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Clin Med III Exam 2 > Alcoholic Liver Disease > Flashcards

Alcoholic Liver Disease Flashcards

1
Q

Leading cause of liver transplant in USA

A

ALD (replaced HCV)

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2
Q

What is ALD?

A

damage to the liver function due to alcohol abuse; spectrum from steatosis to cirrhosis;
no distinct stages – many may be present at the same time

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3
Q

3 stages of ALD

A
  1. Fatty liver (simple steatosis)
  2. Alcoholic Hepatitis
  3. Chronic hepatitis w/ fibrosis or cirrhosis
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4
Q

Risk of developing ALD

A

Men >3 drinks per day > 5 years
Women >2 drinks per day >5 years

F>M
African Am > Hispanic > Caucasian
Obesity & excess body weight
Genetic factors 
Hep C + Alcohol = rapid liver disease progression
ALD + Smoking = HCC
Amount ingested (most important risk factor)
Type of alcohol (beer/spirits>wine)
Pattern of drinks (outside of meals
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5
Q

Most important risk factor

A

Amount of alcohol ingested

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6
Q

What is fatty liver (hepatic steatosis)

A

accumulation of fat droplets in the cytoplasm of liver cells

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7
Q

Pathophys of fatty liver

A

increase FFA from peripheral stores, increased triglyceride formation, decreased FA oxidation, reduced LPL released by liver

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8
Q

Sx of fatty liver

A

asymptomatic & self limited

may have hepatomegaly

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9
Q

Tx for fatty liver

A

MAY BE REVERSIBLE W/ ABSTINENCE AFTER ABOUT 4-6 WEEKS

STOP DRINKING **

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10
Q

What is alcoholic hepatitis

A

inflammation of liver characterized by necrosis (death) and fibrotic scaring

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11
Q

Sx of alcoholic hepatitis

A

usually asymptomatic or mild sx

symptomatic = advanced liver disease

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12
Q

Severe sx w/ alcoholic hepatitis

A 
fever
leukocytosis
hepatic encephalopathy* (toxins)
spider angiomas 
jaundice 
hepatosplenomegaly w/ liver tenderness (scrotal or LE)
edema
ascites
variceal bleeding
oliguria
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13
Q

Labs for alcoholic hepatitis

A

leukocytosis w/ left shift; microcytosis (MCV), thrombocytopenia (low platelets due to splenomegaly); MCV >100 think ETOH

ASH/ALT ratio >2
ALP mildly elevated
Bilirubin elevated
PT/INR elevated (can't make clotting factors)
low albumin
Hyponatremia, hypokalemia (fluid overload)
GTP elevated 
Folate (low)
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14
Q

AST: ALT >2

A

ALD

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15
Q

Histology for alcoholic hepatitis

A

alcoholic hyaline (Mallory)
fatty infiltration
neutrophil infiltration around clusters of necrotic hepatocytes
Mallory bodies! (hyaline clumps)
Fibrosis around hepatic venules (precursor to cirrhosis)

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16
Q

Dx of ALD

A

liver bx REQUIRED when:

  • unclear hx of alcohol use and elevated LFT;
  • confounded by other risk factors
  • considering pharmacotherapy w/ steroid)
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17
Q

Hepatic encephalopathy

A

failure of liver to detox agents due to dysfunction –> ammonia builds up

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18
Q

Prognosis for HE

A

50% survival at 1 year

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19
Q

Tx for HE

A

treat previpitating factors (GI bleed, infection, sedating, meds, electrolyte abnormalities, constipation, renal failure)
LACTULOSE (increase BM)

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20
Q

Signs of HE

A 
EEG changes
flapping tremor (asterxisis)
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21
Q

Grades of HE

A

Grade I: change in behavior, mild confusion, slurred speech, disordered sleep pattern

Grade II: lethargy, moderate confusion; ASTERIXSIS

Grade III: marked confusion (stupor), incoherent speech, sleeping but can arouse

Grade IV: coma, unresponsive to pain

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22
Q

tests for HE

A

Stroop Test (evaluate psychomotor speed and cognitive flexibility)

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23
Q

Asterixis

A

tremor of hand when wrist is extended, resembles “flapping” – grade II HE

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24
Q

Overall labs for alcoholic hepatitis

A 
hx: 10+ drinks/day, recent jaundice
Exam: jaundice, enlarged liver
Bilirubin: high (>5)
AST/ALT: both elevated but <300
AST/ALT: >2
INR: elevated
Absolute neutrophil count: >7,700
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25
Management of AH
hospitilize if high mortalitiy - Model of end stage liver disease (MELD) >20 - maddery discrimant factor (MDF) >32; start steroids? - lillie score* (labs over time) - used to determine if steroids should be continues! D/C all alcohol use!!!
26
Test to determine if steroids should be continues
Lillie Score
27
When to hospitilize for AH
MELD >20
28
Tx for mild-severe AH
treat withdrawl/infection Diuretics (lasix, spironolactone) Severe disease (MDF >32, MELD >20) - consider steroid tx and d/c if not effect on day 7 using lillie score - liver transplant
29
Cirrhosis: what is it?
widespread destruction and regeneration of liver tissue; increased fibrotic CT; regenerated liver tissue forms nodules & permanent alters to the strucutre; scarring and increased CT = impairement of liver function necrosis and inflammatory cell infiltration
30
Types of cirrhosis
compensated cirrhosis | decompensated
31
Compensated cirrhosis
portal pressure <10 (~12 year survival); splenomegaly (thrombocytopenia, leukopenia, anemia, AST elevation)
32
Uncompensated cirrhosis
increased portal pressure; decreased liver function (~2 year survival) ``` microvasculatore very distorted so alot of blood flow bypasses vascular scars Results: - portal HTN - porto-systemic shunting - impaired liver function ```
33
Manifestations of decompensated cirrhosis
``` ascites esophageal & rectal varices splenomegaly (leukopenia, thrombocytopenia) Dilated abdominal veins (caput medusa) encephalopathy Liver function failure: jaundice, HE ``` Fatigue/anorexia, weak, palmar erythma, parotid enlargement, Dupuytren's contracture, jaundice, gynecomastic, muscle wasking; portal HTN signs, asterixis (HE)
34
Manifestation of compensated cirrhosis
splenomegaly
35
Obstruction sites for portal HTN
prehepatic: portal vein thrombosis Intrahepatic: cirrhosis Posthepatic: CHF, constrictive pericarditis
36
Problem w/ portal HTN
increases collateral circulation - varices bleed - splenomegaly - ascites (increased hydrostatic pressure) - hepatic encephalopathy
37
Increased pressure in peritoneal capillaries
Ascites
38
Shunting of blood
Caput medusae Hemorrhoids Esophageal Varices Encephalopathy (shunting ammonia)
39
Splenomegaly causes
anemia/leukopenia thrombocytopenia bleeding
40
Labs for cirrhosis
similar to alcoholic hepatitis AST elevation (normal in compensated, clue to cirrhosis if elevated) Anemia - AOCD, folate deficiency, suppression of hemaotopoeisis from ETOH, hemolysis, GI blood loss, splenomegaly Thrombocytopenia Coag abnormalities Thrombocytopenia, leukopenia (splenomegalY)
41
Tx for cirrhosis
treat complications - Variceal surveillance (EGD) +/- badning - HCC surveillance (US q 5 mo) +/- AFP - Beta-blocker for prevention of variceal bleeding (HR55-60 SPB<90); don't need to continue EGD if goals met
42
Goals VS for variceal bleeding prevention
BB HR 55-60 SBP <90
43
Tx for ascites
2g/d sodium diuretics: lasix, spironolactone Fluid restriction ONLY if sodium <125 Refractory: stop BB, therapeutic paracentisis (w/ albumin if >5-6 L drained) TIPS (transjugular intrahepatic portosystemic shunt) - lowers portal pressure ``` Monitor CBC( 3-6 mo), electrolytes w/ diuretic use, renal funciton, PT/INR HE (lactuose +/- rifaximin) Liver tranplant (refer w/ decompensated cirrhosis + MELD >15) - requires 6 mo abstitence before can consider for tranplant ```
44
How much albumin to give if receiving paracentiesis?
6-8 g albumin infused for each liter >5L removed to prevent kidney injury
45
When to refer for liver transplant
Uncompensated + MELD >15
46
Meds for HE
lactulose | +/- Rifaximin
47
Complications of Cirrhosis
Portal HTN (caput, ascites, congestive splenomegaly, varices) Spontaneous bacterial peritonitis (SBP) HE Hepatorenal syndrome
48
Hepatorenal syndrome: what is it?
functional renal failure in setting of decompensated cirrhosis
49
Types of hepatorenal syndrome
Type 1- Rapid & progressive w/ multi-organ failuer (~4 weeks survival) Types 2: associated w/ refractory ascites (~6 mo survival)
50
Dx criteria for HRS
cirrhosis w/ ascites absence of shock Renal impairment (Cr rise 0.3 mg/dL in 46 hours; 50% increase in baseline w/i 7 days) No improvement w/ correction of volume + albumin x 2 days Absence of other causes of AKI
51
Features of HRS
``` ascites Cr >1.5 Azotemia (increase BUN) Oliguria (<500 ml/d) Hyponatremia (fluid overload) Hypotension ```
52
Prevention of HRS
albumin IV w/ large volume (>5L) paracentesis Protect against GI bleed w/ EGD surveillance of BB Do not use NSAIDs or supplements SBP prophylaxis*
53
When to use SBP prophylaxis
patients w/ previous dx SBP patient that have had variceal bleed x 3-7 days Patients w/ ascetic protein <1.5
54
Prophylaxis for those that had previous SBP
Bactrim q d or Cipro 500 mg q daily
55
Prophylaxis for those w/ variceal bleed
3-7 days IV ceftriaxone
56
Categories of liver masses
benign require no further eval benign w/ further investigation/therapy Malignant requiring management
57
Benign lesions
usually no intervention - Cavernous hemangioma <4 cm - focal nodular hyperplasia - simple cyst <4 cm & asymptomatic - focal fatty change/sparing
58
Benign lesions requiring managment
Adenoma (associated w/ use of OCP) Liver abscess (pyogenic, amebic) Inflammatory pseudotumor Atypical/complex cyst and large symptomatic simple cysts * refer to GI/hepatology
59
associated w/ OCP
adenoma
60
Types of malignant lesions
``` Metastases Lymphoma ("The great masquerader") Primary neoplasm - HCC - cholangiocarcinoma (in bile duct) - other rare (cystadenomcarcinoma, angiosarcoma) ```
61
HCC
arise from parenchymal cells
62
Cholangiocarcinomas
arise from biliary duct cells
63
When to suspect HCC
cirrhotic patients OR patients w/ non-cirrhotic Hep B w/ liver lesion on imagin M>F any chronic liver disease increases risk (Hep C, AIH)
64
At risk of HCC
cirrhotic patient w/ any liver disease (low platelet, US elastrography w/ kPA ?20) Chronic Hep B (non-cirrhotic) - asian females >50 - asian males >40 - any age w/ FH of oHCC and personal dx of Hep B - afircans and Af Am black >20 - screen w/ US q 6 months +/- AFP!!!!
65
Screening for those w/ hep B to avoid HCC
US q 6 months +/- AFP
66
Sx of HCC
``` cachexia (wasting away) weakness Weight loss sudden ascites Eleveated LFT Elevated AFP!!!!!! ```
67
Dx of HCC
1. ) Tri-phasic CT scan 2. ) Tri-phasic MRI if CT is non-diagnostic) 3. ) Liver bx = DIAGNOSTIC (low but finite risk of tumor seeding)
68
When do you not bx for HCC
Imaging is typical | AFP elevated
69
Management of HCC
resection rarely feasible due to background cirrhosis (non-cirrhotic HBV is feasible; cirrhotic HCC w/ normal bilirubin and no portal HTN) Liver transplant for early stage (1 lesion up to 5cm, or 3 lesions up to 3cm AND no vascular invasion) RFA for small tumors (3cm) TACE/TARE (transarterial radioembolization), XRT (radiation) for large tumors Advanced: systemic therapy for distant spread End stage: symptomatic tx

Clin Med III Exam 2 (8 decks)

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