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Internal Medicine > JH IM Board Review - Acute and Chronic Liver Disease III > Flashcards

JH IM Board Review - Acute and Chronic Liver Disease III Flashcards

1
Q

Liver diseases of pregnancy (6):

A
  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.
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2
Q

Hyperemesis gravidarum - Symptoms/signs:

A
  1. Intractable N/V.

2. Dehydration in 1st trimester.

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3
Q

Hyperemesis gravidarum - Labs:

A
  1. Bil up to 5x normal.

2. AST/ALT rarely 20x normal.

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4
Q

Hyperemesis gravidarum - Tx:

A
  1. Antiemetics.

2. IV hydration.

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5
Q

Hyperemesis gravidarum - Mortality risk: Mother/fetus:

A

-/- (resolves spontaneously).

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6
Q

Intrahepatic cholestasis of pregnancy - Symptoms/signs:

A
  1. Pruritus.
  2. Jaundice.
  3. Steatorrhea in 2nd and 3rd trimester.
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7
Q

Intrahepatic cholestasis of pregnancy - Labs:

A
  1. Bil up to 5x normal.
  2. AST/ALT up to 20x normal.
  3. Bile acid up to 100x normal.
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8
Q

Intrahepatic cholestasis of pregnancy - Tx:

A
  1. UDCA.
  2. Dexamethasone.

==> Deliver if fetal distress.

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9
Q

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

A

-/Low.

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10
Q

Preeclampsia/eclampsia - Symptoms/signs:

A
  1. HTN.
  2. Edema.
  3. Proteinuria.
  4. Seizures/coma in late 2nd or 3rd trimester.
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11
Q

Preeclampsia/eclampsia - Labs:

A
  1. Bil <5mg/dL.

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

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12
Q

Preeclampsia/eclampsia - Tx:

A
  1. Tx HTN and edema.
  2. MgSO4.
  3. Deliver in severe cases.
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13
Q

Preeclampsia/eclampsia - Mortality risk: Mother/fetus:

A

+/Low.

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14
Q

HELLP syndrome - Symptoms/signs:

A
  1. RUQ pain.
  2. N/V.
  3. HTN.
  4. Edema.
  5. Proteinuria in late 2nd/3rd trimester or postpartum period.
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15
Q

HELLP syndrome - Labs:

A
  1. AST/ALT up to 10 to 20x normal.
  2. Low haptoglobin.
  3. LDH >600 U/L.
  4. Platelets <100K.
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16
Q

HELLP syndrome - Tx:

A

Delivery.

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17
Q

HELLP syndrome - Mortality risk: Mother/fetus:

A

+/+.

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18
Q

Acute fatty liver of pregnancy - Symptoms/signs:

A
  1. RUQ pain.
  2. N/V.
  3. Fatigue.
  4. Jaundice.
  5. Ascites.
  6. Encephalopathy.
  7. Renal failure in 3rd trimester.
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19
Q

Acute fatty liver of pregnancy - Labs:

A
  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.
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20
Q

Acute fatty liver of pregancy - Tx:

A

Delivery.

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21
Q

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

A

+/+.

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22
Q

Hepatic rupture - Symptoms/signs:

A
  1. Severe abdominal pain.

2. Shock in 3rd trimester.

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23
Q

Hepatic rupture - Labs:

A

Variable.

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24
Q

Hepatic rupture - Tx:

A

Immediate surgery.

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25
Q

Hepatic rupture - Mortality risk: Mother/fetus:

A

+/+.

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26
Q

HCV - Virus info:

A

Heterogeneous RNA virus with at least 6 major genotypes.

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27
Q

HCV - Genotypes vary with geographic distribution?

A
  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.
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28
Q

HCV - Overall global prevalence:

A

2-3%.

Highest in Africa (Eg Egypt), eastern Mediterranean region, and Southeast Asia.

==> Can reach 50% among IVDA.

29
Q

MC hepatotropic infection in the USA:

A

HCV infection.

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

30
Q

HCV - Chronicity:

A

60-85% ==> Adults.

55-70% ==> Pediatric.

31
Q

HCV - What may accelerate the progression of fibrosis?

A
  1. Heavy alcohol use.
  2. Older age at initial HCV infection.
  3. Obesity.
  4. Co-infection with HIV.
32
Q

Risk factors for HCV infection include:

A
  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).
33
Q

HCV - Incubation:

A

2-12 weeks.

==> Acute infections are usually mild/asymptomatic.

34
Q

HCV - Jaundice?

A

<20%.

==> MAY be associated with incr. spontaneous viral clearance.

35
Q

Common symptoms of chronic HCV?

A
  1. Fatigue.
  2. Anorexia.
  3. Myalgias/Arthralgias.
36
Q

HCV - Progression to cirrhosis?

A

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

37
Q

HCV - Once cirrhotic …?

A

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

3% ANNUAL RISK OF HCC.

38
Q

HCV - Extrahepatic manifestations:

A
  1. Mixed cryoglobulinemia.
  2. Leukocytoclastic vasculitis.
  3. Membranous GN.
  4. Porphyria cutanea tarda.
  5. Insulin resistance.
  6. NHL.
39
Q

HCV - Dx - Screening:

A

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.

40
Q

HCV - Dx - Check serum HCV RNA if:

A
  1. Anti-HCV positive.
  2. Considering antiviral Tx.
  3. Suspicion for infection remains despite negative anti-HCV.
41
Q

HCV - Role of HCV RNA?

A
  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.
42
Q

Why to obtain HCV genotyping?

A

To guide appropriate antiviral Tx.

43
Q

HCV - Single-nucleotide polymorphism at the …?

A

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

44
Q

HCV - CC genotype?

A

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

45
Q

HCV - TT genotype?

A

Least favorable.

46
Q

HCV - Frequency of C allele?

A

Highest ==> East Asia.

Intermediate ==> Europe.

Lowest ==> Africa.

47
Q

HCV - What is useful for prognosis to ascertain?

A
  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.
48
Q

HCV - Role of aminotransferases:

A

Do NOT help differentiate the presence or absence of disease.

==> 25-50% of chronic HCV pts may have persistently NORMAL levels.

49
Q

Historical Tx for chronic HCV:

A

Pegylated IFN + Ribavirin +/- NS3/4A PI (ie telaprevir or boceprevir) for UP TO 12 MONTHS.

==> 30-70% EFFECTIVE with side effects.

50
Q

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

A
  1. Simeprevir ==> NS3/4A PI.
  2. Sofosbuvir ==> NS5B POLYMERASE inhibitor.

==> Recommended regimens vary depending on HCV genotype and Hx of HCV Tx.

51
Q

First-ever IFN-free regimen for chronic HCV?

A

Sofosbuvir and Ledipisvir.

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

52
Q

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

A

Routine lab tests + TSH.

53
Q

Tx is generally recommended for acute HCV that …?

A

Does NOT spontaneously clear within 12 WEEKS.

54
Q

ACUTE HCV Tx:

A
  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.

55
Q

HDV - Requires?

A

Presence of HBsAg FOR INFECTION + REPLICATION.

56
Q

HDV - Prevalence?

A
  1. Mediterranean countries.
  2. East Africa.
  3. Central and Northern Asia.
57
Q

HDV - CO-INFECTION:

A

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.

58
Q

HDV - Superinfection:

A

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.

59
Q

HDV - What MUST be present to diagnose HDV infection?

A

HBsAg.

60
Q

HDV - Dx - CO-INFECTION:

A
  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.
61
Q

HDV - Dx - SUPERINFECTION:

A
  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.
62
Q

HDV - Tx:

A

NO effective antiviral therapies exists for acute HDV.

63
Q

HDV - Tx - Role of IFN?

A

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.

64
Q

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

A

NO effect on HDV replication.

65
Q

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

A

25%.

66
Q

HEV - Incubation period?

A

2-8 week.

67
Q

HEV - Chronicity?

A

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

68
Q

HEV - Dx - Role of HEV RNA?

A

Measure HEV RNA titer in immunocompromised or post-transplant individuals.

==> Anti-HEV testing can be unreliable in this cohort.

69
Q

HEV - Tx:

A
  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.

Internal Medicine (106 decks)

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