Noninfectious Hepatobiliary Disease Flashcards
What are the three “patterns” to think of when evaluating elevated liver function tests?
1) Hepatocellular pattern
2) Hyperbilirubinemia
3) Cholestatic pattern
What tests truly test the function of the liver?
INR
Albumin
What enzymes are used in the evaluation of the liver?
Aminotransferases
Alkaline phosphatase
GGT
What is the most important part of the evaluation of a patient with elevated LFTs?
History
What is a prominent feature of patients with long-standing alcoholic liver disease?
Temporal and proximal muscle wasting
What does a Virchow’s node or Sister Mary Joseph’s nodule suggest?
Abdominal malignancy
What does JVD suggest?
Hepatic congestion
When are right pleural effusions seen?
Advanced cirrhosis
What is the hepatocellular pattern of elevated LFTs?
Elevated aminotransferases
What are the common diseases that cause the hepatocellular pattern of elevated LFTs?
Alcohol Hemachromatosis Fatty Liver Medications Supplements Viral Hepatitis
What is the enzyme pattern that is specific for alcoholic liver disease?
AST greater than ALT (2:1)
What is the effect of alcohol on GGT?
Alcohol induces GGT
What does an AST greater than 300 indicate?
An additional problem in addition to alcoholism
What is the difference between alcoholic hepatitis and cirrhosis?
Hepatitis:
- Cell injury and hepatocellular swelling
Cirrhosis:
- Regenerative nodules and fibrosis
What is the treatment for Alcoholic Liver Disease?
1) Abstinence
2) Liver transplant
Explain the etiology of ascites seen in alcoholic liver disease.
1) Cirrhosis causes portal HTN
2) Splanchnic vasodilation and renal vasoconstriction
3) RAA activated–Na+ and H20 retained
4) ADH secreted–retain water
What do you need to remember in terms of dietary and medication restriction in alcoholic liver disease?
1) Limit Na+ (water follows Na+)
2) No NSAIDs– will shut down kidneys
What is the utility of the SAAR?
Determining the etiology of ascites
- SAAR greater than 1.1= portal HTN
- SAAR less than 1.1= NOT portal HTN
How do you treat ascites?
1) Na+ restriction
2) Spironolactone and Furosemide
3) Paracentesis
4) TIPS procedure
What lab should you check in a patient with suspected hepatic enchalopathy?
Ammonia
How can hepatic encephalopathy be treated?
1) Treat the underlying cause
2) Titrate Lactulose, which changes the colonic pH
What is Spontaneous Bacterial Peritonitis?
Ascitic fluid infection
- Advanced cirrhosis
- Caused by gut flora overgrwoth (E.coli and Klebsiella)
How do you approach the management of SBP?
1) If you suspect, paracentesis
2) Measure ascitic neutrophils
3) Neutrophils greater than 250–start abx (Ceftiaxone)
What is the treatment of choice with a ruptured esophageal varice?
Endoscopy followed by:
1) Balloon tamponade
2) TIPS
What is Hepatorenal Syndrome?
Acute renal failure in the face of underlying advanced liver disease
What is the utility of the discriminant function?
Determines the prognosis of alcoholic hepatitis
What does the discriminant function determine?
Determine whether or not to give PREDNISOLONE
What is the magic number for the discriminant function?
32–greater than 32 give PREDNISOLONE
When should you NOT give prednisolone?
1) Infection
2) GI Bleed
Describe the skin pigmentation seen in patients with Hemochromatosis?
“Gray” NOT bronze
What do patients with Hemochromatosis have an increased risk for?
Hepatocellular Carcinoma
What are the labs that are typical of Hemochromatosis?
- High serum iron
- High ferretin
- High transferrin
*Classically, the Transferrin saturation is greater than 45%
What is the liver enzyme elevation pattern seen in NAFLD?
ALT is higher than AST
What is the treatment for NAFLD?
1) Weight loss
2) Control of DM and hyperlipidemia
3) Low fat diet
4) Alcohol avoidance
What is the presentation that would lead you to consider Autoimmune Hepatitis?
- Young to middle aged woman
- Elevated tranaminases with no cause
How does Wilson’s Disease typically present?
Adolesecent with neurologic or psychiatric dysfunction
What PE finding is a hallmark for Wilson’s Disease?
Kayser-Fleischer rings
What lab finding is characteristic of Wilson’s Disease?
Ceruloplasmin
What type of hyperbilirubinemia is seen in Gilbert Syndrome?
UCB
What is the typical presentation of Gilbert Syndrome?
1) Healthy young adult
2) Hyper-UCB
3) No evidence of hemolysis
What lab elevation is associated with the “Cholestatic pattern?”
ALP (and GGT)
If you have a UC patient with an elevated ALP, what diagnosis should come to mind?
Primary Sclerosing Cholangitis
What is pathogmnemonic for PSC on biopsy?
1) Beaded appearance of biliary ducts
2) Onion skin on liver biopsy
What patient population is PBC most commonly seen in?
Middle aged women
What are key clinical features of PBC?
1) Middle aged woman
2) Positive AMA
3) Elevated ALP
4) Puritis and fatigue
5) Obliterated bile ducts
