Liver Disorders (Brown)

Question 1

All of the following are major complications of cirrhosis EXCEPT:

A. Variceal bleeding

B. Ascites

C. Hemachromatosis

D. Hepatic encephalopathy

E. Hepatocellular carcinoma

Answer 1

C

Question 2

This is the most common complication of cirrhosis and is prognostic - about 50% of cirrhotics will die within 2 years

Answer 2

ascites

*diagnostic paracentesis should be performed on these patients as part of the physical exam, to check for signs of infection

Question 3

lab test that tells you, with a fair amount of certainty (~97%), whether cirrhosis is the cause of the presenting ascites

Answer 3

serum-ascites albumin gradient (SAAG)

Question 4

this is the result of bacterial translocation from gut due to impaired barrier function, is common in hospitalized cirrhotics, and most present with abdominal pain, fever, and/or diarrhea

Answer 4

spontaneous bacterial peritonitis (SBP); not all patients present with “peritonitis” signs

Question 5

what microorganisms are most commonly found in a positive culture for spontaneous bacterial peritonitis (SBP)?

Answer 5

gram negative bacteria (ie, e. coli, klebsiella); treat with antibiotics

Question 6

What is the treatment for SBP?

Answer 6

cefotaxime (first line antibiotic) and IV albumin to increase kidney perfusion

*NOT AMINOGLYCOSIDES, which are nephrotoxic

*Prophylactic antibitoics for hospitalized patients with GI bleed and those with low ascites protein

Question 7

How is ascites managed?

Answer 7

diet: sodium restriction
drugs: diuretics (NOT IV DIURETICS - because of renal hypoperfusion)
procedure: paracentesis with IV albumin infusion

Question 8

_____ is a life threatening emergency in which preserving hemodynamic volume is the main priority; should treat with ____ to decrease portal pressure acutely

Answer 8

variceal hemorrhage; somatostatin or octreotide

Question 9

what are the procedural treatments for variceal hemorrhage?

Answer 9

Endoscopic therapy (variceal band ligation), and if that fails, transjugular hepatic portosystemic shunt (TIPS). This eliminates the pressure gradient between portal and systemic circulation that drives bleeding from the varices.

Question 10

what 2 nonselective beta blockers are used in the prophylactic treatment of cirrhotics screened for variceal hemorrhage?

Answer 10

propranolol or nadolol

Question 11

a clinical diagnosis that is a spectrum of potentially reversible neuropsych abnormalities due to impaired hepatic clearance of neurotoxic molecules (ie, ammonia)

Answer 11

hepatic encephalopathy; treat with osmotic laxatives first - if that fails then treat with neomycin or rifaximin

Question 12

All of the following are precipitants of hepatic encephalopathy EXCEPT:

A. Excess dietary protein

B. GI bleed

C. Infection

D. Hypoxia

E. Electrolyte imbalance

Answer 12

A. This is wrong for almost all patients

Question 13

80% of cases of this cancer occur in the presence of cirrhosis, with the risk of developing it being particularly high in the setting of cirrhosis due to viral hepatitis

Answer 13

hepatocellular carcinoma (HCC)

Question 14

screening that is used to predict 3-month mortality, thus a priority for liver transplant; benefit is that it is completely objective and based on creatinine and bilirubin levels

Answer 14

MELD score

Question 15

An elevated alkaline phosphatase is the predominant hallmark of cholestasis, but also may indicate pregnancy in women, because both bone and placenta can be sources of elevation. How can you tell if alk phos elevation is due to a liver problem?

Answer 15

measure GGT or 5’ nucleotidease; these are canalicular enzymes, from the bile canaliculi that join adjacent liver cells, and if elevated indicate liver as the source

Question 16

AST and ALT measurements aren’t specific for liver injury, but a ratio of AST:ALT greater than 2 is highly indicative of what sort of liver problem?

Answer 16

alcoholic liver disease

Question 17

genetic condition affecting up to 5% of the population which causes isolated unconjugated hyperbilirubinemia; occurs with fasting, stress and infection but is not a disease and does not need to be treated

Answer 17

gilbert’s syndrome

Question 18

inflammation of the liver that may present with asymptomatic or nonspecific complaints (ie, joint aches, fatigue, nausea) but often shows huge ALT/AST elevations

Answer 18

acute hepatitis; caused by hepatitis A and E and must resolve in 6 months, or it’s officially chronic hepatitis

note: chronic hepatitis differs from acute in that ALT/AST levels are normal or only mildly elevated

Question 19

hepatitis viruses that are enterically-transmitted

Answer 19

hepatitis A and E (the vowels); B, C, and D are parenterally transmitted via blood and blood products and cause chronic hepatitis

Question 20

Which of the following is not a characteristic of hepatitis A?

A. RNA virus

B. Symptomatic infection is more common in children

C. Spread by fecal-oral route

D. There’s no specific treatment for it but immunity may be gained by resolved infection or vaccine

E. Patients infected have +IgM anti-HAV acutely and +IgG remotely

Answer 20

B. Symptomatic and fulminant infections are more common in adults.

Question 21

Which form of hepatitis is characterized by an acute RNA viral infection that is uncommon in the U.S. and has a high mortality in pregnant women?

Answer 21

hepatitis E (HEV)

Question 22

which form of hepatitis is spread parenterally, particularly through injected drug use, sexual transmission, and (globally) through vertical transmission from mother to fetus?

Answer 22

hepatitis B (HBV)

Question 23

which of the following statements about HBV is incorrect?

A. infants and young children are often asymptomatic but carry lifetime risk of infection and development of hepatocellular carcinoma (HCC)

B. Adults rarely develop fulminant HBV

C. There are currently 7 approved drugs for HBV, none of which are curative

D. Adults are much less likely to develop chronic hepatitis

E. HBsAg is an antibody that indicates the active presence of HBV in the blood

Answer 23

E. HBsAg is actually a piece of the virus, and is a sure indicator of the presence of active HBV. Anti-HBs is the antibody, and it does not appear in the blood until the virus is waning and simply indicates that a person has been exposed to HBV, NOT that there’s an active infection.

Question 24

Which form of hepatitis occurs only in the presence of HBV?

Answer 24

hepatitis D (HDV)

Question 25

which of the following statements about HCV is INCORRECT?

A. Can be cured with new but highly expensive oral regimens that do not rely on interferon

B. It is the most common form of hepatitis, and is the cause of most cases of HCC

C. First line test is Anti-HCV antibody

D. Most people don’t have symptoms with an HCV infection

E. Main difference in serology of HCV is that antibody is made fairly early in the progression of infection, and continues to persist indefinitely

Answer 25

B. It is the most common form of hepatitis, but most cases of HCC are actually attributed to HBV (80%).

Question 26

Disease characterized by mild-moderately elevated AST/ALT, portal hypertension, and on histology shows rounded portal lymphoid aggregates (shown below)

Answer 26

chronic viral hepatitis (C)

Question 27

classical histology of this type of hepatitis includes a ground glass hepatocyte appearance (below)

Answer 27

hepatitis B

Question 28

What is the main histological difference between NAFLD and NASH?

Answer 28

NAFLD = fat accumulation in the liver

NASH = fat + fibrosis in the liver (see below)

Question 29

as shown below, fat (steatosis), ballooned hepatocytes and mallory hyaline are all features of what disease?

Answer 29

alcoholic liver disease

Question 30

Which of the following is not a clinical sign in a patient presenting with alcoholic steatohepatitis?

A. History of alcoholism

B. AST >>>>> ALT

C. Low titre positive ANA

D. Elevated GGT

E. Elevated MCV or macrocytic anemia (B12 deficiency)

Answer 30

C. This is a feature of NALDF/NASH, along with metabolic syndrome and ALT>AST.

Question 31

Disease that affects women (so, it’s either not real and/or probably their fault, according to Dr. Densen) that is difficult to diagnose and may be associated with diseases like Sjogren’s; histology shows complete loss of architecture in the liver and numerous plasma cells (below)

Answer 31

autoimmune hepatitis

Question 32

All of the following factors point toward a diagnosis of autoimmune hepatitis EXCEPT:

A. Female sex

B. Alk phos: ALT < 3.0

C. HLA DR3/4

D. Autoimmune disease in first degree relative

E. HCV+

Answer 32

E. Other forms of hepatitis, significant alcohol history, and AMA+ (which supports cirrhosis diagnosis) all point against autoimmune hepatitis

Question 33

Which of these is NOT a feature of drug induced liver injury?

A. Type A is predictable and dose-dependent while Type B is is not

B. May cause hepatitis or cholestasis

C. Histology shows portal inflammation with eosinophils

D. Diagnosis involves controlled rechallenge of the drug to specify cause

E. Hepatocellular injury usually improves promptly after stopping the offending agent

Answer 33

D. This is rarely justified, as it is dangerous.

Question 34

autosomal recessive disorder that is common among Caucasians, affects multiple organs (–> cirrhosis, diabetes, CHF, arthritis, etc) and is characterized by dysregulated iron absorption

Answer 34

hemachromatosis; HFE transmembrane protein mutations occur only in Caucasians

Question 35

what is the treatment for hemachromatosis?

Answer 35

phlebotomy

Question 36

autoimmune disease that mostly affects women and can be confirmed with a high degree of liability by anti-mitochondrial antibody serologic test

Answer 36

pbc (primary biliary cirrhosis); treated with ursodiol, a gallstone dissolving drug

Question 37

chronic disease more common in men and characterized by inflammation and fibrosis of intra- and extra-hepatic bile ducts, leading to multifocal bile duct strictures

Answer 37

primary sclerosing cholangitis (PSC)

Question 38

Which of the following statements is FALSE?

A. Histologically speaking, florid duct lesions are characteristic of PBC, while PSC shows fibro-obliterative lesions

B. PBC is associated with ulcerative colitis

C. PSC is associated with increased risk of carcinoma

D. PSC is ANCA+ while PBC exhibits antimitochondrial Ab

E. Extrahepatic ducts are not involved in PBC

Answer 38

B. Ulcerative colitis is found about 70% of the time in patients with PSC.

Question 39

episodes of intense pain in the RUQ or epigastrum, sometimes radiating to the right shoulder blade

Answer 39

biliary colic; once this occurs it is likely to happen again, and is reason enough for gallbladder removal

Question 40

caused by persistent obstruction of the cystic duct + chemical mediators derived from bile, with biliary colic that persists for 4-6 hours per episode;

physical exam: +Murphy’s sign, maybe fever

labs: elevated WBC, mild elevations of AST, ALT, bilirubin. ultrasound to confirm diagnosis

Answer 40

acute cholecystitis; have to take out the gallbladder

Question 41

Is ultrasound or CT better for imaging gallstones and cholecystitis?

Answer 41

Ultrasound is very sensitive for stones - hyperechoic lesions and shadowing can be seen. CT might show stones but it’s not a good first step for looking for biliary disease

Question 42

obstruction of bile ducts with superimposed bacterial infection that presents with Charcot’s triad: febrile, jaundice, RUQ; very sick patients who are often septic with elevated WBC, ALT/AST, bili, alk phos

Answer 42

ascending cholangitis - dx by ultrasound and urgent treatment with antibiotics and endoscopic retrograde cholangiopancreatography (ERCP) to establish biliary drainage

Question 43

congenital disorder characterized by fibrous obliteration of the extrahepatic biliary tract and is the most common reason for liver transplant in juvenille population; presents in first 8 weeks of life with clay colored stools, dark urine, jaundice, liver may be firm and enlarged

Answer 43

biliary atresia;

dx: cholangiogram is gold standard to establish lack of patency/continuity of the bile duct from the liver and
tx: kasai procedure, in which a direct connection is established from liver to intestine to allow bile escape; followed by later transplant

Question 44

particularly bad cancer that is usually advanced at presentation with biliary obstruction - main risk factor is PSC and symptoms are jaundice, pruritus, acholic stools, dark urine, abd pain, and weight loss

Answer 44

cholangiocarcinoma (CCC)

Question 45

rare cancer in US but more common worldwide, whose main risk factor is chronic gallstones and infection, but risk increases with age, obesity and diabetes; gallbladder polyps and “porcelain” gallbladder are both increased risks for cancer

Answer 45

gallbladder cancer

Question 46

serious condition marked by acute onset of persistent, severe epigastric/RUQ pain, often radiating to the back, usually accompanied by nausea and vomiting, with relief during sitting up or leaning forward

Answer 46

acute pancreatitis

Question 47

what are the 2 main causes of acute pancreatitis?

Answer 47

gallstones and alcohol

Question 48

clinical features of this disease include pain, sometimes persistent, sometimes exacerbated by meals but amylase and lipase are usually normal; classical signs include pancreatic calcifications, steatorrhea and DM

Answer 48

chronic pancreatitis