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Clin med GI > Liver disease > Flashcards

Liver disease Flashcards

1
Q

What creates bilirubin

A

Hemoglobin gets broken down into heme and globin.

Heme then turns into bilivirdin which becomes unconjugated bilirubin

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2
Q

Which type of bilirubin is bound to albumin

A

unconjugated

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3
Q

What helps make bilirubin conjugated

A

glucoronic acid in the liver

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4
Q

What happens clinically when there is an excess of bilirubin

A

Jaundice

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5
Q

Where is jaundice seen first

A

typically the sclera and darkening urine

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6
Q

Where does conjugation of bilirubin occur

A

hepatocytes

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7
Q

What bilirubin level will cause jaundice

A

2.5-3mg/dL

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8
Q

What should total bilirubin be

A

.2-1.2mg/dL

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9
Q

What level should indirect bilirubin be in labs

A

.2-.8mg/dL

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10
Q

What type of bilirubin is considered unconjugated on labs

A

indirect

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11
Q

What type of bilirubin is considered conjugated on labs

A

direct

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12
Q

What causes unconjugated hyperbilirubinemia

A

Overproduction of hemolysis

impaired uptake secondary to certain drugs

impaired conjugation by glucuronyl transferase

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13
Q

What causes an overproduction of hemolysis

A

sickle cell
hereditary spherocytosis
Rh incompatibility
transfusion reaction

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14
Q

What is the clinical presentation of indirect hyperbilirubinemia

A

+splenomegally
increased unconjugated bilirubin

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15
Q

What causes an impaired uptake of bilirubin

A

Rifampin
cholecystographic contrast

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16
Q

What is the clinical presentation of hyperbilirubinemia from impaired uptake

A

Light to normal colored stool
normal to dark urine
*resolves with drug removal

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17
Q

What causes impaired conjugation with hyperbiliruinemia

A

physiologic neonatal jaundice
Gilbert syndrome
Criglar-Najjar syndrome

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18
Q

What causes neonatal jaundice

A

Fetal bili is cleared by mom
immature GT in newborns

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19
Q

When does bilirubin develop in newborns

A

2-5 days of life

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20
Q

What occurs if bilirubin levels >20mg/dL in newborns

A

encephalopathy and kernicterus

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21
Q

What will make unonjugated bilirubin water soluble = dissolve in bile

A

UV light

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22
Q

How long does it take a newborns bilirubin to return to normal

A

2 weeks

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23
Q

Which gender is Gilbert syndrome more common in

A

Males

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24
Q

What is the underlying issue occurring in Gilbert disease

A

Reduced GT function

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25
Q

When is Gilbert syndrome diagnosed

A

puberty or early adulthood

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26
Q

What symptoms do those with Gilbert syndrome have

A

episodic jaundice and hyperbilirubinemia

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27
Q

What makes Gilbert syndrome worse

A

stress
fatigue
ETOH
illness
decreased caloric intake

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28
Q

What is Crigler-Najjar syndrome

A

Autosomal recessive inherited GT disorder

*partially to complete loss of glucyronyl transferase

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29
Q

Which type of Crigler-Najjar is less severe

A

type 2

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30
Q

When is Crigler-Najjar syndrome diagnosed

A

Neonates and will persist through life

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31
Q

What will the bilirubin level be in those with Crigler-Najjar syndrome

A

20-45

*early liver transplant needed to prevent kernicterus

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32
Q

What is occurring with direct hyperbilirubinemia

A

Decreased excretion of bilirubin

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33
Q

What causes direct hyperbilirubinemia

A

An obstruction of hepatocellular dysfunction

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34
Q

if a patient has an elevated alkaline phosphatase, what type of direct bilirubinemia do they likely have

A

obstructive

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35
Q

What kind of direct bilirubinemia is indicated by elevated AST/ALT

A

hepatocellular issues

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36
Q

What can LFTs help distinguish between

A

different liver disorders

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37
Q

What liver info is included on a CMP

A

T. Bili
albumin
total protein
Alk phos
ALT/AST

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38
Q

Outside of a CMP, what else needs to be ordered to get a complete look at the liver on labs

A

prothrombin time (INR)
urine bilirubin
GGT
5’-nucleotidase

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39
Q

If there is an elevation of AST/ALT, what is it indicative of

A

hepatocellular injury
*most common cause if Non-alcoholic fatty liver disease (NAFLD)

*AST- primarily liver
*ALT is in other tissue

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40
Q

Does the degree of ALT/AST = disease severity

A

no

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41
Q

If AST>ALT what is it indicative of

A

alcohol related liver injury and cirrhosis

*3:1 is highly suggestive

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42
Q

If ALT and AST >1000 units/L what is it indicative of

A

viral hepatitis
ischemic injury
toxins
drug induced
autoimmune

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43
Q

When will Alk Phos be elevated

A

Cholestasis
infiltrative disease

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44
Q

What is low serum albumin reflective of

A

chronic liver disease
cirrhosis

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45
Q

What is elevated PT reflective of

A

poor hepatocyte function

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46
Q

What clotting factors are made in the liver

A

10, 9, 7, 2 (1972)
*vitamin K dependent clotting factors

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47
Q

What is a definitive study for determining cause and severity of liver disorders

A

Liver bx

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48
Q

When is a TJLB typically preformed over a bedside liver bx

A

ascites
coagulopathy

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49
Q

What are the types of acute liver failure

A

Fulminant
subfulminant

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50
Q

Does acute liver failure need a pre-existing liver disease to occur

A

no

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51
Q

What is acute on chronic liver disease

A

acute deterioration in chronic liver disease

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52
Q

What is fulminant liver disease

A

development of hepatic encephalopathy within 8 weeks

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53
Q

What is subfulminant liver disease

A

hepatic encephalopathy 8 weeks to 6 months after onset

54
Q

What is the INR in most people with acute liver failure

A

> 1.5

55
Q

What is the #1 cause of acute liver failure

A

acetaminophen toxicity (APAP)

56
Q

What is the #2 cause of acute liver failure

A

idiosyncratic drug reaction
*TB drugs, anti epileptics, antibiotics)

57
Q

How do those is acute liver failure present

A

jaundice
bleeding disorders
encephalopathy/AMS

58
Q

What are later complications of acute liver failure

A

Systemic inflammatory response syndrome (SIRS) from death of hepatocytes

Multisystem organ dysfunction

59
Q

How do you treat acute liver failure

A

Admit to ICU
consult transplant team

60
Q

What causes of acute liver failure has the best prognosis

A

viral Hep A
APAP
Shock
pregnancy induced
*may not ned transplant

61
Q

What is the rate length of those in ALF who get a liver transplant

A

2 years (90%)

62
Q

What determines the liver transplant priority

A

MELD score
*determines severity of liver disease in those >12

63
Q

What is the antidote for APAP overdose

A

N-acetylcystine

64
Q

with liver transplant, who does UNOS give priority to

A

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

65
Q

What is occurring in fatty liver disease

A

Progressive hepatocyte dysfunction and accumulation of fatty tissue that eventually leads to fibrosis and ultimately cirrhosis

66
Q

what is NASH

A

non-alcoholic steatohepatitis
*occurs after NAFL

67
Q

Which gender is NAFL seen in most

A

men
*hispanic at highest risk

68
Q

What does NAFL have a strong correlation with

A

insulin resistance

69
Q

What is NAFL commonly associated with

A

metabolic syndrome
obesity (BMI>30= 5x increase)
T2DM
Dyslipidemia

70
Q

How do you diagnose NAFL

A

Dx of exclusion.. must r/o ETOH liver disease

71
Q

What is the treatment for NAFL

A

Lifestyle modifications
-gradual weight loss
- anti diabetic agent
- treat dyslipidemia

72
Q

What are risk factors for progression to NASH

A

obesity
older age
non African ethnicity
female
DM
HTN
Worse US

73
Q

What are the top causes of cirrhosis

A

Viral hepatitis
Alcohol
NAFL

74
Q

What are the 3 stages of cirrhosis

A

Compensated
compensated with varices
decompensated

75
Q

What is occurring with decompensated cirrhosis

A

ascites
vatical bleeding
encephalopathy
jaundice

76
Q

What is occurring in the liver leading to cirrhosis

A

hepatocyte dysfunction, increased resistance to flow, portal HTN and portosystemic shunting = symptoms

77
Q

What are the initial symptoms of cirrhosis

A

fatigue
disturbed sleep
muscle cramps
weight loss

78
Q

How will the liver present with cirrhosis

A

firm, palpable, nodular liver

79
Q

What may be seen on laboratory workup with cirrhosis

A

microcytic anemia
TTP
elevated bili
prolong PT-INR
Elevated AST/ALT
low albumin
hepatorenal syndrome
etc

80
Q

What is imaging used for with cirrhosis

A

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

81
Q

What is the only curative treatment for cirrhosis

A

liver transplant

82
Q

What is a side effect of portal HTN

A

third spacing

83
Q

What is done to treat ascites with cirrhosis

A

paracentesis (both diagnostic and therapeutic)

84
Q

What are complications from a paracentesis

A

Bleeding
infection
bowel perforation

85
Q

What labs should be done with a paracentesis

A

cell count
culture
albumin
total protein
LDH
cytology

86
Q

What is lights criteria

A

Determines whether accumulation of fluid is transudative vs exudative

87
Q

What type of ascites is transudative

A

heart failure
cirrhosis
nephrotic syndrome
pulmonary embolism

88
Q

What types of ascites are exudative

A

TB
pancreatitis
malignancy
hemo/chylothorax
esophageal rupture
bacterial/viral pneumonia

89
Q

How do you treat ascites in cirrhosis

A

Sodium restriction
spironolactone + furosemide
large volume para (5L)
TIPS

90
Q

What is a cirrhosis complication from ascites

A

spontaneous bacterial peritonitis

91
Q

What is the treatment of spontaneous bacterial peritonitis

A

cefotaxime

92
Q

What is the most common cause of spontaneous bacterial peritonitis

A

E.coli and strep

93
Q

What is hepatorenal system characterized by

A

Azotemia
Shock
Macroscopic kidney injury
no improvement in renal function despite D/C diuretics

94
Q

What is the life expectancy of those with hepatorenal syndrome

A

3 months

95
Q

How do you treat hepatorenal syndrome

A

dialysis and TIPS

96
Q

What causes hepatic encephalopathy

A

Altered CNS function from ammonia buildup

97
Q

What is the characteristic signs of hepatic encephalopathy

A

Asterixis

98
Q

Which medications can help reduce ammonia levels in the body

A

Lactulose
rifamixin

99
Q

How can coagulopathy with cirrhosis be treated

A

Vitamin K supplementation
*FFP if vit K ineffective

100
Q

What are the signs and symptoms of an acute UGI bleed

A

Hematemesis
coffee ground emesis
melena

101
Q

What is the abx of choice with esophageal varices

A

fluoroquinolones

102
Q

What medication can be given for acute control of bleeding

A

octreotide

103
Q

What types of cirrhosis is at greatest risk of converting to HCC

A

ETOH
Hepatitis

104
Q

What are the contraindications for liver transplant

A

Malignancy (except HCC)
Sepsis
Advanced cardiopulmonary disease

105
Q

What MELD score makes a patient eligible for liver transplant

A

over 15

106
Q

What MELD score makes a patient eligible

A
107
Q

What is Budd chiari syndrome

A

hepatic vein obstruction

108
Q

What can be used for an alcohol screening

A

AUDIT-C

109
Q

What is unhealthy alcohol use in men classified by

in women?

A

5+ drinks in a day

4+ drinks in a day

110
Q

How many grams of alcohol in 1 standard drink

A

14

111
Q

What is the primary liver dysfunction do people develop from harmful alcohol use

A

steatosis

112
Q

What is alcohol related hepatitis

A

acute hepatitis from binge drinking

113
Q

What are risk factors for alcohol liver disease

A

concurrent APAP use
concurrent obesity, DM, HCV

114
Q

Which gender is at higher risk for alcohol related liver disease

A

women

115
Q

How long does it generally take for the liver to progress from injury to cirrhosis

A

decades
*dose dependent

116
Q

What type of imaging is done to evaluate fibrosis of the liver

A

fibroscan

117
Q

How can you treat fatty liver disease

A

abstinence from ETOH
Disulfram
improve nutritipon
treat vitamin deficiencies

118
Q

What type of vitamin deficiencies generally occur with fatty liver disease

A

thiamine
folate
zinc
B6
B12

119
Q

How do you treat cirrhosis

A

abstinence from ETOH
Naltrexone (avoid disulfram)
rehab/ mental health care

120
Q

What medication can be given to help prevent varices in cirrhosis

A

beta-blocker

121
Q

What is the second highest reason for a liver transplant

A

ETOH cirrhosis
*require 6 months abstinence

122
Q

What is ETOH related hepatitis

A

Hepatocyte injury characterized by acute / chronic inflammation, fibrosis, parenchymal necrosis

123
Q

What is the only difference in labs in ETOH hepatitis vs any other liver disease

A

Leukocytosis with left shift

124
Q

What can be used to help treat ETOH related hepatitis

A

ETOH abstinence
corticosteroids
pentoxifylline

125
Q

What is the most important prognostic factor in ETOH hepatitis

A

continued drinking

126
Q

What is Budd-Chiari

And what is its cause

A

Hepatic vein obstruction
Secondary to a clot

Generally from a hypercoagulable state

127
Q

What is the screening test of choice for Budd-Chiari

A

Doppler US
TJLB is US nonconclusive

128
Q

What is the mainstay treatment for Budd-Chiari

A

LMWH

+/- TIPS or angioplasty

129
Q

What is the confirmatory test for portal vein thrombosis

A

MRA

possible EGD

130
Q

How does bacteria get into the liver to cause an abscess

A

via bile duct

#1 cause secondary to obstruction

131
Q

What are the common organisms that cause liver abscess

A

E. Coli
Klebsiella
enterobacter

*staph if it is granulomatous

132
Q

What is the treatment for a liver abscess

A

IV 3rd gen cephalosporin + metronidazole
2-3 week duration

Clin med GI (9 decks)

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