Hepatology & Biliary Tree Disease Flashcards
Which test confirms an active hepatitis A infection?
anti-HAV IgM
What investigation demonstrates a patient has been immunized against HBV?
HBV sAb
Which HBV serology indicates that a patient is immune due to previous infection/exposure?
HBV sAb +
HBV Core IgG + (IgM -)
HBV eAb +
All other serology negative.
What HBV serological indicates on acute infection?
HBV sAg +
HBV IgM +
HBV eAg +
HBV DNA +
Otherwise negative
What HBV serology indicates chronic hepatitis B infection?
HBV sAg +
HBV Core IgG +
HBV DNA +
Variable HBV eAg & HBV eAb
Otherwise negative.
What is the treatment for an acute hepatitis B infection?
- Supportive for patient
- Ensure household and sexual contacts are immune -> provide hepatitis B immune globulin and hepatitis B vaccine if they are not immune
Which patients with chronic hepatitis B infection need to be screened every 6 months for HCC?
Asian M > 40 or Asian F > 50 African > 20 All Cirrhotics Family Hx HCC (Start at age 40) All HIV co-infected patients (Start at 40)
Which patients with chronic HBV do you treat?
Cirrhosis Extra-Hepatic Manifestations HBeAg + w/increased ALT & DNA > 20000 HBeAg - w/increased ALT & DNA > 2000 Pregnancy - to prevent fetal transmission
What is the 1st line treatment for HBV infection?
1st Line: Nucleotide Analogues (tenofovir, enter air, lamivudine)
List 3 extra-hepatic manifestations of HBV infection.
Vasculitis - Polyarteritis Nodosa
Renal - Membranous Nephropathy > MPGN
Heme - Aplastic Anemia
Who should you treat for HCV?
ALL patients except those with short life expectancy owning to comorbidities.
What are the extra intestinal manifestations of HCV?
Autoimmune - thyroid, myasthenia, sjogren’s
Renal - MPGN > MN
Derm - Porphyria cutanea tarda, leukocytoclastic vasculitis, lichen planus
Heme - cryoglobulinemia, lymphoma, autoimmune hemolytic anemia, ITP
How do you use the Maddrey discriminate function score?
< 32 - No role for steroids in alcoholic hepatitis
> or = 32 - Prednislone 40 mg PO daily x 28 days
What are the contraindications to prednisolone in alcoholic hepatitis (4)?
Infection — SBP, active HBV, TB +/- HCV
Active GI Bleeding (relative)
Multi organ failure/shock
AKI with Cr > 221 mmol/L
When should a liver transplant be considered for hepatic failure?
Refer if MELD > or = 21 OR if Child-Pugh C liver cirrhosis.
How is the Lille score utilized in alcoholic hepatitis?
Calculate the Lille Score on Day 7 of prednisolone:
> 0.45 —> not responding, stop steroids
< 0.45 —> responding, continue to complete a 28 day course.
What is the most common cause of death in NAFLD?
Cardiovascular Causes
What is the recommended non-pharmacological treatment for NAFLD?
Weight loss: > or = 3.5 % loss of MW improves steatosis, > or = 7-10% to improve fibrosis.
Dietary Changes
Moderate Intensity Exercise
In which patients with NAFLD would you use pharmacotherapy? What medications can you use?
Pioglitazone (thiazolidinedione) and vitamin E can be used to treat BIOPSY PROVEN NASH and fibrosis only.
What are the components of the Child Pugh score?
Ascites - Absent (0); Slight (1); Mod (2)
Bilirubin - < 34.2 (0); 34.2-51.3 (1); > 51.3 (2)
INR - < 1.7 (0); 1.7-2.2 (1); > 2.2
Albumin - > 35 (0); 28-35 (1); < 28 (2)
Encephalopathy - None (0); Gr 1-2 (1); Gr 3-4 (2)
If a patient with cirrhosis has NO esophageal varices, how often do you screen them?
Compensated - EGD Q2-3 years
Decompensated - EGD at the time of decompensation & then Q1 year
If a patient with cirrhosis has small, low risk varices, how often do you screen the with repeat EGD?
EGD q1-2 years
When do you water restrict patients with cirrhosis and fluid overload/ascites?
When their sodium is < 125
What is the most common compound heterozygote that may result in hemochromatosis?
C282Y/H63D
What infections are patients with hemochromatosis at increased risk for?
Yersinia enterocolitica
Vibrio vulnificus (avoid shellfish)
Listeria monocytogenes
When should you perform genetic testing for hemochromatosis?
Transferrin saturation > 45%
AND/OR
Ferritin > 300 in M
Ferritin > 200 in F
What is the first line treatment in hemochromatosis?
Phlebotomy to target ferritin 50-100
What are the second line agents to treat hemochromatosis?
Chelation agents
What vitamin do you need to avoid in hemochromatosis and why?
Avoid vitamin C supplements (excess) because it increases iron absorption.
What is the definition of SBP?
Neutrophils in ascitic fluid > 250 OR culture positive ascitic fluid.
What is the treatment for confirmed SBP?
Ceftriaxone (or Fluoroquinolone if allergy) x 5 days WITH Day 1: Albumin 1.5 g/kg Day 3: Albumin 1 g/kg IF Cr > 88, BUN > 10.7 OR bilirubin > 68
Which patients require prophylaxis for SBP?
- Patients who have previously had SBP
- Patients with cirrhosis who present with GI bleeding, regardless of whether they have ascites.
- Cirrhotic patients with ascitic fluid protein < 15 g/L AND at least one of:
- impaired renal function (Cr > 106, BUN > 8.9, Na < 130)
- impaired liver function (CP > or = 9 AND bilirubin > 51)
What is the definition for acute pancreatitis?
Need at least 2/3 criteria for diagnosis:
- Consistent abdominal pain
- Lipase and/or analyses > 3x ULN
- Characteristic findings on imaging.
What antibiotics would you use to treat complicated pancreatitis?
Carbapenem OR
Quinolone + metronidazole
What is the treatment for hepatorenal syndrome?
Albumin 1g/kg/day
Midodrine 7.5-12.5 mg PO TID
Octreotide 100-200 ug SC TID
OR
Terlipressin + albumin
When should you suspect hepatopulmonary syndrome?
If ABG reveals PaO2 < 80 & and A-a gradient > or = 15
What workup should you consider if a patient has a PVT or MVT?
Consider thombophilia workup and JAK2 testing if:
(1) No hx of cirrhosis
(2) Prior hx of thrombosis
(3) unusual site of thrombosis (hepatic veins)
(4) family hx of thrombosis
When should you anticoagulation a patient with NO cirrhosis and a chronic PVT/MVT?
Anticoagulate if:
(1) Thrombophilia
(2) Progression of clot into mesenteric veins
(3) Bowel ischemia
