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Fatty Liver Flashcards

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Introductory Sommelier Exam (CMS) flashcards
1
Q

What characterizes NAFLD?

A

Hepatic steatosis and exclusion of secondary causes

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2
Q

what is significant alcohol consumption?

A

generally more than 14 standard drinks (more than 2 a day for women) 21 drinks a week (more than 3 a day for men)

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3
Q

What is the most common cause of fatty liver

A

obesity but can affect non obese individuals

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4
Q

what % of steatosis classifies NAFLD aka simple steatosis

A

5% or greater hepatic steatosis without heptocellular injury of fibrosis

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5
Q

what classifies NASH?

A

5% or greater hepatic steatosis PLUS hepatocellular injury and inflammation with OR without fibrosis

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6
Q

How do you know if someone has injury and inflammation to liver cells

A

gold standard is biopsy

con: invasive

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7
Q

is cirrhosis necessary for liver cancer?

A

No but increases risk

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8
Q

what is prevalence of NAFLD vs. NASH?

A

NAFLD - 20-30% in western countries

NASH - 3-5%

average age = 50
note: 3-10% in children

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9
Q

what ethnicity is most at risk for NAFLD?

A

hispanics > caucasians > african americans

only caucasians: M>F

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10
Q

what are the principle causes of NAFLD?

A

obesity - 40%
DM - 20%
dyslipidemia/hypertriglyceridema - 20%

all associated with insulin resistance (insulin resistance pulls fat into the liver because of the Free fatty acids) and metabolic syndrome

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11
Q

what is metabolic syndrome?

A

any of the 3:
blood pressure
fasting glucose level (> 100)
low levels of HDL (<50 M, <40 F)
triglyceride levels (>150)
WC (>35 F, >40 M)

labs or being on any pharmacotherapy for these

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12
Q

NAFLD maternal risk factors?

A

Maternal obesity
high maternal early pregnancy [glucose]

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13
Q

NAFLD maternal protective factors?

A

breastfeeding >6 months reduces NAFLD risk in offspring and mother

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14
Q

what drugs are risk factors for NAFLD?

A

corticosteroids: eczema, injury, more long term - asthma, autoimmune disease (RA, IBD) more chronic or systemic use.

amiodarone: heart drug used to treat irregular heart beat, early stages of heart failure

diltiazem: hypertension, angina (blocked blood flow to coronary artery)

methotrexate: chemotherapy, RA, severe psoriasis

tamoxifen: breast cancer (hormone therapy)

irinotecan: chemotherapy (lung and colon usually)
oxaliplatin: chemotherapy

antiretroviral therapy: HIV

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15
Q

what toxins are risk factors for NAFLD?

A

pesticides, some metals and explosives, contaminated water (inorganic aresenic)

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16
Q

what dietary and nutritional factors are risk factor for NALFD?

A

excessive fructose
malnutrition
starvation and refeeding
total parenteral nutrition (IV)

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17
Q

Genetic factors are a risk in up to 35% of NAFLD patients. What are some polymorphisms for lean and non-obese people?

A

Apolipoprotein C3

note:
hispanic: PNPLA3
severe NAFLD: TM6SF2
protective: HSD17B13

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18
Q

why is physical activity protective against development of NALFD?

A

help with insulin resistance and improve insulin sensitivity
manage obesity and decrease metabolic syndrome factors

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19
Q

there are 10 conditions that are associated with NAFLD? what are they

A

cushing
hypoituitarism
PCOS
hypothyroidism
hypobetalipoproteinemia (low Ap B and LDL)
Obstructive sleep apnea
gut dysbiosis
altered bile acid metabolism
cholecystectomy
psoriasis

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20
Q

how many patients with simple steatosis will progress to cirrhosis?

A

4%

20% -> NASH
20% -> cirrhosis

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21
Q

what is the strongest predictor of progression to NAFLD?

A

degree of inflammation in the first liver biopsy

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22
Q

is NASH with fibrosis reversible? what about NASH with cirrhosis?

A

fibrosis - yes with diet, exercise, weight loss
cirrhosis - no needs transplant

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23
Q

complications of NAFLD?

A

cardiovascular disease: contributes to mortality in both the following
hepatocellular carcinoma: 1-2% annual risk)
end stage liver disease and liver failure: develops over 10 years in 45% of patients)

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24
Q

NAFLD can coexist with other chronic liver conditions. what can NAFLD predict the risk of?

A

cardiovascular events
chronic kidney disease
colorectal cancers
T2DM

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25
Q

T/F: most with NAFLD are asymptomatic in early stages?

A

True

possibility some fatigue, malaise, and mild abdominal discomfort in the RUQ in early stages

26
Q

what are some symptoms in advanced stages

A

nausea
vomiting
jaundice
pruritus
memory impairment - liver not removing toxins
easy bleeding - liver cannot synthesize proteins that clot blood
loss of appetite

27
Q

what are some signs in advanced stages

A

hepatomegaly (in 75% of patients)

spider angiomas

signs of portal hypertension - edema, ascites, caput medusae

palmar erythema (estrogen metabolism)

gynecomastia (high estrogen we see gynecomastia in males)

dupuytren contracture

petechiae

28
Q

is there any physical exam findings to rule out cirrhosis?

A

No

signs of elevated estrogen are good to help diagnosis the chronic liver disease not specific to cirrhosis

encephalopathy is the best to rule in if present

29
Q

NAFLD can present like any other liver condition so DDx is crucial. Why would you ask someone if they recently travelled?

A

Viral Hepatitis B or C

this could cause cirrhosis to liver.

30
Q

What is Wilson’s disease?

A

inherited disease leads to accumulation of copper in tissues. DDx for NAFLD

31
Q

What are some genetic conditions that can present as NAFLD?

A

hereditary hemochromatosis - iron overload can lead to liver damage

Alpha-1 antitrypsin deficiency

Wilsons disease

32
Q

Can an individual with an autoimmune condition have liver issues?

A

Yes, autoimmune hepatitis. can start to have attacks on liver

33
Q

what are some DDx related to biliary system?

A

primary sclerosing cholangitis
(2 types, problems with bile duct system, inflammation of bile duct system may present like inflammation of liver)

primary biliary cholangitis

34
Q

Why is NAFLD easily missed early on?

A

because only 20% of people will have only mildly elevated enzymes

35
Q

what should the AST/ALT ratio be in early NAFLD? What about in alcohol associated LD?

A

AST divided by ALT should be less than 0.8 in early NAFLD

AST/ALT greater than 1.5 = alcohol associated

most of the time ALT will be higher than AST in NAFLD
in later stages it will mimic alcohol one

36
Q

T/F: AST > ALT as advanced fibrosis and cirrhosis develop

A

True

37
Q

what labs to examine metabolic risk factors?

A

lipid levels
fasting glucose or HbA1C

fasting glucose and fasting insulin for insulin resistance

38
Q

what is HOMA? what is the normal value?

A

homeostatis model assessment

<3.99

39
Q

what is QUICKI? normal value?

A

quantitative insulin sensitivity check index

> 0.35

40
Q

would is at a higher risk for autoimmune hepatitis?

A

women and individuals with a history of thyroid disease

41
Q

what are the clinical features of hereditary hemochromatosis?

A

bronze diabetes (darkening of skin and hyperglycemia), arthritis, congestive heart failure, impotence, family history

42
Q

clinical features of Wilsons disease?

A

neurological and psychological presentation with liver disease at a young age (<40), family history

43
Q

can imaging distinguish between liver inflammation and fibrosis?

A

no, NASH requires biopsy.

44
Q

how do clinicians decide which patients require further testing with imaging?

A

non invasive scoring systems to predict risk of NAFLD, can be used for high risk groups

44
Q

what are the 2 main clinical risk scoring systems?

A

fatty liver index (FLI) - based on BMI, WC, GGT and TG’s

NAFLD-MS

45
Q

what score from the Fatty liver index (FLI) would you consider ultrasound for confirmation/clarification?

A

30 to < 60 (indeterminate) or >60 (high, rule in)

note: low is under 30

46
Q

what is the scoring for NAFLD in metabolic syndrome score (NAFLD-MS)?

A

clinical predictors:
- BMI
- AST/ALT
- ALT > 40
- T2DM
- central obesity

<3 = low
>5 = high

47
Q

what biopsy types and findings = diagnosis of NASH?

A

type 3: fat accumulation and ballooning degeneration

type 4: fat accumulation and ballooning degeneration and either mallory hyaline or fibrosis

48
Q

what is the grading and staging of NAFLD histological lesions?

A

grade 1 = mild (66% steatosis)
grade 2 = moderate (any degree of steatosis)
grade 3 = severe (panacinar steatosis)

stage 0 - no fibrosis
stage 1
stage 2
stage 3 - bridging fibrosis
stage 4 - cirrhosis

49
Q

what further testing do you use for those who have already had a liver biopsy?

A

NAFLD activity score (NAS). based on histology results.

not used to definitively diagnosis NASH

50
Q

Do all NAFLD patients need a liver biopsy?

A

no

noninvasive tools can be used to identify patients at higher risk.

51
Q

when should a liver biopsy be ordered?

A

when noninvasive tests produce an indeterminate result

52
Q
A
53
Q
A
54
Q
A
55
Q
A
56
Q

what non invasive tests could you test for liver fibrosis?

A

fibrosis-4 (FIB-4) index: ultrasound elastography

or enhanced liver fibrosis (ELF) panel: NAFLD fibrosis score (NFS)

57
Q

why is ultrasound elastrography used?

A

liver stiffness: so the most fibrosis there is the more the waves will propagate

57
Q

is NFS or FIB-4 based on more criteria for scoring?

A

NFS is based on BMI, impaired fasting glucose, or diabetes.

58
Q

how often surveillance for hepatocellular carcinoma with a liver ultrasound?

A

every 6 months in patients with NASH with cirrhosis

59
Q

when to refer?

A

fibrotic
NASH with cirrhosis
CV complications

60
Q

to

A

CMS (6 decks)

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