DSA 5: Acute Hepatitis and Acute Liver Failure Flashcards
what is the etiology of acute (fulminant) liver failure (ALF)
massive hepatic necrosis w/ impaired consciousness occurring w/i 8 weeks of the onset of illness
1. acetaminophen
- 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
What are possible complications of ALF
cerebral edema (brainstem compression) & sepsis are the leading causes of death
mortality rate is exceedingly high (>80% pt w/ deep coma)
what is the Hx/PE of ALF
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)
what is diagnositic of ALF
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
how do you treat/manage ALF
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
what is the etiology of acute hepatitis
viral, drugs, ischemia
What are Hx/PE findings of acute hepatitis
stool - acholic
fever, malaise, myalgia, arthalgia, N/V, dirrhea, constipation
PE: RUQ pain = tenderness over liver, jaundice, hepatomegaly, skin changes
what is diagnositic of acute hepatitis
CMP (AST/ALT, total bilirubin, ALP)
PT/INR
acetaminophen level
viral hepatitis serology
what are treatments and managements of acute hepatits
some self-limited
based on etiology - NAC, supportive, anti-viral, stop offending meds, gastric lavage, ABx, liver transplant
what family does HAV belong to?
what is the duration, RF and transmission
ssRNA
duration: acute; incubation = 2-3, up to 6 weeks
RF: international travel; contaminated water/food; inadequately cooked shellfish
transmission: fecal-oral route
what is the presentation of HAV?
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
what labs help diagnose HAV
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
Is there a vaccine for HAV?
what is the mortality?
Vaccine available
good prognosis; low mortality
what family does HBV belong to?
what is the duration, RF and transmission
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)
what is the presentation of HBV?
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
what labs help diagnose HBV
normal-low WBC
increased ALT/AST early in course
no cholestatic pattern
increased bleed risk
many Ag, Ab, HBV DNA. useful for Dx
Is there a vaccine for HBV?
what is the mortality?
Vaccine - high risk groups (prevention)
After unvaccinated person - HBIG immediately - 14 days after sex/birth + vaccine
mortality rate up to 60%
What are complications of HBV
cirrhosis & HCC
what is the window period of acute HBV infxn
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
what is the serology of HBV w/
window period
acute infxn
prior infxn
chronic infxn (inactive)
chronic infxn (active)
immunized
what family does HDV belong to?
what are the RF and mortality
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
what labs help diagnose HDV
Can you prevent it?
labs: HDV RNA PCR; HDV Ag
Vaccine against HBV
what family does HCV belong to?
what is the duration and RF
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
what is the presentation of HCV?
what are possible complications of HCV
marked fluctuating elevation of AST/ALT
>50% chronic
complications: cirrhosis, HCC, HIV co-infxn; pathogenic factor in mixed cryoglobulinemia, chronic HCV - decreased serum cholesterol
what labs help diagnose HCV
Is there a vaccine or prevention method for HCV?
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
is HCV curable?
YES!
what family does HEV belong to?
what is the duration, RF and transmission
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
Is HEV acute or chronic
what are complications of HEV?
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
What labs will help Dx HEV?
IgM or IgG HEV Ab
PCR for HEV RNA
what is the mortality of HEV
high (10-20%) mortality rate in pregnant women
What are causes of toxic/drug-induced hepatits (Drug-induced liver injury)
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
hwo do you treat drug induced liver injury
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
When do you use N-acetylcysteine (NAC)
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)
what is the etiology of budd-chiari syndrome
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)
what are diagnostic findings for budd-chiari syndrome
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
What are complications of budd-chiari syndrome
chronic - bleeding varices, hepatic encephalopathy, hepatopul syndrome
freq complicated by HCC
What is the MCC of jaundice in pregnancy
viral hepatitis
what are characterisitics of pre-eclampsia & eclampsia
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
how does cholestasis of pregnancy present
pruritus in 3rd trimester
darkening of urine & occasionally light stool & jaundice
sign of enigmatic syndrome
what is the presentation of acute fatty liver of pregnancy
spectrum of disorder ranging from subclinical or modest hepatic dysfxn (increase AST/ALT)
–> hepatic failure, coma and death
