Liver Flashcards
1
Q
How many lobes does the liver have? How many Lobules?
A
2 lobes
thousands of lobules
2
Q
What is the portal triad?
A
bile duct, portal vein and hepatic artery
3
Q
What does the hepatic duct do?
A
move bile to gallbladder asnd duodenum
4
Q
How much Cardiac output does the liver get?
A
25%
5
Q
At what point can the liver no longer regenerate?
A
> 70% destruction
6
Q
What does the liver mainly store?
A
B12, iron and others
7
Q
What does the liver synthesize?
A
plasma proteins
8
Q
What is bile needed for? How much is resorbed?
A
emulsify fat, cholesterol, elim wastes
95% resorbed
9
Q
How is does bilirubin get produced?
A
RBC degradation
10
Q
What is fulminant liver failure?
A
irreversible damage and insufficient hepatocytes to function
11
Q
WHat is cholestasis?
A
failure of normal amount of bile
accumulation
12
Q
What can cause cholestasis?
A
gall stones
tumor, alcohol, PBC,PSC
13
Q
WHat is PBC?
A
slow autoimmune destruction of ducts
14
Q
What is lead cause of liver trasnplant in women?
A
PBC
15
Q
WHat is PSC?
A
genetic progressive inflammation and fibrosis of biliary tree
16
Q
What condition is associated with PSC?
A
inflammatory bowel disease
17
Q
Symptoms of Cholestasis?
A
pruritis, jaundice, dark urine, light stool, enlarged liver, growths under skin
18
Q
What can we give for gall stone?
A
ursodiol- lowers cholesterol stauration
19
Q
WHat can we give for pruritis?
A
cholestyramine, antihist (sedate) and Sertraline, Naltrexone and rifampin if refractory
20
Q
What is hemochromatosis?
A
iron absorption is high, and can kill hepatocytes
21
Q
What genetics will give you hemochromatosis?
A
homozygous for it
22
Q
True or false: Liver enzyme measurments indicate level of function.
A
FALSE
23
Q
If a patient gets lab work and ALP and GGT are elevated what condition do they have?
A
cholestasis
24
Q
What conditions have high GGT?
A
LIVER PROBLEMS
25
If a patient had only ALP elevated what are we thinking?
could be due to bones
26
A patient has increased AST and ALT what condition is it?
Hepatocellular injury
27
Which enzyme ALT or AST is more specific?
ALT
28
Why might albumin level not change in acute liver problems?
takes 20 days to notice change
29
What is pre albumin?
transport protein and is more accurate and faster seen
NOT A PRECURSOR
30
What condition can cause an elevated bilirubin?
hemolytic anemia
31
What are the three LFTs?
albumin, bilirubin, PT
32
What is unconjugated bilirubin?
bound to albumin
not water sol
indirect
33
What is conjugated bilirubin?
free
sol in water
direct
34
Where does bilirubin become conjugated?
liver
35
What are the factors measure for PT?
1,2,5,7,9,10
36
When will you see a change in PT?
>70% destruction
37
What enzymes show alcohol is the culprit?
<10x increase of enzymes
AST>ALT 2:1
38
What is the only cure for cirrhosis?
transplant
39
What is definition of cirrhosis?
chronic disease with fibrosis and nodular formation
40
What is NASH?
Non alcohol steatohepatitis
41
What is drink guidlines now?
Low risk= <2 drinks/week
Med risk= 3-6 drinks/week
high risk= >6 drinnks/week
42
Which gender gets more injuries when drunk?
male
43
Which gender is alcohol worse for? Why?
Women= absorb more alcohol
44
What is a drink equivalent?
341 ml of beer
43 ml of spirits
142 ml of wine
45
How can we diagnose cirrhosis?
Fib-4, APRI, uktrasound (first), elastography, biposy
46
What does compensated cirrhosis?
functions well despite scarring
may be asymptomatic
anorexia, loss of weight, weak, NDV
47
What is sx of decompensated cirrhosis?
confusion, edmea, fatigue, bleeding
48
What does the body to to decrease portal HTN?
RAAS and NO to dilate
49
What other organ becomes effected by portal HTN? What does it do?
spleen gets hiuge and destroys RBC
50
What are the consequences of portal shunting?
liver doesnt detoxify what we eat, malabsorb of fat,
51
What is ascites? What causes it?
collection of fluid in the peritoneal cavity
no albumin and retention of water
52
If the ascitic fluid has WBC what does that mean?
infection
53
What is SAAG? What level is liver related?
serum to ascitic albumin ratio
>11
54
What level of protein and SAAG indicates cardiac dysfunction?
>25 and >11
55
What is inital therapy for ascites?
Na and watewr restrict
spirinolactone
furosemide
56
If initial therapy doesnt work for ascites what do we do?
paracentesis, TIPS, transplant
57
What is paracentesis? What else MUST be given?
remove fluid with needle
albumin must be given too
58
What is TIPS?
shunt in liver
59
At what level might we need fluid restriction?
Na <125
60
What dose is typical for ascites?
100 mg up to 400
61
S/e of spironolactone?
man boobs, lower libido, breast tender
62
What is dose of furosemide?
40 mg up to 160 mg
63
What diuretic do we give if cant tolerate spironolcaton?
amiloride
64
What can we add on if ascites is refractory?
metolazone
65
What is refractory Ascites?
unresponsive to initial therpay and max dose of diuretics
66
What drug can cause refracroy ascites?
NSAIDs
67
What do we do if low urine sodium? what about high?
low= more diuresis
high= non adherence
68
What is acceptable weight loss if edema and with?
none= 0.5 kg/day
more for with edmea
69
What is spontaneous bacterial peritonitis?
infection with no cause, HIGH mortality
70
What pathogens are common in bacterial peritonitis?
E coli, Klebsiella, strep pneumonia
71
What is empiric therapy for community acquired and hospital acquired bacterial peritonitis?
Community- Cefotaxime or ceftriaxone for 5 days
Hospital- pip taz, meropenem +- vaancomycin
72
Who should be on prophylactic treatment for bacterial peritonitis? What is the antibiotic?
if survived previous or high risk (low ascitic fluid protein or variceal hemorrhage)
Treat? norfloxacin, septra, ciprofloxacin
73
What is hepatorenal syndrome?
renail failure due to liver dz, no pathological change to liver just vasoconstriction to kidney
74
What are varices? At what mmHg can rupture occur?
high pressure in portal causes shunting and the small vessels become engorged especially in rectal, ab, esophagus
>12 mmHg
75
How can we manage variceal bleeds?
give RBC, antibiotic for prophylaxis
octreotide/ somatostatin to vasoconstrict
band ligation
TIPS
76
Are beta blockers useful in this condition?
YES non selective
Propanolol 20 mg BID
Nadolol 20 mg OD, Low CNS, renally unchanged
use until 55 bpm
77
What is the most effective to stop bleeding in throat?
EVL
78
How does encephalopathy occur in liver dz?
accumulate of ammonia and is neurotoxic
79
How does encephalopathy present?
drowsy, mood change, confusion
80
What are the grades of encephalopathy?
1= mild confusion and tremor, impaired motor
2= lethargy, mod confusion, ataxia
3= stupor, incoherent
4= coma, unresponsive
81
What can make encephalopathy worse?
protein intake, gi bleed
diuretics
alcohol, infection, renal failure
metabolic acidosis
82
How do we manage encephalopathy?
restrict protein intake
no depressants
LACTULOSE
83
How does lactulose help encephalopathy?
reduce pH and reduces ammonia absorb
15-45 ml TID
84
What is the goal with lactulose?
2-3 stools/day
85
s/e of lactulose?
bloat, ND
86
If lactulose doesnt work what can we do?
metronidazole- lowers production of ammonia
rifaximin- same MOA, costly
87
What nutritional deficiencies occur in liver issues?
lower diet intake especially protein and fat soluble vitamins
88
If heavy alcohol is involved what nutrients are deficient?
B1 (thiamine)-low absorption and intake give 200 mg/day
B6- 2 mg OD
folate- 400 ug OD
89
Which hepatitis is a DNA virus?
Hep B
90
How does Hep A spread?
fecal to oral
91
WHat is the presentation of Hep A?
fever, jaundice
92
Is there a vaccine for Hep A and how long does symptoms last for?
YES
3 months
93
Post exposure of Hep A when is a vaccine good for? What can we give if no vaccine available?
good for 14 days after exposure
Ig
94
Is Hep A something to be concerned about?
No. Feel ill just rest
95
If a patient Has total anti-HAV what does this mean?
acute, resolved or immunity to hep A
96
What is the marker for immunity for Hep A? what about for acute infection?
anti-HAV IgG
acute= anti_HAV IgM
97
How does Hep B transmit?
fluids,
98
True or false HIV is better transmissible through needles than Hep B?
FALSE
99
IS there a vaccine for Hep B? Is it lifelong?
Yes
No may need booster
100
Based on Age with Hep B what is the rates of chronic Hep b infection?
HIghest in kids
101
What is symptoms of Hep B? What about for chronic?
usually sx
chronnic= cirrhosis, cancer in liver
102
WHat is the first test we do for Hep B? what does it mean?
HBsAg= current infection
103
What does anti HBs mean?
immunity
104
What does HBV-DNA mean?
asses severity of infection
tells you if it is replicating
105
How can we treat Hep B?
interferons
nucleoside analoguies= iamivudine, tenofovir, adefovir
106
Pros and cons of interferons
pros= no resistance, better cure rate, short course
cons= , no in symptomatic cirrhosis, side effects bad
107
Pros and cons of nucleoside analogues?
Pros= safer, oral
cons= less cure rates, longer therapy, resistance
108
WHat is an issue with lamivudine?
resistance high
109
What is issue with adefovir?
less potent
110
When would we go for tenofovir therapy?
if resistance to lamivudine
very potent
111
If there is resistance to lamivudine, can we add on entecavir?
NO- cross resistance
112
How does Hep C transmit?
fluids
113
Is there a vaccine for hep C?
NO
114
WHat are the symptoms fo Hep C?
MOSTLY asymptomatic but if its the usual
chronic= cirrhosis and cancer
115
What is Hep C usually co infected with?
HIV
116
Which hepatitis has genotypes?
Hep C
117
AFter exposure to Hep C when might you show symptoms?
30 yrs
118
What marker shows infection of Hep C? What is 2 issues with it?
anti- HCV
takes 6 weeks to get the marker after exposure
stays for life despite removal of infection
119
What is a more accurate test for acute infection of Hep C?
HCV PCR
120
WHat is considered a cured Hep C?
NO HCV RNA
121
How long is treatment for Hep C?
8 weeks generally
122
WHat is Harvoni for? WHat are the drugs in it?
Hep C
ledipasvir, sofosbuvir
123
What genotypes is harvoni for?
1,4,5,6
124
What is an issue with Harvoni?
NO PPIs
125
The drug zepatier is for...? What genotypes? What are the drugs?
Hep C geno 1,4
Grazo, ELbasavir
126
WHat lab changes are seen with zepatier?
acute increase in ALT
127
Epclusa is good for which genotypes? What drug interaction are we worried about? What are the drugs in it?
all except maybe 3
NO PPI
sofosbuvir and velpatasvir
128
Which two treatments are the most common and act on all genotypes for Hep C?
Maviret and Epclusa
Vosevi also is all genomes
129
What Hep C treatments need to be taken with food?
Maviret and Vosevi
130
Common drug interactions with Hep C treatment?
PPI= epclusa
Phenytoin, CMZ
herbals!!!!!
contraceptives= for maviret
131
Who should be screened for HepC?
People born in 1945-75, >18 once
PWID, jail,
132
How does Hep D transmit? IS there a vaccine?
Fluids
Yes B vaccine works
133
Treatment for Hep D?
interferon
134
How does Hep E spread? Is there a vaccine?
fecal- oral
NO
135
If Hepatitis infection what do you do for pain?
acet <2 gams a day
136
What is the most common reason a drug is recalled? WHat gender is more affected?
hepatotoxicity
women
137
What hepatoxicity agents are we generally say dont take?
herbals
138
Why is it difficult to classify DILI?
usually caused by multiple pathways
139
How quickly does hepatocellular DILI take? What drug is an example?
in one year
allopurinol
140
What is steatonecrosis? What drug is an example that can cause this?
fatty liver- tetracyclines
141
What drugs can cause cholestasis?
Erythromycin and CMZ
142
What is clinically significant abnormalities of liver tests?
ALT> 3x
Bilirubin>2x
143
What is the R value? How do we calculate it? What does the number mean?
R= (ALT/UL)/(ALP/UL)
>5= hepatocellular
<2= cholestasis
144
What is an example of a intrinsic DILI?
Acetaminophen- well known`
145
How is acetaminophen metabolized?
mostly glucuronidation or sulfation
if saturated then CYP= toxic metabolite that gets fixed by glutathione but that quickly gets depleted
146
WHat is the toxic metabolite from acetaminophen?
NAPQ
147
What are the 4 stages of acet toxicity?
1= 24 hours of GI
2= 1-3 days of ab pain, blood test abnormalities
3= asymptomatic or hepatic failure
4= recovery if survive
148
True or fact overdosing on acetaminophen causes chronic hepatyic issues?
NO
149
WHat levels of acet is toxic for adults and children?
>7.5
>150 mg/kg
150
What are antidotes for Acetaminophen?
Syrup of ipecac
charcoal
acetylcystein
151
WHat is an issue with syrup of ipecac and charcoal?
only help within first hour, charcoal is better than syrup tho
152
How does acetylcysteine work?
enhances glutathione and promotes non toxic conjugation
153
When do you administer Acetylcysteine?
when above treatment line of rumack-mathew nomogram
154
What indicates allergic type DILI? WHat drugs?
sx of rash, fever, high eosinophils
anticonvulsants- phenytoin, Sulfa antibiotics, allopurinol
155
When does non-allergic idiosyncratic DILI present? What are some drugs?
a week to a year
drugs= valproic acid, ketoconazole?
156
What drug causes the most amount of DILI? WHy?
Amoxicillin because it is used SOOOOO much
157
WHat child Pugh score is best survival and worst?
A=100%
C=45%
158
TRue or false People with cirhhosis are more likely to be affected by DILI?
FALSE= just lower recovery
159
