Hepatology

Question 1

What is the function of the liver

Answer 1

Bile production, drug/food/toxin metabolism, protein synthesis, storage and adjustments of vitamins

Question 2

Markers of chronic liver disease

Answer 2

Decreased albumin
Increased INR
increased bilirubin (can be sign of acute or chronic liver disease)

Question 3

Acetaminophen DILI - s/sx, how to assess severity, goals, and treatment, and monitoring

Answer 3

happens when one ingests greater than or equal to 8g of acetaminophen

s/sx: abdominal pain, jaundice, N/V/D

assessment: AST, ALT, and acetaminophen concentration

Goal is to reverse toxic metabolite with NAC +/- activated charcoal (only use charcoal if ingestion was less than or equal to 1 hour ago) (NAC given if ingestion was greater than or equal to 4 hours)

Monitor liver enzyme and s/sx

Question 4

Cirrhosis Causative factors

Answer 4

Chronic alcohol use, viral hepatitis, metabolic liver disease, cholestatic liver disease, drugs

Question 5

S/Sxs of Cirrhosis

Answer 5

Fatigue, jaundice, weight loss, ascites, Hepatomegaly or splenomegaly, Encephalopathy (confusion)

Question 6

Ascites - what is it and what are signs and symptoms

Answer 6

Fluid accumulation in the peritoneal space

s/sx: Abdominal distension, abdominal pain, SOB, nausea

Question 7

Treatment of ascites and monitoring

Answer 7

First line: spironolactone and furosemide Max dosing is spiron 400mg/ 160mg furo

Monitoring: s/sx of ascites, SCr, and K

Question 8

Paracentesis

Answer 8

Second line treatment for ascites for those with refractory/resistant or AKI (Diuretics would worsen AKI)
If >5L removed through paracentesis give patient 25% albumin IV and give 6-8g albumin per liter removed

Question 9

Paracentesis albumin calculation example
DI is a 52 year old male with cirrhosis, who presented to the hospital with tense ascites and is in acute kidney injury (baseline SCr ~1, admission SCr 2.2). Due to the AKI, paracentesis is perfumed and 8L are removed. How much albumin should be given to DI?
A. Albumin 5% 500 mL IV once
B. Albumin 5% 1 L IV once
C. Albumin 25% 200 mL IV once
D. Albumin 25% 300 mL IV once

Answer 9

CORRECT answer is C

A and B are not correct because its 25% albumin IV
8L x (6-8g) = 48- 64g
25% - 25/100ml x 200ml = 50g - within our range for this patient

25% - 25/100 x 300ml = 75g - too much so D is not correct

Question 10

Esophageal Varices (EV)

Answer 10

Portal hypertension causes vasodilation resulting in decreased perfusion which causes compensatory varices and dilation of EV can occur and result in variceal bleeding

Question 11

Variceal bleeding prophylaxis

Answer 11

NSBBs recommended for treatment
Nadolol, propranolol, carvedilol

SE: Drowsiness, bradycardia, hypotension
Monitoring: HR: 55-60bpm, SBP >90, s/sx of VH

EVL - endoscopic procedure which bands off varices - not to be done in combination with NSBB therapy

Question 12

Variceal bleeding Acute management - clinical presentation

Answer 12

Hematemesis, Melena, Fatigue, lightheaded/dizziness, hypotension

Question 13

Variceal bleeding Acute management - Acute treatment

Answer 13

ACUTELY MANAGE:
-Blood transfusions
-Octreotide - used for 2-5 days or 24 hours after successful EVL
SE: N/V, hypertension, bradycardia, hyperglycemia
-Antibiotic prophylaxis - Primary prophylaxis - Ceftriaxone used for max of 7 days or until hemorrhage resolves - SE: diarrhea, Monitoring: s/sx of infection
Surgery:
EVL - GOLD Standard for variceal bleeding cessation

Question 14

Secondary Prophylaxis for varices

Answer 14

EVL: every 1-4 weeks
NSBBS : continued indefinitely
Nadolol or Propranolol

Question 15

Spontaneous Bacterial Peritonitis (SBP) - s/sx

Answer 15

fever, abdominal pain, leukocytosis, encephalopathy, asymptomatic (15%)

Question 16

SBP diagnosis

Answer 16

Positive ascitic fluid bacterial culture (> or equal to 250 cells/mm^3

Question 17

SBP acute treatment

Answer 17

Ceftriaxone for 5-7 days

Day 1: Albumin 1.5g/kg (within 6 hours of SBP)
Day 3: 1g/kg

Question 18

SBP secondary prophylaxis

Answer 18

Bactrim (800/160mg) PO daily - indefinite therapy
SE: AKI, photosensitivity, hyperkalemia, hyponatremia, Stevens-johnson syndrome

Monitor: SCr, electrolytes, CBC

Question 19

Hepatic Encephalopathy (HE)

Answer 19

When to treat - When patient has confusion, delirium, jaundice, and increased ammonia

1st line therapy: Lactulose (target 2-4 BMs a day)

Secondary Prophylaxis: Lactulose (would be given to patient to take home indefinite therapy) Monitor BM and mental status

Question 20

Which vasoconstrictor is used in patients to manage esophageal variceal bleeding?
Ocreotide
Propranolol
Ceftriaxone
Midodrine

Answer 20

Ocreotide

Question 21

What should be monitored with lactulose in treating and preventing hepatic encephalopathy?
Ammonia daily
2-5 bowel movements/day
HR Q8H (55-60 bpm)
Frequency of paracentesis

Answer 21

2-5 bowel movements/day

Question 22

For a patient with confirmed SBP, what is theBEST ACUTETREATMENTrecommendation?
Ceftriaxone x 5 days
Cefotaxime x 10 days
Bactrim SS PO daily
Zosyn x 10 days

Answer 22

Ceftriaxone x 5 days

Question 23

Which medication(s) have evidence as being common causative agents for drug-induced liver injury? Select any which apply.
Acetaminophen
Amoxicillin/clavulanate
Gentamicin
Pantoprazole

Answer 23

Acetaminophen
Amoxicillin/clavulanate

Question 24

Which objective markers would you expect to be altered in a patient with cirrhosis?
Increased AST, increased ALT
Decreased albumin, increased INR
Decreased AST, decreased ALT
Increased albumin, decreased INR

Answer 24

Decreased albumin, increased INR

Question 25

What is the preferred initial dosing of oral diuretics to manage ascites in a patient with cirrhosis?
Spironolactone 100 mg : furosemide 40 mg
Spironolactone 25 mg : furosemide 20 mg
Furosemide 100 mg : spironolactone 40 mg
Furosemide 25 mg : spironolactone 20 mg

Answer 25

Spironolactone 100 mg : furosemide 40 mg

Question 26

DT is a 42-year-old man with a 20-year history of alcohol abuse who presents with altered mental status, anorexia, mild weight loss over the past 3 months, recent abdominal swelling, and general malaise. Upon examination he was found to have palmar erythema and splenomegaly and his labs were significant for mildly elevated aspartate aminotransferase (AST), alanine aminotransferase (ALT), bilirubin, and blood glucose. He is diagnosed with hepatic cirrhosis and the following medications are initiation: nadolol 20 mg daily, spironolactone 100 mg daily, furosemide 40 mg daily, and lactulose 45 mL three times daily. Which of DT’s new medications is being utilized to manage his altered mental status?

A-Furosemide
B-Lactulose
C-Nadolol
D-Spironolactone

Answer 26

B

Question 27

Your patient has a past medical history significant for asthma, type 1 diabetes mellitus, hypertension, atrial fibrillation, and long-standing alcohol abuse. He has also just been diagnosed with cirrhosis and undergoes an endoscopy. Several large esophageal varices are noted and his hepatologist decides that he should be started on propranolol 20 mg po bid. Which of your patient’s past diagnoses constitute a contraindication against the use of propranolol?

A-Alcohol abuse
B-Asthma
C-Atrial fibrillation
D-Type 1 diabetes mellitus

Answer 27

B