Liver Disorders Flashcards
What is hemoglobin brokendown into?
Heme and globin
Heme is converted to what by-product?
Bilivirdin
Bilivirdin becomes what?
Unconjugated bilirubin
What is unconjugated bilirubin?
Indirect bilirubin in labs
*Non-functional, fat soluble, bound to albumin
Where is unconjugated bilirubin conjugated?
Hepatocytes
What are the four phases of bilirubin metabolism?
- Production of bilirubin
- Uptake via liver cells
- Conjugation with glucuronic acid
- Transport via bile/urobilinogen
Where is jaundice typically first seen?
Sclera or darkening of urine
What is hyperbilirubinemia?
Accumulation of bilirubin in body tissues
What is a normal bilirubin level in newborns (total)?
1.0 - 12.0 mg/dL
What is a normal direct bilirubin?
0.1 - 0.3 mg/dL
What is the normal indirect bilirubin?
0.2 - 0.8 mg/dL
At what lab value is jaundice apparent around?
2.5-3 mg/dL
Impaired uptake leading to hyperbilirubinemia is primary the result of
Certain drugs, can be treated by removing drug
Is stool color normal in impaired conjugation caused hyperbili?
Light to normal
What enzyme is immature in physiologic neonatal jaundice?
GT
Why do we use UV light to treat physiologic neonatal jaundice?
UV light makes unconjugated bilirubin water soluble –> dissolves in bile
What is Gilbert Syndrome?
Hereditary disorder –> reduced function of GT (evident with hemolysis)
Presents later in puberty or adulthood, episodic jaundice and hyperbili (worse with stress, ETOH)
What is conjugated (direct) hyperbilrubinemia primary the result of?
Obstruction or hepatocellular dysfunction
Is bilirubin itchy?
Yes, patients will be itchy
What symptoms are found in conjugated (direct) hyperbilirubinemia?
Dark urine, jaundice, light stools
What are the etiologies causing elevated indirect/unconjugated bilirubin?
Hemolysis
Drugs
GT dysfunction
What are the etiologies causing elevated direct/conjugated bilirubin?
Liver dysfunction or obstruction
Most liver studies are included in what lab?
CMP
Elevations in AST/ALT reflect what hepatic problem?
Hepatocellular injury
What is the most common cause of AST/ALT elevations?
Non-alcohol related fatty liver disease
If the AST > ALT the liver injury is more related to what?
Alcohol related livery injury or cirrhosis
What conditions is a livery biopsy better for
Diffuse disorders
How is fulminant acute liver failure defined?
Development of hepatic encephalopathy within 8 weeks
How is subfulminant liver failure defined?
hepatic encephalopathy 8 weeks to 6 months after onset
What medication most commonly will lead to acute liver failure?
Rifampin
What is the presentation of acute liver failure?
Jaundice
Bleeding disorders
Encephalopathy/AMS
What is the cause of systemic inflammatory response syndrome (SIRS)?
Death or hepatocytes
*patients are SICK! Multisystem organ dysfunction
What is the treatment for acute liver failure?
Admit to ICU
*Lots of things to be done
Non-alcohol related liver disease exists on a continuum, what are the different stages?
Normal liver –> NAFLD –> NASH –> Cirrhosis
What liver disease stage is irreversible?
Cirrhosis
Non-alcohol related fatty liver disease has a significant correlation to what resistance?
Insulin resistance
What is the presentation of NAFLD?
**Primarily asymptomatic
+/- RUQ discomfort
+/- Non-specific constitutional symptoms
+/- isolated hepatomegaly
What is the most reliable treatment for NAFLD?
Lifestyle modifications including GRADUAL weight loss
What are the causes of cirrhosis?
- Viral hepatitis (C&B)
- Alcohol
- NAFLD
- Drug toxicity
- Autoimmune
- Metabolic liver disorders
What are the three stages of cirrhosis?
- Compensated
- Compensated with varices
- Decompensated
Are the symptoms of cirrhosis specific?
No, wide array of vague presenting symptoms
When does the first liver positive physical exam finding appear in cirrhosis?
Late stage; will have a firm, palpable, nodular liver
What imaging modality is good in assessing liver size?
US
How do you assess for varices?
EGD
What vaccines should be given to cirrhosis patients?
HAV, HBV, pneumococcal and annual flu
What does portal hypertension lead to?
Third spacing
What are the symptoms of hepatocellular carcinoma (HCC)?
Cachexia, weight loss, weakness
Sudden development of ascites
Enlarging liver with palpable mass
What is the diagnostic test of choice in working up hepatocellular carcinoma (HCC)?
Biopsy
What is the definitive treatment for chirrhosis and associated complications?
Transplant
In order to be eligible for a liver transplant how long must you have sustained from alcohol?
6 months
Is HIV and Hepatitis a contraindication for a liver transplant?
No
Patients on the liver transplant list are prioritized by what score?
MELD score (eligible if 15+)
True or False: Nearly everyone (90%) with harmful alcohol use develops some liver dysfunction
True
Is there a dose effect associated with ETOH?
Yes
What is the spectrum of alcohol related liver disease?
Alcohol related steatosis –> alcohol related hepatitis –> cirrhosis
What is the primary treatment in alcohol related liver disease?
Abstinence from ETOH
What are the two pharmacological agents that can be used to help abstain from alcohol?
Naltrexone (Vivitrol)
Disulfram (Antabuse)
Can you use disulfram in the treatment of alcohol related cirrhosis?
No, it should be avoided. Can use Naltrexone.
