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Spring 2022 > Liver Function/Hepatitis > Flashcards

Liver Function/Hepatitis Flashcards

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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
What are the cholestatic markers?
ALP - Not liver specific - Seen in bone, intestine, lung, placenta Bilirubin
26
What are the GGT, 5-Nucleotidase, and LAP relationships to ALP in liver etiology?
Parallels
27
What can cause isolated increases in indirect bilirubin?
Indirect unconjugated bilirubin is a byproduct of normal RBC breakdown Not excreted in urine Not liver disease Hemolysis or Gilbert's syndrome
28
What can cause increases in direct conjugated bilirubin?
Direct bilirubin is water soluble, can be excreted in urine | Increases seen in cholestasis
29
How to distinguish etiology in patients who present with both hepatocellular and cholestatic abnormalities? AST, ALT elevations LAP, ALP, GGT, 5-N
One usually predominates to guide diagnosis
30
What does NAFL stand for?
Non-alcoholic fatty liver
31
What does NASH stand for?
Non-alcoholic steatohepatitis
32
What are the complications of NASH?
Steatosis and inflammation which can lead to cirrhosis, liver failure, and cancer
33
When do you workup NAFL?
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
How is heavy alcohol use defined?
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
NAFLD and Alcohol considerations
Should not consume heavy amounts of alcohol | No recommendation for non-heavy consumption
36
NAFLD Management
``` 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
Medications and NASH in NAFLD
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
What do IgM and IgG elevations in hepatitis signify in relation to chronicity?
IgM first response, acute IgG response later, subacute or chronic
39
Acute Hepatitis A | Diagnostics
IgM anti-HAV | IgM Antibody to HAV
40
HepA Previous exposure & Immunity Diagnostics
Total Anti-HAV | Total antibody to HAV
41
HepB Diagnostic Components
``` 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
What does +HBsAg signify?
Acute antigen infection or chronic infection
43
What does +HBeAg signify?
Acute active infection | Highly infectious
44
What does +IgM HBcAb signify?
Acute infection
45
What does +HBsAb signify?
Previous exposure | Permanent immunity
46
What does +HBeAb signify?
Acute infection resolution
47
HepC Diagnostics
Anti-HCV | ELISA, PCR
48
HepD Diagnostics
HDAg - early infection | Anti-HDV - later infection
49
HepE Diagnostics
IgG and IgM antibodies | in progress
50
When do HepG infections occur?
Only seen with concurrent HepB or HepC infections, never alone
51
Interpret HBsAg - neg HBcAb - neg HBsAb - neg
Susceptible to HBV
52
Interpret HBsAg - neg HBcAb - pos HBsAb - pos
Immune due to natural HBV infection HBcAb as indicator for infection vs vaccine
53
Interpret HBsAg - neg HBcAb - neg HBsAb - pos
Immune due to HBV vaccine
54
``` Interpret HBsAg - pos HBcAb - pos HBcAb IgM - pos HBsAb - neg ```
Acute HBV infection IgM acute, early infection indicator
55
``` Interpret HBsAg - pos HBcAb - pos HBcAb IgM - neg HBsAb - neg ```
Chronic HBV infection Indicator for chronic infection is positive HBsAg and HBcAb with IgM negative
56
Interpret HBsAg - neg HBcAb - pos HBsAb - neg
``` May be: Resolved infection (most common) False-positive HBcAb, thus susceptible Low level chronic infection Resolving acute infection ```
57
Hepatitis A | Overview
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
Hepatitis B | Overview
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
Hepatitis C | Overview
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
Hepatitis B | Exposure Treatment
PEP: HBIG and HBV vaccine
61
Hepatitis A Exposure Treatment
HAV IgG within 2 weeks

Spring 2022 (14 decks)

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