non-viral hepatitis

Question 1

what is NAFLD ?

Answer 1

non-alcoholic fatty liver disease

Question 2

what are the requirements for defining NAFLD ?

Answer 2

• 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

Question 3

what is defined as significant alcohol consumption ?

Answer 3

> 21 drinks for men per week

>14 drinks for women per week

Question 4

what is the difference between NASH and NAFLD ?

Answer 4

NASH - non alcoholic steato-hepatitis where there is inflammation around the fatty tissue
NAFLD - no inflammation

Question 5

what are the commonly associated abnormalities with NASH?

Answer 5

insulin resistance 
metabolic syndrome 
T2DM 
obesity 
dyslipidemia 
hypertension

Question 6

what is metabolic syndrome ?

Answer 6

it is defined as having at least two of the following:
obesity 
Insulin resistance 
dyslipidemia 
hypertension

Question 7

how does insulin resistance result in the accumulation of triglycerides in hepatocytes ?

Answer 7

impaired oxidation of fatty acids
increased synthesis and uptake of fatty acids
decreased hepatic secretion of LDL cholesterol

Question 8

what happens to fat laden hepatocytes ?

Answer 8

they become exposed to free oxygen radicals which causes oxidative stress
causes mitochondrial death
and eventually cell death

Question 9

what is the presentation of NAFLD like ?

Answer 9

usually asymptomatic but may present with vague right upper quadrant pain with elevated transaminases

Question 10

what may appear upon ultrasound in NAFLD?

Answer 10

bright liver

Question 11

what is the management of NAFLD ?

Answer 11

most importantly lifestyle modification

weight loss reduces hepatic steatosis

Question 12

what medical treatment can be taken for cases of NASH ?

Answer 12

Pioglitazone ( improves histology of the patient)

Vitamin E

Question 13

what surgical treatment may be considered for NAFLD ?

Answer 13

bariatric surgery

Question 14

what are medications that are not recommended for the treatment of NASH ?

Answer 14

Metformin
GLp-1 agonists
Omega 3 fatty acids ( non specific for NASH)

Question 15

what are the treatment options for advanced cases of NASH and NAFLD ?

Answer 15

liver transplantation

patients with cirrhosis should be screened for HCC

Question 16

what is the pathogenesis of primary biliary cholangitis ?

Answer 16

chronic inflammatory autoimmune, more common in smokers

Question 17

if primary biliary cholangitis is left untreated what is the outcome ?

Answer 17

end stage biliary cirrhosis

Question 18

what is PBC characterized by ?

Answer 18

destruction of intrahepatic bile ducts
portal inflammation
scarring

Question 19

what are the cardinal features of PBC ?

Answer 19

non-suppurative destruction of small and medium sized intrahepatic bile ducts

Question 20

what is the onset of PBC ?

Answer 20

insidious onset

Question 21

what cann be found in serology in PBC ?

Answer 21

AMA positive

Question 22

what are the AMA directed against ?

Answer 22

pyruvate dehydrogenase complex

Question 23

what genetic association is there with PBC ?

Answer 23

HLA-DR8

Question 24

what is the clinical picture of PBC ?

Answer 24

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

Question 25

what diseases are associated with PBC?

Answer 25

Autoimmune hashimotos thyroiditis 
Sjogren's disease 
Celiac disease 
Systemic sclerosis 
IBD

Question 26

what is the pattern of cholestasis in lab results ?

Answer 26

raised ALP
raised GGT
hyperbilirubinemia

Question 27

when do we consider the cholestasis chronic ?

Answer 27

when it lasts over 6 months

Question 28

what other extrahepatic causes can raise ALP?

Answer 28

Rapid bone growth in children
Pagets disease
vitamin D deficiency
Pregnancy

Question 29

what is the first step in diagnosing PBC ?

Answer 29

abdominal ultrasound to exclude any mechanical obstruction of the bile duct
if there is any uncertainty then a liver biopsy may be needed

Question 30

what is the management for PBC?

Answer 30

oral UDCA at 13-15 mg/kg/day

Question 31

what can be given for the pruritus ?

Answer 31

cholestyramine

Question 32

how can we asses osteoporosis inn nPBC patients ?

Answer 32

DEXA scan n

Question 33

what is primary sclerosing cholangitis ?

Answer 33

chronic cholestatic disorder characterized by progressive fibrosis and destruction of extra hepatic and intrahepatic bile ducts of all sizes

Question 34

what is the diagnostic criteria for PSC?

Answer 34

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

Question 35

what is the clinical picture of PSC?

Answer 35

fatigue
intermittent jaundice
right upper quadrant abdominal pain
pruritus

Question 36

what diseases are associated with PSC ?

Answer 36

Ulcerative colitis

Question 37

what is the most common cause of death in PSC patients ?

Answer 37

cholangiocarcinoma

Question 38

what does the biochemical screening show in PSC?

Answer 38

cholestatic pattern

Question 39

what is the gold standard investigation inn PSC ?

Answer 39

MRCP

Question 40

when can we use ERCP in PSC ?

Answer 40

for therapeutic purposes inn the case of obstruction of a large duct

Question 41

what is the treatment for PSC?

Answer 41

cholestryamine may be used for the pruritus
endoscopic therapy
| ERCP

Question 42

what is the best predictor of severe fibrosis and disease progression in patients with metabolic syndrome ?

Answer 42

presence of T2DDM
obesity