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HEP Rachel Grainger Created by Rachel GraingerCreated by Rachel GraingerCreated by Rachel Grainger Created by Rachel Grainger THE LIVER Created by Rachel Grainger LIVER FUNCTION TESTSCreated by Rachel GraingerTYPES OF HEP ATITIS •Viral •Autoimmune •Bacterial •Fungal •Substance induced Created by Rachel Grainger Created by Rachel Grainger VIRALAUT OIMMUNE Created by Rachel GraingerCASE 1 Created by Rachel Grainger Created by Rachel Grainger COLIN 60 YEAR OLD MALE A TTENDING THE GP WITH NAUSEA, VOMITING AND DIARRHOEA. Temperature- 39 degrees Symptom duration 3 days Other symptoms- headache and malaise Created by Rachel Grainger PHYSICAL EXAMINA TION Tender over RUQ Rectal exam normal 10 spider naevi on torso Eye exam shows? Created by Rachel Grainger RELEV ANT HISTOR Y • TYPE TWO DIABETES •FORMER SMOKER 21 PACK YEARS •ALCOHOL. DAUGHTERS WEDDING TWO WEEKS AGO WHERE HE CONSUMED A LARGE AMOUNT OF •OTHERWISE NO HISTORY OF ALCOHOLISM •RETURNED FROM FISHING TRIP IN KILKEEL THREE WEEKS AGO- CAUGHT A TURBOT AND BOUGHT 2LB OF SHELLFISH •NEEDLESTICK INJURY TWO YEARS AGO WHEN VOLUNTEERING AT SAFE INJECTION SITE •RECEIVED POST EXPOSURE PROPHYLAXIS •DENIES ILLICIT DRUG USE Created by Rachel Grainger LIVER FUNCTION TESTS LFTS REVEALA FRANK TRANSAMINITIS. Which form of hepatitis is he most likely to have contracted? A. Hep A B. Hep B C. Hep C D. Hep D E. Hep E BONUS POINT:FROM WHICH OF HIS RECENT ACTIVITIES DID HE CONTRACT THE ILLNESS? Created by Rachel Grainger LIVER FUNCTION TESTS LFTS REVEALA FRANK TRANSAMINITIS. Which form of hepatitis is he most likely to have contracted? A. Hep A B. Hep B C. Hep C D. Hep D E. Hep E BONUS PO:FROM WHICH OF HIS RECENT ACTIVITIES DID HE CONTRACT THE ILLNESS? THE TWO POUNDS OF SHELLFISH Created by Rachel Grainger HEP A TITIS A SEROLOGY PCR NOT WIDY AAILABLE YET SO WE USE A BLOOD TEST VOR HA ANTIBODIES ▪ HAV-IGM ANTIBODIES ARE DABLE FROM T LEAST FIVEYSA AFTER THE ONSET OF SYMPTOMS, PEAK DURING THE ACUTE OR EARY CONVALESCENT LASTING FOT MOST SIX MONTHS ▪ HAV-IGG ANTIBODIES ARE PRODUCED IN THE FIRYS OF10 DA INFECTION AND THEN PER.ISTM FOR IMMEDIA TE I.E ACTIVE G FOR GOING ON A I.E PREVIOUS Created by Rachel Grainger Created by Rachel Grainger Colin wants to know how a he contracted hepatitis. WHA T IS THE MODE OF TRANSMISSION OF HEP A TITIS A? A. Respiratory droplets B. Physical contact C. Faecal-oral D. Vector bite E. Bodily fluid contact- e.g dirty needle Created by Rachel Grainger WHA T IS THE MODE OF TRANSMISSION OF HEP ATITIS A? A. Respiratory droplets B. Physical contact C. Faecal-oral D. Vector bite E. Bodily fluid contact- e.g dirty needle Created by Rachel Grainger COLIN A YEAR LA TER COLIN RETURNS WITH THE SAME SYMPTOMS AFTER A SEAFOOD FESTIV AL What would you expect his hepatitis A serology? A. Raised HAV IgM and HAV IgG B. Decreased HAV IgM and HAV IgG C. Normal HAV IgM and HAV IgG D. Raised HAV IgM and decreased HAV IgG E. Decreased HAV IgM and raised HAV IgG Created by Rachel Grainger COLIN A YEAR LA TER COLIN RETURNS WITH THE SAME SYMPTOMS AFTER A SEAFOOD FESTIV AL What would you expect his hepatitis A serology? A. Raised HAV IgM and HAV IgG B. Decreased HAV IgM and HAV IgG C. Normal HAV IgM and HAV IgG D. Raised HAV IgM and decreased HAV IgG E. Decreased HAV IgM and raised HAV IgGTREA TMENT Created by Rachel Grainger SYMPT OM MANAGEMENT Antiemetics Metoclopramide Fluid replacement Normal saline/ water Antipruritic Chlorphenamine Analgesia Paracetamol Hospital admission Only admit if severely unwellCASE 2 Created by Rachel Grainger Created by Rachel Grainger HELEN 43 YEAR OLD WOMAN Helen was found collapsed on the bathroom floor at home by her eldest daughter. Collateral history from eldest daughter: Dad running late home from work, mum seemed unwell- sweating and feverish- while cooking dinner. She went to the bathroom to get a paracetamol for a headache, gone forty minutes when the daughter heard a loud bang. Created by Rachel Grainger ARRIV AL IN A AND E HELEN HAS COME AROUND AND FEELING BETTER AFTER PARAMEDICS STABILISED HER IN THE FIELD. THE PARAMEDICS ARE JUST FINISHING UP THEIR PAPERWORK AND HAVE YET TO GIVE A COMPLETE HANDOVER. YOU NOTICE SHE IS JAUNDICED. WHICH BIOCHEMICAL CAUSES THE YELLOW COLOUR IN THE SKIN? A. BILIRUBIN B. HAEMOGLOBIN C. UROBILINOGEN D. STEACCOBILINOGEN E. CHOLECYSTOKININ Created by Rachel Grainger ARRIV AL IN A AND E HELEN HAS COME AROUND AND FEELING BETTER AFTER PARAMEDICS ADMINISTERED MEDICATION. SHE IS EAGER TO GET BACK HOME BUT YOU NOTICE SHE IS JAUNDICED. WHICH BIOCHEMICAL CAUSES THE YELLOW COLOUR IN THE SKIN? A. BILIRUBIN B. HAEMOGLOBIN C. UROBILINOGEN D. STEACCOBILINOGEN E. CHOLECYSTOKININ Created by Rachel Grainger ANALGESIA IN LIVER IMP AIRMENT Helen states she’s in a lot of pain- 10/10 and has ‘really bad’ diarrhoea. She asks for 10mg of morphine or 100mg of codeine. She is sitting upright in bed and seems comfortable. She does not appear to be in severe pain. Which first line analgesic would be most appropriate? A. Diclofenac B. Paracetamol C. Morphine D. Codeine E. Aspirin Created by Rachel Grainger ANALGESIA IN LIVER IMP AIRMENT Helen states she’s in a lot of pain- 10/10 and has ‘really bad’ diarrhoea. She asks for 10mg of morphine or 100mg of codeine. She is sitting upright in bed and seems comfortable. She does not appear to be in severe pain. Which first line analgesic would be most appropriate? A. Diclofenac B. Paracetamol C. Morphine D. Codeine E. Aspirin Created by Rachel Grainger T ALKING TO HELEN YOU RUN SOME EXTRA BLOOD TESTS ON HETS , YOU EXPAND UPON THE HISTORYESUL What questions would you like to ask her? Created by Rachel Grainger HELEN’S HISTOR Y HELEN GIVES A BRIEF HISTORY WITH NO SIGNIFICANT FINDINGS. SHE STOPPED WORKING FIVE YEARS AGO TO FOCUS ON THE CHILDREN. CLAIMS HER MARRIAGE HAS BEEN ROCKY OVER THE PAST FEW YEARS AND SHE BELIEVES THE COLLAPSES ARE DUE TO STRESS. YOU REVIEW HER BLOOD RESULTS. HER LFTS ARE DERANGED. GGT AND ALP DERANGED BY A FACTOR OF 1.5. ALT AND AST DERANGED BY A FACTOR OF 15. PROTHROMBIN T, BILIRUBIN AND ALBUMIN SHOW REDUCED SYNTHETIC FUNCTION. WHICH TEST RESULT IS THE MOST CONCERNING? A. AST AND ALP B. GGT AND ALP C. PROTHROMBIN TIME D. BILIRUBIN AND ALBUMIN E. ALL OF THESE RESULTS ARE CONCERNING. Created by Rachel Grainger HELEN’S HISTOR Y HELEN GIVES A BRIEF HISTORY WITH NO SIGNIFICANT FINDINGS. CLAIMS HER MARRIAGE HAS BEEN ROCKY OVER THE PAST FEW YEARS BECAUSE OF MONEY ISSUES AND SHE BELIEVES THE COLLAPSES ARE DUE TO STRESS. YOU REVIEW HER BLOOD RESULTS. HER LFTS ARE DERANGED. GGT AND ALP DERANGED BY A FACTOR OF 1.5. ALT AND AST DERANGED BY A FACTOR OF 15. PROTHROMBIN T, BILIRUBIN AND ALBUMIN SHOW REDUCED SYNTHETIC FUNCTION. WHICH TEST RESULT IS THE MOST CONCERNING? A. AST AND ALP B. GGT AND ALP C. PROTHROMBIN TIME D. BILIRUBIN AND ALBUMIN E. ALL OF THESE RESTS ARE CONCERNING. Created by Rachel Grainger PHYSICAL EXAMINA TION You ask her consent to perform a physical exam but she declines, becoming quite irate. She wants to go home and demands to be discharged if you won’t give her what she wants. While she is yelling at you, you notice something on her hand. Created by Rachel Grainger ECR • HELEN WAS IN AN RTA FIVE YEARS AGO- SHATTERED VIS AND BROKE RIGHT RIBS 8-12 • WENT THROUGH ORTHOPAEDIC SERVICE AND REHABILITATION. • ADMITTED TO A AND E IN MTIPLE HOSPITALS OVER THE PAST FEW YEARS WITH SIMILAR EPISODES OF COLLAPSE • FIVE PREVIOUS HOSPITALISATIONS DUE TO ASSTS WITH INJURIES CONSISTENT WITH HER BEING THE AGGRESSOR. • LISTED AS A HOSPITAL HOPPER • CURRENTLY UNDER REVIEW WITH NEUROLOGY AND CARDIOLOGY AS WELL- ECHO SCHEDULED FOR NEXT WEEK • PARAMEDICS FINALY GIVE YOU HANDOVER- THEY USED NALOXONE IM TO REVIVE HER.WHA T DO YOU SUSPECT AND WHY? SUBST ANCE ABUSE Created by Rachel GraingerWHICH OF THESE PEOPLE HA SUBST ANCE ABUSE PROBLEM? Created by Rachel GraingerMIND YOUR UNCONSCIOUS BIASES! Created by Rachel GraingerCreated by Rachel Grainger Created by Rachel Grainger HELEN’S DRUG USE HELEN ADMITS TO INJECTING HEROIN. Given her drug history and symptoms, what should you add to regular bloods? A. Repeat LFTs B. Blood smear C. Ten blood cultures D. Hepatitis B and C and HIV serology E. Urine dip for toxicology report Created by Rachel Grainger HELEN’S DRUG USE HELEN ADMITS TO USING HEROIN IV Give her drug history and symptoms, what should you add to regular bloods? A. Repeat LFTs B. Blood smear C. Ten blood cultures D. Hepatitis B and C and HIV serology E. Urine dip for toxicology report Created by Rachel Grainger HELEN’S SEROLOGY WHA T TYPE OF INFECTION DOES SHE HA VE? A. Active hepatitis B B. Chronic active hepatitis B with high infectivity C. Chronic inactive hepatitis B D. Immunity from vaccination E. Immunity from previous infection Created by Rachel Grainger HELEN’S SEROLOGY WHA T TYPE OF INFECTION DOES SHE HA VE? A. Active hepatitis B B. Chronic active hepatitis B with high infectivity C. Chronic inactive hepatitis B D. Immunity from vaccination E. Immunity from previous infection Created by Rachel Grainger HEP ATITIS B SEROLOGY Created by Rachel Grainger HEP ATITIS C Hepatitis C RNA- absent Hepatitis C ANTI- presentETHICAL DILEMMA: SHOULD WE INFORM HER HUSBAND? Created by Rachel Grainger Created by Rachel Grainger CONT A CTING PUBLIC HEAL TH HER HIV TEST IS NTIVE. BUT AS SHE HAS CHRONIC HEP B AND C, YOU MUST NOTIFY PUBLIC TH. SHE BEGS YOU NOT TO AND PROMISES TO GET CLEAN IF YOU D.N’T SHE CLAIMS THERE IS NO CHANCE HER CHILDREN OR HER HUSBAND HA VE IT SO PUBLIC HTH DON’T NEED TO KNOW . HER YOUNGEST CHILD IS THREE. What should we do?CONT A CT PUBLIC HEAL TH HER CHILDREN AND HUSBAND O BE TESTED! Created by Rachel Grainger Created by Rachel Grainger Thank Y ou. rgrainger01@qub.ac.uk CREDITby Flaticon, and infographics & images by Freepikesgo, and includes icons Peer2Peer Cirrhosis By Nitika Rajpal (nrajpal01@qub.ac.uk) Created by Nitika Rajpal ContentforHepatology Anatomy/ Hepatitis 01 Physiology 02 A, B, C Cirrhosis 03 ALD, NAFLD Created by Nitika RajpalFunctionsoftheliver Created by Nitika Rajpal Cirrhosis Definition: Scarring of the liver, as a result of chronic Common causes inflammation and damage to liver cells - Alcoholic liver disease ● Irreversible - Non-alcoholic fatty liver disease - Hepatitis B Diagnosis - clinical, radiological, fibroscan - Hepatitis C - Autoimmune hepatitis - Primary biliary cirrhosis - Haemachromatosis Stages Compensated - asymptomatic; with scarring on liver Decompensated - symptoms begin to present (jaundice/ascites); very serious stage Created by Nitika Rajpal Cirrhosis:signsandsymptoms Decompensated liver may present with : Scarring → limited ability of liver to: ● Jaundice ● Purify blood ● Break down toxins ● Ascites ● Fatigue ● Produce clotting proteins ● Cachexia ● Absorb fats/fat-soluble vitamins ● Coagulopathy ● Oesophageal varices ● Spider naevi ● Caput medusae ● Palmar erythema ● Bruising ● Asterixis ● Edema / fluid overload ● Hepatomegaly/splenomegaly ● Hepatic encaphalopathy Created by Nitika Rajpal Complicationsofcirrhosis Overall decrease in liver function 1. Decreased detoxification 2. Decreased oestrogen metabolism a. = increased oestrogen in blood i. Gynaecomastia ii. Spider naevi iii. Palmar erythema 3. Decreased bilirubin conjugation a. Increased unconjugated bilirubin b. Jaundice 4. Decreased albumin production a. Hypoalbuminemia 5. Decreased clotting factor production a. Coagulation issues Created by Nitika Rajpal Cirrhosis-prognosis ● Severity / survival score - assesses by Childs Pugh score : ○ encephalopathy ○ ascites ○ bilirubin ○ albumin ○ PT Created by Nitika Rajpal Case#1 A 57 year old woman presents to the ED with a history of “looking a” confusionur, and fatigue. She mentioned that she has noticed herself feeling a lot more tired, and says that her body has begun to feel weak as she has lost a bit of muscle. Her daughter has brought her in and is concerned about her wellbeing, and mentions that the patient works as a lawyer and due to the workload has recently moved into a flat closer to her work. On examination she has an enlarged abdomen, which is positive for shifting dullness. She shows signs of jaundice and cachexia. Created by Nitika Rajpal Question1 1. What primary investigation would you request? a. U&E b. LFTs c. Coagulation screen d. Liver screen e. Full GI exam and history Created by Nitika Rajpal Question1 1. What primary investigation would you request? a. U&E b. LFTs c. Coagulation screen d. Liver screen e. Full GI exam and history questions and the key examination findings for jaundice. Created by Nitika Rajpal Question2 2. Upon taking a more extensive history, you find out that the patient has 2 glasses of wine every night of the week after work. She also mentions a family history of alcoholism on her father’s side. How would you assess this patient’s dependency on alcohol? a. Talk to her about your alcohol tendencies to open up the subject b. Ask her family members c. CAGE screening tool d. Don’t address the topic e. Ask the blatantly patient if they have issues with alcohol abuse that? Q : How many units per week is Created by Nitika Rajpal Question2 2. Upon taking a more extensive history, you find out that the patient has 2 glasses of wine every night of the week after work (~30 units / week). She also mentions a family history of alcoholism on her father’s side. How would you assess this patient’s dependency on alcohol? a. Talk to her about your alcohol tendencies to open up the subject b. Ask her family members c. CAGE Screening tool d. Don’t address the topic e. Ask the blatantly patient if they have issues with alcohol abuse ~30 units / week Created by Nitika Rajpal Assessingalcoholdependence Screening tools : CAGE (2 or more positive answers) ● C : Have you ever felt you should CUT down on your drinking? ● A : ave people ANNOYED you by criticizing your drinking? ● G : ave you felt bad or GUILTY about your drinking? ● E : ave you ever had a drink first thing in the morning to steady your nerves or to get rid of hangover (EYE opener)? Audit-C - shortened version of audit screening tool Created by Nitika Rajpal AlcoholicLiverDisease Definition - caused by damage to the liver due to excessivInvestigations drinking ● U&E - dehydration, hyponatremia, hypo/hyperkalaemia ● Blood glucose - severe liver disease affects glucose Stages stores 1. Alcoholic fatty liver disease - fat accumulates arou●d Coagulation screen - coagulopathy the liver (reversible with alcohol cessation) ● Liver screen 2. Acute alcoholic hepatitis - inflammation of the liver ○ Hepatitis screen - acute viruses (reversible depends on severity of damage) ○ Autoimmune, coeliac, immunoglobulins 3. Alcoholic cirrhosis - severe form, scarred liver ○ Ferritin (irreversible) ○ Copper and caeruloplasmin ○ A-1 anti-trypsin levels Signs and symptoms (*cirrhosis) ● LFTs (AST:ALT >2) ● Radiology - CXR and USS (peritoneal aspiration) Risk factors ● Diagnostic peritoneal tap ● FHx ○ Albumin - SAAG to determine cause of ascites ● Alcohol misuse ○ Cell count to exclude infection ● Binge drinking ○ Culture ● Poor nutrition ● OGD - varices Created by Nitika RajpalBiochemicalinvestigations Created by Nitika Rajpal Liverbiopsy-goldstandardforcirrhosis Used for: Other tests: ● Liver disease of unknown aetiology ● USS: US is quick, inexpensive, and has a ● Differentiating between acute and chronic sensitivity of 65-95% for detection of CLD. disease ● CT: Provides a more detailed view of the ● Unable to differentiate between fibrosis abdominal viscera and is good for and cirrhosis secondary findings (e.g. features of portal hypertension). ● MRI: Is emerging as a highly sensitive and specific modality for liver fibrosis. Created by Nitika Rajpal Question3 3. Given the likely diagnosis, what would you expect to find in this patient's labs? a. Increased ALP , AT, albumin b. Increased bilirubin c. Decreased red blood cell d. Decreased GGT , ALT e. Increased AST , GGT, bilirubin Created by Nitika Rajpal Question3 3. Given the likely diagnosis, what would you expect to find in this patient's labs? a. Increased ALP , AT, albumin b. Increased bilirubin c. Decreased red blood cell d. Decreased GGT , AT e. Increased AST , GGT, bilirubin Created by Nitika Rajpal AlcoholicLiverDisease:management Consider alcoholic hepatitis Ascites ● Tachycardia, leukocytosis, LFTs of hepatitis profile, ● Anti-mineralocorticoid drugs - spironolactone mild fever ● Grade 1 or mild ascites - no treatment required ● GAHS - Glasgow Alcoholic Hepatitis Score (>9 = poor ● Grade 2 or moderate ascites - correct Na+ imbalance prognosis) (dietary restriction, diuretics) ● Maddrey’s discriminant function (>32 mortality as high as 30-50%) Nutrition - refeeding + pabrinex ● Steroids or pentoxifylline ● Multivitamins Alcohol abstinence Transplant ● Guidelines <14 units per week ● Child-Pugh score ● Interventions - evidence, primary care, delivery ● “Mercedes benz scar” (FRAMES) ● Indication → assessment → listing ● Alcohol liaison ● Alcohol rehabilitation Created by Nitika Rajpal Measuringseverity Maddrey discriminant function (DF), Model for End-stage Liver Disease (MELD) and Glasgow alcoholic hepatitis score Determining severity of alcoholic hepatitis is important to highlight patients with poor short-term survival and those who would benefit from pharmacological intervention. Created by Nitika Rajpal Question4 4. This patient returns to the ED 4 weeks after discharge and were found unconscious in their house. They were brought in by their daughter, who is worried that the patient may have relapsed. How would you assess this patient? a. Bloods and exam b. Ask them about their alcohol consumption c. Monitor their GCS and use GMAWS d. Ask them CAGE questions e. Ask an alcohol liaison nurse to take over Created by Nitika Rajpal Question4 4. This patient returns to the ED 4 weeks after discharge and were found unconscious in their house. They were brought in by their daughter, who is worried that the patient may have relapsed. How would you assess this patient? a. Bloods and exam b. Ask them about their alcohol consumption c. Monitor their GCS and use GMAWS d. Ask them CAGE questions e. Ask an alcohol liaison nurse to take over Created by Nitika RajpalCreated by Nitika Rajpal Inhospitalmanagement In DTs/Alcohol withdrawal - important to manage withdrawal (could have seizures, get extremely agitated) ● Iv thiamine (Pabrinex) twin vials x3 per day - to replace vitamins ○ give before any food ○ often re-feeding issues ● Oral / IV benzodiazepines as guided by the GMAWS chart ● Adequate nutrition ● Give laxatives Management for ascites ● Aldosterone antagonists: Can be combined with loop diuretics (i.e. furosemide). ● Paracentesis: Patients with tense (grade III) ascites ● Complication : SBP - serious medical condition with high mortality. ● Neutrophilic ascitic white cell count (WCC) >250/mm3. ● Antibiotics + Human albumin solution EXTRA READING : What is refeeding syndrome? Created by Nitika Rajpal ManagingHE ● bacteria within the gastrointestinal tract (e.g. ammonia). ● hunting of these harmful substances away from the liver into the systemic circulation at portosystemic collaterals (i.e. where the portal venous system joins the systemic venous system), although other mechanisms are postulated. First-line treatments: involves laxatives (i.e. lactulose 15-20 mls QDS) to maintain bowel motions. Should aim for 2-3 bowel motions per day. Second-line treatments: involves the long-term use of antibiotics (i.e. rifaximin) to reduce the proportion of ammonia-producing colonic bacteria. Created by Nitika Rajpal Case#2 A 30 year old woman with T2DM, presented with elevated LFTS when attending her GP for a check up, as she had been recently started on metformin and simvastatin. She has a BMI of 32.6 kg/m^2. She has not noticed any symptoms. AT = 196 U/l (10-45 U/l) These were her LFTs: AST = 132 U/l (15-35 U/l) ALP = 127 U/l (35-105 U/l) GGT = 42 U/l (5-40 U/l) Bilirubin = 15 µmol/L (1.71 to 20.5 µmol/L) Albumin = 48 g/L (34 to 54 g/L) INR = 2.9 (2Created by Nitika Rajpal Question1 1. What is the most likely cause of the LFT derangement given the corresponding presenting complaint? a. Non-alcoholic fatty liver disease b. Hepatitis A c. Alcoholic liver disease d. Cirrhosis e. Hepatocellular carcinoma Created by Nitika Rajpal Question1 1. What is the most likely cause of the LFT derangement given what you know about the patient? a. Non-alcoholic fatty liver disease b. Hepatitis A c. Alcoholic liver disease d. Cirrhosis e. Hepatocellular carcinoma Created by Nitika Rajpal Non-AlcoholicFattyLiverDisease Definition - Non-alcoholic fatty liver disease Signs and symptoms ● Histopathological condition ● Often asymptomatic ● Characterised by excess fat accumulation in the live● Fatigue ● RUQ pain ● Hepatomegaly Pathophysiology ● Presence of risk factors similar to those in metabolic ● Unclear - two-hit hypothesis syndrome (truncated obesity, hypertension, ○ Insulin resistance + further oxidative stress = hypretriglyceridemia, low HDL, hyperglycaemia steatohepatitis secondary to insulin resistance, annual incidence ● Associated with obesity, insulin resistance, metabolic syndrome Risk factors ● Smoking Stages ● Hypertension 1. NFAL - AKA steatosis ● High cholesterol 2. NASH - presence of inflammation and injury ● T2DM 3. Fibrosis - presence of liver scarring ● Poor diet 4. Cirrhosis - advanced fibrosis (irreversible) ● Obesity Created by Nitika RajpalCreated by Nitika Rajpal Question2 2. What would your next investigation be? a. Ferritin and transferrin b. Immunoglobulins c. Fibroscan d. Viral hepatitis screen e. Ultrasound liver assess? : What does a fibroscan Created by Nitika Rajpal Question2 2. What would your next investigation be? a. Ferritin and transferrin b. Immunoglobulins c. Fibroscan d. Viral hepatitis screen e. Ultrasound liver the liver - indication of fibrosis.ess of Created by Nitika Rajpal Non-AlcoholicFattyLiverDisease Investigations ● Identify risk factors + calculate fatty liver index ● If FLI >60 diagnosis of NFLAD ● US liver ● Hep B and C serology ● Autoantibodies ● Caeruloplasmin ● Immunoglobulins ● Alpha-1 antitrypsin antibody ● HbA1c ● Ferritin and transferrin ● Perform enhanced liver fibrosis testing (ELF) - first line recommended for fibrosis ○ Three molecules involved in liver matrix metabolism to give a score reflecting the severity of liver fibrosis ● Fibroscan ● Arrange biopsy - gold standard (in NASH) Created by Nitika Rajpal Question3 3. Now that you have a diagnosis, how would you manage this patient? a. Do nothing b. Dietary advice + manage T2DM c. Bariatric surgery + lose weight d. Liver transplant e. Increase statins NAFLD made?ow is the diagnosis of Created by Nitika Rajpal Question3 3. Now that you have a diagnosis, how would you manage this patient? a. Do nothing b. Dietary advice + manage T2DM c. Bariatric surgery + lose weight d. Liver transplant e. Increase statins and exclusion of other causes of fatty liver Created by Nitika Rajpal Non-AlcoholicFattyLiverDisease Management Conservative ● Dietary advice ● Exercise ● Manage co-morbidities ○ T2DM ○ High blood pressure ○ High cholesterol Pharmacology ● No licensed therapies ● In liver fibrosis - vitamin E or pioglitazone Surgery ● Bariatric surgery - for those unable to lose weight ● Liver transplant - in end-stage liver disease Created by Nitika Rajpal Question4 4. What will you continue to monitor for in this patient? a. Infection b. Chronic kidney disease c. Autoimmune hepatitis d. Hepatocellular carcinoma e. Alcoholic liver disease Created by Nitika Rajpal Question4 4. What will you continue to monitor for in this patient? a. Infection b. Chronic kidney disease c. Autoimmune hepatitis d. Hepatocellular carcinoma e. Alcoholic liver disease Created by Nitika Rajpal Monitoring Oesophageal varicies HCC: Increased pressure → dilated, tortuous vessels known as Patients with cirrhosis or chronic hepatitis B are high risk of varices that are at high risk of bleeding. The management developing hepatocellular carcinoma (HCC). HCC is a depends on whether they have led to acute GI bleeding or not. primary liver cancer that occurs most commonly in patients with cirrhosis. Primary prophylaxis (i.e. no bleeding): Involves the use of non-selective beta-blockers (i.e. propranolol, carvedilol) to Due to the high risk of HCC, patients with cirrhosis should be reduce portal pressure invited to undergo six-monthly surveillance with ultrasound Acute variceal haemorrhage (i.e. acute bleeding): Medical +/- Alpha-fetoprotein (AFP) blood test. emergency, ABCDE management, endoscopic variceal band ligation. *may require an urgent transjugular intrahepatic portosystemic shunt (TIPSS) Created by Nitika Rajpal NAFLD Complications ● Liver-related complications ○ Decompensated cirrhosis ○ Hepatocellular carcinoma ○ Sepsis ● Non-liver complications ○ Cardiovascular disease - common cause of death ○ Higher risk of hypertension, type 2 diabetes mellitus, chronic kidney disease and heart disease Created by Nitika Rajpal Thanks! Any questions? Email - nrajpal01@qub.ac.uk CREDITS: This presentation template was created by Slidesgo, including icons by Flaticon and infographics & images by Freepik Created by Nitika Rajpal
