Lecture 11: Diseases of the Liver Flashcards
1
Q
Anorexia, nausea, vomiting, malaise, and aversion to smoking are characteristic early symptoms of which viral infections?
A
HAV and HBV
2
Q
What is the #1 risk factor for contracting HAV?
A
International travel
3
Q
Detection of what antibody is an excellent test for diagnosing ACUTE HAV?
A
IgM anti-HAV
4
Q
Glomerulonephritis, serum sickness, and polyarteritis nodosa are symptoms that may arise with what type of hepatitis viral infection?
A
HBV
5
Q
Which labs may be elevated in HAV infection?
A
- Markedly elevated AST/ALT
- Elvated bilirubin and alkaline phosphatase = Cholestasis
6
Q
Which antibody indicates immunity/clearance of HBV?
A
Anti-HBs Ab
7
Q
Persistence of what in the serum for >6 months after acute illness w/ HBV signifies a chronic HBV infection?
A
HBsAg
8
Q
Which antibody appears during acute HBV infection and persists indefinetely?
A
IgG anti-HBc
9
Q
Which subset of patients have shown chronic infections due to HEV with progression to cirrhosis?
A
Transplant pts treated w/ tacrolimus
10
Q
If an unvaccinated person is exposed to HBV (i.e., during sex or at birth) what is the recommended therapy?
A
- Give hepatitis B immunoglobulin (HBIG) immediately up to 14 days post-exposure
- Also give them the vaccine (3 doses)
11
Q
What is the most sensitive indicator of HCV infection?
A
HCV RNA
12
Q
If a patient is found to have anti-HCV in serum, without HCV RNA in the serum what does this indicate?
A
Recovery from prior HCV infection
13
Q
What is the effect of chronic HCV infection on serum cholesterol levels?
A
Decreased
14
Q
What is the only marker found in the serum during the “window period” of HBV infection?
A
IgM anti-HBc Ab
15
Q
Which hepatitis viruses can become chronic?
A
- HBV
- HCV
- HDV (w/ HBV)
16
Q
Mixed cryiglobulinemia is an extraintestinal manifestation associated with chronic infection by which virus?
A
HCV
17
Q
Which 2 tests can ID presence or absence of fibrosis (cirrhosis) in chronic hepatitis?
A
- Serum FibroSure and/or
- US elastography
18
Q
What are 2 drugs associated with idiosyncratic drug induced liver injury?
A
- Isoniazid
- Sulfonamides
19
Q
What are 2 common dose-depent causes of drug/toxin induced liver injury?
A
- Mushroom poisoning
- Acetaminophen
20
Q
What is the specific therapy used in treating acetaminophen OD’s?
Important to check acetaminophen at what time period?
A
- Treat w/ sulfhydryl compounds (N-acetylcysteine aka NAC)
- Important to get a 4 hour acetaminophen level
21
Q
How soon should therapy be administered for somone who ingests a toxic dose of acetaminophen?
A
Within 8 hours, but may be effective if given as late as 24-36 hrs after OD
22
Q
Which tool is used during the assessment/treatment of someone with a suspected Acetaminophen OD?
A
Rumack-Matthew Nomogram
23
Q
Massive hepatic necrosis with impaired consciousness occuring within 8 weeks of the onset of illness is known as?
A
Fulminant Hepatitis
24
Q
What are the findings that when summed together equal hepatic failure with encephalopathy?
What is occuring to levels of aminotransferases?
A
- Rapidly shrinking liver + Rapidly rising bilirubin + marked prolongation of the PT + clinical signs of confusion, disorientation, somnolence, ascites, and edema
- Even as aminotransferase levels fall!
25
The intake of what should be restricted in a patient with hepatic failure + encephalopathy?
Protein
26
Which drugs should be administered in someone suffering from hepatic failure w/ encephalopathy?
**Lactulose** or **Neomycin**
27
Meticulous intensive care + _____________ = one factor that **improves** survival in patients with hepatic failure + encephalopathy?
Prophylactic **antibiotic** coverage
28
Which 2 values are used to calculate a Maddrey's discriminant function?
Used in which patients to assess what?
- **PT** and **serum bilirubin**
- Used to **assess risk of mortality** in pts with **alcoholic hepatitis**
29
Which calculated value associated w/ a **Maddrey's discriminant function** indicates a **poor prognosis** in pts with alcoholic hepatitis?
≥32
30
A score of what calculated using the Model for End-Stage Liver Disease (MELD) is associated w/ significant mortality in alcoholic hepatitis?
**\>21**
31
Glasgow Alcoholic Hepatitis Score predicts mortality using which 5 factors?
Patients receiving which drug and a score of ≥9 have higher survival rates than those who didn't?
- Age, **Serum bilirubin**, BUN, **PT**, and peripheral WBC count
- ≥9 who received **glucocorticoids**
32
In patients with alcoholic steatosis what may be the only laboratory abnormality?
**Mild liver enzyme elevations**
33
Leukocytosis with a shift to the left is common in patients in which stage of alcohol related liver damage?
**Severe alcoholic hepatitis**
34
A liver biopsy of a patient with alcoholic hepatitis will often have identical findings of what other disorder?
Nonalcoholic steatohepatitis
35
What are the serum levels of AlkPhos, GGT, and bilirubin like in a patient with alcoholic hepatitis?
Typically **elevated**
36
If glucose is administered during the treatment of somone with alcoholic hepatitis what must be added?
Thiamine --\> can precipitate Wernicke-Korsakoff if not given
37
A patient with alcoholic hepatitis should be given what supplements during treatment?
- Thiamine
- Daily MV
- Folic acid
- Zinc
38
Wernicke Encephalopathy vs. Korsakoff Syndrome?
**Wernicke** = confusion, ataxia, and involuntary eye movements
**Korsakoff** = severe memory issues, confabulation/making up stories
39
With severe alcoholic hepatitis (discriminant function ≥32 or MELD \>20) what therapy should be considered?
What is an alternative to this therapy and has demonstrated improved survival (decreased hepatorenal syndrome)?
- **Steroids**
- **Pentoxifylline** = has demonstrated improved survivial (decreased hepatorenal syndrome)
40
What is absolutely critical for a patient with severe alcoholic hepatitis to do if they are to be considered for a liver transplant?
**Abstain from alcohol for 6 months**
41
Which ethnic group are at increased risk for NAFLD?
Hispanics
42
What are 2 factors that protect against the development of NAFLD?
1) Coffee
2) Exercise
43
Which toxin is associated with fatty liver change?
Vinyl chloride
44
What is the histological characteristic of NAFLD?
Focal infiltration by **PMN's** and **Mallory hyaline**
45
Cirrhosis caused by NASH appears to be uncommon in which ethnic group?
African Americans
46
Lab values in person with NAFLD?
- **Mildly** elevated **Aminotransferase** and **AlkPhos**
- **80%** of patients with hepatic steatosis will have **normal labs!**
47
Most common signs and symptoms of PBC?
- **Pruritus**
- Fatigue
- Progressive jaundice
- **Xanthelasma**
48
What are 4 relevant pieces of someones hx that are risk factors for PBC?
1) **UTI's** (caused by *E. coli* or *L. delbrueckii)*
2) **Smoking**
3) Use of **Hormone Replacement Therapy**
4) **Hair dye**
49
Autoimmune hepatitis is associated with an increased risk for what cancer?
Heptaocellular CA
50
Which drug is used for the treatment of Autoimmune Hepatitis?
Glucocorticoids
51
Hemochromatosis typically manifests when?
**After** the age of **50**
52
Major clinical manifestations of Hemochromatosis?
- Hepatic abnormalities --\> Cirrhosis
- Heart failure
- Hypogonadism
- Arthritis
53
Patients with Hemochromatosis are at an increased risk for infection by what 3 organisms?
1. *Vibrio vulnificus*
2. *Listeria monocytogenes*
3. *Yersinia enterocolitica*
54
What are the major lab findings associated with Hemochromatosis?
- **Mildly** abnormal liver tests (ALT, AlkPhos)
- **Elevated plasma iron** w/ **GREATER** than **45% transferrin saturation**
- Elevated serum **ferritin**
55
What are 3 risk factors for advanced fibrosis in a patient w/ Hemochromatosis?
1. **Male sex**
2. **Excess alcohol consumption**
3. **Diabetes**
56
Iron studies and *HFE* testing should be done in whom?
ALL **first-degree family members**
57
What should patients with Hemochromatosis avoid in their diet?
- Foods rich in **iron** (i.e., **red meat**) + iron supplements
- Alcohol
- Vitamin C
- Raw shellfish
58
Which treatment is indicated for all symptomatic patients w/ Hemochromatosis?
Weekly **phlebotomies** of 1 or 2 units of blood
59
What can be given to patients that have **hemochromatosis + anemia** or w/ secondary iron overload due to **thalassemia who cannot tolerate phlebotomies?**
Deferoxamine
60
Wilson disease is associated with excess copper deposition in the tissue, especially in which 4 places?
- Liver
- Brain
- Cornea
- Kidney
61
Low serum _______ levels can be useful in the diagnosis of Wilson Disease
Ceruloplasmin
62
Budd-Chiari Syndrome is associated with __________ (painful/painless) hepatomegaly, jaundice, splenomegaly, and ascites
Budd-Chiari Syndrome is associated with **painful** hepatomegaly, jaundice, splenomegaly, and ascites
63
Caval webs and right-sided heart failure lead to what characteristic liver finding in Budd-Chiari Syndrome?
**Nutmeg liver** = **centrilobular congestion**
64
What is the screening test of choice for Budd-Chiari syndrome?
Which lobe of the liver will be most prominent?
- **Contrast**-enhanced **US (CEUS) ----\> Color** or **pulsed-Doppler US**
- Prominent **CAUDATE liver lobe**
65
Treatments of choice fo alpha-1 anti-trypsin deficiency?
- Smoking abstinence/cessation
- Liver transplant
66
Which therapy given prior to admission of someone with heart failure may protect against ischemic hepatitis?
Statin therapy
67
What are the hallmark lab findings associated with **ischemic hepatitis due to heart failure**?
- **Elevation of serum aminotrasnferase** levels, often **\>5000 units/L**
- Early **rapid** rise in the serum **LDH level**
68
In right heart failure and patients with passive congestion of the liver ("nutmeg liver") which reflux is present?
With tricuspid regurgitation what may be seen at the liver?
- **Hepatojugular reflux** is present
- With tricuspid regurgiation the **liver** may be **pulsatile**
69
What are the 3 major causes of **non-cirrhotic portal HTN**?
1. Portal vein thrombosis
2. Splenic vein obstruction = gastric varices w/o esophageal varices
3. Schistosomiasis
70
Treatment of thrombocytopenia with **eltrombopag** has been shown to be a risk factor for what?
Noncirrhotic Portal HTN
71
Symptoms/signs of noncirrhotic portal HTN?
Especially if due to acute portal vein thrombosis?
- **Acute portal vein thrombosis** usually causes **abdominal pain**
- Splenomegaly
- GI bleeding
72
If splenic vein thrombosis is the cause of variceal bleeding, which procedure is curative?
Splenectomy
73
What is the most common identifiable cause of hepatic abscess in the US?
Some cases (10%) due to what other causes?
- Ascending cholangitis **= most common**
- Appendicitis or Diverticulitis = **10% of cases**
74
What are the most frequently encountered organisms responsible for Hepatic Abscesses/Ascending Cholangitis?
- *E. coli*
- *Klebsiella pneumoniae*
- *Enterobacter aerogenes*
- *Proteus vulgaris*
75
Pyogenic liver abscess has been observed ti be associated with an increased risk of?
GI malignancy
76
What is the most common **benign** neoplasm of the liver?
How is most often discovered?
- Cavernous hemangioma
- Often **incidental finding** on US or CT
77
Cavernous hemangiomas are known to enlarge in whom?
**Woman** who take **hormonal therapy**
78
Which hypervascular mass found in the liver is not a true neoplasm, but instead a proliferation of hepatocytes in reponse to altered blood flow?
Focal nodular hyperplasia
79
Are oral contraceptives a risk factor for focal nodular hyperplasia of the liver?
Probably **NOT**
80
Which benign neoplasm of the liver occurs **most commonly in women** in the the **3rd-4th decades** of life?
Major risk factor?
- **Hepatocellular adenoma**
- Usually caused by **oral contraceptives**
81
Which benign neoplasm of the liver is **hyper**vascular and which is **hypo**vascular?
- **Focal nodular hyperplasia** = **HYPER**vascular
- **Hepatocellular adenoma** = **HYPO**vascular
82
The only physical finding in focal nodular hyperplasia or hepatocellular adenoma is what in a minority of cases?
Palpable abdominal mass
83
Which 2 imaging techniques can distinguish an hepatocellular adenoma from focal nodular hyperplasia in 80-90% of cases?
- **Arterial phase helical CT**, and
- **Multiphase dynamic MRI w/ contrast**
84
What is the treatment for focal nodular hyperplasia?
Discountinuation of OC's?
- OC's should **not necessarily be discontinued**
- Affected women should undero **annual US** for 2-3 yrs to ensure lesion is not enlarging
85
What is the treatment for Hepatocellular Adenomas?
Discountinuation of OC's?
- **Resection is advised** in all affected men/women in whom the tumor causes **sx's or is 5cm or \>** in diameter, even in absence of sx's
- Regression may follow cessation of OC's
86
What is the initial treatment for a Hepatocellular Adenoma that is complicated by hemorrhage?
Transarterial embolization
87
What are the 3 types of Cirrhosis which can be present?
1. Compensated
2. Compensated **w/ varices**
3. **De**compensated (ascites, variceal bleeding, encephalopathy, or jaundice)
88
Which dermatologic manifestations may be present with Cirrhosis?
- Palmar erythema
- Spinger telangiectasias
- Jaundice
- Glossitis and Cheilosis --\> related to vitamin deficiencies
89
A CBC of someone with Cirrhosis will characteristically show what?
PT time?
- **Anemia** (microcytic due to blood loss, macrocytic due to folate deficiency; hemolytic)
- **Pancytopenia** (hypersplenism)
- **Prolonged PT**
90
What are the characteristic chemistry labs (Na+, K+, glucose, and albumin) associated with Cirrhosis?
- **Hypo**natremia
- **Hypo**kalemic **alkalosis**
- Glucose disturbances
- **Hypo**albunimemia
91
Higher consumption of what has been reported to reduce risk of cirrhosis?
- Coffee
- Tea
92
Which GI malabsorption syndromes have been implicated in the development of Cirrhosis?
- Celiac disease
- Cystic Fibrosis
93
4 most common causes of Cirrhosis?
1. Alcohol
2. Chronic HCV infection
3. NAFLD
4. HBV infection
94
Definitive diagnosis of Cirrhosis often depends on?
Liver biopsy --\> percutaneous, jugular, or open
95
Which scoring system can be used to predict the severity of cirrhosis and risk of complications?
Child-Pugh scoring system
96
What findings/labs are necessary to use the Child-Pugh scoring system for cirrhosis?
- Order: CMP or Hepatic function panel (serum **bilirubin**, **albumin**), **PT/INR**
- PE for: **ascites** and **encephalopathy**
97
Patients with Cirrhosis are at increased risk for what metabolic sydrome?
What vitamin deficiency is often present?
- Diabetes mellitus
- Vitamin D deficiency
98
Elevation of the hepatic venous pressure gradient with portal HTN is associated with an increase in which pressure (Starling)?
Increased **hydrostatic pressure**
99
Portal vein thrombosis, Splenic vein thrombosis, and Massive Splenomegaly are \_\_\_\_\_-hepatic causes of portal HTN
Portal vein thrombosis, Splenic vein thrombosis, and Massive Splenomegaly are **pre**-hepatic causes of portal HTN
100
What are 2 sinusoidal causes of portal HTN?
1) Cirrhosis
2) Alcoholic hepatitis
101
Hepatic sinusoidal obstruction (venoocclusive syndrome) is classified as being a __________ cause of portal HTN
Hepatic sinusoidal obstruction (venoocclusive syndrome) is classified as being a **postsinusoidal** cause of portal HTN
102
Which class of drugs recommended to reduce the risk of 1st variceal hemorrhage in pts with **medium/large varices** or pts with **small varices that have variceal red wale marks or advanced cirrhosis**?
**Non**selective **beta-adrenergic blockers**
103
Which 2 diagnostic modalities can be utilized to determine whether varices are present in a pt?
- EGD
- Capsule endoscopy
104
**Encephalopathy** may complicate an episode of GIB in patients with severe liver disease, which drug can be given to combat this and is the mainstay of treatment?
Lactulose
105
What are the 4 stages of overt encephalopathy associated with severe liver disease?
1. Mild confusion
2. Drowsiness
3. Stupor
4. Coma
106
Most common cause of ascites is __________ secondary to \_\_\_\_\_\_\_\_.
Most common cause of ascites is **portal HTN** secondary to **chronic liver disease**.
107
Which imaging modality reliably establishes the presence of fluid in ascites?
Abdominal **ultrasound**
108
Which technique is performed on all patients with **new onset** ascites, patients admitted to hospital w/ cirrhosis + ascites, and when pts with known ascites deteriorate clinically?
Abdominal paracentesis
109
What is the most important test/study performed on ascitic fluid?
**WBC** count w/ **differential**
110
Which finding on examination of Ascitic Fluid is **highly suggestive** of spontaneous bacterial peritonitis (SBP)?
**PMN** count **greater than 250/mcL (neutrocytic ascites****)**
111
Which study performed on Ascitic Fluid is the single best test for classification of ascites?
Serum-ascites albumin gradient **(SAAG)**
112
What does an SAAG of 1.1 g/dL or more vs. SAAG of less than 1.1 g/dL tell you about the classification of the ascites?
- **Portal HTN** = **SAAG** of **1.1 g/dL or more**
- **Nonportal HTN** = **SAAG** of **less than 1.1 g/dL**
113
How is the serum-ascites albumin gradient (SAAG) calculated?
\*One of the LO's!\*
**Ascitic fluid albumin - serum albumin**
114
Abdominal US **+ Doppler** allows for vascular evaluation and to detect which cause of hepatic dysfunction?
Budd-Chiari syndrome
115
What is the SAAG value associated with Hypoalbuminemia and its associated causes i.e., Nephrotic Syndrome, Protein-losing enteropahty, and Severe malnutrition w/ anasarca?
**SAAG = \< 1.1 g/dL**
116
Myxedema (aka severe hypothyroidism) is associated with an SAAG value of?
SAAG = **\>1.1 g/DL**
117
A diseased peritoneum associated w/ infections, malignant conditions, and others (i.e., familial meditteranean fever, vasculitis, granulomatous peritonitis, and eosiniphilic peritonitis) is associated with what SAAG value?
**SAAG = \<1.1 g/dL**
118
Spontaneous (primary) bacterial peritonitis (SBP) occurs in the absence of?
**Absence** of an apparent intra-abdominal source of infection
119
Which type of bacteria are **not** assocated with spontaneous bacterial peritonitis?
**Anaerobic** bacteria
120
Spontaneous bacterial peritonitis is caused by a **(mono/polymicrobial)** infection?
- **Monomicrobial**
- Most common = *E. coli, Klebsiella, S. pneumonia, V. streptococci, Enterococcus*
121
What is the most important diagnostic test for Spontaneous (primary) Bacterial Peritonitis?
**Abdominal paracentesis ---\> WBC count w/ differential**
122
How is the cause of **secondary bacterial peritonitis** different from **spontaneous bacterial peritonitis**?
How can they be distinguished?
- Secondary is due to ascitic fluid becoming secondarily infected by an **intra-abdominal cause**
- Presence of **multiple organisms** on ascitic fluid gram stain or culture is **diagnostic** of **seondary peritonitis**
123
Since 70% of people who survive an episode of SBP will have another episode within 1 year, what is done clinically as prevention?
**Oral once-daily prophylactic therapy**
124
What is the emperic therapy for SBP?
- **Third-generation cephalosporin IV** (Cefotaxime or Ceftriaxone), OR
- Combo **beta-lactam/beta-lactamase agent** (Ampicillin/Sulbactam)
125
Due to a high risk of nephrotoxicity in patients with chronic liver disease which antibiotic class should not be used to treat SBP?
Aminoglycosides
126
What type of injury develops in 40% of patients with SBP and is a major cause of death?
How can this be dealt with clinically?
- **Kidney** injury
- Give **IV albumin**
127
What is the most effective treatment for reccurent SBP?
Liver transplant
128
Malignant ascites is associated with which value of SAAG?
Most common causes are primary adenocarcinomas arising from where?
- SAAG = \< 1.1 g/dL
- Ovary, uterus, pancreas, stomach, colon, lung, or breast
129
Symptoms presenting in a patient **younger than 20** with episodic bouts of acute peritonitis that may be associated with serositis involving the joints and pleura is associated with what disorder?
Familial Mediterranean Fever
130
Familial Mediterranean Fever is characterized by peritoneal attacks w/ sudden onset of fever, severe abdominal pain, and tenderness, **what occurs if these attacks are left untreated**?
**Resolve** witin **24-48 hours**
131
Which medication has been shown to decrease the frequency and severity of the peritoneal attacks associated with Familial Mediterranean Fever?
**Colchicine**
132
What is the ascitic fluid and cytology like in Mesothelioma?
- Ascitic fluid often **hemorrhagic**
- Cytology is often **negative**
133
Which type of ascites is characterized by the accumulation of **milky,** **lipid-rich lymph** in the peritoneal cavity w/ **triglyceride levels \>1000 mg/dL**?
Most common cause(s)?
- **Chylous** Ascites
- **Lymphoma**, post-op trauma, cirrhosis, tuberculosis, pancreatitis, and filariasis
134
Is pain associated with Pancreatic Ascites?
**NO**, since pancreatic enzymes are not acitvated
135
What will paracentesis of Bile Ascites reveal?
Ratio of ascites bilirubin to serum bilirubin?
- **Yellow fluid** on paracentesis
- **Ascites bilirubin:serum bilirubin = \>1.0**
136
Most important treatment measure for Cirrhosis?
Which vaccines should be given?
- **Abstinence** from alcohol = most important
- **HAV, HBV, pneumococcal,** and **yearly influenza** should be given
137
Which drug is contraindicated in cirrhosis?
Which 2 drug classes should be avoided?
- **NSAIDs = CONTRAINDICATED**
- **ACE inhibitors** and **Angiotensin II antagonists** = should be avoided
138
Which procedure has shown benefit in the treatment of severe refractory ascites, and is an effective tx of variceal bleeding refractory to standard treatment (i.e., endoscopic band ligation)?
Transjugular Intraheptic Portosystemic Shunt (**TIPS**)
139
What has been associated with mortality after TIPS procedure?
- Chronic kideny disease
- Diastolic cardiac dysfunction
- Refractory encephalopathy
- Hyperbilirubinemia
140
What is often the precipitating even of Hepatorenal Syndrome and how do the kidneys appear histologically?
- Acute decrease in cardiac output = precipitating event
- Kidneys appear **normal**
141
Treatment of choice for Hepatorenal Syndrome?
Liver transplant
142
What are the 2 prognostic scoring systems for Cirrhosis?
1) **Child-pugh score** --\> CMP or HFP (serum **bilirubin, albumin), PT/INR** and PE for **ascites** and **encephalopathy**
2) **MELD** score ---\> CMP (**serum bilirubin** and **creatinine**), PT/**INR**
143
What tests must be ordered to calculate a MELD score?
\*NEED TO KNOW\*
- **CMP** ---\> **serum bilirubin** and **creatinine levels**
- PT/**INR**
144
Which MELD score is required for liver transplant listing?
MELD score **\>14**
