JH IM Board Review - Acute and Chronic Liver Disease III

Question 1

Liver diseases of pregnancy (6):

Answer 1

1. Hyperemesis gravidarum.
2. Intrahepatic cholestasis of pregnancy.
3. Preeclampsia/eclampsia.
4. HELLP syndrome (subset of severe preeclampsia).
5. Acute fatty liver of pregnancy.
6. Hepatic rupture.

Question 2

Hyperemesis gravidarum - Symptoms/signs:

Answer 2

1. Intractable N/V.

2. Dehydration in 1st trimester.

Question 3

Hyperemesis gravidarum - Labs:

Answer 3

1. Bil up to 5x normal.

2. AST/ALT rarely 20x normal.

Question 4

Hyperemesis gravidarum - Tx:

Answer 4

1. Antiemetics.

2. IV hydration.

Question 5

Hyperemesis gravidarum - Mortality risk: Mother/fetus:

Answer 5

-/- (resolves spontaneously).

Question 6

Intrahepatic cholestasis of pregnancy - Symptoms/signs:

Answer 6

1. Pruritus.
2. Jaundice.
3. Steatorrhea in 2nd and 3rd trimester.

Question 7

Intrahepatic cholestasis of pregnancy - Labs:

Answer 7

1. Bil up to 5x normal.
2. AST/ALT up to 20x normal.
3. Bile acid up to 100x normal.

Question 8

Intrahepatic cholestasis of pregnancy - Tx:

Answer 8

1. UDCA.
2. Dexamethasone.

==> Deliver if fetal distress.

Question 9

Intrahepatic cholestasis of pregnancy - Mortality risk: Mother/fetus:

Answer 9

-/Low.

Question 10

Preeclampsia/eclampsia - Symptoms/signs:

Answer 10

1. HTN.
2. Edema.
3. Proteinuria.
4. Seizures/coma in late 2nd or 3rd trimester.

Question 11

Preeclampsia/eclampsia - Labs:

Answer 11

1. Bil <5mg/dL.

2. AST/ALT up to 10 to 20x normal.

Question 12

Preeclampsia/eclampsia - Tx:

Answer 12

1. Tx HTN and edema.
2. MgSO4.
3. Deliver in severe cases.

Question 13

Preeclampsia/eclampsia - Mortality risk: Mother/fetus:

Answer 13

+/Low.

Question 14

HELLP syndrome - Symptoms/signs:

Answer 14

1. RUQ pain.
2. N/V.
3. HTN.
4. Edema.
5. Proteinuria in late 2nd/3rd trimester or postpartum period.

Question 15

HELLP syndrome - Labs:

Answer 15

1. AST/ALT up to 10 to 20x normal.
2. Low haptoglobin.
3. LDH >600 U/L.
4. Platelets <100K.

Question 16

HELLP syndrome - Tx:

Answer 16

Delivery.

Question 17

HELLP syndrome - Mortality risk: Mother/fetus:

Answer 17

+/+.

Question 18

Acute fatty liver of pregnancy - Symptoms/signs:

Answer 18

1. RUQ pain.
2. N/V.
3. Fatigue.
4. Jaundice.
5. Ascites.
6. Encephalopathy.
7. Renal failure in 3rd trimester.

Question 19

Acute fatty liver of pregnancy - Labs:

Answer 19

1. Bil commonly <5mg/dL, but HIGHER in severe disease.
2. AST/ALT up to 1000.
3. Hyperammonemia.
4. Azotemia.
5. Hypoglycemia.
6. DIC can develop.

Question 20

Acute fatty liver of pregancy - Tx:

Answer 20

Delivery.

Question 21

Acute fatty liver of pregnancy - Mortality risk: Mother/fetus:

Answer 21

+/+.

Question 22

Hepatic rupture - Symptoms/signs:

Answer 22

1. Severe abdominal pain.

2. Shock in 3rd trimester.

Question 23

Hepatic rupture - Labs:

Answer 23

Variable.

Question 24

Hepatic rupture - Tx:

Answer 24

Immediate surgery.

Question 25

Hepatic rupture - Mortality risk: Mother/fetus:

Answer 25

+/+.

Question 26

HCV - Virus info:

Answer 26

Heterogeneous RNA virus with at least 6 major genotypes.

Question 27

HCV - Genotypes vary with geographic distribution?

Answer 27

1. Genotype 1 ==> North/South Americas, Australia, Europe. 2. Genotype 4 ==> Middle East and Egypt. 3. Genotype 5 ==> South Africa. 4. Genotype 6 ==> Southeast Asia.

Question 28

HCV - Overall global prevalence:

Answer 28

2-3%. Highest in Africa (Eg Egypt), eastern Mediterranean region, and Southeast Asia. ==> Can reach 50% among IVDA.

Question 29

MC hepatotropic infection in the USA:

Answer 29

HCV infection. ==> 4 million people estimated to be Anti-HCV positive.

Question 30

HCV - Chronicity:

Answer 30

60-85% ==> Adults. 55-70% ==> Pediatric.

Question 31

HCV - What may accelerate the progression of fibrosis?

Answer 31

1. Heavy alcohol use. 2. Older age at initial HCV infection. 3. Obesity. 4. Co-infection with HIV.

Question 32

Risk factors for HCV infection include:

Answer 32

1. Birthdate from 1945-1965. 2. History of IVDA. 3. Transfusions or organ transplants before 1992. 4. Hx of long-term hemodialysis. 5. HIV infection. 6. Vietnam war era veterans. 7. Known exposures to HCV (including being born to HCV-positive mothers).

Question 33

HCV - Incubation:

Answer 33

2-12 weeks. ==> Acute infections are usually mild/asymptomatic.

Question 34

HCV - Jaundice?

Answer 34

<20%. ==> MAY be associated with incr. spontaneous viral clearance.

Question 35

Common symptoms of chronic HCV?

Answer 35

1. Fatigue. 2. Anorexia. 3. Myalgias/Arthralgias.

Question 36

HCV - Progression to cirrhosis?

Answer 36

Approx. 20% of pts progress to cirrhosis after 20yrs of chronic HCV.

Question 37

HCV - Once cirrhotic ...?

Answer 37

4% ANNUAL RISK OF CLINICAL DECOMPENSATION (eg ascites). 3% ANNUAL RISK OF HCC.

Question 38

HCV - Extrahepatic manifestations:

Answer 38

1. Mixed cryoglobulinemia. 2. Leukocytoclastic vasculitis. 3. Membranous GN. 4. Porphyria cutanea tarda. 5. Insulin resistance. 6. NHL.

Question 39

HCV - Dx - Screening:

Answer 39

Anti-HCV is the 1st line screening test. ==> It indicates past or chronic HCV infection, but does NOT imply immunity. ==> Anti-HCV becomes detectable within 2-3 months postinfection, so it may miss acute cases.

Question 40

HCV - Dx - Check serum HCV RNA if:

Answer 40

1. Anti-HCV positive. 2. Considering antiviral Tx. 3. Suspicion for infection remains despite negative anti-HCV.

Question 41

HCV - Role of HCV RNA?

Answer 41

1. Presence of HCV RNA suggests active viral replication. 2. HCV RNA is detectable in serum within 2 weeks of infection. 3. Persistence for more than 6 months defines chronic HCV infection. 4. RNA titer does NOT correlate with disease activity or progression.

Question 42

Why to obtain HCV genotyping?

Answer 42

To guide appropriate antiviral Tx.

Question 43

HCV - Single-nucleotide polymorphism at the ...?

Answer 43

IL28B gene on chr. 19 ==> Predicts SPONTANEOUS VIRAL CLEARANCE AND RESPONSE TO ANTIVIRAL Tx.

Question 44

HCV - CC genotype?

Answer 44

Associated with the most favorable spontaneous and Tx-induced clearance rates.

Question 45

HCV - TT genotype?

Answer 45

Least favorable.

Question 46

HCV - Frequency of C allele?

Answer 46

Highest ==> East Asia. Intermediate ==> Europe. Lowest ==> Africa.

Question 47

HCV - What is useful for prognosis to ascertain?

Answer 47

1. Liver fibrotic stage + Degree of inflammatory activity. 2. Liver Bx is gold standard but invasive. 3. Non invasive options ==> Serum biomarkers + Imaging (MRI/US) with elastography.

Question 48

HCV - Role of aminotransferases:

Answer 48

Do NOT help differentiate the presence or absence of disease. ==> 25-50% of chronic HCV pts may have persistently NORMAL levels.

Question 49

Historical Tx for chronic HCV:

Answer 49

Pegylated IFN + Ribavirin +/- NS3/4A PI (ie telaprevir or boceprevir) for UP TO 12 MONTHS. ==> 30-70% EFFECTIVE with side effects.

Question 50

In 2013, 2 new direct-acting antivirals (DAAs) were approved for Tx of chronic HCV:

Answer 50

1. Simeprevir ==> NS3/4A PI. 2. Sofosbuvir ==> NS5B POLYMERASE inhibitor. ==> Recommended regimens vary depending on HCV genotype and Hx of HCV Tx.

Question 51

First-ever IFN-free regimen for chronic HCV?

Answer 51

Sofosbuvir and Ledipisvir. ==> >90% success rates after 12-24 WEEKS of Tx.

Question 52

HCV - Use of IFN and ribavirin requires monitoring of ...?

Answer 52

Routine lab tests + TSH.

Question 53

Tx is generally recommended for acute HCV that ...?

Answer 53

Does NOT spontaneously clear within 12 WEEKS.

Question 54

ACUTE HCV Tx:

Answer 54

1. Viral response to CONVENTION Tx is significantly better. | 2. Peg-IFN MONOTHERAPY FOR AT LEAST 12 WEEKS results in viral clearance in 80-90% of acute HCV.

Question 55

HDV - Requires?

Answer 55

Presence of HBsAg FOR INFECTION + REPLICATION.

Question 56

HDV - Prevalence?

Answer 56

1. Mediterranean countries. 2. East Africa. 3. Central and Northern Asia.

Question 57

HDV - CO-INFECTION:

Answer 57

Biphasic aminotransferase elevations separated by a few weeks because of distinct acute effects of HBV and HDV. ==> Chronic HDV infection occurs in only 2% of cases.

Question 58

HDV - Superinfection:

Answer 58

Hepatitis is more severe with higher rates of FULMINANT LIVER DISEASE (more common in HDV than other types of viral hep). ==> Progression to chronic infection in more than 90% of cases.

Question 59

HDV - What MUST be present to diagnose HDV infection?

Answer 59

HBsAg.

Question 60

HDV - Dx - CO-INFECTION:

Answer 60

1. Positive anti-HDV IgM is preceded by the appearance of anti-HBc-IgM 1 to 2 weeks EARLIER. 2. Anti-HDV IgM disappears after 1.5-3 months, and is followed by anti-HDV IgG positivity. 3. HDAg appears early in serum but is short-lived (because of sequestration in antibody complexes), thus often escapes detection.

Question 61

HDV - Dx - SUPERINFECTION:

Answer 61

1. Rising titers of BOTH anti-HDV IgM + anti-HDV IgG. 2. Early and short-lived presence of serum HDAg. 3. Negative anti-HBc IgM + Positive anti-HBc IgG.

Question 62

HDV - Tx:

Answer 62

NO effective antiviral therapies exists for acute HDV.

Question 63

HDV - Tx - Role of IFN?

Answer 63

1y course of standard IFN-a or Peg-IFN offers modest efficacy for viral suppression in chronic HDV. ==> Peg-IFN tends to be better tolerated. ==> CONTRA IN DECOMPENSATED LIVER DISEASE.

Question 64

HDV - Tx - Role of nucleos(t)ide analogues used against HBV?

Answer 64

NO effect on HDV replication.

Question 65

HEV - Anti-HEV has seroprevalence of approx ...% in the USA.

Answer 65

25%.

Question 66

HEV - Incubation period?

Answer 66

2-8 week.

Question 67

HEV - Chronicity?

Answer 67

RARE ==> In post-liver tranplant or HIV.

Question 68

HEV - Dx - Role of HEV RNA?

Answer 68

Measure HEV RNA titer in immunocompromised or post-transplant individuals. ==> Anti-HEV testing can be unreliable in this cohort.

Question 69

HEV - Tx:

Answer 69

1. Often a mild disease course where supportive care is sufficient. 2. Ribavirin 600 to 8000mg daily for 3 to 6 months associated with viral clearance in immunocompromised pts.