NASH-Jenkins

Question 1

How can alcohol lead to cirrhosis?

Answer 1

alcohol–> fatty liver (inc fat deposition in hepatocytes because inc in FFA) –> alcoholic hepatitis (inflammation)–> cirrhosis

Question 2

***True or False: Alcohol is the most common cause of elevated AST/ALT

Answer 2

FALSE!

Question 3

What is alcoholic hepatitis? What are the pathologic criteria?

Answer 3

-inflammation of the liver parenchyma (progression from fatty liver)

criteria:

• Mallory bodies**
• liver necrosis
• infiltration by neutrophils
• perivenular distribution of inflammation***

Question 4

***What are the AST and ALT findings in alcoholic hepatitis?

Answer 4

AST:ALT 2:1 (or just AST> ALT)

Question 5

What is alcoholic cirrhosis?

Answer 5

Fibrosis of liver parenchyma (scar tissue) due to inflammation (hepatitis) which was due to fatty liver

Question 6

Which imaging tools can be used to diagnose fatty change and cirrhosis?

Answer 6

-ultrasound, *CT and MRI can be used

Question 7

What is the treatment for alcoholic liver disease?

Answer 7

• Abstinence from alcohol
• Nutritional support

For Cirrhosis pts: prevention and management of ascites, spontaneous bacterial peritonitis, variceal bleeding, encephalopathy, malnutrition, and HCC

Question 8

***What is the number one cause of AST and ALT elevation?

Answer 8

Non-alcoholic fatty liver disease (NAFLD)

–> NASH in particular***

Question 9

What is morbid obesity?

Answer 9

patients who are 50-100% or 100 pounds above their ideal body weight

BMI > 39

Question 10

What is NAFLD?

Answer 10

group of conditions where there is accumulation of excess fat in the liver of people who drink little or no alcohol

simple hepatic steatosis (simple fatty liver) –> NASH (non alcoholic steatohepatitis) –> cirrhosis (cryptogenic)

Question 11

***Can diabetes, obesity, metabolic syndrome and high cholesterol cause cirrhosis?

Answer 11

YES!

NAFLD!!

Question 12

What percentage of NASH pts get cirrhosis?

Answer 12

20%

Question 13

What is the most common liver disorder in Western industrialized countries?

Answer 13

NAFLD!

Question 14

How is NAFLD diagnosed?

Answer 14

-Elevated liver enzymes on routine labs.
-Liver ultrasounds or abdominal CT showing steatosis
-Blood serology to r/o viral hepatitis (Hep A, B, C, EBV, CMV, herpes)
Inquire about alcohol intake/history.
-ferritin and ANA to r/o hematochomatosis or autoimmune hepatitis
-History of metabolic syndrome risk factors.
-Liver biopsy if suspect inflammation and fibrosis (NASH)

Question 15

***If a pt is obese and a diabetic with no elevation of AST and ALT, what is the diagnosis?

What about elevated AST and ALT?

Answer 15

• no abnormal liver enzymes=NAFLD

- Abnormal liver enzymes –> NASH*

Question 16

What is the treatment for NAFLD?

Answer 16

-no medication to reverse it

modification of risk factors:

• weight loss and physical activity
• insulin sensitizers medication and other hypoglycemic meds
• lipid lowering meds
• antioxidants and anti-inflammatories

Question 17

What is hereditary hemochromatosis?

Answer 17

• Autosomal Recessive disease of iron absorption

- Abnormal accumulation of iron in parenchymal organs, leading to organ toxicity.

Question 18

***What is the best screening tool for hemochromatosis? Definitive diagnostic tool?

Answer 18

• Screen: ferritin level (high) (if you found that AST and ALT were elevated)
• Diagnosis: genetic testing for HFE 2 (juvenile hemochromatosis) or HFE 3 (adult form)

Question 19

What are the typical signs and symptoms of hemochromatosis?

Answer 19

• 75% asymptomatic initially
• mild elevation of AST and ALT
• Elevated serum iron and ferritin
• symptoms: *skin bronzing/hyperpigmentation, fatigue, impotence, arthralgia, DM, cardiomyopathy

Question 20

Who should be screened for hemochromatosis?

Answer 20

First-degree relatives of hemochromatosis

Question 21

***What is the treatment for hemochromatosis?

Answer 21

• *phlebotomy to get rid of excess iron (weekly at first and then every 2-4 months to maintain)
• iron chelation therapy
• low iron diet
• *surgery when end-stage liver disease progresses despite the iron reduction

Question 22

***True or False: Hemochromatosis is a rare disease

Answer 22

FALSE!

most common autosomal recessive disorder and most common inherited liver disease in white people