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Hepatitis & Cirrhosis Flashcards

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1
Q

Liver Function Tests

A 
Aminotransferases (ALT/AST)
Alkaline phosphatase (AP)
Gamma glutamyl transpeptidase (GGT)
Albumin
Prothrombin time (PT)
BIlirubin
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2
Q

Types of Autoimmune Hepatitis

A 
Type 1 (Classic)
Type 2 (ALK-1)
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3
Q

Who does type 1 autoimmune hepatitis affect?

A

Women of all ages

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4
Q

Who does type 2 autoimmune hepatitis affect?

A

Girls & young women

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5
Q

Clinical Manifestations of Autoimmune Hepatitis

A

Mostly asymptomatic
Advanced cirrhosis
Fulminant hepatitis

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6
Q

Labs for Autoimmune Hepatitis

A

Serological markers present

Aminotransferases more elevated than bilirubin & AP

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7
Q

Extrahepatic Manifestations of Autoimmune Hepatitis

A 
Hemolytic anemia
Thyroiditis
Celiac sprue
ITP
Type I DM
UC
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8
Q

Treatment of Autoimmune Hepatitis

A

Corticosteroids

Azathioprine (2nd line)

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9
Q

Acute Complications of Steroid Therapy

A 
HGN
Hyperglycemia
Insomnia
Psychosis
Gastric Irritaiton
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10
Q

Chronic Complications of Steroid Therapy

A 
Osteoporosis
PUD
Glaucoma
Cataracts
Immunosuppresion
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11
Q

Define Hemochromatotosis

A

Gene defect resulting in increased iron absorption in the intestinal tract from the diet

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12
Q

What does hemochromatosis eventually lead to?

A

Cirrhosis
Cardiomyopathy
DB
Hypogonadism

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13
Q

When do symptoms of hemochromatosis usually occur?

A

Around age 40
Iron stores reach 15-40 g
Females delayed due to menstruation & breast feeding

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14
Q

Clinical Manifestations of Hemochromatosis are Influenced by What

A 
Age
Sex
Alcohol use
Dietary iron
Menstruation & breast feeding
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15
Q

What factors accelerate the process of hemochromatosis?

A

Alcohol abuse

Hepatitis C

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16
Q

Classic Presentation of Hemochromatosis

A

Cutaneous hyperpigmentation
DM
Cirrhosis

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17
Q

Reversible Cardiovascular Manifestations of Hemochromatosis

A

Cardiomyopathy
Vibrio vulnificus
Conduction disturbances
Listeria monocytogenes

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18
Q

Reversible Liver Manifestations of Hemochromatosis

A

Pastcuerlla psudotubercullosis
Abdominal pain
Elevated LFTs
Hepatomegaly

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19
Q

Reversible Skin Manifestations fo Hemochromatosis

A

Bronzing

Grayness

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20
Q

Irreversible Liver Manifestations of Hemochromatosis

A

Cirrhosis

Hepatocellular CA

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21
Q

Irreversible Anterior Pituitary Gland Manifestations of Hemochromatosis

A

Gonadotropin insufficiency

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22
Q

Irreversible Pancreas Manifestations of Hemochromatosis

A

DM

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23
Q

Irreversible Thyroid Manifestations of Hemochromatosis

A

Hypothyroidism

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24
Q

Irreversible Genitalia Manifestations of Hemochromatosis

A

Primary hypogonadism

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25
Irreversible Joint Manifestations of Hemochromatosis
Psuedogout
26
Diagnosis of Hemochromatosis
Clinical + Elevated transferrin Pathologic Liver biopsy (gold-standard)
27
Treatment of Hemochromatosis
``` Avoid red meat/ iron supplements Avoid ETOH Avoid raw seafood Hepatitis A&B vaccinations Phlebotomy: take off blood ```
28
Define Phlebotomy
Removal of 500 mL of blood
29
Goal of Phlebotomy
Hgb = 10-12 gm/dL | Ferritin
30
Maintenance Phlebotomy
Every 2-4 months
31
Define Wilson's Disease
Organ damage due to copper build up in the liver & brain
32
Pathogenesis of Wilson's Disease
Affects the carrier protein of copper | Impairs excretion of copper via bile
33
Clinical Manifestations of Wilson's Disease
Varies & non-specific Liver disease (young children) Neurologic symptoms Psychiatric symptoms
34
Diagnosis of Wilson's Disease
Ceruoplasmin level 24 hour urine Kayser-Fleischer rings in eyes
35
Treatment of Wilson's Disease
Chelation therapy with D-penicillamine
36
Three Stages of Alcoholic Liver Disease
Fatty liver (statosis) Alcoholic hepatitis Alcoholic fibrosis & cirrhosis
37
Fatty Liver
Occur within hours of alcohol binge Tender hepatomegaly Transaminases mildly elevated Can occur in obese individuals & pregnancy
38
Clinical Manifestations of Alcoholic Hepatitis
``` Anorexia N/V Weight loss Abdominal pain Poor nutritional status Jaundice Fever ```
39
Physical Exam Findings in Alcoholic Hepatitis
``` Spider angiomas Palmar erythema Gynecomastia Parotid enlargement Testicular atrophy Ascites Encephalopathy ```
40
Lab Findings in Alcoholic Hepatitis
``` Leukocytosis Anemia Transaminases elevated Increased alkaline phosphatase Hyperbilirubinemia Hypoalbunemia (severe disease) Coagulopathy (severe disease) Elevated ammonia level (severe disease) ```
41
Complications of Alcoholic Liver Disease
``` Alcoholic fatty liver is reversible Alcoholic hepatitis usually reversible Cirrhosis GI bleed Esophageal varices Gastritis/PUD ```
42
Treatment of Alcoholic Liver Disease
Cessation of alcohol Nutrition Vitamin B12 & folate supplements Fluids R/O other causes for fever, liver disease Glucocorticosteroids for severe hepatitis Liver transplant
43
Factors Influencing Toxicity in Toxic Hepatitis
``` Excessive intake Excessive cytochrome P450 activity Decrease metabolism pathways to liver Depletion of glutathione stores Concomitant use of ETOH or other drugs Comorbid illness Advancing age Nutritional status ```
44
Epidemiology of Drug-Induced Liver Injury (DILI)
Most common cause of liver failure in the US
45
Level of Injury in DILI
``` Elevations in liver enzymes Acute hepatitis Cholestasis Cytotoxic or mixed Steatosis Discontinuation of agent ```
46
Most common drugs implicated in DILI in the US
Acetaminophen | Antibiotics
47
Treatment of Acetaminophen Overdose
Acetaminophen level Activated charcoal N-acetylcysteine
48
Greater Risk of Developing Hepatotoxicity in Acetaminophen Intoxication
Ingestion of >7.5-10 g/day | Ingestions of
49
N-acetylcysteine recommended for
Patients with liver tenderness + Elevated aminotransferasis + Acetaminophen concentration >10 mcg/mL Acetaminophen concentrations toxic by nomogram
50
Types of Hepatitis
``` HAV HBV HCV HDV HEV HGV GBV-C ```
51
General Presentation of HAV, HBV, HCV, & HEV
``` Malaise Fatigue Anorexia N/V Myalgias Pale stools Dark urine Jaundice ```
52
Physical Exam Findings for Hepatitis
Jaundice RUQ pain +/- hepatomegaly
53
Labs for Hepatitis Diagnosis
``` Elevated transaminases Hyperbilirubinemia Birirubinuria Alkaline phosphatase mildly elevated WBC normal to low Prolonged PT ```
54
Viral Hepatitis Management
Supportive care Manage symptoms No acetaminophen, ETOH, & avoid other hepatitis viruses
55
Epidemiology of HAV
Worldwide US decreased due to vaccination No chronic infection
56
HAV Routes of Transmission
Fecal-oral route Close personal contact Contaminated food/water Blood exposure
57
SE of Hepatitis A Vaccination
Fever Injection site reactions Rash Headache
58
CBC Recommendations for Obtaining Hepatitis A Vaccination
``` Clotting factor disorders Chronic liver disease Men having sex with men Users of illicit drugs Traveling to endemic countries Anyone wishing to obtain immunity ```
59
Postexposure Prophylaxis HAV
Hepatitis A vaccine | IG
60
Situations for Postexposure Prophylaxis HAV
``` Close personal contact Sexual contact Sharing IV needles Child care centers Food handler cases Schools, hospitals, other work settings ```
61
HBV Modes of Transmission
``` Sexual contact Perinatal Horizontal Percutaneous Organ transplantation Transfusions ```
62
What is the major mode of HBV transmission in developed countries?
Sexual contact
63
What is the major mode of HBV transmission in underdeveloped countries?
Perinatal
64
Methods for HBV Transmission via Percutaneous Route
IVDU Body piercing Nosocomial
65
HBV Prevention
Hepatitis B vaccine
66
Post-exposure Prophylaxis
First dose of vaccine | Administer HBIG
67
Chronic HBV Infection
Nonspecific symptoms Exacerbations similar to acute infection Cirrhosis Hapatocellular CA
68
Extrahepatic Manifestations in HBV Infection
``` Fever Rash Arthralgias, arthritis Polyarteritis nodosa Glomerular disease ```
69
Types of HBV Serology
``` HbsAg HbcAg: Anti-HbsAg HbeAg HBV DNA assays ```
70
Hepatitis B Surface Antigen (HbsAg)
Prior to onset of symptoms | Present
71
Hepatitis B Core Antigen (HbcAg)
Intracellular antigen in affected hepatocytes | Acute infections
72
Anti-HbsAg
Persists for life Carriers of HBV Present after disappearance of HbsAg Only anti-HbsAg = immunization
73
Hepatitis B E Antigen (HbeAg)
Secretory protein | HBV replication & infectivity
74
HBV DNA Assays
Assess HBV replication Recovery from HBV associated with disappearance of HBV DNA Monitor chronic HBV
75
Treatment for Chronic HBV
Interferon | Peginterferon
76
Define Peginterferon
Modification of interferon so they don't have to have it as often
77
Indications for Treatment of HBV
HBeAG + High serum HBV DNA Active liver disease
78
Contraindications for Interferon/Peginterferon
Decompensated cirrhosis | Carriers for HBV
79
SE of Peginterferon
``` Flu-like symptoms Immunosuppression Abdominal pain N/V Dry mouth hair loss Blurred vision Depression Anemia ```
80
Other Medications for Treating Hepatitis B
Lamivudine (Epivir) Adefovir (Hepsera) Entecavir (Baraclude) Telbivudine (Tyzeka)
81
Epidemiology of HCV
Most common chronic liver disease Decreasing in numbers in US Majority of liver transplants in US
82
Transmission of HCV
``` IVDU/sex with IVDU Jail 3+ days Religious scarification Blood transfusion Struck/cut with bloody object Pierced body parts Immunoglobulin injection Perinatal transmission Solid organ transplant ```
83
Who should be screened for HCV?
``` Ever IVDU Clotting factors before 1987 Blood/organs before July 1992 On chronic hemodialysis Evidence of liver disease Infected with HIV Healthcare workers after exposure to HCV + blood/mucus Children born to HCV + mothers ```
84
Symptoms of Chronic HCV Infection
Fatigue
85
Diagnosis fo HCV
HCV rises within 8 days to 8 weeks Anti-HCV + within 12 weeks Difficult to distinguish acute vs. chronic
86
Management of HCV
``` Assess severity of disease ETOH cessation no Tylenol No jail Vaccinate against Hep A & B ```
87
Evaluation for Treatment of HCV
Liver biopsy Test for HIV Evaluate for other liver disease Continued IVDU/ETOH abuse
88
Treatment for Chronic HCV
Peginterferon Ribavirin Protease inhibitors
89
How to assess for treatment response to HCV
HCV RNA - | Sustained RNA - 6 months after treatment
90
SE of Peginterferon or Ribavirin
``` Bone marrow suppression Myalgias Headaches Low grade fever Neuropsychiatric symptoms Non-productive cough/dyspnea Ischemic retinopathy Retinal hemmorrhage Thyroid dysfunction Rash, hair loss, hearing loss, insomnia ```
91
Protease Inhibitors
Showing promise Very spend Many SE
92
Liver Transplantation for HCV Patients
New liver can be infected with HCV Treatment with peg interferon + ribavirin may prolong survival Younger liver that is already HCV + seems to help
93
HDV
Requires HBV to replicated (HBsAG coat)
94
HDV Genotypes & Locations
Genotype 1: western world Genotype 2: eastern world Genotype 3: Venezuela, Columbia, Brazil, Peruvian, & Amazon bases 5 others known
95
Genotype 1 HDV
Increased risk for fulminant course | Progression to cirrhosis rapid
96
Transmission of HDV
Parenteral Close personal contact Multiple transfusions Contaminated dialysis equipment
97
Clinical Features of HDV
Co-infection with HBV | Super-infection on top of chronic HBV
98
Prevention & Treatment of HDV
Hepatitis B vaccine IVIG for Hep B Chronic HDV: pegintereron
99
Epidemiology of HEV
Waterborne virus | No chronic form
100
HEV Transmission
Fecally contaminated water Blood transfusion in endemic areas Mother to newborn
101
Epidemiology of GBV-C
High incidence in US Flavivirus Doesn't cause hepatitis in humans Protective effect with co-infections with HIV
102
Acute Hepatitis Complications
Cholestatis hepatitis Raging fulminant hepatitis Chronic hepatitis (Hep B, C, D)
103
Typical Progression of Chronic Hepatitis
Chronic inflammation in portal areas Necrosis/inflammation Fibrosis Cirrhosis
104
Define Cirrhosis
Development of fibrosis of liver with formation of regenerative nodules Results in impairment of synthetic, metabolic, & hemodynamic functions of liver
105
Diagnostics of Cirrhosis
US CT MRI Biopsy: gold standard
106
How to determine etiology of cirrhosis?
History | labs
107
Etiologies of Cirrhosis
``` Alcohol hepatitis Chronic HCV Cryptogenic Primary biliary cirrhosis (PBC) Chronic HBV Wilson's disease Hemochromatosis Non-alcoholic steatohepatitis ```
108
Lab Abnormalities in Cirrhosis
``` Elevated AST/ALT Slightly elevated alkaline phosphatase Bilirubin elevated Albumin falls PT increases Hyponatremia High levels of ADH Pancytopenia ```
109
Why Anemia in Cirrhosis?
``` Acute/chronic GI bleed Folate deficiency Hypersplenism Bone marrow suppression Anemia of chronic disease ```
110
Define Portal HTN
Increased blood pressure in the portal vein due to increased resistance to the blood passing through the vessels in the liver
111
Portal HTN Results in
``` Esophageal varices Caput medusa Hemorrhoids Splenomegaly Ascites Palmar Erythema ```
112
Management of Portal HTN
Remove ascitic fluid Portal shunts Treat liver disease Liver transplant
113
Reversible Neuropsychiatric Abnormalities in Hepatitis Encephalopathy
Cognitive abilities Psychiatric state Motor impairment
114
Precipitating Causes of Hepatic Encephalopathy
``` Cirrhosis Hypovolemia GI bleed Hypokalemia/metabolic alkalosis Hypoxia Sedatives or tranquilizers Hypoglycemia Infection Hepatoma/ vascular occlusion ```
115
West Haven Criteria for HE Stage 0
Consciousness: normal Intellect & behavior: normal Neurologic: normal
116
West Haven Criteria for HE Stage 1
Consciousness: mild lack of awareness Intellect & behavior: shortened attention span Neurologic: mild asterixis/tumor
117
West Haven Criteria HE Stage 2
Consciousness: lethargic Intellect & behavior: disoriented, inappropriate behavior Neurologic: obvious asterixis, slurred speech
118
West Haven Criteria HE Stage 3
Consciousness: somnolent but arousable Intellect & behavior: gross disorientation, bizarre behavior Neurologic: muscular rigidity, clonus, hyper-reflexia
119
West Haven Criteria HE Stage 4
Consciousness: coma Intellect & behavior: coma Neurologic: decerebrate posturing
120
Diagnosis of HE
Neurotoxins: ammonia & manganese CT MRI
121
Treatment of HE
``` Lactulose Correct hypokalemia Determine stage Exclude non-hepatic causes of altered mental function Low protein Rifampin Intubation ```
122
SE of Lactulose
``` Abdominal cramping Bloating Flatulence Severe diarrhea or electrolyte abnormalities Ileus Hypovolemia ```

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