GI- Liver Flashcards
Common findings of acute liver disease
- Elevated LFTs
- Jaundice
- N/V; fever
- RUQ pain or tenderness
- Hepato(spleno)megaly
Common causes of acute liver disease
- Alcohol
- Medications
- Infections (hepatitis)
- Reye Syndrome
- Biliary Tract Disease
- Autoimmune Disease
What is the classic abnormality on LFT in patients with alcoholic hepatitis?
AST mare than twice ALT. Both elevated
Elevated GGTP and bilirubin
What clues suggest Hep A?
Outbreaks from a food borne source.
Possible acute liver failure
Jaundice
4 week incubation period
Hep A diagnostic serology
IgM antihepatitis A virus (HAV)
IgM may be detected when symptoms begin
How is Hep B acquired?
Needles, Sex, or perinatal transmission.
Minor risk with blood transfusion. Old transfusions still pose a risk.
Tx Chronic Hep B
6+ months of elevated viral load:
- Entcavir
- Adefovir
- Lamivudine
- Telbivudine
- Tenofovir
- INF a-2b (many side effects)
- dipivoxil
Define these Hep B Serology terms: HBsAg HBaAb HBeAg HBeAb HBcAb
HBsAg- Surface antigen (infection) HBaAb- Surface antibody (immunity) HBeAg- "e" antigen (infectivity) HBeAb- "e" antibody (low spread) HBcAb- core antibody (window antibody)
If a patient has a positive HBaAb, what does it mean?
that the patient is immune. Either as a result from recovery of vaccination. HBsAb is never present in chronic hep b.
What Hep B serology is positive if the patient is in incubation? (1-3 months post contact)
HBsAg
HBeAG
What Hep B serology is positive if the patient is in the acute infection state? (3-6 months)
HBsAg
HBeAG
HBcAB
What Hep B serology is positive if the patient is a persistent carrier or chronic hep B?
HBsAg
HBeAg
HBeAb (+/-)
HBcAg
What Hep B serology is positive if the patient is vaccine immune vs recovery immune?
Both have HBsAB
RECOVERY also positive for HBeAb and HBcAb
Possible sequelae of chronic hepatitis B or C?
Cirrhosis and hepatocellular cancer
What should be given to persons acutely exposed to hep B?
Hep B vaccine alone or with Hep B immunoglobulin
Which type of viral hep is more likely to progress to chronic hep.
Hep C. (most likely cause of hep after a blood transfusion)
Hep C is more likely to progress to chronic, chirrhosis and cancer.
What is the CDC recommendation for Hep C?
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.
Describe the Hep C serology
Hep C antibody means previous infection but does not indicate cleared infection or not.
HepC virus RNA detect and quantify virus.
When is Hep D seen?
Hep D is only seen in patients with Hep B. It may become chronic and it is acquired the same way as Hep B.
Describe the Hep D Serology
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.
How is Hep E transmitted? What is special about the infection in pregnant women?
Transmitted like Hep A (contaminated food/ water)
Its often fatal to pregnant women (specially east Asia patients)
What are the classic causes of drug induced hepatitis?
Acetaminophen TB drugs (Isoniazid, rifampin, pyrazinamide) Halothane HMG CoA-reductase inhibitors (statins) Carbon tetrachloride.
Presentation and treatment of idiopathic autoimmune hepatitis?
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
Best initial tests for vital hepatits
Acute: IgM antibody for the acute infection and IgG antibody to detect resolution of infection
Chronic: PCR viral load.
What medications require Hep B surface antigen testing?
Anti CD20 (highest risk): rituximab, ofatumumab, obinutuzumab
Anto CD52: alemutuzumab
HIV PrEP: tenofivir, emtricitabine
Tx Chronic hep C
Sofobuvir + ledipasvir
Sofobuvir + velpatasvir
if only one choice: velpatasvir
Never treat with: simeprevir, telprevir, bocepravir or liver biopsy
Tx acute hep C
Hep C is the only one to be treated acutely.
Velpatasvir
Which lab value best correlates to increased likelihood of mortality from hepatitis?
If PT (prothrombin time) is elevated there is a markedly increased risk of fulminant hepatic failure and death
Which is the best indicator of the need for antiviral Tx in chronic Hep B?
HBeAg is the strongest indicator of active viral replication.
ADR of hepatitis meds: interferon
rarely used. arthalgias thrombocytopenia depression leukopenia
ADR of hepatitis meds: ribavirin
anemia
ADR of hepatitis meds: adefovir
renal dysfunction
Symptoms of chronic liver disease
Gynercomastia Testicular atrophy Palmar erythema & spider angiomas Ascites Asterixis and encephalopathy Coagulopathy Varices
Treatment of cirrhosis symptoms: ascites and edema
Spironolactone (& other diuretics)
Serial paracenteses for large volume ascites
Treatment of cirrhosis symptoms: coagulopathy and thrombocytopenia
FFP and/ or platelets only if bleeding occurs
Prolong PT: Vit K doesn’t help because it cannot be used by liver.
Treatment of cirrhosis symptoms: encephalopathy
lactulose and rifaximin
Treatment of cirrhosis symptoms: varices
propanolol and banding
Treatment of cirrhosis symptoms: Hepatorenal syndrome
renal insufficiency from chronic liver disease.
Somatosatin (octreotide)
Midodrine
Treatment of cirrhosis symptoms: hyperammonemia
Decreased protein intake
lactulose
Last resort: neomycin
Metabolic derangements of liver failure
Hyperbilirubinemia Hypoalbuminemia Hyperammonemia Hypoglycemia DIC
What prevention test should be done on someone with cirrhosis?
U/S every 6 months to screen for cancer
What prevention test should be done on someone with ascities?
paracentesis to rule out SBP in patients with
- New-onset ascites
- New abdominal pain, tenderness, AMS or fever with known ascites
look for elevated WBC, low glucose, high protein, gram stain and culture.
What is the most grave complication of ascites
spontaneous bacterial peritonitis.
infected ascitic fluid that can lead to sepsis.
What organisms can cause SBP
E. coli (most common)
S. pneumoniae
Anaerobes (rare)
Best initial and most accurate diagnostic test for SBP
BIT: paracentesis cell count (>250 neutrophils)
Most accurate: Fluid culture (to slow for decisions)
Treatment of SBP
Cefotaxime
ceftriaxone
Prophylaxis of SBP
TMP/SMX or Cipro
In patients with:
Ascites and vatical bleeding
Ascites with low albumin (<1)
Previous SBP (lifelong prophylaxis)
What is hepatopulmonary syndrome?
Long disease and hypoxia caused by liver failure.
Orthodeoxia (hypoxia when standing)
Tx: Transplant
Causes of cirrhosis:
Alcoholic Liver disease Primary Biliary Cholangitis (PBC) Primary Sclerosing Cholangitis Alpha 1- antitrypsin Deficiency Hemochromatosis
Define Hemochromatosis
Two types:
primary AR genetic C282y gene leading to the overabsorption of iron in the duodenum.
Secondary caused by iron overload (transfusions, ineffective erythropoiesis)
Presentation of hemochromatosis
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)
Diagnostic tests hemochromatosis
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.
Tx Hemochromatosis
Phlebotomy.
liver fibrosis can resolve is phlebotomy is started before cirrhosis develops. urgent if extreme hyperferritinemia (end organ damage)
Opportunistic infections with Hemochromatosis
Vibrio vulnificus
Yersinia
Listeria
these organisms feed on iron.
Presentation and treatment of Alpha 1-antitrypsin deficiency
young adult <40
no risk factors (non-smoker)
combination liver disease and COPD.
Family history (AR inheritance)
Tx: replace enzyme
Presentation of PBC
40s/50s yo women
Pruritus &Jaundice
Xanthelasma/ xanthoma
Osteoporosis
Labs and diagnostic tests for PBC
Normal Bilirubin
Elevated Alk Phos
Anti-mitochondrial antibody
Most accurate: Liver Biopsy
Most accurate blood test: Anti-mitochondrial antibody
Tx PBC
Definitive treatment: transplant
Symptomatic Tx:
Urodeoxycholic acid
Obetichoilic acid (decreases fibrosis)
Cholestyramine
Presentation of Primary sclerosis cholangitis (PSC)
Young adult
80% cases occurs in association with IBD
Pruritus
Looks similar to PBC
Labs and diagnostic test for PSC
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)
What is seen on MRCP/ ERCP of PSC?
beading, narrowing or strictures in the biliary system
Tx PSC
no treatment is effective.
Dilation of strictures helps but doesn’t modify disease.
PSC doesn’t change resolution of IBD
eventually: liver transplant
Define Wilson disease
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.
Presentation of Wilson Disease
- 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
Diagnostic tests for Wilsons Disease
BIT: Slit Lamp for Kayser Fleicher rings
Most Accurate: Urine test with elevated copper after penicillamine
Tx Wilsons Disease
Penicillamine (allergy to penicillin: zinc or Trientine)
Define Non-alcoholic fatty liver disease
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.
What are the two types of non alcoholic fatty liver
- Non-alcoholic Fatty liver - benign no malignant potential
2. Non-alcoholic Steatohepititis- inflammation and fibrosis. progreses to cirrhosis. potentially premalignant
Diagnostic tests non alcoholic fatty liver
Most accurate: Biopsy
shows microvesicular fatty deposits (similar to alcoholic fatty liver)
Tx Non-alcoholic fatty liver disease
Treat obesity, DM and HLD
Vit E for everyone
for Steatohepitits: obethicholic acid (in nonDM), pioglitazone (DM)
What is Focal nodular hyperplasia?
“central stellate scaring” from hyperplastic hepatocellular growth around an abnormal vessel.
Benign no treatment needed
What is hepatic adenoma?
Hyperechoic painful benign mass that changes with hormones (may rupture during pregnancy).
small risk of malignancy. Biopsy is diagnostic.
Which benzo can be used in liver dysfunction
Lorazepam (oral/IV)
Oxazepam
Temazepam
Why cant diazepam be given in liver dysfunction?
Long duration benzos that are metabolized via phase 1 cytochrome p450 oxidation into active metabolites and cause risk of toxic accumulation
