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14 Feb 24 Flashcards

1
Q

Wilson dx CF

A

🧿Hepatic (ALF,chronic hepatitis , cirrhosis)
🧿Neurologic (parkinsons , gait disturbance , dysarthria)
🧿Psych. (Depression , personality changes , psychosis)

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2
Q

Wilson dx Diagnosis?

A

🤖Dec ceruloplasmin
🤖Inc hepatic copper excretion
🤖Keyser fleischer rings on slit lamp exam
🤖Inc Copper content on liver biopsy

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3
Q

Ttt of wilson dx

A

Chelators. D penicillamine , trientine
Zinc. Interferes with copper absorption

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4
Q

NAFLD def

A

Heaptic steatosis on imaging or biopsy
Exclusion of other etiologies
Alcohol
Hep C
Glucocorticoids

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5
Q

NAFLD CF

A

Mostly AS
Metabolic syndrome
AST/ALT <1
Hyperechoic texture on USG

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6
Q

Ttt of NAFLD

A

Weight loss. (Diet modification, exercise)
Bariatric surgery if BMI >-35 kg /m2

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7
Q

Prognosis of NAFLD

A

Heptic fibrosis ass with inc risk for cirrhosis and liver related death

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8
Q

Pathogenesis of NAFLD

A

Insulin resistance coexists with metabolic syndrome

😈Insulin resistance ➡️ inc peripheral lipolysis ➡️ triglyceride synthesis ➡️ inc hepatic acculmulation of FA and triglycerides

😈Insulin resistance ➡️ hyperinsulinemia ➡️ inc lipogenesis ➡️ hepatocyte fat accumulation ➡️ dec VLDL ➡️ dec export to circulation

➡️ dec oxidation ➡️ dec metabolism

😈 FFA accumulation ➡️ free radical and pro inf cytokine generation ➡️ inflammation and hepatocyte injury (steatohepatitis)

😈 FFA worsens insulin resistance by impairing insulin dependent glucose uptake and increasing gluconeogenesis

Histo; macrovesicular fat deposition with peripherally displaced nuclei

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9
Q

How to identify NAFLD

A

Mildy elevated LFTs
AST/ALT <1
ALP mayb inc
Bilirubin and albumin normal until cirrhosis develops

Dx : USG (hyperechoic texture)
Liver biopsy

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10
Q

What is hepatic hydrothorax

A

A pleural effusion not due to cardiac or pulmonary abnormalities

Causes transudative effusions and occurs through small defects in diaphragm
The defects permit peritoneal fluid to pass into pleural space which occurs on RIGHT side (due to less muscular diaphragm)

Although tense ascites can cause dec diaphragmatic excursion but that would not cause UL Symptoms.
To have right sided dullness and decrease breath sounds on right side is hydrothorax

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11
Q

CF of hepatic hydrothorax

A

Dyspnea
Cough
Pleuritic chest pain
Hypoxemia

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12
Q

DX of hepatic hydrothorax

A

Exclude other causes
Echo
Thoracentesis

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13
Q

Ttt of hepatic hydrothorax

A

Salt restriction
Diuretics
Liver transplant

Avoid chest tube as it can lead to large volume protein , fluid , electrolyte losses

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14
Q

Management of cirrhosis

A

🥶treat underlying Liver Dx
HCV , HBV
NASH (weight loss )

🥶 provide preventive care
Avoid alcohol and hepatotoxic medicines
Vaccinate against HAV , HBV(unless already immune)

🥶 manage complications

    Screen for varices endoscopy
    Screen for HCC  (USG , AFP 6-12Mo)
    Freq clinical assessment for ascites and enceph (prophylaxis not recommneded)
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15
Q

CF of Spontaneous Bacterial Peritonitis

A

🤬Temperature >- 37.8
🤬Abd pain /tenderness
🤬AMS (abnormal connect the numbers test)
🤬Hypotension , hypothermia , paralytic ileus with severe infection.

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16
Q

SBP dx from ascitic fluid

A

PMN >-250/mm3
Positive culture ( ecoli klebsiella)
Protein <1g/dl
SAAG. >-1.1 g/dL

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17
Q

Ttt of SBP

A

Empiric AB (3rd gen CEPH cefotaxime)
FQs for prophylaxis.

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18
Q

What is SBP

A

In ascites pts abdominal tenderness and any change in mental status
Rigidity and rebound tenderness are absent as ascitic fluid serves as cushion between parietal and visceral peritoneal surfaces.

Give Empirical AB to pts with >-250 neutrophils in paracentesis.

Severe cases have paralytic ileus.

19
Q

SBP vs peritonitis due to perforation

A

SBP is due to enteral bacterial translocation (e coli). or hematogenous spread(pneumococcus)

20
Q

Causes of Ascites

A

Portal HTN. :
Cardiac ascites
Cirrhosis

Non portal HTN :
Malignancy
Pancreatitis
Nephrotic syndrome
TB

21
Q

How to assess Ascitic fluid. On basis of SAAG

A

>

  • 1.1 g/dL indicates Portal HTN
    Causes include Cirrhosis , HF
    Budd chiari , portal vein thrombosis
    (Inc Hydrostatic pressure in heptic capillary beds)

< 1.1 g/dL indicates nonportal HTN
Malignancy, TB , nephrotic syndrome

22
Q

Ascitic fluid characteristics on basis of Total protien

A

<2.5 g/dL is consistent with cirrhosis or nephrotic syndrome

>

  • 2.5 g/dl suggest RHF (hepatic congestion)
23
Q

Ascitic fluid Cell count assessment

A

> -250 neutrophils is SBP

24
Q

Pt with new onset ascites

A

Do diagnostic paracentesis

   😶‍🌫️Cell count and differential

Lymphocytsosis - malignancy , TB

Neutrophils. - SBP

   😶‍🌫️Albumin(SAAG) 
   😶‍🌫️Total protein
25
Management of ascites in cirrhosis
😱Initial evaluation; Abd USG Diagnostic paracentesis 😱Medical ttt: Spironolactone with furosemide Alcohol abstinence , Sodium restriction Avoid ACEIn , ARBs , NSAIDs 😱Refractory : Large volume paracentesis TIPS
26
How would lactulose lower serum ammonia levels
Non absorbable disaccharides (lactulose , lactitol) Colonic bacteria convert them into lactic acid which converts NH3 into nonabsorbable NH4+ and also cause bowel movement (excretion if fecal nitrogen) Medicine is titrated to produce 2-3 semiformed stools perday.
27
Pt with elevated Conjugated Bilirubin plus Normal LFTs
Dubinjohnson syndrome
28
Dubinjohnson syndrome mech and CF
Impaired excretion of bile due to defect on bilirubin transporter CF : Episodes of jaundice begin in puberty and ppt by illness , pregnancy , OCPs Dubin johnson vs Rotor Biopsy Of DJ showd black liver Rotor has normal biopsy Ttt: Not required. No longterm sequel
29
SS of Ascites
Increased abd girth Weight gain Early satiety Dyspnea (due to impaired diaphragmatic excursion )
30
Cause of Ascites in Cirrhosis
Portal HTN causing splanchnic vasodilation that leads to salt and water retention(edema and ascites)
31
SS of Cirrhosis
Early dx : (ongoing inf) Shrunken liver Spleenomegaly Hepatomegaly Late : Spider angiomas Palmar erythema Jaundice.
32
Signs of decompensation in Cirrhosis
Variceal hemmorhage Jaundice Ascites Hepatic encephalopathy
33
Why dont we do serum ammonia levels to test for enceph
Poor SN and SP Dx of HE is clinical
34
How to manage cirrhosis
Do labs LFTs , INR , abumin , bilirubin 🥶If compensated. Do USG and AFP surveillance 6Mo Endoscopy surveillance for varices 🥶If decompensated Variceal hemm ; Nonselective BB Endoscopy every year Ascites : dietary sodium restriction, furosemide spironolactone , abstinence from alcohol Hepatic enceph : treat underlying cause (infection , bleed) , lactulose
35
Primary prophylaxis for varices
Candidates are pts Who are small varices at risk of bleeding or medium to large varices Non selective BB Nadolol propranolol carvedilol Nadolol and propranolol significantly decrease portal pressure by promoting splanchnic vasoconstriction (disrupting B2 mediated vasodilation ) and lowring cardiac output. Carvedilol blocks Alpha 1 receptors in hepatic sinusoids reducing intrahepatic resistance and portal pressure But its vasodilatory properties inc risk of systemic hypotension. Use carvedilol in compensated cirrhosis (no ascites enceph jaundice) Nadolol and propranolol in decompensated.
36
Endoscopic variceal ligation
EVL For large sized varices BB or EVL depends on pt preference and size of varices
37
Evaluation of cirrhosis acc to common causes In USA
History : medication Social habits (alcohol , drug use , high risk sexual activity) Family History (hemochromatosis) IV drug user (viral hepatitis) Obese (NAFLD )
38
Ischemic hepatitis identification in sceniaro
Shock liver 😡Diffuse liver injury 😡Liver has dual blood supply so diffuse injury more common than focal 😡Massive hypovolemic shock patient 😡Rapid and 25 to 250 times peaked LFTs 😡Bilirubin and ALP also increased LFTs reach >10,000 🥵if pts survive underlying cause liver enzymes reverse in 1-2 weeks.
39
Alcoholic hepatitis CF
😓Jaundice , Anorexia , Fever 😓RUQ pain , epigastric pain 😓Abd distension (ascites) 😓Prox muscle weakness from muscle wasting if malnourished 😓Possible hepatic encephalopathy
40
Labs of alcoholic hepatitis
Elevated AST , ALT <300 but always <500 AST/ALT >2 Elevated GGT , bilirubin , INR ,ferritin (GGT is enzyme in liver and Ferritin is APR) Leukocytisis (neutrophils) Dec albumin (if malnourished) Abd imaging shows fatty liver.
41
If AST , ALT elevated to >25 times the upper limit cause
Acetaminophen Ischemic Viral hepatitis
42
When to Dx NAFLD
Pt with elevated BMI Dx of exclusion First rule out other common causes of liver dx eg alcohol
43
Pt with UC comes with progressive fatigue and elevated ALP
PSC Do MRCP
44
DX of PSC
😬MRCP 😬ERCP (pts who cannot undrrgo MRI ) 😬Liver biopsy (for atypical cases but classic picture if ductal obliteration and onion skin fibrosis is seen in only 25% cases)!

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