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aa Step 2CK: Internal & Peds > GI- Liver > Flashcards

GI- Liver Flashcards

1
Q

Common findings of acute liver disease

A
  • Elevated LFTs
  • Jaundice
  • N/V; fever
  • RUQ pain or tenderness
  • Hepato(spleno)megaly
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2
Q

Common causes of acute liver disease

A
  • Alcohol
  • Medications
  • Infections (hepatitis)
  • Reye Syndrome
  • Biliary Tract Disease
  • Autoimmune Disease
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3
Q

What is the classic abnormality on LFT in patients with alcoholic hepatitis?

A

AST mare than twice ALT. Both elevated

Elevated GGTP and bilirubin

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4
Q

What clues suggest Hep A?

A

Outbreaks from a food borne source.
Possible acute liver failure
Jaundice
4 week incubation period

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5
Q

Hep A diagnostic serology

A

IgM antihepatitis A virus (HAV)

IgM may be detected when symptoms begin

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6
Q

How is Hep B acquired?

A

Needles, Sex, or perinatal transmission.

Minor risk with blood transfusion. Old transfusions still pose a risk.

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7
Q

Tx Chronic Hep B

A

6+ months of elevated viral load:

  • Entcavir
  • Adefovir
  • Lamivudine
  • Telbivudine
  • Tenofovir
  • INF a-2b (many side effects)
  • dipivoxil
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8
Q 
Define these Hep B Serology terms:
HBsAg
HBaAb
HBeAg
HBeAb
HBcAb
A 
HBsAg- Surface antigen (infection)
HBaAb- Surface antibody (immunity)
HBeAg- "e" antigen (infectivity)
HBeAb- "e" antibody (low spread)
HBcAb- core antibody (window antibody)
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9
Q

If a patient has a positive HBaAb, what does it mean?

A

that the patient is immune. Either as a result from recovery of vaccination. HBsAb is never present in chronic hep b.

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10
Q

What Hep B serology is positive if the patient is in incubation? (1-3 months post contact)

A

HBsAg

HBeAG

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11
Q

What Hep B serology is positive if the patient is in the acute infection state? (3-6 months)

A

HBsAg
HBeAG
HBcAB

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12
Q

What Hep B serology is positive if the patient is a persistent carrier or chronic hep B?

A

HBsAg
HBeAg
HBeAb (+/-)
HBcAg

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13
Q

What Hep B serology is positive if the patient is vaccine immune vs recovery immune?

A

Both have HBsAB

RECOVERY also positive for HBeAb and HBcAb

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14
Q

Possible sequelae of chronic hepatitis B or C?

A

Cirrhosis and hepatocellular cancer

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15
Q

What should be given to persons acutely exposed to hep B?

A

Hep B vaccine alone or with Hep B immunoglobulin

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16
Q

Which type of viral hep is more likely to progress to chronic hep.

A

Hep C. (most likely cause of hep after a blood transfusion)

Hep C is more likely to progress to chronic, chirrhosis and cancer.

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17
Q

What is the CDC recommendation for Hep C?

A

High prevalence among “Baby Boomers”. All Americans born b/w 1945 and 1965 have a one time screening.

Blood wasn’t screened for hep C until 1992.

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18
Q

Describe the Hep C serology

A

Hep C antibody means previous infection but does not indicate cleared infection or not.

HepC virus RNA detect and quantify virus.

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19
Q

When is Hep D seen?

A

Hep D is only seen in patients with Hep B. It may become chronic and it is acquired the same way as Hep B.

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20
Q

Describe the Hep D Serology

A

IgM antibodies to Hep D antigen demonstrate resolution of recent infection.

Hep D antigen and Hep D RNA and high levels go IgM antibodies indicate chronicity.

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21
Q

How is Hep E transmitted? What is special about the infection in pregnant women?

A

Transmitted like Hep A (contaminated food/ water)

Its often fatal to pregnant women (specially east Asia patients)

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22
Q

What are the classic causes of drug induced hepatitis?

A 
Acetaminophen
TB drugs (Isoniazid, rifampin, pyrazinamide)
Halothane 
HMG CoA-reductase inhibitors (statins)
Carbon tetrachloride.
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23
Q

Presentation and treatment of idiopathic autoimmune hepatitis?

A 
20-40yo women 
Anti-smooth muscle or ANA
Anti- liver/kidney microsomal antibodies
High IgG
no risk factors

most accurate test: liver biopsy
Tx: steroids

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24
Q

Best initial tests for vital hepatits

A

Acute: IgM antibody for the acute infection and IgG antibody to detect resolution of infection

Chronic: PCR viral load.

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25
Q

What medications require Hep B surface antigen testing?

A

Anti CD20 (highest risk): rituximab, ofatumumab, obinutuzumab
Anto CD52: alemutuzumab
HIV PrEP: tenofivir, emtricitabine

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26
Q

Tx Chronic hep C

A

Sofobuvir + ledipasvir
Sofobuvir + velpatasvir

if only one choice: velpatasvir
Never treat with: simeprevir, telprevir, bocepravir or liver biopsy

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27
Q

Tx acute hep C

A

Hep C is the only one to be treated acutely.

Velpatasvir

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28
Q

Which lab value best correlates to increased likelihood of mortality from hepatitis?

A

If PT (prothrombin time) is elevated there is a markedly increased risk of fulminant hepatic failure and death

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29
Q

Which is the best indicator of the need for antiviral Tx in chronic Hep B?

A

HBeAg is the strongest indicator of active viral replication.

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30
Q

ADR of hepatitis meds: interferon

A 
rarely used. 
arthalgias
thrombocytopenia
depression 
leukopenia
31
Q

ADR of hepatitis meds: ribavirin

A

anemia

32
Q

ADR of hepatitis meds: adefovir

A

renal dysfunction

33
Q

Symptoms of chronic liver disease

A 
Gynercomastia 
Testicular atrophy
Palmar erythema & spider angiomas 
Ascites 
Asterixis and encephalopathy 
Coagulopathy 
Varices
34
Q

Treatment of cirrhosis symptoms: ascites and edema

A

Spironolactone (& other diuretics)

Serial paracenteses for large volume ascites

35
Q

Treatment of cirrhosis symptoms: coagulopathy and thrombocytopenia

A

FFP and/ or platelets only if bleeding occurs

Prolong PT: Vit K doesn’t help because it cannot be used by liver.

36
Q

Treatment of cirrhosis symptoms: encephalopathy

A

lactulose and rifaximin

37
Q

Treatment of cirrhosis symptoms: varices

A

propanolol and banding

38
Q

Treatment of cirrhosis symptoms: Hepatorenal syndrome

A

renal insufficiency from chronic liver disease.

Somatosatin (octreotide)
Midodrine

39
Q

Treatment of cirrhosis symptoms: hyperammonemia

A

Decreased protein intake
lactulose
Last resort: neomycin

40
Q

Metabolic derangements of liver failure

A 
Hyperbilirubinemia
Hypoalbuminemia
Hyperammonemia
Hypoglycemia 
DIC
41
Q

What prevention test should be done on someone with cirrhosis?

A

U/S every 6 months to screen for cancer

42
Q

What prevention test should be done on someone with ascities?

A

paracentesis to rule out SBP in patients with

  1. New-onset ascites
  2. New abdominal pain, tenderness, AMS or fever with known ascites

look for elevated WBC, low glucose, high protein, gram stain and culture.

43
Q

What is the most grave complication of ascites

A

spontaneous bacterial peritonitis.

infected ascitic fluid that can lead to sepsis.

44
Q

What organisms can cause SBP

A

E. coli (most common)
S. pneumoniae
Anaerobes (rare)

45
Q

Best initial and most accurate diagnostic test for SBP

A

BIT: paracentesis cell count (>250 neutrophils)

Most accurate: Fluid culture (to slow for decisions)

46
Q

Treatment of SBP

A

Cefotaxime

ceftriaxone

47
Q

Prophylaxis of SBP

A

TMP/SMX or Cipro

In patients with:
Ascites and vatical bleeding
Ascites with low albumin (<1)
Previous SBP (lifelong prophylaxis)

48
Q

What is hepatopulmonary syndrome?

A

Long disease and hypoxia caused by liver failure.
Orthodeoxia (hypoxia when standing)
Tx: Transplant

49
Q

Causes of cirrhosis:

A 
Alcoholic Liver disease 
Primary Biliary Cholangitis (PBC) 
Primary Sclerosing Cholangitis 
Alpha 1- antitrypsin Deficiency
Hemochromatosis
50
Q

Define Hemochromatosis

A

Two types:
primary AR genetic C282y gene leading to the overabsorption of iron in the duodenum.

Secondary caused by iron overload (transfusions, ineffective erythropoiesis)

51
Q

Presentation of hemochromatosis

A

50s, mildly elevated AST and alk phos

Liver (hepatomegaly, cirrhosis, HCC)
Heart (dilated cardiomegaly)
Skin (pigmentation Bronze diabetes)
Joints (arthralgia, pseudogout, chonedrocalcinosis)
Endocrine (DM, hypothyroid, hypogonadism)
Pituitary (ED or amenorrhea)

52
Q

Diagnostic tests hemochromatosis

A

BIT: Iron study
Confirmation test: Genetic testing for hemochromatosis- associated mutations (HFE)

Liver Biopsy (determines extent, used as confirmation if negative HFE)

EKG and ECHO can show cardiomyopathy.

53
Q

Tx Hemochromatosis

A

Phlebotomy.

liver fibrosis can resolve is phlebotomy is started before cirrhosis develops. urgent if extreme hyperferritinemia (end organ damage)

54
Q

Opportunistic infections with Hemochromatosis

A

Vibrio vulnificus
Yersinia
Listeria

these organisms feed on iron.

55
Q

Presentation and treatment of Alpha 1-antitrypsin deficiency

A

young adult <40
no risk factors (non-smoker)
combination liver disease and COPD.
Family history (AR inheritance)

Tx: replace enzyme

56
Q

Presentation of PBC

A

40s/50s yo women
Pruritus &Jaundice

Xanthelasma/ xanthoma
Osteoporosis

57
Q

Labs and diagnostic tests for PBC

A

Normal Bilirubin
Elevated Alk Phos
Anti-mitochondrial antibody

Most accurate: Liver Biopsy
Most accurate blood test: Anti-mitochondrial antibody

58
Q

Tx PBC

A

Definitive treatment: transplant

Symptomatic Tx:
Urodeoxycholic acid
Obetichoilic acid (decreases fibrosis)
Cholestyramine

59
Q

Presentation of Primary sclerosis cholangitis (PSC)

A

Young adult
80% cases occurs in association with IBD
Pruritus
Looks similar to PBC

60
Q

Labs and diagnostic test for PSC

A

Elevated Alk Phos
Elevated GGTP
Elevated Bilirubin (normal in early)

Most accurate: MRCP (preferred)/ ERCP
(only cause of cirrhosis where biopsy is not the answer)

61
Q

What is seen on MRCP/ ERCP of PSC?

A

beading, narrowing or strictures in the biliary system

62
Q

Tx PSC

A

no treatment is effective.
Dilation of strictures helps but doesn’t modify disease.
PSC doesn’t change resolution of IBD

eventually: liver transplant

63
Q

Define Wilson disease

A

Autosomal recessive disease of abnormally decreased copper excretion. Copper builds up in liver, kidneys, red blood cells and nervous system.

Decreased/ absent levels of ceruloplasmin.

64
Q

Presentation of Wilson Disease

A
  • CNS movement symptoms (tremor, dysarthria, ataxia, Parkinsonism)
  • Psychiatric manifestations (copper in basal ganglia)
  • RUQ abdominal pain
  • Coombs negative hemolytic anemia
  • Renal Tubular acidosis and nephrolithiasis
65
Q

Diagnostic tests for Wilsons Disease

A

BIT: Slit Lamp for Kayser Fleicher rings

Most Accurate: Urine test with elevated copper after penicillamine

66
Q

Tx Wilsons Disease

A

Penicillamine (allergy to penicillin: zinc or Trientine)

67
Q

Define Non-alcoholic fatty liver disease

A

Common condition in which there is excess fat in the liver of those who dont consume alcohol. Associated with obesity, diabetes, hyperlipidemia, and corticosteroid use.

68
Q

What are the two types of non alcoholic fatty liver

A
  1. Non-alcoholic Fatty liver - benign no malignant potential

2. Non-alcoholic Steatohepititis- inflammation and fibrosis. progreses to cirrhosis. potentially premalignant

69
Q

Diagnostic tests non alcoholic fatty liver

A

Most accurate: Biopsy

shows microvesicular fatty deposits (similar to alcoholic fatty liver)

70
Q

Tx Non-alcoholic fatty liver disease

A

Treat obesity, DM and HLD
Vit E for everyone

for Steatohepitits: obethicholic acid (in nonDM), pioglitazone (DM)

71
Q

What is Focal nodular hyperplasia?

A

“central stellate scaring” from hyperplastic hepatocellular growth around an abnormal vessel.

Benign no treatment needed

72
Q

What is hepatic adenoma?

A

Hyperechoic painful benign mass that changes with hormones (may rupture during pregnancy).

small risk of malignancy. Biopsy is diagnostic.

73
Q

Which benzo can be used in liver dysfunction

A

Lorazepam (oral/IV)
Oxazepam
Temazepam

74
Q

Why cant diazepam be given in liver dysfunction?

A

Long duration benzos that are metabolized via phase 1 cytochrome p450 oxidation into active metabolites and cause risk of toxic accumulation

aa Step 2CK: Internal & Peds (71 decks)

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