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864 > Hepatology > Flashcards

Hepatology Flashcards

1
Q

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 ___

A
  • bile
  • protein
  • portal, peritoneal
  • rentention
  • hypoalbuminemia
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2
Q

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)

A
  • aspartate
  • alanine
  • biliary tract
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3
Q

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 ↑ ___

A
  • LFTs, function
  • bilirubin
  • albumin, INR, bilirubin
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4
Q

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 ___

A
  • 8, NAPQI
  • AST, ALT, acetaminophen
  • N-acetylcysteine (NAC), charcoal
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5
Q

N-acetylcysteine (NAC)

Mechanism of action: binds to ___ , decreasing
hepatotoxic effects

A

NAPQI

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6
Q

N-acetylcysteine (NAC)

Indication: based on concentration of acetaminophen (> __ hours after ingestion) and timing since
ingestion
- NAC use determined by ___

A
  • 4
  • Rumack-Matthew Nomogram
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7
Q

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

A
  • 140, 70
  • 15, 5, 10
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8
Q

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
A
  • ingestion
  • NAC
  • psychiatry
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9
Q

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

A

irreversible

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10
Q

Signs and Symptoms of Cirrhosis

A
  • Fatigue
  • Weight loss
  • Ascites
  • Jaundice
  • Hepatomegaly or splenomegaly
  • Encephalopathy
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11
Q

Cirrhosis Complications

A
  • Ascites
  • Esophageal varices (EV)
  • Hepatic encephalopathy (HE)
  • Spontaneous bacterial peritonitis (SBP)
  • Thrombocytopenia
  • Hyponatremia
  • Hepatorenal syndrome (HRS)
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12
Q

Assessing Severity of Cirrhosis

Child-Pugh class

A
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13
Q

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

A

3, transplant

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14
Q

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.
A
  • alcohol
  • hepatitis
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15
Q

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 ___

A
  • peritoneal
  • portal, peritoneal
  • retention
  • hypoalbuminemia
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16
Q

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)
A
  • paracentesis
  • SBP
17
Q

Ascites Management

  • Avoid ___ in cirrhosis patients

Non-PCOL
- Na restriction < __ g/day
- transplant assessment

First line
- ___ antagonists + ___ diuretic

Second Line
- ___
- TIPS

A
  • NSAIDs
  • 2
  • aldosterone, loop
  • paracentesis
18
Q

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+

A
  • 100:40
  • 400: 160
  • AKI
  • increased
  • AKI
  • decreased
19
Q

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)

A
  • AKI
  • 5L
  • 25%
  • 6-8g
20
Q

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

A

C. Albumin 25% 200 mL IV once

50 g albumin (within 48-64 g)

21
Q

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 ___

A
  • 2nd
  • resistant

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