Hepatitis and fatty liver disease

Question 1

ALCOHOLIC LIVER DISEASE

Answer 1

10-15% of those that consume 50 grams of ETOH
daily for 10 years
○ 4 oz of 100 proof whiskey
○ 15 oz of wine*
○ 4-12 oz cans of beer
80 % have been drinking for 5 years before onset
of symptoms

Question 2

Is alcoholic hepatitis episodic or constant?

Answer 2

Can be a single or recurrent episodes over the course of alcoholic liver diseas

Question 3

A standard drink of ETOH is defined as

Answer 3

any drink that contains 14 grams of pure ETOH

Question 4

SIGNS AND SYMPTOMS Alcoholic hepatitis

Answer 4

★ Jaundice
★ Fever
★ Nausea
★ Anorexia
★ Generalized edema
★ Tender right upper quadrant with hepatomegaly

Question 5

Severe S/S alcoholic hepatitis

Answer 5

★ Coagulopathies
★ Ascites
★ Variceal bleeding
★ Hepatic encephalopathy
★ May lead to
○ Renal injury
○ Multiorgan failure
○ 30 day mortality rate of 60%

Question 6

Diagnostic studies alcoholic hepatitis

Answer 6

★ De Ritis quotient AST/ALT ratio > 2.0
★ Elevated bilirubin level
★ Elevated Alkaline phosphatase
★ Prolonged prothrombin time
★ Decline in serum albumin
★ Abdominal ultrasound
★ Upper endoscopy if GI bleeding suspected
★ DX by history and PE biopsy not indicated
★ Model for End stage Liver Disease (MELD)

Question 7

Treatment of alcoholic hepatitis

Answer 7

★ 40 mg prednisone daily for 28 days improves
short term recovery
★ Pentoxifylline 400 mg tid used when prednisone
is contraindicated.

Question 8

_____ Accounts for >40% of liver failure cases in United states

Answer 8

Acetaminophen

Question 9

Drugs that can cause toxic hepatitis

Answer 9

★ HMG-CoA inhibitors -statins
★ Antibiotics-minocycline, sulfa
★ Amiodarone
★ Isoniazid (INH)
★ Methyldopa
★ Sodium valproate
★ Diclofenac
★ Salicylates
★ Phenytoin
★ Carbon tetrachloride
★ Rifampin
★ Indomethacin
★ Mushroom >50 types are hepatotoxic
★ Herbs remedies and dietary supplements

Question 10

S/S toxic hepatitis

Answer 10

★ Nausea
★ Vomiting
★ Diarrhea
★ Abdominal pain
★ Shock
★ 4-12 hours after ingestion
★ High transaminase levels with low bilirubin

Question 11

Treatment of toxic hepatitis

Answer 11

★ Supportive
★ Withdrawal of suspected agent
★ Gastric lavage
★ Oral administration of charcoal or
cholestyramine-bile acid sequestrant, leads to ↓
absorption of Tylenol
★ Liver transplant
★ Acetaminophen treated differently

Question 12

How do you treat toxic hepatitis caused by acetominophen

Answer 12

treated with sulfhydryl compounds
○ Binds the toxic metabolites
○ Stimulate synthesis of hepatic glutathione
○ Start within 8 hours but may be effective up to 36 hours

Question 13

Fatal dosage of acetaminophen

Answer 13

○ 10-15 grams in a single dose
○ >25 grams single dose is usually fatal

Question 14

Autoimmune hepatitis

Answer 14

★ More common in women and men
★ Usually occurs in women ages 30 to 50
★ Characterized by elevated serum IgG and
autoantibodies
★ May be part of a larger autoimmune disorder
★ Diagnoses made on serology results histologic findings and ruling out other chronic liver disease

Question 15

AUTOIMMUNE HEPATITIS types

Answer 15

Type 1 “Classic”
○ Positive ANA -67% of patients (nuclear)
○ Positive ASMA-13% of patients (smooth
muscle)
○ Positive for both-54% of patients
★ Type 2
○ Common in Europe
○ ALKM-1 (anti liver/kidney microsome

Question 16

S/S autoimmune hepatitis

Answer 16

★Fatigue-87% of patients
★ Dark urine and light stools-77% of patients
★ Right upper quadrant pain-48% of patients
★ anorexia -30% of patients
★ Hepatomegaly
★ Palpable spleen
★ Scleral icterus

Question 17

Treatment for autoimmune haptatitis

Answer 17

★ Indicated in patients with elevated transaminase levels >10 times ULN
★ 40-60 mg of prednisone daily with taper
★ 65 to 80% in remission within 24 months
★ 13% achieve partial remission
★ 10% fail to respond to therapy
★ Poor prognosis if bilirubin does not decrease within
2 weeks of steroids to <15 mg/dl

Question 18

NONALCOHOLIC FATTY LIVER DISEASE (STEATOSIS)

Answer 18

★ Broad spectrum of disease ranging from simple steatosis to nonalcoholic steatohepatitis (NASH) and steatofibrosis
★ Commonly associated with
○ Metabolic syndrome
○ Type 2 diabetes
○ dyslipidemia

Question 19

Found in up to 67% of patients with metabolic syndrome

Answer 19

NONALCOHOLIC FATTY
LIVER DISEASE (STEATOSIS)

Question 20

T/F steatosis is the most common cause of increased serum transaminase
levels

Answer 20

T

Question 21

Diagnosis of Nonalcoholic fatty liver disease

Answer 21

★ Diagnosis made after exclusion of other causes of liver
disease
★ Ultrasound, CT*, MRI helpful in detection
★ Liver biopsy required for differentiation of NASH

Question 22

Most important risk factor for NAFLD

Answer 22

Insulin resistance
★ Metabolic syndrome
○ Increased waist circumference
○ Hypertriglyceridemia
○ Hypertension
○ Elevated fasting glucose
○ Low HDL

Question 23

Clinical findings with NAFLD

Answer 23

CLINICAL FINDINGS
Modest elevation of ALT and AST-2 to 3 times
upper limit of normal may increase to 10 times
★ AST/ALT ratio of 1 or less

Question 24

Imaging for NAFLD

Answer 24

★ Ultrasound
★ CT not much more specific and more expensive*
★ MRI allows quantification of hepatic fat-more sensitive and more expensive

Question 25

TREATMENT of NAFLD

Answer 25

★ Weight loss
★ Diet and exercise
★ Treat insulin resistance with metformin or
rosiglitazone
★ Treat hypertriglyceridemia
★ Bariatric surgery
★ Liver transplant-rising number of younger
patients receiving transplants