Liver Flashcards
A 62-year-old female with a history of compensated cirrhosis secondary to nonalcoholic steatohepatitis presents to establish care and has no acute issues. She has read that she may have an increased risk for liver cancer and asks if she should be screened.
Which one of the following should you advise? (check one)
-No routine surveillance, but evaluation based on signs or symptoms
-Ultrasonography every 6 months
- Annual α-fetoprotein testing
-Annual CT
- Annual MRI
Ultrasonography every 6 months
Patients with cirrhosis are at higher risk for development of hepatocellular carcinoma (HCC). Surveillance leads to detection of HCC at earlier stages and improvements in survival rates. It is recommended that adults with cirrhosis undergo ultrasonography surveillance every 6 months with or without the addition of α-fetoprotein levels. Annual CT and annual MRI are not indicated for this patient.
A 40-year-old female presents to your office with jaundice and dark urine. Testing for acute hepatitis A is positive. Her 12-year-old twin boys, who are in good health, have not been vaccinated against hepatitis A or B and are currently asymptomatic.
Which one of the following would be the most appropriate postexposure prophylaxis for these children? (check one)
No prophylaxis
Hepatitis A vaccine only
Immune globulin only
Hepatitis A vaccine and immune globulin
Hepatitis A vaccine only
All unvaccinated household contacts and sexual contacts should receive postexposure prophylaxis following significant exposure to hepatitis A within the previous 2 weeks. Healthy individuals 12 months to 40 years of age should receive the hepatitis A vaccine as prophylaxis. Infants younger than 12 months of age should receive immune globulin as postexposure prophylaxis. Individuals >40 years of age, as well as immunocompromised patients, should receive both hepatitis A vaccine and immune globulin.
A 52-year-old female with morbid obesity is incidentally noted to have mildly elevated AST (SGOT) levels. She does not consume alcohol and denies using recreational drugs. A workup for chronic viral hepatitis and hemochromatosis is negative.
Which one of the following is most likely to improve her hepatic condition? (check one)
Pentoxifylline
Simvastatin (Zocor)
L-carnitine
Vitamin E
Weight loss
Weight loss
Nonalcoholic fatty liver disease is characterized by the accumulation of fat in hepatocytes. It is associated with insulin resistance, central adiposity, increased BMI, hypertension, and dyslipidemia. An incidentally discovered elevated AST level in the absence of alcohol or drug-induced liver disease strongly suggests the presence of nonalcoholic fatty liver disease. The goal of therapy is to prevent or reverse hepatic injury and fibrosis. Diabetes mellitus, hypertension, dyslipidemia, and other comorbid conditions should be appropriately managed.
A healthy diet, weight loss, and exercise are first-line therapeutic measures to reduce insulin resistance in patients with nonalcoholic fatty liver disease. Weight loss has been shown to both normalize AST levels and improve hepatic histology. Vitamin E has been shown to improve AST levels but has no impact on liver histology, and pentoxifylline, simvastatin, and L-carnitine have not been shown to consistently improve either AST levels or liver histology (SOR B).
A 52-year-old male presents for a routine physical examination. His laboratory results reveal an AST (SGOT) level of 124 U/L (N 10–40) and an ALT (SGPT) level of 36 U/L (N 10–55). His (-glutamyl transpeptidase (GGTP) level is also elevated.
The most likely cause of this abnormality is? (check one)
Hepatitis
Hemochromatosis
Nonalcoholic fatty liver disease
Alcoholic liver disease
Statin-induced liver disease
Alcoholic liver disease
In a study of 256 asymptomatic Swedish patients with mildly elevated liver transaminase levels, alcohol was found to be the cause in 10% of cases. An accurate history is important for making the diagnosis. A biopsy alone cannot differentiate alcoholic liver disease from nonalcoholic fatty liver disease. An AST/ALT ratio >2 supports a diagnosis of alcoholic liver disease. Elevated (-glutamyl transpeptidase (GGTP) is also associated with alcohol abuse, especially in a patient with an AST/ALT ratio >2.
A mother calls to ask your advice because her healthy 3-year-old, who has not been immunized against hepatitis A, attends day care with a child who was just diagnosed with the illness. You advise her that her child should receive? (check one)
no prophylactic treatment
hepatitis A vaccine only
hepatitis A vaccine and immunoglobulin
hepatitis A vaccine, along with other family members
hepatitis A vaccine only
Workers and children at child care centers should receive postexposure prophylaxis if one or more cases of hepatitis A is found in a child or worker. Hepatitis A vaccine is preferred over immunoglobulin because of its long-lasting effect, ease of administration, and efficacy. Children younger than 1 year of age should receive immunoglobulin. Family members should receive prophylaxis only during an outbreak and if their child is still in diapers.
A 63-year-old male with a history of alcoholism and compensated hepatic cirrhosis asks if there are pain medications he can use to treat his chronic low back pain and knee and hand osteoarthritis. He also has occasional headaches. He has not used alcohol for several years.
Which one of the following medications is CONTRAINDICATED in this patient?
(check one)
Acetaminophen
Gabapentin (Neurontin)
Naproxen
Pregabalin (Lyrica)
Tramadol (Ultram)
Naproxen
Although patients with chronic mild liver disease may take NSAIDs, they should be avoided in all patients with cirrhosis, due to the risk of precipitating hepatorenal syndrome. Pregabalin and gabapentin are not metabolized by the liver and can be quite helpful. Acetaminophen, while toxic in high doses, can be used safely in dosages of 2–3 g/day. Tramadol is also safe in patients with cirrhosis.
A 28-year-old gravida 2 para 1 at 32 weeks’ gestation presents with severe itching. She denies fever or vomiting. Her physical examination is remarkable for jaundice, but is otherwise benign. Laboratory studies reveal a normal CBC, normal platelets, normal glucose and serum creatinine levels, normal transaminase levels, and a bilirubin level of 4.0 mg/dL (N 0.0–1.0). Which one of the following is the most likely diagnosis? (check one)
Intrahepatic cholestasis of pregnancy
Acute viral hepatitis
Acute fatty liver of pregnancy
Pruritic urticarial papules and plaques of pregnancy (PUPPP)
Hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome
Intrahepatic cholestasis of pregnancy
Intrahepatic cholestasis of pregnancy is rare, occurring in 0.01% of pregnancies. It usually presents in the third trimester. Approximately 80% of patients present with pruritus alone, and another 20% with jaundice and pruritus. Laboratory results usually reveal normal or minimal elevation in transaminase levels, elevated bilirubin (usually <5 mg/dL), and occasional elevations in cholesterol and triglyceride levels. It is important to recognize and diagnose this entity, as it is associated with prematurity, fetal distress, and increased perinatal mortality. Acute viral hepatitis is a common cause of jaundice in pregnancy; however, it usually does not present with severe pruritus, and transaminase levels are markedly elevated. Acute fatty liver of pregnancy is another rare condition occurring in the third trimester and is usually associated with preeclampsia (50%–100% of cases). It presents with nausea and vomiting, anorexia, jaundice, abdominal pain, headache, and neurologic abnormalities. Transaminase levels are moderately elevated, PT and PTT are prolonged, and profound hypoglycemia and renal failure are usually present. Pruritic urticarial papules and plaques of pregnancy (PUPPP) is more common in women that present with severe pruritus. However, jaundice and liver function abnormalities are absent. HELLP syndrome is an uncommon but serious condition which presents in the third trimester with hemolysis, elevated transaminases, and low platelet count.
A 66-year-old male with nonalcoholic steatohepatitis, hyperlipidemia, and hypertension sees you for follow-up. He was recently diagnosed with cirrhosis. He has no new health complaints today. His medications include metoprolol, simvastatin (Zocor), and low-dose aspirin. His vital signs include a blood pressure of 120/75 mm Hg, a heart rate of 72 beats/min, and an oxygen saturation of 96% on room air. The physical examination is notable for mild ascites and trace lower extremity edema.
Which one of the following recommendations would be most appropriate for this patient?
(check one)
Fluid restriction
Limiting sodium intake
A low-protein diet
Discontinuation of metoprolol
Discontinuation of simvastatin
Limiting sodium intake
Dietary counseling is key in the management of cirrhosis. Patients with ascites should be
limited to 2000 mg of sodium daily (SOR A). Fluid restriction is not recommended unless
the serum sodium level is <120 mEq/L, and it is extremely difficult to achieve. Patients
would need to limit fluid intake to less than their urinary output, which is often reduced.
Up to 60% of patients with cirrhosis suffer from malnutrition, so a high-protein diet is
recommended (1.0–1.5 g/kg dry body weight). High-protein diets are tolerated well and
result in improved mental status (SOR B). Protein restriction does not benefit those with
hepatic encephalopathy.
β-Blockers should be stopped when the patient’s mean arterial pressure is <82 mm Hg
(blood pressure 100/73 mm Hg) (SOR B). β-Blockers are used in early cirrhosis for
hypertension, reducing portal pressures, and prevention of varices. They are no longer
effective when the patient becomes hypotensive or has refractory ascites, spontaneous
bacterial peritonitis, or other conditions associated with significant changes in
hemodynamic status. This patient is normotensive on his current dosage of metoprolol. As
his cirrhosis progresses the metoprolol will likely need to be discontinued.
Statins can be safely used in patients with cirrhosis. Their cardiovascular benefits are well
established and the risk of associated liver failure is extremely low (SOR A).
A 52-year-old male sees you for a routine health maintenance examination. He does not take any medications, does not drink alcohol, and is feeling well. A physical examination is normal with the exception of a BMI of 33 kg/m2. Routine laboratory studies reveal mild elevations of ALT (SGPT) and AST (SGOT), which remain elevated on repeat testing 2 months later. Hepatitis B and hepatitis C testing are negative.
In addition to ultrasonography of the liver, which one of the following laboratory studies should be ordered to further evaluate this patient? (check one)
Serum ferritin
Serum phosphorus
α-Fetoprotein
Carcinoembryonic antigen (CEA)
Serum protein electrophoresis
Serum ferritin
Mild asymptomatic elevations (<5 times the upper limit of normal) of ALT and AST are common in primary care. It is estimated that approximately 10% of the U.S. population has elevated transaminase levels. The most common causes of elevated transaminase levels are nonalcoholic fatty liver disease and alcoholic liver disease. The initial evaluation should include assessment for metabolic syndrome and insulin resistance. Waist circumference, blood pressure, a fasting lipid level, and a fasting glucose level or hemoglobin A1c should be obtained. A CBC with platelets and measurement of serum albumin, iron, total iron-binding capacity, and ferritin levels would also be indicated. Iron studies should be ordered to rule out hereditary hemochromatosis, which is an autosomal recessive disease that causes increased iron absorption in the intestines and release by tissue macrophages.
A 42-year-old male presents for a routine health maintenance visit and asks about hepatitis C virus (HCV) testing. He reports that he experimented with intravenous drugs in college but never developed a habit. He consumes 1–2 alcoholic drinks a week and is a nonsmoker. He is not married but is in a monogamous, heterosexual relationship.
Which one of the following would confirm active hepatitis C infection? (check one)
Anti-HCV antibody testing
AST and ALT levels
An AST/platelet ratio index
A CBC with differential and peripheral smear
HCV RNA polymerase chain reaction testing
HCV RNA polymerase chain reaction testing
This patient is at risk for hepatitis C virus (HCV) infection due to his history of intravenous drug use. The initial screening test for HCV is anti-HCV antibody testing, and a positive result could indicate either a prior infection that cleared or an active infection. If the antibody test is positive, HCV RNA polymerase chain reaction testing is the next step to confirm an active infection. AST and ALT levels and a CBC should be obtained if the patient is diagnosed with an active HCV infection. The AST/platelet ratio index is a screening test for hepatic fibrosis and cirrhosis.
You see a 53-year-old female with diabetes mellitus, hypertension, mixed hyperlipidemia, and GERD. Recent laboratory studies include an incidental finding of thrombocytopenia. The patient has no other significant past medical history, and she does not use tobacco or drink alcohol. Her current medications include metformin (Glucophage), lisinopril (Prinivil, Zestril), omeprazole (Prilosec), calcium citrate, and pravastatin (Pravachol). A physical examination is notable for a BMI of 31 kg/m2. Her skin, heart, lungs, abdomen, and extremities are normal. Results of a CBC and a comprehensive metabolic panel are normal with the following exceptions:
Platelets 70,000 (N 150,000–379,000)
Glucose 108 mg/dL
Bilirubin 0.4 mg/dL (N 0.0–0.4)
Alkaline phosphatase 175 U/L (N 38–126)
ALT (SGPT) 52 U/L (N 10–28)
A peripheral smear is normal except for reduced platelets. Tests for hepatitis B, hepatitis C, and HIV are negative.
The most likely etiology of this patient’s thrombocytopenia is (check one)
a hematologic malignancy
chronic liver disease
drug-induced thrombocytopenia
immune thrombocytopenic purpura (ITP)
primary bone marrow failure
chronic liver disease
This patient presents with a typical example of nonalcoholic steatohepatitis (NASH) progressing toward cirrhosis, with multiple risk factors including diabetes mellitus, hyperlipidemia, obesity, and mildly elevated hepatic transaminases. Abnormalities of other cell lines would likely occur if a hematologic malignancy or bone marrow failure were present. While immune thrombocytopenic purpura is a diagnostic consideration, it is much less common than NASH and requires other causes to be ruled out. This patient is not taking any medications that have been frequently reported to cause drug-induced thrombocytopenia.
A 55-year-old male presents with shortness of breath and abdominal pain. He has a history of diabetes mellitus, coronary artery disease, and hepatitis C. He usually is very active and continues to work at a steel plant. He smokes 1 pack of cigarettes each day and drinks alcohol daily. A chest radiograph shows a moderate right-sided pleural effusion. Thoracentesis reveals a pleural fluid protein to serum protein ratio of 0.3, and a pleural LDH to serum LDH ratio of 0.4. The pleural glucose level is 140 mg/dL and his serum glucose level is 150 mg/dL.
Which one of the following is the most likely cause of this pleural effusion? (check one)
Asbestosis
Cirrhosis with ascites
Malignancy
Pneumonia
Viral illness
Cirrhosis with ascites
Evaluation of the pleural fluid is important to assist in determining the cause of the effusion. Protein, glucose, LDH, and cell counts should be measured in the pleural fluid. This can help determine if the effusion is exudative or transudative. A pleural protein to serum protein ratio >0.5 or a pleural fluid LDH to serum LDH ratio >0.6 suggests an exudative effusion. Lower ratios suggest a transudative process. With transudates, the pleural fluid pH is typically between 7.40 and 7.55, with fewer than 1000 WBCs, and the glucose level is similar to the serum glucose level. Cirrhosis with ascites is a cause of transudative effusion. Pleural effusions associated with malignancy, pneumonia, viral illness, and asbestosis tend to be exudative.
An otherwise healthy 32-year-old female sees you for a routine health maintenance examination after having required laboratory screening at work. She has no significant past medical history and the physical examination is normal. Laboratory results are unremarkable except for an elevated alkaline phosphatase level.
Which one of the following would be most appropriate at this point? (check one)
A gamma-glutamyl transferase level
A parathyroid hormone level
Hepatitis C antibody testing
Ultrasonography of the liver
Bone scintigraphy
A gamma-glutamyl transferase level
When an otherwise healthy patient’s alkaline phosphatase level is elevated, it is helpful to determine whether the source of elevated isoenzymes is the liver or bone. One method is fractionation of the alkaline phosphatase by electrophoresis. A gamma-glutamyl transferase or 5 -nucleotidase level can also indicate whether the elevation of the alkaline phosphatase is from the liver. These enzymes are rarely elevated in conditions other than liver disease. Severe vitamin D deficiency can lead to osteomalacia with an elevated alkaline phosphatase.
