pathology 7 - Cirrhosis and portal hypertension-Serum markers of liver and pancreas pathology-Reye syndrome-Alcoholic liver disease-Non-alcoholic fatty liver disease Hepatic encephalopathy

Question 1

During an autopsy, a 52-year-old man from the United States is found to have a shrunken, nodular liver. What is the most likely etiology?

Answer 1

Alcohol (responsible for 60–70% of cirrhosis in the United States)

Question 2

Esophageal varices and caput medusae are caused by ____ (pathologic state) and are partially alleviated by ____ shunts.

Answer 2

Portal hypertension; portosystemic

Question 3

A patient with musty-smelling breath presents to the ED with confusion and asterixis. What skin findings do you expect on exam?

Answer 3

Common skin findings in liver failure are jaundice and spider nevi (the musty breath is fetor hepaticus) & may see caput medusae, edema

Question 4

A patient with melena is found to have esophageal varices. Where else in the GI tract are you concerned for bleeding?

Answer 4

The stomach, due to bleeding peptic ulcers (or may be caused by portal hypertension)

Question 5

Name at least three direct effects of portal hypertension.

Answer 5

Splenomegaly, caput medusae, ascites, esophageal varices with hematemesis, peptic ulcers, anorectal varices, portal hypertensive gastropathy

Question 6

An alcoholic has cirrhosis due to liver failure. What do you expect to find on eye exam?

Answer 6

Scleral icterus

Question 7

While seeing a patient with known cirrhosis, you cannot help but notice his musty breath. What is this called?

Answer 7

Fetor hepaticus

Question 8

Visible dilated capillary proliferation within the skin secondary to the effects of liver failure and cirrhosis is called what?

Answer 8

Spider nevi

Question 9

A man with liver failure also complains of gynecomastia and testicular atrophy. How did this likely develop?

Answer 9

Due to an increase in estrogen

Question 10

A patient with cirrhosis has a coarse, flapping tremor of the hands. What is this called?

Answer 10

Asterixis

Question 11

A cirrhotic patient should be cautioned about what kind of hematologic abnormality(ies) due to her liver cell failure?

Answer 11

Bleeding tendency (decreased production of clotting factors, increased prothrombin time) and anemia

Question 12

Why do patients with cirrhosis have an increased tendency to bleed?

Answer 12

Liver cell failure decreases production of prothrombin and clotting factors

Question 13

Is the bleeding tendency in cirrhosis considered an effect of portal hypertension or an effect of liver cell failure?

Answer 13

Liver cell failure (it is due to the inability to synthesize clotting factors)

Question 14

Is the ankle edema of cirrhosis considered an effect of portal hypertension or an effect of liver cell failure?

Answer 14

Liver cell failure (it is due to the inability to synthesize albumin resulting in lack of oncotic pressure)

Question 15

What is cirrhosis?

Answer 15

Cirrhosis is defined as diffuse fibrotic and nodular regeneration that disrupts the normal architecture of the liver

Question 16

What two gastrointestinal enzymes are markers of injury to hepatocytes?

Answer 16

The aminotransferases, which are alanine aminotransferase and aspartate aminotransferase

Question 17

A patient has viral hepatitis. What do you expect the ratio of aspartate aminotransferase to alanine aminotransferase to be?

Answer 17

Low (in viral hepatitis, AST

Question 18

A patient has alcoholic hepatitis. What do you expect the ratio of aspartate aminotransferase (AST) to alanine aminotransferase (ALT) to be?

Answer 18

High (in alcoholic hepatitis, AST > ALT)

Question 19

A 40-year-old man is intoxicated and not making any sense. Elevated serum γ-glutamyl transpeptidase may indicate which diagnosis?

Answer 19

Chronic alcoholism, along with possible Wernicke encephalopathy

Question 20

A patient has elevated alkaline phosphatase. To differentiate between bone disease and liver pathology, what marker do you use?

Answer 20

γ-glutamyl transpeptidase (like ALP, GGT is elevated in liver and biliary disease, but unlike ALP, it is not elevated in bone disease)

Question 21

Alkaline phosphatase, in addition to being a marker of liver disease, is also a marker of ____ disease.

Answer 21

Bone

Question 22

Which two gastrointestinal enzymes are used as markers for acute pancreatitis? Which one is more specific?

Answer 22

Amylase and lipase; lipase is more specific

Question 23

A patient has epigastric abdominal pain radiating to the back, fever, and nausea. What two enzymes will likely be elevated on lab studies?

Answer 23

Amylase and lipase will likely be elevated (the patient has acute pancreatitis)

Question 24

Which serum protein is decreased in Wilson disease?

Answer 24

Ceruloplasmin

Question 25

A patient has bronze rings in the irises, liver cirrhosis, muscle rigidity, and dystonia. What serum protein is most useful to check?

Answer 25

Ceruloplasmin is decreased, because this patient likely has Wilson disease (the bronze rings are Kayser-Fleischer rings)

Question 26

A boy who has never received any vaccines comes to the ED with an elevated amylase level (lipase is normal). Name a likely diagnosis.

Answer 26

Mumps

Question 27

A 5-year-old boy with seasonal flu is given aspirin for his fever and develops altered mental status and elevated LFTs. Diagnosis?

Answer 27

Reye syndrome

Question 28

What pathologic liver change is associated with Reye syndrome?

Answer 28

Microvesicular fatty changes and, later on, hepatomegaly

Question 29

A 7-year-old girl is thought to have Reye syndrome. What metabolic disturbance do you check for (it shows up on a basic metabolic panel)?

Answer 29

Hypoglycemia

Question 30

A mother brings in her son for lethargy and vomiting. A week ago he had a viral infection treated with a drug. What was he likely given?

Answer 30

Aspirin or salicylates (the boy likely developed Reye syndrome, which can occur in children with viral infections treated with aspirin)

Question 31

A mother asks if she can give her 4-year-old son aspirin for his fever of 101°F. What drug would you recommend instead?

Answer 31

Acetaminophen or ibuprofen

Question 32

How does aspirin cause Reye syndrome in young infants?

Answer 32

Aspirin metabolites reversibly inhibit mitochondrial enzymes and cause a decrease in β-oxidation

Question 33

There is one fever syndrome for which children are actually encouraged to take aspirin. What is it? Why?

Answer 33

Kawasaki disease; aspirin is needed to treat inflammation and prevent clots from forming

Question 34

What potentially reversible liver pathology can be seen with moderate alcohol intake?

Answer 34

Macrovesicular fatty changes of the liver (hepatic steatosis)

Question 35

A patient with chronic alcoholism develops hepatitis. What microscopic changes do you expect to see on liver biopsy?

Answer 35

Swollen and necrotic hepatocytes with neutrophilic infiltration and Mallory bodies (he likely has alcoholic hepatitis)

Question 36

You test the AST and ALT levels of a long-term alcoholic with sustained alcohol consumption. What do you expect them to be?

Answer 36

AST > ALT (the ratio is usually >1.5) (make a toast with alcohol)

Question 37

A 48-y/o woman with chronic alcoholism crashes her car and lacerates her liver. She goes to the OR. How do you expect her liver to appear?

Answer 37

She will likely have a micronodular, irregularly shrunken liver (also called hobnail appearance) (this is alcoholic cirrhosis)

Question 38

An alcoholic patient has jaundice, a "hobnail" liver, and hypoalbuminemia. If the patient quits drinking, will these symptoms go away?

Answer 38

No, as this describes a micronodular, shrunken liver appearance indicating alcoholic cirrhosis, which is irreversible

Question 39

What is the AST:ALT ratio in non-alcoholic fatty liver disease?

Answer 39

ALT > AST (ALT = Lipids)

Question 40

A non-alcoholic, type II diabetic patient has cirrhosis and a high ALT:AST ratio. What pathologic changes are associated with this disease?

Answer 40

Insulin resistance = fatty infiltration of hepatocytes & cellular ballooning on pathology (as seen in non-alcoholic fatty liver disease)

Question 41

What type of syndrome is associated with non-alcoholic fatty liver disease?

Answer 41

Metabolic syndrome (insulin resistance)

Question 42

A non-alcoholic man with a high ALT:AST ratio and metabolic syndrome should be advised that he is at risk for what type(s) of liver disease?

Answer 42

Cirrhosis and HCC (he has non-alcoholic fatty liver disease)

Question 43

A non-alcoholic patient with portosystemic shunt has asterixis. He has eaten only protein powder for the past month. How do you treat him?

Answer 43

Treat with lactulose and rifaximin (he is suffering from hepatic encephalopathy), & he should eat less protein (decreases NH3 production)

Question 44

A patient with decreased NH3 metabolism and neuropsychiatric dysfunction presents with profound delirium. How do you treat him?

Answer 44

Treat with lactulose and rifaximin (he is suffering from hepatic encephalopathy)

Question 45

What are some triggers of hepatic encephalopathy?

Answer 45

Increased NH3 production (protein intake, GI bleeding, constipation, infection), decreased NH3 removal (renal failure, diuretics, TIPS)

Question 46

A patient with hepatic encephalopathy is prescribed lactulose. He is also a medical student who wonders what lactulose does. You say?

Answer 46

Lactulose increases NH4+ generation, which decreases NH3 that can contribute to hepatic encephalopathy

Question 47

A patient with hepatic encephalopathy is prescribed a drug that kills intestinal bacteria to prevent NH3 build-up. What is it?

Answer 47

Rifaximin