Cumulative Final - Hepatology (Isaacs)

Question 1

What are true markers for liver function?

Answer 1

AST
ALT
Alk phos

Question 2

Estimated incidence of DILI

Answer 2

The estimated incidence of DILI is 14-19 cases per 100,000 people

Question 3

Mechanisms/classifications of different types of DILI?

Answer 3

Direct hepatotoxicity, idiosyncratic hepatotoxicity, and indirect hepatotoxicity

Question 4

What medications are highest risk for causing DILI (See Table 3)?

Answer 4

Acetaminophen and anti-infectives (isoniazid, beta lactam antibiotics, fluoroquinolone antibiotics, macrolide antibiotics)

Question 5

What is considered high doses of APAP?

Answer 5

> 8 grams acetaminophen

Question 6

High doses of APAP can result in toxic levels of _____

Answer 6

NAPQI (can cause direct hepatotoxicity)

Question 7

Tx for APAP DILI

Answer 7

Reverse toxic metabolite with NAC (if in grey part on graph) – binds NAPQI

Activated charcoal (if < 2H since ingestion)

Question 8

What do we monitor for APAP DILI?

Answer 8

AST
ALT
S/Sx of OD

Question 9

NAC SE

Answer 9

N/V, GI issues
** If pt cannot handle these, give IV NAC

Question 10

What should be done if APAP DILI was intentional OD?

Answer 10

Psych evaluation is appropriate and monitor for s/sx of depression

Question 11

What is cirrhosis?

Answer 11

Severe, chronic, irreversible fibrosis of the liver

Question 12

1 causative factor of cirrhosis in the US

Answer 12

Chronic alcohol use

Question 13

What is a unique symptom for someone with cirrhosis?

Answer 13

Jaundice

Question 14

Other symptoms of cirrhosis

Answer 14

Weight loss
Ascites
Jaundice
-megaly
Encephalopathy (confusion)

Question 15

How is cirrhosis diagnosed?

Answer 15

Liver biopsy

Question 16

What values do we look at to determine severity of cirrhosis?

Answer 16

Bilirubin
Albumin
Ascites
Encephalopathy
Prothrombin time
(all part of the child-pugh score)

Question 17

What model do we look at for assessing the severity of cirrhosis?

Answer 17

MELD (predicts 3-month mortality)
**Used in transplant prioritizations
**Not used to adjust medications

Question 18

Is cirrhosis reversible?

Answer 18

NO!!!!

Question 19

What are ascites?

Answer 19

Fluid accumulation in the peritoneal space

Question 20

What medication class should we avoid in patients with cirrhosis?

Answer 20

NSAIDs

Question 21

Non-pharm options for ascites management

Answer 21

Na+ restriction (< 2 grams/day)
Assess MELD score

Question 22

First line option for ascites

Answer 22

Aldosterone antagonist (spironolactone) + loop diuretic (furosemide)

Question 23

Recommended ratio of spironolactone: furosemide

Answer 23

100:40

Question 24

Max ratio of spironolactone:furosemide

Answer 24

400:160

Question 25

Second line option for ascites management

Answer 25

Paracentesis TIPS

Question 26

Aldosterone antagonists _____ potassium and loop diuretics ____ potassium levels

Answer 26

Increase Decrease

Question 27

Both, spironolactone and furosemide, can cause

Answer 27

AKI

Question 28

What is given for pts that get more than 5 L removed via paracentesis?

Answer 28

ALBUMIN (helps retain fluid in vasculature)

Question 29

If more than 5L is removed via paracentesis, how much albumin do we give?

Answer 29

6-8 g/L of fluid removed of 25% albumin

Question 30

What is monitored for ascites tx?

Answer 30

S/Sx of ascites Renal function Potassium (goal: 3.5-5)

Question 31

What are esophageal varices?

Answer 31

Compensatory "varices" or small offshoots -Dilation of EV can cause variceal bleeding

Question 32

Variceal bleeding prophylaxis

Answer 32

NSBB EVL ***CHOOSE 1 OR THE OTHER***

Question 33

Titrate NSBB to a HR goal of ____, but maintain a SBP ____

Answer 33

< 60 bpm > 90 mmHg

Question 34

NSBB options for EV

Answer 34

Nadolol Propranolol Carvedilol

Question 35

Are PPI recommended for variceal bleeding?

Answer 35

NO; only used in non-variceal bleeding

Question 36

Upon presentation of EV bleeding, what should be done?

Answer 36

1. Transfusion (Hgb > 7) 2. Octreotide 2-5d 3. Ceftriaxone 7d ***Until we can get surgery

Question 37

What surgery is done for EV bleed?

Answer 37

EVL

Question 38

After EVL, what is done?

Answer 38

Secondary prophylaxis with NSBB AND EVL

Question 39

Underlying patho of HE

Answer 39

Ammonia accumulation -- leads to neuronal dysfunction and HE

Question 40

S/Sx of HE

Answer 40

Jaundice precedes delirium, convulsions

Question 41

Recommended tx for acute management of HE

Answer 41

Lactulose 25 ml BID

Question 42

We adjust lactulose to ___ BM/day

Answer 42

3

Question 43

Diagnosis for SBP

Answer 43

Therapeutic paracentesis **PMN > 250 cells/mm3

Question 44

PMN equation

Answer 44

PMN = WBC from fluid x (% neutrophils)

Question 45

SBP tx

Answer 45

Ceftriaxone IV x 7d + Albumin IV

Question 46

After intial tx for SBP, what is secondary prophylaxis protocol?

Answer 46

Bactrim (SMX/TMP) QD indefinitely Ciprofloxacin QD