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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
Q

Hep A Tx

A
  • Symptomatic treatment
  • Avoid liver toxic meds, alcohol
  • Generally, clinical recovery is complete in 9 wks
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26
Q

Describe the intubation period for Hep B

A

6wks to 6mo (average 3mo)

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27
Q

HBV is usually transmitted by…

A
  • Infected blood or blood products
  • Sexual contact
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28
Q

Hep B RFs

A
  • 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
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29
Q

Hep B pathophys

A
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30
Q

Hep B, if pts have symptoms when do they occur?

A

acute illness generally begins 2-3mo (range 1-6mo) after exposure & may last 2-4mo

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31
Q

Possible Hep B S/S

A
  • Fatigue/fever
  • N/V & RUQ abdo pain
  • low-grade fever
  • jaundice
  • dark urine
  • changes in stool color
  • Hepatomegaly/splenomegaly
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32
Q

Hep B PE

A

Assess for
- fever
- lethargy
- AMS
Skin
- jaundice
Abdomen
- hepatomegaly
- splenomegaly
- RUQ tenderness
- ascites

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33
Q

Hep B Dx

A
  • 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
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34
Q

Hep B Tx

A
  • Infants may get antiviral drugs
  • Symptomatic treatment
  • Avoid hepatotoxic substances
  • Antiviral tx indicated only in cases of liver failure
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35
Q

Duration of chronic Hep B

A

> 6mo

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36
Q

Chronic Hep B can lead to…

A

cirrhosis & liver cancer

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37
Q

Chronic Hep B Tx

A

antivirals (reduce viral load & risk of cancer)

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38
Q

How long is the incubation period for Hep C?

A

2 - 12wks (7wks average)

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39
Q

Hep C can have a coinfx with…

A

HIV or HBV

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40
Q

Hep C RFs

A
  • 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
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41
Q

Hep C pathophys

A
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42
Q

Hep C S/S

A
  • Usually asymptomatic
  • Mild symp may include:
    –> fatigue
    –> myalgia
    –> RUQ abdo pain
    —> anorexia
    _ N/V
  • low-grade fever
  • jaundice
  • malaise
  • dark urine
  • clay colored stools
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43
Q

Hep C PE

A

Typically unremarkable
–> May have RUQ tenderness
–> May have jaundice

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44
Q

Hep C Dx

A

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 (+)

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45
Q

Hep C Tx

A
  • Direct acting antiviral (6wks) has been shown to decr the chance of it progressing to chronic HCV
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46
Q

How long is a Chronic Hep C infx?

A

> 6mo

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47
Q

Chronic Hep C can lead to…

A
  • liver cirrhosis
  • liver cancer
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48
Q

Recommended Tx for Chronic Hep C

A
  • Antivirals
  • cure 90% of pts in 8-12wks
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49
Q

Is there immunity for Hep C?

A

NO

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50
Q

Who gets Hep D?

A

Pts who have Hep B

(However all pts w/ Hep B don’t contract Hep D)

51
Q

Which patients have a 3x risk of hepatocellular carcinoma?

A

Pts with Chronic Hep B & Hep D

52
Q

Who should be tested for Hep D?

A

All pts w/ acute or chronic Hep B

53
Q

Hep D Dx

A

Hep D antigen or Hep D RNA in serum

54
Q

Where is Hep E usually seen?

A
  • Central & Southeast Asia
  • Middle East
  • North Africa
55
Q

When should you consider Hep E as a dx?

A

Pts w/ acute hepatitis after a trip to an endemic area

56
Q

Hep E Tx

A

generally self limited

57
Q

Hep E Dx

A

Anti-HEV IgM is (+)

58
Q

Describe autoimmune Hepatitis

A

Chronic hepatitis w/ high serum globulins & characteristic liver histology

59
Q

Autoimmune Hepatitis Dx

A
  • antinuclear antibody (ANA)
    and/or
  • smooth muscle antibody (+)
60
Q

Autoimmune Hepatitis is usually seen in which pts?

A

young to middle-aged women

61
Q

What may be in the medical hx of a pt w/ autoimmune hepatitis?

A
  • viral illness (Hep A, EBV, measles)
  • drug or toxin (nitrofurantoin, hydralazine, minocycline)
62
Q

Pts. w/ autoimmune Hepatitis are at incr risk of…

A

cirrhosis which incr risk of hepatocellular carcinoma

63
Q

Autoimmune Hepatitis S/S

A
  • may be asymp
  • typical initial symptoms include anorexia, fatigue, abdo & joint pain, itching, & maculopapular rashes
64
Q

Describe acute liver failure

A

Development of hepatic encephalopathy w/n 8 weeks after acute liver injury

65
Q

What is the typical INR in acute liver failure?

A

1.5 or higher

66
Q

What % of acute liver failure cases are due to APAP?

A

45%

67
Q

What % of APAP cases are from attempted suicides?

A

44%

68
Q

Other causes for acute liver failure include:

A
  • Meds
  • viral hepatitis
  • malignancy
  • Viruses (CMV, EBV, HSV, parvovirus B19)
69
Q

Acute Liver Failure pathophys

A
  • 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
Q

Acute Liver Failure Hx

A
  • 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
Q

Acute Liver Failure S/S

A
  • GI symptoms (N/V, anorexia)
  • Jaundice may be absent or minimal early
  • Systemic inflammatory response
  • Acute kidney injury
72
Q

How many grades are there for Hepatic Encephalopathy?

A

4

73
Q

Describe Grade I hepatic encephalopathy.

A

Changes in behavior, mild confusion, slurred speech, disordered sleep

74
Q

Describe Grade II hepatic encephalopathy.

A

Lethargy, moderate confusion

75
Q

Describe Grade III hepatic encephalopathy.

A

Marked confusion (stupor), incoherent speech, sleeping but arousable

76
Q

Describe Grade IV hepatic encephalopathy.

A

coma, unresponsive to pain

77
Q

Acute Liver Failure Dx

A
  • 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
Q

Acute Liver Failure Tx

A
  • 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
Q

Mortality rate of acute liver failure w/ severe encephalopathy is?

A

80%

80
Q

Stages of alcoholic liver dz

A

Stage 1: simple steatosis (fatty liver)

Stage 2: alcoholic hepatitis

Stage 3: chronic hepatitis w/ hepatic fibrosis or cirrhosis

81
Q

Alcoholic hepatitis is the result of…

A

extended excessive alcohol intake causing liver inflammation & impaired liver function

82
Q

List the exacerbating RFs of alcoholic liver dz

A
  • obesity & excess weight
  • chronic viral infx including concomitant infx w/ viral hepatitis
  • genetic factors
83
Q

Alcoholic Liver Disease pathophys

A
  • 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
Q

Alcoholic Liver Disease S/S

A
  • steatosis typically asymp
  • alcoholic hepatitis may present w/ or w/o numerous symptoms:
    –> scleral icterus
    –> jaundice
    –> fever
    –> anorexia
    –> epigastric or RUQ pain
85
Q

Alcoholic Liver Disease cirrhosis S/S

A
  • symptoms ofportal HTN
  • weakness
  • weight loss
  • fatigue
  • anorexia
  • amenorrhea
  • lack of sex drive, impotence
  • muscle cramps
86
Q

Alcoholic Liver Disease Worsening cirrhosis S/S

A
  • jaundice
  • periph edema
  • ascites
  • symptoms of hepatic encephalopathy
    –> confusion
    –> asterixis
87
Q

Alcoholic Liver Disease PE

A
  • 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
Q

Alcoholic Liver Disease Dx

A
  • Elevated AST/ALT, bilirubin, INR
  • Low albumin
  • Leukocytosis
  • Thrombocytopenia
  • Liver biopsy
  • US/CT/MRI will show hepatic steatosis
89
Q

Alcoholic Liver Dz Tx

A
  • No alcohol
  • Folic Acid, thiamine, zinc, Mg++
  • Corticosteroids
  • Nutritional support as needed
90
Q

What is the most common cause of elevated liver enzymes in adults in the US?

A

Non-Alcoholic fatty liver dz

91
Q

Non-Alcoholic fatty liver dz is associated with…

A
  • insulin resistance
  • obesity
  • weight gain
  • DM
92
Q

Non-Alcoholic fatty liver dz can progress to…

A

Non Alcoholic Steatohepatitis (NASH)

93
Q

Non alcoholic fatty liver disease Dx

A
  • usually found on routine screening
  • elevated biochemical markers of liver injury & cholestasis - alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase
  • abnormal liver US or CT
94
Q

Other causes of fatty liver dz

A
  • Cushing syndrome & hypopituitarism
  • Excessive dietary fructose consumption
  • Starvation& refeeding syndrome
  • Hypobetalipoproteinemia
  • Polycystic ovary syndrome
  • Hypothyroidism
  • Obstructive sleep apnea
  • Total Parenteral Nutrition
  • Psoriasis
95
Q

Non-alcoholic fatty liver dz

A
  • weight reduction (diet & exercise)
  • Modification of cardiac risk RFs
  • Tx of underlying condition
96
Q

Drug & Toxin Liver Injury

A
97
Q

What is hemochromatosis?

A

Incr accumulation of iron as hemosiderin in the liver, pancreas, heart, adrenals, testes, pituitary, & kidneys

98
Q

Is Hemochromatosis autosomal dominant or recessive?

A

autosomal recessive

99
Q

Hemochromatosis potentiates liver dz in those who…

A
  • drink alcohol
  • have DM
  • obesity
100
Q

Hemochromatosis S/S

A
  • 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
Q

Hemochromatosis Dx

A
  • 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
Q

Hemochromatosis Tx

A
  • Chelating agents
  • Phlebotomy
  • Decr iron rich food intake
  • Liver transplant
103
Q

Wilson Disease NOTES

A

Rare autosomal recessive disorder that usually manifests in persons b/t 3 - 55yo

Excessive deposition ofcopper in the liver & brain

104
Q

Wilson Disease pathophys

A

excessive absorption ofcopperfrom the small intestine & decr excretion ofby the liver, resulting in incr tissue deposition

105
Q

Wilson Disease S/S

A
  • 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
Q

What are the neurologic manifestations found in Wilson Dz?

A
  • dysarthria
  • dysphagia
  • incoordination
  • spasticity
  • Migraines
  • insomnia
  • seizures
107
Q

Wilson Disease PE

A

Corneal Kayser-Fleischer ring:
–> brownish or gray-green pigmented granular deposits in cornea close to the endothelial surface

108
Q

Wilson Disease Dx

A
  • low serum ceruloplasmin
  • high urinary copper excretion
  • genetic test (+) forATP7Bgene mutation
  • elevated hepatic copper conc. (liver biopsy)
109
Q

Wilson Disease Tx

A

goal of treatment: attain (-) copper balance & remove copper from damaged sites in the liver & CNS

  • advise pts tomodify 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
Q

Describe Budd Chiari Syndrome

A
  • Post hepatic obstruction of blood flow
  • Primary cause thrombosis
  • 2ndary cause tumor compressing the vein
  • Very Rare
111
Q

Budd Chiari Syndrome pathophys

A
112
Q

Budd Chiari Syndrome is primarily usually due to hypercoag state like…

A
  • Polycythemia Vera
  • OCP
  • Pregnancy
  • Lupus
  • Cancer
113
Q

Budd Chiari Syndrome S/S

A
  • tender, painful hepatic enlargement
  • Jaundice
  • Splenomegaly
  • Ascites

chronic disease:
- bleeding varices
- hepatic encephalopathy

114
Q

Budd Chiari Syndrome Dx test of choice

A

Doppler US will show thrombosis, blood flow abnormalities

115
Q

Budd Chiari Syndrome other Dx

A
  • CT or MRI may show evidence of thrombosis/liver congestion

-May have incr liver enzymes

116
Q

Budd Chiari Syndrome Tx

A
  • Treat underlying disease
  • Anticoag w/ LMWH
  • TIPS (trans jugular intrahepatic portosystemic shunt)
117
Q

What % of liver cancers is hepatocellular carcinoma? What % of hepatocellular carcinomas are assoc. w/ cirrhosis?

A

Both 85%

118
Q

Hepatocellular Carcinoma pathophys

A
119
Q

Hepatocellular Carcinoma

A
  • typically asymp

may have nonspecific symp
- jaundice
- anorexia
- weight loss
- malaise
- upper abdo pain
- enlarged liver
- ascites

120
Q

Hepatocellular Carcinoma Dx

A
  • Usually abnormality found on CT/MRI
  • Liver biopsy
  • Chest CT & bone scan to look for mets
  • Labs
121
Q

Hepatocellular Carcinoma Labs

A
  • hepatitis panel
  • bilirubin, transaminases, & alkaline phosphatase
  • prothrombin time/INR, albumin, blood urea nitrogen, & creatinine
  • CBC
  • serum alpha-fetoprotein
122
Q

What’s included on a Hepatitis panel?

A
  • hep B surface antigen,
  • hep B surface antibody
  • hep B core antibody
  • hep C antibody
123
Q

Hepatocellular Carcinoma Tx

A
  • Resection if possible
  • Liver transplant
  • Chemo if advanced

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

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