Liver Flashcards
Most common cause of acute liver failure
Acetaminophen overdose
Acute liver failure signs and symptoms
- Ascites
- Coagulopathy
-Jaundice - ## Encephalopathy/altered mental status (1-4 weeks after jaundice)
Acute liver failure labs
- ALT and AST, bilirubin elevated
- INR elevated
- Leukocytosis (high WBCs)
- Hyponatremia, hypokalemia, hypoglycemia
Acute liver failure: TX
hospitalize, may need transplant
Hepatitis: acute and chronic
Viral is most common cause of both
Which hepatitis viruses are transmitted fecal oral
A and E
- self limited
- abrupt onset
How are hepatitis B, C, D transmitted?
- IV drug use
- tattoos
- infected mother
- blood transfusion
Which hepatitis virus most commonly causes cholestatic hepatitis?
hepatitis A
- prominent jaundice and itching
- elevation in bilirubin, ALK phos
Which hepatitis virus is the most common cause of relapsing hepatitis?
hepatitis A
- symptoms recur in weeks/months
- may see arthritis, vasculitis, excess protein in the blood
Acute viral hepatitis: physical exam
- mild hepatomegaly with tenderness
- mild splenomegaly
- posterior cervical lymphadenopathy
Acute Viral hepatitis (self-limited disease and relapsing hepatitis) treatment
outpatient (unless super dehydrated)
Cholestatic hepatitis: tx
- Prednisone
- Ursodeoxycholic acid
- Cholestyramine (for itching, binds to cholesterol)
Hep A: signs/sx
- fever (uncommon in other viral hepatitis)**
- icteric phase: jaundice peaks at 2 weeks
How long does IgM antibody to HAV stay elevated?
3-6 months
IgM is test of choice***
How long does IgG anti-HAV stay elevated?
lifelong
Which hepatitis viruses have vaccines?
Hep A
Hep B
When should the Hep A vaccine be given?
- at 1 year old
- MSM
- IV drug user
Post exposure Hep A prophylaxis?
Vaccine for 1 -40 years
Immunoglobulin for <1 yr, >40 yr, or immunocompromised
In whom is hepatitis E often more severe and fulminant?
pregnant lady
acute liver failure esp if in 3rd trimester
Hepatitis E
- longer incubation than Hep A**
- Spread by swine/undercooked meat
Hepatitis E: labs
- IgM first
- IgG second
- HEV RNA test confirms and quantifies HEV presence*** (stool or serum)
Hepatitis E: prevention
- no vaccine
- no immunoglobulin
Viral differences
Hep A and E: non-enveloped, not affected by bile/detergents
Hep B, C, D: enveloped, disrupted by bile/detergents
Hep B: general
- DNA virus
- transmission via percutaneous and permucosal routes
- sexually transmitted
- May result in chronically infected state–>esp infants, kids
- Adults more likely to get asymptomatic/self-limited disease
What does HBeAg tell you?
marker of active infection
What does antibody to HBsAg tell you?
immunity to the surface antigen
If the patient has anti-HBs and anti-HBc what does that tell you?
Prior HBV infection
What labs would indicate chronic Hepatitis B infection?
HBsAg for >6 months
If patient has Hep B infection, is young, non-cirrhotic, low HBV DNA level what is the treatment?
Peginterferon alfa-2a
(SQ injections for 48 weeks)
-greater chance of seroconversion
Nucleoside analogues (ex. entecavir, tenofovir)
- inhibit HBV replication, don’t eradicate HBV
- Oral medication
Hep B: passive immunization (ex. newborns of HBsAg moms)
- Immunoglobulin (HBIG)
- give postexposure prophylaxis to casual sexual partners - HBV vaccine series
- 2 shots, 6 months apart
Who should be screened for Hepatitis C?
- high risk
- Born between 1945-1965 [BABY BOOMERS]
Most common Hepatitis C genotype in US?
genotype 1
note: genotype 3 is hardest to treat
Hepatitis C: etiology/risk factors
- transmitted MC between IV drug users**
- Blood transfusion before 1992
- HIV (less likely to clear virus)
Hepatitis C: clinical presentation
- usually asymptomatic
- young women more likely to clear the virus (blacks less likely to clear)
- majority will develop chronic infection
Which lab is needed to diagnose acute Hep C infection?
HCV RNA test***
-if present >6 months =chronic infection
Hep B vs. Hep C in kids
Hep B - kids more likely to become chronic
Hep C - kids more likely to resolve spontaneously
In a patient with chronic Hep C, how do you tell if there is active infection?
+ screening test by EIA (antibodies against the virus)
If your patient has hepatitis C, what other things are important to do?
- screen for HIV
- vaccinate for Hep B, and Hep A
What determines the treatment regimen for hep C?
genotype
What are the new Hep C drugs?
Direct-acting antivirals
-NS3-4 protease inhibitors (ex. Simeprevir)
-NS5B polymerase inhibitors (ex. Sofosbuvir)
What is the main offender for drug-induced liver injury?
- antibioticss (esp. Augmentin, Sulfonamides)***
- Acetaminophen
- Antituberulous Agents (Isoniazid and Rifampin)
What does Maddrey’s discrimination function help you determine?
mortality during current hospitalization for alcoholic hepatitis
Tx: methylprednisolone and pentoxifylline help
Non alcoholic fatty liver disease, and nonalcoholic steatohepatitis: general
- asymptomatic, maybe RUQ pain
- elevated ALT
- <4 alcoholic drinks a day
Autoimmune hepatitis: general
-young to middle aged women
-high serum gamma-globulin level
+ANA
+smooth muscle antibody
Autoimmune hepatitis: Tx
Tx: Prednisone 30mg (taper over month) +/- azathioprine
Autoimmune hepatitis: prognosis/follow up
hepatologist every 3-6 months due to high relapse rate
Wilson disease
- impaired biliary copper excretion
- Autosomal recessive
- decreased serum ceruloplasmin
- Kayser-Fleicher rings
Wilson disease: tx
D-penicillamine
Which organs are affected by Alpha-1 antitrypsin deficiency
Lung and Liver
Primary Sclerosing Cholangitis
-Men 20-40
-Ulcerative colitis
-cholangiocarcinoma
+ P-ANCA
-Elevated: Alk Phos, Bilirubin
Primary Biliary Cirrhosis
-middle aged women
-fatigue and pruritis**
-xanthelasma/xanthoma
+Anti-mitochondrial antibody**
Primary Biliary Cirrhosis: Tx
- Urodeoxycholic acid*
2. Cholestyramine (bile acid resin)
Primary Sclerosing Cholangitis: Dx
ERCP with stenting
-Ursodiol (reduces secretion of cholesterol)
Definitive –>most will need transplant
ESLD hepatic encephalopathy
- hepatocellular dysfunction leads to increased serum ammonia levels
- Neuropsychiatric abnormalities (grade1: short attention span, grade2: personality change, grade3: confusion disorientation, grade4: coma
ESLD: Tx for high ammonia in the blood
Lactulose and/or Rifaximin`
What happens to albumin in end-stage liver disease?
decreases
- more difficulty maintaining osmotic pressure of blood
- less carrying ability for small hydrophobic molecules
End Stage Liver disease: Sodium
- Chronically low - fluid overload
- Indirect marker of portal hypertension
- hyponatremia - risk of cerebral edema and neurologic changes
Model of End-Stage Liver Disease (MELD)
determines transplant eligibility
> 15 MELD score is where 3 month survival starts dropping = consider for transplant
What are strong predictors of 3 month mortality
- Total Bilirubin
- INR
- Cr
- Na+
Hepatocellular Carcinoma (HCC)
MC risk factor = cirrhosis
Image every 6 months = alternating CT/MRI
Serum cancer marker = Alpha feto-protein
Cholangiocarcinoma: etiology
- cancer from bile duct epithelium
- Klatskin tumor –> if near bifurcation of the ducts
- MOST are adenocarcinomas
-Males, between ages 50-70
Cholangiocarcinoma: history and exam
- Painless jaundice
- pruritus
- fever, jaundice, RUQ pain (Charcots)
- palpable gallbladder
- hepatomegaly
- dark urine
- pale stools
Contraindications for liver transplant
- active EtOH or drug abusee
- HCC outside the liver
- Metastatic bile duct cancer
- Non-hepatic malignancy
- Severe cardiopulmonary disease
- Comorbidities (BMI>35)
- Psych/social issues
