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Clin Med: GI (block 3) > Hepatic Disorders > Flashcards

Hepatic Disorders Flashcards

1
Q

What are different stages of liver failure?

A
  1. healthy liver
  2. Inflammation
  3. Fibrosis
  4. Cirrhosis
  5. Liver cancer
  6. End stage liver dz
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2
Q

Describe cirrhosis.

A

End result of injury that leads to both fibrosis & regenerative nodules

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3
Q

Is cirrhosis reversible?

A

yes, if cause is removed

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4
Q

Causes of cirrhosis?

A
  • chronic viral hepatitis
  • alcohol
  • drug toxicity
  • autoimmune & metabolic liver dz, including NAFLD
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5
Q

NOTES Cirrhosis

A

Asymp for long time
Symp - insidious or abrupt

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6
Q

Cirrhosis common S/S

A
  • Fatigue, disturbed sleep, muscle cramps, anorexia, & weight loss
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7
Q

Cirrhosis other S/S

A
  • Nausea & occasional vomiting
  • Reduced muscle strength & exercise capacity
  • Jaundice
  • Hematemesis (15-25%)
  • Fever (35%)
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8
Q

Cirrhosis S/S specific to women

A

amenorrhea

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9
Q

Cirrhosis S/S specific to men

A
  • erectile dysfunction
  • loss of libido
  • sterility
  • gynecomastia
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10
Q

Cirrhosis later finding (S/S)

A
  • ascites
  • pleural effusions
  • peripheral edema
  • ecchymoses
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11
Q

What is portal HTN?

A
  • syndrome of incr pressure in the portal venous system due to incr vascular resistance plus incr blood flow
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12
Q

Portal HTN is most commonly a complication of?

A

cirrhosis

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13
Q

Non cirrhosis causes include:

A
  • Extrahepatic causes such as tumors
  • Intrahepatic causes such as sarcoidosis or cystic fibrosis
  • Post hepatic causes such as Budd Chiari syndrome
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14
Q

What is major complication of portal HTN?

A

esophageal varices

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15
Q

Portal HTN may be asymp, but also present w/….

A
  • variceal hemorrhage
  • splenomegaly
  • ascites
  • abdo pain
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16
Q

Portal HTN Invasive Dx

A
  • portal pressure can only be directly measured by invasive methods w/catheterization of hepatic vein via femoral or jugular route
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17
Q

Portal HTN Less Invasive Dx or identify complications

A
  • upper GI endoscopyto dx varices
  • Doppler USor CT can show collateral vessels, portal venous flow alterations, splenomegaly & ascites
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18
Q

Portal HTN Tx

A
  • Treat underlying cause
  • Endoscopy to treat bleeding varices if present
  • Prophy of bleeding: BB
  • Surg: shunt to reduce pressure
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19
Q

Acute Hep A transmission route

A
  • fecal-oral by either person-to-person
  • ingestion of contaminated food or water
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20
Q

Hep A RFs

A
  • persons traveling to or working in countries that have intermediate-to-high endemicity of infx
  • child care centers & schools
  • men who have sex w/ men
  • homeless people
  • IVDA
  • persons who are administered clotting-factor concentrates
  • persons w/ chronic liver dz
  • food-service establishments or food handlers
  • persons currently or recently incarcerated
  • workers exposed to sewage
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21
Q

Hep A pathophy

A

Ingestion–> replicates in GI tract–> goes to liver (replicates more)–> sheds in bile–> goes to intestines–> shed in feces–> cellular immune response

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22
Q

Hep A S/S

A
  • abrupt or insidious onset
  • Malaise, myalgia, arthralgia, easy fatigability, upper resp symp, & anorexia
  • N/V are frequent, and diarrhea or constipation may occur
  • Defervescence & a fall in pulse rate often coincide w/ the onset of jaundice
  • Abdo pain
    —> Usually mild & constant in the RUQ or epigastrium
  • Jaundice (not common)
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23
Q

Hep A PE

A
  • Hepatomegaly (liver tenderness)
  • Splenomegaly (15% of pts)
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24
Q

Hep A Dx

A
  • HAV total antibody- if (+), indicates present or past infx, or immunization
  • HAV IgM antibody- indicates acute infx w/ HAV
  • HAV IgG antibody- indicates previous exposure to HAV, non-infectivity & immunity
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25
Hep A Tx
- Symptomatic treatment - Avoid liver toxic meds, alcohol - Generally, clinical recovery is complete in 9 wks
26
Describe the intubation period for Hep B
6wks to 6mo (average 3mo)
27
HBV is usually transmitted by...
- Infected blood or blood products - Sexual contact
28
Hep B RFs
- ppl born in areas of high or intermediate prevalence rates for HBV - ppl not Vax as infants whose parents were born in regions w/ high HBV endemicity - household & sexual contacts of HBsAg (+) pts - IVDA - ppl w/ multiple sexual partners or Hx of STDs - men who have sex w/ men - inmates - pts infected w/ hep C virus or HIV pts having renal dialysis - pregnant women
29
Hep B pathophys
30
Hep B, if pts have symptoms when do they occur?
acute illness generally begins 2-3mo (range 1-6mo) after exposure & may last 2-4mo
31
Possible Hep B S/S
- Fatigue/fever - N/V & RUQ abdo pain - low-grade fever - jaundice - dark urine - changes in stool color - Hepatomegaly/splenomegaly
32
Hep B PE
Assess for - fever - lethargy - AMS Skin - jaundice Abdomen - hepatomegaly - splenomegaly - RUQ tenderness - ascites
33
Hep B Dx
- HBsAg--> current infx - HBsAb--> cleared infx or vax - HBeAg--> hep B is multiplying - HBeAb--> Hep B not multiplying & immune system is responding - HBcAb--> has been infected - HBV DNA--> measures amount of Hep B in blood stream
34
Hep B Tx
- Infants may get antiviral drugs - Symptomatic treatment - Avoid hepatotoxic substances - Antiviral tx indicated only in cases of liver failure
35
Duration of chronic Hep B
> 6mo
36
Chronic Hep B can lead to...
cirrhosis & liver cancer
37
Chronic Hep B Tx
antivirals (reduce viral load & risk of cancer)
38
How long is the incubation period for Hep C?
2 - 12wks (7wks average)
39
Hep C can have a coinfx with...
HIV or HBV
40
Hep C RFs
- IVDA **most common* - Long term dialysis - Healthcare workers - Recipients of blood products/organ transplants before 1992 - Unregulated tattoos - Multiple sex partners, sex w/ HIV (+) partner
41
Hep C pathophys
42
Hep C S/S
- Usually asymptomatic - Mild symp may include: --> fatigue --> myalgia --> RUQ abdo pain ---> anorexia _ N/V - low-grade fever - jaundice - malaise - dark urine - clay colored stools
43
Hep C PE
Typically unremarkable --> May have RUQ tenderness --> May have jaundice
44
Hep C Dx
Many pts will have elevated liver enzymes (AST/ALT) --> HCV RNA: viral load-tests for acute infx Anti-HCV: antibodies- (+) about 12wks after infx- will always remain (+)
45
Hep C Tx
- Direct acting antiviral (6wks) has been shown to decr the chance of it progressing to chronic HCV
46
How long is a Chronic Hep C infx?
> 6mo
47
Chronic Hep C can lead to...
- liver cirrhosis - liver cancer
48
Recommended Tx for Chronic Hep C
- Antivirals - cure 90% of pts in 8-12wks
49
Is there immunity for Hep C?
NO
50
Who gets Hep D?
Pts who have Hep B (However all pts w/ Hep B don't contract Hep D)
51
Which patients have a 3x risk of hepatocellular carcinoma?
Pts with Chronic Hep B & Hep D
52
Who should be tested for Hep D?
All pts w/ acute or chronic Hep B
53
Hep D Dx
Hep D antigen or Hep D RNA in serum
54
Where is Hep E usually seen?
- Central & Southeast Asia - Middle East - North Africa
55
When should you consider Hep E as a dx?
Pts w/ acute hepatitis after a trip to an endemic area
56
Hep E Tx
generally self limited
57
Hep E Dx
Anti-HEV IgM is (+)
58
Describe autoimmune Hepatitis
Chronic hepatitis w/ high serum globulins & characteristic liver histology
59
Autoimmune Hepatitis Dx
- antinuclear antibody (ANA) and/or - smooth muscle antibody (+)
60
Autoimmune Hepatitis is usually seen in which pts?
young to middle-aged women
61
What may be in the medical hx of a pt w/ autoimmune hepatitis?
- viral illness (Hep A, EBV, measles) - drug or toxin (nitrofurantoin, hydralazine, minocycline)
62
Pts. w/ autoimmune Hepatitis are at incr risk of...
cirrhosis which incr risk of hepatocellular carcinoma
63
Autoimmune Hepatitis S/S
- may be asymp - typical initial symptoms include anorexia, fatigue, abdo & joint pain, itching, & maculopapular rashes
64
Describe acute liver failure
Development of hepatic encephalopathy w/n 8 weeks after acute liver injury
65
What is the typical INR in acute liver failure?
1.5 or higher
66
What % of acute liver failure cases are due to APAP?
45%
67
What % of APAP cases are from attempted suicides?
44%
68
Other causes for acute liver failure include:
- Meds - viral hepatitis - malignancy - Viruses (CMV, EBV, HSV, parvovirus B19)
69
Acute Liver Failure pathophys
- Hepatic encephalopathy, there is AMS due to failure of the liver to metabolize ammonia to urea. When the brain is exposed to ammonia, there are mental status changes & cerebral edema
70
Acute Liver Failure Hx
- viral infx exposure - details on prescription & nonprescription drugs, herbs, & supplements - consider acetaminophen hepatotoxicity - suspect mushroom poisoning w/n hours - 1 day after ingestion - abdo pain ~ w/ Budd-Chiari syndrome (acute hepatic vein thrombosis)
71
Acute Liver Failure S/S
- GI symptoms (N/V, anorexia) - Jaundice may be absent or minimal early - Systemic inflammatory response - Acute kidney injury
72
How many grades are there for Hepatic Encephalopathy?
4
73
Describe Grade I hepatic encephalopathy.
Changes in behavior, mild confusion, slurred speech, disordered sleep
74
Describe Grade II hepatic encephalopathy.
Lethargy, moderate confusion
75
Describe Grade III hepatic encephalopathy.
Marked confusion (stupor), incoherent speech, sleeping but arousable
76
Describe Grade IV hepatic encephalopathy.
coma, unresponsive to pain
77
Acute Liver Failure Dx
- Severe hepatocellular damage (AST/ALT/bilirubin/Alkaline Phosphatase/INR elevated) - Elevated serum ammonia; correlates w/ develop of encephalopathy - Acetaminophen toxicity, serum aminotransferase elevations are often > 5000 units/L - Order APAP level, etoh level if needed - Liver biopsy - Testing for all viral illnesses that can cause liver failure
78
Acute Liver Failure Tx
- Admit - Placement on liver transplant list (only definitive tx) - N-acetylcysteine for APAP toxicity - D/C hepatotoxic drugs - Supportive care for viral illnesses - Abx (sepsis is common complication) - Higher grades of encephalopathy may require intubation
79
Mortality rate of acute liver failure w/ severe encephalopathy is?
80%
80
Stages of alcoholic liver dz
Stage 1: simple steatosis (fatty liver) Stage 2: alcoholic hepatitis Stage 3: chronic hepatitis w/ hepatic fibrosis or cirrhosis
81
Alcoholic hepatitis is the result of...
extended excessive alcohol intake causing liver inflammation & impaired liver function
82
List the exacerbating RFs of alcoholic liver dz
- obesity & excess weight - chronic viral infx including concomitant infx w/ viral hepatitis - genetic factors
83
Alcoholic Liver Disease pathophys
- As alcohol is metabolized, it signals to the liver to produce more fat, which is deposited in the liver - Metabolized alcohol also causes oxidative stress in the liver
84
Alcoholic Liver Disease S/S
- steatosis typically asymp - alcoholic hepatitis may present w/ or w/o numerous symptoms: --> scleral icterus --> jaundice --> fever --> anorexia --> epigastric or RUQ pain
85
Alcoholic Liver Disease cirrhosis S/S
- symptoms of portal HTN - weakness - weight loss - fatigue - anorexia - amenorrhea - lack of sex drive, impotence - muscle cramps
86
Alcoholic Liver Disease Worsening cirrhosis S/S
- jaundice - periph edema - ascites - symptoms of hepatic encephalopathy --> confusion --> asterixis
87
Alcoholic Liver Disease PE
- Hepatomegaly & jaundice in hepatitis - Abdo pain & tenderness, splenomegaly, ascites, fever, and/or encephalopathy in cirrhosis - Infx, including invasive aspergillosis, is common in pts w/ severe alcoholic hepatitis
88
Alcoholic Liver Disease Dx
- Elevated AST/ALT, bilirubin, INR - Low albumin - Leukocytosis - Thrombocytopenia - Liver biopsy - US/CT/MRI will show hepatic steatosis
89
Alcoholic Liver Dz Tx
- No alcohol - Folic Acid, thiamine, zinc, Mg++ - Corticosteroids - Nutritional support as needed
90
What is the most common cause of elevated liver enzymes in adults in the US?
Non-Alcoholic fatty liver dz
91
Non-Alcoholic fatty liver dz is associated with...
- insulin resistance - obesity - weight gain - DM
92
Non-Alcoholic fatty liver dz can progress to...
Non Alcoholic Steatohepatitis (NASH)
93
Non alcoholic fatty liver disease Dx
- usually found on routine screening - elevated biochemical markers of liver injury & cholestasis - alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase - abnormal liver US or CT
94
Other causes of fatty liver dz
- Cushing syndrome & hypopituitarism - Excessive dietary fructose consumption - Starvation& refeeding syndrome - Hypobetalipoproteinemia - Polycystic ovary syndrome - Hypothyroidism - Obstructive sleep apnea - Total Parenteral Nutrition - Psoriasis
95
Non-alcoholic fatty liver dz
- weight reduction (diet & exercise) - Modification of cardiac risk RFs - Tx of underlying condition
96
Drug & Toxin Liver Injury
97
What is hemochromatosis?
Incr accumulation of iron as hemosiderin in the liver, pancreas, heart, adrenals, testes, pituitary, & kidneys
98
Is Hemochromatosis autosomal dominant or recessive?
autosomal recessive
99
Hemochromatosis potentiates liver dz in those who...
- drink alcohol - have DM - obesity
100
Hemochromatosis S/S
- adults may present w/ abnormal liver studies on routine screening or may be identified as high risk due to family history - though common in the past, pts rarely present w/ classic presentation of fully established dz ("bronze diabetes"), consisting of --> cirrhosis --> diabetes --> skin pigmentation
101
Hemochromatosis Dx
- mildly abnormal liver chemistries - elevated plasma iron w/ > 45% transferrin saturation - elevated serum ferritin - Genetic testing - CT or MRI may show iron overload - Liver biopsy
102
Hemochromatosis Tx
- Chelating agents - Phlebotomy - Decr iron rich food intake - Liver transplant
103
Wilson Disease NOTES
Rare autosomal recessive disorder that usually manifests in persons b/t 3 - 55yo Excessive deposition of copper in the liver & brain
104
Wilson Disease pathophys
excessive absorption of copper from the small intestine & decr excretion of by the liver, resulting in incr tissue deposition
105
Wilson Disease S/S
- Consider the dx in any child or young adult w/ the following --> Hepatitis and/or splenomegaly --> Hemolytic anemia --> Neurologic or psychiatric abnormalities - Hepatic involvement may range from elevated liver tests to fulminant hepatitis, cirrhosis & portal HTN - Neurologic manifestations - Psychiatric features include behavioral & personality changes & emotional lability
106
What are the neurologic manifestations found in Wilson Dz?
- dysarthria - dysphagia - incoordination - spasticity - Migraines - insomnia - seizures
107
Wilson Disease PE
Corneal Kayser-Fleischer ring: --> brownish or gray-green pigmented granular deposits in cornea close to the endothelial surface
108
Wilson Disease Dx
- low serum ceruloplasmin - high urinary copper excretion - genetic test (+) for ATP7B gene mutation - elevated hepatic copper conc. (liver biopsy)
109
Wilson Disease Tx
goal of treatment: attain (-) copper balance & remove copper from damaged sites in the liver & CNS - advise pts to modify diet to avoid intake of water & foods w/ high conc. of copper, such as liver, chocolate, mushrooms, soy, shellfish, brain, & nuts - Chelating agents given to incr urinary excretion
110
Describe Budd Chiari Syndrome
- Post hepatic obstruction of blood flow - Primary cause thrombosis - 2ndary cause tumor compressing the vein - Very Rare
111
Budd Chiari Syndrome pathophys
112
Budd Chiari Syndrome is primarily usually due to hypercoag state like...
- Polycythemia Vera - OCP - Pregnancy - Lupus - Cancer
113
Budd Chiari Syndrome S/S
- tender, painful hepatic enlargement - Jaundice - Splenomegaly - Ascites chronic disease: - bleeding varices - hepatic encephalopathy
114
Budd Chiari Syndrome Dx test of choice
Doppler US will show thrombosis, blood flow abnormalities
115
Budd Chiari Syndrome other Dx
- CT or MRI may show evidence of thrombosis/liver congestion -May have incr liver enzymes
116
Budd Chiari Syndrome Tx
- Treat underlying disease - Anticoag w/ LMWH - TIPS (trans jugular intrahepatic portosystemic shunt)
117
What % of liver cancers is hepatocellular carcinoma? What % of hepatocellular carcinomas are assoc. w/ cirrhosis?
Both 85%
118
Hepatocellular Carcinoma pathophys
119
Hepatocellular Carcinoma
- typically asymp may have nonspecific symp - jaundice - anorexia - weight loss - malaise - upper abdo pain - enlarged liver - ascites
120
Hepatocellular Carcinoma Dx
- Usually abnormality found on CT/MRI - Liver biopsy - Chest CT & bone scan to look for mets - Labs
121
Hepatocellular Carcinoma Labs
- hepatitis panel - bilirubin, transaminases, & alkaline phosphatase - prothrombin time/INR, albumin, blood urea nitrogen, & creatinine - CBC - serum alpha-fetoprotein
122
What's included on a Hepatitis panel?
- hep B surface antigen, - hep B surface antibody - hep B core antibody - hep C antibody
123
Hepatocellular Carcinoma Tx
- Resection if possible - Liver transplant - Chemo if advanced

Clin Med: GI (block 3) (8 decks)

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