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Foundations III GI (Cholley) > Liver > Flashcards

Liver Flashcards

1
Q

What is acute liver failure?

A

Liver injury, hepatic encephalopathy, & coagulopathy

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2
Q

What causes acute liver failure?

A

Hepatocyte necrosis due to:

  • Viral hepatitis
  • Drug induced
  • Toxins
  • Metabolic
  • Vascular
  • Wilson’s disease, autoimmune, tumor, transplant
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3
Q

What is the #1 cause of acute liver failure?

A

Acetaminophen overdose

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4
Q

What are s/s of acute liver failure?

A 
AMS 
Cerebral edema
Coagulopathy 
Organ failure
Ascites & anasarca 
Shrinking liver
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5
Q

What are clinical features of acute hepatic failure?

A

Coagulopathy & jaundice

Encephalopathy within 1-4 wks

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6
Q

What are clinical features of subacute hepatic failure?

A

Encephalopathy within 12-24wks

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7
Q

What are lab findings w/ acute liver failure?

A

Increased PT/INR

Leukocytosis

Hyponatremia, hypokalemia, hypoglycemia

Elevated bilirubin, ALT/AST

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8
Q

How do you treat acute liver failure?

A

Transfer to liver transplant
Await for resolution
If no recovery –> transplant

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9
Q

Which type of hepatitis is transmitted fecal-orally & do not cause chronic infection?

A

A & E

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10
Q

How are hep B, C, & D transmitted?

A

Parenterally or MM contact

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11
Q

What does acute viral hepatitis look like on PE?

A

Enlargement/ tenderness of liver

Splenomegaly & posterior cervical lymphadenopathy

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12
Q

What are s/s of cholestatic hepatitis?

A

Severe jaundice for several month

Prominent pruritis

Persistent anorexia & diarrhea

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13
Q

What are s/s of relapsing hepatitis?

A

Arthritis, vasculitis, cryoglobulinemia

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14
Q

What are lab findings in acute viral hepatitis?

A 
ALT/AST > 500, ALT > AST
Bilirubin: nl - 10mg
Alk phos: nl - mild elevation
Prolonged Pt/INR 
Albumin: nl - mild decrease
WBC nl - mild leukopenia
Lymphocytosis
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15
Q

What are the lab findings in cholestatic hepatitis?

A

Bilirubin ≥ 20
Alk phos elevated
ALT/AST may decrease

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16
Q

What are the lab findings in relapsing hepatitis?

A

ALT, AST elevated

Bilirubin recurs

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17
Q

How do you treat cholestatic hepatitis?

A

Prednisone & urso

Cholestyramine for pruritis

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18
Q

What are RFs for hep A?

A

Living in endemic region
Contact w/ infected person
MSM
Foodborne outbreak

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19
Q

What are s/s of hep A?

A

Incubation = 28 days
Preicteric phase lasts 5-7 days
Fever, jaundice, RUQ TTP
Fulminant course

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20
Q

How do you dx hep A?

A

IgM antibody to HAV, which is then replaced by IgG anti-HAV

Elevated ALT/AST

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21
Q

How do you treat hep A? What is the prognosis?

A

Supportive
85% recover within 3 mos
nearly all recover within 6mos

10-20% can have relapsing course

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22
Q

How do you prevent hep A?

A

Handwashing
Disposal of wastes
Immunization
Avoid excessive APAP & Etoh

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23
Q

In hep A, when can children return to school?

A

1 week after the onset

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24
Q

When should you give someone postexposure prophylaxis for hep A?

A

If recently exposed & not vaccinated

Give ASAP/within 2 wks

12mos-40yo –> HAV vaccine

< 12mos or > 40, immunocompromised, liver disease –> immune globulin

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25
Q

In hep A, transmission usually precedes sx by…

A

2 weeks!

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26
Q

What are RFs for hep E?

A

Mexico, Cuba, Asia, Africa, Middle East

Consumption of undercooked pork, deer meat, shellfish

Contaminated water = MC

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27
Q

What are clinical features of hep E?

A

Abrupt onset of prodromal sx

Acute liver failure occurs in pregnant

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28
Q

How do you dx Hep E?

A

IgM anti-HEV detectable for at least 6wks, then replaced by IgG anti-HEV (detectable for 12-20 mos)

HEV RNA confirms & quantifies

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29
Q

How do you prevent hep E?

A

Good sanitation

Avoid unpurified H2O, boil & chlorinate

Avoid raw pork & venison

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30
Q

What are general characteristics of HAV & HEV?

A

Nonenveloped viruses

Linear RNA molecules

Survive when exposed to bile

Shed in feces

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31
Q

What are general characteristics of HBV, HDV, & HCV?

A

Enveloped

Disrupted by bile/detergents

A/w chronic liver disease

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32
Q

What are high prevalence areas w/ Hep B?

A

West Africa & South Sudan

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33
Q

What does the outer envelope of hep B contain?

A

HBsAg

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34
Q

What does the inner envelope of hep B contain?

A

HBcAg (structural protein): induces response against HBV

HBeAg (non-structural): marker for active replication

DNA polymerase: reverse-transcriptase

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35
Q

What are strong RFs for Hep B?

A 
Perinatal exposure 
Multiple sex partners 
MSM 
Injection drug use 
Asian, European, African 
FHx of HBV or liver disease
FHx of HCC 
Contact w/ HBV
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36
Q

What are weak RFs for Hep B?

A 
Male 
Hx of STDs
HIV, Hep C 
Blood transfusion 
HCW 
Hx of incarceration 
Hemodialysis
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37
Q

What are s/s of hep B?

A

Insidious onset of prodromal sx

Serum sickness-like syndrome in 10%: F/C, malaise, maculopapular or urticarial rash, N/V, arthralgia/arthritis

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38
Q

What are s/s of hep B in those that are chronically infected?

A

Asx

s/s of chronic liver disease:

  • cirrhosis
  • HCC
  • failure
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39
Q

What are all the lab findings for hep B?

A

See page 149 in PANCE book

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40
Q

How do you treat hep B?

A

Acute –> self-limiting

Fulminant –> transplant

Chronic –> anti-viral (only if ALT elevated, which indicated active inflammation)

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41
Q

What are 1st line pharmocological options for chronic hep B?

A

Peginterferon alpha-2a SQ x 48wks

Nucleoside analogues PO QD (may be indefinitely): Entecavir & tenofovir

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42
Q

How do you prevent hep B?

A

Active immunization:
- Hep B vaccine

Passive immunization:
- Hep B immune globulin (used for postexposure prophylaxis)

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43
Q

When should you suspect HDV?

A

Fulminant HBV
Relapsing HBV
Progressive chronic HBV

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44
Q

How do you treat HDV?

A

High dose interferon alpha & PEG IFN

45
Q

Who should be screened for hep C?

A

High risk

All people born btwn 1945-1965, all baby boomers

46
Q

Hep C has how many genotypes & subtypes?

A

6 genotypes & > 50 subtypes

75% in US are genotype 1

47
Q

What causes hep C?

A

MC = IVDU

Sex activity, perinatally, accidental blood contact

48
Q

What are strong RFs for hep C?

A

IVDU
Blood transfusion
HIV

10% have no known RF.

49
Q

How does hep C present?

A

Asx

30% have prodromal sx & jaundice

50
Q

How do you dx hep C?

A

Hepatitis C antibody (anti-HCV)

HCV RNA needed to dx acute infection

51
Q

Which genotype of hep C has more frequent spontaneous resolution vs less frequent?

A

More frequent = genotype CC

Less frequent = genotype CT & TT

52
Q

What are characteristics of chronic Hep C?

A

HCV RNA in blood ≥ 6 months

Presents w/:
chronic liver disease
cirrhosis
HCC

53
Q

What factors influence progression of chronic hep C liver disease?

A 
Older age
Male 
Concurrent chronic HBV 
HIV 
Alcohol
54
Q

How do you screen for chronic HCV?

A

EIA (detects antibodies)

55
Q

How do you use qualitative vs quantitative studies?

A

Qualitative: confirms viremia, low limits of detection

Quantitative: give wide dynamic range of viral loads, best way to confirm response to tx

56
Q

How do you treat HCV?

A

1st test for genotype, bc this determines the regimen

  • PEGIFN weekly (no longer considered SOC)
  • Ribavirin
  • Oral antivirals = 1st line
57
Q

What are examples of direct acting antivirals (DAAs) used for the tx of HCV?

A

NS3-4 protease inhibitors: genotype 1 & 4 (“previr”)

NS5B polymerase inhibitors: all genotypes (“buvir”)

NS5A replication complex inhibitors: (“asvir”)

58
Q

What is RVR?

A

Rapid viral response

HCV RNA undetectable by week 4 of tx

59
Q

What is EOT?

A

End of treatment

HSV RNA undetectable at the end of tx

60
Q

What is SVR?

A

Sustained virologic response

Undetectable HCV RNA at 12 weeks after tx

61
Q

What is nonresponse?

A

Failure to attain undetectable HCV RNA at any point

62
Q

What is relapse?

A

EOT response followed by return of HCV RNA after completion of tx

63
Q

What are major offenders of drug-induced liver injury (DILI)/ toxic hepatitis?

A 
Antimicrobials (MC)
CNS agents
Immunomodulators
Analgesics 
Lipid-lowering
64
Q

How does drug-induced liver injury (DILI)/ toxic hepatitis present?

A

Ranges from subclinical LFT elevation to acute liver failure

Liver injury may develop in days or within several wks of ingestion

Labs may reveal hepatoxic injury, cholestatic, or mixed

65
Q

How does acetaminophen overdose present?

A

30mins-24 hrs: GI sx

2 days after: R abd pain & oliguria, elevated LFTs & prolonged PT/INR

3-5 days: hepatic necosis w/ elevated aminotransferases, renal failure, & ALF

5-10 days: recovery phase

66
Q

What determines the likelihood of death or need for transplant?

A

pH < 7.3

Stage 3-4 encephalopathy w/ PT/INR > 6.5 & Cr > 3.4

Factor V level ≤ 10%

67
Q

How do you treat acetaminophen overdose?

A

IV N-acetylcysteine for serial doses

Charcoal within 1 hr

Gastric lavage within 4 hrs

68
Q

What abnormalities are seen w/ alcoholic liver disease?

A

Steatosis
Steatohepatitis
Cirrhosis

69
Q

What are clinical features of alcoholic liver disease?

A

Asx to advanced liver failure

Portal HTN

Fever, anorexia, nausea, RUQ pain, hepatomegaly, jaundice

70
Q

What are the lab findings found in alcoholic liver disease?

A

AST elevated (but not above 300) > ALT

Elevated alk phos

Elevated TG, glucose

K, phosphate, Mg deficient

71
Q

How do you determine the short-term px in pts w/ worsening alcoholic hepatitis?

A

Maddrey’s discrimination fuction (DF)

DF = 4.6 x (the difference btwn the patient’s & control prothrombin time) + bilirubin

If DF > 32 –> pt has 50% mortality

72
Q

What drug reduces 4wk mortality & frequency of hepatorenal syndrome in alcoholic liver disease?

A

Pentoxifylline

73
Q

What is hepatic steatosis?

A

Accumulation of TG droplets in hepatocytes

Benign

74
Q

What is non-alcoholic steatohepatitis (NASH)?

A

Necroinflammatory changes on liver bx, may progress to cirrhosis

75
Q

What are RFs for NAFLD?

A 
Insulin resistance
DM2
Obesity 
Lipid abnormalities 
Tamoxifen &amp; corticosteroids
76
Q

How does NAFLD present?

A

Usually asx

May have RUQ pain, hepatomegaly

77
Q

What labs are seen in NAFLD?

A

Elevated aminotransferase levels

78
Q

What are the lab results seen in autoimmune hepatitis?

A

ALT elevated 8 fold

AST elevated 7 fold

Bilirubin elevated 2 fold

Gamma-globulin elevated 1.5 fold

Alk phos elevated 1.5 fold

79
Q

What does autoimmune hepatitis look like on liver bx?

A

Interface hepatitis w/out bridging necrosis & no cirrhosis

80
Q

What are features of autoimmune hepatitis?

A

Young - middle aged females

Chronic hep w/ globulins

Positive ANA &/or SM antibody

Responds to corticosteroids

81
Q

What are s/s of autoimmune hep?

A

Usually insidious

Fatigue, jaundice, hepatomegaly

May be severe/fulminant

82
Q

How do you dx autoimmune hepatitis?

A

Autoantibodies (need at least 1 for dx): ANA or SM ≥ 1.4, anti-SLA, anti-LKM1 ≥ 1.4

83
Q

How do you treat autoimmune hep?

A

Prednisone w/ or w/out azathioprine

84
Q

What is the f/u like for autoimmune hep?

A

If remission achieved, f/u every 3-6mos due to high likelihood of relapse

85
Q

How do you treat Wilson disease?

A

D-penicillamine

86
Q

What are manifestations of hereditary hemochromatosis?

A 
High serum iron or ferritin 
Cardiac disease 
DM 
Joint disease 
Infections
87
Q

What gene mutation is typically found in hereditary hemochromatosis?

A

HFE gene

88
Q

What is the pathogenesis behind primary biliary cirrhosis?

A

T cell attack on bile ducts –> bile duct loss & scarring –> cirrhosis

89
Q

What are features/sx of primary biliary cirrhosis?

A

Middle aged

Asx, fatigue & pruritis

Jaundice, xanthelasma, xanthoma, steatorrhea

90
Q

What are the lab findings in primary biliary cirrhosis?

A

Elevated alk phos
+ AMA
Elevated IgM
Increased cholesterol

91
Q

How do you treat primary biliary cirrhosis?

A

Cholestyramine w/ water or juice 3 times daily for pruritis

Urso (slows progression)

Consider liver transplant

92
Q

What is primary sclerosing cholangitis strongly a/w?

A

Cholangiocarcinoma

UC

93
Q

What is the clinical presentation of primary sclerosing cholangitis?

A

M > F , 41 yo = average

Jaundice & pruritis MC

Fatigue, wt loss, RUQ pain

Hepatomegaly, splenomegaly

Hx of UC

94
Q

What are the lab findings in PSC?

A

Elevated alk phos & bilirubin

Mild elevation of transferases

Positive p-ANCA

95
Q

What procedures do use to dx PSC?

A

MRCP/ERCP

Liver bx

96
Q

How do you treat PSC?

A

Stent

Recurrent ERCPs

Urso

97
Q

What are complications of ESLD?

A
  • Jaundice
  • Palmar erythema
  • Spider angioma
  • Encephalopathy w/ asterixis
  • Portal HTN
  • Portal vein thrombosis
  • Ascites, muscle wasting
  • Spontaneous bacterial perotinitis
98
Q

What does hepatic encephalopathy lead to?

A

Increased ammonia –> neuropsychiatric abnormalities

99
Q

How do you treat hepatic encephalopathy?

A

Lactulose: removes ammonia from gut

100
Q

What imaging do you use to dx portal vein thrombosis?

A

Doppler US, CT, MRI

101
Q

How do you treat portal vein thrombosis?

A

Anticoag w/ heparin or LMWH

102
Q

How do you treat ascites, LE edema, or pleural effusion?

A

1st line = diuretics (furosemide & spironolactone)

2nd = paracentesis/thoracentesis

3rd = transjugular shunt

103
Q

How do you treat spontaneous bacterial peritonitis?

A

IV cefotaxime
IV albumin

Post infection bactrim

104
Q

How do you assess degree of ESLD?

A

MELD

Bilirubin + INR + Cr

Mortality decreases at 15

105
Q

What is the MC RF for HCC?

A

Cirrhosis

106
Q

What imaging/lab should you perform for HCC?

A

CT/MRI every 6 mos

AFP

107
Q

How do you treat HCC?

A

Transplant

Monitor via imaging

Ablation & TACE

108
Q

Klatskin tumors

A

Perihilar tumors involving the bifurcation of biliary ducts

Intrahepatic

109
Q

What is the MC age range for dx of cholangiocarcinoma?

A

50-70!!! (2/3)

Foundations III GI (Cholley) (10 decks)

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