Noninfectious Hepatobiliary Disease

Question 1

What are the three “patterns” to think of when evaluating elevated liver function tests?

Answer 1

1) Hepatocellular pattern
2) Hyperbilirubinemia
3) Cholestatic pattern

Question 2

What tests truly test the function of the liver?

Answer 2

INR

Albumin

Question 3

What enzymes are used in the evaluation of the liver?

Answer 3

Aminotransferases
Alkaline phosphatase
GGT

Question 4

What is the most important part of the evaluation of a patient with elevated LFTs?

Answer 4

History

Question 5

What is a prominent feature of patients with long-standing alcoholic liver disease?

Answer 5

Temporal and proximal muscle wasting

Question 6

What does a Virchow’s node or Sister Mary Joseph’s nodule suggest?

Answer 6

Abdominal malignancy

Question 7

What does JVD suggest?

Answer 7

Hepatic congestion

Question 8

When are right pleural effusions seen?

Answer 8

Advanced cirrhosis

Question 9

What is the hepatocellular pattern of elevated LFTs?

Answer 9

Elevated aminotransferases

Question 10

What are the common diseases that cause the hepatocellular pattern of elevated LFTs?

Answer 10

Alcohol 
Hemachromatosis 
Fatty Liver 
Medications 
Supplements 
Viral Hepatitis

Question 11

What is the enzyme pattern that is specific for alcoholic liver disease?

Answer 11

AST greater than ALT (2:1)

Question 12

What is the effect of alcohol on GGT?

Answer 12

Alcohol induces GGT

Question 13

What does an AST greater than 300 indicate?

Answer 13

An additional problem in addition to alcoholism

Question 14

What is the difference between alcoholic hepatitis and cirrhosis?

Answer 14

Hepatitis:
- Cell injury and hepatocellular swelling

Cirrhosis:
- Regenerative nodules and fibrosis

Question 15

What is the treatment for Alcoholic Liver Disease?

Answer 15

1) Abstinence

2) Liver transplant

Question 16

Explain the etiology of ascites seen in alcoholic liver disease.

Answer 16

1) Cirrhosis causes portal HTN
2) Splanchnic vasodilation and renal vasoconstriction
3) RAA activated–Na+ and H20 retained
4) ADH secreted–retain water

Question 17

What do you need to remember in terms of dietary and medication restriction in alcoholic liver disease?

Answer 17

1) Limit Na+ (water follows Na+)

2) No NSAIDs– will shut down kidneys

Question 18

What is the utility of the SAAR?

Answer 18

Determining the etiology of ascites

• SAAR greater than 1.1= portal HTN
• SAAR less than 1.1= NOT portal HTN

Question 19

How do you treat ascites?

Answer 19

1) Na+ restriction
2) Spironolactone and Furosemide
3) Paracentesis
4) TIPS procedure

Question 20

What lab should you check in a patient with suspected hepatic enchalopathy?

Answer 20

Ammonia

Question 21

How can hepatic encephalopathy be treated?

Answer 21

1) Treat the underlying cause

2) Titrate Lactulose, which changes the colonic pH

Question 22

What is Spontaneous Bacterial Peritonitis?

Answer 22

Ascitic fluid infection

• Advanced cirrhosis
• Caused by gut flora overgrwoth (E.coli and Klebsiella)

Question 23

How do you approach the management of SBP?

Answer 23

1) If you suspect, paracentesis
2) Measure ascitic neutrophils
3) Neutrophils greater than 250–start abx (Ceftiaxone)

Question 24

What is the treatment of choice with a ruptured esophageal varice?

Answer 24

Endoscopy followed by:

1) Balloon tamponade
2) TIPS

Question 25

What is Hepatorenal Syndrome?

Answer 25

Acute renal failure in the face of underlying advanced liver disease

Question 26

What is the utility of the discriminant function?

Answer 26

Determines the prognosis of alcoholic hepatitis

Question 27

What does the discriminant function determine?

Answer 27

Determine whether or not to give PREDNISOLONE

Question 28

What is the magic number for the discriminant function?

Answer 28

32--greater than 32 give PREDNISOLONE

Question 29

When should you NOT give prednisolone?

Answer 29

1) Infection | 2) GI Bleed

Question 30

Describe the skin pigmentation seen in patients with Hemochromatosis?

Answer 30

"Gray" NOT bronze

Question 31

What do patients with Hemochromatosis have an increased risk for?

Answer 31

Hepatocellular Carcinoma

Question 32

What are the labs that are typical of Hemochromatosis?

Answer 32

- High serum iron - High ferretin - High transferrin *Classically, the Transferrin saturation is greater than 45%

Question 33

What is the liver enzyme elevation pattern seen in NAFLD?

Answer 33

ALT is higher than AST

Question 34

What is the treatment for NAFLD?

Answer 34

1) Weight loss 2) Control of DM and hyperlipidemia 3) Low fat diet 4) Alcohol avoidance

Question 35

What is the presentation that would lead you to consider Autoimmune Hepatitis?

Answer 35

- Young to middle aged woman | - Elevated tranaminases with no cause

Question 36

How does Wilson's Disease typically present?

Answer 36

Adolesecent with neurologic or psychiatric dysfunction

Question 37

What PE finding is a hallmark for Wilson's Disease?

Answer 37

Kayser-Fleischer rings

Question 38

What lab finding is characteristic of Wilson's Disease?

Answer 38

Ceruloplasmin

Question 39

What type of hyperbilirubinemia is seen in Gilbert Syndrome?

Answer 39

UCB

Question 40

What is the typical presentation of Gilbert Syndrome?

Answer 40

1) Healthy young adult 2) Hyper-UCB 3) No evidence of hemolysis

Question 41

What lab elevation is associated with the "Cholestatic pattern?"

Answer 41

ALP (and GGT)

Question 42

If you have a UC patient with an elevated ALP, what diagnosis should come to mind?

Answer 42

Primary Sclerosing Cholangitis

Question 43

What is pathogmnemonic for PSC on biopsy?

Answer 43

1) Beaded appearance of biliary ducts | 2) Onion skin on liver biopsy

Question 44

What patient population is PBC most commonly seen in?

Answer 44

Middle aged women

Question 45

What are key clinical features of PBC?

Answer 45

1) Middle aged woman 2) Positive AMA 3) Elevated ALP 4) Puritis and fatigue 5) Obliterated bile ducts