Lecture 7: Liver Disease

Question 1

elevations in ALT and AST

Answer 1

Point to hepatocellular injury (ex. Hepatitis)

Question 2

elevations in alkaline phosphate with or without increased bilirubin

Answer 2

Point to cholestasis (bile flow stops or slows)

Question 3

1) which aminotransferase is more specific for liver?
2) which one is higher in many forms of chronic liver disease

*height of aminotransferases correlate poorly with injury severity

Answer 3

ALT

ALT>AST in chronic liver disease
aLt=LIVER baby

Question 4

1) what aminotransferase can come from other tissues (muscle, RBCs)
2) if high which aminotransferase is suggestive of alcoholic liver disease?

*height of aminotransferases correlates poorly with severity of injury

Answer 4

AST

AST>= 2xALT suggest alcoholic liver disease

Question 5

ALT/AST

Answer 5

1) diagnosis of MILD hepatocellular injury pattern
- chronic viral hepatitis
- NAFLD (Non-alcoholic fatty liver disease)
- autoimmune hepatitis
- drug-induced liver injury
- congestive hepatopathy
- wilson’s disease
- alpha 1-antitrypsin deficiency

Question 6

ALT/AST >= 30 x ULN (1,000 + U/L)

Answer 6

1) Diagnosis of EXTREME hepatocellular injury pattern
- acute viral hepatitis
- hepatic ischemia (shock liver)
- DILI-drug induced liver injury (acetaminophen)
- toxin (mushroom poisoning)

Question 7

Diagnosis of Cholestatic Injury Pattern

Answer 7

1) Primary biliary cholangitis (PBC)
2) Primary sclerosing cholangitis (PSC)
3) DILI
4) Biliary obstruction
5) Infiltrative processes
- TB, amyloidosis, lymphoma, diffuse metastatic diseases

Question 8

Diagnosis of hyperbilirubinemia without cholestasis (bile flow stopping or slowing)

Answer 8

1) Hyperbilirubinemia of sepsis
- direct bilirubin, minimal alk phos ALT, or AST elevation

2) Gilbert’s Syndrome
- unconjugated (indirect) hyperbilirubinemia

3) Hemolysis
- same as Gilbert’s but with signs of hemolysis on peripheral smear, increased LDH, decreased haptoglobin (cells burst releasing hemoglobin which haptoglobin binds to so lower haptoglobin)

Question 9

Patient presents with high direct bilirubin, minimal alk phos ALT, or AST elevation

Answer 9

Hyperbilirubinemia of sepsis

Question 10

increased LDH

decreased haptoglobin

Answer 10

Hemolysis

Question 11

Patient presents with:

1) Terry’s white nails
2) palmar erythema
3) spider angiomata
4) Dupuytren’s contracture
5) gynecomastia

What’s the problem yo?

Answer 11

Chronic liver disease/cirrhosis

Question 12

Is coagulopathy a contraindication to paracentesis?

Answer 12

1) Hell NO!
2) tap everyone!
3) complication rate is 1% and presence of coagulopathy in 70% of patients
4) no objectively determined threshold for platelets or clotting parameters beyond which tab should not be done
5) NO role for prophylactic fresh frozen plasma or platelets

Question 13

What labs should you order on ascitic fluid in a first time tap on a new onset ascites due to suspected cirrhosis?

Answer 13

1) serum ascites-albumin gradient

2) cell count with differential

Question 14

What labs should you order on subsequent taps on ascitic fluid in hospitalized patients or patients where there is concern for infection?

Answer 14

1) cell count with differential

2) ascitic fluid culture for infection

Question 15

What labs should be ordered on ascitic fluid on patients where there is NO other liver disease or suspicion of cancer?

Answer 15

1) cytology-study cells

2) AFB (acid fast bacilli) culture

Question 16

Serum Albumin-Ascitic Fluid Albumin= SAAG

Answer 16

SAAG>=1.1= PORTAL HYPERTENSION

SAAG

Question 17

What do you have if >= 250 PMNS in ascitic fluid?

and how do you treat it?

Answer 17

Diagnosis of Spontaneous Bacterial Peritonitis (cultures negative 1/2 time)

1) Treat Cefotaxime 2g 8 hrs IV 5-7 days or as dictated if culture +
2) IV albumin 1.5 g/kg at diagnosis, 1 g/kg on day 3 given to prevent renal dysfunction
3) prophylatic antibiotics given to cirrhotics admitted with GI bleeding

Question 18

How do you manage/treat Ascites?

Answer 18

1) SODIUM RESTRICTED DIET (2g/d)
2) usual starting dose: spironalactone 100 mg and furosemide 40 mg
3) AVOID IV diuretics!
4) fluid restriction NOT needed for serum Na>120
5) avoid use of NSAIDS in cirrhosis patients
- adverse renal effects on top of bleeding risks
- acetaminophen is OK

Question 19

What causes >=80% cases of upper GI bleeding in cirrhotics?

Answer 19

1) VARICEAL HEMORRHAGE!
2) imp cause of morbidity and mortality
3) hemodynamic resuscitation-large bore IVs, blood products as needed
4) consider intubation
5) Call GI
6) begin octreotide drip
7) antibiotic prophylaxis

Question 20

What disease am I describing?

1) diagnosis usually made based on signs of advanced liver disease of asterixis and hyperreflexia
2) may be precipitated by bleeding, infection, dehydration, electrolyte abnormalities, narcotics, or benzos
3) elevated blood ammonia levels NOT required to make diagnosis and do NOT need to be followed

Answer 20

Hepatic Encephalopathy

Question 21

How do you treat Encephalopathy?

Answer 21

1) Lactulose orally or per enema
2) Rifaximin (non-absorbed antibiotic) 550 mg BID
3) no role for protein restriction

Question 22

How do you treat autoimmune hepatitis and the consequences of cirrhosis?

Answer 22

1) start on sodium restriction and diuretics
2) referred for liver transplant evaluation
3) began treatment with prednisone and azathioprine