Liver Issues Flashcards

1
Q

liver diseases associated with pregnancy

A

*hyperemesis gravidarum
*intrahepatic cholestasis of pregnancy (ICP)
*preeclampsia
*acute fatty liver of pregnancy (AFLP)
*HELLP syndrome

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2
Q

normal effects of pregnancy on LFTs

A

*serum alkaline phosphate INCREASES (due to placental production)
*GGT should be normal
*AST and ALT should be NORMAL
*serum albumin DECREASES due to hemodilution
*spider angiomata and palmar erythema can occur in the absence of liver disease due to estrogen excess

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3
Q

hyperemesis gravidarum

A

*intractable vomiting in the first trimester:
-loss of 5% of body weight, ketonuria, severe enough to require IV hydration

*abnormal LFTs in up to 50% of patients (elevated ALT and AST up to 100, occasional jaundice)

*tx: supportive care

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4
Q

intrahepatic cholestasis of pregnancy - overview

A

*cardinal sx = PRURITUS
-due to elevated bile acid levels
-affects all parts of the body, but itching of palms & soles predominate
*jaundice & elevated AST and ALT

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5
Q

intrahepatic cholestasis of pregnancy - risk to fetus

A

*main risk in ICP is to the fetus
*fetal distress, occurs in 20-40%
*fetal complications include placental insufficiency, premature labor, sudden fetal death

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6
Q

intrahepatic cholestasis of pregnancy - treatment

A

*UDCA (ursodeoxycholic acid)

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7
Q

preeclampsia

A

*new onset during pregnancy of:
-HTN
-proteinuria

*liver involvement in preeclampsia is unusual but signifies severity and need for immediate delivery

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8
Q

HELLP syndrome - acronym

A

*H - hemolysis (LDH > 600)
*E and L - elevated liver enzymes (ALT and AST of 70-6000)
*L and P - low platelets (platelets < 150K)

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9
Q

HELLP syndrome - pathophysiology

A

*pathophysiology is related to endothelial injury and intravascular fibrin deposition, resulting in hepatic hemorrhage and necrosis

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10
Q

HELLP syndrome - clinical presentation

A

*typically presents in the 3rd trimester
*most common presenting sx:
-epigastric & RUQ abdominal pain
-nausea, vomiting, headache, malaise
-usually occurs in the setting of preeclampsia

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11
Q

HELLP syndrome - treatment

A

*immediate delivery (most require a C-section)

*complications if not treated: DIC, abruptio placenta, eclampsia, perinatal mortality

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12
Q

acute fatty liver of pregnancy - pathophysiology

A

*microvesicular fatty infiltration of the liver
*due to abnormal fatty acid oxidation in the mitochondria of the hepatocytes (LCHAD complex)

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13
Q

acute fatty liver of pregnancy - clinical presentation

A

*sudden onset in the 3rd trimester
*sx: anorexia, nausea, vomiting, RUQ pain, headache
*exam: HTN, jaundice, edema, ascites, encephalopathy
*lab: ALT-AST 300-1000, bilirubin < 5
*histologic dx, but liver biopsy usually not necessary

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14
Q

acute fatty liver of pregnancy - treatment

A

*immediate delivery (C-section)
*maternal mortality and fetal mortality significant
*25% chance of recurrence in subsequent pregnancies

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15
Q

vascular diseases of the liver

A

*ischemic hepatitis
*portal vein thrombosis
*congestive hepatopathy
*Budd-Chiari syndrome
*sinusoidal obstruction syndrome

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16
Q

ischemic hepatitis

A

*the dual blood supply (hepatic artery, portal vein) prevents isolated vascular lesions (thrombosis, embolism) from resulting in hepatic infarction
*ischemic hepatitis is almost always associated with profound systemic hypotension, resulting in decreased hepatic artery and portal vein flow
*characterized by a rapid rise in AST and ALT to > 1000, with rapid return to normal

17
Q

portal vein thrombosis - causes

A

*CIRRHOSIS (related to sluggish portal vein flow)
*hypercoagulable states
*oral contraceptive use
*hepatocellular carcinoma
*intraabdominal infection or inflammation (IBD, pancreatitis)

18
Q

acute vs. chronic portal vein thrombosis

A

*acute: abdominal pain, fever (RARE)
*chronic: cavernous transformation of the portal vein

19
Q

portal vein thrombosis - clinical manifestations

A

*most often subclinical, discovered accidentally on imaging
*esophageal variceal hemorrhage
*ascites (rarely)
*propagation of clot into the SMV, resulting in bowel infarct

20
Q

portal vein thrombosis - management

A

*evaluate for underlying etiology
*screen for esophageal varices
*consider anticoagulation for acute PVT

21
Q

congestive hepatopathy

A

*classically seen with chronic heart failure (R-sided failure “cor pulmonale”)
*often asymptomatic with minor LFT abnormalities
*increased unconjugated bilirubin, increased ALT and AST < 2x upper limit of normal, increased INR
*can present with RUQ pain, jaundice, ascites
*on exam:
-hepatomegaly
-jugular venous distension
-hepatojugular reflex
-pulsatile liver with tricuspid regurgitation

22
Q

Budd-Chiari syndrome - overview

A

*occlusion of the major HEPATIC VEINS (carry blood from liver to heart), most often thrombosis
*underlying etiologies include: hypercoagulable states, oral contraceptive use

23
Q

Budd-Chiari syndrome - diagnosis

A

*presentation: abdominal pain, hepatomegaly, ascites
*LFT abnormalities
*ultrasound with doppler evaluation of hepatic veins

24
Q

Budd-Chiari syndrome - management

A

*anticoagulation, thrombolytics
*interventional radiology
*angioplasty, stents
*TIPS
*liver transplant?

25
sinusoidal obstructive syndrome (SOS)
*seen almost exclusively FOLLOWING BONE MARROW TRANSPLANTATION *presentation: RUQ pain, jaundice, hepatomegaly, ascites, edema, weight gain *increased bilirubin, increased AST + ALT, increased INR
26
benign lesions of the liver
*liver cyst *cavernous hemangioma *focal nodular hyperplasia *hepatic adenoma *hepatic abscess
27
liver cyst
*benign lesion of the liver *usually discovered incidentally with abdominal imaging *most are solitary and < 5 cm in size *no clinical significance, except to distinguish from cystic neoplasms
28
cavernous hemangioma
*benign lesion of the liver *most common tumor of the liver *most are solitary and < 5 cm in size *usually discovered incidentally with abdominal imaging *of no clinical significance, except avoid biopsy and distinguish from malignant neoplasms
29
focal nodular hyperplasia
*not a true neoplasm *seen most often in women (8:1) *most are solitary and < 5 cm in size *usually discovered incidentally with abdominal imaging *of no clinical significance, except avoid biopsy and distinguish from malignant neoplasms
30
hepatic adenoma
*uncommon benign tumor of the liver seen in young women, characterized by plates of normal-appearing hepatocytes, without the typical architecture of a liver lobule *STRONGLY ASSOCIATED WITH ORAL CONTRACEPTIVES *can enlarge under influence of estrogen (OCP or pregnancy); can regress with d/c of OCPs *can undergo malignant transformation *dx based on imaging *tx: stop estrogens; consider surgical resection
31
hepatic abscess
*2 major categories: pyogenic & parasitic *pyogenic result from hematogenous, biliary, or penetrating traumatic introduction of bacteria (untreated appendicitis or diverticulitis); now commonly seen with biliary disease *parasitic in immigrants; usually amebic or echinococcal infection *presentation: RUQ pain, fever *tx: antimicrobials, drainage of abscess
32
malignant lesions of the liver
*hepatocellular carcinoma (HCC) *cholangiocarcinoma *metastatic cancer - most common cancer of liver
33
risk factors for hepatocellular carcinoma (HCC)
*cirrhosis of any etiology: -cirrhosis due to HBV, HCV the highest risks -cirrhosis due to alcohol, PBC, and hereditary hemochromatosis *hepatitis B carriers without cirrhosis
34
guidelines for hepatocellular carcinoma (HCC)
*patients with risk factors should be entered into surveillance program: -ultrasound & alpha-fetoprotein screening at 6 month intervals
35
hepatocellular carcinoma (HCC) - diagnosis
*almost always based on imaging; rarely biopsied
36
hepatocellular carcinoma (HCC) - treatment
*surgical resection *radiofrequency ablation *liver transplantation