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GI/Hepatic Final > DILD > Flashcards

DILD Flashcards

1
Q

What are Hy’s laws?

A

ALT > 3x ULN and T Bili > 2x ULN
ALT > 3x ULN x symptoms
ALT > 5x ULN for > 2 weeks
ALT > 8x ULN anytime

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2
Q

What are the symptoms for Hy’s law?

A 
Fatigue
N/V
RUQ pain or TN
Fever
Rash/eosinophilia (>5%)
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3
Q

What must be ruled out before determining fatal risk of DIL injury?

A

Viral and Environmental causes

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4
Q

What are drug RFs for DILD?

A

Cumulative dose
Duration of treatment
Concurrent hepatotoxic agents (alcohol/APAP)

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5
Q

What are the disease RFs for DILD?

A

Chronic liver disease
Chronic renal disease
HIV
Obesity

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6
Q

What are the patient RFs for DILD?

A

Age (very young/old)

Occupation: agriculture, dyes (textile), plastic (fabrication)

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7
Q

What would we look for in a patient’s history as RFs for DILD?

A

Medical
Concurrent medication
Alcohol use

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8
Q

What are the RFs for medications in DILD?

A

Dose (acute/cumulative)

Duration

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9
Q

Which phase in drug metabolism creates reactive metabolites?

A

Phase I

Potentially hepatotoxic

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10
Q

Which phase in drug metabolism creates inactive metabolies?

A

Phase II

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11
Q

Lack of which metabolite causes hepatotoxic metabolites in APAP and bactrim?

A

Glutathione

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12
Q

Which phase is glutathione a part of?

A

Phase II

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13
Q

What are the three mechanisms of hepatic injury?

A

Intrinsic hepatotoxicity
Hypersensitivity
Idiosyncratic hepatotoxicity

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14
Q

What is intrinsic hepatotoxicity?

A

Usually dose and/or duration dependent = time of onset (predictable)

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15
Q

What are examples of intrinsic hepatotoxins?

A

Methotrexate (cumulative dose > 1.5g; duration > 2 yrs)

Ceftriaxone (dose > 1g/d; duration > 7 days)

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16
Q

How long is the sensitization period in hypersensitivity?

A

1-5 weeks

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17
Q

What are the systemic manifestations of hypersensitivity?

A

Eosinophilia
Rash
Fever

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18
Q

What medications re common for hypersensitivity?

A

Amox
NSAIDs
Convulsants
Allopurinol

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19
Q

What causes idiosyncratic hepatotoxicity?

A

Toxic metabolites that result from abnormal metabolic pathways in a susceptible patient
Both genetic factor (enzyme deficiency) + acquired factor (age)

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20
Q

What are drugs that cause idiosyncratic hepatotoxicity?

A

Valproic acid = results from enzyme deficiency (involving oxidation) greatest frequency in children < 2 yo
Isoniazid = slow acytelators (NAT2) = increase predisposition (increased in adults > 35 yo)

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21
Q

What are the classifications of DILD?

A

Hepatocellular
Cholestatic
Vascular
Neoplasia (hepatic)

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22
Q

How do hepatocellular changes cause DILD?

A

Interferes with metabolic processes

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23
Q

How do cholestatic changes cause DILD?

A

Interferes with secretory processes

24
Q

What is a mixed presentation of DILD?

A

Has both hepatocellular and cholestatic causes for DILD

25
Q

What is hepatocellular DILD?

A

Selective hepatocyte injury

26
Q

What is the pathology hepatocellular DILD?

A

Local or diffuse necrosis

Steatosis = fat droplet deposition in the hepatocytes

27
Q

What is the presentation of hepatocellular DILD?

A

Anicteric or icteric
Resemble viral hepatitis = fever, arthralgias, hepatomegaly
Labs = R >/= 5

28
Q

How do we calculate R?

A

ALT/ULN ÷ AP/ULN

29
Q

What can hepatocellular DILD lead to?

A

Fulminant hepatitis

30
Q

What is fulminant hepatitis?

A

Encephalopathy
Increased INR
Death

31
Q

What are the mortality rates for hepatocellular DILD?

A

> /= 10% if bili > 3x ULN

32
Q

What is cholestatic DILD?

A

Selective disturbances in bile secretion

33
Q

What is the pathology of cholestatic DILD?

A

Mild to severe canalicular cell damage

Disabled bile salt transport proteins

34
Q

What is the presentation of cholestatic DILD?

A 
Jaundice and pruritis
Acholic stools (no bile = gray); dark urine (bilirubinuria)
Severe form = fevere, RUQ pain
Lab: R = 2; bile stasis with canalicular injury/inflammation
35
Q

What drugs can cause cholestatic DILD?

A

Ceftriaxone

36
Q

What is the mortality for cholestatic DILD?

A

< 1% - not fatal

37
Q

What are the labs seen in mixed hepatocholestatic DILD?

A

R between 2 and 5

38
Q

What drugs can cause mixed DILD?

A

Anticonvulsants
Abx
NSAIDs

39
Q

How does vascular injury cause DILD?

A

Involves partial or full thrombosis of hepatic vein

40
Q

What is Budd-Chiari syndrome?

A 
Acute onset of ascites, rapid weight gain and jaundice
\+ ab pain (severe upper quadrant)
\+ Hepatomegaly
Increased D-dimer
LFTs variable but all elevated
41
Q

What drugs can cause vascular injury?

A

BC (+ additional RFs)

42
Q

What is hepatic neoplasia

A

Benign tumors filled with blood found w/in the liver that can rupture

43
Q

What can hepatic neoplasia lead to?

A

Clinically dramatic hemoperitoneum upon rupture
-May occur in as many as one third of cases
-Rare, but seen with anabolic steroids (avg 6 yrs from initiation)
Regression often occurs when the medication is withdrawn

44
Q

What are the presentations of hepatic neoplasia?

A

Ab pain
Wt loss
Fatigue
LFTs: mild increase

45
Q

What are examples of drugs that cause hepatic neoplasia?

A 
Anabolic steroids
Oral contraceptives (HD estrogen)
46
Q

What are the preventions for DILD?

A

Baseline LFTs
Patient counseling (at the very least)
Take precautionary measures

47
Q

What sx do we tell a patient to contact their doctor if they develop?

A

N/V and/or ab pain of unexplainable origin lasting several days
OR
Mental status changes/bleeding episodes/jaundice

48
Q

How often should LFT follow ups be preformed?

A

1-3 months

49
Q

How do we take precautionary measures with intrinsic hepatotoxins?

A

Limit/watch dose

Duration of therapy

50
Q

How do we take precautionary measures with hypersensivity reactions?

A

Watch for h/o allergies

51
Q

How do we take precautionary measures with idiosyncratic hepatotoxins?

A

Watch for age/concurrent medications

52
Q

How fast does a 50% reduction in LFTs occur upon discontinuation of hepatotoxin?

A

If injury is mild to moderate
2 weeks - hepatocellular
4 weeks - cholestatic

53
Q

When do we not rechallenge?

A

Fulminant hepatitis

Hypersensitivity reaction

54
Q

When do we rechallenge?

A

Diagnosis of DILD is questionable (only after s/sx resolved)
AND
Imperative medication only

55
Q

How do we manage DILD?

A 
Supportive care
Symptomatic pruritis - cholestyramine
Encephalopathy - lactulose
Coagulopathy - vit K
Spontaneous bacterial peritonitis - abx

GI/Hepatic Final (6 decks)

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