Jaundice DSA - McGowan Flashcards

1
Q

transfusion reactions, sickle cell anemia, thalassemia (inadequate Hg), autoimmune disease

A

prehaptic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

hepatitis, cancer, cirrhosis, congenital disorders, drugs

A

intrahepatic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

gallstones, inflammation, scar tissue or tumors that block the flow of bile into the intestines

A

posthepatic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

primary injury is to the hepatocytes

  • primarily AST/ALT elevation
  • ALT more specific for liver injury than AST
A

hepatocellular injury

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

primary injury is to the bile ducts

  • primarily Alk Phos and bilirubin elevated
  • failure of bile to reach duodenum
  • jaundice and pruritis
  • pure cholestasis (no signs of hepatocellular necrosis)
A

cholestatic injury

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

what are the TRUE liver function tests that McGowan wants us to know?

NOTE: AST/ALT, Alk Phos and bilirubin (LDH, GGT) can come from other sources and are not accurate to determine liver’s function

A
  • PT/INR
  • albumin
  • cholesterol
  • ammonia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

what are the 4 main DDx for unconjugated (indirect) jaundice?

A
  1. hemolytic syndrome (anemia/reaction)
  2. Gilbert syndrome
  3. Criggler-Najjar syndrome
  4. viral hepatitis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

what are the 5 main DDx for conjucated (direct) jaundice?

A
  1. hepatitis (acute/chronic, infectious/non-infectious)
  2. cirrhosis
  3. obstruction
  4. Dubin-Johnson syndrome
  5. Rotor syndrome
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

what are the first steps in evaluating pt with jaundice?

A
  1. determine conjugated vs unconjugated

2. other biochemical liver tests are normal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

how to diagnose jaundice

A
  • order CBC to look for anemia and thrombocytopenia
  • order chemistry labs: AST/ALT, total bilirubin, Alk phos (will need to request fractionated bilirubin to tell you indirect vs. direct)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

when ALP is elevated, what is your next step?

A

fractionate by ordering gamma glutamyl transferase (GGT)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

what if ALP and GGT are elevated?

A

most commonly coming from liver source

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

what if ALP elevated, but GGT is normal?

A

consider bone or other source (placenta) for elevated ALP

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

what would you order to look for anemia and thrombocytopenia?

A

CBC

- can check for hemolysis: haptoglobin (low), reticulocyte count (elevated) and LDH (elevated)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

reduced activity of uridine diphosphate glucuronyl transferase

  • unconjugated (indirect) bilirubin
  • benign, asymptomatic hereditary jaundice, hyperbilirubinemia increased by 24-36 hour fast
A

Gilbert syndrome

  • no tx required
  • assoc with reduced mortality from cardiovascular disease
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

AR, absent UGT1A1 activity

  • no liver pathology
  • fatal in neonatal period
A

Crigler-Najjar Type 1

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

AD with variable penetrance, decreased UGT1A1 activity

  • no liver pathology
  • generally mild, occasional kernicterus
A

Crigler-Najjar Type 2

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

AR, decreased UGT1A1 activity

  • no liver pathology
  • innocuous (not harmful) clinical course
A

Crigler-Najjar Type 3

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

AR, impaired biliary excretion of bilirubin glucuronides due to mutation in canalicular multidrug resistance protein (MRP2)

  • pigmented cytoplasmic globules
  • innocent clinical course
A

Gilbert Syndrome

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

what is the main serum antibody present in acute viral hepatitis?

A

IgM

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

what is the main serum antibody present in chronic?

A

IgG

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

viral, drugs, ischemia, Budd-Chiari

  • pt has aversion to smoking
  • stools my be acholic (no bile = pale yellow)
  • dx: CVC, CMP, PT/INR, acetaminophen level (use rumack-matthew nomogram)
A

acute hepatitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q
  • ssRNA virus
  • aversion to smoking
  • 2-3 week incubation
  • enlarged tender liver, jaundice, acholic stools
  • fecal-oral transmission
  • elevated bilirubin and alk phos = cholestasis
  • both IgM and IgG are detectable in serum soon after onset
A

Hep A
- vaccine!

NOTE: detection of IgN anti-HAV is excellent test for dx acute Hep A

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q
  • partially dsDNA
  • acute illnes usually subsides over 2-3 weeks, 5-10% chronic
  • low-grade fever, enlarged and tender liver, jaundice
  • assoc with polyarteritis nodosa
  • parenteral, sexual, perinatal transmission
  • endemic in sub-saharan Africa and SE Asia
  • HBsAg-positive mothers may transmit HBV at delivery, risk of chronic infection in infant is 90%
  • elevated aminotransferases early in course (higher than HAV infection)
  • substantial risk for cirrhosis -> HCC
A

Hep B

- vaccine!

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
what is the window period of HBV infection?
between HBsAg disappearing and HBaAb appearing, which may take several weeks - pt is still considered to have acute HBV - infection is only detectable with **HBcAb IgM** NOTE: VERY important when screening blood donations
26
persistence of HBsAg more than 6 months after acute illness signifies what?
chronic Hep B
27
what appears in most individuals after clearance of HBsAg and after successful vaccination against Hep B?
anti-HBsAb
28
what does IgM anti-HBc indicate?
acute Hep B | - may also reappear during flares of previously inactive chronic Hep B
29
what appears during acute Hep B but persists indefinitely?
IgG anti-HBc
30
what is HBeAg?
Hep B envelope Ag = secretory form of HBcAg - in serum shortly after detection of HBsAg - indicated viral replication and infectivity - persistence of HBeAg beyond 3 months = increased likelihood of chronic Hep B
31
defective RNA virus that required HBV for replication - endemic among HBV carriers in Mediterranean Basin - spread by non-percutaneous (not skin) means - non-endemic areas (US, Europe) spread percutaneously (skin)
Hep D | - vaccinate against HBV!
32
ssRNA flavi-like virus (7 genotypes) - coinfection with HCV found in 30% of HIV patients - accounts for 90% of transfusion-assoc hepatitis - IV drug use accounts for >50% of cases - **boxers! bloody fisticuffs can transmit** - most sentitive serum indicator is RNA - cirrhosis, HCC, mixed cryoglobulinemia, MPGN, increased risk non-Hodgkin lymphoma
Hep C - pt with chronic liver dz should be vaccinated against HAV and HBV NOTE: occasional persons found to have anti-HCV in serum, without HCV RNA in serum -> recovery from prior HCV infection (spontaneous clearance)
33
what are the CDC and USPSTF screening recommendations for HCV?
all persons born between 1945-1965 should be screened - vaccinate against HAV and HBV - check for co-infection with HIV
34
ssRNA hepevirus - risk factor for immunocompromised hosts - endemic in Asia, middle east, North Africa, Central America, India - fecal-oral transmission, waterborne epidemics, **spread by swine** - chronic infection with progression to cirrhosis reported in transplant patients treated with tacrolimus (immunosupressant) - high mortality in pregnant women
HEV
35
what is the main cause of drug-induced hepatitis?
acetaminophen
36
what is the tx of drug-induced hepatitis (DILI)?
supportive - withdraw suspected agent - include use of gastric lavage and oral administration of charcoal or cholestyramine
37
what is the #1 cause of acute liver failure?
acetaminophen
38
nausea, vomiting, icterus and jaundice, itching, elevated liver enzymes - life threatening coagulation abnormalities - hepatic encephalophathy - asterixis
acute liver failure NOTE: in acetaminophen toxicity, AST/ALT > 500 u/L
39
what is the tx of acetaminophen overdose?
N-acetylcysteine (NAC) - provides a reservoir of sulfydryl groups to bind to the toxic metabolites or by stimulating synthesis of hepatic glutathione - **should be given within 8 hours of ingestion**
40
development of hepatic encephalopathy within 8 weeks after the onset of acute liver disease - coagulopathy (INR 1.5 or higher)
fulminant hepatic failure
41
development of hepatic encephalopathy between 8 weeks - 6 months
subfulminant hepatic failure
42
acute deterioration in liver function in pt with preexisting chronic liver disease
acute-on-chronic liver failure
43
massive hepatic necrosis with impaired consciousness occurring within 8 weeks of onset of illness - **rapidly shrinking liver size + rapidly rising bilirubin level** - marked prolongation of PT - disorientation, somnolence, ascites, edema
fulminant hepatitis
44
what is the tx/management of fulminant hepatitis?
supportive, maintenance of fluid balance, support of circulation, respiration - oral lactulose and neomycin administered - meticulous intensive care + prophylactic abx coverage can improve survival - consider liver transplant
45
what is the dx of chronic hepatitis?
biopsy -> histologic classification classified based on: - grade (necrosis and inflammatory activity) - stage (disease progression/degree of fibrosis)
46
classic, ANA (most common) and/or ASA (anti-smooth muscle antibodies)
Type 1 autoimmune hepatitis
47
associated with anti-liver/kidney microsomal (anti-LKM antibodies)
Type 2 autoimmune hepatitis
48
what is the dx of AIH?
* *serologic abnormalities** - type 1: hypergammaglobulinemia, smooth muscle Ab, ANA - type 2: anti-LKM Ab **serum aminotransferase levels may be greater than 1000 units/L, and total bilirubin is usually increased
49
what is the tx of AIH?
**glucocorticoids** complications: leads to cirrhosis -> increased risk HCC
50
excessive alcohol use can cause fatty liver - exceeds 80g/day in men and 30-40g/day in women - Hep B and C may be cofactors in dvlpment of liver disease
alcohol liver disease
51
asymptomatic -> severe liver failure with jaundice, ascites, GI bleeding, encephalopathy - typical anorexia, nausea vomiting, fever, jaundice, tender hepatomegaly and RUQ pain - **2:1 AST:ALT ratio** - Mallory-Denk bodies
alcohol liver disease
52
what is the main risk of alcoholic cirrhosis?
> 50 grams of alcohol (5 drinks) daily for over 10 years
53
what is the tx/management of alcohol liver disease?
abstinence from alcohol! - glucose administration increase the thiamine requirement and can precipitate Wernicke-Korsakoff syndrome if thiamine is not coadministered - if severe, can consider Pentoxifylline or liver transplantation (pt's must abstain from alcohol for 6 months to be considered)
54
what are the complications of alcoholic liver disease?
- Wernicke encephalopathy (confusion/ataxia) - Korsakoff syndrome (severe memory issues) - adverse prognostic factor: critically ill pts with alcoholic hepatitis have 30-day mortality rates >50%
55
what does the Glasgow Alcoholic hepatitis score predict?
mortality based on: - age - serum bilirubin - BUN - prothrombin time - peripheral WBC count
56
what is a Model for End-Stage Liver Disease (MELD) score > 21 associated with?
significant mortality in alcoholic hepatitis
57
triad: (only 10% have all 3) - confusion - ataxia (staggering/stumbling/lack coordination) - treat with thiamine
Wernicke encephalopathy
58
- permanent - progressive from Wernicke - severe memory issues - confabulate/make up stories to fill in gaps
Korsakoff syndrome
59
a way to estimate disease severity and mortality risk in patients with alcoholic hepatitis - patients with a DF value > 32: have high short-term mortality and may benefit from treatment with **glucocorticoids** - those with lower scores have low short term-mortality and do not appear to benefit from glucocorticoids
Maddrey discriminant function
60
what does a GAH score > 9 mean?
survival benefit for those who received glucocorticoids compared with those who did not
61
what does a GAH score < 9 mean?
no survival benefit with glucocorticoids
62
what is the threshold used to allow diagnosis of NAFLD?
<20 g of alcohol per day in women and <30g in men
63
what is steatosis? | what is steatohepatitis?
``` steatosis = fatty liver steatohepatitis = fatty liver than causes liver inflammation ```
64
what is the most common cause of chronic liver disease in the US?
NAFLD
65
obesity, DM, hypertriglyceridemia in association with insulin resistance as part of the metabolic syndrome -> increased risk for cardiovascular disease, chronic kidney disease and colorectal cancer
principal causes of NAFLD
66
asymptomatic, or may have mild RUQ discomfort - hepatomegaly is up to 75% of cases - labs may show mildly elevated aminotransferase and alk phos - macrovascular steatosis may be seen on US or CT - **biopsy: focal infiltration by polymorphonuclear neutrophils and Mallory hyaline** indistinguishable from alcoholic hepatitis and referred to as nonalcoholic steatohepatitis (NASH)
NAFLD
67
what is the tx of NAFLD?
lifestyle modification - weight loss, dietary fat restriction, exercise, vitamin E - statins are NOT contraindicated
68
HFE gene mutation on chromosome 6 - men>women - elevated iron saturdation or serum ferratin - increased accumulation of iron as hemosiderin in liver, pancreas, heart, adrenals, testes, pituitary, and kidneys - hepatic and pancreatic insufficiency, heart failure, and hypogonadism may develop
hemochromatosis | - increased iron absorption in the duodenum
69
what is the classic tetrad of hemochromatosis?
- cirrhosis with hepatomegaly - abnormal skin pigmentation - DM - cardiac dysfunction
70
what are the later clinical manifestations of hemochromatosis?
- arthropathy (and ultimate need of joint replacement) - hepatomegaly - skin pigmentation - DM - ED in men
71
- elevated plasma iron with greater than 45% transferrin saturation - elevated serum ferretin - liver biopsy: homozygous for C282Y - HFE mutation
hemochromatosis
72
what is the tx/management of hemochromatosis?
- avoid foods right in iron - weekly phlembotomies of blood - PPI -> reduces intestinal iron absorption - chelating agent deferoxamine (for pt with hemochromatosis and anemia)
73
what is the main association/complication that McGowan wants us to know with hemochromatosis?
Yersinia infection
74
AR, mutation in ATP7B - people under age 40 - results in impaired copper excretion into bile and a failure to incorporate copper into ceruloplasmin - leads to hemolytic anemia (copper is toxic to RBC) - liver disease in adolescents and neuropsychiatric disease in young adults
Wilson disease
75
what is the pathognomic sign of Wilson disease?
Kayser-Fleischer rings (brown-green rings around the iris) | - represents fine pigmented granular deposits in Descemet membrane in the cornea
76
elevated liver enzymes: - AST/ALT - alk phos - bilirubin - **low serum ceruloplasmin** molecular analysis of ATP7B mutations can be diagnostic
Wilson disease | - tx: **oral penicillamine** increases urinary extretion of chelated copper
77
AR, defective a1AT - most commonly diagnosed inherited hepatic disorder in infants and children - Pi gene chromosome 14 - development of pulmonary (panacinar) emphysema - causes liver disease as a consequence of hepatocellular accumulation of the misfolded protein
alpha-1 antitrypsin deficiency | - tx: smoking abstinence/cessation and liver transplant
78
``` HBsAg: + HBcAb IgM: + HBcAb IgG: + HBeAg: + HBV DNA: + ``` HBs Ab: -
chronic Hep B infection
79
- African Americans have higher rate of chronic disease, but lower fibrosis - coffee slows progression - pts have normal AST/ALT - high risk of cirrhosis and HCC (higher risk in genotype 1b)
chronic HCV
80
passive congestion of the liver **nutmeg liver** - ischemic hepatitis = ischemic hepatopathy, hypoxic hepatitis, shock liver, acute cardiogeneic liver injury - statin therapy prior to admission may protect against ischemic hepatitis - **hepatojugular reflex is present** -> tricuspic regurg may be pulsatile - jaundice associated with worse outcomes
right heart failure
81
- markedly elevated serum N-terminal-proBNP or BNP - rapid and striking **elevation of serum aminotransferase** (often greater than 5000 units/L) - **early rapid rise in the serum lactate dehydrogenase**
right heart failure
82
development of liver fibrosis to the point that there is architectural distortion with formation of regenerative nodules -> decreased liver function
cirrhosis mexican and blacks > whites
83
what are the 3 types of cirrhosis?
1. compensated 2. compensated with varices 3. decompensated
84
what has been reported to reduce the risk of cirrhosis?
higher coffee and tea consumption
85
- spider telangiectasias - palmar erythema - dupuytren contractures - glossitis and cheilosis - jaundice - caput medusae - asterixis
signs of cirrhosis
86
what are the diagnostic studies of cirrhosis?
- CBC: pancytopenia, anemia - prolonger PT/INR - glucose disturbances - hypoalbuminemia
87
definitive diagnosis of cirrhosis depends on what?
liver biopsy | - histologic classification (grade and stage)
88
what is the tx/management of cirrhosis?
* *abstinence from alcohol!** - pts should receive HAV, HBV, pneumococcal, and yearly flu vaccines - **transjugular intrahepatic portosystemic shunt (TIPS/TIPSS)** * *NSAIDS ARE CONTRAINDICATED** - Ang-converting enzyme inhibitors and Ang II antagosnists should be avoided
89
SAAG > 1.1 g/dL
- portal HTN | - myxedema
90
SAAG < 1.1 g/dL
- hypoalbuminemia | - diseased peritoneum (peritonitis, peritoneal cancer)
91
increasing abdominal girth - alcohol consumption, transfusions, tattoos, IV drug use, hx of viral hepatitis or jaundice - fevers -> infected peritoneal fluid - PE: elevated JVP, **asterixis, shifting dullness**
ascites
92
what diagnostic tool reliably establishes the presence of fluid?
abd US + Doppler - abdominal paracentesis: development of fever, adb pain, rapidly declining renal function, or worsened hepatic encephalopathy -> **exclude SPONTANEOUS BACTERIAL PERITONITIS**
93
what are the routine studies on ascitic fluid?
CBC: - **WBC with diff = most important test** -> increase in ascitic white blood cell count highly suggestive of SBP - albumin: serum-ascites albumin gradient (SAAG) is best single test for ascites classification
94
how is SAAG calculated?
subtract ascitic fluid albumin from serum albumin | - the gradient correlates directly with portal pressure
95
alteration in mental status and cognitive function occuring in the presence of liver failure - elevated ammonia levels - confusion, slurred speech, change in personality, asterixis (flapping tremor) - precipitated by GI bleeding, azotemia, constipation
hepatic encephalopathy | - tx: **lactulose, or rifaximin if lactulose not tolerated**
96
spontaneous bacterial infection - occurs in the absence of apparent intra-abdominal source of infection - caused by monomicrobial infection - NOT assoc with anaerobic bacteria - hx of chronic liver disease and ascites
SBP - **IMPERATIVE THAT ANY PATIENT PRESENTING WITH ASCITES, ESPECIALLY WITH INFECTION SX GET A PARACENTESIS TO RULE OUT SBP**
97
what is the dx of SBP?
- **WBC count with diff is MOST important test** (NL = less than 500 leukocytes, less than 250 PMNs) - ascitic fluid PMN count GREATER THAN 250
98
what is the most effective tx of SBP?
liver transplant - empiric abx: third-generation cephalosporin IV (ceftriaxome) NOTE: kidney injury develops in 40% of patients and is a major cause of death
99
what must spontaneous bacterial peritonitis be distinguished from?
SECONDARY bacterial peritonitis - secondary: ascitic fluid has become secondarily infected by an intra-abdominal infection - tx: broad-spectrum abx
100
male: female ratio 4:1 - tumor usually develops in cirrhotic liver - high incidence in Asia and Africa - *Aflatoxin* exposure contributes to etiology and leaves molecular signature -> mutation in codon 249 of p53 gene
HCC
101
* pt with known liver disease develops an abnormality on - US - rising AFP * abnormal liver function tests/liver enzymes
HCC
102
what is the tx/management of HCC?
- surgical resection or liver transplantation - radiofrequency ablation - transcatheter arterial embolization (TACE)
103
stones in common bile duct
choledocolithiasis | - tx: **ERCP with sphincterotomy and stone extraction**
104
charcot triad: RUQ pain, fever, jaundice Raynold pentad: triad + altered mental status, hypotension labs show positive blood culture for E.coli, klebsiella, or enterococcus
ascending cholangitis
105
chronic liver diease - autoimmune destruction of small intrahepatic bile ducts and cholestasis - asymptomatic isolated elevation in alk phos - PE: pruritis, jaundice, *xanthelasma* - dx: positive AMA in 90-95%, elevated serum alk phos, bilirubin, cholesterol, and IgM - biopsy: **florid duct lesion**
primary biliary cirrhosis/cholangitis (PBC) | - tx: ursodeoxycholic acid, calcium and vit D given for osteoporosis
106
- associated with IBD (primarily UC) - men (20-50 years old) - **beads on a string** on MRCP or ERCP - **onion skinning** on liver biopsy - smoking and coffee consumption decrease risk of UC and PSC - associated with increased risk of cholangiocarcinoma
primary sclerosing cholangitis (PSC) - no proven therapy exists - symptomatic treatment with steroids, bile salt chelators for pruritis - liver transplant
107
female - 95% AMA positive - florid duct lesions and loss of small ducts only
primary biliary cirrhosis
108
male - 70% associated with IBD - 65% ANCA positive - strictures and beading of large bile ducts, pruning of smaller ducts
primary sclerosing cholangitis
109
occlusion of hepatic veins or IVC - caval webs (on venography), right sided heart failure - hypercoaguable state (75% of patients) - in India, China, South Africa is associated with poor standard of living - tender, painful hepatic enlargement (RUQ pain), jaundice, splenomegaly, ascites, nutmeg liver - imaging: prominent caudate liver lobe - **screening test of choice is contrast-enhanced CEUS** - color or pulsed-Doppler US
Budd-Chiari syndrome | - tx: symptomatic, sometimes anticoag or thrombolytic therapy
110
painless jaundice, weight loss, steatorrhea - if there is pain, is worse at night laying down - trousseau sign of malignancy - courvoisier sign - **CA19-9 elevated**
pancreatic cancer
111
conjugated hyperbilirubinemia - reduced excretory function of hepatocytes - benign, asymptomatic hereditary jaundice - gallbladder does not visualize on oral cholecystography - **liver DARKLY PIGMENTED on gross exam**
Dubin-Johnson syndrome
112
conjugated hyperbilirubinemia - reduced hepatic reuptake of bilirubin conjugates - similar to Dubin-Johnson, but liver is NOT pigmented, and the gallbladder IS visualized on oral cholecystography
Rotor syndrome
113
predominantly conjugated hyperbilirubinemia - cholestasis - benign cholestatic jaundice, usually occuring in third trimester of pregnancy - itching, GI symptoms, abnormal liver excretory function tests - cholestasis noted on liver biopsy - excellent prognosis, but recurrence with subsequent pregnancies or use of oral contraceptives
intrahepatic cholestasis of pregnancy