Hepatitis and fatty liver disease Flashcards
ALCOHOLIC LIVER DISEASE
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
Is alcoholic hepatitis episodic or constant?
Can be a single or recurrent episodes over the course of alcoholic liver diseas
A standard drink of ETOH is defined as
any drink that contains 14 grams of pure ETOH
SIGNS AND SYMPTOMS Alcoholic hepatitis
★ Jaundice
★ Fever
★ Nausea
★ Anorexia
★ Generalized edema
★ Tender right upper quadrant with hepatomegaly
Severe S/S alcoholic hepatitis
★ Coagulopathies
★ Ascites
★ Variceal bleeding
★ Hepatic encephalopathy
★ May lead to
○ Renal injury
○ Multiorgan failure
○ 30 day mortality rate of 60%
Diagnostic studies alcoholic hepatitis
★ 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)
Treatment of alcoholic hepatitis
★ 40 mg prednisone daily for 28 days improves
short term recovery
★ Pentoxifylline 400 mg tid used when prednisone
is contraindicated.
_____ Accounts for >40% of liver failure cases in United states
Acetaminophen
Drugs that can cause toxic hepatitis
★ 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
S/S toxic hepatitis
★ Nausea
★ Vomiting
★ Diarrhea
★ Abdominal pain
★ Shock
★ 4-12 hours after ingestion
★ High transaminase levels with low bilirubin
Treatment of toxic hepatitis
★ 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
How do you treat toxic hepatitis caused by acetominophen
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
Fatal dosage of acetaminophen
○ 10-15 grams in a single dose
○ >25 grams single dose is usually fatal
Autoimmune hepatitis
★ 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
AUTOIMMUNE HEPATITIS types
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
S/S autoimmune hepatitis
★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
Treatment for autoimmune haptatitis
★ 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
NONALCOHOLIC FATTY LIVER DISEASE (STEATOSIS)
★ Broad spectrum of disease ranging from simple steatosis to nonalcoholic steatohepatitis (NASH) and steatofibrosis
★ Commonly associated with
○ Metabolic syndrome
○ Type 2 diabetes
○ dyslipidemia
Found in up to 67% of patients with metabolic syndrome
NONALCOHOLIC FATTY
LIVER DISEASE (STEATOSIS)
T/F steatosis is the most common cause of increased serum transaminase
levels
T
Diagnosis of Nonalcoholic fatty liver disease
★ Diagnosis made after exclusion of other causes of liver
disease
★ Ultrasound, CT*, MRI helpful in detection
★ Liver biopsy required for differentiation of NASH
Most important risk factor for NAFLD
Insulin resistance
★ Metabolic syndrome
○ Increased waist circumference
○ Hypertriglyceridemia
○ Hypertension
○ Elevated fasting glucose
○ Low HDL
Clinical findings with NAFLD
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
Imaging for NAFLD
★ Ultrasound
★ CT not much more specific and more expensive*
★ MRI allows quantification of hepatic fat-more sensitive and more expensive
TREATMENT of NAFLD
★ 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
