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LMCC - Medicine > Gastroenterology - Liver Disease > Flashcards

Gastroenterology - Liver Disease Flashcards

1
Q

List the stigmata of chronic liver disease

A
  • Jaundice, scleral icterus
  • Temporal muscle wasting
  • parotid gland enlargement
  • spider nevi
  • caput medusa
  • ascites
  • gynecomastic
  • testicular atrophy
  • asterixis
  • clupping
  • Dupuytren’s contrature
  • palmar erythema
  • thenar and hypothenar wasting
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2
Q

Discuss the differential for jaundice

A 
Primarily Conjugated/Direct Bilirubin
- Hepatic Cellular/High AST/ALT
       - alcoholic hepatitis
       - non-alcoholic hepatitis
       - Hepatitis A,B,C,D,E
       - Tylenol
       - Hemachromatosis
       - Wilson's disease
       - Alpha-1 anti-trypsin
       - Autoimmune chronic active hepatitis
       - portal vein thrombosis, budd-chiari syndrome
- Cholestasis/High ALP/GGT
       - extra-hepatic 
            - gallstone disease
            - malignancy (pancreatic, cholangiocarcinoma)
            - stricture (primary sclerosing, cholangitis)
       - intra-hepatic
            - medication (amox-clav)
            - sepsis
            - TPN
            - pregnancy
            - primary biliary cirrhosis
            - primary sclerosing cholangitis
Primary Unconjugated/Indirect Bilirubin
- hemolysis
- Gilbert's syndrome
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3
Q

Discuss further investigation for hepatic cellular causes of jaundice

A 
Alcohol Hepatitis
- chronic alcohol abuse
- AST:ALT >2
NASH
- metabolic syndrome
Hepatitis A
- positive anti-hepatitis A virus IgM antibodies
Hepatitis B
- Acute: HBsAg+, HBeAg +, Anti-HBc IgM
- Chronic high HBV DNA: HBsAg+, HBeAg+ Anti-HBc IgG
- Chronic low HBV DNA: HBsAg+, Anti-HBe+, Anti-HBc IgG
- Resolved: Anti-HBs+/-, Anti-Hbe+/-, Anti-HBc IgG
Hepatitis C
- positive HCV RNA
- treat with oral-interferon free therapy (sofosburvir/ledipasvir)
Hemachromatosis
- high ferritin >1000
- high transferrin
- high % iron saturation (>50%)
- genetic testing
Wilson's Disease
- low ceruloplasmin
- high 24hr urinary copper
Autoimmune Chronic Active Hepatitis
- positive ANA
- positive anti-smooth muscle antibody
- treat with corticosteroid and azathioprne
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4
Q

Discuss further investigation for cholestasis jaundice

A
  • differentiate intra and extra hepatic through ultrasound and dilation of bile duct
    Extra-Hepatic
  • gallstone
  • mass
  • Primary Sclerosing Cholangitis: positive ANA, positive smooth muscle antibody, positive peri-nuclear anti-neutrophil cystoplasmic antibody
    Intra-Hepatic
  • Primary biliary cirrhosis: positive anti-mitochondrial antibody, positive ANA
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5
Q

Discuss the complications of liver cirrhosis

A 
Decreased Liver Function
- increased INR and coagulopathy
- decreased albumin leading to ascites, spontaneous bacterial peritonitis and hepatic renal syndrome
- hyperbilirubinemia
- increased ammonia leading to hepatic encephalopathy
Portal Hypertension
- varices
- portal hypertensive gastropathy
- gastric antral vascular ectasia
Hepato-Cellular Carcinoma
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6
Q

Discuss diagnotics paracentesis and interpretation

A

Paracentesis
- cell count and differential
- biochemistry including albumin, bilirubin, protein, amylase, lipase T protein, triglyceride
- gram stain, culture
- cytology
Serum Ascites Albumin Gradient (SAAG)
- albumin concentration in serum - albumin concentration in ascites fluid
- SAAG >11 with low protein (<2.5) then portal hypertension due to cirrhosis
- SAAG >11 with high protein (>2.5) then portal hypertnesion due to heart failure
- SAAG <11 then ascites not due to portal hypertension (TB, pancreatitis, renal failure)

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7
Q

Discuss the pathophysiology, presentation, investigations, diagnosis and management for ascites

A 
Pathophysiology
- cirrhosis have decreased albumin leading to decreased oncotic pressure resulting in extravasation of fluid into peritoneum
Presentation
- distended abdomen
- ankle swelling
- bulging flanks
- positive shifting dullness 
- positive fluid wave test
Investigation
- paracentesis
- abdominal ultrasound or CT
Management
- discontinue NSAID, ACEi, ARB, BB
- salt restriction <2g/day
- Diuretics spironolactone 100mg PO daily + Furosemide 40mg PO OD
- therapeutic paracentesis
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8
Q

Discuss the pathophysiology, presentation, investigations, diagnosis and management for spontaneous bacterial peritonitis

A 
Pathophysiology
- bacterial infection of peritoneum
- e coli, streptococcus, kliebsella
Presentation
- abdominal pain
- confusion
- fever, hypotension
- jaundice
Diagnosis
- paracentesis with neutrophil >250
Treatment
- fluid resuscitation with albumin
- antibiotics for 5 days
      - Cefotaxime 2g IV Q8H or Ceftriaxone 2g IV Q8H
      - Ciprofloxacin 200mg Q12H
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9
Q

Discuss the pathophysiology, presentation, investigations, diagnosis and management for hepatorenal syndrome

A 
Pathophysiology
- low albumin lead to extravasation of fluid, decreased effective circulating volume -> increase RAS and sympathetic activity -> renal vasoconstriction and failure
Types
- 1: rapidly progressive renal failure over 2 weeks (doubling creatinine >250 in 2 weeks or halfing creatinine clearance <20mL/min)
 - 2: slowly progressive renal failure
Management
- reverse precipitant
- octreotide 100-200mcg SC TID
- Midodrine 7.5-12.5mg PO OD
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10
Q

Discuss the pathophysiology, presentation, investigations, diagnosis and management for hepatic encephalopathy

A 
Pathophysiology
- inability to detoxify ammonia into urea with poor liver function and encephalopathy
Presentation
- day night reversal, confusion
- lethargy, personality change
- worsened confusion
- coma
- asterixis
- fail to connect number test or clock drawing
Management
- discontinue sedatives and diuretics
- Lactulose 30-45mL BID
- Rifaximin 550mg PO BID to change gut flora and remove ammonia
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11
Q

Discuss liver transplant criteria

A

Model of End-Stage Liver Disease

  • accounts for serum bilirubin, serum creatinine and INR
  • 7 normal
  • > 15 require liver transplant
  • > 25 require full liver transplant
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12
Q

Discuss the differential for >1000 club serum transaminases

A
  • Viral Hepatitis
  • Drugs/toxins
  • Autoimmune hepatitis
  • Hepatic ischemia
  • Common bile duct stone
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13
Q

Discuss the presentation of acute viral hepatitis

A 
- lasts <6month
Presentation
- flu-like prodrome before jaundice
- Pale stools dark urine
- Hepatomegaly
- RUQ pain
Management
- Supportive
- Treatment in Hep B and Hep C
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14
Q

Discuss the 4 phases of Hepatitis B

A

Immune Tolerance
- high HBV DNA, HBeAg positive but with normal AST/ALT
- incubation period
Immune Clearance
- High HBV DNA, HBsAg positive
- Progressive disease with worsening liver function
- Benefit from entecavir, inteferon treatment
Inactive Carrier
- Lower HBV DNA, HBsAg negative, Anti-HBe positive and AST/ALT normal
- No liver damage
- Risk of reactivation with immunosuppression
Immune Escape
- Elevated HBV DNA, HBe-Ag-negative, anti-HBe positive, high AST/ALT
- progressive disease
- benefit from treatment

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15
Q

Discuss the criteria for treatment in hepatitis B

A
  • screen every 6 months for hepatacellular carcinoma with ultrasound
  • Risk of severe infection if hepatitis D positive
    Therapy if:
  • HBeAg+ with high HBV DNA (>20,000) and elevated ALT or
  • HBeAg-, HBV DNA (>2000), elevated ALT and >=2 stage 2 fibrosis of liver
  • Undergoing immunosuppressive therapy
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16
Q

Discuss the pathophysiology, presentation and management of wilson’s disease

A 
Pathophysiology
- autosomal recessive defect in copper metabolism resulting in decreased biliary excretion and decreased incorporation into ceruloplasmin
Presentation
- Hepatitis
- Kayser-Fleischer rings (copper deposit in Descemet's membrane)
- CNS: tremor, dysarthria, dysphagis, incoordination, psychosis
- hemolysis
- Arthritis
Investigations
- <50% reduction in ceruloplasmin
- Increased urinary excretion
- Increased copper on liver biopsy
- Genetic assay
Management
- Penicillamine chelates copper
- Trientine chelates
- Zinc impairs absorption
- Tetrathiomolybdate (preffered with neuro involvmeent)
17
Q

Discuss the pathophysiology, presentation and management of hemachromatosis

A 
Pathophysiology
- Excessive iron storage (total body store 20-40g)
- Hepcidin deficiency resulting in increased absorption in primary (recessive - C282Y mutation)
Presentation (ABCD)
- Arthralgia
- Bronze skin (due to melanin)
- Cardiomyopathy, cirrhosis (HCC)
- diabetes
- Hypogonadism
Investigations
- Transferring >45%
- Ferritin >400
- % saturation >60% in males and >50% in females
- HFE gene analysis (C282Y)
- Liver biopsy
Treatment
- Phlebotomy weekly or q2 to every 2-6mon
- Deferoxamine if contraindicated
18
Q

Discuss the pathophysiology, presentation and management of non-alcoholic fatty liver disease

A 
- Most common liver disease
Pathophysiology
- insulin resistance leading to hepatic steatosis
- metabolic syndrome
- rapid weight gain/loss
Presentation
- Asymptomatic
Investigation
- Elevated LFT, AST/ALT <1
- echogenic liver on ultrasound
- Fibrotest
- Liver biopsy (cannot differentiate between alcoholic and non-alcoholic)
Management
- Gradual weight loss (0.5-1kg/wk) for 7-10% of BW
- Vitamin E (800U) daily
19
Q

Discuss the pathophysiology, presentation and management of Primary Sclerosing Cholangitis

A 
Pathophysiology
- Narrowing of biliary tree
- primary associated with IBC (UC), common reason for liver transplant
- Male more common
Presentation
- Fatigue and pruritus
- Episodic bacterial cholangitis
- Can cause cholangiocarcinoma
Investigations
- Increased ALP
- p-ANCA and IgM
- MRCP and ERCP show narrowing
Management
- MRCP annually for detection of cholangiocarcinoma
- Endoscopic sphincterectomy or stent
- Liver transplantation
20
Q

Discuss the pathophysiology, presentation and management of primary biliary cholangitis

A 
Pathophysiology
- Chronic inflammation and fibrous obliteration of intrahepatic bile ductules
- Autoimmune
- Middle-aged women
Presentation
- Asymptomatic
- Pruritis and fatigue
- Jaundice
Investigation
- Increased ALP, GGT
- positive anti-mitochondrial antibody
- increased serum cholesterol
- Liver biopsy
Management
- ursodiol
- Cholestyramine for pruritis and hypercholesterolemia
- Liver transplant

LMCC - Medicine (40 decks)

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