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GI Board Review > Liver > Flashcards

Liver Flashcards

1
Q

What are the patterns of liver injury in HAV?

A
  1. ALF
  2. predominantly cholestatic (can last for months)
  3. relapsing (can last ON/OFF for up to a year)
  4. precursor to developing AIH
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2
Q

How do you acquire HEV?
How do you treat HEV in immunocompromised?

A

Acquired fecal-oral from animals (think hunters, or India)

in the immunocompromised, decrease immunosuppression first, if doesn’t clear then ribavirin x3 months

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3
Q

What factors increase the risk of cirrhosis in HCV infection?

A

HBV/ HIV co-infection
genotype 3

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4
Q

what are the treatment regimens for non-cirrhotics with HCV.

A

glecaprevir/pibrentasvir x8 weeks
sofosbuvir/velpatasvir x 12 weeks

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5
Q

what are the treatment regimens for compensated cirrhotics with HCV?

A
  1. glecaprevir/pibrentasvir x 8 weeks
  2. 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

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6
Q

What is immune tolerant HBV and how do you manage it?

A

+sAg
+cAb
+eAg
>1million HBV DNA
normal ALT

no NOT Rx
monitor with labs q3 months x 1 year then every 6 months

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7
Q

What is chronic active HBV infection and how do you manage it?

A

+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)

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8
Q

What is chronic inactive HBV infection and how do you manage it?

A

+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

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9
Q

When do you treat HBV in pregnancy? How do you manage baby?

A

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

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10
Q

HBV and HCC Screening guidelines

A

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).

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11
Q

Which patient with HBV qualify for prophlyaxis before immunosupression?

A

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

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12
Q

For mom with chronic HCV, when should you screen baby after delivery for HCV?

A

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)

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13
Q

How do you managed these conditions in pregnancy?
AIH
PBC
PSC
Wilsons
Hepatic Adenoma

A

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

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14
Q

Cirrhotic HCM during pregnancy

A
  1. variceal screening if no EGD in past year - treat with EBL or propranolol
    US to screen for splenic artery aneurysm
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15
Q
A

PBC-
florid bile duct lesion
Portal inflammation around an injured bile duct
No fibrosis at bile duct

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16
Q

Who should be screened for HDV and how are they treated?

A

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)

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17
Q

How do you manage occupational exposure to HCV, HBV, HAV?

A

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-

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18
Q

What are the features of HSV infection in pregnancy?

A

anicteric liver failure
very high AST/ALT, normal TB

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19
Q

hyperemesis gravidarum

A

<20 weeks
mild AST/ALT elevation (<200)
mild AP elevation (2x ULN)
mild elevated unconjugated bili
associated with thiamine deficiency
treat with supportive care

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20
Q

Intrahepatic cholestasis of pregnancy
risk factors, timing, symptoms, mortality, treatment, risk of recurrence

A

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

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21
Q

Continuum of Pre-eclampsia, eclampsia, and HELLP syndrome

A

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

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22
Q

Acute fatty liver of pregnancy

A

*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

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23
Q

EtOh hepatitis
MDF and MELD cut off values
nutritional recommendations
RF for injury

A

-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

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24
Q

NASH
- diagnosis
- prognostication tools
- treatments

A
  • 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
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25
Q

SOS/ VOD

A

non-cirrhotic portal hypertension
post-sinusoidal injury (not post hepatic like budd chiari)

clinical features- TB >2, ascites, hepatomegaly, weight gain

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26
Q

Tylenol toxicity pathway

A

Worse toxicity if
CYP2E1 is upregulated (chronic etOH, isoniazid, phenytoin)
CYP2E1 is in competition- bactrim
glutathione is depleted- starvation

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27
Q

What abx are most commonly associated with DILI

A
  1. augmentin- cholestasis
  2. macrolides- cholestasis
  3. tetracycline- steatosis
  4. bactrim- mixed
  5. nitrofurantoin- mixed, granulomatous necrosis
  6. antifungals - cholestasis
28
Q

DILI with isoniazid

A

mainly ALT elevation in patients >50years old

liver will adapt and med can be continued

29
Q

DILI with methotrexate

A

total accumulated exposure to methotrexate (risk increases with >2g)
stop if there is bridging fibrosis

30
Q

what drugs can result in a AIH like picture?

A

nitrofurantoin
minocycline
diclofinac

may need to treat with steroids

31
Q

in DILI, when should you stop a medication?

A

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

32
Q

in DILI, when is it ok to continue the medication?

A

AST/ALT <3x ULN
asymptomtic
no jaundice

this is probably an adaptation phase for the liver

33
Q
A

steatohepatitis

34
Q
A

PBC

35
Q

high urinary copper
high serum copper

A

PBC, PSC
vs wilsons that has low serum copper, high urinary copper

36
Q

PBC has what kind of portal hypertension?

A

pre-sinusoidal portal hypertension, so varices w/o cirrhosis

37
Q

Cholestasis of PBC, PSC is associated with

A

vitamin malabasorption
coagulopathy (vitamin K)
osteoporosis
high cholesterol with normal CAD risk

38
Q

PBC treatment

A

ursodiol 13 to 15mg/kg with goal of lowering alk phos
obetacholic acid, will worsen pruritis and CI in cirrhosis and pregnancy

39
Q

How do you manage PBC/PSC/AIH overlap syndromes?

A

If LFTs and serologies are not consistent, get a liver biopsy and treat according to the pathology

40
Q

AIH type 1 vs AIH type 2

A

type 1- ANA, anti smooth muscle
type 2- anti LKM, anti LC1

41
Q

When do you treat AIH and how?

A

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

42
Q

PSC- what are routine screening exams?

A

colonoscopy q 1 year
annual GB US
no screening for cholangio

43
Q

PSC + worsening TB + weight loss

A

worrisome for cholangio, get CEA and CA 19-9

44
Q
A

PSC

45
Q
A

IgG4 sclerosing cholangiopathy
distal bile duct pruning and sausage dilations
treat with seroids, MMF, ritux

46
Q
A

PSC

47
Q
A

PSC

48
Q

alagille syndrome

A

AD JAG1 mutation

butterfly vertebrae
pulmonary artery stenosis
bile duct paucity
triangular face, prominent forehead

49
Q

cystic fibrosis related liver disease

A

chronic cholestasis
treat with uro, although it is not disease modifying

50
Q

What are the inherited intrapatic cholestasis conditions =?

A

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)

51
Q

causes of unconjugated + unconjugated hyperbilirubinemia

A

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

52
Q

In hepatopulmonary syndrome what are findings on TTE and when is someone not a tx candidate?

A

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

53
Q

What are the genetic mutations in hemochromatosis?

A

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

54
Q

What does A1AT level <10 mean?

A

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

55
Q

Which patient needing hepatitis B virus (HBV) vaccination will require double-dose conventional recombinant HBV vaccine?

A

HIV and ESRD on iHD

56
Q

What is the most common type of infection 1 month post liver transplant?

A

Bacterial infection
especially enterococcus

57
Q

HIV+
HBcAb +
sAg -
sAb-
How do you manage this patient who wants to start HIV treatment?

A

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.

58
Q

Dose of ursodiol for PBC vs IC of pregnancy?

A

ursodiol 10 to 15 mg/kg for IC of pregnancy
13 to 15 mg/kg for PBC

59
Q

treatment options for decomensated cirrhosis with HCV.

A

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

60
Q

After clearing HBV infection, who should continue to have HCC screening?

A

cirrhosis
family history of hepatocellular carcinoma
long duration of infection

61
Q

In PBC, what does urso help treat?

A

-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)

62
Q

Young woman
severe abdominal pain
fever, elevated WBC
elevated liver tests

A

PID
do a pelvic exam
treat with IV abx

63
Q

4 most common GI cancers (in order)

A

Colorectal cancer, pancreatic cancer, liver cancer, gastric cancer

64
Q

hemachromatosis genes

A

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.

65
Q

Conditions associated with PBC

A

Sjogrens, CREST, raynauds

66
Q

what are the different types of HE?

A

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.

67
Q
A

Classic rash of pellagra (face, neck, feet and hands)
B3 deficiency
dermatitis, dementia, diarrhea
seen in carcinoid syndrome

GI Board Review (15 decks)

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