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Pathophys > Liver lecture 2 > Flashcards

Liver lecture 2 Flashcards

1
Q

what is hepatitis? what can it be due to?

A

acute or chronic inflammation of the liver due to virus, alcoholism, drug toxicities (Tylenol), and autoimmune

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2
Q

what elevated lab values signal the presence of hepatocyte damage?

A

LFTs (AST/ALT)

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3
Q

what are three lab tests of liver function?

A

albumin, bilirubin, PT/INR

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4
Q

what does disease of the biliary drainage system cause?

A

it obstructs the flow of bile and interferes with the elimination of bile salts and bilirubin (produces cholestatic liver damage bc of bile backup into liver)

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5
Q

what does disease of the hepatocytes cause?

A

disorders of carb, protein, fat metabolism; causes disorders of metabolism and removal of drugs, hormones, toxins. ammonia, and bili

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6
Q

what do elevations in bili and alk phos levels a sign of?

A

signal the presence of cholestatic liver damage

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7
Q

what is acute hepatitis? what viruses cause it?

A

disease duration of less than 6 months; all five virus forms can cause it

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8
Q

what is chronic hepatitis? what virus types can cause it?

A

disease duration greater than 6 months; only B C and D can cause chronic hep

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9
Q

what two things do hep viruses B, C, and D have the potential to cause? what is the main tx for these viruses?

A

cirrhosis and hepatocellular carcinoma; tx = liver transplant

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10
Q

is chronic hepatitis symptomatic?

A

not always (depends on the patient)

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11
Q

what are the three phases of acute symptomatic viral hepatitis?

A

1) . prodromal “pre-jaundice”
2) . icterus
3) . convalescent

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12
Q

what is the prodromal/pre-jaundice phase of acute viral hep characterized by?

A

abrupt to insidious onset

general malaise, myalgia, arthralgia, fatigue (overall vague symptoms, sounds like flu)

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13
Q

what is the icterus phase of acute viral hep characterized by?

A

follows phase #1 by 5-10 days; jaundice, pruritis (bile salts cause irritation), liver pain

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14
Q

what is the convalescent phase of acute viral hep characterized by?

A

increased sense of well being, return of appetite, jaundice resolves

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15
Q

what is the largest group of chronic HBV infected patients?

A

inactive carriers

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16
Q

what three hep viruses can have a carrier state?

A

HBV, HCV, and HDV (pt doesn’t have symptoms but can transmit the disease)

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17
Q

what % of inactive hep B carriers undergo spontaneous reactivation of Hep B?

A

20-30%

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18
Q

how is Hep A and E transmitted?

A

fecal-oral

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19
Q

how is hep b, c and d transmitted? (4)

A

blood transfusion, needle sticks, sexual, across the placenta

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20
Q

what disease can hep A cause? what are symptoms of that disease?

A

acute viral hepatitis: fever, jaundice, and painful enlarged liver

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21
Q

what are four clinical courses of hep B?

A

acute viral hep, fulminant hep, chronic hep (10%), coinfection/superinfection with hep delta virus

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22
Q

what is fulminant hepatitis?

A

severe acute hepatitis with rapid destruction of the liver

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23
Q

what are two main complications of hep B?

A

primary hepatocellular carcinoma and cirrhosis

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24
Q

what % of people with hep A will develop fulminant hepatitis?

A

1%

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25
Q

what two types of hepatitis are more likely found in a person who traveled to a less developed country?

A

A and E

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26
Q

what are some common risk factors for acquiring Hep c? (4)

A

sexual contact w infected person, recipients of blood products, IV drug users, infected needles (healthcare workers or tattoos/piercings)

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27
Q

what are some risk factors for acquiring Hep B & D? (6)

A

men having sex with other men, multiple partners, IV drug users, healthcare providers in contact w infected needles, blood product recipients, pts undergoing dialysis

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28
Q

what is incubation period for Hep A? what three places can the virus live? what age people may be asymptomatic and spread disease more?

A

4 weeks; seawater, freshwater, and soil; young children less than 6

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29
Q

presentation of Hep A? how long does it usually last?

A

fever, malaise, nausea, anorexia, abd pain, dark urine, jaundice; about 2 months

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30
Q

what are lab manifestations of Hep A? (3)

A

resembles hepatocellular inflammation; increased AST/ALT ratio (usually 1-1 ratio); if bilirubin is over 2 pt will have jaundice

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31
Q

what is hepatitis without jaundice called?

A

non-icteric hepatitis

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32
Q

how long does it take for Hep A to resolve?

A

2 months (0.1% fatality rate)

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33
Q

what is tx for Hep A?

A

supportive care

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34
Q

what is the vaccine series for Hep A? what age is it recommended to vaccine?

A

2 shots, 6 months apart; recommended for all children at 1 yr

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35
Q

what type of person has a sicker/more difficult course of Hep A?

A

pregnant women

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36
Q

what are the three most prevalent modes of Hep B spread?

A

IV drug use, people with multiple partners, and perinatal (infants born of HBV positive mothers)

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37
Q

what is the incubation period of hep b?

A

4-10 weeks

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38
Q

what is the first serology marker that appears for Hep B? what does this mean? what does it not distinguish?

A

Hep B surface antigen (HBsAg); patient is infectious and has active disease; doesn’t distinguish between acute vs chronic

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39
Q

what is HBeAg? what does it indicate?

A

pre core envelope antigen for Hep B; indicates active viral replication (VERY infected)

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40
Q

what is the first antibody to Hep B to show up on serology? what is IgM and IgG to anti-HBc mean?

A

anti-HBc (antibody to hep B core antigen); IgM to antiHBc is a marker of acute disease; IgG to HBc is marker of prior infection

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41
Q

what is anti-HBs a marker of?

A

antibody to hep B surface antigen is a marker of prior vaccination or resolution of the infection (no longer ACTIVE infection or infectious to others)

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42
Q

presence of what in the serum is the most reliable indicator of hep B infection ?

A

viral DNA (HBV DNA); even seen in chronic disease

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43
Q

what is the serologic gap or window period for Hep B?

A

HBsAg is no longer present, but anti-HBs is not present either. The patient is infectious. This period of time is detected by the presence of IgM anti-HBc (this antibody is a marker of acute disease, but does not confer immunity like anti-HBs).

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44
Q

What is tested in blood donors to prevent transfusion of infectious blood during the patient’s serologic window?

A

IgM antiHBc

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45
Q

what are the lab findings for Hep B? what if the pt is jaundiced?

A

inc ALT and AST; if jaundiced will have increased total bilirubin

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46
Q

what % of Hep b cases have acute fatality rate? what type of Hep can hep B lead to? what % of people develop this type of hepatitis?

A

1%; can lead to chronic hepatitis (2-10%), which then can lead to cirrhosis

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47
Q

cirrhosis secondary to HBV is a risk factor for what?

A

hepatocellular carcinoma

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48
Q

what % of infants born from HBV infected mothers develop Hep B if not treated with vaccine/immunoglobulin within 12 hrs of birth?

A

10-85% (variation due to misdiagnosis of mother or mother didn’t do tx)

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49
Q

Hep B prognosis is related to what 4 things?

A

albumin, PT/INR (unresponsive to vitamin K), bilirubin elevation (prognostic marker for severity of disease), physical findings of ascites and hepatic encephalopathy (liver cant convert ammonia to urea)

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50
Q

what is albumin a measure of?

A

synthetic function of the liver

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51
Q

what is Hep B tx for acute and chronic courses?

A

acute- supportive (rest & hydration)

chronic- interferons or antivirals (-vir drugs)

52
Q

what are the two HBIg (hep b immuneglobulin) prevention guidelines?

A

within 12 hrs of infant birth if mother was HBV positive and for healthcare worker exposed to infected pts’s blood/bodily fluids within 24 hrs

53
Q

what does the Hep B vaccine contain?

A

HBsAg (recombinant hep B surface antigen)

54
Q

what hep virus is the most common cause of chronic hepatitis?

A

C

55
Q

what is the incubation period of hep c? what is the major mode of transmission?

A

6-12 weeks; IV drug abuse (less frequent sexual transmission/perinatal)

56
Q

what are some elevated lab findings of Hep C?

A

mildly elevated AST and ALT

57
Q

what Hep C serology test is the most accurate for infection? what about marker of disease?

A

HCV RNA- infection

Anti-HCV antibody- marker for disease (not sign of immunity)

58
Q

describe clinical course of Hep C: symptoms, infection type, has potential to develop what things?

A

nonspecific symptoms; typically becomes chronic in 75-80% of people; can develop cirrhosis, end stage liver disease, hepatocellular carcinoma

59
Q

tx for Hep c

A

interferons, nucleotide analog (ribavirin), and/or DAAs (direct acting antiviral agents)

60
Q

what are prevention methods for hep c?

A

no vaccine, immunoglobulin not helpful post exposure

61
Q

what two things must a Hep D patient already have to be classified as having Hep D?

A

pt needs to already be infected with HBV and be positive for HbsAg

62
Q

is serology helpful in diagnosing Hep D?

A

no because titers of IgM and IgG anti-HDV are present only sometimes

63
Q

how does Hep D impact the severity of Hep B infection?

A

it increases Hep B severity and increases the risk of developing chronic hep from hep B infection

64
Q

what is the tx for Hep D?

A

PEGylated interferon alpha is only effective drug

65
Q

what is the prevention for Hep D?

A

vaccination for HBV

66
Q

why is there a high mortality rate in pregnant pts for Hep E?

A

20% mortality rate is due to developing fulminant hepatitis (worse than Hep A)

67
Q

what is autoimmune hepatitis? what two things can it be due to? what population is it most commonly found in? Is it symptomatic?

A

its immune mediated liver disease; due to genetics (HLA that encodes histocompatibility complexes) and/or environmental factors (drugs, prior viruses); most common in young women; may or may not be symptomatic

68
Q

what are the two types of autoimmune hepatitis?

A

type 1 and type 2

69
Q

what type of autoimmune hepatitis is most common? does it have high or low levels of antinuclear antibodies? how about anti-smooth muscle antibodies?

A

most common is type 1; high levels of both antibodies

70
Q

what aged kids get type 2 autoimmune hepatitis? what two things do these kids have positive antibodies to?

A

2-14 yrs old; positive antibodies to liver/kidney microsomes and liver cytosol

71
Q

what lab values do you look for in autoimmune hepatitis?

A

elevated ALT, AST, ALP; neg serology for viral hepatitis; look for positive antibodies specific to each type; hypergammaglobulinemia (inc immunoglobulin in blood serum)

72
Q

what is the tx for autoimmune hepatitis?

A

PREDNISONE, immunosuppressants, transplant

73
Q

what is a fibrotic liver?

A

continuous inflammation of liver caused by Hep B, which leads to fibrosis (formation of scar tissue within the liver)

74
Q

what is a cirrhotic liver?

A

scar tissue replaces normal, healthy tissue & blocks blood flow through the liver & prevents the liver from working normally

75
Q

what is acute fulminant hepatitis? what type of people does this occur in?

A

hepatic failure that progress from hepatitis to hepatic encephalopathy within 2-3 weeks; in persons who don’t have chronic liver disease(considered worst sequalae of acute liver injury)

76
Q

what is the most common cause of acute fulminant hepatitis?

A

acetaminophen toxicity (45%)

77
Q

what is tx for acute fulminant hep?

A

correct underlying issue, supportive tx, and liver transplant

78
Q

what is the mortality rate for acute fulminant hep?

A

85% in people without transplant and 35% with one

79
Q

what are presentation signs of acute fulminant hep?

A

GI symptoms, inflammatory response, hemorrhagic signs, may/may not jaundice, labs reveal hepatocellular damage, elevated NH3

80
Q

what is primary biliary cirrhosis (cholangitis)? what population does it usually occur in? what does the immune system destroy?

A

its a immune mediated cholestatic liver disease; middle aged women; immune destruction of intrahepatic small bile ducts (inflammation and scar tissue is in ducts)

81
Q

describe the progression of primary biliary cirrhosis? what are the three lab findings?

A

slow progression, symptoms of pruritus, fatigue which leads to cirrhosis and liver failure; elevated alk phos, inc cholesterol, and 90% positive for antimitochondrial antibodies

82
Q

what is tx for primary biliary cirrhosis?

A

symptomatic, ursodiol (inc bile flow and dec toxicity of bile contents); transplant is definitive tx (& disease DOESNT recur after)

83
Q

what is secondary biliary cirrhosis? what are the two most common causes? what is tx?

A

cirrhosis that results from prolonged obstruction of extrabiliary tree; cholelithiasis or tumor; surgery to relieve obstruction

84
Q

what is primary sclerosing cholangitis? what population does it affect? what disease it is usually associated with?

A

disease of large bile ducts causing scars within the ducts, leads to liver damage; most often affects men; often associated with inflammatory bowel disease, UC

85
Q

what is two lab values will be elevated in primary sclerosing cholangitis? what is most effective tx?

A

will present with obstructive labs (elevated direct bili and AP); transplant

86
Q

what is the leading cause of acute liver failure in US?

A

drug induced liver disease (Tylenol)

87
Q

what does drug induced liver disease cause?

A

hepatocyte injury or death OR injuring biliary drainage structures

88
Q

what labs are elevated in drug induced liver dz? how is prognosis when jaundice is present? what is tx?

A

ALT, AST, bili mildly elevated alk phos; poor prognosis w jaundice; tx is remove offending agent from system (activated charcoal first and then mucomyst)

89
Q

what is the max dose of acetaminophen per 24 hours?

A

4000 mg but recommended telling pts 3000 mg (usually takes about 10,000 mg to overdose)

90
Q

what is the first enzyme to be elevated in alcoholic liver disease?

A

GGT

91
Q

for alcohol induced liver disease, what are the three stages of progression?

A

fatty liver disease, alcoholic hepatitis, then alcoholic cirrhosis

92
Q

what is fatty liver disease? describe reversibility

A

fat in the hepatocytes; reversible once ETOH is stopped

93
Q

what two things occur during alcoholic hep? how is the AST/ALT ratio? how are liver enzymes impacted? what symptoms are present

A

hepatic inflammation and necrosis; 2-1 ratio; inc liver enzymes; jaundice, ascites, anorexia, fever

94
Q

what is alcoholic cirrhosis?

A

nodules compress hepatic veins causing portal HTN, extrahepatic shunts, and cholestasis (can get bleeding esophageal varices here)

95
Q

what is nonalcoholic fatty liver disease (NAFLD)? what is it often associated with? what are the three stages in the spectrum of dz?

A

spectrum of liver disease that resembles alcoholic liver disease but in people who don’t abuse alcohol; lipid accumulation in hepatocytes; fatty liver (steatosis), non-alcoholic steatohepatitis, cirrhosis

96
Q

describe AST/ALT ratio in NAFLD.. what is prevention for it? tx is what?

A

normal 1:1 ratio; prevention is weight loss, exercise, and avoid ETOH; liver transplant if behavioral changes don’t improve

97
Q

what does cirrhosis cause?

A

portal HTN, liver failure, inc bleeding risk, thrombocytopenia, gynecomastia, encephalopathy

98
Q

what is Wilson’s disease?

A

recessive genetic disorder where copper accumulates in tissues (leads to neurological/psych symptoms and liver disease); need meds that reduce copper absorption or transplant

99
Q

describe pH and H/H levels for cirrhosis

A

pH- decrease

H/H- decreased (leads to anemia)

100
Q

what is portal HTN? what five things can it cause?

A

inc resistance to flow in portal venous system and inc pressure (>10mmg); ascites, caput medusae, congestive splenomegaly, encephalopathy, formation of shunts with bleeding from esophageal varices

101
Q

what are prehepatic, intrahepatic, and posthepatic causes of portal HTN?

A

prehepatic- obstructive thrombosis, massive splenomegaly
intrahepatic- cirrhosis
posthepatic- right sided heart failure and hepatic vein outflow obstruction

102
Q

what is tx for portal HTN?

A

BB’s, tx varices, Na+ restriction

103
Q

what is ascites? what volume is it noticeable at? whats it most often caused by?

A

increased fluid in the peritoneal cavity (>25cc); noticeable at 500 ml; portal HTN

104
Q

what is Tx for ascites?

A

Na+/water restriction, diuretic therapy, spironolactone, give K+ to prevent hypokalemia, paracentesis, consider TIPS for refractory ascites

105
Q

what is TIPS?

A

tract created within the liver which connects the hepatic and portal veins (keeps it open with a stent)

106
Q

what formula do you use to determine where the ascites is coming from?

A

SAAG (serum albumin ascites gradient) = albumin concentration of serum- albumin concentration of ascetic fluid

107
Q

explain what a high SAAG result means? what about a low gradient?

A

high gradient (>1.1) means ascites is due to portal HTN w 97% accuracy; low is worse (can be caused by pancreatitis, kidney failure, bowel obstruction, malignancy)

108
Q

what is budd chaiari syndrome? what is it a sign of?

A

blood clot occlusion of the hepatic veins that drain the liver; sign of portal HTN

109
Q

what is spontaneous bacterial peritonitis? what % of cirrhotic pts w ascites does it occur in? hows the mortality rate?

A

bacterial infection of ascetic fluid without any intrabdominal source of infection; 10-20%; high mortality rate

110
Q

what are some symptoms besides cirrhotic pt with ascites for SBP?

A

fever, abd pain, change in clinical status

111
Q

what is dx for SBP?

A

paracentesis with >250 neutrophils and protein concentration 1 g/dl or less

112
Q

what is tx for SBP?

A

based on peritoneal neutrophil count (NOT culture results); ABX: cefotaxime 2 g every 8 hrs

113
Q

how do you get splenomegaly from portal HTN? what three things does this cause?

A

portal HTN shunts blood into the splenic vein; causes dec life span of blood elements (anemia, thrombocytopenia, leukopenia)

114
Q

what is the primary prevention strategy of bleeding esophageal varices or secondary prevention of rebleeding? how about surgical tx?

A

nonselective BB (propranolol); cauterize varices

115
Q

what is a significant cause of mortality in cirrhotic pts with portal HTN?

A

esophageal varices

116
Q

what percent loss of liver function classifies liver failure? what is tx of failure?

A

80-90%; correct fluid/electrolyte imbalances, dec ammonia production by controlling protein intake, eliminate alcohol, provide nutrition, transplant

117
Q

what is hepatic encephalopathy? what is often elevated in this disease?

A

CNS disturbance from liver failure; elevated serum ammonia due to inability to convert to urea

118
Q

what is tx of hepatic encephalopathy?

A

protein restriction (protein breakdown leads to ammonia), lactulose which dec ammonia absorption, rifaximin (ABX that dec intestinal load of ammonia producing bacteria)

119
Q

what is the MELD score?

A

reliable measure of mortality risk in pts with end stage liver disease; assesses disease severity to prioritize liver transplant allocation (higher the number, the higher the mortality)

120
Q

what are the two types of liver cancer?

A

hepatocellular and cholangiocarcinoma

121
Q

what two things confirm diagnosis of hepatocellular cancer?

A

biopsy and 90% increase in serum alpha-fetoprotein

122
Q

where is hepatocellular cancer located? what disease is it usually associated with?

A

hepatocytes; associated with chronic liver disease (chronic viral hep B, C, D, alcoholism, or cirrhosis)

123
Q

what is tx of hepatocellular cancer?

A

surgery (hepatectomy), chemo and radiation are palliative (7% 5 yr survival rate)

124
Q

what is cholangiocarcinoma? what causes it? what is more common than primary liver carcinoma?

A

carcinoma of the bile ducts; its jaundice related to long standing inflammation and injury in bile duct epithelium; metastatic tumors to the liver from other cancers are most common

125
Q

what is the earliest lab finding for cholangiocarcinoma? what is diagnostic confirmation?

A

inc AP; liver biopsy

126
Q

what lab value is elevated in cholestasis?

A

alk phos

Pathophys (13 decks)

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