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GI Remediation > Liver > Flashcards

Liver Flashcards

1
Q

Four stages of cirrhosis

A

1) Compensated. undetectable w/o bx
2) Compensated w/ varices.
3) Decompensated. This is when we start seeing our real symptoms,

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2
Q

Major common complications of cirrhosis (think decompensated)

A

WE DON’T SEE THESE UNTIL LATE STAGE

Ascites
HRS
pHTN
Spontneous bacterial peritonitis
Coagulopathy 
Varices
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3
Q

Biggie causes of cirrhosis

A 
HCV
EtOH
HCV and EtOH
Cryptogenic (NAFLD)
HBV
Weird random things like PSC/hemochromatosis/wilson
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4
Q

Symptoms of cirrhosis dt the liver malfunctioning (pHTN, portosystemic shunting, dec detox)

A 
Fatigue
Sleep disturbance
Weight loss/wasting
Spider telangiectasis
Caput medusa
Abdominal pain dt liver enlargement
Hematemesis
GYN dysfunction (amenorrhea/ED)
Jaundice
Pruritis
Confusion/AMS
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5
Q

PE findings of cirrhosis

A

LATE.

Appear sick
Palpable liver
SPlenomegaly
Caput medusa
Ascites
Pleural effusion
Jaundice
Derm findings (caput medusa, spider nose)
Esophageal/gastric varices (hematemesis/melena)
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6
Q

Labs for cirrhosis

A

Not until starting to compensate less.

Anemia
WBC low
THrombocytopenia

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7
Q

Imaging for cirrhosis

A

US- liver size/ascites/nodular liver

CT/MRI characterize nodular liver

LIVER BIOPSY IS IMPERFECT GOLD STANDARD. Can indicate etiology. Transjugular approach.

EGD for varices

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8
Q

Use of fibrosure test for cirrhosis

A

Biomarker. Uses 6 serum tests to generate score which is equivalent in predictive value to a liver biopsy in patients with known chronic liver disease!

Kinda cool, we would use this before doing a biopsy. If someone has chronic liver disease and a low fibrosure, this excludes adv cirrhosis. If someone has a high score, then you know it is liver cirrhosis and don’t need to confirm that with a biopsy.

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9
Q

Role of Fibroscan (transient elastography) in cirrhosis

A

Bedside US that measures the liver stiffness/fibrosis.

Can be used to stage the disease & determine if treatment is warranted. Limited by ascites, obesity and severe liver inflammation. Nice idea, not super practical

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10
Q

MELD score in cirrhosis

A

Prognostic scoring system. Measures a mortality risk for pts with end stage liver disease, and useful for predicting short term survival. Also determines where you are on the liver transplant list

Scored from 6->40 made up of lab values that actually has nothing to do with liver

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11
Q

MELD score >26?

MELD Score 16-20?

A

90 day mortality of 85%

90 day mortality of 56%

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12
Q

Level of pHTN that collaterals begin to develop

A

> 10-12mmhg

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13
Q

Sequelae of pHTN

A

Ascites
Varices (eso/gastric)
Hepatic encephalopathy
Splenomegaly/thrombocytopenia dt sequestration.

Beginning of the ned

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14
Q

Ppx tx for variceal bleeding/pHTN

A

Nonselective BB! Nadolol and propranolol!

Reduce portal/collateral blood flow and decrease the portal pressure slightly.

Totally useless once the bleeding starts, but it reduces the first bleed likelihood by 50%

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15
Q

Prehepatic causes of portal HTN

A

Thrombosis/stenosis

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16
Q

Intrahepatic causes of portal HTN

A 
Cirrhosis!!!
Hepatitis
Cancer
PSC
Wilson
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17
Q

Post hepatic causes of pHTN

A

Budd chiari
Tumor compression
R sided HF (backflow)
IVC thrombosis (backflow)

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18
Q

Three main causes of ascites

A

Cirrhosis (80%)
Neoplasm
CHF

Protein level will tell you what it is. Elevated protein means it’s not cirrhosis. Same or lower is straight up portal HTN caused

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19
Q

Ascites PE and why it’s innaccurate

A

Need at least 1,500 ml to see it on PE. That’s massive.

Abdominal distention
Bulging flanks
Shifting dullness to percussion
Thrills

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20
Q

Large volume paracentesis amount

A

5-10L

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21
Q

Large volume paracentesis albumin supplementation

A

Supplement 5g of albumin for every liter you tap out over 5L

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22
Q

Two lab values you should get in large volume paracentesis

A

CBC & Cx to r/o SBP

Albumin and total protein to determine etiology

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23
Q

First line therapy for ascites

A

Sodium restriction (<1.5 Na) and fluid restriction (<1.5L) This is for the grade I fluid that is only seen on US

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24
Q

Second line tx for ascites

A

Diuretics. Spironolactone, then furosemide if we don’t see a good enough change. Make sure K is okay

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25
Surgical management for grade III ascites (thrills)
Large volume paracentesis (symptomatic relief) TIPS liver transplant
26
Not every patient with wicked bad ascites can get TIPS, why? What criteria do we use?
Need MELD <18 and TB <3 (???). Otherwise we're putting the patient at risk of hepatic encephalopathy and exacerbating the liver dysfunction
27
Two theories behind hepatic encephalopathy etiology
Ammonia buildup, it isn't being detoxed into urea. GABA inc NT inhibition
28
PE signs of encephalopathy
Asterixis, twitchiness. PE signs are just as reliable as getting an ammonia level
29
Common causes of hepatic enceph
``` SBP Diuretic therapy Hypovolemia (ammonia buildup) Renal failure GIB Constipation (ammonia buildup in gut) ```
30
Tx for enceph
Lactulose to clear out ammonia | Abx- Xifaxan absorbs ammonia
31
Most common site of gastroesophageal varices
Distal esophagus and proximal stomach. It's where the IVC and SVC hang out
32
RF for rupturing existing GE varices
Anything that increases the pHTN EtOH Red marks on varices (seen on EGD, called the red wale sign) Liver failure
33
Sx of a vairceal bleed
Hematemesis/melena/hematochezia Hemorrhagic shock sx Liver disease/cirrhosis signs
34
Emergent tx of a variceal bleed
``` pRBC until Hb>7 NGT w/ lavage Octerotide (splanchic vasoconstriction) Balloon tamponade ENDOSCOPY (banding, sclerotherapy) ```
35
Endoscopy doesn't work in a variceal bleed, what now?
TIPS! Decompresses the varices. Can also consider angiotherapy or open surg.
36
Endoscopy for variceal bleed has a lot of treatment options to stop the blood. Let's talk about them, what's best?
Band ligation has the least rebleeding/complications. But it's operator dependent, esp during an acute bleed. Also epi injection Sclerosant injection Hemoclipping
37
What is acute hepatitis? What are the two types?
Inflammation of the liver. ``` Infectious etiology (Viral) Non infectious (AI, Toxiv, EtOH) ```
38
Acute hepatitis sx
Varies from subclinical to fulminant liver failure. ``` Fatigue/malaise Anorexia N/V Fever Enlarged liver Jaundice Normal to low WBC Markedly elevated aminotransferase (>1000) ```
39
Let's just talk about hepatitis A
Fecal oral transmission. International travel is the leading RF. ``` Vaccine available Mortality very low unless pt already has HCV Anti HAV appears early Symptomatic tx Full clinical recovery w/n 3 months ```
40
IgM indicates ___ disease, whereas IgG indicates _____
IgM- active disease | IgG- previous exposure
41
How is HBV transmitted
Blood
42
HBV adults/infant recovery discrepancies
95% of adults totally recover and have lowkey infections. 90% of infants born with HBV develop acute infection, and of those kids 50% of them develop chronic HBV
43
Exposed to HBV? What do we do
HBIG w/n 7 days of exposure followed by HBV vaccination series.
44
Newborns w/ HBV + mom
For newborns at risk (mom +) we do a vaginal delivery and give HBIG and HBV vax w/n 12 hours of birth. We'll also put mom on antiviral therapy during third trimester is the viral load is high
45
HbsAg
First evidence of HBV infection. If it persists >6mo, this indicates chronic infection
46
HBV DNA?
Active replication :(
47
AntiHBc IgM AntiHBg IgG
Acute hepatitis infection that you're fighting IgG indicates chronic or recovered infection
48
HIV/HCV coinfection
30%
49
HCV and chronic illness
Unlike HBV, 85% of these patients will develop chronic HCV
50
Diagnosing HCV labs
HCV RNA PCR serology is confirmatory. Can also do an ELISA and antiHCV?
51
HCV tx
8-12 weeks Harvoni (ledipasvir/sofosbuvir) Takes 3-6 mo for full clinical recovery
52
Hepatitis D is associated with
HBV!! Terrible disesae with fulminant hepatic failure/cirrhosis but like you can only get this if you're actively infected with HBV. Africa, central asia, eastern europe, amazon
53
Hepatitis E Let's talk about it
Very rare. Fecal oral Can be spread by pig No chronic state Only seen typically in IC patients
54
Autoimune hepatitis, who's our most common patient? How often does it turn into acute hepatitis?
The same patient that gets AI anything. Young to middle aged women. Despite an insidious onset, this actually turns acute 40% of the time
55
Labs for acute AI hepatitis
Aminotransferase >1000 Positive ANA and/or smooth muscle ab IgG elevated
56
What is needed to establish dx of AI hepatitis
Liver biopsy
57
AI hepatitis Tx
Corticosteroids. It's AI silly
58
Is alcoholic hepatitis reversible?
Hell yeah!
59
Labs in EtOH hepatitis
Macrocytic anemia Thrombocytopenia (EtOH has a direct toxic effect) AST/ALT 2:1 & mildly elevated (not >300) TB elevated PT/INR elevated
60
Imaging for EtOH hepatitis
US- ascites | CT/MRI- moderate/severe steatosis but not inflammation or fibrosis
61
Emergent tx for improving short term mortality for EtOH Hep
32mg PO methylprednisone QD for 1 mo if MELD >18
62
Most common drugs that cause drug induced hepatitis
MACROBID AND MINOCYCLINE. That's just because of the widesperad use of them though. These suckers can cause some problems thru potentiation efx IND, rifampin, APAP, etOH
63
1/3 of the worlds population has
HBV. Mostly from being born with it :(
64
Dominant cause of cirrhosis and HCC
HBV
65
How much does HBV inc HCC risk
20-30% | Having a high viral load is a predictor of cirrhosis/HCC risk
66
First line for chronic HBV
Entecavir/Tenofavir. Lifelong therapy, prevents repliation
67
When do we consider HCV to be chronic
>6 mo of persistent HCV RNA serology
68
HCC is associated with
Underlying liver disease. Hepatitis, NASH
69
HCC clinical presentation
``` Insidious until cirrhotic Weakness, weight loss, anorexia Ascites Jaundice, icterus pruritis Tender enlarged liver ```
70
HCC WU
``` CBC CMP Lipase PT Alpha fetoprotein HCV/HBV testing Alpha 1 antitrypsin EtOH ```
71
Imaging for HCC
US | MRI
72
Diagnostic for HCC
Biopsy, but 1-3% chance of seeding with needle.
73
Size of tumor and biopsy guidelines <1cm? 1-2cm?
<1cm gets CT/MRI every 3 months to assess for enlarging lesion 1-2? Bx should be performed
74
>2cm HCC lesion w/ cirrhosis, elevated AFP levels?
Manage w/o biopsy. Don't need the risk, that's definitely cancer
75
Only long term cure for HCC
Surgical. Be it resection or transplant. HCC is radioinsensitive and chemo is ineffective. VEGF blockers have been shown to slow progression.
76
HCC tumor near the hepatic artery?
Can try transarterial chemoembolization (TACE) or transarterial radioembolization (TARE)

GI Remediation (6 decks)

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