Chapter 80: Hepatic Disorder Flashcards by wilson cuartel

Vitamin K dependent clotting factors

II, VII, IX, X; protein C and S

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A pivotal characteristic of chronic liver disease and is a hallmark of liver failure

Encephalopathy

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Hyperbilirubinemia can occur for one of three reasons

Overproduction
Inadequate cellular processing
Decreased excretion of bilirubin

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Risk factors specific to NAFLD

Obesity
DM2
Hyperlipidemia

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Laboratory tests for hepatobiliary disease can be divided into four categories

(1) markers of acute hepatocyte injury or death
(2) measurements of hepatocyte synthetic function
(3) indicators of hepatocyte catabolic activity
(4) tests to diagnose specific disease entities

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Tests that reflect hepatocyte synthetic function the liver

Prothrombin time and albumin

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Tests that reflect hepatocyte catabolic function of the liver

Ammonia

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Less than 5 times elevation of transaminases indicates?

Alcohol liver disease and nonalcoholic steatohepatitis

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An aspartate aminotransferase–to–alanine aminotransferase ratio of greater than 2 indicates?

Alcoholic hepatitis

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This may rise γ-Glutamyl transpeptidase production

Alcohol
Phenobarbital
Warfarin

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How many increase above normal result of alkaline phosphatase is suggestive of cholestasis?

Four times

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Viral hepatitis serologies for screening panels

Hepatitis A - antiHAV antigen IgM
Hepatitis B - HbsAg
Hepatitis C - antiHCV antibodies

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How long will you see masking of result in hepatitis C?

6 to 8 weeks

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Diagnosis for spontaneous bacterial peritonitis

A total WBC count >1000/mm3 or a neutrophil count >250/mm3 diagnoses SBP

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True or False

Will you wait for gram stain and culture media to start antibiotic in ascitic fluid aspirate?

False
Gram stains and culture results can be falsely negative 30% to 40% of the time, so empiric antibiotics should be started in the ED based on clinical suspicion

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The test of choice for identifying portal vein and hepatic vein thrombosis

US with duplex doppler

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Most common cause of acute hepatitis

Viral infection and toxic ingestion

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Most common cause of toxic cause of acute hepatitis

Alcohol and Acetaminophen ingestion

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The most common transmission of hepatitis A

Asymptomatic children to adult

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Incubation period of Hepatitis A

15 to 50 days

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True or False

Hepatitis A virus does not have a chronic component, and death from hepatic failure is rare

True

Hepatitis A virus does not have a chronic component, and death from hepatic failure is rare

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Incubation period of Hepatitis B

1 to 3 months

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When is the hepatitis B infectious?

5 to 15 weeks after onset of symptoms

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Side effect of interferon in hepatitis B infection

Neutropenia and thrombocytopenia

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True or False | Hepatitis C virus is most often asymptomatic in the acute phase of infection

True

Percent of acute hepatitis C that progress to chronic hepatitis C

>75%

The most sinister side effect of treatment with direct-acting antivirals in hepatitis C is ____

The most sinister side effect of treatment with direct-acting antivirals in hepatitis C is the reactivation of dormant hepatitis B infection

How many bottles of alcohol patient needs to develop alcoholic liver disease

6 bottles per day

True or False | Treatment with N-acetylcysteine should be consider in paracetamol intoxication only?

False Treatment with N-acetylcysteine should be considered whether the insult is from acetaminophen, nonacetaminophen medica- tion, or mushroom toxicity, according to the American Association for the Study of Liver Diseases guidelines

One of the hallmarks of cirrhosis

Ascites

Recommended diuretics for mild ascites?

Spironolactone, 50 to 200 milligrams/d | Amiloride, 5 to 10 milligrams/d

True or False For therapeutic paracentesis, American Asso- ciation for the Study of Liver Diseases guidelines recommend the use of IV albumin, 6 to 8 milligrams/L of fluid removed, for amounts greater than 5 L

False For therapeutic paracentesis, American Asso- ciation for the Study of Liver Diseases guidelines recommend the use of IV albumin, 6 to 8 milligrams/L of fluid removed, for amounts greater than 4 L

The most common life- threatening complication of ascites

Spontaneous bacterial peritonitis

The most common isolates in SBP are

Escherichia coli, Klebsiella pneumoniae, and Streptococcus pneumoniae

Accepted first-line parenteral treatment for SBP

Cefotaxime

In addition to antibiotic therapy it may may reduce renal failure and hospital mortality in patients with SBP

IV albumin (1.5 grams/kg at diagnosis, 1 gram/kg on day 3)

Common complication after transjugular intrahepatic portosystemic shunt

Hepatic encephalopathy

Stages of Clinical Hepatic Encephalopathy

I - General apathy II - Lethargy, drowsiness, variable orientation, asterixis III - Stupor with hyperreflexia, extensor plantar reflexes IV - Coma

True or False | Another manifestation of asterixis is back-and-forth tongue movement when the tongue is extended

True | Another manifestation of asterixis is back-and-forth tongue movement when the tongue is extended

True or False | Hepatic encephalopathy is a diagnosis of exclusion

True | Hepatic encephalopathy is a diagnosis of exclusion

Is the current mainstay of therapy for hepatic encephalopathy

Lactulose

How lactulose is given?

The oral dose is 20 grams diluted in a glass of water, fruit juice, or carbonated drink. For rectal administration, dilute 300 mL of syrup with 700 mL of water or normal saline. The enema should be retained for 30 minutes

Second line antibiotic for hepatic encephalopathy

- Rifaximin (best tolerated) - Neomycin (limited use d/t adverse effects) - Vancomycin - Metronidazole

It is defined as acute renal failure in a patient with histologically normal kidneys in the presence of preexisting chronic or acute hepatic failure

Hepatorenal syndrome

Type of hepatorenal syndrome that is more serious and is identified by progressive oliguria and doubling of serum creatinine over a 2 week period

Type 1 hepatorenal syndrome

One of the more dangerous complications of cirrhosis

Coagulopathy

The final common pathway for several types of liver disease

Liver failure

What are the clinical hallmarks of acute liver failure?

- Hepatic encephalopathy - Hepatorenal syndrome - Coagulopathy

The most ominous complications of hepatic failure

- Cerebral edema | - Intracranial hypertension

Recommended resuscitation fluid for hypotension with liver disease

PNSS

The initial vasopressor of choice with liver failure

Norepinephrine

The American Association for the Study of Liver Diseases also recommends a trial of ____ in cases of persistent hypotension

The American Association for the Study of Liver Diseases also recommends a trial of hydrocortisone in cases of persistent hypotension

Prophylaxis to give in patient with liver failure to reduce cerebral edema

Goal of sodium level of 145 - 155mEq/L

For patient with confirmed increased intracranial pressure. What to give?

Mannitol 0.5 to 1 gram/kg

The second most common diagnosis among patients awaiting liver transplant

NAFLD cirrhosis

The most common manifestation of NAFLD is

Hepatic steatosis or simply fatty liver,

Mainstay of treatment for NAFLD

Weight loss and exercise

A familial liver disorder that produces occasional elevations in liver function tests and bilirubin

Gilbert's syndrome

Acute thrombosis, the major symptom is ____

Acute thrombosis, the major symptom is colicky abdominal pain

Thrombotic obstruction of the posthepatic portal venous system and also has both acute and chronic presentations

Hepatic vein thrombosis, or Budd-Chiari syndrome

Treatment of thrombotic liver disease

Depends if presence or absence of cirrhosis If non-cirrhosis use anticoagulant

Who to admit in patient with hepatitis?

bilirubin ≥20 mg/dL, prothrombin time 50% above normal, hypoglycemia, or GI bleeding

Safe options for neuropathic pain in patient with hepatic disease

Gabapentin and Pregabalin

Opioids would not be use in patient with hepatic disease except

Fentanyl and Tramadol at reduced doses and increased dosing intervals are possible choices in select patients because they lack the toxic metabolites of traditional opioids

True or False For drugs with high hepatic extraction, reduce the initial and maintenance doses. For drugs with intermediate hepatic extraction, initially use the low range of the normal dose, and reduce maintenance dosing. For drugs with low hepatic extraction, initial dosing remains unchanged, but reduce the maintenance dose

True For drugs with high hepatic extraction, reduce the initial and maintenance doses. For drugs with intermediate hepatic extraction, initially use the low range of the normal dose, and reduce maintenance dosing. For drugs with low hepatic extraction, initial dosing remains unchanged, but reduce the maintenance dose