Diseases Of The Liver Flashcards
Dunlap disease
My belly dun lapped over my belt
-just means obesity
What reduces the risk of NFLD
Drinking coffee
What was the bonded cause of NAFLD on that slide?
Vinyl chloride
What to do to definitively diagnose ascites
Physical exam only!
What do we HAVE to rule out if someone comes in with uncompensated cirrhosis
Spontaneous bacterial peritonitis
What is important about ammonia levels
It means encephalopathy
What is a SAG score?
Serum albumin ascites gradient
If you find bilirubin in the acsitic fluid, what’s going on?
Gallbladder problems!
-not liver like you think
What do we need to look for in the ascitic fluid if they are malnourished in a liver cirrhosis test?
They are at super risk for TB, so we need to look for adenosine deaminase
What significant number in the SAAG score?
1.1
How to calculate SAAG score
Serum album- ascitic albumin
What do we have to look for in an alcoholic liver disease patient?
Esophageal varices
-do an EGD scope
If the patient has HBcAb IgM, what is that?
The window period
-that shows up before HBsAg
Where is chronic HBV endemic?
Asia and sub Saharan Africa
What do we have to look at to see if someone has an HCV antibodies .
Order HCV RNA to see if there is an active infection
- you can’t just look at the antibodies
- if the RNA is negative, that means they cleared it
Which cancer do HCV patients have a higher risk for?
HCC and non Hodgkin lymphoma
What goes with Hep B?
Polyarteritis nodosa
What vasculitis is associated with hep C?
Mixed cryoglobulinemia
What slows progression of HCV?
DRINKING COFFEE
What kind of hepatitis do people taking tacrolimus get?
Hep E
Autoimmune hepatitis
Smooth muscle antibodies
At risk for HCC
-positive ANA
What lab value is crazy high in acetaminophen overdose
AST and ALT
What is Reynaud’s Pentad
Charcot’s triad with hypotension and altered mental status changes
What do you have to give an alcoholic person who is having neurological problems before anything else
Thiamine: Vitamin B1
-or else their eyes will start moving everywhere
Wernicke-Korsakoff syndrome
Confusion
Ataxia
Goofy eye movements (this and above is wernicke
Severe memory issues (korsakoff)
What is the key feature of decompensated cirrhosis?
Altered mental status changes
Child-Pugh…. What is it
.
Meld score
.
What gene goes with hemochromatosis?
HFE
What is related to PBC?
Hair dye
Anti mitochondrial antibodies
Smoking
Where does iron get absorbed in hemochromatosis?
The duodenum
-bile gets absorbed by the ileum
Where will we see iron overload on MRI in someone with hemochromatosis?
The heart
RUQ ultrasound with pulsed Doppler flow is associated with….
Budd Chiari syndrome
“Beads on a string”
Primary sclerosing cholangitis
Apple core appearance on barium swallow?
Colon cancer
What does budd Chiari lead to
Congestion
What does congestion present as?
Nutmeg liver!
Hepatocellular adenoma
39 yo female no oral contraception
- no smoking or alcohol or drugs
- CT shows a mass in the liver
What is more specific for liver injury, AST or ALT?
ALT
What do we see in hepatocellular problems?
elevations in ALT and AST
-alanine and aspartate aminotransferase
What do we see in cholestasis?
elevation in ALP (alkaline phosphatase)
What viruses are responsible for hepatitis?
ABCDE and in immunocompromised patients, Mono, CMV, HSV
What were the bolded liver function tests?
PT and serum albumin
what is the most common cause of Ascites?
portal HTN from chronic liver disease
-non-portal causes are infections, malignancy, inflammatory disorders…. etc.
What are some causes of Fatty liver… hepatic steatosis?
alcohol related fatty liver disease
NAFLD
-Vinyl chorlide, carbon tetrachloride and yellow phosphorus (occupational exposure leads to angiosarcoma)
How do calculate SAAG?
Serum albumin-ascitic fluid albumin
If someone has acites, what do we need to do imperatively?
get a paracentesis and rule out spontaneous bacterial peritonitis (SBP)
What is the most important test to run on the ascitic fluid?
WBC count
What do we think if theres an elevated WBC count and lymphocyte predominance?
TB or peritoneal carcinomatosis
Hepatitis A virus?
Acute
-high aminotransferases… elevated Alk phos and bilirubin (marked cholestasis)
Hepatitis B virus
Acute or chronic
- fever, tender, hepatomegaly, jaundice
- mother to baby at delivery
- previously been incarcerated or treated for STI
Acute HBV
similar to HAV but there’s no marked choestasis so the Amniotransferase levels are higher than they are in HAV
Where is HBV endemic?
Asia and sub-Saharan africa
-90% of infants with maternal transmission
HDV
needs HBV to go… so there must be HBsAg present
- chornic HBV with superinfection by HDV is bad
- has defective RNA
HCV
body piercing, tattoos, and hemodialysis are risk factors
- no vaccine
- high rate of acute progressing to chronic
Dx HCV
confirmed by HCV RNA
-anti HCV in serum but negative HCV RNA= recovery from past infection
HCV complications
myxed cryoglobulinemia
- membranoproliferative GN
- cirrhosis and HCC
- decrease in serum cholesterol and LDL
- HCV genotype 3 can lead to hepatic steatosis
HCV recommendations
CDC and USPSTF recommend screening persons born between 1945-65 (baby boomers)
- dont share toothbrushes or razors
- curable with proper treatment
Chronic HCV
- black ppl have higher rate of chronic HCV but lower fibrosis
- coffee slows progression
- pts can have normal AST/ALT
- high risk of cirrhosis and HCC
- MOST HCV IS CURABLE
HEV
- major cause of acute hepatitis throughout central and SE Asia, the middle east, and North Africa
- *transplant recipients: particularly those treated with tacrolimus rather than cyclosporine for immunosuppression
How do you treat a tylenol OD?
treat with NAC if in the toxicity area
- important to get a 4 hour acetaminophen level so we can plot it on a nomogram
- if we can’t find out when it was taken, use empiric treatment of acetylcysteine
Autoimmune hepatitis
- young to mid age women
- +ANA and/or smooth muscle AB
- Anti-LKM1 (liver-kidney microsome type 1)
- super high AST/ALT (1000)
- Tx with steroids and maybe azathioprine
- maybe liver transplane
- increased risk of cirrhosis and HCC
`Wernicke-Korsakoff Syndrome
- Wernicke encphalopathy: confusion, ataxia, involuntary abnormal eye movements
- Korsakoff Syndrome: severe memory issues, confabulate/Make-up stories to fill in the gaps
Alcoholic liver disease
AST is actually higher than ALT for a change
- increased hepatic iron stores
- Bx: mallory bodies… like in NASH
- Reversible
- Most common precursor to cirrhosis in US
- Tx: abstinence from alcohol
What do we have to watch out for when treating ALD?
glucose administration increases the thiamine requirement and can precipitate Wernicke-Korsakoff syndrome if thiamine is not co-administered
Risk of alcoholic cirrhosis
> 50 grams daily for over 10 years
Maddrey Discriminant function
- how we estimate disease severity in pts with alcoholic hepatitis
- Pts with a DF value >32 have high short-term mortality and may benefit from tx with glucocorticoids
- those with lower scores have hlow short-term mortality and do not appear to benefit from glucocorticoids
- you need PT and Control PT and Serum bilirubin
Glasgow alcoholic hepatitis score
GAH
- mortality in alcoholic hepatitis
- > 9, glucocorticoids
Sign of CLD or Cirrhosis
jaundice, palmar eythema, spider angioma, gynecomastia, ascites and caput medusae, muscle wasting
What is Dupuytren’s contracture?
when the 4 and 5 digits flex I guess….
What do Cirrhosis labs look like?
Macrocytic anemia… folic acid deficiency from alcohol use
- low WBC (hypersplenism)
- high infection (SBP)
- thrombocytopenia
- long PT… reduced levels of clotting factors
- decrease in albumin
- Vitamin D deficiency
What are the 5 things that go into a Child-Pugh scoring system?
- Ascites
- Encephalopathy
- Bilirubin
- Albumin
- Prothrombin time
- all given a score 1-3… higher score is bad*
PBC
Autoimmune destruction of small intrahepatic bile ducts and cholestasis
- isolated elevated Alk phos
- anti mitochondrial Ab
- increased IgM
- Risk factors: Hx of UTI, smoking, HRT, hair dye
How do you treat PBC?
Ursodeoxycholic acid
What major syndrome is associated with PBC?
Sjogren syndrome
Hemochromatosis
increased iron absorption from the duodenum
-risk of infection with vibrio vulnificus, listeria, and yersinia enterocolitica
Tx Hemochoromatosis
avoid food rich in iron, alcohol, vitamin C, raw shellfish, and supplemental iron
- phlebotomies
- PPI reduces intestinal iron absorption
- Deferoxamine is another consideration- chelating agent
What gene is wrong is Wilson Disease?
ATP7B
Tx for Wilson
- oral penicillamine (increases urinary excretion of chelated copper)
- liver transplant
What is Budd Chiari?
occlusion of flow to hepatic vein of IVC
- hypercoagulable state
- complicated by HCC
Dx budd chiari
imaging will show prominent caudate lobe, due to occlusion of its venous drainage
- direct venography will have spider web patter
- Bx: centrilobular congestion with likely fibrosis and multiple regenerative nodules (nutmeg liver)
Alpha-1 antitrypsin deficiency
production of defective A1AT accumulates in hepatocytes and causes liver damage and low serum levels of the protease inhibitor
- PI gene chromosome 14
- Micronodular cirrhosis… increased risk of HCC
- Panacinar emphysema
Tx of A1AT
smoking abstinence/cessation and liver transplant
-MC genetic cause requiring liver transplant in children
