Flashcards in Hepatitis and Liver Disease Deck (96)
AST/ALT levels leading to differentials
Toxic or ischemic injury when >1000
Acute Hep C, A, C >300-3000
Chronic Hep B and C about 100
Liver disease with highest prevalence in US
Nonalcoholic fatty liver disease
Abnormal labs seen in hepatitis
Liver tests/LFTs: hepatocellular pattern (<10xULN)
Predominantly increased ALT and AST (liver transaminases)
Maybe elevated ALP (sometimes see in NASH)
What is hepatitis?
Inflammation of the liver
General guidelines to interpret increased AST/ALT
AST:ALT >2 (alcoholic liver disease)
ALT>AST (NASH and usually ratio is less than 1 and acute/chronic viral hepatitis)
What is a fatty liver?
What is non-alcoholic steatoheatitis (NASH)?
Fatty liver with inflammation of liver with hepatocyte injury (higher risk in developing fibrosis and cirrhosis)
Biopsy may show fibrosis (scarring of liver)
What is a non-alcoholic?
<20g ETOH/day (<2-3 drinks/day)
Subtypes of nonalcoholic fatty liver disease
Isolated steatosis (NAFL)
Non alcoholic steatohepatitis (NASH)
What is isolated steatosis?
Fatty liver without injury or fibrosis of hepatocytes on bx
Minimal risk of progression to cirrhosis
What should be considered in all pts with NAFLD?
Aggressive modification of CVD risk factors (also DM)
Risk factors of NAFLD
DM2 (insulin resistance)
Hyperlipidemia (high TG and low HDL)
Genetic factors-PNPLA3, TM6SF2 and age (less common)
Strongest predictor for NASH
What is seen on biopsy for NAFLD/NASH?
Steatosis (fat accumulation)
Inflammation and maybe fibrosis
(will see fatty infiltration on imaging)
*gold standard but not necessary for dx
Lab features of NASH
Hepatocellular pattern (mild elevation ALT/AST rarely above 300)
Normal bilirubin, albumin, INR
Ferritin elevated (marker for inflammation)
ALP elevated in 1/3 and maybe GGT
Cornerstone of management for NASH
Exercise and weight loss
How can weight loss help NASH?
>3% improves steatosis
7-10% NASH resolution
>10% fibrosis regression seen
Other management for NASH
Minimize alcohol, modify CVD risk factors, control DM and HLD, monitor LFTs, vaccinate Hep A and B (check for IgG Ab etc)
What is hereditary hemochromatosis?
Hereditary disorder of iron metabolism (genetic mutation results in increased GI absorption of iron and leads to accumulation in liver/pancreas/heart/other organs)
Clinical findings of hereditary hemochromatosis
FHx or incidental note increase AST/ALT
Caucasians or northern european origin
Fatigue, malaise, RUQ discomfort
Late manifestations of hereditary hemochromatosis
(generally seen in 4th-5th decade)
Hepatomegaly, hepatic insufficiency, cirrhosis, DM, impotence, arthralgia (2nd and 3rd MCPs), bronze pigmentation of skin, cardiomegaly with/without CHF
Triad of DM, bronze pigmentation of skin and cirrhosis
Labs in hereditary hemochromatosis
Elevated LFTs (AST, ALT, alk phos)
Screen with serum Fe and TIBC and ferritin (Fe/TIBC equals transferrin saturation)
What to do if transferrin sat >45 and/or ferritin >200 ng/mL in men or >150 ng/mL in women?
Proceed to GI (HFE mutation and analysis)
Tx is therapeutic phlebotomy
How to diagnose hereditary hemochromatosis
Genetic testing and maybe liver biopsy
Tx for hereditary hemochromatosis
Prevent cirrhosis from iron overload
Avoid vit C and iron supplements, uncooked shellfish and EToH
Do regular phlebotomy (therapeutic)
Cirrhosis screen q 6 mos (US and AFP)
What to do for all 1st degree relatives in hereditary hemochromatosis?
Genetic screening (HFE genotype) and iron testing
Who do you screen for hereditary hemochromatosis in (AASLD)?
Elevated liver tests (AST/ALT)
Abnormal iron studies
First degree relative dx with HH
Evidence of liver disease
Suggestive sxs of HH
What is Wilson's disease?
Very rare hereditary disorder of copper metabolism
Genetic defect results in decreased excretion of copper into bile and accumulation of copper in liver (when exceeds that it builds up everywhere else)