[Approach to Jaundice] AST/ALT >>>> ALT

Hepatocellular pattern 1. Viral 2. Drug-induced 3. Ceruloplasmin 4. ANA, SMA, SPEP

Liver Diseases Flashcards by Clyde Silverio

[Approach to Jaundice]

ALP&raquo_space;> AST/ALT

Cholestatic pattern, do UTZ

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[Approach to Jaundice]

AST/ALT&raquo_space;» ALT

Hepatocellular pattern

Viral
Drug-induced
Ceruloplasmin
ANA, SMA, SPEP

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Inherited disorders that can cause indirect hyperbilirubinemia

Gilbert

2. Crigler-Najjar

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Inherited disorder that can cause direct hyperbilirubinemmia

Dubin-Johnson
Rotor

Remember: Direct: Dubin,

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Entities that could elevate AST and ALT up to thousands

Viral hepatitis
Drug-induced
ischemic hepatitis
Transient blocking of CBD by a choledocholith

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Drug toxicity that can cause Pure cholestasis resulting to jaundice

Anabolic steroid

2. Contraceptive steroids

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Drug toxicity that can cause cholestatic hepatitis resulting to jaundice

Chlorpromazine

2. Erythromycin estolate

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Drug toxicity that can cause cholestatic cholestasis resulting to jaundice

Chlorpromazine

2. Prochlorpromazine

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Most common and most characteristic symptom of liver disease

fatigue

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Hallmark symptom of liver disease

jaundice

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Single most common risk factor for Hep C

injection drug use

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[Blood test in liver disease]

AST:ALT >2

alcoholic liver disease

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[Blood test in liver disease]

AST:ALT < 1

chronic viral hepatitis, NAFLD

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Procedure of choice for visualization of biliary tree

ERCP, MRCP

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Gold standard in diagnosing most liver diseases

liver biopsy

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This replaced liver biopsy in evaluating cirrhosis

liver elastography

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Most important serologic test to check for acute Hep A and Hep B

Anti HAV Igm
HBsAg
Anti-HBc IgM

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How many percent of patients infected with HCV will recover spontaneously?

15%

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[Interpret the serology]

HBsAg: +
Anti-HBs: -
Anti-HBc: IgM
HBe: +
Anti-HBe: -

Acute, Hep B high infectivity

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[Interpret the serology]

HBsAg: +
Anti-HBs: -
Anti-HBc: IgG
HBe: +
Anti-HBe: -

Chronic, Hep B, high infectivity

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[Interpret the serology]

HBsAg: +
Anti-HBs: -
Anti-HBc: IgG
HBe: -
Anti-HBe: +

Late acute or chronic,

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[Interpret the serology]

HBsAg: -
Anti-HBs: -
Anti-HBc: IgM
HBe: -
Anti-HBe: -

Anti HBc window

Acute Hepatitis B

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[Interpret the serology]

HBsAg: -
Anti-HBs: -
Anti-HBc: IgG
HBe: -
Anti-HBe: -

Low-level Hep B carrier

2. Hepatitis B in remote past

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[Interpret the serology]

HBsAg: -
Anti-HBs: +
Anti-HBc: IgG
HBe: -
Anti-HBe: -

Recover

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[Interpret the serology] ``` HBsAg: - Anti-HBs: + Anti-HBc: - HBe: - Anti-HBe: - ```

Immunization

What is the marker for hepatitis A during acute illness?

IgM Anti-HAV

What is the marker that predominates during the first 6 months after acute infection. Present eve at the window period

IgM Anti-HBc

What is the marker to diagnose Hep C

Anti-HCV

[Diagnose] palmar erythema, gynecomastia, testicular atrophy ``` HBsAg: + Anti-HBs: - Anti-HBc: IgG HBe: - Anti-HBe: + ```

Chronic active Hep B, high infectivity

Scleral icterus is seen when the TB is ___

>2.5 to 3 mg/dL

Derangement of this liver enzyme indicates worse prognosis

The only serologic marker present during the window period

Anti HBc

Hepatitis A vaccine is given ___ doses, ___ month apart

2 doses | 6 months apart

Hepatitis B vaccine is given ___ doses

three doses, over 6 months

What is the mainstay treatment for hepatic encephalopathy?

lactulose

Cut off value for portal hypertension

>5mmHg

Significant alcohol intake means an alcohol level of ____ grams per day

30g or more 3 pilsen cans per day

[Type of hepatorenal syndrome] AKI in less than 2 week with oliguria. More serious

Type 1

[Type of hepatorenal syndrome] Renal impairment less severe, ascites refractory to diuretics

Type 2

___ syndrome seen i cirrhotic patients mainly due to nitric oxide in the splanchnic circulation causing peripheral vascular resistance

Hepatorenal syndrome

dyspnea in the upright position is called ___

platypnea

____ refers to cirrhotic patients desaturation greater than 4mmHg or 5% sats from supine to upright

Orthodeoxia

What are the stigmata of cirrhosis

1. Palmar erythema 2. Spider angiomata 3. Testicular atrophy 4. Dupuytren's contracture 5. caput medusae

[Cirrhosis] beta blocker lower ___

portal pressure

What is an alternative to surgery for patients who fail endoscopic and medical treatment?

Transjugular intrahepatic portosystemic shunt (TIPS)

___ are potent splanchnic vasoconstrictor, decreases HR and CO resulting to decreased portal blood flow

1. Propranolol | 2. Nadolol

___ is added to propranolol since it further decreases the hepatic vascular tone thereby decreasing hepatic resistance

Carvedilol

What is the next step after confirming that a patient has ascites via UTZ?

Paracentesis (LLQ)

What is the most common cause of ascites?

Liver cirrhosis

What is the initial treatment of cirrhotic ascites?

restrict sodium next: spironolactone + furosemide

[Causes of SAAG} < 1.1 g/dL

NONPORTAL HPN 1. Biliary leak 2. Nephrotic Syndrome 3. Pancreatitis 4. Peritoneal carcinomatosis 5. TB

[Causes of SAAG} SAAG >= 1.1 Ascitic protein <2.5

PORTAL HPN hepatic sinusoids are damaged 1. Cirrhosis 2. Massive liver mets 3. Late Budd-Chiari

[Causes of SAAG] SAAG >= 1.1 Ascitic protein >= 2.5

PORTAL HPN increased pressure in the hepatic sinusoids 1. Heart Failure/constrictive pericarditis 2. Early Budd-chiari 3. IV obstruction 4. Sinusoidal obstruction syndrome remember, HIVES

[Ascites] white, milky, Triglyceride >2000

chylous ascotes

[Ascites] Dark brown fluid, high bilirubin

Biliary Tract Perforation

[Ascites] black fluid

pancreatic necrosis or metastatic melanoma

[Ascites] Ascitic glucose <50 Ascitic LDH > serum LDH Polymicrobial

Secondary peritonitis

[Ascites] Ascitic fluid lymphocytosis elevated ascitic adenosine deaminase

Tuberculous peritonitis

What is the tumor marker for HCC?

AFP

Screening tool for HCC?

Liver UTZ

In HCCA, best tool to determine tumor size, extent, presence of portal vein invasion

Triphasic CT of the abdomen and pelvis

What are the CT triphasic findings HCCA

1. Arterial phase: Pre-arterial blush | 2. Venous phase: Delayed washout

What are the CT triphasic findings metastatic liver mass

1. Arterial phase: no mass detected | 2. Venous phase: mass present

Imaging criteria developed for HCC that do not require biopsy proof since it has a 90% specificity

1. Nodule >1cm, with arterial enhancement and portal venous washout 2. <1cm nodule, growth rates of 2 scans performed <6 months apart

HCCA Screening strategies for HBV and HCV carrier

1. UTZ + AFP every 6 months in the presence of cirrhosis or worsening LFT

Corkscrew esophagus

diffuse esophageal spasm