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GI Exam > Viral, Toxic, and Immune-Mediated Liver Diseases > Flashcards

Viral, Toxic, and Immune-Mediated Liver Diseases Flashcards

1
Q

ddx for abnormal ASTs and ALTs (viral, toxic, and immune causes)

A

*viruses
*meds
*autoimmune hepatitis

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2
Q

ddx for abnormal alkaline phosphatase (viral, toxic, and immune causes)

A

*medication-induced cholestasis
*primary biliary cholangitis
*primary sclerosing cholangitis

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3
Q

hepatitis A virus - overview

A

*HAV is an RNA virus
*transmission: fecal-oral
*no treatment
*no chronic phase
*elevated IgM anti-HAV
*typically questions have a traveler returning to America from an endemic area

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4
Q

clinical presentation of all hepatitis viruses

A

*episodes of fever, jaundice
*elevated ALT and AST

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5
Q

risk factors for hepatitis B

A
  1. heterosexual activity
  2. injecting drug use

hep B is a DNA virus

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6
Q

acute HBV infection

A

*IgM anti-HBc is the diagnostic serology tool

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7
Q

acute HBV serology panel

A

*HBSAg = +
*HBcAb IgM = +
*HBcAb IgG = -
*HBSAb = -

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8
Q

resolved HBV serology panel (natural immunity)

A

*HBSAg = -
*HBcAb IgM = -
*HBcAb IgG = +
*HBSAb = +

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9
Q

chronic HBV serology panel

A

*HBSAg = +
*HBcAb IgM = -
*HBcAb IgG = +
*HBSAb = -

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10
Q

HBV vaccinated serology panel

A

*HBSAg = -
*HBcAb IgM = -
*HBcAb IgG = -
*HBSAb = +

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11
Q

risk factor for hepatitis C

A

*IV drug use

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12
Q

acute hepatitis panel

A

*HAV antibody (IgG + IgM) - if positive, lab will proceed to test for IgM
*HBSAg
*HBcAb (IgG + IgM) - if positive, the lab will proceed to test for IgM
*HCV Ab - if negative, test HCV RNA!!

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13
Q

treatment for chronic hepatitis C

A

there IS a very effective treatment (a cure) for HCV [direct-acting antiviral therapy]

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14
Q

hepatitis D - overview

A

*RNA virus
*requires the presence of HBV for complete virion assembly and secretion
*clinical presentation: SUPERINFECTION IS WORSE than coinfection
*diagnosis - serum testing for HDV RNA (PCR) [but only in the setting of HBSAg +]

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15
Q

hepatitis E and pregnancy

A

*clinical course: fulminant hepatitis in pregnant patients
*risk maternal mortality, worse in 3rd trimester
*pregnant women should avoid travel to endemic areas
*dx:
-HEV RNA in serum or stool
-serum HEV IgM Ab

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16
Q

drug-induced liver disease (DILI)

A

*most common cause of acute liver failure in the United States (acetaminophen is the most common drug but it is usually considered separately)

17
Q

3 mechanisms of drug toxicity for drug-induced liver disease

A
  1. direct hepatotoxicity
  2. hepatic conversion of the drug to an active toxin
  3. immune-mediated liver injury, in which the drug or a metabolite act as a hapten, converting a cellular protein into an immunogen
18
Q

making the diagnosis of drug-induced liver injury (DILI)

A

*history is key:
-careful medication history with start date (avg onset within 2 weeks)
-also consider other meds
*serologic evaluation for viral, autoimmune, and metabolic liver diseases
*correlate clinical features and LFT pattern “signature” (google “livertox”)
*consider liver biopsy for histologic differentiation

19
Q

acetaminophen hepatotoxicity - doses

A

danger dosages (70 kg patient):
-toxicity possible > 10 gm
-severe toxicity certain > 25 gm
-lower doses potentially hepatotoxic in: chronic alcoholism, malnutrition or fasting, dilantan, tegretol, etc
*NOT in acute EtOH ingestion and NOT in non-alcoholic chronic liver disease

20
Q

acetaminophen hepatotoxicity - timeline

A

*day 1: nausea, vomiting, malaise, or asymptomatic
*day 2-3:
-initial symptoms resolve
-AST and ALT begin to rise by 36 hours
-RUQ pain, tender enlarged liver on exam
*day 4:
-AST and ALT peak > 3000
-liver dysfunction: INR, encephalopathy, jaundice
-acute kidney injury: acute tubular necrosis

21
Q

acetaminophen hepatotoxicity - treatment

A

*if < 4 hours from ingestion: activated charcoal
*IV N-acetylcysteine (NAC) !!!
*use the nomogram to determine probability of hepatic toxicity

22
Q

what do we use N-acetylcysteine to treat

A

acetaminophen hepatotoxicity (N-acetylcysteine regenerates glutathione)

23
Q

acetaminophen toxicity - pathogenesis

A

*acetaminophen metabolic depletes glutathione and forms toxic tissue byproducts in liver
*N-acetylcysteine (treatment of choice) regenerates glutathione

24
Q

Reye’s Syndrome

A

*mitochondrial dysfunction in liver and brain
*seen predominantly in children
*associated with ASPIRIN given for fever
*typically presents with vomiting, confusion, seizures, and coma
*liver biopsy shows microvesicular steatosis

25
Q

test pearls for acute hepatitis

A

*ALT > AST and levels > 1000
*ddx: viral, toxic, ischemic
*lab evaluation:
-viral hepatitis panel: HAV IgM, HBSAg, HBcAb IgM, HCV RNA
-acetaminophen level

26
Q

acute liver failure - definition

A

rapid development of hepatic dysfunction
*hepatic encephalopathy
INR > 1.5
*no prior history of liver disease

27
Q

2 requirements for acute liver failure

A
  1. hepatic encephalopathy
  2. INR > 1.5
28
Q

acute liver failure - most common causes

A

*acetaminophen
*unknown
*drug-induced liver injury
*acute viral hepatitis

29
Q

autoimmune hepatitis - overview

A

*widely variable clinical presentations:
-asymptomatic LFT abnormality (ALT & AST)
-severe hepatitis with jaundice
-cirrhosis and complications of portal HTN
*FEMALE:male ratio 4:1
*often associated with other autoimmune diseases

30
Q

gender prevalence in autoimmune hepatitis

A

FEMALE > male (4:1)

31
Q

autoimmune hepatitis - diagnosis and treatment

A

*diagnosis:
-abnormal LFTs, primarily ALT and AST
-ANA or ASMA with titer 1:80 or greater
-IgG > 1.1 upper limits of normal
-liver biopsy: portal lymphocytes + plasma cells

*treatment: prednisone + azothioprine

32
Q

primary biliary cholangitis

A

*cholestatic liver disease (ALP):
-immune attack on MICROSCOPIC bile ducts (intrahepatic)
-most common sx: pruritis + fatigue
*FEMALE:male ratio 9:1
*diagnosis:
-AMA titer 1:80 or greater (95% sens/spec)
-abnormal LFTs, primarily ALP
-liver biopsy (bile duct destruction)

*treatment: UDCA (ursodeoxycholic acid)

33
Q

gender prevalence of primary biliary cholangitis

A

FEMALE > male (9:1)

34
Q

primary sclerosing cholangitis

A

*cholestatic liver disease (ALP elevation)
*immune attack on LARGE BILE DUCTS (intra and extra-hepatic)
*90% associated with IBD
*diagnosis: MRCP & p-ANCA
*cholangiocarcinoma risk
*treatment = liver transplant

35
Q

periportal liver fibrosis

A

*most causes of liver inflammation and fibrosis
*HBV, HCV, AIH, PBC, PSC, HH, A1AT, WD
*liver injury from toxins and viruses

36
Q

centrizonal fibrosis

A

*ASH, NASH
*congestive hepatopathies: Budd-Chiaria, cor pulmonale, CHF, etc
*liver injury from oxidative stress (alcohol, non-alcohol fatty liver diseases, etc)

GI Exam (54 decks)

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