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Spring 2022 > Liver Function/Hepatitis > Flashcards

Liver Function/Hepatitis Flashcards

1
Q

Vascular and hematologic functions of the liver

A

Blood storage
Bacterial and foreign particle removal
Synthesis of clotting factors
Produce bile to absorb fat-soluble vitamins
Reticuloendothelial system produces monocytes, macrophages, antigens

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2
Q

What minerals and vitamins are stored by the liver?

A 
Vitamin A
Vitamin D
Vitamin B12
Iron 
Copper
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3
Q

How are liver abnormalities classified?

A

Liver function/synthesis: Prothrombin (PT/INR) and albumin
Hepatocellular markers: Aminotransferases, ALT & AST
Cholestatic Markers: Alkaline phosphatase and bilirubin

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4
Q

Role of PT/INR and albumin in assessing liver?

A

Monitors synthetic function in acute and chronic liver disease
Unreliable markers if taking warfarin, nephrotic syndrome, malabsorption, or malnutrition

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5
Q

Liver Function Tests (LFTs)

A 
ALT - Alanine aminotransferase (SGPT)
ALP - Alkaline phosphatase (SGOT)
GGT - Gamma-glutamyl transpeptidase 
LAP - Leucine aminopeptidase
5'-Nucleotidase
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6
Q

Viral hepatitis ALT/AST ratio

A

> 1

About equal

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7
Q

Causes of increased ALT?

A

Damage to liver parenchymal cells
Liver disease
Viral hepatitis

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8
Q

What causes an increase in ALP1?

A

Liver pathology with increase in 5’-nucleotidase

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9
Q

What causes an increase in ALP2?

A

Bone pathology with normal 5’-necleotidase

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10
Q

What causes significant increases in ALP?

A

Extrahepatic and intrahepatic biliary disease

Cirrhosis

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11
Q

What causes increases in GGTP levels?

A

Biliary obstruction
Cholangitis
Cholecystitis
Elevations after acute MI

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12
Q

What causes increases in LAP?

A

Liver disorders
Parallels ALP
Useful in differential diagnosis of increased ALP

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13
Q

What causes increases in 5’-nucleotidase?

A

Increased ALP + 5’-nucleotidase = liver pathology
Specific to cholestasis (bile formation and flow obstruction)
Similar to GGT

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14
Q

What are the hepatocellular markers?

A

Aminotransferases

ALT, AST

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15
Q

Young healthy adults and mild ALT/AST elevations considerations

A

<5x upper limit of normal seen commonly in healthy young adults
Workup if persists >6mos

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16
Q

Causes of persistent elevations in ALT/AST

A

Hepatitis B, Hepatits C, Wilson’s disease, hemochromatosis, autoimmune hepatitis, medications, Celiac’s, alpha1-antitrypsin deficiency, fatty liver

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17
Q

What does ALT>AST indicate?

A

Inflammation - drugs or infection

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18
Q

What does AST>ALT indicate?

A

Alcohol use usually

May be associated with APAP use or statins

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19
Q

What do severe elevations in AST or ALT (>1000) indicate?

A

Infection
Toxins
Shock liver

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20
Q

What causes ALT elevations?

Pneumonic

A

Avandia (rosiglitazone) and Actos (pioglitazone),
Liver infection
Therapeutic agents and toxins

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21
Q

What causes AST elevations

Pneumonic

A

Alcohol
Statin
Tylenol

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22
Q

What can cause AST/ALT elevations 1-5x the norm?

A

Alcohol use, skeletal muscle injury r/t seizure, protracted immobilization

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23
Q

What can cause AST/ALT elevations >5x the norm?

A

Infectious hepatitis

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24
Q

Significance of GGT elevations?

A

Normal GGT 0-45 U/L

Marked sustained elevation with binge drinking and high alcohol intake

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25
Q

What are the cholestatic markers?

A

ALP

  • Not liver specific
  • Seen in bone, intestine, lung, placenta

Bilirubin

26
Q

What are the GGT, 5-Nucleotidase, and LAP relationships to ALP in liver etiology?

A

Parallels

27
Q

What can cause isolated increases in indirect bilirubin?

A

Indirect unconjugated bilirubin is a byproduct of normal RBC breakdown
Not excreted in urine
Not liver disease
Hemolysis or Gilbert’s syndrome

28
Q

What can cause increases in direct conjugated bilirubin?

A

Direct bilirubin is water soluble, can be excreted in urine

Increases seen in cholestasis

29
Q

How to distinguish etiology in patients who present with both hepatocellular and cholestatic abnormalities?

AST, ALT elevations
LAP, ALP, GGT, 5-N

A

One usually predominates to guide diagnosis

30
Q

What does NAFL stand for?

A

Non-alcoholic fatty liver

31
Q

What does NASH stand for?

A

Non-alcoholic steatohepatitis

32
Q

What are the complications of NASH?

A

Steatosis and inflammation which can lead to cirrhosis, liver failure, and cancer

33
Q

When do you workup NAFL?

A

Workup incidental finding on imaging:
S/S of liver disease or abnormal liver biochemistries: Full NAFLD workup
No s/s and normal liver biochemistries: assess risk factors and alternate causes (ETOH, meds)
Asymptomatic and have normal liver biochemistries - liver biopsy not recommended

34
Q

How is heavy alcohol use defined?

A

Men: 4> drinks per day or >21 drinks on average per week

Women: 3> drinks per day or >14 drinks on average per week

35
Q

NAFLD and Alcohol considerations

A

Should not consume heavy amounts of alcohol

No recommendation for non-heavy consumption

36
Q

NAFLD Management

A 
Minimize alcohol use
Manage CVD risk factors and diabetes 
Hep A and Hep B immunizations if serologically negative
PPSV-23 age 19-64
Bariatric surgery
Refer to hepatologist
37
Q

Medications and NASH in NAFLD

A

Atorvastatin-found to be safe NAFLD
Pioglitozone DM2 Tx- Not as primary therapy
Metformin?-recent studies have not shown improvement histology
Vitamin E 400 IU for those advanced fibrosis on bx without DM or CAD
UDCA (ursodeoxycholic acid) and Omega-3

38
Q

What do IgM and IgG elevations in hepatitis signify in relation to chronicity?

A

IgM first response, acute

IgG response later, subacute or chronic

39
Q

Acute Hepatitis A

Diagnostics

A

IgM anti-HAV

IgM Antibody to HAV

40
Q

HepA Previous exposure & Immunity Diagnostics

A

Total Anti-HAV

Total antibody to HAV

41
Q

HepB Diagnostic Components

A 
Central core (c) antigen (ag)
Surrounding envelop (e)
Surface (s) antigen (Ag)

HBcAg core antigen
HBeAg envelop antigen
HBsAg surface antigen

HBcAb
HBeAb
HBsAb

42
Q

What does +HBsAg signify?

A

Acute antigen infection or chronic infection

43
Q

What does +HBeAg signify?

A

Acute active infection

Highly infectious

44
Q

What does +IgM HBcAb signify?

A

Acute infection

45
Q

What does +HBsAb signify?

A

Previous exposure

Permanent immunity

46
Q

What does +HBeAb signify?

A

Acute infection resolution

47
Q

HepC Diagnostics

A

Anti-HCV

ELISA, PCR

48
Q

HepD Diagnostics

A

HDAg - early infection

Anti-HDV - later infection

49
Q

HepE Diagnostics

A

IgG and IgM antibodies

in progress

50
Q

When do HepG infections occur?

A

Only seen with concurrent HepB or HepC infections, never alone

51
Q

Interpret
HBsAg - neg
HBcAb - neg
HBsAb - neg

A

Susceptible to HBV

52
Q

Interpret
HBsAg - neg
HBcAb - pos
HBsAb - pos

A

Immune due to natural HBV infection

HBcAb as indicator for infection vs vaccine

53
Q

Interpret
HBsAg - neg
HBcAb - neg
HBsAb - pos

A

Immune due to HBV vaccine

54
Q 
Interpret
HBsAg - pos
HBcAb - pos
HBcAb IgM - pos
HBsAb - neg
A

Acute HBV infection

IgM acute, early infection indicator

55
Q 
Interpret
HBsAg - pos
HBcAb - pos
HBcAb IgM - neg
HBsAb - neg
A

Chronic HBV infection

Indicator for chronic infection is positive HBsAg and HBcAb with IgM negative

56
Q

Interpret
HBsAg - neg
HBcAb - pos
HBsAb - neg

A 
May be:
Resolved infection (most common) 
False-positive HBcAb, thus susceptible
Low level chronic infection
Resolving acute infection
57
Q

Hepatitis A

Overview

A

ROT: Fecal-oral
Sequelae: Survive or die
Vaccine available
PEP with HAV IgG for close contacts
Acute infection: HAV IgM confirms active infection, elevated liver enzymes
Total anti-HAV/HAV IgG confirms past infection

58
Q

Hepatitis B

Overview

A

ROT: Blood, body fluids
Sequelae: chronic HBV infection, hepatocellular carcinoma
Vaccine available
PEP with HBV IgG for blood or body fluid exposure
Acute disease: HBsAg, HBeAg extra contagious, elevated liver enzymes
Chronic disease: No symptoms, Normal or slightly elevated liver enzymes, HBsAg
Past infection: HBsAb

59
Q

Hepatitis C

Overview

A

ROT: Blood, body fluids
Sequelae: chronic HCV infection, hepatocellular carcinoma
No vaccine
No PEP
Acute disease: Anti-HCV, HCV viral RNA, elevated liver enzymes
Chronic disease: Anti-HCV, HCV viral RNA, no symptoms, Normal or slightly elevated liver enzymes
Past infection: Anti-HCV, HCV RNA absent, normal hepatic enzymes

60
Q

Hepatitis B

Exposure Treatment

A

PEP: HBIG and HBV vaccine

61
Q

Hepatitis A Exposure Treatment

A

HAV IgG within 2 weeks

Spring 2022 (14 decks)

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