Lecure 5 - Liver 2 Flashcards
Presence of hepatic steatosis w/o cause for secondary hepatic fat accumulation?
What two subdivisions?
NAFLD
Nonalcoholic Fatty Liver (NAFL)
Nonalcoholic steatohepatitis (NASH)
Most common causes of NAFLD?
Obesity
Diabetes
Hypertriglyceridemia (as part of metabolic syndrome + insulin resistance)
Studies indicate an association between NAFLD and what?
cholecystectomy
Most NAFLD pts are asymptomatic. However, pts with NASH may complain of what?
Fatigue
Malaise
vague RUQ discomfort
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
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)
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)
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
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)
Tx for alcoholic steatosis?
Abstinence (from alcohol)
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)
AST:ALT ration greater than 2:1 elevated serum bilirubin elevated GGT leaukocytosis w/ predominance of neutrophils elevated INR
lab findings for alcoholic steatohepatitis
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)
Cirrhosis is late stage progressive hepatic fibrosis characterized by?
distortion of the hepatic architecture
formation of regenerative nodules
Alcoholic liver disease
Chronic viral hepatitis (hep C, B)
NAFLD
Hemochromatosis
Common causes of cirrhosis
A,B,C Not-A, Iron
Cirrhosis can be classified morphologically as?
Which is associated w/ ETOH?
mixed, micro, macronodular
MICRONODULAR is associated w/ ETOH
***alcoholic cirrhosis is from chronic alcohol intake… what are the metrics?
10 years of 30-50g/day
Progression to cirrhosis significantly increased in patients who have established ___ and continue to ____?
Steatohepatitis and continue to consume alcohol
Three stages of cirrhosis?
correlates w/ thickness of fibrous septa
- Compensated
- Compensated w/ varices
- Decompensated (ascites, variceal bleeding, encephalopathy, jaundice)
The clinical features of cirrhosis result from?
Hepatocyte dysfunction, portosystemic shunting, portal HTN
Features of compensated cirrhosis?
May be asymptomatic (most likely)…
Or may present w/ nonspecific ssx such as anorexia, wt loss, weakness, fatigue
Jaundice
Pruritus
Signs of upper GI bleeding (hematemesis, melena, hematochezia)
Abd disention/ascites
Confusion (due to hepatic encephalopathy)
DECOMPENSATED cirrhosis
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
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….
- Cloudy?
- Milky?
- Bloody?
- cloudy = infection
- milky = chyle (malignancy?)
- 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
