Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

GI 2 > Clin Med - NAFLD > Flashcards

Clin Med - NAFLD Flashcards

1
Q

What is non-alcoholic fatty liver disease (NAFLD)?

A
  • Often called “Fatty Liver”
  • The hepatic manifestation of metabolic syndrome
  • Although initially benign, it can slowly progress to hepatitis and even cirrhosis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Where are the lipids deposited in the liver?

A

Into the hepatocytes

-it takes up space and the cells can’t function properly, signals inflammatory response

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

How will fatty liver appear on ultrasound?

A

Increased echogenicity - pale and dense

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Fibrosis and mortality

A

The more fibrosis, the worse the prognosis.

*Fibrosis is an early indication of which patients with fatty liver will have the most difficult disease progression.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Progression of Fatty Change

A
  1. simple liver steatosis
  2. non-alcoholic steatohepatitis (NASH)
  3. non-alcoholic steatohepatitis with fibrosis
  4. cirrhosis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Gross morphology of NAFLD

A

Soft, yellow, greasy, often enlarged

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Define simple fatty liver

A

i. e. “hepatis steatosis”
- Fat accumulation in hepatocytes
- 70% of NAFLD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Define non-alcoholic hepatosteatosis

A

i. e. “NASH”
- Fat + inflammation, causes cell injury, a hepatitis, can elevate liver enzymes
- 30% of NAFLD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Define fibrosis

A
  • Scarring in liver tissue

- NASH + fibrosis = very predictive progression to ESLD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Define cirrhosis

A
  • scar –> nodules

- irreversible damage likely to progress to ESLD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Epidemiology of NAFLD

A
  • most common form of chronic liver disease in the Western world
  • parallels the obesity epidemic
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Population prevalence of NAFLD

A
  • Highest in Hispanics, followed by non-Hispanic caucasians

- Lowest in non-Hispanic blacks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Future predictions

A

in 20 years, NASH will be the #1 cause for liver transplant (surpassing both chronic hepatitis C and alcoholic cirrhosis)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Pathogenesis - hepatic lipogenesis leading to hepatic steatosis

A
  • insulin resistance –> lipolysis –> increased plasma free fatty acids –> inappropriately shifted to the liver
  • de novo hepatic synthesis of fat, genetics
  • accumulation of triglyceride as lipid droplets in cytoplasm of hepatocytes
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

“Multiple hit theory”

A

1st Hit: hepatic steatosis (insulin shifts)
2nd Hit: oxidative stress due to free radical formation, cardiolipin peroxidation, cytokines, apoptosis, and gut-derived bacterial endotoxinemia
3rd Hit: gene involvement (PNPLA3), impaired hepatocyte regeneration

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Risk Factors of NAFLD

A
  • OBESITY with or without: metabolic syndrome, insulin resistance, and/or type II DM
  • hypothyroidism, sleep apnea, PCO, past surgeries, meds, parenteral nutrition
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Diff Dx for NAFLD

A
  • Alcoholic Hepatitis
  • Hepatitis C
  • Medications
  • Parenteral nutrition
  • Wilson’s disease
  • Severe malnutrition
  • Hemochromatosis
  • Autoimmune liver disease
  • Alpha-1 antitrypsin deficiency
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Is NAFLD diagnosed on clinical presentation?

A

NO! Most patients are asymptomatic

  • might c/o weight gain
  • mild elevated of liver enzymes
  • maybe RUQ discomfort
  • PMH of insulin resistance or metabolic syndrome
  • dx requires NO history of “heavy” alcohol consumption
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What is “heavy” alcohol use?

A

Men: > 4 drinks per day or > 14 drinks per week

Women: > 3 drinks per day or > 7 drinks per week

A standard alcoholic drink is:

  • 12 oz beer
  • 5 oz wine
  • 1.5 oz liquor
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

NAFLD - physical exam

A
  1. Obesity
  2. +/- Hepatomegaly
  3. Mild RUQ tenderness, negative Murphy’s Sign
  4. Stigmata of liver disease or cirrhosis (rarely would present with these)
    - palmar erythema, spider nevi, caput medusa, telangiectasia, ascites, edema, jaundice, mental fog or confusion
21
Q

NAFLD liver enzymes tests

A

NAFLD is most common cause of incidental abnormal LFTs in western world!!!

22
Q

Do you see AST or ALT most predictive of fatty liver?

A

ALT

23
Q

When AST > ALT you think…

A

the patient is consuming alcohol

24
Q

Upper range of normal for AST, ALT, Alk Phos

A

AST - aspartate aminotransferase 10 – 40 IU/L

ALT - alanine aminotransferase 7 – 56 IU/L

Alkaline Phosphatase 44-147 IU/L

25
Q

What are the true liver function tests?

A

PT/INR + albumin + platelet count

26
Q

NAFLD lab findings

A

↑AST and ↑ALT levels <250
+/- mild alk phos elevation

If AST or ALT >300, look for another cause (toxin, meds, autoimmune, virus)

27
Q

AST:ALT ratio < 1

A

suggests NAFLD

28
Q

AST:ALT ratio > 2

A

suggests alcohol

29
Q

Other markers for liver disease are normal if no cirrhosis

A
  • Serum Albumin
  • Prothrombin, INR
  • Bilirubin
  • Platelets
30
Q

Serum ferritin in NAFLD

A
  • Mild elevation is common with NASH

- Non-specific inflammatory marker

31
Q

Other lab findings

A
  • Fasting glucose or random glucose (maybe hemoglobin A1-C)

- Fasting lipid profile

32
Q

Ferritin and Iron

A
  • Ferritin >1.5 upper limit of normal was associated with more advanced fibrosis
  • If serum ferritin and transferrin saturation are elevated (NAFLD pt) genetic hemochromatosis should be excluded
33
Q

When should you consider liver biopsy?

A

if high ferritin and high iron saturation to determine extent of hepatic iron accumulation and evaluate for liver injury

34
Q

Imaging Studies - US/Sonogram

A

highly sensitive if steatosis in > 30% of the liver

*increased echogenicity

35
Q

Imaging Studies - CT

A
  • Less sensitive than ultrasound in detecting steatosis
  • Radiation exposure
  • Higher cost
36
Q

Imaging Studies - MRI

A
  • More sensitive than CT for detecting steatosis
  • Can measure hepatic triglyceride content
  • High cost
  • Would NOT use for initial work up of fatty liver
37
Q

What is the gold standard diagnostic?

A

Liver biopsy - best prognostic value

-Differentiates simple steatosis from NASH, fibrosis, and cirrhosis

38
Q

Liver Biopsy

A

-Menghini technique: ultrasound or CT-guided

39
Q

Who should get a liver biopsy?

A

patients who are at increased risk of having SH and/or advanced fibrosis:

  • alcoholics
  • elevated ferritin
  • obese patients
40
Q

Define elastography

A
  • Liver stiffness correlates to amount of fibrosis
  • Can be measured by VCTE (vibration controlled transient elastography) or MRE (magnetic resonance elastographyn)
  • Helpful to identify patients who are at risk for SH or advanced fibrosis
  • These patients need a liver biopsy
41
Q

NAFLD Tx - diet

A

Healthy, clean, low carb, avoid simple sugars, avoid high fructose corn syrup completely!

More omega-3, less omega-6, trade out corn oil for canola/olive oil, eat fish

42
Q

NAFLD Tx - weight loss

A
  • modest 5-10% of total body weight can sometimes completely reverse fatty liver
  • increasing physical activity superior to diet alone
  • alcohol abstinence
43
Q

NAFLD Tx - vitamin E 800 IU/day

A
  • only antioxidant that has shown to improve steatosis (but not fibrosis)
  • oxidative stress is main mechanism of progression to NASH
  • first line agent in nondiabetics with biopsy proven NASH
44
Q

NAFLD Tx - management

A

Manage comorbid conditions related to metabolic syndrome - type II DM, obesity, hyperlipidemia

45
Q

Is bariatric surgery recommended for NAFLD?

A

Not yet, no controlled study has been performed

46
Q

Prognosis - simple fatty liver

A
  • monitor regularly for progression of disease
  • monitor LFTs
  • consider ultrasound
  • risk varies: predictors of fibrosis include age ( > 50) and HTN
  • vaccinate for HCV + HBV when appropriate
47
Q

Prognosis - NASH

A
  • monitor regularly for progression of disease with labs: LFTs, CMP, CBC, PT/INR
  • 25-35% develop fibrosis
  • 9-20% develop cirrhosis
  • diabetes and obesity promote fibrosis progression
48
Q

Carcinogenesis

A
  • if advanced fibrosis present, 25x increased risk for HCC!

- screen for hepatocellular carcinoma with alpha fetoprotein, ultrasound

49
Q

Prognosis if NAFLD pts have lipid issues…

A

If ↑ TG, ↑ VLDL, and high apolipoprotein B to apolipoprotein A-1 ratio, ↑ LDL, ↓ HDL they are TWICE as likely to die of CVD than the general population

GI 2 (11 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions