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Pneumo/gastro c’est bow > Cirrhosis > Flashcards

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)
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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)

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3
Q

Approach to varices, what should patients receive for secondary prophylaxis ?

A

NSBB AND EVL

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4
Q

Ascites with SAAG > 11 : transudative or exsudative ?

A

Transudative

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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

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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

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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

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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
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9
Q

Chronic Hep B mother : what tx for the baby ?

A

Should get HBIG + HBV vaccine after birth

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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)
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11
Q

Do you need bx for alcohol associated hepatitis ?

A

Clinical dx, bx rarely needed
CONSIDER if AST/AST > 400, other dx suspected

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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

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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
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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

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15
Q

Hep C : criteria for population level screening ?

A

Anyone born between 1945 and 1975

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16
Q

Hepatite B serology : immunized ?

A

AntiHbs

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17
Q

Hepatitis B serology : acute infection ?

A

HbsAg + Core IgM + HbeAg + HBV DNA

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18
Q

Hepatitis B serology : immune, prior infection ?

A

HbsAg + core IgG + Anti Hbe

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19
Q

Hepatitis C : autoimmune extra hepatic manifestations ?

A

AI thyroid disease, myasthenia gravis, Sjogren’s

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20
Q

Hepatitis C : CUTANEOUS extra hepatic manifestations ?

A

Porphyria cutanea tarda, leukocytoclastic vasculitis

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21
Q

Hepatitis C : factors which increase risk of cirrhosis ?

A

Older age, male sex, HIV/HBV co infection, obesity/DM/fatty liver, ROH

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22
Q

Hepatitis C : factors which increase risk of HCC ?

A

Cirrhosis or co existing liver disease which may accelerate fibrosis

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23
Q

Hepatitis C : heme extra hepatic manifestations ?

A

Lymphome (NHL), AI hemolytic anemia, ITP, cryo

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24
Q

Hepatitis C : other extra hepatic manifestations ?

A

Insuline resistance, diabete mellitus

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25
Q

Hepatitis C : renal extra hepatic manifestations ?

A

MPGN > membranous glomerulopathy

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26
Q

Hepatitis C : who should you treat ?

A

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

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27
Q

Hepatitis C and pregnancy, who should you treat ?

A

Not enough evidence to recommend tx during pregnancy or breastfeeding
(different from hep B)

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28
Q

Hereditary hemochromatosis : recessive or dominant ?

A

Recessive

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29
Q

Hereditary hemochromatosis : which population epidemiologically ?

A

Northern european descent

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30
Q

HH : who/when should you treat ?

A

C282Y homozygotes if ferritin > 300 (M) or > 200 (F) AND sat > 45

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31
Q

How do you determine the etiology of ascites ?

A

SAAG > 11 : transudate
SAAG < 11 : exsudative

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32
Q

How do you diagnose hepatopulmonary syndrome ?

A
  • Suspect HPS if ABG reveals PaO2 < 80, A-a gradient ≥ 15
  • TT echo with agitated saline (bubble study) demonstrates intrapulmonary shunting
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33
Q

How do you diagnose hepatorenal syndrome ?

A
  • 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%
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34
Q

How do you diagnose MASLD ?

A
  • Evidence of steatosis
  • Rule out 2e causes
    MASH can only be dx definitively on bx
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35
Q

How do you do fibrosis assessment for hep C ?

A

Can use APRI score or FIB 4: if > F2 : fibroscan
Fibroscan > 12.5 kPA = cirrhosis

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36
Q

How do you treat confirmed SBP ?

A
  • 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
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37
Q

How long should you give SBP prophylaxis to cirrhosis patients who present with upper or lower GI bleed ?

A

7 days
No need to have ascites

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38
Q

How many pts progress to chronic HBV if they have acute hep B ?

A

<5%

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39
Q

How should you manage heterozygotes HH patients ?

A

Iron indices annually, no tx needed
Evaluate for other causes of iron overload, consider MRI / bx to estimate hepatic iron concentration (HIC)

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40
Q

How should you treat HH pts ?

A
  • 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
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41
Q

If ascitic gluid protein < 15g/L, which other condition needs to be met to give SBP prophylaxis to a cirrhotic patient ?

A
  • Impaired renal function (Cr ≥ 106, BUN ≥ 8.9, Na ≤ 130)
  • Impaired liver function (Child-Pugh ≥ 9 and Bili ≥ 51 umol/L)
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42
Q

If simple HCV with no cirrhosis or co infection, how should you treat ?

A

Choose one of 2 pan genotypic regimes
- Sofosbuvir/velpatasvir (die x 12wks ; Epclusa)
- Glecaprevir/Pibrentasvir (die x 8wks ; Maviret)

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43
Q

Increased risk of HCC in hepatitis B ?

A

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

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44
Q

Labs in alcohol associated hepatitis ?

A

AST > 50, AST/ALT > 1.5-2 and both values < 400, T bili > 51

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45
Q

Link between eAg and risk for cirrhosis in hep B ?

A

Increased risk of cirrhosis if prolonged time to eAg seroconversion or eAg negative mutant

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46
Q

Link between sAg and eAg and increased risk of HCC in hep B ?

A

Increased risk of HCC if :
- sAg positive > sAg negative
- Prolonged time to eAg seroconversion
- eAg negative mutant

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47
Q

Need ROH abstinence for liver transplant?

A

No no longer rule, case by case

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48
Q

Nephrotic syndrome : ascites transudative or exsudative ?

A

Exsudative

49
Q

Pentoxifylline in addition to steroids for alcohol associated hepatitis ?

A

No role, trend toward benefit in HRS

50
Q

Post tx completion for Hep C, how do you know if cured ?

A

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
Q

Prophylactic ATB in alcohol associated hepatitis ?

A

No mortality benefit so no

52
Q

ROH associated hepatitis : definition ?

A

Acute onset hepatitis associated with ongoing alcohol intake within 8 wks

53
Q

Tx for acute hepatitis B ?

A

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
Q

UGIB in pt with cirrhosis : name 5 management key points.

A
  • 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
Q

Varices : when should be your next EGD in case of EVL ?

A

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
Q

Varices primary prophylaxis : what is the next step if med/large varices on initial gastroscopy ?

A

NSBB OR EVL and no need to repeat EGD if on NSBB

57
Q

Varices primary prophylaxis : what is the next step if no varices on initial gastroscopy ?

A

Compensated : EGD q 2-3 y
Decompensated : EGD at time of decomp then q1y

58
Q

Varices primary prophylaxis : what is the next step if small varices on initial gastroscopy ?

A

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
Q

What are 4 extrahepatic manifestations of hep B ?

A

Polyarteritis nodosa, membranous > MPGN, aplastic anemia

60
Q

What are disease associations with MASLD ?

A

Associated with T2DM (MOST IMP RF), high lipids, HTN, obesity, metabolic synd, OSA

61
Q

What are other chronic liver diseases that causes secondary iron overload ?

A

MASLD
Alcohol related liver disease
Hep C

62
Q

What are the 5 criteries in the child pugh score ?

A

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
Q

What are the cons of nucleotide analogues in tx of chronic HBV ?

A

Many years of therapy, can be life long (especially in eAg negative disease)
Expensive
Unlikely to convert to seroconvert sAg

64
Q

What are the cons of peg interferon in tx of chronic hep b ?

A
  • Side effects ++
  • Only specific patients benefits
    Low DNA, high ALT
    Non cirrhotic hbeAg + CHB
  • CANNOT use in decompensated cirrhosis
65
Q

What are the endocrine and skin manifestations in HH ?

A

Bronze hyperpigmentation
Hypopituitarism (impotence, amenorrhea)
Diabetes (islet cell destruction)

66
Q

What are the indication sfor SBP prophylaxis ?

A
  • 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
Q

What are the MSK implications of HH ?

A

Arthropathy : 2nd or 3rd MCP hooked osteophytes

68
Q

What are the pros of peg-interferon in tx of chronic hep B ?

A
  • Finite therapy (typically 48w)
  • Generally more durable response
69
Q

What are the two mutations that cause iron overload in HH ?

A

C282Y homozygous (diagnostic)
C282Y/H63D heterozygous (possible)

70
Q

What are the two phenotypes of chronic hep B that you should treat ?

A

Immune active and chronic hepatitis
The two phenotypes with aN ALT and aN fibroscan

71
Q

What are the two types of hepatorenal syndrome ?

A

Type 1 / HRS AKI : severe abrupt
Type 2 / HTS NAKI : gradual decline kidney function w refractory ascites

72
Q

What are two diagnosis if HbsAg positive on hep B serology ?

A

Acute infection or chronic hepatitis

73
Q

What does the Child Pugh score predicts ?

A

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
Q

What is hep A transmission ?

A

Fecal oral

75
Q

What is high risk patient in context of varices screening ?

A

Child Pugh C or EGD stigmata : red wale sign, red spot

76
Q

What is the 1st line tx for chronic HBV ?

A

Nucleotide analogues : tenofovir, entecavir as very high barrier to resistance and well tolerated

77
Q

What is the baseline work up for Hep B sAg+?

A
  • Physical exam
  • ALT, CBC, Cr, HBV DNA, HBe serology, fibroscan
  • HIV, Hep D in high risk groups
78
Q

What is the benefit in giving steroids for alcohol associated hepatitis ?

A

Lowers 28d mortality ; max benefit at MELD 25-39

79
Q

What is the definition for the diagnosis of SBP ?

A

Neutrophils in ascitic fluids > 250 OR culture positive ascitic fluid
** culture negative ascitis still requires complete course of tx

80
Q

What is the dx threshold for cirrhosis on a fibroscan for hep C patients ?

A

> 12.5 kPa = cirrhosis

81
Q

What is the follow up for Hep B sAg + ?

A
  • 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
Q

What is the initial management of ascites related to portal HTN ?

A
  • Salt restriction (<2g or 88mmol/d)
    Water restriction NOT necessary unless Na < 125
  • Diuretics : spirono 100 and lasix 40 and titrate
83
Q

What is the link between infection and HH ?

A

Increased risk of infection (listeria, yersinia, e coli, vibrio)

84
Q

What is the management of ascites in case of failing medical therapy ?

A
  • Serial therapeutic paracentesis + give albumin 6-8 g/L of fluid removed for taps > 4L
  • TIPS if no CI (encephalopathy, HCC)
  • Liver transplant
85
Q

What is the most common cause of death in MASLD ?

A

Cardiac

86
Q

What is the new terminology for fatty liver disease ?

A

MASLT (NAFLD) : fatty liver with no hepatocellular injury
MASH (NASH) : + hepatocellular injury
Met-ALD : MASLD + increased ROH (2-3 conso selon sexe)

87
Q

What is the serologic definition of CHRONIC hep B ?

A

Surface Ag positive over 6 months

88
Q

What is the serology for immune tolerant chronic hepatitis B phase ?

HbsAg
HbsAb
HbeAg
HBV DNA
ALT
Fibroscan

A

HbsAg +
HbsAb -
HbeAg +
HBV DNA > 10^7
ALT N
Fibroscan N

89
Q

What is the serology of chronic hep B chronic hepatitis ?

HbsAg
HbsAb
HbeAg
HBV DNA
ALT
Fibroscan

A

HbsAg +
HbsAb -
HbeAg -
HBV DNA 10^3-10^7
ALT high or fluctuating
Fibroscan aN

90
Q

What is the serology of chronic hep B chronic INFECTION ?

HbsAg
HbsAb
HbeAg
HBV DNA
ALT
Fibroscan

A

HbsAg +
HbsAb -
HbeAg -
HBV DNA < 2000
ALT N
Fibroscan N or mildly abN

91
Q

What is the serology of chronic hep B immune active ?

HbsAg
HbsAb
HbeAg
HBV DNA
ALT
Fibroscan

A

HbsAg +
HbsAb -
HbeAg +
HBV DNA 10^4-10^7
ALT high or fluctuating
Fibroscan aN

92
Q

What is the tx for MASLD ?

A
  • 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
Q

What is the typical clinical presentation of spontaneous bacterial peritonitis ?

A

Abdominal pain and fever

94
Q

What is the work up diagnosis for Hep C ?

A
  • HCV genotype testing, HCV RNA level, HIV, HBV
  • Liver enzymes, liver function testing
  • Abdominal ultrasound
  • Fibrosis assessment, prognostication (APRI, bx, fibroscan)
95
Q

What MELD score should prompt a liver transplant assessment ?

A

MELD ≥ 15

96
Q

When should you ask for HFE genotype to dx HH ?

A

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
Q

When should you do HCC survceillance with US in case of hep B ? Name 5 points.

A
  • All cirrhotics
  • Asian M > 40, F > 50
  • African > 20
  • Family hx HCC in 1st degree relatives
  • HIV co infected > 40
98
Q

When should you give albumin in case of paracentesis ?

A

Replace with 100cc of 25% albumin for each 4L of fluid removed

99
Q

When should you give Hep B immunoglobulins ?

A

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
Q

When should you give steroids for alcohol associated hepatitis ?

A
  • 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
Q

When should you perform diagnostic paracentesis ?

A

Every pt with new ascites AND in every cirrhotic with ascitis who presents to hospital

102
Q

When should you refer cirrhosis patients to palliative care team ?

A

If decompensated cirrhosis at any point in journey (improves sx, quality of life, carefiver stress)

103
Q

When should you screen for HCC in HH patients ?

A

Only if cirrhosis
ACG recommends against screening if fibrosis ≤ stage 3

104
Q

Which ATB for prophylaxis post SBP ?

A

Lifelong prophylaxis with norfloxacin, septra DS or cipro

105
Q

Which diet should you recommend for hepatic encephalopathy ?

A

High calorie, high protein diet

106
Q

Which genotype is associated with higher risk of cirrhosis in hep B ?

A

Genotype C

107
Q

Which hepatitis B phenotypes have a aN fibroscan ?

A

Immune active and chronic hepatitis
Chronic infection can be mildly abN

108
Q

Which medication for hepatorenal syndrome ?

A

Terlipressin + albumin > octreotide + midodrine + albumin

109
Q

Which medication should you avoid in cirrhosis ?

A

Sedatives, AINS, ACEi/aRBs

110
Q

Which mutation causes HH ?

A

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
Q

Which NSBB is currently prefered ?

A

Carvedilol 12.5 mg/d

112
Q

Which vaccines should you recommend for cirrhosis ?

A

HAV, HBV, COVID, TdAP, Pneumococcus, flu

If > 50 : zoster

113
Q

Which value of ferritin should make you suspect end organ dommage in HH ?

A

Ferritin > 1000
Liver biopsy for fibrosis staging

114
Q

When is post exposure prophylaxis necessary for hepatitis A ?

A

Household contacts of Hep A infected pts, co workers and clients of infected food handlers, contacts in childcare

115
Q

Who should you screen for clinically significant fibrosis in MASLD ?

A

T2DM, obesity, 1st degree relative with MASH cirrhosis, ROH use
FIB4 for everyone and if > 1.3 : fibroscan

116
Q

What is the only option with mortality benefit for patients with cirrhosis who have GI bleeding?

A

Ceftriaxone

117
Q

Does portopulmonary hypertension reverse with liver transplantation ?

A

Rarely whereas hepatopulmonary synd commonly reverses with transplant
MPAP > 50 is a CI to liver transplantation as mortality is 100%

118
Q

What is the mean pulmonary pressure value that is a CI to liver transplant ?

A

MPAP > 50 is a CI as mortality is 100%

119
Q

Can you do TIPS in case of right heart failure ?

A

No CI as TIPS would increase right ventricular and PA pressure and worsen the patient’s condition

Pneumo/gastro c’est bow (5 decks)

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