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GEN MED GI > Gen Med Liver Disorders > Flashcards

Gen Med Liver Disorders Flashcards

1
Q

Inflammation of the liver, less than 6 mo

A

Acute Hepatitis

Chronic is over 6 months

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2
Q

Persistently elevated AST and ALT

A

Chronic Hepatits

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3
Q

Most Common Viral Hepatic Dz Worldwide

A

Hep B

Vaccine not yet available

Often transmitted @ birth or by blood or mucus membranes (sexually even kissing)

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4
Q

Most Common Viral Hepatic Dz in US

A

Hep C

Kids vaccinated for B since 1980s

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5
Q

Flu-ey: malaise, muscle & joint aches

Headache/fever, N/V/D

A

If not flu - think Acute Hepatitis A,B or C

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6
Q

Incubation of Hepatitis A&B

A

7-10 days

Surface Antigen will present during this pd

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7
Q

Jaundice, Smokers w/smoke aversion
Profound loss of appetite
Clay colored stools, Abdominal Discomfort
Choluria

A

Chronic Hepatitis B or C (A is just acute)

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8
Q

What’s on a Hepatitis Panel?

A 
Hep A Antibody: IgM    2d - 6 mo
Hep B Surface Antigen earliest to rise 
Hep B Core Antibody: IgM
Hep C Antibodies - nonspec as to M/G
-You must order Billir, ALT/AST 
  CBC, total protein/albumin & PT-INR
  separately
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9
Q

Why test PTT/PT-INR in suspected Hepatitis?

A

Liver makes clotting factors, High PTT or low PT-INR suggests they’re not being made right

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10
Q

CBC results in Hepatitis

A

Right shift, should be Lymphos

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11
Q

Add which test if alcoholism is the suspected cause of Hepatitis symptoms:

A

GGT
-Usefule to confirm liver source of elevated Alk Phos

-Persistent elevation in alcoholism but goes up even for a brief binge so you can monitor alcohol intake with GGT

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12
Q

AST

A

Aspartate Transaminase

  • up when liver, muscle & RBCs are damaged
  • If only AST is up, probably not the liver. If it’s elevated with ALT and ALK PHOS and of course GGT, then its a hepatic source
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13
Q

ALT

A

Alanine Transaminase

  • Up when Muscle Liver & Kidneys are damaged. This one is very livery, second to GGT If its up, think liver
  • On statins? Remove and retest in few weeks
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14
Q

LDH

A

Lactate DeHydrogenase
-Up when Cardiac Cells, Liver Cells & RBCs are elevated

-Only useful in liver testing if all the others are up too

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15
Q

Alk Phos

A

Alkaline Phosphatatse

  • In liver, Alk Phos is secreted around bile ducts so it rises in obstructive liver dz like stones in the hepatic/common bile duct, cholangitis etc.
  • Elevated during bone growth: i.e. growth spurts OR bone cancer, obviously age is a factor in this. If its up after the growth plates close, that’s not good unless in pregnancy.
  • Also a marker for Kidney & Intestinal issues so it’s not a good marker for liver in isolation
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16
Q

Hepatocellular Dz

A

Hepatocytes are damaged

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17
Q

Cholestatic Dz

A

Biliary ducts are damaged

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18
Q

Infiltrative Hepatic Dz

A

Liver is invited by neoplasm or amyloid plaque

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19
Q

Significance of Bilirubin

A

Spleen breaks down Heme to “unconjugated “ Bilirubin then attaches it to Albumin and sends it to the liver to be in corporated into Bile

In the liver, unconjugated bilirubin is separated from albumin and attached to Glucuronic Acid (now it’s CONJUGATED) and can be excreted

If Conjugated Bilirubin is high, then the liver is conjugating fine but is unable to secrete it - think biliary obstruction

If unconjugated bilirubin is high and conjugated is normal, the problem is upstream of the liver, think Hemolysis/Bleeding/Spleen trouble

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20
Q

Neonatal Jaundice

A

Neonates often lack enough liver enzyme to conjugate their indirect bilirubin, so that level rises and they also have an incomplete BBB so it can get into their brains and cause brain damage.

We degrade indirect bilirubin with UV light, so that’s why babies get bililighted. In a few days, the liver gets itself together and can conjugate on its own unless there is a congenital anomaly.

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21
Q

Budd Chiari Syndrome

A

Hepatic Vein Blockage by thrombosis (primary) or by compression (tumor pressing on it, secondary)

  • Abd Pain + Ascities + Hepatomegaly, usually jaundice. This is obstructive liver dz but on the way OUT not in. Portal system will back up below the obstruction - no esophageal varix
  • Polycythemia Vera, Oral Contraceptives, Hepatic cancer, Pregnancy/Post Partum
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22
Q

Hepatitis A (HAV)

A

Self limiting, usually less than 6 mo
-Vaccine Available 2 dose series
babies over 1 yr adults under 40
- Give IgG and Vaccine ASAP for Exposure to
prevent development of Dz
- Adults over 40 or babies under 1 year get
IgG instead of Vaccine

Fecal Oral - can’t work in food prep during acute phase

IgM peaks in 1st week, stays up for months
Marks Acute phase, contagious
IgG rises in 1 month, stays up for years
Marks “Convalescent” Stage, non infectious
No antigen test

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23
Q

Hep B (HBV) Incubation/transmission

A 
1-10 weeks
Blood-Blood
   IV Drug Users
   Health Workers
   Transfusion/Transplant (outside US)
   Dialysis contamination
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24
Q

Screen for Hep B

A

Pts w/acute hepatitis sxs
Pts w/chronically elevated LFTs
Foreigners
Pregnant Women (need to stop transmission at birth) All pregnant women are screened in US

Prison inmates
IV drug users
Partners of B+
Dialysis Pts, regularly

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25
Q

Rx HBV for neonate with + mother

A

IgG and HBV vaccine at birth
Effective

All babies are supposed to get their first HBV vaccination before leaving the Hosp after birth.

26
Q

HBsAg

A

Hep B Surface Antigen
Acute/contagious marker

Rises 1-10 weeks post exposure before Sxs & ALT

Gone after 4-6 months

27
Q

AntiHbs

A

Antibody to Hep B Surface Antigen

rises only after surface antigen disappears - it is made to fight surface antigen and so we can’t detect it while it’s fighting, it’s too busy. We detect it after it “won”

Can stay up for a lifetime and is an immunity marker.

If someone has + AntiHBs and + AntiHBc they had the dz and have immunity.

This one can rise again during a second bout or reinfection or a relapse.

28
Q

Anti HBc

A

Antibody to the Hep B core antigen

The core antigen rises when sxs begin whereas Hbs antigen is pre-sxs. It’s presence without HBc antibodies indicates acute infection. Once the antibodies appear, we can tell that they’ve fought the antigen and are now circulation on patrol and the acute phase is over.

29
Q

Hep B IgM

A

indicates acute infectious Hep B, rises between disappearance of the surface antigen and before core antibodies.

Hep B IgM rises and then the long term IgG is the marker of actual immunity.

30
Q

HBe Antigen

A

Rises during high viral replication after HB surface antigen rises.

Marker of high infectiousness

Antibodies to HBe (anti - HBe) is a good marker of immunity post natural infection, not all virus types produce HBe though and this is not produced by the vaccination.

31
Q

Ground Glass Hepatocytes on Biopsy

A

Very high viral load - infectious

32
Q

First Line Rx for Hep B

A 
Antivirals:  NucleoSIDE/TIDE alalogs:
     -Entecavir (Baraclude)
              NucleoSIDE analog
               Infrequent resistance
               Suppresses HBV DNA
      -Tenofovir disoproxil (Viread)
           NucleoTIDE analog
          Used if resistant to Entecavir
          Infrequent resistance
33
Q

Entecavir & Tenofovir

A

First line Hep B nucleoside analog antivirals

34
Q

Adafovir

A

Can’t use this alone in Hep B

Must use with Lamivudine

35
Q

Anti HVC

A

Hep C antibodies

Not detected until 2-8 weeks AFTER LIVER DAMAGE (after LFTs rise!) May still be negative 6 months after, if body is not fighting off infection well. There has to be a lull in the battle for these to become detectable but not finding them in serum doesn’t mean they’re not in there working.

36
Q

EIA test

A

Elisa test for Hep C (HCV)

+ EIA gets retested w/ HCV RNA assay

37
Q

RT-PCR

A

Rapid Test for HCV reverse transcriptase

Can detect viral activity within days of exposure

Use for needle stick/ post exposure

38
Q

Determines extent of liver damage in HCV

A

Biopsy

39
Q

Must co-exist with Hep B

A

Hep D (HDV)

IV Drug Users/Kidney Dialysis

Test all who are + for HBV

Antigen rises FAST 1-3 days
IgM rises FAST 10 days

No Rx for HDV

40
Q 
ALT 3X Normal Limt
       and/or
ALP 2X Normal Limit
        with /without
Billirubin 2X normal limit
A

Think Toxic Hepatitis, drug induced

  • Think Statins, Aspirin, INH (in TB)
  • Phenytoin (Dilantin Seizures)
  • MethylDopa (A2 Agonist for HTN, Hydralazine and Clonadine…)
41
Q

Itching & Jaundice

A

Signs of Cholestasis/ Bile Obstruction

Think Stones or clotting in the hepatic veins. Clotting is usually medication related. Get Sonogram for stones then move to clotting if Negative

OCP’s, anabolic steroids, androgens, allopurinol, carbamazepine, chlorpromazine,
flucloxacillin

42
Q

Steatosis Hepatitis

Fatty Liver Disease

A

High Triglycerides in Liver Damage

Reye’s Syndrome in kids (no aspirin !)

Normal TGs is 150, damaged liver overproduces

43
Q

Liver Mets are from:

A

Colon, Lung & Breast Cancer

44
Q

Hepatocellular Carcinoma (HCC)

A

Most common Malignant Carcinoma of the liver

Pale masses in the liver caused by repeated inflammation & recovery

80% are associated with cirrhosis, mainly from alcoholism and Hep C

Likes to move into the portal vein and the hepatic veins, where it causes Ascites and Splenomegaly -these aren’t really mets, as they’re still in the liver they’re called ‘vascularizations’

Mets to Lung, Bones, Lymph Nodes then Adrenal Glands

45
Q

HCC signs

A

Chronic Hepatitis sxs + weight loss & muscle wasting

46
Q

Alpha Fetaprotien elevated

A

Tumor marker for Hepatocellular carcinoma
and various congenital disorders of the fetal liver

Elevated in 50%- 70% of HCC cases

47
Q

Tumor Capsule (and septum)

A

EXCEPT in HEPATOCELLULAR CARCINOMA, Capsules are typically the division between benign and malignant tumors. “Benign tumors are encapsulated” but this doesn’t always hold true and NOT IN HCC.

Well established HCC and benign tumors have capsules but metastasis occurs when the capsule ruptures

Still, the presence/absence of a capsule is pursued as part of staging:

The capsule is best imaged with MRI

48
Q

Wilson Disease

A

Hepatic Copper malprocessing, Congenital

High Copper leads to organ damage

Mainly Japan

49
Q

Painless Jaundice

A

Obstruction, think cancer

50
Q

Most common imaging to dx Hepatocellular Carcinoma

A

CT scan

Though for staging, MRI picks up tumor capsule best

51
Q

Rx for Hepatocellular Carcinoma

A

Resection
Transplant - only if no mets

Cryosurgury/Ultrasound if not a surgical candidate

Selective Internal Radiation: Radioactive pellets injected into the artery that feeds the tumor, sclerosing it to cut off supply and irradiating it from within.

52
Q

HCC dx testing

A

Suspicious? Have chronic hepatitis/cirrhosis sxs WITH weight loss and muscle wasting… GET A SONOGRAM

We don’t like to poke the liver that shows nodules on CT w/contrast, we can “seed” new tumors that way and cause bleeding that the body can’t handle due to low clotting factor production.

If SONO is + for masses, CT w/contrast is diagnostic and we spread out to look for mets to lung, bonescan adrenals and lymph nodes once HCC is noted in the liver.

53
Q

Reye Syndrome

A

Aspirin in Kids & Teens w/viral illness Just don’t use aspirin for anyone but adults

Causes mitochondrial damage in the liver. Usually in youths with a congenital abnormality but we don’t test for this regularly.

Causes encephalopathy, brain damage and death

54
Q

Dx testing for Cirrhosis

A

Sonogram first, then biopsy

We don’t biopsy if we suspect cancer but we do with cirrhosis as things aren’t that bad yet.

55
Q

Hepato-Pulmonary Syndrome

A

Hepatic disease w/dyspnea

Dyspnea worse sitting than lying (opposite of CHF)

Thought to be caused by decreased liver clearance of endogenous vasodilators like NO2 resulting in ventilation-perfusion mismatch (too much blood to the lungs)

Pulse Ox should be low, get arterial blood gases. Bubbles in Left Atrium may show on echocardiogram

No RX other than liver transplant, constricting vasculature to lungs with somatostatin is experimental

56
Q

Test LFTs q 6 mo if on these meds

A

Januvia - sitagliptin DPP-4

Statins

NSAIDS

57
Q

Liver 911

A 
Varices - cough/vomit blood get endoscopy
Ascities - get endoscopy
Encephalopathy
Peritonitis
Platelets under 50,000
58
Q

TIPS

A

Trans Jugular IntraHepatic Stent

Bypasses liver, relieves ascites, varices, portal hypertension

59
Q

K+ in Encephalopathy

A

As NH3+ rises, K+ dives

Sxs are Weakness, Tingle/Numbness
Cramping Palpitations Constipation

60
Q

Ca 19-9

A 
Tumor Marker for Pancreatitis
Also
Colon Cancer
Hepatocellular Carcinoma
Esophageal Carcinoma

GEN MED GI (4 decks)

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