Liver Flashcards
What are the patterns of liver injury in HAV?
- ALF
- predominantly cholestatic (can last for months)
- relapsing (can last ON/OFF for up to a year)
- precursor to developing AIH
How do you acquire HEV?
How do you treat HEV in immunocompromised?
Acquired fecal-oral from animals (think hunters, or India)
in the immunocompromised, decrease immunosuppression first, if doesn’t clear then ribavirin x3 months
What factors increase the risk of cirrhosis in HCV infection?
HBV/ HIV co-infection
genotype 3
what are the treatment regimens for non-cirrhotics with HCV.
glecaprevir/pibrentasvir x8 weeks
sofosbuvir/velpatasvir x 12 weeks
what are the treatment regimens for compensated cirrhotics with HCV?
- glecaprevir/pibrentasvir x 8 weeks
- sofosbuvir/velpatasvir x 12 weeks (doesn’t work for g3 if NSSA RAS for Y93H is positive)
** don’t start any meds if on phenytoin
What is immune tolerant HBV and how do you manage it?
+sAg
+cAb
+eAg
>1million HBV DNA
normal ALT
no NOT Rx
monitor with labs q3 months x 1 year then every 6 months
What is chronic active HBV infection and how do you manage it?
+sAg
+cAb
+/-eAg
>2k DNA
elevated ALT
Treat:
eAg+, DNA>20k, ALT >2xULN (goal of seroconversion)
eAg-,DNA >2k, ALT >2xULN (goal of lifelong treatment)
What is chronic inactive HBV infection and how do you manage it?
+sAg
+cAb
+eAb
<2k DNA
normal ALT
Do NOT treat, unless cirrhotic
monitor 3 to. 6months to make sure they don’t revert back to chronic active disease
**ULN ALT- 25 females, 35 males
When do you treat HBV in pregnancy? How do you manage baby?
if they meet any of the traditional criteria
OR
HBV DNA >200k, +eAg
Start at 2nd trimester
Treat baby with HBiG at birth
vaccine at 12 hours, 1 mo, and 6 mo
ok to breastfeed on TDF
HBV and HCC Screening guidelines
chronic HBV and
Asian/Black men >40
asian women >50
FDR with HCC (start at any age)
HDV co-infection (start at any age)
In persons who achieve sustained HBsAg seroclearance, routine ALT and HBV-DNA monitoring are no longer required. HCC surveillance should continue if the person has cirrhosis, a first-degree family member with HCC, or a long duration of infection (>40 years for males and >50 years for females who have been infected with HBV from a young age).
Which patient with HBV qualify for prophlyaxis before immunosupression?
sAg +, cAb + always treat
sAg-, cAb +- only treat if high risk therapy
it doesn’t really matter about sAb
high risk therapy = ritux, sct, doxorubicin, pred
For mom with chronic HCV, when should you screen baby after delivery for HCV?
Don’t treat mom during pregnancy. OK to breastfeed with meds.
Test baby RNA x2 before 6 months
OR HCV Ab once after 18 months (Ab are passed through the placenta)
How do you managed these conditions in pregnancy?
AIH
PBC
PSC
Wilsons
Hepatic Adenoma
AIH- pred, AZA, budesonide are all oK in pregnancy, watch closely for flare post-partum
PBC- urso is ok, do NOT use obetacholic acid
PSC- no change
Wilson’s - ok to continue chelators but dose reduce in 3rd trimester, don’t breast feed
Hepatic adenoma- <5cm monitor with US every trimester, >5cm treat in 2nd trimester
MMF must be held at least 6 weeks before conception
Cirrhotic HCM during pregnancy
- variceal screening if no EGD in past year - treat with EBL or propranolol
US to screen for splenic artery aneurysm
PBC-
florid bile duct lesion
Portal inflammation around an injured bile duct
No fibrosis at bile duct
Who should be screened for HDV and how are they treated?
Screening- MSM, HIV, IVDU, endemic area, increased ALT with low HBV DNA levels
treat with interferon alpha for 1 year (along with Rx for HBV)
How do you manage occupational exposure to HCV, HBV, HAV?
HCV
-baseline labs
-labs after 4 to 6 months, most people will spontaneously clear the infection
HAV
<40yo HAV vaccine
>40yo or chronic liver disease- IgG and HAV vaccine
HBV
if unvaccinated
-sAg + exposure –> give HBiG +vaccine series
-sAg - exposure –> vaccine series
if vaccinated
-sAB titer >10 then do nothing
-sAb titer <10, then give HBiG +vaccine x2 if exposed to sAg +; or give vaccine booster if exposed to sAg-
What are the features of HSV infection in pregnancy?
anicteric liver failure
very high AST/ALT, normal TB
hyperemesis gravidarum
<20 weeks
mild AST/ALT elevation (<200)
mild AP elevation (2x ULN)
mild elevated unconjugated bili
associated with thiamine deficiency
treat with supportive care
Intrahepatic cholestasis of pregnancy
risk factors, timing, symptoms, mortality, treatment, risk of recurrence
risk factors- HCV infection, advanced maternal age, twins
timing- 2nd/3rd trimester
symptoms- nocturnal pruritis, nausea, vomiting, abdominal pain
mortality- increased infant mortality (no effect on mom)
treatment- urso 10-15mg.kg.day, vitamin k at birth
risk of recurrence -yes
Continuum of Pre-eclampsia, eclampsia, and HELLP syndrome
pre-eclampsia
-SBP >140, edema, proteinuria >3g/day
eclampsia
-SBP >160, proteinuria >5g/day, seizure/coma
HELLP syndrome- hemolytic anemia, elevated liver enzymes, low platelets
complications
-liver infarct (from microthombi)- fever, shock, very high LFTs
-hepatic capsule rupture- abdominal pain, shock
Acute fatty liver of pregnancy
*microvesicular fat
can occur 3rd trimester or post-partum
caused by LCHAD deficiency in baby and this builds up in mom’s liver
labs- AST/ALT <1000, WBC >15, TB <10, hypoglycemia, coagulopathy
Rx is delivery
EtOh hepatitis
MDF and MELD cut off values
nutritional recommendations
RF for injury
-MDF and MELD cut off values - MDF >32, MELD >20
-Lile score >0.45 poor prognosis, stop steroids
-nutritional recommendations 35kcal/kg total calories, 1.5g/kg protein
-RF for injury -weight loss surgery lowers threshold for etoh injury
NASH
- diagnosis
- prognostication tools
- treatments
- diagnosis - liver biopsy is gold standard
- prognostication tools
low risk - Fib-4 <1.45, NASH FS <-1.45, repeat in 2 yrs
int risk- fibroscan >9.9kPA then get liver biopsy
high risk- Fib-4 >3.2, NASH FS >.06 get liver biopsy - treatments -
weight loss (5% reduces fat, 10% reduces fibrosis)
exercise 300min/150min, statin,
vitamin E (not for diabetics),
pioglitazone (only if biopsy proven NASH)
do not refer for bariatric surgery for NASH alone
SOS/ VOD
non-cirrhotic portal hypertension
post-sinusoidal injury (not post hepatic like budd chiari)
clinical features- TB >2, ascites, hepatomegaly, weight gain
Tylenol toxicity pathway
Worse toxicity if
CYP2E1 is upregulated (chronic etOH, isoniazid, phenytoin)
CYP2E1 is in competition- bactrim
glutathione is depleted- starvation
What abx are most commonly associated with DILI
- augmentin- cholestasis
- macrolides- cholestasis
- tetracycline- steatosis
- bactrim- mixed
- nitrofurantoin- mixed, granulomatous necrosis
- antifungals - cholestasis
DILI with isoniazid
mainly ALT elevation in patients >50years old
liver will adapt and med can be continued
DILI with methotrexate
total accumulated exposure to methotrexate (risk increases with >2g)
stop if there is bridging fibrosis
what drugs can result in a AIH like picture?
nitrofurantoin
minocycline
diclofinac
may need to treat with steroids
in DILI, when should you stop a medication?
AST/ALT >5x ULN
jaundice, TB >2.5
hypersensitivity reaction
Hy’s law- in DILI with hepatocellular injury if there is new jaundice, this is a bad prognostic sign
in DILI, when is it ok to continue the medication?
AST/ALT <3x ULN
asymptomtic
no jaundice
this is probably an adaptation phase for the liver
steatohepatitis
PBC
high urinary copper
high serum copper
PBC, PSC
vs wilsons that has low serum copper, high urinary copper
PBC has what kind of portal hypertension?
pre-sinusoidal portal hypertension, so varices w/o cirrhosis
Cholestasis of PBC, PSC is associated with
vitamin malabasorption
coagulopathy (vitamin K)
osteoporosis
high cholesterol with normal CAD risk
PBC treatment
ursodiol 13 to 15mg/kg with goal of lowering alk phos
obetacholic acid, will worsen pruritis and CI in cirrhosis and pregnancy
How do you manage PBC/PSC/AIH overlap syndromes?
If LFTs and serologies are not consistent, get a liver biopsy and treat according to the pathology
AIH type 1 vs AIH type 2
type 1- ANA, anti smooth muscle
type 2- anti LKM, anti LC1
When do you treat AIH and how?
no treatment if asymptomatic and AST/ALT <10xULN
treat if active hepatitis on bx, symptoms, ALF, AST/ALT >10x ULN
treat with prednisone 60-40-30-20-10, hold x 2 years
can add AZA 1-1.5mg/kg or methotrexate (2nd line)
if relapse- start combo therapy
alternative include budesonide or tacro
PSC- what are routine screening exams?
colonoscopy q 1 year
annual GB US
no screening for cholangio
PSC + worsening TB + weight loss
worrisome for cholangio, get CEA and CA 19-9
PSC
IgG4 sclerosing cholangiopathy
distal bile duct pruning and sausage dilations
treat with seroids, MMF, ritux
PSC
PSC
alagille syndrome
AD JAG1 mutation
butterfly vertebrae
pulmonary artery stenosis
bile duct paucity
triangular face, prominent forehead
cystic fibrosis related liver disease
chronic cholestasis
treat with uro, although it is not disease modifying
What are the inherited intrapatic cholestasis conditions =?
progressive familial intrahepatic cholestasis
benign recurrent intrahepatic cholestasis
Low- ggt
-PFIC1/ BRIC 1 (pancreatitis) (ATP8B1)
-PFIC2 (HCC)/ BRIC 2 (Gallstones) - ABCBB11
High -ggt
-PFIC3 (ABCB4)
causes of unconjugated + unconjugated hyperbilirubinemia
unconjugated- HA, newborn, gilbert syndrome (AR), criggler najar (AR, rx with phenobarb, type 1 full KO, type 2 partial KO)
conjugated- dubin johnson (no Rx), rotor syndrome, IH syndrome, biliary, hepatic parenyhchma
In hepatopulmonary syndrome what are findings on TTE and when is someone not a tx candidate?
late bubbles (after 3 cycles), can also diagnose with a TCMAA rbain scan
can tx if Pa02 <70 but tx is contraindicated if Pa02 <50
What are the genetic mutations in hemochromatosis?
Type 1 HFE gene (AR)
C282Y/C282Y - Highest risk
C282Y/H63D- risk only if there is another co-factor
H63D/H63D- no risk
Type 2
Hepcidin, hemojuvelin
Type 3
transferrin receptor 2
Type 4
ferroportin- SCL 40A1
only AD inherited
What does A1AT level <10 mean?
pt has the null mutation and will only develop lung disease
liver disease happens with piZZ
pt are at risk for liver disease with piZM but need a second hit
SERPINA1 gene
Which patient needing hepatitis B virus (HBV) vaccination will require double-dose conventional recombinant HBV vaccine?
HIV and ESRD on iHD
What is the most common type of infection 1 month post liver transplant?
Bacterial infection
especially enterococcus
HIV+
HBcAb +
sAg -
sAb-
How do you manage this patient who wants to start HIV treatment?
Patients with HIV or those who are immune-compromised who are hepatitis core antibody-positive should be vaccinated, as this antibody is not protective to prevent reactivation.
Dose of ursodiol for PBC vs IC of pregnancy?
ursodiol 10 to 15 mg/kg for IC of pregnancy
13 to 15 mg/kg for PBC
treatment options for decomensated cirrhosis with HCV.
sofosbuvir (400 mg)/velpatasvir (100 mg) for G1-6
sofosbuvir (400 mg)/ledipasvir (90 mg) NOT G2 or 3
24 weeks with 2 drugs
12 weeks if adding riboviran
After clearing HBV infection, who should continue to have HCC screening?
cirrhosis
family history of hepatocellular carcinoma
long duration of infection
In PBC, what does urso help treat?
-reduces the risk of the development of gastroesophageal varices.
-reduces serum low-density lipoprotein
- slower histologic progression
(no change in autoimmune features, bone disease, fatigue, or pruritus)
Young woman
severe abdominal pain
fever, elevated WBC
elevated liver tests
PID
do a pelvic exam
treat with IV abx
4 most common GI cancers (in order)
Colorectal cancer, pancreatic cancer, liver cancer, gastric cancer
hemachromatosis genes
Type 1, 2 (juvenile), and 3 (TFRrelated) - low hepcidin levels, autosomal recessive
Type 4 (ferroportin disease)- a high level of hepcidin, autosomal dominant, it is prevalent in African countries.
Conditions associated with PBC
Sjogrens, CREST, raynauds
what are the different types of HE?
Type A is associated with acute liver failure, and this is the correct answer based on this patient’s history and presentation.
Type B is associated with bypass shunts in the absence of cirrhosis.
Type C is gradual onset, rarely fatal, and associated with cirrhosis and portosystemic shunting.
Classic rash of pellagra (face, neck, feet and hands)
B3 deficiency
dermatitis, dementia, diarrhea
seen in carcinoid syndrome
