E2: Hepatitis/LIver Disease Flashcards
What kind of liver injury will have the highest LFTs?
“Shock liver” or Tylenol toxicity
What is steatohepatitis? What is reflected by on bloodowork?
- inflammation of the liver by fat deposition
- Can be reflected by abnormal liver tests in a hepatocellular pattern
Does does an AST:ALT ratio of >1.5 indicate?
Alcoholic liver disease
What does an ALT>AST AST: ALT ration < 1 indicate?
NASH, acute or chronic hepatitis
What is NAFLD?
Hepatic steatosis without secondary causes of hepatic fat accumulation
What are the two subtypes of NAFLD?
NAFL and NASH
What is the difference between NAFL and NASH?
- NAFL: Fatty liver without injury or fibrosis of hepatocytes on biopsy
- NASH: fatty liver and inflammation leading to Hepatocyte injury, risk of progression to fibrosis and cirrhosis is significant
What are the risk factors of NAFLD?
- Abdominal obesity
- DM2
- HLD
- Metabolic syndrome
- PCOS
What are the decision aids that can identify patients who are at risk for progression from NAFLD to NASH and advanced fibrosis?
- NAFLD fibrosis score
- Fibrosis-4 index (FIB-4)
- Vibration-controlled transient elastography
What might you seen on labs in a patient with NAFLD?
- Elevated ALT and AST in a Hepatocellular pattern
- Normal albumin, bilirubin, and INR
- Elevated ferritin (marker for inflammation)
- Hyperlipidemia
- ALP elevated
What will you se on a liver fibroscran if the patient has NAFLD?
> 5% liver fat on imaging or liver biopsy
What is the Gold standard for characterizing liver histological alternations in NAFLD?
Liver biopsy
When should you obtain a liver biopsy for a patient with NALFD?
If they have NAFLD with one of the following:
- Increased risk for steatohepatitis and/or advanced fibrosis
- metabolic syndrome and elevated LFTs
- Competing etiologies for hepatic steatosis and inability to exclude/assess severity of coexisting CLD without biopsy
What are patients with NAFLD at increased risk for? How can you treat them?
Cardiovascular morbidity and mortality
-aggressive modification of CVD risk factors should be considered, such as statin therapy in dyslipidemia
What is the recommended management of NASH?
- Exercise and weight loss is the cornerstone management
- Minimize or discontinue alcohol use
- control DM and HTN
- Vaccinate for Hep A and B if not immune
What is Hereditary hemochromatosis?
-Hereditary disorder of iron metabolism that results from a genetic mutation that results in increased GI absorption of iron that leads to accumulation of iron in the liver, pancreas, heart, adrenals, testes, pituitary, skin, and kidney
What are the late manifestations of hereditary hemochromatosis?
-Hepatomegaly, hepatic insufficiency, cirrhosis, DM, impotence, arthralgia, bronze skin pigmentation, cardiac arrhythmia
What is Bronze diabetes?
-Triad of DM, bronze pigmentation of skin, and cirrhosis
What lab findings are consistent with hereditary hemochromatosis?
- Elevated LFTs
- Screen with serum Fe and TIBC, and ferritin
- Ferritin >200 in men, >150 in women
- transferrin >45
If you suspect hereditary hemochromatosis based on patients blood work, How can you confirm the diagnosis?
-Refer to GI for HFE mutation analysis and possible liver biopsy
What is the treatment of hereditary hemochromatosis?
-Therapeutic phlebotomy and HCC screening every 6 months
-Avoid Vitamin C, iron containing supplements, uncooked shellfish, and alcohol
-
What is ordered to screen for HCC?
US and AFP
What is Wilson’s disease?
- A very rare hereditary disorder of copper metabolism
- Autosomal recessive mutation that results in decreased excretion of copper in bile and accumulation of copper in the liver
What are the 3 hepatic presentations of Wilson’s disease?
- Acute hepatitis
- chronic liver disease
- Acute on chronic liver failure
When the livers capacity for copper is exceed in Wilson’s disease, what happens?
The copper is released into the blood stream and begins to accumulate in the brain, cornea, joints, kidney, heart, and pancreas
What findings are pathognomonic for Wilson’s disease?
Kayser-Fleischer rings + neurologic manifestations
What lab finding is often low with Wilson’s disease?
-Serum ceruloplasmin
DX confirmed with liver biopsy with possible molecular testing
What is the treatment for Wilson’s disease?
- Chelating agents
- Transplant in liver failure
What is alpha-1 antitrypsin deficiency?
-Genetic disorder characterized by decreased levels of alpha 1 antitrypsin in circulation
What should you be suspicious of if you have a young, non-smoker patient with emphysema or with childhood cirrhosis?
Alpha 1 antitrypsin deficiency
Who should you screen for alpha 1 antitrypsin deficiency?
- Emphysema in young patients, non-smokers, or predominant basilar changes on CXR
- Adult onset asthma
- Clinical findings or history of unexplained CLD
- Family hx of emphysema and/or liver disease
- Hx of panniculitis
What lab findings are consistent with alpha 1 antitrypsin deficiency?
- Mild elevation of AST/ALT
- Serum alpha 1 antitrypsin decreased
- test for alpha 1 antitrypsin phenotype/genotype
What are the possible clinical presentations of autoimmune hepatitis?
- Asymptomatic with elevated liver enzymes and concurrent autoimmune disease
- Acute hepatitis
- CLD
- Nonspecific symptoms such as fatigue, malaise, anorexia, pruritis, abd pain, arthritis
What is the acute disease presentation of autoimmune hepatitis?
Hepatomegaly and tenderness
Jaundice
Splenomegaly
Fever
What are the serological markers you need to order to diagnose autoimmune hepatitis?
- Antinuclear antibodies (ANA)
- Smooth muscle antibodies, anti-actin (SMA)
- Immunoglobin G (IgG)
- Liver kidney microsomes antibody (LKMA-1)
**order livery biopsy as well
What is the management of Autoimmune Hepatitis?
- Prednisone +/- Azathioprine combination strongly recommended and continue until remission >2 years
- monitor bone density
- Liver transplant is treatment if fulminant liver failure
How is Hepatitis A transmitted?
-Fecal - oral, person to person, contaminated food or water
Does Hep A cause chronic infection?
No
What is the clinical presentation of Hep A?
- Children <6 are likely asymptomatic
- Adults are more likely to be symptomatic with a prodrome period of “flu like” illness
- icteric phase: jaundice, dark urine, pruritis, light colored stool
What are the two most commonly observed abnormalities in Hepatitis A?
Hepatomegaly and Jaundice
What does a positive IgM anti HAV indicate?
Acute infection of Hep A
What does a positive IgG anti-HAV indicate?
Immunity to Hep A
A patient presents with elevated LFTs, bilirubin, and ALP. IgM anti HAV is positive. What is their diagnosis?
Acute Hep A
What is the management of Hep A?
- Supportive care (fluids and rest)
- Hospitalize if elderly, multiple comorbidities, underlying liver disease, or fulminant liver failure
What is the leading cause of cirrhosis and HCC worldwide?
Hep B
How is Hep B transmitted?
Blood/blood derived body fluids, person to person through blood, sexual contact, parenteral contact, and peri-natal transmission
Is Hep B chronic?
- <5% of adults will become chronic, but 80-90% of infants will become chronic
What are the clinical signs of acute Hep B?
- N/V, RUQ pain, jaundice, malaise, fever
- elevated bilirubin and ALP
- Elevated LFTs, with ALT >15x normal
What is the management of acute Hep B?
- Supportive care as (5% of adults recover with immunity
- possible antiviral therapy, but only in acute liver failure or protracted course
- admit if underlying liver disease, multiple comorbidities, or signs of liver failure
What does it mean if the Anti-HBs is positive?
- Pt was previously infected with Hep B, or received Hep B vaccination
- This the antibody to the surface antigen
What are the common complications of Chronic Hep B?
- Cirrhosis
- HCC
When is Hep B most likely to become chronic?
- If patient is immunocompromised
- if exposure was as an infant
What are the lab findings in a chronic Hep B infection?
- Hep B surface Ag positive > 6 months
- elevated LFTs
What does a positive HBsAg indicate?
Active disease, either acute or chronic
** Hepatitis B surface antigen
What does a positive IgM anti-HBC indicate?
-acute exposure
What does a positive IgG anti-HBc indicate?
Positive Total anti-HBc?
Both indicate previous infection
What is the first detectable marker of infection in Hep B?
Hepatitis B surface antigen (HBsAg)
- Rises before the onset of symptoms
- detectable in blood after exposure
What is the hallmark of an active Hep B infection?
HBsAg
** if elevated for more than 6 months, indicates chronic infection
Which antibody persists indefinitely after a Hep B infection?
IgG anti HBc
Which antibody signifies recovery and immunity from a Hep B infection?
Antibody to surface antigen (anti-HBs)
What does it mean if a patient has a positive Anti-HBd and a positive IgG anti-HBc?
Prior infection with resulting immunity
What does it mean if a patient has a positive Anti-HBs, but a negative IgG Anti-HBc?
Prior vaccination with resulting immunity
** Anti-HBc is negative because they have never seen the virus before so the cannot make this antibody
What is the Hepatitis B e-antigen used for?
Used as an index of infectivity and a marker of replication
What is the management of Chronic Hep B?
- Vaccinate for Hep A
- Counsel of prevention precautions
- HCC surveillance (with or without cirrhosis)
What is the management of Hepatitis C?
- Refer to GI for treatment with new oral medications
- most are treated for 8-12 weeks induration with direct acting antiviral agents
What is required for a Hepatitis D infection?
Hepatitis B infection
How do you diagnosed Hep D?
HDV with Abs and HDV s Ag (+) with acute liver failure
What labs are indicative of Hep C?
-Elevated LFTs and bilirubin
- (-) Hep C Ab with (+) RNA viral load
OR
(+) Hep C Ab when it was previously negative
