Hepatology Flashcards
functions of the liver
bile production, drug/food/toxin metabolism, protein synthesis (albumin and coag factors), storage and adjustment of vitamins and gluconeogenesis.
Lab markers
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)
what does elevated bilirubin indicate?
sign of acute or chronic liver issues
chronic liver disease impact on proteins
decreased albumin, increased INR, and increased bilirubin
DILI incidence?
14 to 19 cases per 100,000
medications that cause idiosyncratic DILI
augmentin, isoniazid, macrobid, bactrim, minocycline, cefazolin, z-pack, cipro, tylenol, niacin, glucocortocoids, antineoplastic agents
what causes acetaminophen DILI
> 8g acetaminophen = toxic levels of N-acetyl-p-benzoquinone imine (NAPQI)
signs and symptoms of DILI
abd pain, jaundice, n/v/d
Treatment for acetaminophen DILI
N-acetylcysteine (NAC) and activated charcoal
NAC MOA
Binds to NAPQI
NAC dosing
oral: 140mg/kg, then 70mg/kg q4h x72H
IV: 150 mg/kg x1 hours, then 50 mg/kg x4h, then 100mg/kg x10 hours
cirrhosis causes
alcohol, hepatitis, metabolic liver disease, cholestatic liver disease, drugs (amiodarone, methotrexate)
cirrhosis s/sx
fatigue, weight loss, ascites, jaundice, hepatomegaly, encephalopathy
cirrhosis complications
ascites, esophageal varices, encephalopathy, spontaneous bacterial peritonitis, thrombocytopenia, hyponatremia, hepatorenal syndrome
child-pugh assessment
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)
Child-pugh classifications
A = score <7 = mild
B = score 7-9 = moderate
C = score 10-15 = severe
Model for end stage liver disease (MELD)
score <9 = 1.9% 3 month mortality
10-19 = 6%
20-29 = 20%
30-39 = 53%
>40 = 71%
ascites s/sx
abdominal distention, abd pain, SOB, nausea
ascites pathophys
portal HTN drives fluid into peritoneal space, hypoalbuminemia
ascites management
sodium restriction <2g/day
aldosterone antagonist (spironolactone + furosemide)
second line: paracentesis, TIPS
Meds to avoid
NSAIDS
Diuretics for Ascites
Initiate at ratio of Spironolactone 100mg to furosemide 40mg
(max 400/160). monitor Scr, K+
paracentesis
if removing >5L, then give albumin
25% albumin IV, then 6-8g albumin per liter removed
variceal bleeding prophylaxis
non-selective beta blocker (moderate disease only) or endoscopic variceal ligation monotherapy
