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HPIM Gastro > 357: Approach to the Patient with Liver Disease > Flashcards

357: Approach to the Patient with Liver Disease Flashcards

1
Q

Review: Characteristics of the liver

A

Largest organ of the body
Weight: 1-1.5kg, 1.5-2.5% of lean body mass
Receives dual blood supply: 20% from hepatic artery, 80% from portal vein

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2
Q

Special cell types found in the liver

A
  1. Kupffer cells (member of reticuloendothelial system)

2. Stellate cells (Ito or fat-storing)

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3
Q

Review: Zones of the liver based on function

A

Zone 1: Both arterial and portal venous blood entering the acinus from the portal areas
Zone 3: Flowing through the sinusoids to the terminal hepatic veins
Zone 2: Intervening hepatocytes

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4
Q

Blood flow in portal areas

A

Zone 1 to Zone 3

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5
Q

Bile flow in portal areas

A

Zone 3 to Zone 1

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6
Q

Lie within the sinusoidal vascular space and represent the largest group of fixed macrophages in the body

A

Kupffer cells

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7
Q

Located in the space of Disse; produce collagen and matrix when activated

A

Stellate cells

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8
Q

Most common liver “function” tests

A
  1. Serum bilirubin - measure of hepatic conjugation and excretion
  2. Serum albumin - measures of protein synthesis
  3. Prothrombin time - measures of protein synthesis
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9
Q

Basic classification of causes of liver diseases

A
  1. Hepatocellular diseases (viral hepatitis, alcoholic liver disease)
  2. Cholestatic (obstructive) (gallstone or malignant obstruction, primary biliary cirrhosis, some drug-induced liver disease)
  3. Mixed (cholestatic forms of viral hepatitis, many drug-induced liver diseases)
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10
Q

Goals in evaluation of liver disease

A
  1. Establish the etiologic diagnosis
  2. Estimate disease severity (grading) - e.g. active or inactive; mild, moderate, or severe
  3. Establish the disease stage (staging) - e.g. early or late; precirrhotic, cirrhotic or end-stage
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11
Q

Most common and most characteristic symptom of liver disease

A

FATIGUE

*after activity or exercise, intermittent, variable in severity

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12
Q

T or F: Poor appetite with weight loss are more frequent in ACUTE liver disease and rare in CHRONIC disease except in cirrhosis

A

True

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13
Q

ITCHING in acute liver disease

A
  1. Early in obstructive jaundice
  2. Later in hepatocellular disease (acute hepatitis)
  3. Preceding onset of jaundice in chronic liver diseases
  4. Once cirrhosis develops
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14
Q

Hallmark symptom of liver disease;

Most reliable marker of severity

A

JAUNDICE

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15
Q

Bilirubin level where jaundice is rarely detectable

A

<43 umol/L (2.5mg/dL)

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16
Q

What does lightening of color of stools and steatorrhea indicate?

A

Severe cholestasis

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17
Q

Symptom which usually indicates indirect (unconjugated) hyperbilirubinemia and typical of hemolytic anemia, Gilbert’s syndrome and Crigler-Najjar syndrome

A

Jaundice WITHOUT dark urine

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18
Q

Major risk factors for liver disease sought in clinical history

A
  1. Alcohol use
  2. Medication use (herbal, birth control pills, OTC drugs)
  3. Personal habits
  4. Sexual activity (# of lifetime sexual partners, Men: MSM)
  5. Travel
  6. Exposure to jaundiced or other high-risk persons
  7. Injection drug use
  8. Recent surgery
  9. Remote or recent blood transfusion
  10. Occupation
  11. Accidental exposure to blood or needlestick
  12. Familial history of liver disease
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19
Q

T or F: Sexual exposure is a common mode of spread of both Hepatitis B and Hepatitis C.

A

False

Sexual exposure RARE in Hep C

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20
Q

Transmission is more common among HIV-co-infected mothers and linked to prolonged and difficult labor and delivery, early rupture of membranes and internal fetal monitoring.
Hepatitis B or Hepatitis C?

A

Hepatitis C

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21
Q

Injection drug use is now the single most common risk factor for: Hepatitis B or Hepatitis C?

A

Hepatitis C

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22
Q

Traveling to developing area of the world, exposure to persons with jaundice, and exposure to young children in day-care centers are risk factors for:
Hepatitis A or Hepatitis E?

A

Hepatitis A

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23
Q

One of the more common causes of jaundice in Asia and Africa but uncommon in developed nations:
Hepatitis A, Hepatitis B, Hepatitis C or Hepatitis E?

A

Hepatitis E

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24
Q

Trivia: What does autochthonous means?

A

Non-travel-related

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25
Q

Occasional cases associated with eating raw or undercooked pork or game (deer and wild boars) occurring predominantly in elderly without typical risk factors for viral hepatitis: Hepatitis C, Hepatitis D, or Hepatitis E?

A

Hepatitis E

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26
Q

T or F: Hepatitis E are always acute and never chronic?

A

False

Chronic in immunosuppressed individuals

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27
Q

Alcohol consumption associated with increased rate of alcoholic liver disease

A

More than 2 drink (22-30g) per day in WOMEN; and 3 drinks (33-45g) in MEN

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28
Q

Defined by behavioral patterns and consequences of alcohol intake and not by the AMOUNT

A

Alcoholism

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29
Q

Repetitive pattern of drinking alcohol that has adverse effects on social, family, occupational, or health status

A

Abuse

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30
Q

Defined by alcohol-seeking behavior, despite its adverse effects

A

Dependence

*More serious and advanced form of alcoholism

31
Q

Clinically helpful approach to diagnosis of alcohol dependence and abuse through this questionnaire.

A

CAGE questionnaire (see TABLE 357-2)

C : Cut down
A : Annoyed
G : Guilty
E : Eye-opener

One “yes” response: raise suspicion of alcohol use problem
More than one “yes”: strong indication of abuse or dependence

32
Q

Signs of ADVANCED liver disease

A
  1. Muscle wasting
  2. Ascites
  3. Edema
  4. Dilated abdominal veins
  5. Hepatic fetor
  6. Asterixis
  7. Mental confusion
  8. Stupor
  9. Coma
  10. Bruising
33
Q

T or F: Spider angiomata and palmar erythema occur only in chronic liver disease

A

False

Acute and chronic; even in normal individuals; common during pregnancy

34
Q

Superficial, tortous arterioles fill from the center outward. Occur only on the arms, face and upper torso; pulsatile and difficult to detect in dark-skinned individuals.

spider angiomata, simple telangiectasia or caput medusa?

A

Spider angiomata

35
Q

Conditions where marked hepatomegaly can be seen

A
  1. Cirrhosis
  2. Veno-occlusive disease
  3. Infiltrative disorders: amyloidosis
  4. Metastatic or primary cancers of liver
  5. Alcoholic hepatitis
36
Q

Most reliable physical finding in liver examination

A

HEPATIC TENDERNESS

37
Q

T or F: Peripheral edema never occurs without ascites in liver diseases

A

False

It can occur with or without ascites

38
Q

Defined as occurrence of signs and symptoms of hepatic encephalopathy in a person with severe acute or chronic liver disease

A

Hepatic failure

39
Q

Signs of hepatic encephalopathy

A

Change in sleep patterns
Change in personality
Irritability
Mental dullness

40
Q

Slightly sweet, ammoniacal odor than can develop in patients with liver failure

A

Fetor hepaticus

41
Q

Appearance of this condition during acute hepatitis is the major criterion for diagnosis of fulminant hepatitis and indicates poor prognosis

A

Hepatic encephalopathy

42
Q

How to measure hepatic encephalopathy?

A

Mental status examination
Use trail-making test
Drawing of abstract objects
Comparison of signature to previous examples

Rare: electroencephalography and visual evoked potentials

43
Q

Other signs of ADVANCED liver disease

A
  1. Umbilical hernia fr ascites
  2. Hydrothorax
  3. Prominent veins over the abdomen
  4. Caput medusa
44
Q

Condition consisting of collateral veins radiating from the umbilicus and results from recanulation of umbilical vein

A

Caput medusa

45
Q

Defined by the TRIAD of liver disease, hypoxemia, and pulmonary arteriovenous shunting

A

Hepatopulmonary syndrome (HPS)

O2 sat is a reliable screening test

46
Q

Symptoms of HPS characterized by shortness of breath and oxygen desaturation that occur paradoxically upon the assumption of an upright position

A

Platypnea (opposite of orthopnea) AND

Orthodeoxia

47
Q

Skin changes associated with liver disease

A
  1. Hyperpigmentation
  2. Xanthelasma and tendon xanthoma
  3. Slate-gray pigmentation (w/ hemachromatosis)
  4. Mucocutaneous vasculitis with palpable purpura
48
Q

Consist of golden-brown copper pigment deposited in Descemet’s membrane at periphery of the cornea and occur in Wilson’s disease

A

Kayser-Fleischer rings

49
Q

Dupuytren contracture and parotid enlargement are suggestive of what conditions?

A

Chronic alcoholism

Alcoholic liver disease

50
Q

Most common causes of ACUTE liver disease

A
  1. Viral hepatitis (A,B,C)
  2. Drug-induced liver injury
  3. Cholangitis
  4. Alcoholic liver disease
51
Q

Most common causes of CHRONIC liver disease

A
  1. Chronic hepatitis C
  2. Alcoholic liver disease
  3. Nonalcoholic steatohepatitis
  4. Chronic hepatitis B
  5. Autoimmune hepatitis
  6. Sclerosing cholangitis
  7. Primary biliary cirrhosis
  8. Hemochromatosis
  9. Wilson’s disease
52
Q

Define whether alkaline phosphatase elevations are due to liver disease

A

y-glutamyl transpeptidase

53
Q

Autoimmune marker to diagnose primary biliary cirrhosis

A

Antimitochondrial antibody

54
Q

Autoimmune marker to diagnose sclerosing cholangitis

A

Peripheral antineutrophil cytoplasmic antibody (P-ANCA)

55
Q

Autoimmune marker to diagnose autoimmune hepatitis

A

Anti-nuclear, smooth-muscle, and liver-kidney microsomal antibody

56
Q

T or F: MRCP is superior to ultrasound and CT in detecting choledocholithiasis but less specific

A

True

57
Q

Useful in diagnosis of bile duct obstruction and congenital biliary abnormalities.
ERCP or MRCP?

A

MRCP

58
Q

More valuable in evaluating ampullary lesions and primary sclerosing cholangitis.
ERCP or MRCP

A

ERCP

59
Q

Modalities used to assess hepatic vasculature and hemodynamics and to monitor surgically or radiologically placed vascular shunts

A

Doppler ultrasound and MRI

60
Q

Procedures of choice for identification and evaluation of hepatic masses, staging of liver tumors and preoperative assessment

A

MRI with contrast-enhancement

61
Q

Criterion standard in evaluation of patients with liver disease, particularly chronic liver disease

A

Liver biopsy

62
Q

Criterion standard in evaluation of patients with liver disease, particularly chronic liver disease

A

Liver biopsy

63
Q

Most accurate means of assessing severity and stage of disease, particularly in chronic liver disease

A

Liver biopsy

64
Q

Most commonly used well-verified numerical scales for grading activity in chronic liver disease

A
  1. Histology activity index

2. Ishak histology scale

65
Q

Noninvasive tests suggesting advanced fibrosis

A
  1. Mild elevations of bilirubin
  2. Prolongation of prothrombin time
  3. Slight decreases in serum albumin
  4. Mild thrombocytopenia (1st indication of worsening fibrosis)
66
Q

Importance of staging the liver disease

A
  1. Prognosis

2. Optimal management of complications

67
Q

T or F: Patients with cirrhosis are candidates for screening and surveillance for esophageal varices and hepatocellular cardinoma.

A

True

Patients without advanced fibrosis need not undergo screening.

68
Q

Reliable staging system for cirrhosis in predicting survival and likelihood of major complications of cirrhosis such as bleeding from varices and SBP.

A

Modified Child-Pugh classification (Scores: 5-15)

5-6: class A ("compensated cirrhosis")
7-9: class B (candidate for liver transplantation)
10-15: class C
69
Q

Reliable staging system for cirrhosis in predicting survival and likelihood of major complications of cirrhosis such as bleeding from varices and SBP.

A

Modified Child-Pugh classification (Scores: 5-15)

5-6: class A ("compensated cirrhosis")
7-9: class B (Indicates cirrhosis [score of >/=7]; candidate for liver transplantation)
10-15: class C
70
Q

Prospectively derived system designed to predict the prognosis of patients with liver disease and portal hypertension.

A

Model for End-stage Liver Disease (MELD)

Provides standard critera for listing patient as candidate for liver transplantation

71
Q

Variables in MELD score

A
  1. Prothrombin time expressed as INR ratio
  2. Serum bilirubin level
  3. Serum creatinine concentration
72
Q

Variables in Child-Pugh Classification

A
  1. Serum bilirubin
  2. Serum albumin
  3. Prothrombin time
  4. Ascites
  5. Hepatic encephalopathy
73
Q

This vaccine is recommended for all patients with liver disease

A

Hepatitis A vaccine

74
Q

Optimal regimen for surveillance for hepatocellular carcinoma

A

Ultrasound of liver at 6-12 month intervals

HPIM Gastro (7 decks)

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