DSA 5: Acute Hepatitis and Acute Liver Failure Flashcards

1
Q

what is the etiology of acute (fulminant) liver failure (ALF)

A

massive hepatic necrosis w/ impaired consciousness occurring w/i 8 weeks of the onset of illness

1. acetaminophen

  1. idiosyncratic drug rxn

increased risk w/ DM & outcome is worse w/ obesity

statins can casue increase AST/ALT but rarely cause true hepatitis or ALF-no longer Cl in liver dz

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2
Q

What are possible complications of ALF

A

cerebral edema (brainstem compression) & sepsis are the leading causes of death

mortality rate is exceedingly high (>80% pt w/ deep coma)

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3
Q

what is the Hx/PE of ALF

A

rapidly shrinking liver size + rapidly rising bilirubin level + marked prolongation of the PT + clinical signs of confusion, disorientation, ascities, edema = hepatic failure w/ encephalopathy –> deep coma (cerebral edema)

life-threatening coagulation abnormalities (INR > 1.5)

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4
Q

what is diagnositic of ALF

A

labs = rapidly rising bilirubin levels + marked prolongation of PT even as AST/ALT decreases

acetaminophen toxicity - AST/ALT > 5,000 u/L

ammonia level elevated –> encephalopathy & intracranial HTN

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5
Q

how do you treat/manage ALF

A

support the pt - maintain fluids, circulation and respiration; control bleeding, correction of hypoglycemia & tx other complications

protein intake should be restricted

give oral lactulose/neomycin

meticulous intensive care + prophylactic ABx= one factor that improves survivial

early transfer to transplant center for liver transplantation should be considered

N-Acetylcysteine in acetominophen OD

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6
Q

what is the etiology of acute hepatitis

A

viral, drugs, ischemia

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7
Q

What are Hx/PE findings of acute hepatitis

A

stool - acholic

fever, malaise, myalgia, arthalgia, N/V, dirrhea, constipation

PE: RUQ pain = tenderness over liver, jaundice, hepatomegaly, skin changes

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8
Q

what is diagnositic of acute hepatitis

A

CMP (AST/ALT, total bilirubin, ALP)

PT/INR

acetaminophen level

viral hepatitis serology

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9
Q

what are treatments and managements of acute hepatits

A

some self-limited

based on etiology - NAC, supportive, anti-viral, stop offending meds, gastric lavage, ABx, liver transplant

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10
Q

what family does HAV belong to?

what is the duration, RF and transmission

A

ssRNA

duration: acute; incubation = 2-3, up to 6 weeks

RF: international travel; contaminated water/food; inadequately cooked shellfish

transmission: fecal-oral route

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11
Q

what is the presentation of HAV?

A

anorexia, N/V, malaise, constant/mild RUQ or epigastrum, aversion to smoking

stool may be acholic

illness more severe in adults than children

acute only

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12
Q

what labs help diagnose HAV

A

marked increase in AST/ALT

increased bilirubin and ALP = cholestasis

Anti-HAV early in illness; both IgM & IgG anti-HAV soon after onset

detection of IgM anti-HAV = excellent test for diagnosing acute hep A

if IgG anti-HAV - indications of previous exposure, non=infectivity and immunity

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13
Q

Is there a vaccine for HAV?

what is the mortality?

A

Vaccine available

good prognosis; low mortality

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14
Q

what family does HBV belong to?

what is the duration, RF and transmission

A

partially dsDNA

duration - 2-26 week incubation, acute resolves 2-3 weeks & chronic = 5-10%

RF: M-sex-M, inject drugs, hemodialysis center, healthcare workers

transmission:

  • parentral
  • sexual
  • perinatal : endemic in sub-saharan Africa & SE Asia (HBs-Ag (+) mom transmit HBV at delivery; risk of chronic infxn (90%)
  • percutaneous (needle stick)
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15
Q

what is the presentation of HBV?

A

fever (low-grade), enlarged & tender liver, jaundice

aversion to smoke, N/V, anorexia

association w/ polyarteritis nodosa, glomerulonephtritis, serum sickness

acute (90% recover)

5-10% is chronic

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16
Q

what labs help diagnose HBV

A

normal-low WBC

increased ALT/AST early in course

no cholestatic pattern

increased bleed risk

many Ag, Ab, HBV DNA. useful for Dx

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17
Q

Is there a vaccine for HBV?

what is the mortality?

A

Vaccine - high risk groups (prevention)

After unvaccinated person - HBIG immediately - 14 days after sex/birth + vaccine

mortality rate up to 60%

18
Q

What are complications of HBV

A

cirrhosis & HCC

19
Q

what is the window period of acute HBV infxn

A

window= btn HBsAg disappearing and HBsAb appearing (could be several weeks

pt is still considered to have ACUTE HBV, and infxn is only detectable w/ HBcAb IgM

This is very important when screening blood donations

20
Q

what is the serology of HBV w/

window period

acute infxn

prior infxn

chronic infxn (inactive)

chronic infxn (active)

immunized

A
21
Q

what family does HDV belong to?

what are the RF and mortality

A

defective RNA - required HBV for replication

RF: acute or chronic; either co-infected w/ HBV or superinfects a chronic HBV carrier

non-percutaneous /percutaneously in HBsAg+ IV drug users or hemaphiliac transfusion

mortality: increase severity of HBV infxn

22
Q

what labs help diagnose HDV

Can you prevent it?

A

labs: HDV RNA PCR; HDV Ag

Vaccine against HBV

23
Q

what family does HCV belong to?

what is the duration and RF

A

ssRNA

MC = chronic, incubation is 4-26 weeks; acute asymptomatic w/ wax/wane AST/ALT

RF: transfusion related hepatitis (HCV accounts for >90%), IV drug use (50% HCV cases), intranasal drug use; co-infection w/ HCV in 30% HIV infected persons; in developing world - unsafe medical practice; bloody fisticuffs & incarceration in prison

24
Q

what is the presentation of HCV?

what are possible complications of HCV

A

marked fluctuating elevation of AST/ALT

>50% chronic

complications: cirrhosis, HCC, HIV co-infxn; pathogenic factor in mixed cryoglobulinemia, chronic HCV - decreased serum cholesterol

25
Q

what labs help diagnose HCV

Is there a vaccine or prevention method for HCV?

A

labs = HCV Ab in serum ; most sensitive indicator = HCV RNA

occasionally - anti-HCV in serum, w/o HCV RNA in serum –> recovery from prior HCV infxn

vaccine: NONE, CLD-HCV pt vaccinated w/ HAV and HBV

prevention = birth cohort screening of persons born btn 1945-65 for HCV infxn; new recs all over 18 should have at least once in a lifetime screening for HCV; HCV-pt should practice safe sex

26
Q

is HCV curable?

A

YES!

27
Q

what family does HEV belong to?

what is the duration, RF and transmission

A

ssRNA

duration: incubation = 4-5 wks

RF : immunoCOMPROMISED host; endemic in asia, middle east, N. africa, central america and india

transmission = fecal-oral- waterborne epidemic; spread by swine

28
Q

Is HEV acute or chronic

what are complications of HEV?

A

HEV is acute w/ no carrier state; in transplant pts treated w/ tacrolimus instance of chronic w/ progression to cirrhosis

arthritis, pancreatitis, monoclonal gammopathy, thrombocytopenia

guillain-barre and peripheral neuropathy

29
Q

What labs will help Dx HEV?

A

IgM or IgG HEV Ab

PCR for HEV RNA

30
Q

what is the mortality of HEV

A

high (10-20%) mortality rate in pregnant women

31
Q

What are causes of toxic/drug-induced hepatits (Drug-induced liver injury)

A

Dose-dep: w/i 48 hrs; mushroom poisoning, acetaminophen, tetracycline, valproic acid

Idiosyncratic: variable dose & time of onset; fever, rash, arthralgia, eosinophilia; isoniazid, sulfonamides, halothane, phenytoim, methyldopa, carbamazepine, diclofenac, oxacillin

32
Q

hwo do you treat drug induced liver injury

A

supportive: withdraw agent; use gastric lavage & oral administration of activated charcoal/cholestyramine (w/i 1 hour post ingestion is ideal)

liver transplantation if necessary

NAC for acetaminophen OD

33
Q

When do you use N-acetylcysteine (NAC)

A

for acetaminophen OD

get a 4 hour acetaminophen level

critical ingestion-tx interval for maximum protection against severe hepatic injury is btn 0-8 hrs (begin therapy w/i 8 hours of ingestion)

34
Q

what is the etiology of budd-chiari syndrome

A

occlusion of flow to hepatic V or IVC

caval webs, R-HF (–> nutmeg liver)

predispose pt to hepatic V obstruction (aka Budd-Chiari) –> hereditary and acquired hypercoagulable states (polycythemia vera)

35
Q

what are diagnostic findings for budd-chiari syndrome

A

occlusion/absence of flow in hepatic Vs or IVC

imaging:

  • prominent caudate liver lobe;
  • screening test of choice is contrasted-enhanced (CEUS);
  • color/pulsed-doppler ultrasonography
  • direct venography - deliniate caval webs & occluded hepatic Vs (spider web pattern)

liver Bx: centriloular congestion (nutmeg liver) & fibrosis

36
Q

What are complications of budd-chiari syndrome

A

chronic - bleeding varices, hepatic encephalopathy, hepatopul syndrome

freq complicated by HCC

37
Q

What is the MCC of jaundice in pregnancy

A

viral hepatitis

38
Q

what are characterisitics of pre-eclampsia & eclampsia

A

preeclampsia - 3-5% - characterized by maternal HTN, proteinuria, peripheral edema, coagulation abnormalities

may be life-threatening - hyperreflexia and convulusion occurs (eclampsia)

HELLP syndrome: hemolysis, elevated liver enzyme and low platelets

39
Q

how does cholestasis of pregnancy present

A

pruritus in 3rd trimester

darkening of urine & occasionally light stool & jaundice

sign of enigmatic syndrome

40
Q

what is the presentation of acute fatty liver of pregnancy

A

spectrum of disorder ranging from subclinical or modest hepatic dysfxn (increase AST/ALT)

–> hepatic failure, coma and death