non-viral hepatitis Flashcards
what is NAFLD ?
non-alcoholic fatty liver disease
what are the requirements for defining NAFLD ?
- evidence of hepatic steatosis either by imaging or histology
along with lack of secondary causes of hepatic fat accumulation
- lack of secondary cause of hepatic fat accumulation such as significant alcohol consumption
what is defined as significant alcohol consumption ?
> 21 drinks for men per week
>14 drinks for women per week
what is the difference between NASH and NAFLD ?
NASH - non alcoholic steato-hepatitis where there is inflammation around the fatty tissue
NAFLD - no inflammation
what are the commonly associated abnormalities with NASH?
insulin resistance metabolic syndrome T2DM obesity dyslipidemia hypertension
what is metabolic syndrome ?
it is defined as having at least two of the following: obesity Insulin resistance dyslipidemia hypertension
how does insulin resistance result in the accumulation of triglycerides in hepatocytes ?
impaired oxidation of fatty acids
increased synthesis and uptake of fatty acids
decreased hepatic secretion of LDL cholesterol
what happens to fat laden hepatocytes ?
they become exposed to free oxygen radicals which causes oxidative stress
causes mitochondrial death
and eventually cell death
what is the presentation of NAFLD like ?
usually asymptomatic but may present with vague right upper quadrant pain with elevated transaminases
what may appear upon ultrasound in NAFLD?
bright liver
what is the management of NAFLD ?
most importantly lifestyle modification
weight loss reduces hepatic steatosis
what medical treatment can be taken for cases of NASH ?
Pioglitazone ( improves histology of the patient)
Vitamin E
what surgical treatment may be considered for NAFLD ?
bariatric surgery
what are medications that are not recommended for the treatment of NASH ?
Metformin
GLp-1 agonists
Omega 3 fatty acids ( non specific for NASH)
what are the treatment options for advanced cases of NASH and NAFLD ?
liver transplantation
patients with cirrhosis should be screened for HCC
what is the pathogenesis of primary biliary cholangitis ?
chronic inflammatory autoimmune, more common in smokers
if primary biliary cholangitis is left untreated what is the outcome ?
end stage biliary cirrhosis
what is PBC characterized by ?
destruction of intrahepatic bile ducts
portal inflammation
scarring
what are the cardinal features of PBC ?
non-suppurative destruction of small and medium sized intrahepatic bile ducts
what is the onset of PBC ?
insidious onset
what cann be found in serology in PBC ?
AMA positive
what are the AMA directed against ?
pyruvate dehydrogenase complex
what genetic association is there with PBC ?
HLA-DR8
what is the clinical picture of PBC ?
fatigue pruritus may precede by jaundice scratch marks right upper quadrant abdominal discomfort jaundice bone pain or fractures xanthelasma mild hepatomegaly splenomegaly with the development of portal hypertension
what diseases are associated with PBC?
Autoimmune hashimotos thyroiditis Sjogren's disease Celiac disease Systemic sclerosis IBD
what is the pattern of cholestasis in lab results ?
raised ALP
raised GGT
hyperbilirubinemia
when do we consider the cholestasis chronic ?
when it lasts over 6 months
what other extrahepatic causes can raise ALP?
Rapid bone growth in children
Pagets disease
vitamin D deficiency
Pregnancy
what is the first step in diagnosing PBC ?
abdominal ultrasound to exclude any mechanical obstruction of the bile duct
if there is any uncertainty then a liver biopsy may be needed
what is the management for PBC?
oral UDCA at 13-15 mg/kg/day
what can be given for the pruritus ?
cholestyramine
how can we asses osteoporosis inn nPBC patients ?
DEXA scan n
what is primary sclerosing cholangitis ?
chronic cholestatic disorder characterized by progressive fibrosis and destruction of extra hepatic and intrahepatic bile ducts of all sizes
what is the diagnostic criteria for PSC?
beading and stenosis of the biliary system on cholangiography
absence of history of bile duct surgery
exclusion of bile duct cancer
and is a diagnosis of exclusion
what is the clinical picture of PSC?
fatigue
intermittent jaundice
right upper quadrant abdominal pain
pruritus
what diseases are associated with PSC ?
Ulcerative colitis
what is the most common cause of death in PSC patients ?
cholangiocarcinoma
what does the biochemical screening show in PSC?
cholestatic pattern
what is the gold standard investigation inn PSC ?
MRCP
when can we use ERCP in PSC ?
for therapeutic purposes inn the case of obstruction of a large duct
what is the treatment for PSC?
cholestryamine may be used for the pruritus
endoscopic therapy
| ERCP
what is the best predictor of severe fibrosis and disease progression in patients with metabolic syndrome ?
presence of T2DDM
obesity
