Liver Diseases CIS Flashcards
hepatocellular- labs
-ALT and AST
cholestasis
-ALK phos
IgM and IgG
- IgM- acute
- IgG- chronic
liver fxn tests
PT and serum albumin
ascites- caused by? risk factors?
- portal HTN from chron liver dz
- ETOH, transfusions, tattoos, IVDU, viral hepatitis
fatty liver (hepatic steatosis)- caused by
- NAFLD
- alcoholic related fatty liver dz
- vinyl chloride
NAFLD- sx, etiology
- usually asymptomatic- RUQ pain, hepatoemgaly
- obesity, DM, hypertriglyceridemia, metabolcic syndrome
- coffee reduces risk of fibrosis and cirrhosis
- protective- physical activity
NAFLD- histology
- macrovesicular steatosis
- NASH (nonalcoholic steatohepatitis)- macrovesicular steatosis and focal infiltration by PMN’s and Mallory hylain
NAFLD- imaging, tx
- US- can see macrovascular steatosis
- liver bx- diagnostic
- tx- weight loss, dietary fat restriction, exercise, vit E, gastric bypass
do what test for ascites?
-US
if abd pain, ascites, and fever- must rule out what? via?
spontaneous bacterial peritonitis
- via Paracentesis!!- run WBC count with differential!
- if malnourished- run adenosine deaminase- for tb!!
spontaneous bacterial peritonitis- caused by? presentation?
- ascitic fluid infection w/o an apparent source
- translocation of gut bacteria- gram neg (E coli or Klebsiella) or gram + (strep pneumo, viridans, enterococcus)
- 10-20% of known cirrhotic pts- present with decompensation- encephalopathy, fever, abd pain, worsening renal fxn!!!!
spontaneous bacterial peritonitis- lab test
- paracentesis- WBC count with diff
- PMN > 250 with 75% of all white cells!!!- highly suggestive
- if elevated WBC count and lymphocyte predominance- think TB or peritoneal carcinomatosis
calculate SAAG
- serum albumin - ascitic fluid albumin
- > 1.1 = a portal HTN cause
- <1.1= non portal HTN cause!!
causes for ascites
Portal HTN (SAAG >1.1)- most common -hepatic congestion -liver dz -portal v occlusion Hypoalbuminemia (SAAG <1.1)
alcoholic- follow up for?
EGD- esophageal varices
Hepatitis A- Dx, Tx
- RNA hepatovirus
- acute
- inc aminotransferases- inc Alk phos and bilirubin
- fecal-oral transmission- international travel is a risk factor!!
- Dx- IgM anti-HAV
- Tx- self limited
Had Hep A but not anymore
-Anti-HAV IgG
Had Hep C but not anymore
-Anti-HCV with neg HCV RNA
acute HBV infection- window period
- b/w HBsAg disappearing and HBsAb appearing
- ACUTE HBV!!
- only detectable with HBcAb IgM
- important for screening blood donations
Hepatitis B
- acute or chronic
- dsDNA genome
- inc aminotransferases- elevated Alk phos and billirubin
- transmitted- infected blood, sexual contract, mother to baby at delivery!!- asia!
- HBV vaccine
Acute HBV- presentation
- variable
- asymptomatic-> fulminant dz and death (<1%)
- aminotransferase levels > HAV
- can become chronic
HBV- window period- lab
-Anti-HBc IgM +
HBV-Acute Infx- lab
- HBsAg +
- HBeAg +
- Anti-HBc IgM +
- HBV DNA +
HBV- prior infection- lab
-Anti-HBs +!!!!
-Anti-Bc IgG +
-Anti-Hbe +/-
(ASIA- maternal transmission)
HBV- chronic infection- lab
- HBsAg +
- HBeAg +
- Anti-HBc IgM +
- Anti-HBc IgG +
- Anti-HBe +/-
- HBV DNA +
HBV- immunization- lab
-Anti-HBs +
Chronic HBV- where?
Asia!
- 90% of infants with maternal transmission
- risk of HCC and cirrhosis
HDV (delta agent)
- acute or chronic
- only in assoc with HBsAg
- percutaneous exposure
- immigrants from endemic areas
HDV- dx
- anti-HDV
- HDAg
- HDV RNA
HCV
- ssRNA
- 50% by IV drug use
- risk factors- body piercing, tattoos, hemodialysis
- sexual and maternal-fetal transmission is LOW
- 80% chronic
- no vaccine!!
HCV- dx
- enzyme immunoassay for Anti-HCV
- confirmed by HCV RNA
- +anti-HCV in serum but neg HCV RNA = recovery from past infection
HCV complications
- mixed cryoglobulinemia
- membranoproliferative GN
- lichen planus, autoimmune thyroiditis, idiopathic pulm fibrosis
- inc risk for Non-Hodgkin lymphoma!
- HCV genotype 3- hepatic steatosis
- dec in serum chol and LDL
- cirrhosis and HCC
HCV- recommendations
- screen ppl born b/w 1945-1965
- vaccinate against HAV and HBV
- check for co infection with HBV and HIV
- safe sex practice
- CURABLE
Chronic HCV- cirrhosis progression inc in?
- after 20 yrs of dz
- men
- drink > 50g of ETOH daily
- acquire infx after 40 yo
- immunocompromised
- tobacco and cannabis smoking
- Af Am- higher rate of chronic HCV but lower fibrosis
- coffee- slows progression
- risk of cirrhosis and HCC
- HCV is curable!
HEV- in who? dx?
- acute hepatitis in Asia, Africa
- waterborne- pets, swine
- self-limited
- transplant recipients- those treated with tacrolimus!!!
- Dx- IgM anti-HEV
Acute Liver Failure- causes
- Acetaminophen
- idosyncratic drug rxn
- risk inc with DM, outcome worse in the obese
acute liver failure- sx
- fulminant = hepatic encephalopathy within 8 wks and coagulopathy
- labs= severe hepatocellular damage!
- acetaminophen toxicity- AST/ALT > 5000
- ammonia level elevated- encephalopathy and intracranial HTN
Tylenol OD
- treat with NAC if in toxicity area
- get a 4 hr acetaminophen level!!
- empiric treatment if ingestion is unknown- acetylcysteine
Autoimmune hepatitis- who? labs?
- young-mid age women
- +ANA and/or smooth m AB (type I)
- Anti-LKM1 (type II)
- AST/ALT can be >1000
- inc risk of cirrhosis and HCC
Autoimmune hepatitis- tx
steroids +/- azathioprine
alcoholics- what vit def?
-thiamine (B1)- wernicke korsakoff syndrome
wernicke encepalopathy
- encephalopathy- confusion, ataxia, involuntary abnormal eye movements
- syndrome- memory issues, confabulate/make up stories
Alcoholic Liver Disease- labs
- AST 2x > ALT
- when total bili > 10 and PTT > 6 sec = severe alk hep with 50% mortality; susceptible to infections
Alcoholic Liver Disease- effects
- dec platelets- direct effect on megakaryocytes prod or hypersplenism
- inc hepatic iron stores
- reversible!
- most common precursor to cirrhosis in US!
- risk of HCC
Alcoholic Liver Disease- Bx, Tx
- polymorphonuclear infiltration with hepatic necrosis (Mallory bodies) and perivenular/perisinusoidal fibrosis
- abstinence from alcohol!!
- nutritional support for anorectic pts- glucose admin increases the thiamine requirement!!
- 6 month abstinence before liver transplant
Risk of alcoholic cirrhosis
->50 grams daily for over 10 yrs
Maddrey Discriminant function- used for?
- disease severity and mortality risk in pts with alcoholic hepatitis
- > 32 = high short-term mortality- may benefit from tx with glucocorticoids!!
Glascow alcoholic hepatitis score (GAH)
- predicts mortality in alcoholic hepatitis
- > 9 who received glucocorticoids- higher survival rates than those who didnt receive glucocorticoids!!
- no survival benefit with glucocorticoids <9
Cirrhosis- who? caused by? risk factors?
- fibrosis and regenerative nodules
- Mex Ams and Af Ams > whites
- causes- alcohol, chronic HCV, HBV, NAFLD, hemochromatosis
- risk factors- heavy alcohol use, obesity, iron overload
- coffee and tea consumption reduces risk
- methotrexate and vit A assoc with fibrosis and cirrhosis
Cirrhosis- signs/sx
- asymptomatic for a long time
- fatigue, disturbed sleep, m cramps, weight loss
- portal HTN
- others- gynecomastia, spider telangiectasias, palmar erythema, dupuytren contractures, asterixis
Cirrhosis- effects
- portal HTN- varices, ascites, hyperdynamic circulatory state
- liver insufficiency- cant syn albumin, coag factors, and cant excrete bilirubin
- portosystemic shunts
Cirrhosis- labs
- macrocytic anemia- folic acid def, hemolysis (hypersplenism)
- dec WBC (hypersplenism)
- inc infection
- thrombocytopenia- marrow suppression, sepsis
- prolongation of prothrombin time
- elevation of AST, Alk phos, T bilirubin
- dec in albumin
- inc risk of DM!!
- vit D def
Cirrhosis- imaging
- US- liver size, ascites, nodules
- contrasted CT- nodules- biopsy
- fibrosure- low/high excludes/predicts advanced fibrosis
- liver bx
- EGD
- detect varices or causes of bleeding in esophagus, stomach, duodenum
Cirrhosis- complications
- Upper Gi bleeding- portal HTN gastropathy, gastroduodenal ulcer, varices
- liver failure
- hepatic encephalopathy
- SBP (spontaneous bacterial peritonitis)
- hepatorenal syndrome
- coagulopathy
- HCC
- osteoporosis
Ascites- caused by?
- secondary to portal HTN!
- found in 50% of pts with cirrhosis
- 1/3 will develop upper GI bleeding
- upper endoscopy- dx!
Child Pugh score
estimates cirrhosis severity!
- ascites, encephalopathy, bilirubin, albumin, PT time
- Class A- 5-6
- class B- 7-9
- Class C- 10-15
MELD score
(model for end-stage liver dz)
- predict survival in pts with cirrhosis
- serum bilirubin, creatinine, INR
- inc of 2 in first wk- predict in-hospital mortality
PBC (primary biliary cholangitis)- lab, assoc with? risk factors? tx
- autoimmune destruction of small intrahepatic bile ducts and cholestasis
- W>M
- isolated elevated Alk phos!!!
- antimitochondrial ab!!!
- IgM elevated, inc chol
- assoc HLA DRB1 and DQB1
- asoc with Sjogren, autoimmune thyroid, raynaud, scleroderma, celiac
- risk factors- smoking
- TX- ursodeoxycholic acid
Absorption- colon, duodenum, ileum
- colon- water
- duodenum- iron
- ileum- vit B12, bile salts
Hemochromatosis- caused by?
- autosomal recessive
- HFE mutation- C282Y
- iron accum- liver, pancreas, heart, adrenals, testes, pituitary, kidneys
Hemochromatosis- sx
- usually not until fifth decade!!
- cirrhosis, HF, hypogonadism, arthritis, skin pigmentation, DM
hemochromatosis- tx?
- avoid food rich in iron (Red meat), alcohol, vit C, raw shellfish, supplemental iron
- phelbotomies
- PPI- reduces intestinal iron abs
- Deferoxamine- chelating agent
Wilson disease- sx, tx
(hepatolenticular degeneration)
- autosomal recessive, <40
- N european
- copper deposition- brain, kidney, liver
- neuropyschiatric disease
- kayser-fleischer rings
- tx- oral penicillamine, liver transplant
Wilson dz- lab findings
- serum ceruloplasmin- low
- urinary excretion of copper- high
- hepatic copper- high
Budd-Chiari
- RUQ pain, painful hepatic enlargement, ascites, HSCM, jaundice
- occlusion of hepatic v or ICV
- hypercoagulable state!!
- complicated by HCC!
Budd-Chiari- Dx
- prominent caudate lobe!!
- screening- Doppler ultrasonography
- direct venography- “spider web” pattern!
- Bx- centrilobular congestion! (nutmeg liver)
assoc with oral contraception
-hepatocellular adenoma
Alpha-1 antritrypsin def
- autosomal recessive
- defective alpha1-AT accum in hepatocytes
- chrom 14- PIZZ
- micronodular cirrhosis- risk of HCC
- panacinar emphysema
- TX- smoking abstinence, liver transplant
