2. HB Clinical Medicine Flashcards by J L

CBC

• Most basic test we can order > CBC
	○ L: saw horse
	○ Basic CBC > \_\_\_\_, Hbg, \_\_\_\_ and platelets
	○ Important to understand liver status
• Can be drawn by an X
• There's an expanded > when getting a differential of the \_\_\_\_
	○ Can include \_\_\_\_ indices

WBC
Hct
WBC
RBC

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Platelet count (Plt)
• Range: 150,000 - \_\_\_\_ cells/mm3

High (thrombocytosis)
____ reactions, blood d/o, ____, post- splenectomy
Low (thrombocytopenia)
____ (due to portal hypertension)
associated with ____• Higher than normal > thrombocytosis
• Lower than normal > thrombocytopenic
○ Problematic in that you may alter treatment based on how low
§ <50k > consult physician if patient needs ____ esp in a lot of bleeding
□ <20k may see ____ bleeding in oral cavity

400k
inflam
malignancy

hypersplenism
liver cirrhosis

platelet infusion
spontaneous

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Liver Function Assessment
LIVER INJURY TESTS (enzymes)
____, ALT, ____

TESTS OF SYNTHETIC FUNCTION
____, prothrombin time

MARKER OF HEPATIC TRANSPORT CAPABILITY
Serum ____

• Liver injury tests
• Tests of synthetic function
• Marker of hepatic transport capabilty
	○ Cricial lab values that request from physicain in a patient that we know has liver disease in order to make sure they're stable for treatment

AST
ALP
albumin
bilirubin

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Aspartate aminotransferase (AST)
• \_\_\_\_ [serum glutamic oxaloacetic transaminase] 
• Released from injured \_\_\_\_
• Range: \_\_\_\_ U/L
• AST > ALT in \_\_\_\_ liver disease 
• \_\_\_\_:1

* Old name = SGOT
* Liver disease > has more AST
* Can look at AST/ALT values > can tell the etiology of the disease usually

SGOT
hepatocytes
8-33
alcohol-realted
2

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Alanine aminotransferase (ALT)

____ [serum glutamic pyruvic transaminase]
Released from injured ____
Range: ____ U/L
ALT > AST in ____
____:1• Can look at just lab test and look at just ALT and AST and figure out the disease type

SGPT
hepatocytes
4-36
viral hepatitis
10

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Alkaline phosphatase (ALP)
• Released from injured hepatocytes (often due to \_\_\_\_ obstruction)
• Range: \_\_\_\_ U/L
• high = \_\_\_\_, cholestatic liver dz., \_\_\_\_ dz., hyperparathyroidism, \_\_\_\_, osteomalacia
• low = \_\_\_\_, hypothyroidism

• Pagets/OM = bone disorders

biliary
20-130
ESLD
metastatic
pagets
scurvy

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Albumin

Protein synthesized in ____ • ____% of total protein
Range: ____g/dL
Low = ____ disease, malnutrition, ____

liver
65
3.5-5.0
liver
dehydration

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activated Prothrombin Time (aPT)
• Screening test to identify acquired or inherited deficiencies in the activities of factors ____, prothrombin and ____
• Monitor oral anticoagulant therapy with ____, which decreases the activity of ____ and prothrombin
• Range = ____s

* Order regularly in a clinic setting
* Pt > patients on warfarin (coagulant) > affected by warfarin > assessing their Pt and their INR

V, VII, X
fibrinogen
warfarin
VII, IX, X
10-12.5

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aPT
• Prolongation of the aPT occurs when there is:
- ____ disease
- ____ deficiency
- Disseminated ____ coagulation
- ____ Syndrome
- Treatment with certain antibiotics, chemotherapeutics, or antithrombotic drugs

• Elevated PT > coagulation issue

liver
vitamin K
intravascular
nephrotic

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INR: International Normalized Ratio
• Mathematical “____” (of the ____ ratio) for differences in the sensitivity of thromboplastin reagents
• Relies upon “____” thromboplastins
• Allows for comparison of results between labs and standardizes
reporting of the activated prothrombin time
• Range=____

• Primary test clinically > INR
	○ Activated PT > differences in values that couldn't be standardized based on diff reagents used
		§ Couldn't get a standard number > INR created to correct that
• Important to understand INR in context of PT; look at both!
	○ If PT is sig elevated > and INR is normal > still not \_\_\_\_
• 1.0 is a normal value for someone who is not anticoagulated

correction
aPT
reference
0.8-1.2
normal

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activated Partial Thromboplastin Time (aPTT)

• Screening test to identify acquired or inherited deficiencies in the activities of Factors ____
• Monitor ____ anticoagulation
• Screening test to assess reduction in the activity of fibrinogen, Factors ____
(____ more sensitive)
• Range = ____s

• Clinically > heparinized (patients are usually hospitalized, or on low MW heparin)
	○ Blood thinner is usually warfarin, but some heparin patients in hospital
• Range is diff from aPT

IX, VIII and XI
heparin
V and X
PT
25-41

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Serum bilirubin
• Breakdown product of ____ that is transported / metabolized by liver
• Total (____ mg/dl)

Increased in patients with:
____
Cirrhosis
____ obstruction
Hemolysis
____• Hyperbilirubinemia > common in ____
○ Liver isn’t processing RBC as quickly
○ Look jaundiced > go under special light to break up the pigment
○ Common finding in newborns to determine how well liver is functioning

hemoglobin
0.3-1.0
hepatitis
biliary
fasting
newborns

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Cirrhosis

A late stage of progressive hepatic ____ characterized by distortion of the hepatic architecture and formation of ____ nodules
Compensated vs. Decompensated
Considered ____
Only therapeutic option may be liver ____• Clinically > is patient is compensated or decompensated
○ Comp: functioning ____
○ Decomp: develop the ____ > the stigmata of liver disease
○ A question asked if patient is aware of medical status

fibrosis
regenerative
irreversible
transplanation
actively
sequalae

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• Irregualr surface and nodules > ____ appearance

Natural history of CLD
	• CLD > progress > compensated (liver funcitons and maintains homeostasis) > transition marked by things that may present in oral cavity or on the face:
		○ \_\_\_\_ hemorrhage
		○ Ascites
		○ \_\_\_\_ (altered mental)
		○ Jaundice
			§ Can see it on the \_\_\_\_
	• Then decompensated > higher risk for death

variceal
encephalopathy
gingiva

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Decomp shortens survival

• Survival times in cirrhosis
	○ 260 patients who had comp cirrhosis
	○ Median survival of all w cirrhosis: \_\_\_\_ years; but those w sequalae of decomp > \_\_\_\_ years
		§ Difference in life expectancies

1.6

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I : Confirming the diagnosis

____ examination findings
____ testing findings
____ showing evidence of portal hypertension (with varices)
May present ab initio with one of the life threatening complications
Histologically (____): GOLD STANDARD
Discovered incidentally at ____ or autopsy

physical
radiologic
endoscopy
biopsy
surgery

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Physical Examination Findings Jaundice
• Patient is jaundiced
○ ESLD
• Yellowing of ____

Physical Examination Findings Palmar Erythema
	• Palmar erythema
		○ \_\_\_\_ change w ESLD
			§ Redness
			§ Can be decompensated

Physical Examination Findings Spider Angiomas
• Spider angiomas
○ Cirrhosis/ESLD
○ Not always in obvious position, can see on ____

Physical Examination Findings Ascites
• Portal hypertension and fluid retention > ascites
○ Don’t do dentistry > end stage liver dx > should be in the ____

Physical Examination Findings Hepatic Encephalopathy
• Hepatic encephalopathy
○ Altered mental status:
○ I: ____ changes
○ II: ____, flapping tremor and muscle ____
○ III: ____, loud and ____

sclera
vascular
neck
hospita;
personality
lethargy
twitching
noise
violent

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Radiologic diagnosis

* Liver on an axial view
* \_\_\_\_ of the liver, no smooth surface > representative of liver cirrhosis

nodularity

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Endoscopic Diagnosis
Varices

• Endoscopic diagnosis
	○ Looking for varices > rupture and you will see blood in the \_\_\_\_ lumen > difficult to stop the bleeding

esophaegeal

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Histologic Diagnosis
Cirrhosis is defined by the presence of ____ septa that diffusely involve the liver and ____ the parenchyma into nodules

• Gold standard = \_\_\_\_

fibrosis
subdivide
histologic dx

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II : Determining the etiology
\_\_\_\_
\_\_\_\_
      \_\_\_\_
\_\_\_\_ ingestion

• Once pt comes in and they have symptoms of liver dx > what is causing it?
	○ Focusing on viral and alcohol related
		§ But genetic and autoimmune is also seen

viral
autoimmune
genetic
toxic

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Viral Hep - overview

A
Source of virus: \_\_\_\_
Route of xmission: \_\_\_\_
Chfronic infection: \_\_\_\_
Prevention: \_\_\_\_

B
Source of virus: \_\_\_\_
Route of xmission: \_\_\_\_
Chfronic infection: \_\_\_\_
Prevention: \_\_\_\_

C
Source of virus: \_\_\_\_
Route of xmission: \_\_\_\_
Chfronic infection: \_\_\_\_
Prevention: \_\_\_\_

D
Source of virus: \_\_\_\_
Route of xmission: \_\_\_\_
Chfronic infection: \_\_\_\_
Prevention: \_\_\_\_

E
Source of virus: \_\_\_\_
Route of xmission: \_\_\_\_
Chfronic infection: \_\_\_\_
Prevention: \_\_\_\_

feces
fecal-oral
no
pre/post-exposure immunization

blood/blood-derived body fluids
percut permucosal
yes
pre/post-exposure immunication

blood/blood-derived body fluids
percut permucosal
yes
blood donor screening; risk behavior mod

blood/blood-derived body fluids
percut permucosal
yes
pre/post-exposure immunization; risk behacvior mod

feces
fecal-oral
no
ensure safe drinking water

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Estimates of acute and chronic disease burden for viral hepatitis

	• Estimated burden of disease
	• Chronic inf mostly related to \_\_\_\_ and \_\_\_\_
		○ HBV
		○ HCV
			§ Shown to be more than \_\_\_\_!

HBV
HCV
HBV

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Hepatitis A Virus
• ____
• Single ____ worldwide
• Acute disease and asymptomatic infection
• No ____ infection
• Protective ____ develop in response to infection
• Confers lifelong ____

* One serotype worldwide > easy to develop vaccine
* Endemic outbreaks of HPA > from restaurants, food

rna picornavrius
serotype
chronic
abs
immunity

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Geograph distribution of HPA • HPA vaccine is recommended for people who ____ or work in areas where the prevalence is high

travel

HPA transmissino - viral infection of the liver spread when ____ matter enters the mouth - may last several weeks and can be debiliatting but most people ____ completely - preventable w careful ____, keeping toilets and bathrooms clean, avoiding infected water sources ``` • Symptoms ○ ____ ○ Vomiting ○ (High ____) • Spread by ○ Direct ____ ○ Food/beverages ○ ____ and spoons ```

fecal recover hand washing nausa fever contact cups

Hepatitis A : Clinical Features • Jaundice by age group: <6 yrs 6-14 yrs >14 yrs <10% 40%-50% 70%-80% ``` • Rare complications: ____ hepatitis ____ hepatitis ____ hepatitis • Incubation period: Average ____ days Range 15-45 days • Chronic sequelae: ____ ``` • Jaundice is primarily in patients >____ years of age (younger kids usually do not!) • Rare complications ○ Different types of liver complications • Will take a month for someone to develop HPA infection w symptoms ○ Tough to go back and trace what people were doing ○ Two weeks to month and half

``` fulminant cholestatic relapsing 25 none 14 ```

``` Prevention of Hepatitis A • ____ (e.g., hand washing) • ____ (e.g., clean water sources) • Hepatitis A ____ (pre-exposure) • Immune ____ (pre- and post-exposure) ```

hygiene sanitation vaccine globulin

Hepatitis D (Delta) Virus • Co-infection with ____ – Severe, acute disease – low risk of ____ infection • Super-infection – usually develop chronic ____ infection – high risk of severe, ____ liver disease • Don't see it often • No HBV > cannot get HBD ○ Exam question • Can be infect w HBV, and then HBD can come in > superinfection

HBV chronic HDV chronic

Hepatitis E • Small, ____-stranded 7.5 kb ____ virus • Most outbreaks associated with ____-contaminated drinking water • Minimal ____ transmission • U.S. cases usually have history of ____ to HEV-endemic areas • Fecally-contam drinking water > similar to HPA

``` single RNA fecally person-to-person travel ```

Hepatitis E - Clinical Features • Range: ____ days • Case-fatality rate: Overall, 1%-3% ____ women 15%-25% • Illness severity: Increased with ____ • Chronic sequelae: ____ identified

15-60 pregnant age none

Hepatitis B Virus: Fast Facts • 2 billion people have been infected by HBV – 240 million chronic infections • Most people with HBV are in ____ or Africa • Transmission in Asia/Africa usually at ____ / childhood – 80-100% will remain infected • Transmission in the U.S. occurs in ____ / early adulthood – Only 5-10% remain infected • Long term implications regarding patient stability and therapy > liver transplant

Asia birth adolescence

Geographic Distribution of Chronic HBV Infection • Geographic distribution of HBV ○ ____, Canda, Mexico > lower prevalence of HBV infection

Hepatitis B: Disease Progression • Acute infection ○ All infected ____ progress to chronic disease ○ Smaller % of ____ will develop chronic • Chronic infection ○ 30% > ____ ○ 5-10% > ____ § Poor prognosis > die ○ 25% > undergo ____/decomp liver failure § 25% decomp within ____ years of dev cirrhosis § Can undergo transplantation § Or decompensate to death

``` children adults cirrhosis HCC liver failure 5 ```

HBV Serology First serologic marker following exposure is hep b surface antigen known as ____ can be seen about a month after infection but can range from 1-9 weeks and precede symptoms • Symptoms usually occur ____ weeks after exposure but can range from 9-21 weeks. • When serologic test is positive, HBV ____ can be detected in the patients blood. • About 50% of patients will test negative by ____ weeks after symptoms have appeared. • All recovered patients will test negative for ____ and HBV ____ 15 weeks after symptoms appear. • Hep B e antigen is usually detected with ____ disease. Usually correlates with ____ titers of infection of the virus and greater infectivity. • Anti-HBe (yellow bar) generally indicates ____ levels of virus titer and therefore lower infectivity. • Diagnosis of acute HBV ca n be made with ____ antibody to the hepatitis B core antigen, IgM anti HBc (pink one) and becomes undetectable 6-9 months. • Total antibody IgM and IgG to hepatitis b cor antigen referred to ____ (purple line) remains as a marker of ____ infection. • Antibody to hep b surface antigen (Anti HBs, orange line) becomes detectable during ____ and after HBsAg disappearance and generally shows the ____ from infection.

``` HBsAg 12 DNA 7 BHsAg DNA acute higher lower IgM total antiHBc past convalescence recovery ```

HBV Serology • There is a period of time (window period) when ____ is gone and before ____ appears. During this time, when diagnosing ____ and and ____ may be the only ones presence. • Also an early period when only ____ is present. • A person with chronic hep b virus infection will have both ____ (red) and total antibody to ____ (Blue). These will both be constantly present through serologic testing. • HBV DNA will usually be detected as well using a ____ test. • HBeAg will usually indicate ____ DNA levels and infectivity. • ____ (purple) conveys the opposite • Chronic HBV infection is diagnosed when a patient has a positive result for ____ or or HBeAg or HBV ____ on at least two samples 6 months apart • Or can be diagnosed if there is any of of these on a single sample with a negative test for I____

``` HBsAg antiHBs IgM total anti HBc HBsAg ``` hep b surface antigen hepatitis B core antigen ``` nuclear acid higher antiHBe HBsAg HBeAg DNA IgM anti HBC ```

HBV Serology Successful vaccination against HBV results in the production of ____. Needs ____ mIU/mL to define as immunized against HBV 1-2 months after series. This not ____ significant. Serological test result can indicate immunity with at least 3 doses of vaccine. Without repeated exposure, antibodies will declined over time. Even if below 10, ____ likely remains. This chart summarizes everything nicely. Acute infection will start off with ____ being positive but as it resolved levels will drop to where it will be negative.

``` antiHBs 10 clinically immunity HBsAg ```

• Vaccinated against HBV ○ First dose when ____ ○ Second dose after a couple ____ ○ Bt ____ months > third dose • Decline of ab to the HBV vaccine > vaccine confers imm to infectious process ○ Marker of 10 INTunits ○ Over time > may need a ____ to see your level is over time

birth months 6-18 titer

Hepatitis C: Fast Facts • 170-200 million people infected globally • The leading cause of chronic ____, cirrhosis, liver cancer and primary indication for liver ____ in the Western World • ____ major HCV genotypes • Predominant risk factor for HCV acquisition is ____ – Among US adults ages 20-59, with any history of illicit drug use, prevalence of HCV infection is > 45% • Predominant HCV genotypes > important for diagnostics

hepatitis transplantation 5 IVDA

Hepatitis C screening ``` • Transmission ○ ____% of patients don't know how they got it ○ ____ is predominant ○ Blood ____ § Before 1992 ○ ____ activity ○ ____, body piercing ○ Illicient ____ drug use ○ ____ factors § Before 1987, wasn't screened ```

``` 30 IV drug abuse transfusions sexual tattoos intranasal clotting ```

* Hep C preferentially affects a certain age group > born bt ____ have highest probability of developing hepC * 3 mill infected > most are ____ * ____ people infected don't know they have the virus * 1945-65 > tested for hepC

45-65 baby boomer 3/4

Natural history of HCV infection • Know what year your patient was born • Chronic disorder • Exposed > acute phase > 15-40% ____ the infection and won't dev chronic inf; 60-85% dev ____ hepC infection; 20% go to ____ ○ 6% go onto ____ ○ 4% go onto ____ § Both of which, 3-4% develop transplant or death • 20 year progression rate accel w ____ and ____

``` recover chronic cirrhosis ESLD HCC HIV alcohol ```

``` Diagnosis of HCV: What test to use ? • Hepatitis C ____ (Anti-HCV) • Hepatitis C ____(PCR) • HCV ____ • Liver biopsy –____ (determine inflammation) –____ (determine fibrosis) ```

``` antibody virus RNA genotype grade stage ```

HCV serology With new infections, most are ____ but 15-30% of cases are ____. 85% though will go on to have chronic HCV infection. Those who clear the virus on their own are said to have resolved the virus. In recently acquired HCV infections liver enzymes may be elevated to ____ IU/L or more. This is depicted by the marker ____ in blue. Most newly infected persons are ____ free so many go undiagnosed acute infection. Those with symptoms don't develop symptoms until about ____ weeks, ranging from 2-26 weeks. Persist when enzymes levels are high. About 40% of infected will have ____present (pink line) in serum about 10-11 weeks after exposure. With percent increasing by 18 weeks and almost all people after ____ months of exposure. Generally remains positive for ____. HVC RNA can be detected by ____ assay and can be detected 2 weeks after exposure. Liver ____ will go away as the disease procresses and HCV ____ disappears as anti HCV rises. Lab antibody tests alone cannot ____ between chronic, acute, or resolved. Chronic- persistence of HCV RNA and fluctuating ALT. ____ will be lower though. Recommended ____ sequence is shown in the flow chart.

asymptomatic symptomatic 200 ALT symptom 6 anti-HCV 6 ``` life NAT enzymes RNA distinguish ALT testing ```

Non-alcoholic fatty liver disease (NAFLD) • Subcategories – Non-alcoholic fatty liver (NAFL) • (+) hepatic ____ • (-) hepatocyte ____ – Non-alcoholic steatohepatosis (NASH) • (+) hepatic ____ • (+) hepatocyte ____ (ballooning +/- fibrosis) • Most ____ chronic liver disease in developed countries – Global ____ epidemic • U.S.prevalence – Approx. 30% of general pop. • ____ > males • Mean age of diagnosis is ____ • ____ > Caucasians > Blacks • Risk of developing ____ ``` • NAFL ○ Hepatic steatosis - fatty change ○ No hepatocyte injury • NASH ○ See fatty change, but you also see hepatocyte injury ```

steatosis injury steatosis injury ``` prevalent obesity female 50 hispancis HCC ```

NAFLD Pathophysiology • ____ metabolic disorder – Genetic factors – genetic ____ (e.g. PNPLA3) – ____ factors - (e.g. insulin resistance) – ____ factors – (e.g. obesity / physical inactivity) * Associated with ____ Syndrome * Associated with ____ * T2DM, HTN – greater disease ____ * NAFL→____ * Type 2 is very common * NAFL can progress to NASH (histologic damage to the liver > predisposes to cirrhosis)

``` complex polymorphisms hormonal nutritional metabolic type 2 diabetes progression NASH ```

``` NAFLD Diagnosis • ____ in majority of patients • ____ history • Hepatic serologies – May be ____ in NAFLD • Hepatic imaging – US / CT / MRI to detect architectural changes • Liver biopsy – ____ grade, ____ grade, ____ staging system – NAFL vs NASH ``` * ALT, AST, albumin, PT, PTT may be normal or abnormal * ____ live on imagery can be an end-stage representation of this * Staging system that determines severity of disease

``` asymptomatic medical normal steatosis activity fibrosis nodular ```

NAFLD Treatment • ____ therapy • Lifestyle interventions (e.g. nutrition, exercise) • Pharmacologic therapy – ____-sensitizing agents (e.g. metformin) – Antioxidants (e.g. vitamin E) – ____ (e.g. GLP-1 agonists) – Lipid-lowering agents (e.g. rosuvastatin) – ____-loss medications (e.g. orlistat) • ____ surgery • Liver transplantation * Things you use to treat diabetes * Bariatric surgery > regarding the ____ epidemic

``` multimodal insulin incretins weight obesity ```

Alcoholic Liver Disease (ALD) • Exact prevalence unknown • ~ 5% adult Americans estimated to meet clinical criteria for ETOH abuse • ~ 4% for ETOH dependence • In 2003, 44% of all deaths from liver disease attributed to ____ • Complications of alcoholism contribute to 250,00 deaths annually • ALD: health care cost expenditure - $____ billion annually • Productivity is also lost because of ALD ○ A lot of economic costs

ETOh | 3

Spectrum of alcoholic liver disease ``` • Exposed to alcohol > ____ ○ Perivenular fibrosis • Stop alcohol > is ____ • Severe exposure > can lead to ____ ○ Inflammatino of liver ○ ____ change ○ ____ ○ Can still ____ to normal archiecture • Steatosis can go to hepatitis, but hepatitis doesn't go to ____ • Repearted attacks of liver inflammation of either > cirrhosis ○ ____ ○ Hyperplastic ____ ```

``` steatosis reversible hepatitis fatty necrosis revert steatosis ```

Not completely a ____-dependent phenomenon | Relationship between alcohol QUANTITY consumed and development of LIVER DISEASE is not ____

dose | linear

ALD: Risk modifiers ``` DRINKING BEHAVIOR - what - when - how often >> ____ drinking (outside of meals) more toxic than regular drinking Beer / spirits more toxic than ____ ``` ``` DEMOGRAPHICS - gender - ethnicity - co-morbid conditions >> ____ 2x more sensitive ♂ ____ higher death rates ____: 4-8x risk; Obesity: 2x risk ``` HEREDITY - genetic polymorphisms >> e.g. ____, IL-10, superoxide ____

binge wine females hispanics hep c TNF dismutase

Neoplasia – Hepatocellular Carcinoma (HCC) • Common disease worldwide • High incidence areas – ____, Taiwan, Korea, sub-Saharan Africa • 120 cases / 100,000 population • U.S. – ____ cases / 100,000 population • Median age of diagnosis is in ____th decade • ____ > females

china US four males

HCC - known and possible risk factors Known - ____ - chornic hep b - ____ w/ cirrhosis - nonalcoholic steatohepatitis w cirrhosis - inherited ____ disorders - carcinogens Possible - ____ (no cirrhosis) - smoking - ____ or estrogenic steroids

``` cirrhosis chronic hep c metabolic alcohol anabolic ```

HCC – Clinical Considerations Clinical presentation • ____ pain • Weight loss • ____ ``` Diagnosis • ____ – US / CT / MRI • Liver biopsy • ____ evaluation ```

abdominal asymptomatic imaging laboratory

HCC – Treatment / Prognosis * Surgery (resection) * Liver ____ * Radiofrequency ablation * ____ injections * Chemoembolization * Targeted ____ therapy * Systemic chemotherapy • Overall prognosis is poor – Often diagnosed in ____ stage – Mean survival of weeks to months – Potentially ____ (HBV vaccination)

transplantation ethanol molecular advanced preventable

III : Assessing the severity • Model for End-Stage Liver Disease (____) score • Liver transplantation • MELD score ○ Determine sif patient is candidate for ____

MELD | transplant

• UNOS - primary org that runs the transplant organ list here in US • 500k organ transplants ○ Majority were kidney ○ #2 was ____ ○ Heart > lung > kidney/panc > panc > intestine > heart/lung

liver

• MELD is a formula • Numerical score based on urgency of transplant in a 3 month window ○ Date of birth ○ ____ ○ Serum ____ ○ ____ ○ Serum ____ § Plugged into an equation > a ____ number □ Score range isf rom 6 (less ill) > up to ____ (gravely ill) □ How livers are allocated in the US □ Affects position on waiting list ( not the only factor) • In younger people ○ PELD score §

``` bilirubin sodium INR creatinie whole 40 ``` ``` 12 bilirubin INR albumin height/weight ```

Liver Transplantation * >16,000 patients are currently listed for liver transplantation in the U.S. * Approximately 7000 patients undergo liver transplantation annually * The number of patients on the transplant waiting list remained ____ during the late 2000s * Approximately 2000 patients die annually while awaiting liver transplantation * Overall adjusted survival rates following deceased donor liver transplantation * 87% at 1 year * 73% at 5 years * 59% at 10 years • Liver transplants work ____

stable | longitudinally

Liver Transplantation - Donor Selection Criteria 1. Adequate allograft volume A. Volume should be at least ____% - 40% of normal liver size for the recipient B. The minimum percentage of allograft to body weight is ____% 2. ____ type compatibility 3. Absence of significant liver ____ or steatosis (<20% - 30%) 4. Donor age less than ____ years 5. Confirmed ____ death 6. Absence of evidence of ____ or fungal infection 7. Absence of risk factors for, or evidence of, chronic viral ____ or HIV infection 8. Absence of significant comorbid conditions (e.g. ____ mellitus, obesity, or extrahepatic malignant disease

35 0.8 blood fibrosis 60 brain bacterial hepatitis diabetes

* Living donor liver transplantation (LDLT) * 200 - 300 patients annually in the U.S.; < 5% of transplantations * Not recommended with MELD score >____ * Post-transplant mortality ____x higher than that for recipients of deceased donor allografts * Risk to the donor is a major consideration: * Mortality rate = 0.1% - 0.5% * Complication rate = 30% - 40% * Risk decreases with increased liver transplant program LDLT experience * Split liver transplants * Donor organ is split between two ____ * Division into grafts for one ____ and one adult recipient

30 3 recipients pediatric

``` Post-transplant considerations • ____ • Complications • Primary graft non-function • ____ artery thrombosis or stenosis • Biliary tract complications • ____ rejection • Infections • Renal failure • ____ disease • Malignant disease • Post-transplant metabolic syndrome ``` • Patients have to be followed for long periods of time

immunosuppression hepatic allograft recurrent

``` Gallstone Disease • Affects 30 million individuals in the U.S. • Risk Factors – ____ – Female gender – ____ – Obesity – Rapid ____ loss – Hypertriglyceridemia – ____ (e.g., Pima Indians, Chileans) ```

age parity weight genetic

Gallstone Disease: Cholelithiasis 85% of cases ____: no treatment

asymptomatic

Gallstone Disease: Acute cholecystitis Ultrasound Imaging→ Laparoscopic ____

cholecystectomy

Gallstone Disease: Choledocholithiasis a) ____: stone extraction b) Laparoscopic ____

ECRP | cholecystectomy

Gallstone Disease: Acute bacterial cholangitis a) IV ____ b) ERCP c) Laparoscopic ____

anitbiotics | cholecystectomy

Primary Biliary Cirrhosis (PBC) • Primary biliary cholangitis (favored terminology) • Slowly ____, obliterative ____ disorder involving the small and ____-sized bile ducts • Approximately 10 cases / 100,000 population • ____ predilection (95% of cases) • Commonly diagnosed between ____ years of age

``` progressive autoimmune medium female 20-60 ```

PBC – Clinical Considerations ``` • Clinical presentation • ____ – >50% of cases at time of diagnosis • Fatigue • ____ ``` ``` • Diagnosis • Serology – Elevated ____ – (+) AMA titer of >1:____ • Imaging – US • Liver ____ ```

``` asymptomatic pruritus ALP 40 biopsy ```

PBC – Treatment / Prognosis ``` • Treatment • Ursodeoxycholic acid (UDCA) – Reduces ____ – Possible ____ effect on cell membranes • Liver transplantation ``` * Progressive * Majority of asymptomatic patients become ____ in 2 – 4 years after initial diagnosis * Median survival time after initial diagnosis is ____ years

intracellular hydrophobic bile acids cytoprotective asymptomatic 9

Gallbladder Cancer ``` • Most common biliary cancer – Approximately 7000 cases diagnosed annually in U.S. • Disease of the ____ • ____ > males • Association with ____ • Majority are ____ • Local vs. metastatic disease – Surgery for local disease (____) • Median survival time is ____ months ```

``` elderly females gallstones adenocarcinomas curative 3 ```

Acute Pancreatitis • Approximately 30 cases / 100,000 population • Majority due to biliary disease (e.g. ____) and heavy ____ intake • Acute abdominal pain – ____ / boring / severe • Pain is worse with ____ / lying supine • Nausea/vomiting • Elevated serum ____ / lipase • Imaging • Various scoring systems to determine ____ • Mild disease treated with ____ modification / analgesics – Mortality rate = 5% • Severe disease treated ____ – Mortality rate = 25%

``` gallstone EtOH steady walking amylase severity diet aggressively ```

Chronic Pancreatitis • Most often associated with EtOH abuse – ____ variant • Persistent / recurrent episodes of ____ pain • Nausea / vomiting / weight loss / ____ • Elevated serum ____ / lipase during acute attacks ``` • Imaging • Medical management – ____ modification / GI meds / Pain meds / Abstinence from EtOH use • Surgical management – As indicated • Reduced life expectancy • Risk of pancreatic cancer ```

``` autoimmune epigastric steatorrhea amylase diet ```

Pancreatic Cancer (PC) ``` • Common malignancy • 2012 – Approx. 44,000 new cases diagnosed – ____% increase in new cases in 15 years • ____ > females • Higher incidence in ____ • Diagnosed > ____ years of age – Sharp increase after 70 years of age ```

60 males blacks 40

PC – Risk Factors Hereditary Factors ``` - Genetic ____ – Risk increases according to number of family members with disease • Hereditary ____ • Hereditary syndromes – ____ syndrome ``` ``` Environmental Factors • ____ smoking • Diet – High ____ / carbohydrate diet linked to PC • ____ ```

predisposition pancreatitis MEN type I cigarette fat obesity

PC – Clinical Considerations ``` Clinical presentation • ____ pain • Weight loss • ____ • Vomiting • ____ • Lack of characteristic features ``` Diagnosis • Imaging – CT / US / MRI • Laboratory evaluation

abdominal diarrhea weakness

PC – Treatment / Prognosis • Local disease (resectable) – Surgery • Locally advanced disease (____) – ____ and radiation • Metastatic disease – ____ – ____ care • Overall 5-year survival rate – 5% • Surgical resection – 5 year survival rate = 25% • Locally advanced and metastatic disease – Mean survival time of ____ months

unresectable chemotherapy chemotherapy palliative 4-12

2. HB Clinical Medicine Flashcards

(79 cards)