Hepatology Flashcards
Functionality of the Liver
- ___ production
- Drug/food/toxin metabolism
- ___ synthesis (including albumin and coagulation factors)
- Storage/adjustment of vitamins/gluconeogenesis
Pathophysiology
- Increased pressures with ___ HTN drives fluid into ___ space
- Compensatory mechanisms from portal HTN results in increased
fluid ___
- Hypo ___
- bile
- protein
- portal, peritoneal
- rentention
- hypoalbuminemia
Objective Markers
___ transaminase (AST)
- 0-50 IU/L
- ↑ with acute liver injury
___ transaminase (ALT)
- 0-50 IU/L
- ↑ with acute liver injury
Alkaline phosphatase (Alk phos)
- 30-120 IU/L
- ↑ with ___ injury from acute
liver injury (i.e. gallstone)
- aspartate
- alanine
- biliary tract
Objective Assessment Summary
Term ___ (used for liver enzymes) are NOT true markers of liver ___
- Liver enzymes (AST, ALT, Alk phos) usually markers of acute liver injury
Elevated ___ can be a sign of acute and/or chronic liver issues
Chronic liver disease can decrease liver production of proteins resulting in
- ↓ ___ , ↑ ___ , and/or ↑ ___
- LFTs, function
- bilirubin
- albumin, INR, bilirubin
Acetaminophen Drug-induced Liver Injury (DILI)
Acute ingestion of high doses (> __ g acetaminophen) can result in
___ , which causes direct hepatotoxicity
- Signs/symptoms: abdominal pain, jaundice, nausea/vomiting/diarrhea
- if not managed, can induce irreversible liver damage
assess severity through ___ , ___ , and ___ concentration
- Goal is to reverse toxic metabolite through use of ___ +/- activated ___
- 8, NAPQI
- AST, ALT, acetaminophen
- N-acetylcysteine (NAC), charcoal
N-acetylcysteine (NAC)
Mechanism of action: binds to ___ , decreasing
hepatotoxic effects
NAPQI
N-acetylcysteine (NAC)
Indication: based on concentration of acetaminophen (> __ hours after ingestion) and timing since
ingestion
- NAC use determined by ___
- 4
- Rumack-Matthew Nomogram
NAC Dosing
Oral:
- ___ mg/kg loading dose followed by ___ mg/kg Q4H x 72H
IV:
- 1st Dose: 150 mg/kg (max ___ g) infused over 1 hour
- 2nd Dose: 50 mg/kg (max ___ g) infused over 4 hours
- 3rd Dose: 100 mg/kg (maximum ___ g) infused over 10 hours
Monitor: liver enzymes (~Q12-24H) and signs/symptoms
- 140, 70
- 15, 5, 10
Acetaminophen DILI Summary
- Assess timing of ___
- Using acetaminophen concentration from lab and timing of ingestion, determine need for ___ using Rumack-Matthew nomogram
- Monitor liver enzymes and signs/symptoms of acute liver injury
- If intentional overdose, ___ evaluation appropriate
- ingestion
- NAC
- psychiatry
Cirrhosis Overview
Cirrhosis: severe, chronic, ___ fibrosis of the liver
- Associated with increased morbidity and mortality
- Annual mortality risk is 10% or more (based on severity)
Complications are related and increase with severity
irreversible
Signs and Symptoms of Cirrhosis
- Fatigue
- Weight loss
- Ascites
- Jaundice
- Hepatomegaly or splenomegaly
- Encephalopathy
Cirrhosis Complications
- Ascites
- Esophageal varices (EV)
- Hepatic encephalopathy (HE)
- Spontaneous bacterial peritonitis (SBP)
- Thrombocytopenia
- Hyponatremia
- Hepatorenal syndrome (HRS)
Assessing Severity of Cirrhosis
Child-Pugh class
Assessing Severity of Cirrhosis
Model for End-stage Liver Disease (MELD)
MELD = 9.57 × ln (creatinine) + 3.78 × ln (total bilirubin) + 11.2 × ln (INR) + 6.43
- Predicts __ month-mortality risk and used in ___ prioritization
3, transplant
Cirrhosis Summary
- Disease with high morbidity and mortality
- Multiple complications which are interconnected, but focus on the signs/symptoms of the patient
- Ideally, trying to prevent cirrhosis through ___ cessation, treatment of viral ___ , monitoring/cessation of hepatotoxic medications, etc.
- alcohol
- hepatitis
Ascites
Fluid accumulation in the ___ space
Signs/symptoms
- Abdominal distension
- Abdominal pain
- Shortness of breath
- Nausea
Patho
- Increased pressures with ___ HTN drives fluid into ___ space
- Compensatory mechanisms from portal HTN results in increased
fluid ___
- Hypo ___
- peritoneal
- portal, peritoneal
- retention
- hypoalbuminemia
Goals of Care
- Minimize ascitic fluid accumulation and symptoms
- improving QOL
- Reduce need for ___
- Limit side effects from therapies
- Prevent subsequent complications from uncontrolled ascites ( ___ , hepatorenal syndrome)
- paracentesis
- SBP
Ascites Management
- Avoid ___ in cirrhosis patients
Non-PCOL
- Na restriction < __ g/day
- transplant assessment
First line
- ___ antagonists + ___ diuretic
Second Line
- ___
- TIPS
- NSAIDs
- 2
- aldosterone, loop
- paracentesis
Diuretics for Ascites
Dosing: Recommended to initiate at ratio of spirolactone ___ : ___
furosemide PO once daily (can titrate every 3-5 days)
- Max daily dose ___ mg spironolactone/ ___ mg furosemide
- Combination is superior to monotherapy, but if using one,
spironolactone is superior to furosemide in cirrhosis
Side effects
aldosterone antagonists:
- ___ (hypoperfusion)
- ___ K
- gynecomastia
loop diuretics
- ___ (hypoperfusion)
- ___ K
Monitoring: s/sx of ascites, SCr, K+
- 100:40
- 400: 160
- AKI
- increased
- AKI
- decreased
Paracentesis
2nd line for chronic management (can be used acutely if tense ascites)
- Indicated in refractory/resistant ascites or in cases of ___
If > __ L removed via paracentesis, albumin has been shown to ↓ morbidity and ↓ mortality
- Administer ___ % albumin IV and give __ - __ g albumin per liter removed (see next slide for example)
- AKI
- 5L
- 25%
- 6-8g
Albumin Calculation
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
C. Albumin 25% 200 mL IV once
50 g albumin (within 48-64 g)
Ascites Summary
Assess signs/symptoms
- For ascites, encourage non-pharm and diuretic therapy
- Monitor s/sx of ascites, renal function, and potassium
- Paracentesis is ___ line, unless treatment ___
- 2nd
- resistant
