Liver disease Flashcards
What creates bilirubin
Hemoglobin gets broken down into heme and globin.
Heme then turns into bilivirdin which becomes unconjugated bilirubin
Which type of bilirubin is bound to albumin
unconjugated
What helps make bilirubin conjugated
glucoronic acid in the liver
What happens clinically when there is an excess of bilirubin
Jaundice
Where is jaundice seen first
typically the sclera and darkening urine
Where does conjugation of bilirubin occur
hepatocytes
What bilirubin level will cause jaundice
2.5-3mg/dL
What should total bilirubin be
.2-1.2mg/dL
What level should indirect bilirubin be in labs
.2-.8mg/dL
What type of bilirubin is considered unconjugated on labs
indirect
What type of bilirubin is considered conjugated on labs
direct
What causes unconjugated hyperbilirubinemia
Overproduction of hemolysis
impaired uptake secondary to certain drugs
impaired conjugation by glucuronyl transferase
What causes an overproduction of hemolysis
sickle cell
hereditary spherocytosis
Rh incompatibility
transfusion reaction
What is the clinical presentation of indirect hyperbilirubinemia
+splenomegally
increased unconjugated bilirubin
What causes an impaired uptake of bilirubin
Rifampin
cholecystographic contrast
What is the clinical presentation of hyperbilirubinemia from impaired uptake
Light to normal colored stool
normal to dark urine
*resolves with drug removal
What causes impaired conjugation with hyperbiliruinemia
physiologic neonatal jaundice
Gilbert syndrome
Criglar-Najjar syndrome
What causes neonatal jaundice
Fetal bili is cleared by mom
immature GT in newborns
When does bilirubin develop in newborns
2-5 days of life
What occurs if bilirubin levels >20mg/dL in newborns
encephalopathy and kernicterus
What will make unonjugated bilirubin water soluble = dissolve in bile
UV light
How long does it take a newborns bilirubin to return to normal
2 weeks
Which gender is Gilbert syndrome more common in
Males
What is the underlying issue occurring in Gilbert disease
Reduced GT function
When is Gilbert syndrome diagnosed
puberty or early adulthood
What symptoms do those with Gilbert syndrome have
episodic jaundice and hyperbilirubinemia
What makes Gilbert syndrome worse
stress
fatigue
ETOH
illness
decreased caloric intake
What is Crigler-Najjar syndrome
Autosomal recessive inherited GT disorder
*partially to complete loss of glucyronyl transferase
Which type of Crigler-Najjar is less severe
type 2
When is Crigler-Najjar syndrome diagnosed
Neonates and will persist through life
What will the bilirubin level be in those with Crigler-Najjar syndrome
20-45
*early liver transplant needed to prevent kernicterus
What is occurring with direct hyperbilirubinemia
Decreased excretion of bilirubin
What causes direct hyperbilirubinemia
An obstruction of hepatocellular dysfunction
if a patient has an elevated alkaline phosphatase, what type of direct bilirubinemia do they likely have
obstructive
What kind of direct bilirubinemia is indicated by elevated AST/ALT
hepatocellular issues
What can LFTs help distinguish between
different liver disorders
What liver info is included on a CMP
T. Bili
albumin
total protein
Alk phos
ALT/AST
Outside of a CMP, what else needs to be ordered to get a complete look at the liver on labs
prothrombin time (INR)
urine bilirubin
GGT
5’-nucleotidase
If there is an elevation of AST/ALT, what is it indicative of
hepatocellular injury
*most common cause if Non-alcoholic fatty liver disease (NAFLD)
*AST- primarily liver
*ALT is in other tissue
Does the degree of ALT/AST = disease severity
no
If AST>ALT what is it indicative of
alcohol related liver injury and cirrhosis
*3:1 is highly suggestive
If ALT and AST >1000 units/L what is it indicative of
viral hepatitis
ischemic injury
toxins
drug induced
autoimmune
When will Alk Phos be elevated
Cholestasis
infiltrative disease
What is low serum albumin reflective of
chronic liver disease
cirrhosis
What is elevated PT reflective of
poor hepatocyte function
What clotting factors are made in the liver
10, 9, 7, 2 (1972)
*vitamin K dependent clotting factors
What is a definitive study for determining cause and severity of liver disorders
Liver bx
When is a TJLB typically preformed over a bedside liver bx
ascites
coagulopathy
What are the types of acute liver failure
Fulminant
subfulminant
Does acute liver failure need a pre-existing liver disease to occur
no
What is acute on chronic liver disease
acute deterioration in chronic liver disease
What is fulminant liver disease
development of hepatic encephalopathy within 8 weeks
What is subfulminant liver disease
hepatic encephalopathy 8 weeks to 6 months after onset
What is the INR in most people with acute liver failure
> 1.5
What is the #1 cause of acute liver failure
acetaminophen toxicity (APAP)
What is the #2 cause of acute liver failure
idiosyncratic drug reaction
*TB drugs, anti epileptics, antibiotics)
How do those is acute liver failure present
jaundice
bleeding disorders
encephalopathy/AMS
What are later complications of acute liver failure
Systemic inflammatory response syndrome (SIRS) from death of hepatocytes
Multisystem organ dysfunction
How do you treat acute liver failure
Admit to ICU
consult transplant team
What causes of acute liver failure has the best prognosis
viral Hep A
APAP
Shock
pregnancy induced
*may not ned transplant
What is the rate length of those in ALF who get a liver transplant
2 years (90%)
What determines the liver transplant priority
MELD score
*determines severity of liver disease in those >12
What is the antidote for APAP overdose
N-acetylcystine
with liver transplant, who does UNOS give priority to
Absence of pre-existing liver disease
life expectancy less than 7 days
ICU w/ dialysis, 2.0 INR, ventilation
onset of hepatic encephalopathy within 8 weeks of onset of ALF
What is occurring in fatty liver disease
Progressive hepatocyte dysfunction and accumulation of fatty tissue that eventually leads to fibrosis and ultimately cirrhosis
what is NASH
non-alcoholic steatohepatitis
*occurs after NAFL
Which gender is NAFL seen in most
men
*hispanic at highest risk
What does NAFL have a strong correlation with
insulin resistance
What is NAFL commonly associated with
metabolic syndrome
obesity (BMI>30= 5x increase)
T2DM
Dyslipidemia
How do you diagnose NAFL
Dx of exclusion.. must r/o ETOH liver disease
What is the treatment for NAFL
Lifestyle modifications
-gradual weight loss
- anti diabetic agent
- treat dyslipidemia
What are risk factors for progression to NASH
obesity
older age
non African ethnicity
female
DM
HTN
Worse US
What are the top causes of cirrhosis
Viral hepatitis
Alcohol
NAFL
What are the 3 stages of cirrhosis
Compensated
compensated with varices
decompensated
What is occurring with decompensated cirrhosis
ascites
vatical bleeding
encephalopathy
jaundice
What is occurring in the liver leading to cirrhosis
hepatocyte dysfunction, increased resistance to flow, portal HTN and portosystemic shunting = symptoms
What are the initial symptoms of cirrhosis
fatigue
disturbed sleep
muscle cramps
weight loss
How will the liver present with cirrhosis
firm, palpable, nodular liver
What may be seen on laboratory workup with cirrhosis
microcytic anemia
TTP
elevated bili
prolong PT-INR
Elevated AST/ALT
low albumin
hepatorenal syndrome
etc
What is imaging used for with cirrhosis
US to assess liver size and assess HCC
Doppler US for liver patency of hepatic, splenic, portal veins
liver bx for cirrhotic histology
EGD for varices of UGI bleeding
What is the only curative treatment for cirrhosis
liver transplant
What is a side effect of portal HTN
third spacing
What is done to treat ascites with cirrhosis
paracentesis (both diagnostic and therapeutic)
What are complications from a paracentesis
Bleeding
infection
bowel perforation
What labs should be done with a paracentesis
cell count
culture
albumin
total protein
LDH
cytology
What is lights criteria
Determines whether accumulation of fluid is transudative vs exudative
What type of ascites is transudative
heart failure
cirrhosis
nephrotic syndrome
pulmonary embolism
What types of ascites are exudative
TB
pancreatitis
malignancy
hemo/chylothorax
esophageal rupture
bacterial/viral pneumonia
How do you treat ascites in cirrhosis
Sodium restriction
spironolactone + furosemide
large volume para (5L)
TIPS
What is a cirrhosis complication from ascites
spontaneous bacterial peritonitis
What is the treatment of spontaneous bacterial peritonitis
cefotaxime
What is the most common cause of spontaneous bacterial peritonitis
E.coli and strep
What is hepatorenal system characterized by
Azotemia
Shock
Macroscopic kidney injury
no improvement in renal function despite D/C diuretics
What is the life expectancy of those with hepatorenal syndrome
3 months
How do you treat hepatorenal syndrome
dialysis and TIPS
What causes hepatic encephalopathy
Altered CNS function from ammonia buildup
What is the characteristic signs of hepatic encephalopathy
Asterixis
Which medications can help reduce ammonia levels in the body
Lactulose
rifamixin
How can coagulopathy with cirrhosis be treated
Vitamin K supplementation
*FFP if vit K ineffective
What are the signs and symptoms of an acute UGI bleed
Hematemesis
coffee ground emesis
melena
What is the abx of choice with esophageal varices
fluoroquinolones
What medication can be given for acute control of bleeding
octreotide
What types of cirrhosis is at greatest risk of converting to HCC
ETOH
Hepatitis
What are the contraindications for liver transplant
Malignancy (except HCC)
Sepsis
Advanced cardiopulmonary disease
What MELD score makes a patient eligible for liver transplant
over 15
What MELD score makes a patient eligible
What is Budd chiari syndrome
hepatic vein obstruction
What can be used for an alcohol screening
AUDIT-C
What is unhealthy alcohol use in men classified by
in women?
5+ drinks in a day
4+ drinks in a day
How many grams of alcohol in 1 standard drink
14
What is the primary liver dysfunction do people develop from harmful alcohol use
steatosis
What is alcohol related hepatitis
acute hepatitis from binge drinking
What are risk factors for alcohol liver disease
concurrent APAP use
concurrent obesity, DM, HCV
Which gender is at higher risk for alcohol related liver disease
women
How long does it generally take for the liver to progress from injury to cirrhosis
decades
*dose dependent
What type of imaging is done to evaluate fibrosis of the liver
fibroscan
How can you treat fatty liver disease
abstinence from ETOH
Disulfram
improve nutritipon
treat vitamin deficiencies
What type of vitamin deficiencies generally occur with fatty liver disease
thiamine
folate
zinc
B6
B12
How do you treat cirrhosis
abstinence from ETOH
Naltrexone (avoid disulfram)
rehab/ mental health care
What medication can be given to help prevent varices in cirrhosis
beta-blocker
What is the second highest reason for a liver transplant
ETOH cirrhosis
*require 6 months abstinence
What is ETOH related hepatitis
Hepatocyte injury characterized by acute / chronic inflammation, fibrosis, parenchymal necrosis
What is the only difference in labs in ETOH hepatitis vs any other liver disease
Leukocytosis with left shift
What can be used to help treat ETOH related hepatitis
ETOH abstinence
corticosteroids
pentoxifylline
What is the most important prognostic factor in ETOH hepatitis
continued drinking
What is Budd-Chiari
And what is its cause
Hepatic vein obstruction
Secondary to a clot
Generally from a hypercoagulable state
What is the screening test of choice for Budd-Chiari
Doppler US
TJLB is US nonconclusive
What is the mainstay treatment for Budd-Chiari
LMWH
+/- TIPS or angioplasty
What is the confirmatory test for portal vein thrombosis
MRA
possible EGD
How does bacteria get into the liver to cause an abscess
via bile duct
#1 cause secondary to obstruction
What are the common organisms that cause liver abscess
E. Coli
Klebsiella
enterobacter
*staph if it is granulomatous
What is the treatment for a liver abscess
IV 3rd gen cephalosporin + metronidazole
2-3 week duration
