Liver

Question 1

What is the structure of a liver lobule?

Answer 1

Hepatic vein in the center of the lobule with hepatocytes surrounding it funneling endocrine, secretory and metabolic hormones into the vein.
There are about 50-100k lobules per liver

Question 2

What are the vessels that run into and out of the liver and where do they come from?

Answer 2

Hepatic artery runs from heart to liver
Hepatic portal vein runs from intestines to liver
Hepatic vein runs from liver back to heart

Question 3

What is the role of the liver?

Answer 3

Secrete glycogen for glucose homeostasis
Metabolize fats, proteins, bilirubin and drugs and hormones
Detox blood
Produce prothrombin

Question 4

What lab tests can you do for liver damage? Which are most commonly used and which one is most specific?

Answer 4

AST and ALT most common
ALT most specific (Liver damage only)
AST: liver, heart and skeletal muscle damage
ALP: Liver, bile ducts and bone damage
GGT: liver, heart, kidney and brain damage
Serum/urine bilirubin concentration (Conj and unconj)
Prothrombin time and INR

Question 5

What causes the yellowing of the skin seen in jaundice?

Answer 5

Bilirubin buildup in blood

Question 6

Where would you see yellowing in jaundice

Answer 6

Fornices of eyelids and conj
Skin
Mucous membranes (like inside of cheeks)

Question 7

What’s the normal path of bilirubin starting as old hemoglobin?

Answer 7

Old hemoglobin to spleen to become unconjugated bilirubin to liver to become conjugated bilirubin to stool

Question 8

What symptoms do you see if the bilirubin path is dysfunctional?

Answer 8

Pale stools (no bilirubin) and dark urine (Bilirubin spillover)

Question 9

What gene abnormality leads to Wilson’s Disease? What inheritance pattern is it?

Answer 9

ATP7B copper transport dysfunction. Autosomal recessive

Question 10

What is dysfunctional in Wilson’s Disease?

Answer 10

ATP7B copper transport

Question 11

Where does the copper tend to build up in Wilson’s Disease?

Answer 11

Liver, brain and eyes

Question 12

When does Wilson’s disease manifest?

Answer 12

Between ages 12-20

Question 13

Wilson’s disease leads to disease of the eye, brain and liver. What liver symptoms do you see in Wilson’s?

Answer 13

Liver failure, hepatitis and cirrhosis

Question 14

Wilson’s disease leads to disease of the eye, brain and liver. What eye symptoms do you see in Wilson’s?

Answer 14

Sunflower cataract (PSC and ASC)
Kaiser flescher ring
50% likely if only liver affected
100% if brain affected too

Question 15

Wilson’s disease leads to disease of the eye, brain and liver. What neurological symptoms do you see in Wilson’s?

Answer 15

Parkinson’s like symptoms + drooling

Question 16

What clinical manifestations would you note for Wilson’s disease?

Answer 16

Liver biopsy, psych changes, ocular manifestations

Question 17

What lab tests could you do to test for Wilson’s disease?

Answer 17

Decrease serum ceruloplasmin (100mcg/day)
Poor ALT and AST
Gene tests

Question 18

What are treatments for Wilson’s disease

Answer 18

Chelate copper with EDTA
Increase zinc in diet
Decrease copper in diet (mushrooms, shellfish, liver, nuts harder for vegetarians)
Check drinking water

Question 19

What is the route of transmission for Hepatitis A?

Answer 19

Fecal oral

Question 20

In whom is Hepatitis A more prevalent

Answer 20

Low socioeconomic status

Question 21

Can you be vaccinated for Hep A?

Answer 21

Yes

Question 22

How long does it take for HepA to incubate?

Answer 22

30 days

Question 23

What are symptoms of HepA?

Answer 23

Prodromal = fatigue, fever, nausea, anorexia, upper right quadrant pain
Jaundice

Question 24

How would you test for HepA?

Answer 24

HAV antibodies

Question 25

Treatment for HepA?

Answer 25

Supportive therapy Self limiting disease Most recover in 3 months Almost all recover in 6 months

Question 26

True or false? HepB is typically Chronic

Answer 26

False. HepB is typically acute

Question 27

How is HepB transferred?

Answer 27

Sex, drugs (and rock and roll)

Question 28

Where is HepB found in the world?

Answer 28

Africa and SE Asia

Question 29

Symptoms of acute HepB?

Answer 29

Typically asymptomatic May have flulike symptoms Rarely get jaundice or liver failure

Question 30

What's serum sickness?

Answer 30

Body allergic to Hepatitis B. Get hives, fever and joint pain

Question 31

Symptoms of chronic HepB?

Answer 31

Cirrhosis, carcinoma, liver failure

Question 32

What are the antigen tests for HepB?

Answer 32

HB(s)Ag, HB(e)Ag, HB(c)Ag | IgM or IgG test for acute or chronic testing for HB(c)Ag

Question 33

How would you test to differentiate acute and chronic HepB?

Answer 33

IgM or IgG test for acute or chronic testing for HB(c)Ag

Question 34

How do you treat acute HepB?

Answer 34

Supportive therapy

Question 35

How do you treat chronic HepB?

Answer 35

Antivirals "-Vudine" "-Ovir" "-voxil"

Question 36

What's the most common cause of liver disease and transplant?

Answer 36

HepC

Question 37

Is HepC more often acute or chronic?

Answer 37

Chronic. 30% end up getting cirrhosis within 30 years

Question 38

Symptoms of acute HepC?

Answer 38

Asymptomatic Fatigue, myalgia, N/V and poor appetite Upper right abdominal pain

Question 39

Symptoms of chronic HepC?

Answer 39

Asymptomatic until liver damage

Question 40

True or false? HepC can also be coinfection with HepD and HepE

Answer 40

False. Coinfection with HepA and HepB

Question 41

What tests can you run for HepC?

Answer 41

ALT and AST HAV antigen test RT PCR for HAV RNA Liver Biopsy

Question 42

Treatment for HepC?

Answer 42

``` Antivirals "-evir" "-virin" peginterferons Check at the end of therapy and 6 months later to ensure still good ```

Question 43

What drugs are choice but very expensive for HepC?

Answer 43

Sofosbuvir and ribavirin

Question 44

What eyesigns are associated with which drugs for HepC?

Answer 44

Interferon retinopathy. Get cottonwool spots, ONH edema and BRAO that can lead to RD

Question 45

What is required for a HepD infection to take hold?

Answer 45

HepB in body as well

Question 46

Differene between HepD and HepB coinfection vs superinfection?

Answer 46

``` Coinfection = acute Superinfection = chronic ```

Question 47

How do you test for HepD?

Answer 47

HBV antigen test | HepD RT-PCR

Question 48

Treatment for HepD? What doesn't it do?

Answer 48

Interferon alpha. Doesn't treat viral or liver disease

Question 49

Prognosis for HepD?

Answer 49

75% chance progressive liver disease

Question 50

How is HepE spread?

Answer 50

Poo water

Question 51

There are 4 genotypes with 24 subtypes of HepE. A higher mortality exists in pregnant women. The presentation's not yet understood

Answer 51

Free card

Question 52

Similar to HepA in tx and symptoms

Answer 52

HepE

Question 53

How would you diagnose HepE?

Answer 53

HepE antigen test (IgM) | HEV detection

Question 54

How many drinks may result in alcohol liver disease?

Answer 54

Women: 14 drinks per week Men: 21 drinks per week

Question 55

What liver problems occur with alcohol liver disease?

Answer 55

Hepatic steatosis

Question 56

Symptoms of hepatic steatosis?

Answer 56

asymptomatic

Question 57

Symptoms of alcoholic hepatitis?

Answer 57

Ascities, jaundice, anorexia | Fever, muscle wasting and pain

Question 58

What's cirrhosis?

Answer 58

Fibrosis of liver and regenerative nodules

Question 59

What are some general symptoms of cirrhosis that you may notice with alcohol liver dz?

Answer 59

Finger clubbing, palm erythema, asterixis Gynecomastia Jaundice, ascities, splenomegaly

Question 60

What diagnostic tests can you run for alcohol liver dz?

Answer 60

Elastography | MRI to quantify steatosis

Question 61

What are causes of cirrhosis?

Answer 61

HepB and HepC, alcohol liver disease, hepatic steatosis

Question 62

What're the symptoms of cirrhosis?

Answer 62

Ranges from itching to liver dysfunction to infertility

Question 63

How would you diagnose cirrhosis?

Answer 63

Imaging | ALT/AST

Question 64

Treatment for cirrhosis?

Answer 64

Protect liver | Liver transplant

Question 65

Prognosis for cirrhosis?

Answer 65

40x increase in hepatocellular carcinoma

Question 66

Epidemiology for hepatocellular carcinoma?

Answer 66

Black or asian males 50-60yo

Question 67

What tests would you NOT do for hepatocellular carcinoma?

Answer 67

Lab tests not definitive

Question 68

What tests would you do to test for hepatocellular caricnoma?

Answer 68

Biopsy and ultrasound If nodules greater than 1 cm, do MRI or CT scan PET scan to monitor metastases

Question 69

What is hepatocellular carcinoma?

Answer 69

Fibrosis/nodular regeneration of liver

Question 70

Symptoms of hepatocellular carcinoma?

Answer 70

No symptoms other than chronic liver disease. Similar to cirrhosis

Question 71

Risk factors/reasons to screen for hepatocellular carcinoma?

Answer 71

Fhx, alcoholic, HepB/C, autoimmune hepatitis, Primary biliary cirrhosis, nonalcoholic steatohepatitis, hemochromatosis

Question 72

How would you treat hepatocellular carcinoma?

Answer 72

Liver resection/transplant | Radiofrequency or transarterial chemoembolization ablation