Hepatitis, Cirrhosis, Hepatocellular Carcinoma Flashcards
cirrhosis is the end result of what?
end result of hepatocellular injury which causes fibrosis and nodular regeneration
what does the end result of hepatocellular injury cause?
cirrhosis - fibrosis and nodular regeneration
how does cirrhosis occur?
take normal liver and overtime with injury to the liver, inflammation to the liver, cell death to the liver you get fibrotic scarring to the liver as it tries to heal itself - also get abnormal nodules that form
-gives appearance and stiffness of cirrhosis
is the initial fibrosis in cirrhosis reversible?
may be reversible if cause is removed but cirrhosis is NOT reversible
how is cirrhosis staged?
- Compensated
- Compensated w/varices
- Decompensated - END STAGE LIVER FAILURE (Ascites, variceal bleeding, encephalopathy, jaundice)
what is the difference b/w compensated cirrhosis and decompensated cirrhosis?
compensated cirrhosis pts don’t have sx’s related to their cirrhosis
decompensated cirrhosis pts have sx’s related to cirrhosis (ascites, variceal bleeding, encephalopathy, jaundice)
what sx’s do decompensated cirrhosis pts exhibit?
ascites, variceal bleeding, encephalopathy, jaundice
what is the most common complication of cirrhosis?
ASCITES (60% within 10 years)
Major common complications of cirrhosis
ASCITES (60% w/in 10 years), Hepatorenal syndrome, Portal HTN, Hepatic encephalopathy, Spontaneous bacterial peritonitis, Coagulopathy, Gastroesophageal varices
what is hepatic encephalopathy?
complication of cirrhosis
-ammonia collects in brain b/c liver can’t detoxify it
what is the most common cause of cirrhosis?
ETOH is the MOST COMMON
Hep C, Hep B, and Nonalcoholic fatty liver disease are also common
what are cryptogenic causes of cirrhosis?
Non-alcoholic fatty liver disease
-have obesity, DM, hypertriglyceridemia which are risk factors and person develops cirrhosis from NAFLD
when do the classic sx’s of cirrhosis occur?
only in LATE STAGE (DECOMPENSATED) cirrhosis - when they are in end-stage liver failure
do most people with cirrhosis have sx’s and PE findings?
NO!!! DON’T DEVELOP SX’S or PE FINDINGS UNTIL LATE STAGE DISEASE
what are the sx’s of cirrhosis due to?
portal HTN, portosystemic shunting, and decreased detoxification
what are sx’s of cirrhosis?
spider telangiectasis or caput medusa (dilated abd and thoracic veins)
dupuytren contracture of 4th digit
abd pain d/t liver enlargement, ASCITES
Melena, hematemesis - if variceal bleed
CONFUSION/ALTERED MENTAL STATUS = ENCEPHALOPATHY
Cirrhosis PE findings
Palpable/firm liver
Ascites
Pleural effusion (decreased breath sounds)
Icteric sclera, jaundice (not initial sign)
cirrhosis labs
usually absent
See:
- Macrocytic (high MCV, w/ETOH) anemia
- suppression of EPO d/t ETOH
- THROMBOCYTOPENIA (d/t ETOH)
cirrhosis imaging
U/S - determines liver size, ascites, nodular liver
what will liver biopsy for cirrhosis dx indicate? what approach do you take for liver biopsy?
may indicate etiology (chronic hep or ETOH, NAS)
do transjugular approach
is it common to do a liver biopsy to dx cirrhosis?
NO!
what else besides labs and imaging do you need to work up a cirrhotic pt?
EGD to look for gastroesophageal varices
what 2 non-invasive procedures can you dx cirrhosis without liver biopsy?
FibroSure test and Transient elastography (fibroscan)
what is the FibroSure test for cirrhosis dx?
biomarker test that uses results of 6 serum tests to generate score which is equivalent to predictive value of liver bx
pts with liver disease and low FibroSure score = excludes advanced cirrhosis or high FibroSure = cirrhosis thus preventing need for liver bx
NOT GOOD FOR PTS IN THE MIDDLE
what is the Transient elastography (fibroscan) for cirrhosis dx the best for?
BEST WAY TO ASSESS HOW SEVERE DISEASE IS AND ALLOWS YOU TO FOLLOW CIRRHOSIS PTS WITH ADVANCED DISEASE
how does the Transient elastography (fibroscan) for cirrhosis dx work?
bedside U/S that measures stiffness of the liver or hepatic fibrosis
what are the limitations of Transient elastography (fibroscan) for cirrhosis dx?
ascites, chest wall fat, obesity, severe liver inflammation -> all cause abnormal reading with U/S
what is the MELD SCORE for cirrhosis?
Prognostic scoring system for cirrhosis that is also a measure of mortality risk in pts with end stage liver disease
tells you if pt needs to be put on transplant list or not
what is the definition of portal HTN? what begins to develop?
increased pressure in portal vein >10-12mmHg
collaterals begin to develop d/t blood being backed up (varices, splenomegaly, see thrombocytopenia)
sequelae of portal HTN
- ascites
- esophageal and gastric varices
- hepatic encephalopathy
- splenomegaly and thrombocytopenia
ppx treatment for portal HTN varices
use Nadolol or propranolol
-reduces portal and collateral blood flow
what screening is done in portal HTN?
screening EGD for varices and then annually
common causes of portal HTN (pre-hepatic, intra-hepatic, post-hepatic)
Pre-hepatic:
-portal vein thrombosis
Intra-hepatic:
-cirrhosis (ETOH or chronic hepatitis)
Post-hepatic: IVC thrombosis, right heart failure
what is ascites? most common cause?
pathologic accumulation of excess fluids the peritoneal cavity
most common cause is cirrhosis b/c of portal HTN
what are concerned about if young woman or person w/no hx of liver disease presents with ascites?
malignancy
causes of ascites
most common is cirrhosis d/t portal HTN
neoplasm
CHF
ascites PE
SHIFTING DULLNESS TO PERCUSSION
ascites dx
U/S
Paracentesis to rule out SBP (spontaneous bacterial peritonitis)
first line tx of ascites
Na+ restriction and Fluid restriction
restrict these b/c RAAS is trying to hold onto fluid d/t low flow
what is second line tx of ascites
Spironolactone - blocks aldosterone -> blocks fluid build up
Furosemide - but be careful in renal failure
when is surgical therapy for ascites done?
when medical therapies don’t work
what is surgical therapy for ascites?
most common is TIPS (transjugular intrahepatic portosystemic shunt) for MASSIVE ASCITES
what is TIPS (transjugular intrahepatic portosystemic shunt)?
surgical tx for MASSIVE ASCITES - create shunt b/w hepatic vein and portal vein
pts MELD score must be <18 and total bili < 3
what must pts MELD scores be for TIPS procedure and why?
pts MELD score must be <18 and total bili < 3 (b/c can cause hepatic encephalopathy and exacerbate severe underlying liver dysfunction)
last line tx for ascites?
liver transplant
what is hepatic encephalopathy a complication of?
cirrhosis and end-stage liver disease
LATE COMPLICATION
what are the sx’s of hepatic encephalopathy?
confusion & leathery, memory impairment, decreased coordination, possibly coma
-have depressed level of consciousness
PT MAY BE PASSED OUT
hepatic encephalopathy causes
Ammonia builds up in brain b/c liver can’t detoxify it b/c liver not working d/t cirrhosis
GABA builds up in brain (GABA is NT inhibitor)
hepatic encephalopathy PE
asterixis (tremor in hand when wrist extended), twitchiness
INCREASED AMMONIA LEVELS
hepatic encephalopathy etiologies
spontaneous bacterial peritonitis = #1 cause
hypovolemia
dehydration and low flow = top risk factors
hepatic encephalopathy tx
Lactulose (laxative that makes you poop out ammonia) -> M/C
Antibotics (xifaxan)
what are varices? d/t what?
dilated veins that when broken bleed a lot
common in stomach and esophagus (gastroesophageal varices)
d/t portal HTN
are gastroesophageal varices dangerous?
YES!!! when bleed, bleed a lot and don’t know how much pt is bleeding until BP drops and go into shock
HIGH MORTALITY RISK
where do gastroesophageal varices bleed into?
stomach and bowel -> will see melena on DRE
what can cause varices to bleed?
anything that increases portal HTN (already have high portal pressure)
ETOH
Red marks on varices = red wale sign
what sign is red marks on varices?
red wale sign
gastroesophageal varices signs/sx’s
HEMATEMESIS/MELENA
HEMORRHAGIC SHOCK
gastroesophageal varicesl tx
- 2 large bore IV access/Cental access for blood transfuion
- pRBC transfusion w/vitamin K and FFP
- Octreotide (constricts vessels)
- ***ENDOSCOPY!!!
- TIPS
- Balloon tube tamponade (TEMPORARY!!!)
what is the main tx of gastroesophageal varices
Endoscopy
NEED TO STOP THE BLEEDING
what is the preferred management to prevent rebleeding of varices?
Band ligation
- least complications
- strangles varix w/band and it falls off
what is acute hepatitis? most common infectious etiology?
inflammation of the liver
most common infectious etiology of acute hepatitis? most common non-infectious etiology?
viral is most common infectious etiology
-Hep B and C are most common
Non-infectious = toxic/drugs (nitrofurantoin), alcohol
acute hepatitis sx’s
LOOKS LIKE THE FLU
***ENLARGED TENDER LIVER
what are the AST/ALT values like in acute hepatitis?
VERY ELEVATED (>1000U/L)
hepatitis A transmission
fecal-oral route transmission associated w/crowding and poor sanitation
is there a vaccine for hep A?
YES!!! - usually get when travel to endemic areas
cause of death of hep A? mortality rate high or low?
DIARRHEA!!! don’t die from liver failure
but mortality rate is low
is two combinations of hepatitis is very deadly?
Hep A and Hep C
-if pt has Hep C then MUST get vaccinated for Hep A
hep A tx
self-limiting
clinical recovery w/in 3 months and no chronic liver disease
hep B transmission
infected blood products, sexual contact, delivery by HBV+ mother
do adults full recover from hep B? what about infants?
most adults fully recover
infants have a 50% chance of getting chronic Hep B
is there a vaccine for Hep B?
YES!!!
-infants, children, employment w/risk of exposure get it
how to treat for Hep B exposure
Hep B Ig (HBIG) for 1 week, followed by HBV vaccine series
hep B and newborns; how do you treat them? what about the mother?
newborns are at risk for hep B infection if mom is hep B+ and does vaginal delivery
newborns given HBIG for 1 week and then HBV vaccine
moms get antiviral therapy in 3rd trimester if viral load high
what is the HBsAg lab for hep B? what does it indicate?
hep B lab
first evidence of infection and if persistent >6 months after illness indicates chronic infection
if HBsAg persistent >6 months after illness, what’s that indicate?
chronic Hep B infection
what is HBV DNA lab?
active viral replication
what is anti-HBc lab?
core antibody
IgM indicating acute hepatitis infections and IgG indicating chronic or recovered infection
what is the anti-HBs lab?
Hep B antibodies - show up after vaccination or recovery from HBV infection
what are the initial screening tests for hep B?
HBsAg and Anti-HBc
most common cause of hep C?
IV drug use
what is a common co-infection of Hep C?
HIV - must be tested for HIV
do most people with acute Hep C develop chronic Hep C? what about pts with acute Hep B?
most pts w/acute Hep C will develop chronic Hep C
most pts w/acute Hep B will NOT develop chronic Hep B
acute hep C diagnosis
Anti-HCV ELISA (looking for antibody)
HCV RNA PCR is confirmatory (will see high Hep C viral load)
acute hep C tx
8-12 weeks of Harvoni (ledipasvir/sofosbuvir) - protease inhibitors
when do pts with hep C recover?
in 3-6 months w/low overall mortality
acute hep D only associated with what?
ONLY associated with HBV infection
how do you get hep D?
blood usually percutaneous exposure
testing for hep D?
use anti-HDV
acute hep E transmitted how? common where? how’s it spread? tx?
fecal oral transmission (waterborne)
common in endemic countries (Africa, Asia, etc.)
spread by undercooked meats (pig) or pet
Tx: Sofosbuvir
autoimmune hepatitis common in who?
young to middle aged women
autoimmune hepatitis presents when?
following viral illness or drug exposure
autoimmune hepatitis labs
AST/ALT >1000
Positive ANA and/or smooth muscle antibody
IgG elevated
what is used to dx autoimmune hepatitis?
liver biopsy
autoimmune hepatitis tx?
IMMUNOSUPPRESSANTS - Corticosteroids +/- Azathioprine
what is alcoholic hepatitis?
acute or chronic inflammation and necrosis of liver from drinking too much
is inflammation in alcoholic hepatitis reversible?
YES!!! IF THE PT STOPS DRINKING THE INFLAMMATION WILL GO AWAY UNLESS ALREADY HAVE CIRRHOSIS
how much alcohol must be consumed per day for alcoholic hep pts to develop cirrhosis?
> 50g ETOH/day
who is more susceptible to developing cirrhosis from alcoholic hepatitis?
women
presentation of alcoholic hepatitis
recent period of heavy drinking usually precedes sx’s
alcoholic hepatitis labs
***THROMBOCYTOPENIA
***AST/ALT ratio of 2:1 and mildly elevated
alcoholic hepatitis imaging
U/S = ascites
CT/MRI = moderate-severe steatosis (but not inflammation or fibrosis)
alcoholic hepatitis medical tx
EMERGENT TX
Methylprednisolone with MELD >18
Pentoxiphylline if steroids contraindicated
alcoholic hepatitis general tx
STOP DRINKING!!!
Correct nutritional deficiencies with multivitamin
Assist with abstinence (naltrexone, baclofen - help minimize urges; acamprosate = antibuse)
when can an alcoholic hepatitis pt get a liver transplant?
only when abstinent from alcohol for 6 months
most common cause of drug/toxin induced hepatitis?
antibiotics (Macrobid and minocycline)
what must you consider when a pt has drug/toxin induced hepatitis?
coadministration of agents which can potentiate toxicity of an agent
-isoniazid, rifampin, Tylenol, alcohol
what is the most common cause of direct hepatotoxicity in drug/toxin induced hepatitis?
Acetaminophen and alcohol
CAUSE DIRECT HEPATOTOXICITY AND ANYONE IS SUSCEPTIBLE
what is the dominant cause of cirrhosis and HCC?
chronic Hep B (global health problem!!!)
what is a predictor of cirrhosis and HCC?
high HBV DNA (high viral load)
chronic hep B associated with what?
extra hepatic manifestations
- glomerulonephritis (mostly children)
- polyarteritis nodosa
what lab values are for acute hep B?
+HBsAg and anti-HBc IgM and IgG
what lab values are for chronic hep B?
HBsAg and anti-HBc IgG
chronic HBV risk factors for progression to cirrhosis, liver failure, HCC
persistently elevated HB DNA or ALT
AFP elevated (cancer marker for HCC)
chronic hep B tx
ETV (Entecavir), Tenofovir
- lifelong therapy
- prevents viral replication
when do you treat for chronic hep B?
when ALT high for >3-6 months and HBV DNA is high
what characterizes chronic Hep C?
Anti-HCV is high and >6 months of persisting HVC RNA
factors associated with increased risk of developing cirrhosis from chronic hep C
- chronic alcohol ingestion
- male
- HCV >40 y/o
- co-infection w/HIV and/HBV
HCC risk and chronic hep C
increased risk of HCC from cirrhosis (must have cirrhosis first w/Hep C before get HCC)
prevention of chronic hep C?
needle exchange for IVDA
what are the 2 goals of chronic HCV tx?
make viral load 0 at 6 months and prevent progression to further liver disease
tx for chronic hep C is recommended for who?
EVERYONE
chronic hep C tx
Harvoni for 12 weeks
12 weeks w/o cirrhosis and 24 weeks w/cirrhosis
what is hepatocellular carcinoma (HCC)?
primary malignancy of liver
risk factors for HCC?
Hep B, Hep C, NASH, and NAFLD
HCC screening
screening cirrhotic pts in US improved identification of HCC
-imaging every 6 months and AFP test (HCC biomarker)
HCC clinical presentation
insidious until cirrhotic pt deteriorates - REASON TO SCREEN OFTEN
HCC labs
Alpha fetoprotein (AFP) - not sensitive but specific to HCC
what is key to diagnosing HCC?
IMAGING
U/S (sreen for hepatic nodules in high risk pts) and CT
MRI (best for small lesions)
HCC and liver bx
diagnostic but chance of seeding w/needle
done with 1-2cm lesions
who should not get liver bx for HCC?
2cm lesions, cirrhosis, classic findings on MRI (arterial hypervascularity and delayed washout), elevated AFP values
if pt has HCC small lesions, do you bx liver?
No!! if <1cm lesions then do CT/MRI every 3 months to assess for enlarging lesions
what is the only long term cure for HCC?
SURGERY!!! (resection = tumor <5cm and no/minimal cirrhosis)
HCC and liver transplant
High MELD score (increase MELD score if 3 or less < 3 cm tumors or 1 < 5 cm tumor)
removes cirrhotic liver and no chance of recurrence @ resection margin
HCC medical/palliative tx
Sorafenib (VEGF blocker) - slows progression with advanced HCC
Can do TACE or TARE procedures (bridge to liver transplant)
chemo is ineffective!!!
