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Clin Med 3 > Hepatitis, Cirrhosis, Hepatocellular Carcinoma > Flashcards

Hepatitis, Cirrhosis, Hepatocellular Carcinoma Flashcards

1
Q

cirrhosis is the end result of what?

A

end result of hepatocellular injury which causes fibrosis and nodular regeneration

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2
Q

what does the end result of hepatocellular injury cause?

A

cirrhosis - fibrosis and nodular regeneration

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3
Q

how does cirrhosis occur?

A

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

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4
Q

is the initial fibrosis in cirrhosis reversible?

A

may be reversible if cause is removed but cirrhosis is NOT reversible

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5
Q

how is cirrhosis staged?

A
  • Compensated
  • Compensated w/varices
  • Decompensated - END STAGE LIVER FAILURE (Ascites, variceal bleeding, encephalopathy, jaundice)
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6
Q

what is the difference b/w compensated cirrhosis and decompensated cirrhosis?

A

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)

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7
Q

what sx’s do decompensated cirrhosis pts exhibit?

A

ascites, variceal bleeding, encephalopathy, jaundice

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8
Q

what is the most common complication of cirrhosis?

A

ASCITES (60% within 10 years)

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9
Q

Major common complications of cirrhosis

A

ASCITES (60% w/in 10 years), Hepatorenal syndrome, Portal HTN, Hepatic encephalopathy, Spontaneous bacterial peritonitis, Coagulopathy, Gastroesophageal varices

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10
Q

what is hepatic encephalopathy?

A

complication of cirrhosis

-ammonia collects in brain b/c liver can’t detoxify it

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11
Q

what is the most common cause of cirrhosis?

A

ETOH is the MOST COMMON

Hep C, Hep B, and Nonalcoholic fatty liver disease are also common

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12
Q

what are cryptogenic causes of cirrhosis?

A

Non-alcoholic fatty liver disease

-have obesity, DM, hypertriglyceridemia which are risk factors and person develops cirrhosis from NAFLD

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13
Q

when do the classic sx’s of cirrhosis occur?

A

only in LATE STAGE (DECOMPENSATED) cirrhosis - when they are in end-stage liver failure

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14
Q

do most people with cirrhosis have sx’s and PE findings?

A

NO!!! DON’T DEVELOP SX’S or PE FINDINGS UNTIL LATE STAGE DISEASE

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15
Q

what are the sx’s of cirrhosis due to?

A

portal HTN, portosystemic shunting, and decreased detoxification

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16
Q

what are sx’s of cirrhosis?

A

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

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17
Q

Cirrhosis PE findings

A

Palpable/firm liver

Ascites

Pleural effusion (decreased breath sounds)

Icteric sclera, jaundice (not initial sign)

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18
Q

cirrhosis labs

A

usually absent

See:

  • Macrocytic (high MCV, w/ETOH) anemia
  • suppression of EPO d/t ETOH
  • THROMBOCYTOPENIA (d/t ETOH)
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19
Q

cirrhosis imaging

A

U/S - determines liver size, ascites, nodular liver

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20
Q

what will liver biopsy for cirrhosis dx indicate? what approach do you take for liver biopsy?

A

may indicate etiology (chronic hep or ETOH, NAS)

do transjugular approach

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21
Q

is it common to do a liver biopsy to dx cirrhosis?

A

NO!

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22
Q

what else besides labs and imaging do you need to work up a cirrhotic pt?

A

EGD to look for gastroesophageal varices

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23
Q

what 2 non-invasive procedures can you dx cirrhosis without liver biopsy?

A

FibroSure test and Transient elastography (fibroscan)

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24
Q

what is the FibroSure test for cirrhosis dx?

A

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

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25
Q

what is the Transient elastography (fibroscan) for cirrhosis dx the best for?

A

BEST WAY TO ASSESS HOW SEVERE DISEASE IS AND ALLOWS YOU TO FOLLOW CIRRHOSIS PTS WITH ADVANCED DISEASE

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26
Q

how does the Transient elastography (fibroscan) for cirrhosis dx work?

A

bedside U/S that measures stiffness of the liver or hepatic fibrosis

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27
Q

what are the limitations of Transient elastography (fibroscan) for cirrhosis dx?

A

ascites, chest wall fat, obesity, severe liver inflammation -> all cause abnormal reading with U/S

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28
Q

what is the MELD SCORE for cirrhosis?

A

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

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29
Q

what is the definition of portal HTN? what begins to develop?

A

increased pressure in portal vein >10-12mmHg

collaterals begin to develop d/t blood being backed up (varices, splenomegaly, see thrombocytopenia)

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30
Q

sequelae of portal HTN

A
  • ascites
  • esophageal and gastric varices
  • hepatic encephalopathy
  • splenomegaly and thrombocytopenia
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31
Q

ppx treatment for portal HTN varices

A

use Nadolol or propranolol

-reduces portal and collateral blood flow

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32
Q

what screening is done in portal HTN?

A

screening EGD for varices and then annually

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33
Q

common causes of portal HTN (pre-hepatic, intra-hepatic, post-hepatic)

A

Pre-hepatic:
-portal vein thrombosis

Intra-hepatic:
-cirrhosis (ETOH or chronic hepatitis)

Post-hepatic: IVC thrombosis, right heart failure

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34
Q

what is ascites? most common cause?

A

pathologic accumulation of excess fluids the peritoneal cavity

most common cause is cirrhosis b/c of portal HTN

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35
Q

what are concerned about if young woman or person w/no hx of liver disease presents with ascites?

A

malignancy

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36
Q

causes of ascites

A

most common is cirrhosis d/t portal HTN

neoplasm

CHF

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37
Q

ascites PE

A

SHIFTING DULLNESS TO PERCUSSION

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38
Q

ascites dx

A

U/S

Paracentesis to rule out SBP (spontaneous bacterial peritonitis)

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39
Q

first line tx of ascites

A

Na+ restriction and Fluid restriction

restrict these b/c RAAS is trying to hold onto fluid d/t low flow

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40
Q

what is second line tx of ascites

A

Spironolactone - blocks aldosterone -> blocks fluid build up

Furosemide - but be careful in renal failure

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41
Q

when is surgical therapy for ascites done?

A

when medical therapies don’t work

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42
Q

what is surgical therapy for ascites?

A

most common is TIPS (transjugular intrahepatic portosystemic shunt) for MASSIVE ASCITES

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43
Q

what is TIPS (transjugular intrahepatic portosystemic shunt)?

A

surgical tx for MASSIVE ASCITES - create shunt b/w hepatic vein and portal vein

pts MELD score must be <18 and total bili < 3

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44
Q

what must pts MELD scores be for TIPS procedure and why?

A

pts MELD score must be <18 and total bili < 3 (b/c can cause hepatic encephalopathy and exacerbate severe underlying liver dysfunction)

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45
Q

last line tx for ascites?

A

liver transplant

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46
Q

what is hepatic encephalopathy a complication of?

A

cirrhosis and end-stage liver disease

LATE COMPLICATION

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47
Q

what are the sx’s of hepatic encephalopathy?

A

confusion & leathery, memory impairment, decreased coordination, possibly coma

-have depressed level of consciousness

PT MAY BE PASSED OUT

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48
Q

hepatic encephalopathy causes

A

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)

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49
Q

hepatic encephalopathy PE

A

asterixis (tremor in hand when wrist extended), twitchiness

INCREASED AMMONIA LEVELS

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50
Q

hepatic encephalopathy etiologies

A

spontaneous bacterial peritonitis = #1 cause

hypovolemia

dehydration and low flow = top risk factors

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51
Q

hepatic encephalopathy tx

A

Lactulose (laxative that makes you poop out ammonia) -> M/C

Antibotics (xifaxan)

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52
Q

what are varices? d/t what?

A

dilated veins that when broken bleed a lot

common in stomach and esophagus (gastroesophageal varices)

d/t portal HTN

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53
Q

are gastroesophageal varices dangerous?

A

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

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54
Q

where do gastroesophageal varices bleed into?

A

stomach and bowel -> will see melena on DRE

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55
Q

what can cause varices to bleed?

A

anything that increases portal HTN (already have high portal pressure)

ETOH

Red marks on varices = red wale sign

56
Q

what sign is red marks on varices?

A

red wale sign

57
Q

gastroesophageal varices signs/sx’s

A

HEMATEMESIS/MELENA

HEMORRHAGIC SHOCK

58
Q

gastroesophageal varicesl tx

A
  • 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!!!)
59
Q

what is the main tx of gastroesophageal varices

A

Endoscopy

NEED TO STOP THE BLEEDING

60
Q

what is the preferred management to prevent rebleeding of varices?

A

Band ligation

  • least complications
  • strangles varix w/band and it falls off
61
Q

what is acute hepatitis? most common infectious etiology?

A

inflammation of the liver

62
Q

most common infectious etiology of acute hepatitis? most common non-infectious etiology?

A

viral is most common infectious etiology
-Hep B and C are most common

Non-infectious = toxic/drugs (nitrofurantoin), alcohol

63
Q

acute hepatitis sx’s

A

LOOKS LIKE THE FLU

***ENLARGED TENDER LIVER

64
Q

what are the AST/ALT values like in acute hepatitis?

A

VERY ELEVATED (>1000U/L)

65
Q

hepatitis A transmission

A

fecal-oral route transmission associated w/crowding and poor sanitation

66
Q

is there a vaccine for hep A?

A

YES!!! - usually get when travel to endemic areas

67
Q

cause of death of hep A? mortality rate high or low?

A

DIARRHEA!!! don’t die from liver failure

but mortality rate is low

68
Q

is two combinations of hepatitis is very deadly?

A

Hep A and Hep C

-if pt has Hep C then MUST get vaccinated for Hep A

69
Q

hep A tx

A

self-limiting

clinical recovery w/in 3 months and no chronic liver disease

70
Q

hep B transmission

A

infected blood products, sexual contact, delivery by HBV+ mother

71
Q

do adults full recover from hep B? what about infants?

A

most adults fully recover

infants have a 50% chance of getting chronic Hep B

72
Q

is there a vaccine for Hep B?

A

YES!!!

-infants, children, employment w/risk of exposure get it

73
Q

how to treat for Hep B exposure

A

Hep B Ig (HBIG) for 1 week, followed by HBV vaccine series

74
Q

hep B and newborns; how do you treat them? what about the mother?

A

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

75
Q

what is the HBsAg lab for hep B? what does it indicate?

A

hep B lab

first evidence of infection and if persistent >6 months after illness indicates chronic infection

76
Q

if HBsAg persistent >6 months after illness, what’s that indicate?

A

chronic Hep B infection

77
Q

what is HBV DNA lab?

A

active viral replication

78
Q

what is anti-HBc lab?

A

core antibody

IgM indicating acute hepatitis infections and IgG indicating chronic or recovered infection

79
Q

what is the anti-HBs lab?

A

Hep B antibodies - show up after vaccination or recovery from HBV infection

80
Q

what are the initial screening tests for hep B?

A

HBsAg and Anti-HBc

81
Q

most common cause of hep C?

A

IV drug use

82
Q

what is a common co-infection of Hep C?

A

HIV - must be tested for HIV

83
Q

do most people with acute Hep C develop chronic Hep C? what about pts with acute Hep B?

A

most pts w/acute Hep C will develop chronic Hep C

most pts w/acute Hep B will NOT develop chronic Hep B

84
Q

acute hep C diagnosis

A

Anti-HCV ELISA (looking for antibody)

HCV RNA PCR is confirmatory (will see high Hep C viral load)

85
Q

acute hep C tx

A

8-12 weeks of Harvoni (ledipasvir/sofosbuvir) - protease inhibitors

86
Q

when do pts with hep C recover?

A

in 3-6 months w/low overall mortality

87
Q

acute hep D only associated with what?

A

ONLY associated with HBV infection

88
Q

how do you get hep D?

A

blood usually percutaneous exposure

89
Q

testing for hep D?

A

use anti-HDV

90
Q

acute hep E transmitted how? common where? how’s it spread? tx?

A

fecal oral transmission (waterborne)

common in endemic countries (Africa, Asia, etc.)

spread by undercooked meats (pig) or pet

Tx: Sofosbuvir

91
Q

autoimmune hepatitis common in who?

A

young to middle aged women

92
Q

autoimmune hepatitis presents when?

A

following viral illness or drug exposure

93
Q

autoimmune hepatitis labs

A

AST/ALT >1000

Positive ANA and/or smooth muscle antibody

IgG elevated

94
Q

what is used to dx autoimmune hepatitis?

A

liver biopsy

95
Q

autoimmune hepatitis tx?

A

IMMUNOSUPPRESSANTS - Corticosteroids +/- Azathioprine

96
Q

what is alcoholic hepatitis?

A

acute or chronic inflammation and necrosis of liver from drinking too much

97
Q

is inflammation in alcoholic hepatitis reversible?

A

YES!!! IF THE PT STOPS DRINKING THE INFLAMMATION WILL GO AWAY UNLESS ALREADY HAVE CIRRHOSIS

98
Q

how much alcohol must be consumed per day for alcoholic hep pts to develop cirrhosis?

A

> 50g ETOH/day

99
Q

who is more susceptible to developing cirrhosis from alcoholic hepatitis?

A

women

100
Q

presentation of alcoholic hepatitis

A

recent period of heavy drinking usually precedes sx’s

101
Q

alcoholic hepatitis labs

A

***THROMBOCYTOPENIA

***AST/ALT ratio of 2:1 and mildly elevated

102
Q

alcoholic hepatitis imaging

A

U/S = ascites

CT/MRI = moderate-severe steatosis (but not inflammation or fibrosis)

103
Q

alcoholic hepatitis medical tx

A

EMERGENT TX

Methylprednisolone with MELD >18

Pentoxiphylline if steroids contraindicated

104
Q

alcoholic hepatitis general tx

A

STOP DRINKING!!!

Correct nutritional deficiencies with multivitamin

Assist with abstinence (naltrexone, baclofen - help minimize urges; acamprosate = antibuse)

105
Q

when can an alcoholic hepatitis pt get a liver transplant?

A

only when abstinent from alcohol for 6 months

106
Q

most common cause of drug/toxin induced hepatitis?

A

antibiotics (Macrobid and minocycline)

107
Q

what must you consider when a pt has drug/toxin induced hepatitis?

A

coadministration of agents which can potentiate toxicity of an agent

-isoniazid, rifampin, Tylenol, alcohol

108
Q

what is the most common cause of direct hepatotoxicity in drug/toxin induced hepatitis?

A

Acetaminophen and alcohol

CAUSE DIRECT HEPATOTOXICITY AND ANYONE IS SUSCEPTIBLE

109
Q

what is the dominant cause of cirrhosis and HCC?

A

chronic Hep B (global health problem!!!)

110
Q

what is a predictor of cirrhosis and HCC?

A

high HBV DNA (high viral load)

111
Q

chronic hep B associated with what?

A

extra hepatic manifestations

  • glomerulonephritis (mostly children)
  • polyarteritis nodosa
112
Q

what lab values are for acute hep B?

A

+HBsAg and anti-HBc IgM and IgG

113
Q

what lab values are for chronic hep B?

A

HBsAg and anti-HBc IgG

114
Q

chronic HBV risk factors for progression to cirrhosis, liver failure, HCC

A

persistently elevated HB DNA or ALT

AFP elevated (cancer marker for HCC)

115
Q

chronic hep B tx

A

ETV (Entecavir), Tenofovir

  • lifelong therapy
  • prevents viral replication
116
Q

when do you treat for chronic hep B?

A

when ALT high for >3-6 months and HBV DNA is high

117
Q

what characterizes chronic Hep C?

A

Anti-HCV is high and >6 months of persisting HVC RNA

118
Q

factors associated with increased risk of developing cirrhosis from chronic hep C

A
  • chronic alcohol ingestion
  • male
  • HCV >40 y/o
  • co-infection w/HIV and/HBV
119
Q

HCC risk and chronic hep C

A

increased risk of HCC from cirrhosis (must have cirrhosis first w/Hep C before get HCC)

120
Q

prevention of chronic hep C?

A

needle exchange for IVDA

121
Q

what are the 2 goals of chronic HCV tx?

A

make viral load 0 at 6 months and prevent progression to further liver disease

122
Q

tx for chronic hep C is recommended for who?

A

EVERYONE

123
Q

chronic hep C tx

A

Harvoni for 12 weeks

12 weeks w/o cirrhosis and 24 weeks w/cirrhosis

124
Q

what is hepatocellular carcinoma (HCC)?

A

primary malignancy of liver

125
Q

risk factors for HCC?

A

Hep B, Hep C, NASH, and NAFLD

126
Q

HCC screening

A

screening cirrhotic pts in US improved identification of HCC

-imaging every 6 months and AFP test (HCC biomarker)

127
Q

HCC clinical presentation

A

insidious until cirrhotic pt deteriorates - REASON TO SCREEN OFTEN

128
Q

HCC labs

A

Alpha fetoprotein (AFP) - not sensitive but specific to HCC

129
Q

what is key to diagnosing HCC?

A

IMAGING

U/S (sreen for hepatic nodules in high risk pts) and CT

MRI (best for small lesions)

130
Q

HCC and liver bx

A

diagnostic but chance of seeding w/needle

done with 1-2cm lesions

131
Q

who should not get liver bx for HCC?

A

2cm lesions, cirrhosis, classic findings on MRI (arterial hypervascularity and delayed washout), elevated AFP values

132
Q

if pt has HCC small lesions, do you bx liver?

A

No!! if <1cm lesions then do CT/MRI every 3 months to assess for enlarging lesions

133
Q

what is the only long term cure for HCC?

A

SURGERY!!! (resection = tumor <5cm and no/minimal cirrhosis)

134
Q

HCC and liver transplant

A

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

135
Q

HCC medical/palliative tx

A

Sorafenib (VEGF blocker) - slows progression with advanced HCC

Can do TACE or TARE procedures (bridge to liver transplant)

chemo is ineffective!!!

Clin Med 3 (21 decks)

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