Chronic Liver Disease - part 2

Question 1

What does Right sided Heart Failure cause in the liver?

Answer 1

Passive congestion (nutmeg liver)

Question 2

What labs will be elevated with Right sided Heart Failure that is affecting the liver?

Answer 2

Increased AST/ALT

Really INCREASED BNP

Question 3

What is Ischemic Hepatitis?

Answer 3

“Shock liver” - hypoxic hepatitis due to fall in cardiac output (ex. MI)

Question 4

What may protect against Ischemic Hepatitis?

Answer 4

Statin therapy

Question 5

What labs will be elevated with Ischemic Hepatitis?

Answer 5

SUPER ELEVATED AST/ALT > 5000

Increased LDH

Question 6

What sign will be present with the liver and heart failure?

Answer 6

Hepatojugular reflux

Question 7

Cirrhosis is a complication of many liver disease. List the 3 most common.

Answer 7

Alcohol-Induced Liver Injury
NAFLD
Hepatitis C

Question 8

How does Cirrhosis arise?

Answer 8

• Liver injury
• Inflammation
  = Fibrosis and regenerative nodules

Question 9

What is the usually in the history with Cirrhosis?

Answer 9

Jaundice
Ascites - look pregnant
Encephalopathy - confusion

Question 10

With Cirrhosis the physical exam shows the stigmata of Cirrhosis. The physical exam can be normal until?

Answer 10

End stage

Question 11

List abdominal changes with Cirrhosis

Answer 11

Ascites
Caput medusae (abdominal vein dilation)
Umbilical hernia

Question 12

List skin changes with Cirrhosis

Answer 12

Jaundice
Spider Angiomata (telangiectasias)
Gynecomastia in males

Question 13

List hand/wrist changes with Cirrhosis

Answer 13

Asterixis
Dupuytren’s contracture
Nail changes

Question 14

What causes the nail changes that are seen with Cirrhosis?

Answer 14

HYPOalbuminemia

Question 15

List esophagus and mental changes with Cirrhosis

Answer 15

Esophageal varices
Vitamin deficiencies
Mental status changes

Question 16

What are possible complications of Cirrhosis?

Answer 16

Hepatocellular carcinoma

Portal HTN - Ascites, variceal bleeding, SBP

Question 17

With Cirrhosis what should you treat?

Answer 17

Underlying cause

Question 18

With Cirrhosis, it can cause Hepatocellular carincoma, so you should monitor?

Answer 18

Alpha Fetoprotein (AFP) and US every 6 months

Question 19

2 prognoses for Cirrhosis that are important for the transplant list?

Answer 19

• Child - Turcotte - Pugh Score

- MELD

Question 20

What scores for the Child-Turcotte-Pugh score with Cirrhosis are severe?

Answer 20

C

> 7

Question 21

What scores for the MELD are severe with Cirrhosis?

Answer 21

> 10-14

Question 22

SAAG

Answer 22

Serum Albumin - Ascites Albumin

Question 23

Ascites can either be?

Answer 23

Portal HTN

Non-portal HTN

Question 24

SAAG > ____ is portal HTN Ascites

Answer 24

1.1

Question 25

SAAG < ____ is non-portal HTN Ascites

Answer 25

1.1

Question 26

Portal HTN Ascites likely causes?

Answer 26

Cirrhosis CHF Budd-Chiari Syndrome

Question 27

Ascites

Answer 27

Accumulation of fluid in peritoneal cavity

Question 28

Most common cause of Ascites?

Answer 28

Cirrhosis (portal HTN)

Question 29

What will be seen on physical exam with Ascites?

Answer 29

Increasing abdominal girth, larger tender liver | (+) shifting dullness

Question 30

What will an Abdominal US show with Ascites?

Answer 30

Fluid

Question 31

When should an Abdominal paracentesis be performed with an Ascites patient?

Answer 31

- new onset ascites - pts admitted to hospital for ascites - when ascites pts start to deteriorate

Question 32

What is the most important test to run on the Ascites fluid and why?

Answer 32

WBC | - PMN>250 == SBP

Question 33

SBP

Answer 33

Spontaneous (primary) Bacterial Peritonitis

Question 34

SBP is most common in patients with?

Answer 34

Cirrhosis

Question 35

What causes SBP?

Answer 35

Hematogenous spread of organisms to ascitic fluid because the liver cannot filter them

Question 36

Is a single organism usually isolated with SBP?

Answer 36

Yes - e. coli/cocci

Question 37

Signs of SBP?

Answer 37

Fever, Abdominal pain and signs of peritoneal irritation | - OR nonspecific manifestations

Question 38

PMN > _____ in peritoneal fluid classifies SBP

Answer 38

250

Question 39

What else should you perform on the peritoneal fluid with SBP besides WBC check?

Answer 39

Blood cultures because bacteremia is common

Question 40

What is the treatment for SBP?

Answer 40

Empirical antibiotic treatment

Question 41

Hepatic Encephalopathy

Answer 41

Alteration in mental status in presence of liver failure | - neurotoxins are not removed by the liver

Question 42

What will be increased with Hepatic Encephalopathy?

Answer 42

Ammonia

Question 43

What are a few precipitants to Hepatic Encephalopathy?

Answer 43

GI bleed Constipation Sepsis

Question 44

What is the treatment for Hepatic Encephalopathy?

Answer 44

Lactulose - causes diarrhea | - Remove precipitants and correct electrolytes

Question 45

What are the grades for Hepatic Encephalopathy?

Answer 45

1 - mild confusion 2 - drowsy 3 - stupor 4 - coma

Question 46

Who is at risk for Hepatocellular carcinoma?

Answer 46

Males with cirrhosis

Question 47

What will be increased with Hepatocellular carincoma?

Answer 47

Alpha Fetoprotein (AFP)

Question 48

In patients with known liver disease, you should screen for hepatocellular carcinoma.. how?

Answer 48

AFP and abdominal US every 6 months

Question 49

In patients with known liver disease, you should screen for hepatocellular carcinoma.. how?

Answer 49

AFP and abdominal US every 6 months

Question 50

What is the treatment for Hepatocellular carcinoma?

Answer 50

Surgery, ablation, liver transplant