Hepatology

Question 1

functions of the liver

Answer 1

bile production, drug/food/toxin metabolism, protein synthesis (albumin and coag factors), storage and adjustment of vitamins and gluconeogenesis.

Question 2

Lab markers

Answer 2

AST (0-50 IU/L) >50 with acute liver injury
ALT (0-50 IU/L) >50 with acute liver injury
ALK Phos (30-120 IU/L) >120 with biliary tract injury from liver injury (ex:gallstones)

Question 3

what does elevated bilirubin indicate?

Answer 3

sign of acute or chronic liver issues

Question 4

chronic liver disease impact on proteins

Answer 4

decreased albumin, increased INR, and increased bilirubin

Question 5

DILI incidence?

Answer 5

14 to 19 cases per 100,000

Question 6

medications that cause idiosyncratic DILI

Answer 6

augmentin, isoniazid, macrobid, bactrim, minocycline, cefazolin, z-pack, cipro, tylenol, niacin, glucocortocoids, antineoplastic agents

Question 7

what causes acetaminophen DILI

Answer 7

> 8g acetaminophen = toxic levels of N-acetyl-p-benzoquinone imine (NAPQI)

Question 8

signs and symptoms of DILI

Answer 8

abd pain, jaundice, n/v/d

Question 9

Treatment for acetaminophen DILI

Answer 9

N-acetylcysteine (NAC) and activated charcoal

Question 10

NAC MOA

Answer 10

Binds to NAPQI

Question 11

NAC dosing

Answer 11

oral: 140mg/kg, then 70mg/kg q4h x72H
IV: 150 mg/kg x1 hours, then 50 mg/kg x4h, then 100mg/kg x10 hours

Question 12

cirrhosis causes

Answer 12

alcohol, hepatitis, metabolic liver disease, cholestatic liver disease, drugs (amiodarone, methotrexate)

Question 13

cirrhosis s/sx

Answer 13

fatigue, weight loss, ascites, jaundice, hepatomegaly, encephalopathy

Question 14

cirrhosis complications

Answer 14

ascites, esophageal varices, encephalopathy, spontaneous bacterial peritonitis, thrombocytopenia, hyponatremia, hepatorenal syndrome

Question 15

child-pugh assessment

Answer 15

bilirubin <2 (1pt), 2-3 (2 pts), >3 (3pts)
albumin g/dL >3.5 (1 pt), 2.8-3.5 (2 pts), <2.8 (3 points)
ascites: none (1 pt), mild (2 pts), mod-severe (diuretic refractory) (3 pts)
prothrombin time: 1-3 (1 pt), 4-6 (2 pts), >6 (3 pts)

Question 16

Child-pugh classifications

Answer 16

A = score <7 = mild
B = score 7-9 = moderate
C = score 10-15 = severe

Question 17

Model for end stage liver disease (MELD)

Answer 17

score <9 = 1.9% 3 month mortality
10-19 = 6%
20-29 = 20%
30-39 = 53%
>40 = 71%

Question 18

ascites s/sx

Answer 18

abdominal distention, abd pain, SOB, nausea

Question 19

ascites pathophys

Answer 19

portal HTN drives fluid into peritoneal space, hypoalbuminemia

Question 20

ascites management

Answer 20

sodium restriction <2g/day
aldosterone antagonist (spironolactone + furosemide)
second line: paracentesis, TIPS

Question 21

Meds to avoid

Answer 21

NSAIDS

Question 22

Diuretics for Ascites

Answer 22

Initiate at ratio of Spironolactone 100mg to furosemide 40mg
(max 400/160). monitor Scr, K+

Question 23

paracentesis

Answer 23

if removing >5L, then give albumin
25% albumin IV, then 6-8g albumin per liter removed

Question 24

variceal bleeding prophylaxis

Answer 24

non-selective beta blocker (moderate disease only) or endoscopic variceal ligation monotherapy

Question 25

beta blocker and dosing

Answer 25

Nadalol (20-40mg PO daily) (max doses 80 ascites, 160 no ascites) Propranolol (20-40mg PO BID) max doses (160,320mg) Carvedilol 6.25mg daily to bid (max dose 12.5 mg PO daily)

Question 26

Beta blocker for prophylaxis monitoring

Answer 26

HR Goal: 55-60 BPM BP: SBP >90 mmHg

Question 27

variceal bleeding treatment

Answer 27

- blood transfusion - Octreotide (somatostatin (vasoconstrictor)) - antibiotics _ NO PPIs

Question 28

Octreotide MOA

Answer 28

- inhibits release of vasodilatory peptides (glucagon) - Splanchnic vasoconstriction and decreased blood flow.

Question 29

Octreotide SE

Answer 29

N/V, HTN, bradycardia, hyperglycemia

Question 30

EVL (endoscopic variceal ligation)

Answer 30

- gold standard for variceal bleeding cessation - within 12 hours of presentation

Question 31

Other variceal bleeding treatment

Answer 31

- ceftriaxone x7 days or until hemorrhage resolution (SE = diarrhea) - NOT vitamin K (INR will be elevated)

Question 32

Secondary prophylaxis for varices

Answer 32

- endoscopic variceal ligation every 1-4 weeks - NS BB: - Nadolol 20-40mg PO daily (max 80/160) Propranolol 20-40mg PO BID (max 160/0mg)

Question 33

SBP risk

Answer 33

10-30% due to bacterial translocation

Question 34

SBP clinical presentation

Answer 34

fever abd pain, leukocytosis, encephalopathy, asyptomatic

Question 35

diagnosed through paracentesis

Answer 35

ascitic fluid with >250 cells/mm3 polymorphonuclear leukocytes (PMN)

Question 36

SBP treatment

Answer 36

- ceftriaxone (SE = diarrhea) x5-7 days - albumin 1.5g/kg x1 (within 6 hours - day 3 1g/kg x1

Question 37

SBP secondary prophylaxis

Answer 37

- avoid PPIs - BActrim DS 800/160mg daily - Cipro 500mg daily - indefinite duration

Question 38

dosing in liver insufficiency

Answer 38

- highly bound protein drugs increase free drug concentration but not total drug concentration

Question 39

when can activated charcoal be used for tylenol overdose

Answer 39

within an hour