Cirrhosis Flashcards
1
Q
Apart from steroids, other tx for alcohol associated hepatitis ?
A
- EtOH cessation and nutrition (high calorie, high protein)
- NAC can be considered in addition to steroids (may improve 30d survival if severe AH)
2
Q
Approach to varices : what is the primary prophylaxis for patients with cirrhosis ?
A
Screen every patient at dx of cirrhosis AND at time of decompensation
Patients receive NSBB or EVL
(nadolol, propanolol, carvedilol ; titrate to HR > 55-60 and maintain SBP > 90)
3
Q
Approach to varices, what should patients receive for secondary prophylaxis ?
A
NSBB AND EVL
4
Q
Ascites with SAAG > 11 : transudative or exsudative ?
A
Transudative
5
Q
Chronic Hep b : 3 goals of treatment ?
A
- Supress viral replication (decrease HBV DNA level)
- eAg seroconvert (eAg +/eAb- -> eAg-/eAb+)
- sAg seroconvert (sAg+/sAb- -> sAg-/sAb+)
= convert to lower risk serology
6
Q
Chronic Hep b : when should you treat HbeAg positive pts ? HbeAg negative pts ?
A
HbeAg positive : ↑ALT, HBVDNA≥2,000IU/ml
HbeAg negative: ↑ALT, HBVDNA≥2,000IU/ml
7
Q
Chronic hep B : when should you treat pregnant women ?
A
End 2nd/start of 3rd trimester + high DNA levels (HBV DNA > 200 000) : tenofovir to prevent fetal transmission
8
Q
Chronic Hep B : who should you treat ?
Name 5.
A
- Cirrhosis (if fibrosis > stage 1, regardeless of ALT or HBeAg status, with HBV DNA > 2000)
- Extra hepatic manifestations
- HbeAg positive, ↑ ALT, HBV DNA ≥ 2000
- HbeAg negative, ↑ ALT, HBV DNA ≥ 2000
- Pregnancy (end 2nd/start of 3rd + high DNA levels (> 200 000) : tenofovir to prevent fetal transmission
9
Q
Chronic Hep B mother : what tx for the baby ?
A
Should get HBIG + HBV vaccine after birth
10
Q
DDX of secondary iron overload ?
Name 3.
A
- Dyserythropoeisis (sickle cell, thalassemia)
- Chronic transfusions
- Other chronic liver diseases ( MASLD*****, Alcohol related liver disease, Hep C)
11
Q
Do you need bx for alcohol associated hepatitis ?
A
Clinical dx, bx rarely needed
CONSIDER if AST/AST > 400, other dx suspected
12
Q
Factors which increase risk of cirrhosis in hep B ?
A
Host : older age, male, immunocompromised, coinfection HIV/HCV/HDC, EtOH, metabolic synd
Disease : High DNA/ALT, prolonged time to eAg seroconversion, ***eAg negative mutant, genotype C
13
Q
For cirrhotic patients on diuretics, how do you know if patient compliant to Na restriction ?
A
- 24h uNa < 78 mmol : diuretic resistant at current doses so increase doses
- 24h uNa > 78 AND not losing weight : NON COMPLIANT
- 24h uNa > 78 AND weight loss : adherent
14
Q
For patients not on diuretics, how do you know if cirrhotic patient compliant to Na restriction ?
A
24h urine Na < 78 mmol : COMPLIANT
24h urine Na > 78 mmol : NON COMPLIANT
Can use spot urine Na/K ratio > 1-1.8 as surrogate
15
Q
Hep C : criteria for population level screening ?
A
Anyone born between 1945 and 1975
16
Q
Hepatite B serology : immunized ?
A
AntiHbs
17
Q
Hepatitis B serology : acute infection ?
A
HbsAg + Core IgM + HbeAg + HBV DNA
18
Q
Hepatitis B serology : immune, prior infection ?
A
HbsAg + core IgG + Anti Hbe
19
Q
Hepatitis C : autoimmune extra hepatic manifestations ?
A
AI thyroid disease, myasthenia gravis, Sjogren’s
20
Q
Hepatitis C : CUTANEOUS extra hepatic manifestations ?
A
Porphyria cutanea tarda, leukocytoclastic vasculitis
21
Q
Hepatitis C : factors which increase risk of cirrhosis ?
A
Older age, male sex, HIV/HBV co infection, obesity/DM/fatty liver, ROH
22
Q
Hepatitis C : factors which increase risk of HCC ?
A
Cirrhosis or co existing liver disease which may accelerate fibrosis
23
Q
Hepatitis C : heme extra hepatic manifestations ?
A
Lymphome (NHL), AI hemolytic anemia, ITP, cryo
24
Q
Hepatitis C : other extra hepatic manifestations ?
A
Insuline resistance, diabete mellitus
25
Hepatitis C : renal extra hepatic manifestations ?
MPGN > membranous glomerulopathy
26
Hepatitis C : who should you treat ?
Treat ALL with chronic hep C except those with short life expectancy due to comorbidities
- Sometimes if decompensated may treat after liver transplant
- Ongoing IV drug use not a CI but ask for addiction medicine
27
Hepatitis C and pregnancy, who should you treat ?
Not enough evidence to recommend tx during pregnancy or breastfeeding
(different from hep B)
28
Hereditary hemochromatosis : recessive or dominant ?
Recessive
29
Hereditary hemochromatosis : which population epidemiologically ?
Northern european descent
30
HH : who/when should you treat ?
C282Y homozygotes if ferritin > 300 (M) or > 200 (F) AND sat > 45
31
How do you determine the etiology of ascites ?
SAAG > 11 : transudate
SAAG < 11 : exsudative
32
How do you diagnose hepatopulmonary syndrome ?
- Suspect HPS if ABG reveals PaO2 < 80, A-a gradient ≥ 15
- TT echo with agitated saline (bubble study) demonstrates intrapulmonary shunting
33
How do you diagnose hepatorenal syndrome ?
- Cirrhosis / acute portal HTN with ascites
- No improvement with diuretic withdrawal + 1g/kg IV alb x 2 days
- Suggestion of renal vasoconstriction with a FeNa < 0.2%
34
How do you diagnose MASLD ?
- Evidence of steatosis
- Rule out 2e causes
MASH can only be dx definitively on bx
35
How do you do fibrosis assessment for hep C ?
Can use APRI score or FIB 4: if > F2 : fibroscan
Fibroscan > 12.5 kPA = cirrhosis
36
How do you treat confirmed SBP ?
- Ceftriaxone (or fluoroquinolone if pen allergic) x 5 days
- HRS prophylaxis : Albumine 1.5 g/kg on day 1 and 1g/kg on day 3
In practice, everyone gets albumine
but guidelines only if Cr > 88, BUN > 10.7 or bili > 68
37
How long should you give SBP prophylaxis to cirrhosis patients who present with upper or lower GI bleed ?
7 days
No need to have ascites
38
How many pts progress to chronic HBV if they have acute hep B ?
<5%
39
How should you manage heterozygotes HH patients ?
Iron indices annually, no tx needed
Evaluate for other causes of iron overload, consider MRI / bx to estimate hepatic iron concentration (HIC)
40
How should you treat HH pts ?
- Phlebotomy targeting ferritin 50-100
- If refractory (anemia, high output CF) : chelation (desferoxamine, deferiprone, deferasirox)
- Limit Vit C supplements (increase iron absorption)
- Avoid uncooked seafood
- No need to limit red meat/dietary iron if undergoing phlebotomy
- Liver transplant PRN
41
If ascitic gluid protein < 15g/L, which other condition needs to be met to give SBP prophylaxis to a cirrhotic patient ?
- Impaired renal function (Cr ≥ 106, BUN ≥ 8.9, Na ≤ 130)
- Impaired liver function (Child-Pugh ≥ 9 and Bili ≥ 51 umol/L)
42
If simple HCV with no cirrhosis or co infection, how should you treat ?
Choose one of 2 pan genotypic regimes
- Sofosbuvir/velpatasvir (die x 12wks ; Epclusa)
- Glecaprevir/Pibrentasvir (die x 8wks ; Maviret)
43
Increased risk of HCC in hepatitis B ?
Host: immunocompromised, family history, born in sub-Saharian Africa, coinfection, EtOH, metabolic syndrome, smoking, aflatoxin
Disease : High DNA/ALT, sAg positive > sAg negative, prolonged time to eAg seroconversion, eAg negative mutant, genotype C
44
Labs in alcohol associated hepatitis ?
AST > 50, AST/ALT > 1.5-2 and both values < 400, T bili > 51
45
Link between eAg and risk for cirrhosis in hep B ?
Increased risk of cirrhosis if prolonged time to eAg seroconversion or eAg negative mutant
46
Link between sAg and eAg and increased risk of HCC in hep B ?
Increased risk of HCC if :
- sAg positive > sAg negative
- Prolonged time to eAg seroconversion
- eAg negative mutant
47
Need ROH abstinence for liver transplant?
No no longer rule, case by case
48
Nephrotic syndrome : ascites transudative or exsudative ?
Exsudative
49
Pentoxifylline in addition to steroids for alcohol associated hepatitis ?
No role, trend toward benefit in HRS
50
Post tx completion for Hep C, how do you know if cured ?
Check viral load 12 w post tx completion : if negative is CURED = sustained virological response SVR 12
(no risk of reactivation, different from Hep B)
51
Prophylactic ATB in alcohol associated hepatitis ?
No mortality benefit so no
52
ROH associated hepatitis : definition ?
Acute onset hepatitis associated with ongoing alcohol intake within 8 wks
53
Tx for acute hepatitis B ?
Mainly supportive
Consider antiviral therapy
Ensure household and sexual contacts are immune and provide Hep B vaccine if they are not
Hep B immunoglobulins within 48h if sexual contacts or percutaneous exposure if immune status unknown
54
UGIB in pt with cirrhosis : name 5 management key points.
- Restrictive transfusion stratefy
- IV vasoactive drug, continue x 5days post endoscopy if variceal bleed
- IV PPI
- Endoscopy within 12h
- ATB prophylaxis (ceftri 1g x 5-7d)
Following variceal bleed + EVL : initiate NSBB when vasoactive drugs stopped
55
Varices : when should be your next EGD in case of EVL ?
If you do EVL, need to repeat q2-8w until obliteration of varices. Then, repeat EGD q3-6m after eradication and every 6-12m thereafter.
56
Varices primary prophylaxis : what is the next step if med/large varices on initial gastroscopy ?
NSBB OR EVL and no need to repeat EGD if on NSBB
57
Varices primary prophylaxis : what is the next step if no varices on initial gastroscopy ?
Compensated : EGD q 2-3 y
Decompensated : EGD at time of decomp then q1y
58
Varices primary prophylaxis : what is the next step if small varices on initial gastroscopy ?
Low risk : EGQ q1-2 y
High risk : NSBB and no need to repeat EGD if on NSBB
High risk : CP-C or stigmata (red wale sign, red spot)
59
What are 4 extrahepatic manifestations of hep B ?
Polyarteritis nodosa, membranous > MPGN, aplastic anemia
60
What are disease associations with MASLD ?
Associated with T2DM (MOST IMP RF), high lipids, HTN, obesity, metabolic synd, OSA
61
What are other chronic liver diseases that causes secondary iron overload ?
MASLD
Alcohol related liver disease
Hep C
62
What are the 5 criteries in the child pugh score ?
Ascites (3 for moderate)
Bilirubin (3 for > 51)
Coagulopathy (INR) (3 for > 2.2)
Albumin (3 for < 28)
Encephalopathy (3 for grade 3-4)
63
What are the cons of nucleotide analogues in tx of chronic HBV ?
Many years of therapy, can be life long (especially in eAg negative disease)
Expensive
Unlikely to convert to seroconvert sAg
64
What are the cons of peg interferon in tx of chronic hep b ?
- Side effects ++
- Only specific patients benefits
Low DNA, high ALT
Non cirrhotic hbeAg + CHB
- CANNOT use in decompensated cirrhosis
65
What are the endocrine and skin manifestations in HH ?
Bronze hyperpigmentation
Hypopituitarism (impotence, amenorrhea)
Diabetes (islet cell destruction)
66
What are the indication sfor SBP prophylaxis ?
- Previously had SBP : indefinite prophylaxis
- Cirrhosis who present with upper OR lower GI bleed (don’t need to have ascites) : prophylaxis for 7 days
- Cirrhotic with ascitic fluid protein < 15g/L AND at least one of :
Impaired renal function (Cr ≥ 106, BUN ≥ 8.9, Na ≤ 130)
Impaired liver function (Child-Pugh ≥ 9 and Bili ≥ 51 umol/L)
67
What are the MSK implications of HH ?
Arthropathy : 2nd or 3rd MCP hooked osteophytes
68
What are the pros of peg-interferon in tx of chronic hep B ?
- Finite therapy (typically 48w)
- Generally more durable response
69
What are the two mutations that cause iron overload in HH ?
C282Y homozygous (diagnostic)
C282Y/H63D heterozygous (possible)
70
What are the two phenotypes of chronic hep B that you should treat ?
Immune active and chronic hepatitis
The two phenotypes with aN ALT and aN fibroscan
71
What are the two types of hepatorenal syndrome ?
Type 1 / HRS AKI : severe abrupt
Type 2 / HTS NAKI : gradual decline kidney function w refractory ascites
72
What are two diagnosis if HbsAg positive on hep B serology ?
Acute infection or chronic hepatitis
73
What does the Child Pugh score predicts ?
Predicts periop mortality for open abdominal surgery
CP A (score 5-6): 10%, CP B (score 7-9) 30%, CP C (score 10-15) 80%
74
What is hep A transmission ?
Fecal oral
75
What is high risk patient in context of varices screening ?
Child Pugh C or EGD stigmata : red wale sign, red spot
76
What is the 1st line tx for chronic HBV ?
Nucleotide analogues : tenofovir, entecavir as very high barrier to resistance and well tolerated
77
What is the baseline work up for Hep B sAg+?
- Physical exam
- ALT, CBC, Cr, HBV DNA, HBe serology, fibroscan
- HIV, Hep D in high risk groups
78
What is the benefit in giving steroids for alcohol associated hepatitis ?
Lowers 28d mortality ; max benefit at MELD 25-39
79
What is the definition for the diagnosis of SBP ?
Neutrophils in ascitic fluids > 250 OR culture positive ascitic fluid
**** culture negative ascitis still requires complete course of tx
80
What is the dx threshold for cirrhosis on a fibroscan for hep C patients ?
> 12.5 kPa = cirrhosis
81
What is the follow up for Hep B sAg + ?
- ALT and HBV DNA q6-12 months
- Repeat fibroscan if persistent elevated ALT and HBV DNA
- US q8months for HCC surveillance if
Cirrhotic
Asian M > 40, F > 50
African > 20
Fm hx HCC in 1st degree relatives
all HIV coinfected > 40
82
What is the initial management of ascites related to portal HTN ?
- Salt restriction (<2g or 88mmol/d)
Water restriction NOT necessary unless Na < 125
- Diuretics : spirono 100 and lasix 40 and titrate
83
What is the link between infection and HH ?
Increased risk of infection (listeria, yersinia, e coli, vibrio)
84
What is the management of ascites in case of failing medical therapy ?
- Serial therapeutic paracentesis + give albumin 6-8 g/L of fluid removed for taps > 4L
- TIPS if no CI (encephalopathy, HCC)
- Liver transplant
85
What is the most common cause of death in MASLD ?
Cardiac
86
What is the new terminology for fatty liver disease ?
MASLT (NAFLD) : fatty liver with no hepatocellular injury
MASH (NASH) : + hepatocellular injury
Met-ALD : MASLD + increased ROH (2-3 conso selon sexe)
87
What is the serologic definition of CHRONIC hep B ?
Surface Ag positive over 6 months
88
What is the serology for immune tolerant chronic hepatitis B phase ?
HbsAg
HbsAb
HbeAg
HBV DNA
ALT
Fibroscan
HbsAg +
HbsAb -
HbeAg +
HBV DNA > 10^7
ALT N
Fibroscan N
89
What is the serology of chronic hep B chronic hepatitis ?
HbsAg
HbsAb
HbeAg
HBV DNA
ALT
Fibroscan
HbsAg +
HbsAb -
HbeAg -
HBV DNA 10^3-10^7
ALT high or fluctuating
Fibroscan aN
90
What is the serology of chronic hep B chronic INFECTION ?
HbsAg
HbsAb
HbeAg
HBV DNA
ALT
Fibroscan
HbsAg +
HbsAb -
HbeAg -
HBV DNA < 2000
ALT N
Fibroscan N or mildly abN
91
What is the serology of chronic hep B immune active ?
HbsAg
HbsAb
HbeAg
HBV DNA
ALT
Fibroscan
HbsAg +
HbsAb -
HbeAg +
HBV DNA 10^4-10^7
ALT high or fluctuating
Fibroscan aN
92
What is the tx for MASLD ?
- Weight loss (bariatric if obese)
- Identify + manage CV risk factors (ex: statins)
Pharmacotherapy :
- semaglutide for MASH + T2DM/obesity
- Pioglitaxone for bx proven MASH + T2DM but risk of edema, CHF
- Vitamine E 800 IU for bx proven MASH w/o T2DM but may increased risk of adverse CV outcomes
93
What is the typical clinical presentation of spontaneous bacterial peritonitis ?
Abdominal pain and fever
94
What is the work up diagnosis for Hep C ?
- HCV genotype testing, HCV RNA level, HIV, HBV
- Liver enzymes, liver function testing
- Abdominal ultrasound
- Fibrosis assessment, prognostication (APRI, bx, fibroscan)
95
What MELD score should prompt a liver transplant assessment ?
MELD ≥ 15
96
When should you ask for HFE genotype to dx HH ?
For a sx patient / asx with ALT/AST > 35 / 1st degree relative
Ask for genotype if TS ≥ 45% AND ferritin > 300 (M) or > 200 (F)
97
When should you do HCC survceillance with US in case of hep B ? Name 5 points.
- All cirrhotics
- Asian M > 40, F > 50
- African > 20
- Family hx HCC in 1st degree relatives
- HIV co infected > 40
98
When should you give albumin in case of paracentesis ?
Replace with 100cc of 25% albumin for each 4L of fluid removed
99
When should you give Hep B immunoglobulins ?
No need for Hep B immunoglobulin for household contacts
Sexual contacts and those with percutaneous exposure YES within 48h if immune status unknown/low titre
100
When should you give steroids for alcohol associated hepatitis ?
- If Severe AH : Maddrey ≥ 32 or ,MELD > 20 or presence of encephalopathy : prednisolone 40 PO daily
- If Lille score at 4 or 7 days < 0.45 : continue pred x 28d then taper
If ≥ 0.45 stop and consider early liver transplant (no minimum period of abstinence)
MAKE SURE NO CI : uncontrolled infection, uncontrolled GI bleed, AKI
101
When should you perform diagnostic paracentesis ?
Every pt with new ascites AND in every cirrhotic with ascitis who presents to hospital
102
When should you refer cirrhosis patients to palliative care team ?
If decompensated cirrhosis at any point in journey (improves sx, quality of life, carefiver stress)
103
When should you screen for HCC in HH patients ?
Only if cirrhosis
ACG recommends against screening if fibrosis ≤ stage 3
104
Which ATB for prophylaxis post SBP ?
Lifelong prophylaxis with norfloxacin, septra DS or cipro
105
Which diet should you recommend for hepatic encephalopathy ?
High calorie, high protein diet
106
Which genotype is associated with higher risk of cirrhosis in hep B ?
Genotype C
107
Which hepatitis B phenotypes have a aN fibroscan ?
Immune active and chronic hepatitis
Chronic infection can be mildly abN
108
Which medication for hepatorenal syndrome ?
Terlipressin + albumin > octreotide + midodrine + albumin
109
Which medication should you avoid in cirrhosis ?
Sedatives, AINS, ACEi/aRBs
110
Which mutation causes HH ?
Mutation of HFE gene
- TYPE 1A : C282Y homozygous is DX
- TYPE 1B : C282Y/H63D heterozygous less likely but possible iron overload
Other genotypes do not lead to significant iron overload ( C282Y/ wildtype, H63D/ wildtype, H63D homozygote, S65C mutation (type 1C hemochromatosis))
111
Which NSBB is currently prefered ?
Carvedilol 12.5 mg/d
112
Which vaccines should you recommend for cirrhosis ?
HAV, HBV, COVID, TdAP, Pneumococcus, flu
If > 50 : zoster
113
Which value of ferritin should make you suspect end organ dommage in HH ?
Ferritin > 1000
Liver biopsy for fibrosis staging
114
When is post exposure prophylaxis necessary for hepatitis A ?
Household contacts of Hep A infected pts, co workers and clients of infected food handlers, contacts in childcare
115
Who should you screen for clinically significant fibrosis in MASLD ?
T2DM, obesity, 1st degree relative with MASH cirrhosis, ROH use
FIB4 for everyone and if > 1.3 : fibroscan
116
What is the only option with mortality benefit for patients with cirrhosis who have GI bleeding?
Ceftriaxone
117
Does portopulmonary hypertension reverse with liver transplantation ?
Rarely whereas hepatopulmonary synd commonly reverses with transplant
MPAP > 50 is a CI to liver transplantation as mortality is 100%
118
What is the mean pulmonary pressure value that is a CI to liver transplant ?
MPAP > 50 is a CI as mortality is 100%
119
Can you do TIPS in case of right heart failure ?
No CI as TIPS would increase right ventricular and PA pressure and worsen the patient’s condition
