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Medicine - Cirrhosis + Portal HTN (iii) (LFTs (ALT, elevated in...…
Medicine - Cirrhosis + Portal HTN (iii)
HE
neuropsych manifestations of liver disease
pathogenesis unclear but ammonia = central
but don't request blood ammonia levels - only lead to confusion
4 stages: confusion -> drowsiness -> somnolence -> coma
hep flap (clonus) @ stage 2 = hallmark of dx
best noted with outstretched arm attempting to dorsiflex hand with fingers extended
initially a 'scissors' movement of the fingers, then a downward drift of hand with incomplete recovery motion, followed by sudden palmar flexion. Hand ten returns to initial position by dorsiflexion
40% die within 1 yr
precipitants
GI bleeding
sedatives/hypnotics
diuretics
TIPSS
alcohol binge
constipation
give lactulose, phosphate enemas, rifaximin (long-term non-absorbable antibiotic) - aim for 2-3 BMs / day
infection
myth = high protein die (encourage patient to eat protein as helps with muscle loss)
Jaundice/abnormal LFTs
assess urgently in OPD unless likely to be Hep A
see again in gastroenterology OPD ideally fasting, unless septic/encephalopathic/needs pain control (admit straight away)
LFTs
bili
if elevated: bile duct obstruction, haemolysis, Gilbert's
ALT, elevated in...
hepatocellular damage
HBV or HCV
AIH, PBC, PSC
drug reactions: co-amox, NSAIDs, flucloxacillin, anti-TB, statins
alcohol
genetic conditions
HFE
Wilsons (if under 40)
A1AT
NAFLD: steatosis, NASH (commonest cause of raised LFTs)
ductal disease (stones or tumours)
neoplasia (primary or secondary)
ischaemia/congesion (right HF)
more specific for liver damage than AST
AST
ALP
if elevated with gGT: obstruction or infiltration (tumour, sarcoid, amyloid)
if elevated but gGT normal: bone origin - Paget's (interferes with recycling process, fragile misshapen bones), osteomalacia, mets, growth
gGT
isolated elevation: alcohol, drugs
increased in...
cholestatis (PBC, PSC)
mechanical obstruction (large or small duct)
space-occupying lesion (tumour, abscess)
infiltration (sarcoid, amyloid, lymphoma)
alcohol
medications
Albumin
INR
glucose