Clinical Approach to the Hepatobiliary Patient: Chronic Liver Disease and Cirrhosis

Question 1

what is the time frame for chronic liver disease?

Answer 1

at least 6 months

Question 2

What are 2 ways you can identify the presence or absence of fibrosis (cirrhosis) in chronic hepatitis?

Answer 2

serum fibrosure (lab) and/or ultrasound elastography (imaging)

Question 3

Where is HBV endemic?

Answer 3

sub-saharan africa and southeast asia

Question 4

What 3 things is HBV associated with?

Answer 4

glomerulonephritis, serum sickness, and polyarteritis nodosa

Question 5

What are people with chronic HBV at substantial risk for?

Answer 5

cirrhosis (portal HTN) and hepatocellular carcinoma

Question 6

How do you make the diagnosis of chronic HCV?

Answer 6

HCV Ab+ HCV RNA in serum

Question 7

What is the most sensitive indicator of HCV infection?

Answer 7

HCV RNA

Question 8

What indicates recovery from prior HCV infection?

Answer 8

anti-HCV in serum without HCV RNA in serum

Question 9

What are 3 complications associated with chronic HCV?

Answer 9

cirrhosis, hepatocellular carcinoma, pathogenic factor in mixed cryoglobulinemia

Question 10

What is the most common form of autoimmune hepatitis?

Answer 10

Type 1: classic: anti-smooth muscle and/or antinuclear antibodies (ANA)

Question 11

what is the typical manifestation of classic autoimmune hepatitis?

Answer 11

female, 30-50 yo, healthy appearing young woman with stigmata of cirrhosis

Question 12

What are the extrahepatic manifestations associated with autoimmune hepatitis?

Answer 12

rash, arthralgias, keratoconjunctivitis sicca, thyroiditis, hemolytic anemia, nephritis, ulcerative colitis

Question 13

How do you make the diagnosis of autoimmune hepatitis?

Answer 13

look for serologic abnormalities: type I: SMA; type 2: anti-LKM antibody

Question 14

How would you treat autoimmune hepatitis?

Answer 14

glucocorticoids, azathioprine, monitor liver function tests monthly, liver transplant may be required

Question 15

How does alcoholic hepatitis present?

Answer 15

asymptomatic–> severe liver failure with jaundice, ascites, GI bleeding, and encephalopathy

Question 16

what would a liver biopsy look like in a patient with alcohol-induced liver disease?

Answer 16

Mallory bodies (alcoholic hyaline)

Question 17

how do you treat alcohol-induced liver disease with hypoglycemia?

Answer 17

abstinence from alcohol; daily multivitamin, thiamine, folic acid, zinc; you need to give thiamine first before glucose

Question 18

what are 3 different scores used to assess prognosis of alcohol-induced liver disease?

Answer 18

A Maddrey’s discriminant function (DF); Glasgow alcoholic hepatitis score; a model for end-stage liver disease (MELD)

Question 19

what are the principal causes of NAFLD?

Answer 19

metabolic syndrome (obesity, DM, hypertriglyceridemia)

Question 20

What protects against NAFLD?

Answer 20

physical activity and coffee consumption

Question 21

What is the liver biopsy like in a patient with NAFLD?

Answer 21

it is indistinguishable from that of alcoholic hepatitis

Question 22

how does alpha-1 anti-trypsin deficiency present in young? in smokers?

Answer 22

pulmonary emphysema in lower lobes; pulmonary emphysema of upper lobes

Question 23

How do you diagnose alpha-1 anti-trypsin deficiency?

Answer 23

check alpha-1 antitrypsin phenotype; Pi gene on chromosome 14

Question 24

What is the classic tetrad associated with hemochromatosis?

Answer 24

cirrhosis with hepatomegaly, abnormal skin pigmentation, diabetes mellitus, cardiac dysfunction

Question 25

Patients affected by hemochromatosis are at increased risk of infection with what?

Answer 25

yersinia enterocolitica, vibrio vulnificus, listeria monocytogenes, and siderophilic organisms

Question 26

how do you treat hemochromatosis?

Answer 26

phlebotomy or the chelating agent deferoxamine

Question 27

How do you make the diagnosis of wilson disease?

Answer 27

low serum ceruloplasmin

Question 28

How do you treat wilson disease?

Answer 28

oral penicillamine or liver transplant

Question 29

How does right heart failure affect the liver?

Answer 29

patients will have passive congestion of the liver (nutmeg liver)

Question 30

What is ischemic hepatitis?

Answer 30

ischemic hepatopathy, hypoxic hepatitis, shock liver; when there is an acute fall in cardiac output due to acute MI, arrhythmia, or septic or hemorrhagic shock

Question 31

What is the hallmark of ischemic hepatitis aka "shock liver"?

Answer 31

rapid and striking elevation of serum aminotransferase levels- often greater than 5000 units/L; early rapid rise in the serum lactate dehydrogenase (LDH) level

Question 32

What is fibrosure and how does it work?

Answer 32

it is a noninvasive blood test of biochemical markers that provides fibrosis staging and necroinflammatory grading; low excludes advanced fibrosis; high predicts advanced fibrosis

Question 33

How do you check/diagnose a spontaneous bacterial peritonitis in a patient with cirrhosis?

Answer 33

blood culture or paracentesis; check fluid for albumin, WBC with differential, culture and gram stain; if it is greater than 250 PMNs/mL think SBP

Question 34

How do you determine the prognosis of cirrhosis?

Answer 34

you always calculate Child-turcotte-Pugh score and MELD/MELD-Na score

Question 35

How do you screen for HCC?

Answer 35

alpha fetoprotein (AFP) and ultrasound every 6 months to screen for HCC

Question 36

What is the most common cause of ascites?

Answer 36

portal hypertension (chronic liver disease)

Question 37

How do you diagnose ascites?

Answer 37

abdominal ultrasound or abdominal paracentesis

Question 38

What are the routine studies done on ascitic fluid?

Answer 38

1) cell count 2) albumin and total protein 3) culture and gram stain

Question 39

What is primary spontaneous bacterial peritonitis?

Answer 39

it is most common among patients with cirrhosis; it is a hematogenous spread of organisms to ascitic fluid

Question 40

how do you treat spontaneous bacterial peritonitis?

Answer 40

appropriate empirical antibiotic treatment: a third generation cephalosporin or piperacillin/tazobactam

Question 41

What are the 4 risks of increased risk of bleeding from esophageal varices?

Answer 41

1) the size of the varices (larger than 5mm) 2) the presence at endoscopy of red wale markings 3) the severity of liver disease 4) active alcohol abuse

Question 42

How do you prevent rebleeding of esophageal varices?

Answer 42

nonselective beta-adrenergic blockers (propranolol, nadolol)

Question 43

How do you treat hepatic encephalopathy?

Answer 43

remove precipitants, correct electrolyte imbalances, lactulose

Question 44

How do you diagnose HCC?

Answer 44

a patient with known liver disease develops an abnormality on ultrasound or rising alpha fetoprotein (AFP)