Hepatology Flashcards by Paola Lopomo

What is the pattern of hepatocellular injury?

Very high ALT (specific)
Very high AST (non-specific)
Mildly high bilirubin
Direct bilirubin >50% total bilirubin (because its conjugated hyperbilirubinemia)

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What is the pattern of cholestatic injury?

Very high alk phos
Minorly high AST and ALT
+/- jaundice
Usually direct bilirubin is a high percentage (conjugated hyperbilirubinemia)

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What is the pattern of Hep B and C?

Moderately high of everything (Alk phos, ALT, AST)

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What is the pattern of muscle injury?

Very high AST, mildly high ALT. Normal bilirubin

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What should you do in a patient with isolated unconjudgated (indirect) hyperbilirubinemia and no symptoms?

Nothing. This is probably Gilbert syndrome. If it were cholestatic, it would be at least 50% conjugated/direct.

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What is the pathogenesis of Gilbert syndrome?

Reduced expression of the enzyme that conjugates bilirubin (glucoronyltransferase)

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What is the highest total bilirubin concentration you would see in Gilbert disease?

3.0

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What 2 things can cause a high INDIRECT (unconjugated) bilirubin?

Hemolytic anemia

2. Gilbert syndrome

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What are indications for cholecystectomy?

Symptomatology. Even if it resolves, you take the gall bladder out after it resolves, because there is a 30% chance of recurrence within 3 months

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What is ERCP shincterotomy used for?

Remove obstructing stones from the gall bladder

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What can you do for patients who have gallstones but can’t undergo surgery?

ursodeoxycholic acid (although this mostly only helps prevent future stones)

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Is primary sclerosing cholangitis seen more with UC or with Crohn disease?

Ulcerative Colitis

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How is a diagnosis of PSC confirmed. Why do we use this method?

Use ERCP because you can both diagnose it AND place stents at places with big stictures, AND take biopsies to rule out cholangiocarcinoma

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If you can’t use ERCP, what would you use to diagnose PSC?

MRI cholangiopancreatogrpahy

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What are the symptoms of acute Hep A?

fatigue, nausea, mild upper abdominal pain, juandice

AST and ALT>500 (often >1000 if acute)

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What is the pattern of liver enzyme elevation in PSC?

cholestatic (high alk phos, high direct bilirubin). Minorly high AST and ALT

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What is the charcot triad, and what is it for?

fever
jaundice
RUQ pain

classic for ascending cholangitis (stone at the bottom of the biliary tree with inflammation) or cholecystitis (inflamed gall bladder)

*memory: Charcot was right, hot and yellow

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How do you treat acute cholangitis?

Immediately start broad spectrum antibiotics for anaeroebes, aerobes, and enterococci
then do ERCP to remove the stone

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How do you SCREEN for hepatocellular carcinoma?

Liver ultrasound

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Can patients with chronic Hep B but no cirrhosis develop HCC?

Yes

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How do you diagnose hepatocellular carcinoma?

A liver ultrasound with a subsequent AFP>500 is enough for diagnosis. You don’t need a biopsy.

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How do you get Hep A?

Contaminated food, contaminated water, contact with an infected person

How long can Hep A jaundice last?

Up to 6 months

How do you treat Hep A?

Supportive therapy

2. Serum immunoglobulin for household members and intimate contacts

Who should get the Hep A vaccine?

1. People going to underdeveloped countries 2. MSWM 3. Injection drug users 4. Chronic liver dz

What are symptoms of acute Hep C?

Usually nothing

What is the liver enzyme pattern for alcoholic hepatitis?

AST:ALT > 2:1 AST and ALT are always

Which antibodies are frequently positive in autoimmune hepatitis?

1. ANA (nuclear antibody) 2. anti-SMA (smooth muscle antibody) 3. anti-LKM1 (liver kidney microsome type 1)

What are the symptoms of autoimmune hepatitis?

``` Fatigue (85%) Jaundice (46%) Anorexia (30%) Myalgias (30%) Diarrhea ```

Which antibody is positive in Primary Biliary Cirrhosis?

antimitochondrial antibody *memory: Princess Biliary Cinderlla had an AMAzing night

What is the biggest difference in liver enzyme pattern between PBC and autoimmune hepatitis?

Alk phos is usually super high in PBC and near-normal in autoimmune hepatitis

Can IgM antibody be positive during acute infection?

yes

What antibody is positive in patients with chronic hep B?

Antibody to hep B CORE antigen (not antibody to hep B surface antigen... that would mean they are immune)

What is the gold standard for diagnosing hep c infection?

HCV RNA in the blood (antibody to hep c is cheaper and also reliable though). If RNA is positiive, there is ACTIVE infection (not just exposure)

What is the screening test for hep C positivity?

Hep c antibody

How much alcohol do you have to drink to cause cirrhosis?

3 drinks/day for 10 years (women) 6 drinks/day (men)

What are signs of NASH (non-alcoholic steatohepatitis)?

Patient with obesity, HLD, DM2, ascites, liver enzymes in the 100's, female

What is the difference between NASH and NAFLD?

NASH is the most extreme form of NAFLD. NASH: Presence of inflammation and fibrosis. Patients usually have DM2, HTN, HLD NAFLD: Just steatosis (no inflam or dysfunction necessarily). Patients usually only have risk factors of metabolic syndrome

How many patients with NASH develop cirrhosis?

2-3%

How many obese patients have NASH?

20%

How is NASH diagnosed?

Sometimes you need a biopsy to be sure. But ultrasound, CT, or MRI can confirm steatosis.

When is diagnostic paracentesis indicated?

Any patient with new-onset ascites

How do you interpret SAAG?

>1.1 g/dL (11 g/L) means portal hypertension (because a high SAAG means there's like no albumin in the fluid, which means the fluid is just water being pushed out)

How do you calculate SAAG?

SAAG= serum albumin - ascites albumin So a higher SAAG means less albumin in the fluid

What can cause portal hypertension?

Cirrhosis Budd-chiari syndrome R sided heart failure Constrictive pericarditis

How do you manage hepatic encephalopathy?

1. Increase dose of lactulose | 2. Treat precipitating factors (ex: UTI, new meds, dehydration)

How do you dose lactulose for acute hepatic encephalopathy?

Increase until you get 2-3 soft stools/day with pH

How well dose lactulose work for acute hepatic encephalopathy?

70-80% of patients improve with it

What is the main side effect of TIPS?

Can cause hepatic encephalopathy because blood bypasses the liver so blood is "dirtier"

What is the definition of hepatorenal syndrome?

kidney dysfunction in patients with portal hypertension after RULING OUT prerenal azotemia, renal parenchymal disease, and obstruction

What can cause precipitate syndrome?

SBP diuretics paracentesis GI bleeding

What can you use for SBP?

cefotaxime and albumin infusion

What are HIDA scans used for?

diagnose acute cholecystitis when ultrasound is equivocal

Difference in lab tests between acute cholangitis and cholecystitis?

acute cholangitis has AST and ALT>1000 and bilirubin>4, cholecystitis only mildly elevated AST, ALT, bilirubin