Chapter 80: Hepatic Disorder Flashcards
Vitamin K dependent clotting factors
II, VII, IX, X; protein C and S
A pivotal characteristic of chronic liver disease and is a hallmark of liver failure
Encephalopathy
Hyperbilirubinemia can occur for one of three reasons
- Overproduction
- Inadequate cellular processing
- Decreased excretion of bilirubin
Risk factors specific to NAFLD
- Obesity
- DM2
- Hyperlipidemia
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
Tests that reflect hepatocyte synthetic function the liver
Prothrombin time and albumin
Tests that reflect hepatocyte catabolic function of the liver
Ammonia
Less than 5 times elevation of transaminases indicates?
Alcohol liver disease and nonalcoholic steatohepatitis
An aspartate aminotransferase–to–alanine aminotransferase ratio of greater than 2 indicates?
Alcoholic hepatitis
This may rise γ-Glutamyl transpeptidase production
- Alcohol
- Phenobarbital
- Warfarin
How many increase above normal result of alkaline phosphatase is suggestive of cholestasis?
Four times
Viral hepatitis serologies for screening panels
Hepatitis A - antiHAV antigen IgM
Hepatitis B - HbsAg
Hepatitis C - antiHCV antibodies
How long will you see masking of result in hepatitis C?
6 to 8 weeks
Diagnosis for spontaneous bacterial peritonitis
A total WBC count >1000/mm3 or a neutrophil count >250/mm3 diagnoses SBP
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
The test of choice for identifying portal vein and hepatic vein thrombosis
US with duplex doppler
Most common cause of acute hepatitis
Viral infection and toxic ingestion
Most common cause of toxic cause of acute hepatitis
Alcohol and Acetaminophen ingestion
The most common transmission of hepatitis A
Asymptomatic children to adult
Incubation period of Hepatitis A
15 to 50 days
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
Incubation period of Hepatitis B
1 to 3 months
When is the hepatitis B infectious?
5 to 15 weeks after onset of symptoms
Side effect of interferon in hepatitis B infection
Neutropenia and thrombocytopenia
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
