Mehlman: NASH, Alcoholic hepat, paracetmol, other drugs 11-15 (2)

Question 1

NASH. what case in usmle?

Answer 1

overweight patient with normal labs or can be mild transaminitis.

tipo 50 proc normal
50 proc mild transaminitis

tipo the condition starts with normal labs then progresses to mild transaminitis.

Question 2

NASH. underrated diagnosis.
It’s assumed most overweight people have some degree of fatty liver.

Answer 2

.

Question 3

NASH. what other presentation of patient?

Answer 3

metabolic syndrome : incr. BMI and Incr. lipids

Question 4

NASH. Tx? 2

Answer 4

exercise (eg treadmill)
normal diet (sto eat stupid junk food).

Question 5

Alcohol. what labs? classically AST>ALT

Answer 5

tipo sako kad ratio 2:1, bet nebutinai.
NBME gali but tik mild transaminitis, eg. both AST and ALT are <100, but ast slightly higher than ALT.

tipo normal skaitosi <50U/l

Question 6

Alcohol. whan seen on biopsy? cia cj step1.

Answer 6

USMLE wants you to know mallory hyaline is seen on biopsy.

Question 7

Acetaminophen (M). This overdose is most important for USMLE.
antidote?

Answer 7

N-acetylcysteine is antidote.

Question 8

Acetaminophen (M). breakdown of it produces what?

Answer 8

Breakdown of acetaminophen produces metabolite called NAPQI that depletes reduced glutathione. The latter normally mops up free radicals / prevents oxidation.

Question 9

Acetaminophen (M). how long will be asymptomatic?

Answer 9

asymptomatic for 24-48h

Question 10

Acetaminophen (M). what starts/detected after asymptomatic period?

Answer 10

then will proceed to get ALT and AST in the tens of thousands + require liver transplant or death.

Question 11

Acetaminophen (M).
N-acetylcysteine regenerates reduced glutathione.!!!!!

Oxidized glutathione had disulfide bond (-S—S-); reduced glutathione has thiol (-SH).

Answer 11

.

Question 12

Acetaminophen (M). what do immediately once patient with OD present (acutely after administration of this drug)?

Answer 12

administer activated charcoal

Question 13

Other drugs (M). what 6 most important that cause mild transaminitis?

Answer 13

Statins and fibrates, methotrexate, lithium, valproic acid, propylthiouracil.

Question 14

Other drugs (M). eg use one of these 6 drugs –> mild transaminitis –> what to do with dose?

Answer 14

ANSWER IS: You do not need to decrease dose.

Question 15

Other drugs (M). For statins, myopathy is more common than toxic hepatitis (on NBME).

Answer 15

.