clin med- hepatitis lectures Flashcards
At what point can you still reverse liver damage (alcohol related)
Steatosis
reversible after 4-6 weeks of abstinence
Alcoholic Liver Dz 3 main patterns of injury
Fatty liver (simple steatosis)
Alcoholic Hepatitis
Chronic Hep w Fibrosis or Cirrhosis
ALD risk factors
> 1 drink/day for women, >2 drinks/day for men
Pattern (daily, binge, fasting)
Obese
Fatty liver
A-sx, reversible and self limited (after 4-6 wks of abstinence)
Tx: lifestyle (weight loss and exercise) stop drinking
AH
Alcohol Hepatitis
Necrosis and fibrotic scarring
Sx can be none —-> severe
AH severe manifestations
Hepatic encephalopathy jaundice Hepatosplenomegaly Edema Ascites Variceal bleeding
AST/ALT ratio in Alcoholic Hepatitis
> 1.5
Mallory Denk body
Alcoholic Hepatitis
Histology of Alcoholic Hepatitis
Neutrophilic lobe inflammation
Clumps of Mallory Denk
Degranulation and fibrosis
Definite dx of Alcoholic Hepatitis
Liver biopsy
Confounding factors
reasons why Alcohol might not be the cause of the liver damage
Lilie Model
response to Steroid
Hepatic Encephalopathy
Ammonia travels to brain: neurotoxin
Tx: Lactulose
Sx: EKG change, tremor
4 grades of Hepatic Encephalopathy
syndrome of impaired brain fx w/ advanced liver dz
Asterixsis (hand tremor)
a sign of Hepatic Encephalopathy
Severe Alcoholic Hepatitis
Variceal bleeding
Ascites
Jaundice
Tx of Severe Alcoholic Hepatitis
Diuretics
Hepatic Enceph: Lactulose, Rifaximin
Severe Alc Hep diagnostics
MDF >32
Tx of Severe Alc Hep
Steroids, but stop if not effective after 7 days (using Lilie score)
Liver transplant if meds fail
Liver cirrhosis
Process of destruction, regeneration, necrosis, fibrosis and progressive deterioration
Compensated cirrhosis
12 yr survival
Portal pressure is not an issue (<10)
Splenomegaly
Anemia
AST elevation
Uncompensated Cirrhosis
<2 yr survival
Portal HYPERTENSION
Porto-systemic shunting
Dupuytren's contracture Spider nevi Hepatic enceph Jaundice Muscle wasting Portal HTN Asterixis
Decompensated Cirrhosis
3 possible sites of obstruction causing Portal HTN
Prehepatic: Portal vein clot
Intrahepatic: Cirrhosis
Posthepatic: CHF, constrictive pericarditis
HCC surveillance
Hepatocell CA
US every 6 mo and AFP
TIPS
Transjugular Intrahepatic Portosystemic Shunt
Tx if you have decompensated cirrhosis and MELD score >15
Liver transplant
HepatoRenal syndrome
Inc BUN (Azotemia) prog rise in Cr
HepatoRenal synd
two subtypes
Type 1: rapidly progressing, multi organ failure (survival <4 wks)
Type2: assoc w refractory ascites (longer survival about 6mo)
Benign Liver lesions that require NO FURTHER TX
Cavernous hemangioma <4 cm
Focal nodular hyperplasia
Simple cyst (no sx)
Focal fatty change
Benign Liver lesions REQUIRING further investigation
Adenoma
Liver abscess
Inflammatory pseudotumor
Atypical cyst or Large
Refer to GI/Hepatology
High suspicion of Hepatocellular CA in
Cirrhosis
Hep B
How to screen Cirrhotic pts for HCC
Platelet count
US elastography
How to screen Hep B pts for HCC
US every 6 mo + AFP
HCC sx
Sudden appearance of Ascites
Cachexia
Weight loss
Dx of HCC
High AFP and ALP
Order: CT first, then Tri phasic MRI if CT not helpful
DIAGNOSTIC For HCC
Liver biopsy
but try Tri phasic CT –> MRI first
HCC tx
Resection rarely feasible
Liver transplant early stage
RFA/Microwave for small tumors
Chemo
Most at risk for Fatty liver (steatohepatitis)
Asian indians
Ratio of >1.5
Alcoholic liver dz
Order of ALT values- Highest to lowest
Shock Acute hep Alcohol Chronic hep Cirrhosis Normal
Progression of Fatty liver
NAFL (no evidence of liver cell injury) –> NASH (inflammation w liver cell injury) –> NASH Cirrhosis (cirrhosis + steatosis)
NAFL
no injury
NASH
hepatocyte injury present
Two main risk factors for NAFLD
Obesity
DM2
Fibroscan results indicating fatty liver
Fibroscan (VCTE) >5%
HH
accum of IRON
HH
Caucasians
Bronze skin, joint, cardiomegaly
Triad of Bronze skin, DM, and Cirrhosis
HH
Transferrin and
Ferritin values indicating HH
Transferrin> 45
Ferritin > 200 or 150 (men, women respectively)
Tx for HH
Phlebotomy every 6 mo with CA screening (US and AFP)
How is HH dx confirmed
HFE gene testing +/- liver bx
Screen for HH if pt has
Elevated AST/ALT Abn iron studies 1st deg relative w HH Evidence Liver dz Sx of HH
Wilson dz
Copper
Keyser fisher ring + Neuro
Dx Wilson dz (copper)
24 hr Urinary copper
Confirm w Liver bx
Tx of Wilson dz (copper)
Chelating agent
Liver transplant
A1 deficiency
Inc risk:smoking
Panniculitis
Emphysema and or Neonatal cholestasis/childhood cirrhosis
A1 deficiency tx
Liver transplant
AIH: Autoimmune Hepatitis
Non spec sx
(fatigue, abd pain, pruritis, joint pain)
Acute onset if <30 days: hepatomegaly, tender, jaundice, splenomegaly, fever
Serological markers for AIH: Autoimmune Hep
ANA
SMA
IgG
LKMA-1 (kids)
Tx for AIH: Autoimmune Hep
Prednisone +/- Azothioprine
Hep A
Asia, Africa
sanitation
Does NOT cause chronic
Flu like sx in prodrome
Icteric: jaundice, dark urine, pruritis, light colored stool, jaundice
Hep A titers
IgM anti-HAV: Acute infection
M MEANS ACUTE
IgG anti-HAV: Immunity
G means you’re GOOD
Tx for Hep A
Supportive
High risk: hospitalize
Leading cause of Cirrhosis and Liver CA
Hep B
Hep B
Usually becomes chronic in kids
Adults usually recover with immunity
Acute Hep B is more severe in elderly of what age
> 60 YO
Tx for Hep B
Supportive +/- Antiviral (only in acute liver failure or protracted course)
Hospitalize risky pts
Hep C
MOST become Chronic
Testing for Hep C
RNA viral load of Hep C Antibody
Hep C screening
One time testing for ALL 18 YO or older
Hep C tx
Stop drinking
DAAT
Vaccinae for Hep A and B
Hep E is most dangerous in what term of pregnancy
2nd and 3rd trimester
