Section 4: Acute Hepatitis and Cirrhosis

Question 1

CF of hepatitis

Answer 1

• Jaundice
• Fatigue
• Weight loss
• Dark urine caused by bilirubin in the urine

Hepatitis B and C are more likely to present with serum sickness-phenomena like:

• Joint pain
• Urticaria, and
• Fever

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 6501-6505). . Kindle Edition.

Question 2

Hepatitis

1. Indications for hepatitis A and B vaccines
2. Specific indications for hepatitis A
3. Specific indications for hepatitis B

Answer 2

1. Indications for hepatitis A and B vaccines
   
   • Chronic liver disease
   • Household contacts of those with hepatitis A or B
   • MSM
   • Chronic recipients of blood products
   • Injection drug users
2. Travelers
3. Specific indications for hepatitis B
   
   • Health care workers
   • patients on dialysis

Question 3

Prodromal Phase of Hepatitis B

1. Describe Presentation
2. These symptoms are similar to what reaction?

Answer 3

1. Fever, Rash, Joint Pain
2. Serum Sickness

* Due to CIRCULATING IMMUNE COMPLEXES

Question 4

Hepatitis B

1. What % of pts with Acute Hepatitis B will develop Chronic Hepatitis B?
2. What % of infants exposed perinatally, will develop Chronic Hepatitis B?

Answer 4

1. <5%
2. 90%

Question 5

Hepatitis and Treatment

1. Treatment of Acute Hepatitis B
2. Treatment of Hepatitis B with End Stage Liver Disease
3. Treatment of Hepatitis C

Answer 5

1. Supportive measures only
2. Liver Transplant
3. Infereron & Ribavirin

Question 6

Hepatitis C

1. Risk factors
2. Diagnosis
3. When do you treat?
4. What do you treat with? (i.e. what meds?).

Answer 6

1. IV drug users
2. HCV RNA by PCR
3. You treat only if:
   - AST is elevated, or
   - Liver biopsy shows moderate inflammation or fibrosis
   Otherwise, you just observe
4. INTERFERON & RIBAVIRIN + BOCEPREVIR (or TELAPREVIR)

Question 7

Hepatitis:

1. HBeAg+ versus HBeAb+

Answer 7

1. HBeAg+ = Pt is infectious; HBeAb+ = Pt has low likelihood of spreading the dz

Question 8

Hepatitis B:

• • HBsAg
• • HBeAg
• • IgM anti- HBc
• • HBsAb

Answer 8

Acute Hepatitis B

Question 9

Hepatitis B:

• • HBsAG
• • anti- HBe
• • IgG anti- HBc
• • HBsAb

Answer 9

Chronic Hepatitis

Question 10

Hepatitis C:

1. HCV Ab +
2. Anti-HCV Ab - and HCV RNA + by PCR
3. Anti-HCV Ab + HCV RNA by PCR -
4. Anti-HCV Ab - and HCV RNA by PCR -

Answer 10

• Means that the pt has had a prior exposure, but does not mean that the pt has recovered
• Acute hepatitis c infection (b/c it’s acute, the body has not had time to form antibodies yet)
• Resolved Hepatitis C infection
• No infection

Question 11

OCP and Liver Disease:

1. OCP use can cause ___ in the liver?
2. How do you treat this?

Answer 11

1. Hepatic Adenoma (usually incidental finding)
2. STOP OCPs. If > 5cm or if symptomatic, then you need surgical resection

Question 12

List the side effect of Kava (herbal suppliment)

Answer 12

• Hepatitis
• Cirrhosis
• Liver failure/Toxicity

Question 13

How do you diagnose Alcholic Liver Dz?

Answer 13

1. Elevated AST and ALT (AST/ALT ratio of 2:1) OR
2. Elevated GGT (Gamma glutamyl transaminase)

Question 14

• • Spontaneous Bacterial Peritonitis**
    1. Seen in what patients?
    2. Presentation
    3. Diagnosis
    4. MCC of SBP
    5. What happens if not treated?

Answer 14

1. Pts w/CIRRHOSIS and ASCITES
2. Abdominal pain, worsening ascities, fever, AMS, renal dysfunction
3. Paracentesis (fluid will have elevated WBCs)
4. E. Coli
5. If not treated, SBP can lead to sepsis and multi organ failure

Question 15

Reye Syndrome

Answer 15

Liver dz in a child after aspirin use for fever

Question 16

Hemachromatosis

1. Mode of transmission
2. Explain the etiology of the disease
3. Presentation/Symptoms
4. Best initial test
5. Most accurate test
6. Treatment

Answer 16

1. Autosomal recessive
2. Excessive iron is absorbed through the gut and deposited in the LIVER, PANCREAS, HEART, SKIN, and JOINTS
3. Symptoms:
   
   • LIVER -> cirrhosis, liver cancer (hepatoma)
   • PANCREAS -> Diabetes
   • HEART -> restrictive cardiomyopathy
   • SKIN -> Hyperpigmentation (bronze skin)
   • JOINTS -> arthralgia
   • REPRODUCTIVE -> infertility
   • PITUITARY -> panhypopituitarism
4. Elevated serum iron and ferritin levels with a low iron-binding capacity
5. Liver biopsy OR MRI of liver + Genetic testing for HFe gene mutation
6. Phlebotomy

Question 17

• *Wilson’s Disease**
  1. Mode of transmission
  2. Explain the etiology of the disease
  3. Important Lab values
  4. Presentation/Symptoms
  5. Treatment

Answer 17

1. Autosomal Recessive
2. Excessive copper
3. Labs:
   - Ceruloplasmin is low
   - Serum copper is elevated or nml
   - Liver Bx: excessive copper (most accurate test)
4. Kay-Fleischer rings in eyes; CNS or pyschiatric manifestations due to copper deposits in basal ganglia
5. PENICILLAMINE (Copper chelator)

Question 18

Likely diagnosis

1. Alpha1 Antitrypsin deficiency
2. Anti-Nuclear Antibody and Anti-Smooth Muscle Antibdoy
3. IgA Endomysial antibodies
4. Anti-Mitochondrial Antibody

Answer 18

1. Cirrhosis and emphysema with out risk factors for either
2. Seen in Auto-immune Hepatitis
3. Celiac Disease
4. Seen in Primary Biliary Cirrhosis

Question 19

• • Primary Biliary Cirrhosis**
    1. Who is it mainly seen in?
    2. What is the common presentation?
    3. Important lab values
    4. Treatment
    5. Pts are at risk of developing what dz?

Answer 19

1. Middle aged women with no risk factors
2. Pruritis
3. Elevated ALK PHOS &
   ANTI-MITOCHONDRIAL ANTIBODIES and liver biopsy
4. Ursodeoxycholic acid
5. Osteoporosis/Osteopenia (due to malabsorption of Vit D)

Question 20

list the causes of elevated ALK PHOS and Normal LFTs

Answer 20

• Primary Biliary Cirrhosis
• Granulomatous Dz (sarcoidosis)
• Malignancy
• Infection
• Meds

Question 21

Sarcoidosis is a type of granulomatus Dz that has multiple granulomas in multiple organs (i.e. lung, liver, eyes).

1. It is MC seen in ___
2. Lab values ___
3. CXR findings ____
4. Dx:

Answer 21

1. African american women
2. Elevated Alk Phos, normal LFTs
3. Bilateral hilar fullness
4. Liver Bx

Question 22

Primary Sclerosing Cholangitis is seen in pts with ___

Answer 22

Ulcerative Colitis

Question 23

• *Jaundice + Palpable Gallbladder**
  1. What sign is this?
  2. What does it mean?

Answer 23

1. Courvoisier sign
2. Common bile duct obstruction from cancer (usually pancreatic cancer)

Question 24

Nonalcoholic steatohepatitis (NASH)

• CF
• Best initial test
• Most accuate test
• Rx

Answer 24

• NASH is strongly associated with obesity, diabetes, and hyperlipidemia. Hepatomegaly is often present.
• ALT > AST
• Liver biopsy showing fatty infiltration. The liver biopsy looks just like The liver biopsy looks just like alcoholic liver disease
• No specific therapy exists to reverse NASH. Control the underlying causes with weight loss, diabetes control, and management of the hyperlipidemia.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 6741-6745). . Kindle Edition.

Question 25

**Autoimmune Hepatitis** * CF * Best initial test * Most accurate test * Rx

Answer 25

* Young woman with other autoimmune diseases, such as Coombs positive hemolytic anemia, thyroiditis, and ITP * ANA and antismooth muscle antibody test. **Serum protein electrophoresis (SPEP)** shows hypergammaglobulinemia * Liver biopsy * Prednisone. Azathioprine when Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 6731-6735). . Kindle Edition.

Question 26

Ascites: * Indications for parencentesis * Value of serum-to-ascites albimin gradient (SAAG) that indicates portal HTN * Criterion for diagnosing spontaneous bacterial peritonitis (SBP) and Rx of SBP

Answer 26

* New ascites; Pain, fever, or tenderness * SAAG \> 1.1 * Cell count of \>250 neutrophils. Rx is with cefotaxime

Question 27

List the CF of liver cirrhosis

Answer 27

* Edema from low oncotic pressure: Treat with spironolactone and diuretics * Gynecomastia * Palmar erythema * Splenomegaly * Thrombocytopenia caused by splenic sequestration * Encephalopathy: Treat with lactulose * Ascites: Treat with spironolactone * Esophageal varices: Propranolol will prevent bleeding. Perform banding of the varices if they bleed. Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 6655-6659). . Kindle Edition.

Question 28

Rx of hepatic adenoma in a female on oral contraceptive pills (OCPs)

Answer 28

Small lesions (\<5cm) and asymptomatic hepatic adenomas are usually managed by **discontinuing the OCPs** Symptomatic patients and patients with bigger lesions should undergo **surgical resection**

Question 29

What is the diagnosis based on the following lab results in the table below?

Answer 29

Answers are shown below

Question 30

The American Association for the Study of Liver Diseases (AASLD) recommends that any patient with cirrhosis and upper GI bleed receive prophylactic antibiotics, preferably before endoscopy for prevention of bacteremia. What is the route and antibiotic of choice?

Answer 30

IV Ciprofloxacine

Question 31

**Bleeding esophageal varices (BEV)** True or False: 1. Balloon tamponade is placed for 48 hours 2. Sclerotherapy is superior to band ligation in the management 3. TIPS is the goal in the urgent management of BEV 4. Vasopressin is superior to Somatostatin in BEV management

Answer 31

1. False. No more than 24 hours 2. False: Equal in efficacy 3. False: TIPS is an elective procedure 4. False: Somatostatin less side effects. None has a mortality benefit

Question 32

What is the most common side effect of **ribavirin**?

Answer 32

Hemolytic anemia