiency), hepatic vein Fatigue, weakness, LOW Hepatomegaly or small liver Bloods – such as NSAIDs
chronic liver congestion or vascular anomalies (Budd-Chiari syndrome), Recurrent infections Splenomegaly FBE – thrombocytopenia Routine vacc – pneumococcal, hep A/B, flu
disease most cryptogenic cirrhosis Decreased libido -testicular Dupuytren’s contracture UEC - ↓Na from ascites High protein, low salt intake; HCC screening;
commonly results Pathophys – degeneration + necrosis of hepatocytes → fibrotic atrophy Bruising/bleeding LFTs – AST>ALT; low variceal screening
from chronic hep B, tissue + regenerative nodules (from stellate cells) replace liver Muscle atrophy serum alb Treat underlying Ax of cirrhosis
C, alcohol-related parenchyma → loss of liver function Extra Exam stuff Peripheral oedema – low Alb Coags – ↑PT HCC screening – 6 monthly liver US + serum
liver disease & Micronodular – Alcohol, NASH/NAFLD, haemochromatosis, Clubbing Portal HTN w/o ascites, ? AFP + Variceal screening
non-alcoholic fatty PBC/PSC Leukonychia varices
Imaging –
liver disease Macronodular – Infectious hepatitis, Wilson’s, A1AT Confusion Pharm – non-selective BB – propranolol
Endoscopy –
Xanthelasma Decompensated gastrooesophageal Spironolactone + frusemide – manages ascites
Child-Pugh Score Compensated – Pathological, but preservation of hepatic Cyanosis Ascites – shifting dullness + varices + oedema
– bilirubin, albumin, synthetic function; NO ascites, varices, variceal bleeding, Loss of secondary sexual abdo distention USS – evaluation + Surg + intervention – paracentesis –
INR, ascites, encephalopathy or jaundice hair in males Varices – oesophageal, HCC screening decompress abdo due to ascites
encephalopathy Decompensated – evidence of comps from fibrosis (HTN) & loss haemorrhoids, caput Biopsy – trichome strain TIPSS – lowers portal pressure + manages Cx
of liver function medusae; Bleeding – for fibrous tissue
Ax - ↑alcohol, infection, constipation, drugs, GIT bleed, haematemesis or melaena Bone mineral density for Surgery – liver transplant is the only curative
dehydration, Ca Encephalopathy – hepatic bone disease option
Comps – ascites, hepatic encephalopathy, bacterial peritonitis, flap, ASC, fetor hepaticus
hepatorenal syndrome, portal HTN, hepatopulmonary syndrome Jaundice – itch
Hepatic Encephalopathy Mx – protein
Oedema
restriction, lactulose, phosphate enemas,
rifaximin
Alcoholic Liver 1st stage – asymptomatic + reversible alcoholic fatty liver Asymptomatic Jaundice Bedside – BSL + Urine Lifestyle – alcohol abstinence + reduction
Disease (steatosis); 2nd stage – alcoholic hepatitis (inflammation + Fatigue Hepatomegaly dipstick Medication review – avoid hepatotoxic meds
Progressive liver necrosis); 3rd stage – alcohol cirrhosis RUQ pain (dull) Splenomegaly Bloods – Smoking cessation, flu + pneumococcal +
conditions caused Ax – chronic excessive alcohol intake; not just a few binges; Nausea/vomiting BMI>30 FBE (leukocytosis, ↓ hepatitis A/B vacc
by chronic and >2std drinks/day; F – lower alcohol Jaundice Ascites Plts) Good nutritional intake – calories, low salt, high
excessive alcohol Pathophys – hepatic degradation of ethanol to acetyl co-A by Anorexia Malnutrition LFTs (↑AST>↑ALT; 2:1; protein
consumption alcohol dehydrogenase → ↑ NADH → ↑G3P + fatty acids → Haematemesis/melaena Atrophy ↑bilirubin, ↓albumin) Medical –
steatohepatitis → chronic inflammation leads to hepatic fibrosis + LOW/weight gain Parotidmegaly – EtOH use Coags – ↑ INR/APTT T2DM – Metformin + all the other drugs
sclerosis → portal HTN, cirrhosis RF – amount of alcohol, Bruising, leukonychia, UEC/CMP Weight loss – orlistat
Epi – M>F, BUT women more susceptible, 5 yr survival rate FHx, NAFLD things, clubbing, palmar erythema, Iron studies –
>50% if abstinent from alcohol hepatitis infection, spider naevi, haemachromatosis ?corticosteroids – suppress immune system
Comps – oesophageal or gastric variceal bleeding, ascites, haemochromatosis, hep C gynaecomastia, testicular Hep serology Sedatives + anticoags contraindicated in those
coagulopathy, hepatic encephalopathy, HCC, SBP, sepsis atrophy CRP/ESR w/ decompensation
Dupuytren contracture Imaging –
US (Fibroscan)
Abdo CT/MRI +/- biopsy
(?HCC)
Non-alcoholic Ax – part of metabolic syndrome (central obesity, HTN, Absence of significant Hepatosplenomegaly Bedside –
, Nikita Goyal; Hepatobiliary
fatty liver disease ^glycaemia, dyslipidaemia) alcohol use Truncal obesity
Simple fatty Pathophys – fat accumulation within the liver (more circulating Fatigue, malaise Bloods – FBE –
infiltration TAG’s (obesity) and hence gets taken up by the liver, reversible RUQ abdo discomfort anaemia, ↓ Plts
NASH – presence process; can involve inflammation and fibrosis LFT – (↑ AST, ↑ALT;
of fat leading to ?insulin resistance appears to be the key mechanism leading to AST:ALT<1, ↑bilirubin,
lipotoxicity and triglyceride accumulation in the liver ALP, GGT can also be
RF – obesity, diabetes,
inflammatory elevated, ↓alb)
^lipidaemia, ^tension,
damage to Epi – chronic liver disease in the Western world; prevalence is CMP - ↓Na
metabolic syndrome, rapid
hepatocytes 30% of adults Lipid panel
LOW, medications, total
parenteral nutrition, FHx Coags - ↑INR/APTT
Dx based on exclusion of other Ax e.g alcohol
Portal HTN Portal v – formed by SMV + splenic v; drains blood from the abdo Malaena Caput medusae Same as cirrhosis Primary – variceal screening; Non-selective
Pathological GI tract, spleen and pancreas into the liver Haematemesis (sudden) Anorectal varices BB (propranolol) – splanchnic vasoconstriction
evidence of Ax – pre-hepatic (portal/splenic vein thrombosis), intrahepatic Haematochezia – frank PR Haemorrhoids Would also lead to ECG + banding
elevated portal (cirrhosis), post-hepatic (Budd-Chiari syndrome, RHF, constrictive bleed Oesophageal + epigastric – RVH, pericarditis Ax
venous pressure pericarditis) varices G&H – variceal TIPSS – shunts portal v to vena cava; some
resulting from Pathophys - ↑blood flow via portosystemic anastomoses – RF – HF, alcohol intake, ↑ Splenomegaly – bleeding, haemorrhage risk of encephalopathy as GIT blood is not
obstructions in Paraumbilical + epigastric v – caput medusae; rectal v – BMI, Hx of HBV, HCV – bruising passing the liver
portal flow haemorrhoidal or anorectal varices; veins of gastric fundus + IVDU, sex, etc, thrombotic Upper GI bleeding
distal oesophagus – oesophageal/gastric varices Hx Ascites
Ascites –
Congestive splenomegaly → hypersplenism (thrombocytopenia);
1 Salt restriction <100mmol/day
transudative ascites
2 Diuretic therapy - Spironolactone +/-
Epi – 55% have oesophageal varices when diagnosed w/
frusemide
cirrhosis; Alcohol > NAFLD > Viral; oesophageal varices lethal in
3 Paracentesis – protein + MCS on first
20-30%; cirrhosis 2-5% annual risk of HCC
presentation; therapeutic on presentations
Comps – acute haemorrhage, gastropathy from pressure, HCC,
after; + albumin 20% IV during or soon after the
SBP
drain
4 TIPSS (bypass procedure) or Liver
Transplant
Variceal Bleed –
1 Haemodynamic Resus – IV/Central line
access, fluid resus to raise BP; conservate
blood transfusion to increase Hb to 70-80g/L
2 Airway protection – endotracheal intubation
if mandatory
3 Pharm – Abx – 3-5 days of IV ceftriaxone,
pip-taz or oral fluroquinolone; vaso-active meds
i.e terlipressin or octreotide for 3-5 days +
before endoscopy
4 Endoscopic therapy – Endoscopic variceal
ligation (oesophageal); endoscopic injection of
tissue adhesives (gastric)
5 Salvage therapy – balloon tamponade w/ a
Minnesota tube or TIPSS
Genetic and
