4. Fxnl Liver Tests and tx of Chronic Hepatitis

Question 1

LO1: AST abnl

Answer 1

1) signals hepatocellular damage

Question 2

LO1: ALT abnl

Answer 2

1) Hepatocellular damage

231480

Question 3

LO1: Alk phos abnl

Answer 3

1) Cholestasis
2) Infiltrative dz
3) biliary obstruction

Question 4

LO1: Bili Abnl

Answer 4

1) Cholestasis
2) Impaired conjugation
3) biliary obstruction

Question 5

LO2: Hepatocellular pattern of labs

Answer 5

1) Predominantly Elevated ALT and AST

Question 6

LO2: Cholestatic pattern of labs

Answer 6

Predominantly Alk phos elevation

Question 7

LO3: Bilirubin metabolism

Answer 7

NL heme degradation product

1) unconjugated bili (unBR) exits sinusoid into hepatocyte
2) unBR + UDP glucuronyl transferase (UDP GT) = Conjugated bili (cBR)
3) cBR pumpred into bile canaliculus via ATP

Question 8

LO3: Jaundice: Conjugated bili

Answer 8

1) hemolytic jaundice - overwhelmed conjugation
2) biliary obstruction -intra or extrahepatic
3) Dubin-Johnson Defective secretion of conjugated bili -rare, MRP-2 mutation, benign

Question 9

LO3: Jaundice: Unconjugated bili

Answer 9

1) Gilbert’s Dz -decreased bili uptake
- mutation in gen for UDP GT
2) Crigler-Najjar Syndrome -impaired bili conjugation
- -rare
3) Increased RBC destruction in cirrhosis

Question 10

LO4: abnl Liver algorithm: AST and ALT < 5x NL

Answer 10

1) Hx and PE
2) D/c hepatotoxic meds
3) alk phos, bili, INR, albumin, viral hepatitis serologies, iron studies
4a) neg serologies, symptomatic
- US, ANA, Anti-SM Ab, ceruloplasmin, Alpha-1-antitrypsin
5a) Liver biopsy
4b) neg serologies, asymptomatic
- lifestyle modification
5b) Repeat liver chemistry in 3-6 months, if abnl -> 4a

Question 11

LO6: Hep B Tx

Answer 11

1) Interferon
- 1 yr
2) Nucleoside/tide analoges-tenofovir
- fewer SE

Question 12

LO6: Hep C Tx

Answer 12

Ledipasvir/sofosbuvir +/- Ribavirin

Question 13

LO6: Hereditary hemochromatosis: Tx, indications for tx and cause

Answer 13

1) Therapeutic phlebotomy, endpt= ferritin of 50 ng/mL or chelation tx
2) HFE gene- homozygote C282Y
3) Inherited disroder -> increased inestinal Fe absorption

Question 14

LO6: Autoimmune Hepatitis: Tx, indications for tx and cause

Answer 14

1) Corticosteroids, azathioprine. Relapse common
2) ANA +, symptomatic
3) Chronic hepatitis -immunologic and autoimmune

Question 15

LO6: Primary Biliary Cirrhosis: Tx, indications for tx and cause

Answer 15

1) Ursodeoxycolic acid (UDCA)-improves bile acid transport, detoxify bile, and cytoprotective
- -improve liver chem
- -improve survival
- -reduce liver transplant
2) cholestatic w/o increased bili. AMA +
3) Immune mediated -damage to small intrahepatic bile ducts

Question 16

LO6: Primary Sclerosing cholangitis: Tx, indications for tx and cause

Answer 16

1) No effective med tx. Manage obstruction - stenting strictures, antibx for cholangitis
2) Strictures and obstruction of bile duct can lead to cirrhosis
2a) increased risk of cholangiocarcinoma
3) Inflamm of intr and extrahepatic large bile ducts
4) CT dilated bile ducts

Question 17

LO6: Wilson Dz: Tx, indications for tx and cause

Answer 17

1) copper chelation
-D-penicillamine
-Trientine
Maintenance tx - zinc
2) Low ceruloplasmin
Kayser-Fleisher rings -eyes
3) AR. Decreased hepatocellular Cu excretion - > hepatic Cu accumulation and injury

Question 18

LO6: non-alcoholic steatohepatitis: Tx, indications for tx and cause

Answer 18

1) Modify risk factors
-Obesity
-DM2
Dyslipidemia
? DM meds, Vit E
2)
3) NASH- hepatic steatosis and inflamm w/ hepatocyte injury (ballooning)

Question 19

Albumin and PT abnl

Answer 19

1) Signals synthetic dysfxn

Question 20

PT time deficiency vs dysfxn

Answer 20

1) Administer SQ Vit K
- -no correction -liver dysfxn
- -normalzie -Vit K deficient

Question 21

4 patterns of dz that LFT can indicate

Answer 21

1) Hepatocellular injury or necrosis
2) cholestasis
3) synthetic dysfxn -mixed
4) Infiltrative -predominant alk phos elevated

Question 22

AST vs. ALT: Location in hepatocyte

Answer 22

AST- cytosol and mitochondria

ALT - Cytosol

Question 23

AST vs. ALT: Organ expression

Answer 23

AST - Liver, heart, muscle, blood

ALT -liver only

Question 24

AST: ALT patterns

Answer 24

> 1 =cirrhosis
2 = ETOH
-lower ALT from B6 deficiency, which is cofactor for ALT
-preferential injry to mitochondria w/ AST

Question 25

Alk phos

Answer 25

1) cleaves phosphates
2) Present in nearly all tissues
3) Elevation causes
- cholestatic or infiltrative
- biliary obstruction
- bone dz
- Pregnancy

Question 26

Alk phos: hepatobiliary vs. nohepatobiliary

Answer 26

1) 5-nucleotidease -only up in liver dz, highest in cholestatic dz
2) GGT
- not in bone
- up in ETOH and all types of liver dz

Question 27

Infiltrating dz leading to alk phos up

Answer 27

1) sarcoidosis
2) Tuberculosis
3) fungal infxn
4) Amyloidosis
5) Lymphoma
6) mets
7) HCC

Question 28

Elevated Alk phos algorithm

Answer 28

1) Hx and PE
2) Liver chemistries
3a) NL AST and ALT
4a) GGT or 5’-nucleotidease-> 4b if elevated
5a) Nl -not hepatobiliary

3b) abnl liver chem
4b) RUQ US for biliary dilation
5bi) biliary dilated - ERCP or MRCP
5bii) not dilated - AMA
6bii) Positive =PBC
6bii1) Negative - test for elevated ALT, liver biopsy, and/or ERCP or MRCP

Question 29

HBsAg

Answer 29

1) active infection

2) > 6 mo = chronic hepatitis B

Question 30

HBsAb

Answer 30

Immunity to Hep B

Question 31

HBcAb

Answer 31

Marker of active or prior infxn

Question 32

HBeAg

Answer 32

surrogate of high viral load

Question 33

HBeAb

Answer 33

associated w/ lower viral load

Question 34

HBV DNA

Answer 34

Active viral replication

Question 35

Goal of HBV Tx

Answer 35

1) Loss of HBeAg, develop HBeAb, neg HBV DNA

2) Prevent decompensated cirrhosis

Question 36

Goal of HCV Tx

Answer 36

1) Chronic HCV = HCV RNA in blood > 6 mo after infxn
2) HCV RNA neg 12 weeks after d/c tx
3) Sustained SVR = cure