Liver disease Flashcards
Acute viral hepatitis can present w/ what symptoms?
Which viruses are known to cause hepatitis (5)?
Acute viral hepatitis is:
usually asymptomatic
can present w/ non specific symptoms: fatigue, anorexi, fever, nausea/vomiting, abdominal pain, jaundice
Viruses that cause viral hepatitis: Hepatitis A, B,C, D, E
The method of transmission of Hep A is ___, typically thru consumption of contaminated __(type of seafood)
T/F: Hep A doesn’t have a chronic disease state and infection confers immunity
What is the Rx of Hep A?
The method of transmission of Hep A is fecal-oral, typically thru consumption of contaminated shellfish
True: Hep A doesn’t have a chronic disease state and infection confers immunity
Rx of Hep A: supportive care. Infection is generally self ltd
**note comment on immunosuppressed pts and Dx**
Which liver enzymes and antibody levels are indicated in the graph below?
ALT and IgM
ALT rises with increasing viral load
IgM also rises (then decreases later), as expected, IgG stays high
___ is a dna virus that causes hepatitis. It can be transmitted vertically, through blood or bodily fluids
T/F: Most adults can clear this infection
T/F: Infection w/ this virus can lead to fulminant liver failure and hepatocelllar carcinoma in abscence of cirrhosis
There are 3 molecules used to Dx this infection. What are they?
Hepatitis B (aka Hepadna virus) is a dna virus that causes hepatitis. It can be transmitted vertically - note that people become chronic carriers, through blood or bodily fluids
True: Most adults can clear this infection
True: Infection w/ this virus can lead to acute/fulminant liver failure and hepatocelllar carcinoma in abscence of cirrhosis
There are 3 molecules used to Dx this infection: HbsAg, Hb Igm Ab, HBV dna
Describe the graph below
What comes up first following infection:
HBsAg >> HBeAg >> anti-HBc IgM
*recall that you can’t measure HBcAg that’s why you need the antibody levels*
Fill in the table below
Describe the phases of Hep B infection in the table below
HB e antigen is used to determine the severity of liver disease in pts w/ Hep B infection (sort of)
At what viral levels (e antigen negative or +ve) is a pt w/ Hep B recommended for treatment? What is the ultimate goal of treatment?
When would you use treatment w/ interferon vs treatment w/ antivirals (name the 2 most common drugs)?
see slide below:
high viral load: >2k eAg +ve, >20k eAg -ve; goal of Rx is seroconversion
Use interferon w/ a younger pt/ pt who isn’t trying to take antivirals indefinitely (note this is an older therapy tho)
use antivirals indefinitely/until seroconversion: 2 most common antivirals are entecavir + tenofovir
___ is an RNA virus primarily transmitted via infectious blood/bodily fluids (mainly IV drug use)
Hepatitis C is an RNA virus primarily transmitted via infectious blood/bodily fluids (mainly IV drug use)
**note the rule of 20s on the slides**
Describe the graph below
First test is either the antibody or the viral load
Peak in ALT with acute infection (most pts become chronic) then variable ALT levels over time
Most pts spontaneously clear infection within about 1 yr
What are some extrahepatic complications from Hepatitis C infection? (6)
Cryoglobulinemia
Lichen planus - “Lichen planus is an inflammatory skin condition, characterized by an itchy, non-infectious rash on the arms and legs. It consists of small, many-sided, flat-topped, pink or purple bumps” - medical news today
Porphyria cutanea tarda
Diabetes mellitus
B cell lymphoproliferative disorders
*Increased risk of cardiovascular disease*
What is the treatment of Hepatitis C? (hint: generally 3 drug combo)
Hep C Rx: NS5A/NS5B/PI combination
drugs that end in -previr, -svir, - buvir
**note that PI’s have a black box warning: can lead to decompensation in pts w/ cirrhosis**
___ is a defective Hepatitis rna virus that requires Hep B to propagate
How do you Dx and Rx this viral infection?
Hep D is a defective Hepatitis rna virus that requires Hep B to propagate
Dx: Hep D IgM ab, HDV rna
Rx: interferon
___ is a hepatitis virus that is transmitted fecal-orally and can cause fulminant liver failure in pregnant women
How do you Dx and Rx this viral infection?
Hepatitis E is a hepatitis virus that is transmitted fecal-orally and can cause fulminant liver failure in pregnant women
Dx: HE IgM or IgG ab (IgM for acute infection)
Rx: generally self ltd
___ results from a cell-mediated immune response against tje liver is characterized by the presence of which autoimmune markers (3) and antibody levels (1) ?
This disease can present as chronic hepatitis (characterized by ___) or acute/fulminant hepatitis (characterized by mixed elevations of ___(4) )
What 2 characteristics would you expect to find on biopsy?
Autoimmune hepatitis results from a cell-mediated immune response against the liver and is characterized by the presence of +ve autoimmune markers: ANA, SMA, LKM-1, and IgG levels
This disease can present as chronic hepatitis – chronically elevated liver enzymes, or occasionally as acute/fulminant hepatitis – mixed elevations of AST/ALT, Alk Phos, bilirubin
On biopsy: plasma cells and interfaced hepatitis
Autoimmune hepatitis can be confused w/ viral or drug induced disease so Dx is based on __
Describe the (simplified) diagnostic criteria for autoimmune hepatitis
(you can also Dx this disease by seeing if the pt responds to __(drug name) )
Autoimmune hepatitis can be confused w/ viral or drug induced disease so Dx is based on combined histologic + serologic findings
**see below for Dx criteria**
(you can also Dx this disease by seeing if the pt responds to prednisone)
What is the 1st line of Rx of autoimmune hepatitis?
If the pt fails treatment or can’t tolerate the 1st line Rx, which drugs are 2nd line for treatment? (3)
1st line: Prednisone + Azathrioprine combo
2nd line: Budesonide (has less systemic side effects compared to prednisone), Mycophenolate, Tacrolimus/Cyclosporin
___ is an autoimmune disease affecting the bile ducts
Describe the symptoms of this disease (4) (hint: one of them is due to elevated cholesterol)
Diagnosis is based on ___ + ___( greater 1.5x the upper limit of normal)
Biopsy may reveal ___ and ___
Primary biliary cholangitis is an autoimmune disease affecting the bile ducts
Symptoms include: fatigue, pruritus, jaundice, xanthelasma (due to elevated cholesterol)
Diagnosis is based on anti-mitochondrial antibody (AMA) + Alk Phos ( greater 1.5x the upper limit of normal)
Biopsy may reveal bile duct inflammation and periductal granulomas
What is the treatment of PBC? (what do you use instead if this fails?)
The levels of __ are an indicator of prognosis of PBC
T/F: Pts who respond well to therapy can delay/prevent progression to cirrhosis or the need for transplant
PBC treatment: ursodiol 10/13 mgs/kg daily; if that fails, use orsodeoxycholic acid
The levels of serum bilirubin are an indicator of prognosis of PBC
True: Pts who respond well to therapy can delay/prevent progression to cirrhosis or the need for transplant
**note that pts need to also be monitored for fat soluble vitamin -‘s + bone density
Primary sclerosing cholangitis is an autoimmune disease leading to __ of the bile ducts
T/F: Most pts with this disease have IBD/ulcerative colitis
Describe the presentation of PSC (4)
Pts with PSC are at increased risk of __ and should be routinely screened
Primary sclerosing cholangitis is an autoimmune disease leading to inflammation + scarring of the bile ducts
True: Most pts with this disease have IBD/ulcerative colitis
Symptoms include: fatigue, pruritus, jaundice + ascending cholangitis
Pts with PSC are at increased risk of cholangicarcinoma and should be routinely screened
How do you diagnose PSC? (5 things to consider/look for)
Pt is typically age 30-40s
Elevated Alk phos > 1.5x upper limit of normal
MRCP/ERCP showing biliary strictures of irregularities**
Liver biopsy**
+ve P-ANCA (most pts)
(Start w/ MRCP if possible because ERCP also carries risk of infection or pancreatitis)
What is the condition below?
Beaded appearance of bile ducts in PSC
How do you treat PSC?
No good Rx right now, sometimes use Ursodiol
Name 3 different types of alcoholic liver disease and describe each
Hepatic steatosis (aka fatty liver disease) - macrovesicular fatty change in liver that’s reversile w/ alcohol cessation
Alcoholic steatohepatitis (fatty liver disease w/ inflammation) - requires sustained, long term consumption.
***Characterized by hepatocyte necrosis + neutrophilic infiltrate, hepatocyte ballooning (swelling), Mallory bodies (intracytoplasmic eosinophilic includions of damaged keratin filaments)***
Alcoholic cirrhosis - charaterized by regenerative nodules surrounded by fibrous bands in response to chronic liver injury >> portal HTN + end stage liver disease
T/F: There is a greater AST:ALT ratio with alcoholic hepatitis
Pts with alcoholic hepatitis can present w/ jaundice and what other symptoms (4) +/- cirrhosis?
True:There is a greater AST:ALT ratio with alcoholic hepatitis
Pts with alcoholic hepatitis can present w/ jaundice, encephalopathy, renal failure, ascites +/- cirrhosis, enlarged fatty liver
How do you treat alcoholic hepatitis?
Steroids but otherwise no real treatment.
Whether or not steroids are given is determined by prognosis prediction models:
Maddrey’s Discriminant Function (>32) or Lille Model (@ day 4 or 7 of steroid Rx)
Two groups of non-alcoholic fatty liver disease are ___ and ___
NAFL: non-alcoholic fatty liver disease
NASH: non-alcoholic steatohepatitis
___ (aka non-alcoholic fatty liver) is characterized by fatty infiltration of hepatocytes w/o significant inflammation or fibrosis
Non alcoholic fatty liver disease (aka non-alcoholic fatty liver) is characterized by fatty infiltration of hepatocytes w/o significant inflammation or fibrosis
(ALT>AST)
NASH is characterized by ___ and can progress to advanced fibrosis, cirrhosis, hepatocellular carcinoma
NASH is characterized by hepatic inflammation + necroinflammatory changes and can progress to advanced fibrosis, cirrhosis, hepatocellular carcinoma
(this is bascially steatohepatitis not due to alcohol consumption)
The biggest risk factor for non-alcoholic fatty liver disease is ___
The biggest risk factor for non-alcoholic fatty liver disease is metabolic syndrome:
central adiposity
diabetes mellitus
HTN
hypertriglyceridemia
low HDL
*note the prevalence of this disease*
What is the treatment of non-alcoholic fatty liver disease?
Rx: diet + exercise for weight loss
*more on slide below*
Describe the pathologies below
Describe the slide below
With increasing weight loss, these are the things that get reversed
>10% weight loss = reversal of fibrosis
___ is an AR disorder characterized by copper accumulaion in the liver, brain, kidneys, cornea and increased urine copper
What is the cause of this disease?
What pt population (age) is typically affected by this disease and how does it present? (5)
Wilson’s disease is an AR disorder characterized by copper accumulaion in the liver, brain, kidneys, cornea and increased urine copper
Caused by mutation in ATP7B gene on chromosome 13 - hepatocyte copper transporting ATPase
Typically seen in pts younger than 40; presents w:
liver failure
refractory coagulopathy
Coombs -ve hemolytic anemia
acute renal failure
neuro-psychiatric symptoms
How is Wilson’s disease diagnosed? (5 things; and don’t forget the eyes)
Low ceruloplasmin
High free copper (non-ceruloplasmin bound)
Very low Alk phos
Kayser-Fleischer rings
Alk phos : total bilirubin ratio <4
Study this please
When is liver disease likely to occur in pregnancy?
Acute fatty liver disease of pregnancy is characterized by increased __ (liver enzymes), ___ (not seen on routine ultrasound) and non-specific symptoms
What is a rare complication of liver disease in pregnancy?
Liver disease in pregaz: confined to 3rd trimester + after delivery
Acute fatty liver disease of pregnancy is characterized by increased AST/ALT, microvascular steatosis and non-specific symptoms
Rare complication of liver disease in pregnancy: hepatic rupture
Hemolysis, elevated liver enzymes, low platelets are all characteristic of ___
Hemolysis, elevated liver enzymes, low platelets are all characteristic of eclampsia (complications of eclampsia)
___ (aka “shock liver”) is characterized by hepatocyte necrosis due to decreased perfusion
What are some conditions that can cause this? (5)
Ischemic hepatitis (aka “shock liver”) is characterized by hepatocyte necrosis due to decreased perfusion
What are some conditions that can cause this:
cardiac arrest
hypotension
arrythmias
congestive heart failure
drugs (e.g. cocaine, niacin, meth)
Explain the graph below
Basically showing rise in AST/ALT and LDH in ischemic hepatitis
What is Budd-Chiari syndrome?
Budd Chiari syndrome: hepatic vein thrombosis >>congestive liver disease
characterized by triad of abdominal pain, massive hepatomegaly and new ascites + nutmeg liver appearance
**more common in females; ass’d w/ hypercoagulable state, PCV, postpartum state
How do you Dx Budd Chiari syndrome?
Ultrasound, CT, or MRI
**see slide for details**
How does acetaminophen overdose cause liver disease?
What are symptoms of acetaminophen overdose?
Acetaminophen is broken down by the liver CYP450s and forms the toxic inermediate NAPQI
Symptoms include: nausea, vomiting w/ 24 hrs >> abdominal pain, anorexia
Describe the King’s college criteria for acetaminophen induced liver failure
*see slide*
How do you Rx acetaminophen overdose? (3)
Activated charcoal w/in 3 hours of ingestion
NAC (IV or oral) - increases glutathione >> binds toxic NAPQI metabolites
Liver transplantation for progressive disease
___ is characterized by mixed elevations of liver enzymes, bilirubin and alk phos and occurs w/in 1st 6 mths of drug use (hint: not dose related)
Drug induced liver injury is characterized by mixed elevations of liver enzymes, bilirubin and alk phos and occurs w/in 1st 6 mths of drug use (hint: not dose related)
**usually NSAIDs, anticonvulsants, antibiotics**
A pt presents w/ severe abdominal symptoms within one day of eating freshly picked mushrooms. Labs show sky high AST/ALTs. You treat the pt w/ penicillin G and milk thistle and the pt responds well to therapy. What is the most likely diagnosis?
Mushroom poisoning
