Lecure 5 - Liver 2 Flashcards by Cal Schiller

Presence of hepatic steatosis w/o cause for secondary hepatic fat accumulation?

What two subdivisions?

NAFLD

Nonalcoholic Fatty Liver (NAFL)

Nonalcoholic steatohepatitis (NASH)

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Most common causes of NAFLD?

Obesity
Diabetes
Hypertriglyceridemia (as part of metabolic syndrome + insulin resistance)

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Studies indicate an association between NAFLD and what?

cholecystectomy

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Most NAFLD pts are asymptomatic. However, pts with NASH may complain of what?

Fatigue

Malaise

vague RUQ discomfort

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Pts w/ NAFLD usually discovered b/c of elevated what?

transaminase levels

or incidental finding of hepatic steatosis on abd imaging ordered for another reason

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NAFLD lab findings?

in particular, what’s a particular ratio we might be concerned about?

elevated transaminases… 1:1 AST/ALT ratio

Elevated ALK PHOS

(hepatic US/biopsy shows sign of steatosis – but we must r/o other causes of fatty liver disease, e.g., alcohol consumption)

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NAFLD tx?

Prognosis?

Lifestyle changes (diet, exercise, wt. loss, Vit E, insulin sensitizing agents like ***Metformin)

Prognosis = usually benign course (worse prognosis in elderly, diabetic, higher BMI)

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Alcohol abuse may lead to steatosis, steatohepatitis, cirrhosis, and hepatocellular carcinoma.

What is seen in roughly 90% of heavy drinkers?

Hepatic steatosis

1/3 of patients w/ steatosis will develop steatohepatitis if they continue to drink… 8-20% of pts w/ stetosis will eventually progress to cirrhosis

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Alcoholic steatosis (fatty liver)

Typically found incidentally (asymptomatic – though may have hepatomegaly on PE)

What do the labs look like?

Elevation of transaminases w/ ratio at 2:1 AST:ALT

Elevated GGT

(referral for US/biopsy if suspected)

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Tx for alcoholic steatosis?

Abstinence (from alcohol)

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Alcoholic steatohepatitis is a progression from?

Classic ssx?

Simple steatosis

Jaundice, anorexia, fever, tender hepatomegaly (maybe muscle wasting, abd distension/ascites)

**elevated transaminase w/ 2:1 ratio (AST:ALT)

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AST:ALT ration greater than 2:1
elevated serum bilirubin
elevated GGT
leaukocytosis w/ predominance of neutrophils
elevated INR

lab findings for alcoholic steatohepatitis

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General tx measures for alcoholic steatohepatitis?

R/o other causes of acute hepatitis

Obtain US/biopsy

Admit to GI for (alcohol abstinence tx, fluid/nutritional support, infection surveillance, prophylaxis for gastric mucosal bleeding – IV PPI)

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Cirrhosis is late stage progressive hepatic fibrosis characterized by?

distortion of the hepatic architecture

formation of regenerative nodules

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Alcoholic liver disease

Chronic viral hepatitis (hep C, B)

NAFLD

Hemochromatosis

Common causes of cirrhosis

A,B,C Not-A, Iron

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Cirrhosis can be classified morphologically as?

Which is associated w/ ETOH?

mixed, micro, macronodular

MICRONODULAR is associated w/ ETOH

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***alcoholic cirrhosis is from chronic alcohol intake… what are the metrics?

10 years of 30-50g/day

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Progression to cirrhosis significantly increased in patients who have established ___ and continue to ____?

Steatohepatitis and continue to consume alcohol

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Three stages of cirrhosis?

correlates w/ thickness of fibrous septa

Compensated
Compensated w/ varices
Decompensated (ascites, variceal bleeding, encephalopathy, jaundice)

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The clinical features of cirrhosis result from?

Hepatocyte dysfunction, portosystemic shunting, portal HTN

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Features of compensated cirrhosis?

May be asymptomatic (most likely)…

Or may present w/ nonspecific ssx such as anorexia, wt loss, weakness, fatigue

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Jaundice
Pruritus
Signs of upper GI bleeding (hematemesis, melena, hematochezia)
Abd disention/ascites
Confusion (due to hepatic encephalopathy)

DECOMPENSATED cirrhosis

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Systemic manifestations of cirrhosis include fatigue, fever, wt loss, muscle wasting… and what else?

Decreasing BP/MAP

pts w/ HTN may normalize or even become HOTN

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Hyperdynamic circulation in cirrhotic pts means what?

decrease in SVR and arterial pressure -> reduction in arterial blood volume -> diminished renal flow stimulates RAAS -> increase HR/CO

Abd findings/manifestions of systemic cirrhosis?

``` Ascites (shifting dullness) Hepatomegaly Splenomegaly Caput medusa Venous hum (Cruvheilhier-Baumgarten murmur) ```

Dermatologic findings of systemic cirrhosis?

``` Jaundice Spider angiomata Palmar erythema Nail changes Nail clubbing ```

Muehrcke nails (white linear patches) Terry nails (pink band just proximal to lunula)

Nail findings of systemic cirrhosis

Endocrine cirrhosis manifestations in women?

Chronic anovulation/amenorrhea/irregular menstrual bleeding

Endocrine cirrhosis manifestations in men?

Hypogonadism (impotence, infertility, loss of sexual drive, testicular atrophy) GYNECOMASTIA

HEENT signs of systemic cirrhosis?

Hepatic fetor (sweet pungent breath) Parotid gland enlargement

Neurlogic ssx of cirrhosis?

Hepatic encephalopathy Asterixis (bilateral/asynchronous flapping motions of outstretched, dorsiflexed hands)

Early/compensated cirrhosis may show minimal/no findings.... Later, you might see what?

LATer signs of compensated cirrhosis = Leukocytosis/leukopenia Anemia Thrombocytopenia (due to splenomegaly)

In cirrhosis, a hepatic panel would show an icnraesed in everyting but?

Albumin (also might see hyponatremia in Serum chemistry) (NOTE: the slides don't specifically say thrombocytopenia... BUT yeah, thrombocytopenia in late compensated cirrhosis, so we can assume...)

Shrunken, irregular, nodular appearing liver?

Cirrhotic liver on US

How might you determine the extent of esopahgeal varices and gastropathy in a patient w/ cirrhosis?

capsule endoscopy

Tx for cirrhosis?

Abstinence from ETOH (monitored/in patient) Dietary consult Immunizations (ultimately a liver transplant)

Most common cause of ascites?

Portal HTN (from liver disease) Hypoalbuminemia Chylous/pancreatic/bile ascites infections/malignancies

Primary symptom is bloating/increasing abd girth (w/w/o abd pn) W/ this sign... what should you ask?

this is ascites Ask about h/o liver disease, risk factors liver disease (Alcohol abuse? Risk factors for hep? Hx of CA?)

PE ssx of portal HTN?

Hepatomegaly Elevated JVP Large abd wall veins Signs of liver disease (Muscle wasting, malnourishment) FEVER = BACTERIAL PERITONITIS

Abd paracentesis.... 1. Cloudy? 2. Milky? 3. Bloody?

1. cloudy = infection 2. milky = chyle (malignancy?) 3. Bloody = traumatic/malignancy (other studies include WBC, albumin/total protein/culture and gram stain)

SAAG is 1.1 g/dL or higher means?

portal HTN

For treatment of portal HTN as etiology of ascites... we can use?

Transjugular Intrahepatic Portosystemic Shunt (TIPS) diversion of portal blood flow into the hepatic vein

Spontaneous BActerial peritonitis?

infection of ascitic fluid in absence of intraaddominal source ``` Strep pneumo Enterococcus E. coli Klebsiella Strep viridans ``` (must differentiate from secondary)

Ascites Fever Abd pn w/o TTP (abd ttp suggests other source)

Spontaneous bacterial peritonitis

Most important lab test for spontaneous bacterial peritonitis? What do you do if you suspect bacterial peritonitis?

Most important is evaluation of ascetic fluid via paracentesis (gram stain culture and CBC w/ diff) If secondary suspected, CT for source of infection

Treatment for spontaneous bacterial peritonitis? Prophylaxis?

ADMIT! 3rd gen cephalosporin Ceftriaxone Prophylaxis = cipro or TMP-SMX DS

Complication of cirrhosis Represents end stage of a sequence of reductions in renal perfusion PROGNOSIS IS SUPER POOR... what is this and what is it characterized by?

Hepatorenal syndrome azotemia in absence of parenchymal renal injury/dz SrCR of 1.5 mg/dL or higher

Therapy for hepatorenal syndrome is improvement of LIVER function... what else should we do?

If short liver function improvement is not possible, reverse the acute kidney injury. ADMISSION TO ICU!

Complication of cirrhosis Systemic build up ammonia Neuropsychiatric abnormalities

hepatic encephalopathy

``` AMS Sleep pattern inversion Mood changes (euphoria/depression) Decreased attention Imparied short term memory ``` (late signs = somnolence, confusion, coma)

Hepatic encephalopathy

Late signs of hepatic encephalopathy?

Somnolence (super sleepiness) Confusion Coma

``` Asterixis Bradykinesia Ataxia Slurred speech Hyperactive deep tendon reflees ``` Nystagmus

PE exam findings for hepatic encephalopathy

Tx for hepatic encephalopathy?

Admission * PROTEIN REDUCTION * LACTULOSE - reduces ammonia in serum fluid/electrolyte replacement pre/probiotics have shown efficacy in improving hepatic encephalopathy

MELD score... Model for End Stage Liver Disease

Higher = worser

Hepatoxic substances?

NSAIDs Acetaminophen Statins Abx Tylenol + Alcohol = potentiation

Direct hepatotoxicity is predictiable...

dose related severity latent period after exposure universal susceptibility

Diagram for acetaminophen? Tx for OD?

Rumack-Matthew Nomogram Tx w/ N-acetylcysteine

Toxic liver injury... classified by pathogenesis and pattern of injury... such as?

Hepatocellular injury (hepatitis) Cholestatic injury (non-inflammatory or inflammatory [cholangitis]) Mixed injury

Tx for toxic liver injury?

DISCONTNUE THE AGENT Inpatient vs. outpatient depends on severity Referral to GI/hepatology Serial LFTs to monitor for nomalization