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Outpatient Medicine > Hepatology > Flashcards

Hepatology Flashcards

1
Q

What is the pattern of hepatocellular injury?

A
  1. Very high ALT (specific)
  2. Very high AST (non-specific)
  3. Mildly high bilirubin
  4. Direct bilirubin >50% total bilirubin (because its conjugated hyperbilirubinemia)
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2
Q

What is the pattern of cholestatic injury?

A
  1. Very high alk phos
  2. Minorly high AST and ALT
  3. +/- jaundice
  4. Usually direct bilirubin is a high percentage (conjugated hyperbilirubinemia)
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3
Q

What is the pattern of Hep B and C?

A

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

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4
Q

What is the pattern of muscle injury?

A

Very high AST, mildly high ALT. Normal bilirubin

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5
Q

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

A

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

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6
Q

What is the pathogenesis of Gilbert syndrome?

A

Reduced expression of the enzyme that conjugates bilirubin (glucoronyltransferase)

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7
Q

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

A

3.0

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8
Q

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

A
  1. Hemolytic anemia

2. Gilbert syndrome

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9
Q

What are indications for cholecystectomy?

A

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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10
Q

What is ERCP shincterotomy used for?

A

Remove obstructing stones from the gall bladder

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11
Q

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

A

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

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12
Q

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

A

Ulcerative Colitis

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13
Q

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

A

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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14
Q

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

A

MRI cholangiopancreatogrpahy

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15
Q

What are the symptoms of acute Hep A?

A

fatigue, nausea, mild upper abdominal pain, juandice

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

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16
Q

What is the pattern of liver enzyme elevation in PSC?

A

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

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17
Q

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

A
  1. fever
  2. jaundice
  3. 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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18
Q

How do you treat acute cholangitis?

A
  1. Immediately start broad spectrum antibiotics for anaeroebes, aerobes, and enterococci
  2. then do ERCP to remove the stone
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19
Q

How do you SCREEN for hepatocellular carcinoma?

A

Liver ultrasound

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20
Q

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

A

Yes

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21
Q

How do you diagnose hepatocellular carcinoma?

A

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

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22
Q

How do you get Hep A?

A

Contaminated food, contaminated water, contact with an infected person

23
Q

How long can Hep A jaundice last?

A

Up to 6 months

24
Q

How do you treat Hep A?

A
  1. Supportive therapy

2. Serum immunoglobulin for household members and intimate contacts

25
Q

Who should get the Hep A vaccine?

A
  1. People going to underdeveloped countries
  2. MSWM
  3. Injection drug users
  4. Chronic liver dz
26
Q

What are symptoms of acute Hep C?

A

Usually nothing

27
Q

What is the liver enzyme pattern for alcoholic hepatitis?

A

AST:ALT > 2:1

AST and ALT are always

28
Q

Which antibodies are frequently positive in autoimmune hepatitis?

A
  1. ANA (nuclear antibody)
  2. anti-SMA (smooth muscle antibody)
  3. anti-LKM1 (liver kidney microsome type 1)
29
Q

What are the symptoms of autoimmune hepatitis?

A 
Fatigue (85%)
Jaundice (46%)
Anorexia (30%)
Myalgias (30%)
Diarrhea
30
Q

Which antibody is positive in Primary Biliary Cirrhosis?

A

antimitochondrial antibody

*memory: Princess Biliary Cinderlla had an AMAzing night

31
Q

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

A

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

32
Q

Can IgM antibody be positive during acute infection?

33
Q

What antibody is positive in patients with chronic hep B?

A

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

34
Q

What is the gold standard for diagnosing hep c infection?

A

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)

35
Q

What is the screening test for hep C positivity?

A

Hep c antibody

36
Q

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

A

3 drinks/day for 10 years (women)

6 drinks/day (men)

37
Q

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

A

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

38
Q

What is the difference between NASH and NAFLD?

A

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

39
Q

How many patients with NASH develop cirrhosis?

40
Q

How many obese patients have NASH?

41
Q

How is NASH diagnosed?

A

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

42
Q

When is diagnostic paracentesis indicated?

A

Any patient with new-onset ascites

43
Q

How do you interpret SAAG?

A

> 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)

44
Q

How do you calculate SAAG?

A

SAAG= serum albumin - ascites albumin

So a higher SAAG means less albumin in the fluid

45
Q

What can cause portal hypertension?

A

Cirrhosis
Budd-chiari syndrome
R sided heart failure
Constrictive pericarditis

46
Q

How do you manage hepatic encephalopathy?

A
  1. Increase dose of lactulose

2. Treat precipitating factors (ex: UTI, new meds, dehydration)

47
Q

How do you dose lactulose for acute hepatic encephalopathy?

A

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

48
Q

How well dose lactulose work for acute hepatic encephalopathy?

A

70-80% of patients improve with it

49
Q

What is the main side effect of TIPS?

A

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

50
Q

What is the definition of hepatorenal syndrome?

A

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

51
Q

What can cause precipitate syndrome?

A

SBP
diuretics
paracentesis
GI bleeding

52
Q

What can you use for SBP?

A

cefotaxime and albumin infusion

53
Q

What are HIDA scans used for?

A

diagnose acute cholecystitis when ultrasound is equivocal

54
Q

Difference in lab tests between acute cholangitis and cholecystitis?

A

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

Outpatient Medicine (16 decks)

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