Hepatology Lecture Flashcards
Valveless*
Pressure is 3-5 mmHg
75% of total liver blood supply by volume
Posterior to bile duct and hepatic artery
Formed by SMA
Portal vein
Venous drainage of the liver thru 3 valveless veins into infereior vena cava
*takes blood back to heart
made up of…R, middle, L
Hepatic veins
Parasympathetic innervation of the liver comes from the…
Vagus N
Parasympathetic and Sympathetic fibers into the liver come from the…
Celiac plexus
Make up the parenchyma of liver
Survive 200-300 days
If healthy..divide and replicate
Hepatocytes
“Stem cells” of liver
Allow for regeneration
Ovalcytes
Fxns of liver?
Metabolic
Catabolic
Storage
Excretory functions
Gluconeogenesis
Synthesis of phospholipids and cholesterol
Detox of meds and alcohol
Metabolic and catabolic fxns of liver
Glycogen
Protein
Triglycerides
Iron
Copper
Fat soluble vitamins
Storage in the liver
Synthesis and secretion of of bile
Excretory fxn of liver
Coag factors: PT/INR, PTT
Plasma proteins: albumin
Acute phase proteins: cytokines
Carb metabolism: glycogen, lactate
Lipid metabolism: cholesterol, TGs, lipoproteins
Bilirubin metabolism: bile excretion
Synthetic functions of liver
(in hepatocytes)
is AST elevated in acute or chronic conditions?
Acute
Is ALT elevated in acute or chronic conditions?
Chronic
ALT > AST in….
Viral, fatty liver
AST > ALT in…
Alcohol (2:1)
or drug toxicity
What labs do you want if you are checking for hepatocellular damage or inflammation?
AST
ALT
What labs do you want if you are checking for obstructive dz?
Bilirubin
Alk-Phos
GGTP (not part of LFTs)
Which is water soluble, which is not water soluble:
Direct (conjugated) bilirubin
Indirect (unconjugated) bilirubin
Direct (conjugated) bili is water soluble
Indirect (unconjugated) bili it NOT water soluble
Hemolysis of RBCs
Impaired hepatocyte function
..will result in elevation of?
Indirect bilirubin (pre-hepatic)
Obstruction of excretion of bilirubin, cholestasis
…will result in elevation of?
Direct bilirubin (post-hepatic)
Found in bone, liver, intestine, kidney, placenta and leukocytes
*can be fractionated to determine origin
Alk-Phos
**Liver specific!!
Will help differentiate if Alk Phos is elevated because of the liver
GGTP
(Gamma-glutamyltransferase)
Elevated alk phos (ALP) and elevated GGTP means…
obstruction!
Best first step diagnostic for looking at liver?
Ultrasound with doppler
MC hereditary cause of increased bilirubin
Results in impaired enzymatic conjugation of indirect bilirubin
Gilbert’s disease
S/S: icteric sclera and jaundice..esp at birth and acute illness
Labs:
elevated indirect bili
normal direct bili
Tx: only tx in infancy with bili lights to prevent liver failure
Gilbert’s disease
(normal ultrasound!)
No signs and symptoms unless cirrhosis has developed
Increased echotecture on U/S
Labs: ALT > AST (opposite of alcohol disease)
Non alcoholic fatty liver disease (NASH)
What is the relationship of ALT and AST in non alcoholic fatty liver disease (NASH)?
ALT>AST (opposite of ETOH disease)
Autosomal recessive genetic D/O resulting in iron deposition in organs
males > females, often onset 50 yo
Hemochromatosis
Labs: high ferritin and high % saturation
HFE Gene analysis***
Liver biopsy with iron stain
Sxs: can be asymptomatic
arthralgias, hepatomegaly, gray skin, cardiomegaly, conduction D/O
Tx: phlebotomy
Hemochromatosis
Rare genetic autosomal recessive DO
liver unable to excrete copper..OVERLOAD
Wilson’s disease
Labs:
- *low ceruloplasmin** (first thing to test)
- *elevated 24H urine copper** (second thing to test)
Sx: Visual disturbances (**Kayser-Fleischer ring around iris**) Neuro, psych changes
Tx:
Copper chelators, like zinc
Wilson’s disease
MC cause of cirrhosis
Alcoholic hepatitis
AST>ALT 2:1
Alcoholic hepatitis
(think alcohol when you see this 2:1 ratio!)
Occurs with binging, heavy use
Can be fatal, pts often have encephalopathy
Hepatosplenomegaly with ascites
Jaundice
Acute phase of alcoholic hepatitis
What do you give for tylenol OD
N-acetylcysteine
Associated with autoimmune dzs
Females 14-50
Need biopsy to make diagnosis!
Tx= prednisone, Imuran
Autoimmune hepatitis
75% of cases are pts with ulcerative colitis
mostly males
“beading” of bile ducts on MRCP
tx= Ursodiol cure= transplant
Primary biliary cirrhosis
65% of hepatitis cases in US
single stranded RNA enterovirus
fecal oral route!..think travel, contaminated food/water, close contact with infected individuals
Hep A
Incubation pd= 2-6 weeks
Severity depends on age
Prodrome phase= flu like
Icteric phase= dark urine appears first (bilirubinuria)***
pale stools soon follow
RUQ pain
pruritus
arthalgias
hepatomegaly
Hep A
Greatest shedding of virus is during days 14-21
Hep A
Which Ig is present during acute infection? (pos for 3-6 mos)
Which Ig means youre immune?
IgM= acute infection
IgG= immunity
Increase in ALT and AST (>8x norm)
Increase in bilirubin (5-15x norm)
labs in….
HAV
HAV tx?
Usually self limiting. supportive care
Transmission= perinatal, sexual, blood
80% of hepatocellular carcinoma (HCC) cases
3 categories:
- immune (thru vaccine or natural infxn)
- acute infxn
- chronic infxn (active or inactive)
Hep B
1-6 mo incubation pd
70% are subclinical
30% develop icteric hepatitis
-severe transaminitits and elevated bilirubin
Acute Hep B
HBcIgM (core IgM)
…means?
Acute Hep B infection
Hepatitis B surface antigen (HBsAg) indicates…
ongoing infection of any duration
Hepatitis B core antibody (anti-HBc) indicates…
Acute hepatitis
MC bloodborne infection in US
test everyone born between 1945-1965
*RNA virus…1a, 1b, 2, 3, 4 are MC in US
Hep C
Transmission:
IV drug use
tattoos
needlsticks
pre 1990-transfusions
Hep C
Most pts asymptomatic
80% go on to chronic state
**high risk of developing cirrhosis and HCC*****
Hep C
Acute Hep C tx
Supportive care
Avoid hepatotoxic drugs
Viral load
Genotype
Tx hx
LFTs
Coags
ETOH/drug screen
HIV screen
Staging of liver for fibrosis/cirrhosis with fibroscan or bx
Factors that determine best tx option for HCV
Direct antiviral agents (DAAs)
Sovaldi, Harvoni, Vikiera Pak, Olysio, Daklina
*100% cure rate
*tx 12-24 weeks
treatment for Hep C
Is there a vaccination or immunoglobulin (for post exposure) for Hep C?
NO! must screen!!
Suddent onset deterioration of hepatocyte function resulting in coagulopathy
Causes:
Tylenol (45%)
Alcohol/drugs
Viral
Acute hepatic failure
+/- jaundice
Increased transaminases (AST/ALT)
Coagulopathy INR >1.5
Encephalopathy due to increased ammonia
*may reuqire emergent transplant
Acute hepatic failure
Chronic end stage dz of liver marked by degeneration of cells from inflammation resulting in fibrous thickening of tissue
Cirrhosis
There are 4 stages of fibrosis, last being…..
cirrhosis
Dx:
abdominal U/S with doppler:
nodular appearing liver
+/- hepatosplenomegaly
assess portal vein
ascites
liver biopsy:
able to stage the fibrosis
Cirrhosis
Early: weakness, fatigue, insomnia, muscle cramps, wt loss
Late: N/V, abdominal pain, spider angiomas, palmar erythema, portal HTN, HSM, dilated veins in abdomen, ascited, encephalopathy
Cirrhosis
Varices occur when portal pressure exceeds..?
10 mmHg
- Upper GI bleeds from esophageal varices
- Ascites
- Encephalopathy (due to increase ammonia)
- Splenomegaly
- Hepatorenal syndrome (poor prognosis)
Consequences of portal HTN
Nonselective beta blockers
banding for varices
diuretics and paracentesis for ascites
lactulose and Xifaxan for enceph.
Management for portal HTN
What is the cure for cirrhosis?
Liver transplant
associated with cirrhosis
weight loss
painless jaundice
+/- palpable mass
hepatomegaly
6x more common in males
Hepatocellular carcinoma (HCC)
Dx:
Triple phase CT or MRI
percutaneous bx of lesion
increased LFTs
Hepatocellular carcinoma (HCC)
Alpha fetoprotein tumor marker is elevated with….
HCC!
..may also be elevated with chronic Hep C and cirrhosis
MC neoplasm of liver
Metastatic liver cancer
from: lung, colon, breast, prostate, pancreas, stomach
how much of the liver can you remove?
80%
albumin, synthetic ability regained by 3rd week
