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GI Topics > Chronic Liver Disease > Flashcards

Chronic Liver Disease Flashcards

1
Q
  1. Vascular Disease (pericentral): Hepatic venous outflow obstruction; Ischemic necrosis
  2. Steatophepatitis (pericentral)
  3. Chronic Hepatitis (periportal)
  4. Chronic Cholestatic Syndromes (bile duct injury)
A

Classifications of Chronic Liver Disease

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2
Q
  • a histological diagnosis of severe fibrous scarring encircling regenerative nodules of hepatocytes
  • Micronodules (3cm): assoc w/ chronic hepatitis
  • Results in loss of collagen type III architectural framework between hepatocytes
  • associated with clinical liver dysfunction (decreased detoxification and decreased protein synthesis) and portal hypertension
A

Cirrhosis

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3
Q
  • hepatitis C now predominates in U.S. (approximately 26%)
  • Alcohol (21%)
  • Alcohol + HCV (15%)
  • Cryptogenic (18%)
  • hepatitis B (15%)
  • other causes (5%)
A

Most common etiologies of cirrhosis

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4
Q
  • reside in space of disse between hepatocytes and sinusoidal epithelium
  • normally quiescent
  • activated during liver injury –> flatten and behave as fibroblasts; release collagen
A

Stellate Cells

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5
Q
  • Jaundice: inadequate metabolism and excretion of bilirubin; a late sign of chronic liver disease
  • Palmar Erythema
  • Telangiectasia / Spider Angiomata
  • Testicular atrophy & gynecomastia: due to failure of the liver to clear circulating estrogenic precursors
  • Dupuytren’s contractures: contractures of the palmar fascia; of unknown cause
A

Stigmata of Chronic Liver Disease

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6
Q
  • Portosystemic shunts / Varices
  • Ascities
  • Congestive splenometgaly/hypersplenism
A

Consequences of Portal hypertension (due to cirrhosis)

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7
Q
  • dilated veins resulting from obstruction to portal blood flow
  • especially gastric, esophageal, periumbilical (“caput medusa”) and peri-rectal veins (hemorrhoids)
  • high risk of hemorrhage after erosion & coagulopathy
  • stasis in the portal circulation is predisposing to thrombosis
  • endoscopy (EGD) for diagnosis and treatment
A

Varices

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8
Q

Normal: HVWP - IVC < 4 mmHg

Cirrhosis: HVWP = IVC > 4mmHg; > 12 mmHg is clinically signficant

A

Hepatic Venous Wedge Pressure

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9
Q
  • Beta blocker (propranolol)

- EGD to band larger varicose

A

Prophylaxis for Variceal bleeding

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10
Q
  • Engorgement and congestion of the spleen related to portal hypertension.
  • Complications can include significant sequestration/consumption of RBCs and platelets (thrombocytopenia)
A

Slpenomegaly

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11
Q

Coagulopathy due to impaired synthesis of:

  • coagulation factors (2, 5, 7, 9, 10): increased PT
  • epoxide reductase (diminished vit K activtaion)

Hypoalbuminemia with edema: decreases oncotic pressure of the blood

A

Consequences of decreased protein synthesis

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12
Q
  • fluid accumulation in peritoneal space

Pathogenesis:

  • New hypothesis: systemic arterial vasodilation: increases in nitroc oxide with increased blood volume in splanchnic circulation
  • “overflow hypothesis”: primary renal sodium & water retention; expanded intravascular volume is displaced to the peritoneal space by effects of cirrhosis and portal hypertension
  • “compensatory hypothesis” ascites accumulates as a result of cirrhosis and portal hypertension, causing decreased intravascular volume; induces renal retention of sodium and water
A

Ascites

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13
Q
  • Diuretics: Spironolactone or furosemide

- limit salt intake (

A

Ascites Management

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14
Q
  • Renal failure in setting of ascites and cirrhosis
  • Marked sodium retention is unresponsive to volume expansion and diuresis
  • Kidneys show no tissue pathology
  • poor prognosis
  • tx: possible TIPS shunt or liver transplant
A

Hepatorenal Syndrome

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15
Q
  • New onset ascites must be tapped
  • clear transudate in common causes of uncomplicated cirrhosis
  • Serum-ascites albumin gradient: SAAG >1.1 is consistent with portal hypertension; if
A

Diagnostic Paracentesis

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16
Q
  • Infection in the ascites
  • translocation of bacteria from gut or seeding from circulation is not cleared due to low opsonins and complement, most commonly due to E. coli, Klebsiella, or Strep. pn.
  • Systemic presentation: low-grade fever, abdominal tenderness, encephalopathy, “ ascites, renal failure
  • Labs - high WBC, acidosis; WBC > 500 mm3, polys > 250 mm3
  • if clinical evidence, treat empirically with I.V. cefotaxime (broad spectrum)
A

Spontaneous Bacterial Peritonitis

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17
Q
  • a neuro-psychiatric syndrome with signs of mental confusion and neurological instability; early hyper-reflexia and asterixis (flapping tremor) progressing to coma
  • due to decreased hepatic clearance
  • EEG: triphasic slow waves
  • Fetor: odor of mercaptans
  • Constructional apraxia: slow to remake the shape with sticks

Dx: measure NH3 ammonia
Tx: reduce the amount of protein in the gut; avoid constipation (prescribe lactulose)

A

Hepatic Encephalopathy

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18
Q

The clinical parameters include:

(1) low albumin (normal 3.5-5.0 g/ dl)
(2) jaundice (bil. greater than 2.5-3.0 mg/ dl)
(3) ascites
(4) encephalopathy
(5) state of nutrition, or prothrombin time (prolonged > 3”)

A

Child’s Criteria

19
Q

Indications: evidence of end-stage liver disease

  • expected survival 1.8 INR , Bil > 3
  • Mayo End-stage Liver Disease model (MELD)

Contraindications:

  • systemic infection or AIDS
  • severe cardiopulmonary disease
  • metastatic malignancy
A

Indications for Liver transplant

20
Q
  • significant complication of cirrhosis

clinical profile/risk factors:

  • cirrhosis of several years
  • Hepatitis B and Hepatitis C
  • Aspergillus induce p53 mutations)

Diagnosis:

  • LFTs may show deterioration, especially AlkP (obstruction by mass-effect)
  • CT or sonogram (mass)
  • alpha-fetoprotein (↑)

Increased risk for Budd-Chiari Syndrome

A

Hepatocellular Carcinoma

21
Q
  • a venous thrombosis of the hepatic vein
  • usually associated with a hypercoagulopathy (oral contraceptives, polycythemia, or inherited hypercoagulable states (anti-thrombin III deficiency); occasionally due to hepatocellular carcinoma
  • May result in liver infarction
  • Presents with painful hepatomegaly and ascites

Liver function tests:

  • Acute disease: high AST,ALT ~5X norm
  • Subacute: normal LFTs
A

Budd-Chiari Syndrome

22
Q
  • multiple sublobular hepatic venous thrombosis and sclerosis (smaller veins)
  • most commonly associated with chemotherapy (azathioprine, 6MP) or graft-vs-host disease (50% incidence with 20-40% mortality).
A

Veno-Occlusive Disease

23
Q
  • Fatty Change
  • Centrilobular Neutrophilic Infiltrate (vs. lymphocyte/monocyte)
  • Hepatocyte balloon degeneration
  • Mallory bodies

Alcohol-related:
- AST > ALT (alcohol is a mitochondrial poison)

Non-alcohol related:

  • Associated with obesity
  • diagnosis of exclusion: ALT > AST
A

Chronic Steatohepatitis

24
Q
  • AST & ALT > 1.5x normal
  • 4-6 months duration
  • periportal mononuclear (lymphocytes & monocytes) infiltrate
  • Viral
  • Autoimmune
  • Drug related (methyldopa, isoniazid)
  • Granulomatous: TB, sarcoidosis
  • Metabolic
A

Chronic Hepatitis

25
Q
  • Pathogenesis - damage to hepatocytes associated with presence of auto-antibodies
  • Type 1 (ANA and SMA antibodies) is most common
  • predominately young females (
A

Autoimmune Hepatitis

26
Q
  • Drugs commonly cited as causes of chronic hepatitis include: α-methyldopa, nitrofurantoin, oxyphenacetin, and isoniazid.
  • Pathogenesis - chronic hepatitis tends to occur as a result of drug-induced immune-mediated hypersensitivity
  • Treatment and prognosis - discontinue the drug
A

Drug-Induced Hepatitis

27
Q
  • Iron overload, leading to deposition in tissues and organs
  • autosomal recessive, strongly associated genetic marker (C282Y)
  • Tissue damage due to generation of free radicals

Extrahepatic organ involvement:

  • skin → bronze color (“bronze diabetes”)
  • pancreas → diabetes
  • heart → failure
  • joints → chondrocalcinosis, pain/ arthiritis

Labs:

  • increased ferritin (storage)
  • decreased TIBC
  • increased serum iron
  • increased % transferrin saturation
  • Use prussian blue stain to distinguish iron (blue) from lipofuscin (brown)
A

Hemochromatosis

28
Q
  • Autosomal recessive defect in ATP7B gene, decreasing hepatocyte copper excretion into bile, leading to copper accumulation

Presents with:

  • cirrhosis
  • cornea → Kaiser-Fleischer ring
  • basal ganglia → ataxia, dysarthria, chorea, and Parkinsonian symptoms
  • RBC → hemolysis
  • Renal tubules → renal tubular acidosis

Dx:

  • measure ceruloplasmin (key molecule that carries copper in blood; decreases in WD)
  • Rhodanine: stain for copper
A

Wilson’s Disease

29
Q
  • Auto-codominant inherited disorder of the protease inhibitor, αAT (PiZZ phenotype),
    resulting in accumulation of αAT in hepatocytes (trapped) and relative serum deficiency
  • results in unchecked protease activity, which is tissue-toxic in liver (cirrhosis) and lung (pan-lobular emphysema)

Diagnostic tests

  • decreased serum αAT
  • alpha-AT eiosinophilic globules in hepatocytes
  • PAS-D positive
A

α-Antitrypsin deficiency

30
Q
  • inability for bile/cholesterol to exit via canaliculi, resulting in increase in serum cholesterol and bile acids
  • causes steatorrhea and deficiency of fat-soluble vitamins (ADEK)

Clinical presentation:

  • Pruritis
  • Xanthomas: cholesterol deposits in skin
  • Xanthelasma: Cholesterol deposits around eyes and eyelids
A

Chronic Cholestasis

31
Q
  • Chronic inflammation of extrahepatic bile ducts with few neutrophils
  • commonly caused by a stone, stricture, or tumor mass that narrows the common bile duct and impedes bile flow
  • Lab: increase in alkaline phosphatase, GGT and bilirubin

Complication:

  • Ascending Cholangitis: Bile duct necrosis, with neutrophils
  • Chronic Cholangitis: Ductopenia
A

Chronic Extrahepatic Obstruction (EHO)

32
Q
  • Autoimmune granulomatous destruction of intrahepatic bile ducts
  • classically in women ~40 y.o.
  • florid bile duct lesion

Labs:

  • increased alk phos, GGT and bilirubin
  • AMA (antimitochondrial antibody) positive
  • increase in IgM globulin

Dx: requires liver biopsy

A

Primary Biliary Cirrhosis (PBC)

33
Q
  • inflammation and fibrosis of intrahepatic and extrahepatic bile ducts
  • Periductal fibrosis with onion-skin appearance
  • predominantly in males
  • associated with ulcerative colitis
  • increased risk for cholangiocarcinoma

Labs:

  • increase in alk phos, GGT and bilirubin
  • p-ANCA positive

Diagnosis: requires imaging

A

Primary Sclerosing Cholangitis

34
Q
  1. Amount of periportal lymphocytic infiltrate
  2. Amount of lobular necrosis (“acidophilic bodies”)
  3. Amount of portal tract necrosis: Erosion of limiting plate/piecemeal necrosis/interface hepatitis
A

Grade/Activity/Severity of Inflammation of Chronic Hepatitis

35
Q
  • degree of fibrosis
  1. Mild: expansion of portal tracts
  2. Moderate: bridges of fibrosis between portal tracts to hepatic veins
  3. Severe: Cirrhosis, encircling nodules
A

Stage of Hepatitis

36
Q

Ground-glass hepatocytes: Pale cells with fine, pink cytoplasm
- virtually pathopneumonic of HBV

A

Hepatitis B

37
Q
  • common, discrete small tumors (< 3cm)
  • form vascular lakes
  • if large, can cause heart failure, thrombocytopenia
A

Hemangioma

38
Q
  • Discrete vascular mass w/ fibrous capsule
  • affects mostly females
  • growth can bes stimulated by estrogen/birth control
  • normal hepatocytes, but not portal tracts/central veins
  • risk of rupture
A

Hepatic Adenoma

39
Q
  • Discrete mass
  • females 2:1
  • Similar to hepatic adneoma, but with central scar and fibrous arms
A

Focal Nodular Hyperplasia

40
Q
  • Malignant tumor of hepatocytes

Dx: increase in alpha-fetoprotein

Risk factors:

  • Chronic Hep B +/- cirrhosis
  • Cirrhosis
  • Aspergillus

Complication:
- increased risk for Budd-Chiari syndrome: presents with painful hepatomegaly and ascites

A

Hepatocellular Carcinoma

41
Q
  • dense collagen stroma in healthy young adults w/o cirrhosis
  • better prognosis
A

Fibrolamellar Variant of Hepatocellular Carcinoma

42
Q
  • an adenomcarcinoma from bile duct epithelium (intrahepatic or extrahepatic)
  • positive stain for Mucin and CEA
A

Cholangiocarcinoma

43
Q
  • from colon, pancreas, lung or breast
  • multiple nodules
  • detected as hepatomegaly
A

Metastases to liver

GI Topics (17 decks)

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