Hepatology Flashcards
(524 cards)
1
Q
Can non-hepatitis viruses (EBV, CMV, HSV, Influenza, COVID) that cause viral hepatitis, cause CHRONICITY?
A
NO!
2
Q
Which VIRUS is the most COMMON cause of non-hepatitis virus ACUTE HEPATITIS?
A
EBV
3
Q
Who is most SUSCEPTIBLE to VIRAL HEPATITIS from the non-hepatitis viruses (EBV, COVID, etc.)?
A
Children and Immunocompromised (HIV, Transplant, Chemotherapy)
4
Q
Which HEPATITIS VIRUS has shown the greatest INCREASE in INCIDENCE over the past 10 years?
A
HAV (narcotics, homelessness)
5
Q
What can SIMULTANEOUS CO-INFECTION with HBV & HDV cause?
A
Fulminant Hepatic Failure
6
Q
What causes a HIGH-RATE of hepatitis CHRONICITY in patients infected with HBV?
A
HDV Superinfection (found in 40% of patients infected with HBV - immigrants)
7
Q
If a patient from OUTSIDE the USA presents with HEPATITIS symptoms but tests for HAV, HBV, HCV are negative, WHAT should you test for next?
A
HEV (very prevalent outside the US - food) and in OLDER 60-80 age groups - FECES of PIG, SHEEP, WILD BOAR, DEER, FISH - genotypes III & IV - hunters, eating the meat, handling feces**
8
Q
What PHASE of hepatitis infection is ASYMPTOMATIC and how long is it for HAV, HBV and HCV?
A
INCUBATION phase:
HAV (4 WEEKS)
HBV (3 MONTHS)
HCV (6 WEEKS)
9
Q
What PHASE of hepatitis infection presents with FLU-LIKE symptoms (3-5 days), RUQ tenderness, LFT elevations and POSITIVE serology?
A
PRODROME
10
Q
An UNCOMMON (<20%) hepatitis PHASE which can last DAYS to WEEKS?
A
ICTERIC
11
Q
In which hepatits PHASE do the LFTs normalize and ANTIBODIES are formed?
A
RESOLUTION
12
Q
Which HBV patients develop CHRONIC infection at a rate of 90% vs 5-10%?
A
INFANTS (vertical transmission)
13
Q
Which hepatitis VIRUSES have the HIGHEST potential for CHRONIC infection?
A
HBV (INFANTS ONLY - 90% vs 5-10% adults)
HCV - 85%
HDV - 90% (only with SUPERINFECTION i.e. on top of HBV)
14
Q
Which VIRAL hepatitis NEVER causes Acute Liver Failure?
A
HCV
15
Q
Age >40, HAV/HEV or HBV, ALT >10,000, Bilirubin >10, elevated INR, ENCEPHALOPATHY?
A
ALF (Acute Liver Failure) 80% mortality without TRANSPLANT
16
Q
What 2 factors increase RISK of ALF in HAV?
A
- Age >40
- CHRONIC liver disease
17
Q
What FACTOR increases the RISK of ALF in HEV?
A
PREGNANCY
18
Q
What 3 factors increase the RISK of ALF in HBV?
A
- Age >40
- Seroconversion (from viral infection to antibody production HBeAb, HBsAb)
- Superinfection with HDV
19
Q
What are the COMMON EXTRAHEPATIC (immune-complex deposition) manifestations of HBV and HCV?
A
Cryoglobulinemia
Glomerulonephritis
Lichen Planus
Guillian Barre (HBV)
Polyneuropathy (HCV)
20
Q
What are the UNIQUE EXTRAHEPATIC manifestations of HBV?
A
Polyarteritis Nodosa (PAN)
Bullous Pepnhigoid
21
Q
What are the UNIQUE EXTRAHEPATIC manifestations of HCV?
A
Porphyria Cutanea Tarda (PCT)
DM-II
B-Cell Lymphoma
22
Q
Arthritis, Adult Still Disease and ATN are seen in EXTRAHEPATIC manifestations of what hepatitis virus?
A
HAV
23
Q
Pancreatitis, Myocarditis and Thyroiditis are EXTRAHEPATIC manifestations of what hepatitis virus?
A
HEV
24
Q
In which VARIANT of viral hepatitis are the ALK PHOS and T.bilirubin HIGHLY ELEVATED with jaundice and can last up to 12 WEEKS?
A
CHOLESTATIC variant of HAV
25
In which **VARIANT** of viral hepatitis do the **LFTs** (ALT & Bili) normalize then **RELAPSE** every **4-15 WEEKS** for up to a **YEAR** with **POSITIVE** **IgM**?
**RELAPSING HAV**
26
The **ELEVATED** **LFTs** which ocurr in **acute HBV** infection is associated with what?
**POSITIVE SEROLOGIES** (HBcAb IgM & IgG, HBsAg, HBeAg, HBV DNA)
27
**HBsAb** & **HBeAb** develop in what percentaage of the population signifying what?
**>95%** (spontaneous **resolution** of HBV - **immune** to re-infection)
28
Which patients typically develop **HBV IMMUNE TOLERANT STATE**?
Those who contracted the virus in **INFANCY**
29
Which **SEROLOGIES** remain **POSITIVE** in the **HBV IMMUNE TOLERANT STATE** (normal ALT, no inflammation, no fibrosis)?
HBV **DNA** (very **HIGH**)
HB**sAg**
HB**eAg**
HB**cAb IgG**
30
What is the **TREATMENT** of **HBV IMMUNE TOLERANT STATE**?
**NONE**
31
What is **CHRONIC HBV** (loss of immune tolerant stage)?
HB**eAg** **POSITIVE**
32
A patient with a **DROP** in **HBV DNA**, **POSITIVE** HB**eAg**, **ELEVATED ALT** from a state of **HIGH HBV DNA** with normal **ALT** indicates what?
Conversion to **ACTIVE HBV** infection and **LOSS** of **IMMUNE TOLERANT STATE** (50% of immune tolerant patients in 5 years)
33
What should be done with **IMMUNE TOLERANT STATE** patients?
**MONITORED** regularly for convesion to **CHRONIC HBV** and loss of immune tolerant state - **50% in 5 years** (may develop the HBeAb)
34
Which **Hep B** patients in the **IMMUNE TOLERANT** (IT) phase should be **TREATED**?
Those at **HIGH-RISK** of **LIVER CANCER** (family history, ALT >25, age >45, significant inflammation or fibrosis on liver biopsy)
35
What is the **DETERMINING** **FACTOR** of whether a patient has **ACTIVE** or **INACTIVE** Hep B?
**Presence** or **Absence** of the HB**eAg**
If present (active) if HB**eAb** present (**inactive**)
36
What happens when **CHRONIC Hep B** patients have a **FLARE** (**LFTs** go up) in which **HBeAg** **dissapears** and HB**eAb** **appears** (HBsAg still present, HBcAb IgG present, HB**cAb IgM** may be positive again, HBV **DNA decreases** or disappears)?
Spontaneous loss of HBeAg with **INACTIVE** Hep B
37
What can happen if a **Hep B** patient **FLARES** (loss of HBeAg)?
Can develop **Acute Liver Failure** (ALF)
38
How can you have HB**eAg** **NEGATIVE ACTIVE Hep B**?
**Mutation** in the **e-GENE** of the **HBV**
39
Why is the **eAg** so important in **Hep B**?
Because it is the **TARGET** of the **IMMUNE** response to **INACTIVATE** **Hep B** (without it, HBV CANNOT be inactivated)
40
What is **DIFFERENT** about the **CHOLESTATIC** form of **Hep A** infection vs non-cholestatic form?
In the CHOLESTATIC form, **Alk Phos** is **MUCH** **HIGHER**
41
What remains **POSITIVE** in the **RELAPSING** form of **Hep A**?
Hep A **IgM**
42
In **Hep B** patients, what is significant about **LOSS** of **HBsAg** and gain of the **HBsAb**?
**RESOLUTION** of Hep B
43
WHY is the **E-antigen** **PRESENCE** important?
Because it is the **TARGET** of our **IMMUNE** response, without it, an e-Ag
44
What did the **REVEAL** study show?
That the risk of developing cirrhosis amd HCC from HBV was DIRECTLY related to **HBV DNA** levels
45
At what level of **HBV DNA** is the risk of developing **HCC VERY HIGH**?
>20,000
46
At what **HBV DNA** level should you treat a patient with **chronic diseases**, **comorbidities**, **>50** yo and **HBeAg NEGATIVE** status?
**>2,000** (because RISK of HCC starts getting higher between 2,000-20,000)
47
In otherwise **HEALTHY** patients especially **HBeAg POSITIVE**, at what level of **DNA** would you start treatment?
>20,000
48
What **MUST** be tested for **ALL** individuals who have **Hep B** whether active or inactive disease?
**US** every **6 MONTHS**
49
In which hepatitis, **HBV** or **HCV** can you develop **HCC** **WITH** or **WITHOUT** **cirrhosis**?
**HBV** (in HCV, ONLY with cirrhosis)
50
Whom whould be **vaccinated** for **Hep B**?
ALL **CHILDREN** (and healthcare workers)
51
Whom should be **vaccinated** for **Hep A**?
ALL individuals prior to **TRAVEL** to endemic areas (Caribbean, Mexico)
52
In households of **INTIMATE CONTACTS** of individuals with **HAV** or **HBV**, how should they be treated?
**Serum IgG** or **HBIG (Hep B IgG)**
53
What individuals require a **Hep B BOOSTER**?
If initially vaccinated and **responded** (**HBsAb+**) and then when **exposed**, you had **HBsAb-** (years later), **GET** a **BOOSTER** and **document HBsAb+** **THAT'S IT**, **NO MORE** boosters after further exposures
54
**50%** of **Hep B GENOTYPE A** patients **SEROCONVERT** (HBsAb/HBeAb) with what **DRUG**?
PEG-Interferon
55
In what **HBV** patients is **PEG-INF NOT** able to be used?
**HBeAg NEGATIVE** (only TDF, **TAF-less drug, less toxic** or Entecavir)
56
**WHEN** can you **stop therapy** in **HBeAg NEGATIVE** patients?
**NEVER**
57
**WHEN** can you **STOP THERAPY** in **HBeAg POSITIVE** patients?
**6 MONTHS** after they **SEROCONVERT**(HBeAb)
58
When initiating **ANTIBIOLOGIC** treatment for **IBD** in a patient positive for **HBV** an **HCV** what else do you do?
**TREAT** for **BOTH** **HBV** and **HCV** as well as the **IBD** (because **HBV WILL FLARE** even if inactive)
59
**HBV** patients with **POSITIVE HBsAg** treated with long-term **IMMUNOTHERAPY**, **MONOCLONAL BIOLOGIC** agents, **CANCER CHEMOTHERAPY** or treatment of **CHRONIC HCV CO-INFECTION MUST BE TREATED** for?
**HBV** with **ANTIVIRAL** agents
60
When using **RITUXIMAB**, if a patient is **HBsAg NEGATIVE BUT HBcAb POSITIVE**, or **HBsAg NEGATIVE and HBsAb NEGATIVE** or **LOW-TITER HBsAb**, they require treatment for?
**HBV** with **ANTIVIRAL** agents
61
In a patient with chronic **HCV** and **Y93H** mutation, how do you **TREAT**?
EPCLUSA (**SOF**osbuvir + **VEL**patasvir) for **12 WEEKS** (DO NOT use in **CIRRHOSIS** with the Y93H mutation)
62
**HCV** patients with **CHILDS CLASS B & C** cannot use **WHAT** antiviral drugs in their treatment regimens?
**PROTEASE INIBITORS** (**SOF**osbuvir)
63
Which **HCV** patients are **NOT** treatment candidates?
**LIMITED life** expectancy and **MILD fibrosis**
**ADVANCED** stage **3-4 HCC**
**CHILDS Class C CIRRHOSIS** with **HIGH MELD** who ARE **TRANSPLANT** candidates
**ACTIVE IVDA** who don't want to stop
64
What do you use to **SCREEN ALL** patients for **HBV** who will begin treatment for **HCV**?
**ALL 3** MARKERS: HBsAg, HBcAb, HBsAb
65
Patient has **ACTIVE HBV** and is about to begin treatment for **HCV**, how do you treat?
**BOTH** HBV and HCV therapy
66
Patient has **INACTIVE HBV** and is about to begin treatment for **HCV**, how do you treat?
Treat **HCV** and **HBV** (prophylaxis) then **STOP HBV** treatment **6 MONTHS after HCV is cured**
67
Patient has **ISOLATED HBcAb** and is about to begin treatment for **HCV**, how do you treat?
**ONLY the HCV**, monitor for HBV
68
Patient has **RESOLVED HBV (HBsAb)** and is about to begin treatment for **HCV**, how do you treat?
**ONLY HCV**
69
If a patient is **POSITIVE** for **HBsAg**, what do you test for next?
**HBV DNA;
HBeAg;
HBeAb**
70
What happens to the **LIVER** of patients who are **successfully treated** for **HBV** and **HCV**?
**Regression** of **FIBROSIS** and **CIRRHOSIS**
71
**Curing** patients of **HCV** reduces their **RISK** of developing what **THREE** associated **DISEASES**?
**B-Cell Lymphoma**; **DM**, **ESRD**
72
Does **CHRONIC LIVER DISEASE** or **CIRRHOSIS** increase the risk of drug-induced hepatotoxicity?
**NO**
73
What happens if **DRUG TOXICITY** occurs in a patient with **CIRRHOSIS** or **CHRONIC LIVER DISEASE**?
It will be **MORE SEVERE** and increase the risk of developing **ALF**
74
What are the two most common agents of **DILI** in **CHILDREN**?
**ASA**, **VALPROIC ACID**
75
What factors increase the risk for **DILI** in adults?
Age **>50**, **Obese**, **Malnourished**, **Women**, **Dose**, **Alcohol**
76
Hepatic **Phase I** (cyt **P450**) does what to an ingested drug that makes it potentially toxic or an allergen (fever, rash, eosinophilia)?
Makes it into an **ACTIVE METABOLITE**
77
What is the hepatic **Phase II** reaction of an ingested drug?
**DETOXIFIES** active metabolites and makes them into **waste** products
78
What **GENETIC** mechanism results in **PRESENCE** or **ABSENCE** of **TOXICITY** to **INH**?
Genetic variation in **ACETYLATING** enzymes (fast/slow) in individuals
79
What do cyt **P450** **competitor** drugs cause?
**REDUCTION** of active metabolite (toxic or not)
80
What do cyt **P450** **INDUCER** drugs cause?
**INCREASE** of active metabolite (toxic or not)
81
What happens when two or more drugs **COMPETE** for cyt **P450**?
**ACTIVE** (potentially toxic) **metabolites** get created more **SLOWLY**, hence **LESS** active drug and less **TOXICITY**
82
Which are the **FOUR** (4) most common cyt **P450 INDUCERS** (cause active metabolite to be created whether toxic or not)
**ETHANOL**, **PHENYTOIN**, **RIFAMPIN**, **OMEPRAZOLE**
83
What is the **HEPATIC** process of **ADAPTATION**?
Initial **LFT** **ELEVATION** with a drug (up to **3x NL**) then the LFTs **normalize**
84
If a patient does not undergo hepatic **ADAPTATION** with a new drug, what could be the **UNDERLYING** cause?
**NAFLD**
85
In a patient whom was started on a drug and **LFTs** are in the **3-5 x ULN**, what is the next step?
If **NO JAUNDICE**, **monitor**. If develops jaundice STOP (10% risk of ALF)
86
In a patient started on a drug, **LFTs** are in the **3-5 x ULN** and they develop **JAUNDICE**, or if the LFTs are **5 x ULN**, what is the next step?
**STOP** the drug, give **N-acetylcysteine**
87
In a patient taking a new **DRUG**, with **LFT** elevation, what do you do if **JAUNDICE** occurs?
Immediately **STOP** the drug
88
What is the most **COMMON** type of **DILI**, it resolves when the drug is **STOPPED**, there is **JAUNDICE** and **ITCHING**?
**CHOLESTATIC** (elevated **ALK PHOS** and **BILIRUBIN** rather than ALT/AST) jaundice is **NOT** an ominous sign as with non-cholestatic DILI
89
In a patient whom received **CHEMOTHERAPY** in the past, what is the most common **HEPATIC** presentation?
**ASCITES**
90
**THROMBOSIS** of which **HEPATIC** vessel causes **ASCITES**?
**HEPATIC VEIN** (not portal vein) - becauses it causes **NON-CIRRHOTIC PORTAL HTN**
91
What is **SINUSOIDAL OBSTRUCTIVE SYNDROME** (SOS)?
**Chemotherapy**-induced liver injury with **PORTAL HTN**, **ASCITES**, **VARICES** but **NORMAL-APPEARING LIVER** on imaging
92
Besides sinusoidal obstructive syndrome, what is the other liver **INJURY** that **CHEMOTHERAPY** can cause?
**NODULAR REGENERATIVE HYPERPLASIA** vascular injury to the portal tracts (hepatocytes proliferate between fortal tracks WITHOUT cirrhosis) - liver **LOOKS NODULAR**
93
What type of **IMMUNOTHERAPY** causes **HEPATOTOXICITY** in **~60 DAYS** after starting drug, **AST/ALT** elevated (**600**) and **ALP** (**300**)? How is it **TREATED**?
**Check Point Inhibitors** (CHI)
Treat with **STEROIDS** **+/- Mycophenolate Mofetil** or **STOP DRUG**
94
If a patient develops **HEPATOTOXICITY** with **Check Point Inhibitors**, what is their **RISK** of developing this again with **RE-TREATMENT**?
**17%-28%**
95
What is meant by an acetaminophen **THERAPEUTIC** **MISADVENTURE**?
When an acetaminophen **OVERDOSE** is caused by a **LOWER THAN NORMAL** toxic dose taken in **COMBINATION** with other cyt **P450** **INDUCERS** like **ALCOHOL**
96
What **INCREASES RISK** of **HEPATOTOXICITY** with **ACETAMINOPHEN** in patients with **CHRONIC LIVER DISEASE** or **CIRRHOSIS**?
Drinking **ALCOHOL** in past **6 MONTHS**
97
How **LATE** post **ACETAMINOPHEN TOXICITY** is **N-ACETYLCYSTEINE** still **100% EFFECTIVE**?
Up to **16 HOURS** (16-24 hours 3% mortality, >24 hours 15% mortality)
98
If a patient presents with **ACETAMINOPHEN TOXICITY >24 HOURS**, how do you **TREAT**?
**IMMEDIATE N-ACETYLCYSTEINE** and **TRANSFER** to **TRANSPLANT** center
99
**STEROIDS** are **ONLY** effective treatment for what **LIVER DISEASES**?
**AIH** (includes checkpoint inhibitors)
ACUTE **ALCOHOLIC** HEPATITIS
100
Which **SEROLOGIC** markers are relevant to **AIH**, **PBC** and **PSC**?
**AIH**: ANA, SMA
**PBC**: AMA
**PSC**: ANCA
101
What are the **BIOCHEMICAL** patterns seen in **AIH**, **PBC** and **PSC**?
**AIH**: Hepatocellular (AST/ALT)
**PBC**: Cholestatic (ALP/Bili)
**PSC**: Cholestatic/Mixed
102
What is the **HISTOLOGY** pattern seen in **AIH**, **PBC** and **PSC**?
**AIH**: **Piecemeal Necrosis**, Lobular Inflammation, **Interface hepatitis**
**PBC**: Inflammatory **Cholangiopathy**
**PSC**: Bland Portal and Periductal **FIBROSIS**
103
Which of **AIH**, **PBC**, **PSC** is seen predominantly in **MEN**?
**PSC**
104
Which of **AIH**, **PBC**, **PSC** is associated with **HLA DR3/DR4**?
**AIH**
105
Which of **AIH**, **PBC**, **PSC** is associated with **HLA DRW8**?
**PBC**
106
Which of **AIH**, **PBC**, **PSC** is associated with **HLA B8/DR3**?
**PSC**
107
**Sicca** Syndrome, **RA** and **Thyroid** disease are AI disorders seen in which **autoimmune liver disease**?
**PBC**
108
IBD (80% **UC**) is associated with which **autoimmune liver disease**?
**PSC**
109
What are the positive **SEROLOGIC** markers seen in **AIH** **Type-I**?
**ANA**, **SMA**
110
A more **SEVERE** and **RAPIDLY PROGRESSIVE** form of **AIH** found in **EUROPEANS**, **Type-II** has which **SEROLOGIC** markers?
**Anti-LKM** (liver, kidney, microsomal)
**Anti-LC1**
111
**PERSISTENT ALT/AST** elevation, abnormal liver **US**, abnormal **ELASTOGRAPHY** but **NEGATIVE SEROLOGIC** markers? Next step?
**AIH** - ALWAYS **BIOPSY** before treating
112
What is **OFTEN** confused for **NASH** prior to **BIOPSY** based on ALT/AST and imaging?
**AIH**
113
A patient found with **STABLE** or **DECOMPENSATED** cirrhosis with **NORMAL LFTs**, **NO INFLAMMATION** on liver biopsy, and positive **SEROLOGIC** markers for **AIH**? How do you **TREAT**?
**CRYPTOGENIC** (burned-out) CIRRHOSIS
**NO TREATMENT** (no improvement)
114
What do you do for a patient with **AIH** who develops hepatic **DECOMPENSATION**?
Liver **TRANSPLANT**
115
How **LONG** do you treat **AIH** with **PREDNISONE** for? **Then**?
Until **ALT** is **NORMAL** (start at **60**, HOLD at **20**)
Once ALT is normal **KEEP** at **5-10 mg DAILY** for a **YEAR**
Then **ADD** Immunologic (**azathioprine**, MMF, etc.)
116
Can AIH be treated **ONLY** with **PREDNISONE** then taper to OFF?
**NO**, must add bilologic (**azathioprine**, MMF, etc.)
117
How **LONG** do you treat **AIH** with prednisone + azathioprine prior to **DISCONTINUING** prednisone?
**12-24 MONTHS**
118
When **AIH** treatment **RELAPSE** occurs, what **DOSE** of prednisone do you **RESTART**?
**20** mg
119
What can you **SUBSTITUTE** for **PREDNISONE** when treating **AIH** if patient is intolerant?
**BUDESONIDE**
120
If patient with **AIH** is intolerant to **azathioprine**, what else can you use?
**Mycophenolate** Mofetil or **Cyclosporine** or **Tacrolimus**
121
In a patient treated for **AIH** whose **ALT** does **NOT NORMALIZE** by **6 MONTHS**, what do you do?
**CHANGE** treatement (budesonide, MMF, cyclosporine, tacrolimus) or consider alternative diagnosis
122
How do you treat **MILD** to **MODERATE AIH** (very **mild ALT** elevation and **very MILD** to **NO INFLAMATION** on **BIOPSY**)?
**MONITORING** of ALT, FIBROSCAN and RE-BIOPSY as needed
122
Once **PREDNISONE** or budesonide is **STOPPED** for a patient with **AIH**, how **LONG** do you continue **IMMUNOTHERAPY** and **MONITORING** (azathioprine, etc)?
**LIFE-LONG** (80% will relaspe if stopped)
123
**WHAT** will you see on liver **BIOPSY** in **33%** of **AIH** patients in spite of **NORMAL ALT** and on immunosuppressive therapy?
Progression of **FIBROSIS**
124
Sarcoidosis, Amyloidosis, TB, Lymphoma, SCC, Fungal infections all casue what type of **LIVER DISORDER**?
**INTRAHEPATIC CHOLESTASIS** (elevated **ALP**) - these must be **BIOPSIED** as well
125
Which **AMA** assay is done by most labs (for **PBC**)?
**M2** (directed against the pyruvate dehydrogenase of the inner mitochondrial membrane)
126
These symptoms require **LIVER TRANSPLANTATION** intractable **PRURITUS**, **JAUNDICE**, **ASCITES**, **VARICEAL BLEEDING**, **HE** and are found in?
**PBC**
127
What is the **TREATMENT** of **PBC** (to normal **ALP**)? If treating for months and ALP is lower but **still not normal**?
**URSO** (ursodeoxycholic acid 15 mg/kg) - reduces toxicity of bile
**Obeticholic** acid (5 mg and increase to 10 mg depending on response)
128
In patients with **PBC**, what **SEROLOGY** determines risk of **MORTALITY** (or need for liver **TRANSPLANT**)?
**ALP** (and biliruibin)
129
Patients **>50 yo** treated for **PBC** with **URSO** long term require **MONITORING** for what?
**OSTEOPOROSIS** (**DEXA** scan) - start **CALCIUM + VIT D** if diagnosed or consider ESTROGEN if postmenopausal
If **DECREASED** bone density but not osteoporosis, start **DIPHOSPHONATE**
Also **DENTAL CARIES**
130
**PBC** can also cause **HYPERCHOLESTEROLEMIA** (xantolasmas) why does this **NOT** cause **CAD** and why is it **NOT TREATED**?
Because it is **HDL** that is **ELEVATED**
131
**STRICTURES** & **BEADING** in large to medium size **BILE DUCTS**, **MRCP** is diagnostic?
**LARGE-DUCT PSC** (biopsy is ONLY needed for staging, prefer **FIBROSCAN**)
132
**ALP** elevated, with **NORMAL AST/ALT**, **NORMAL CHOLANGIOGRAM**, need **BIOPSY** for **DIAGNOSIS**?
**SMALL-DUCT PSC** (can use URSO but NO defined treatment for SMALL DUCT ONLY - if no drop in ALP, can stop)
133
What indicates future need for **TRANSPLANTATION** in patient with **PSC** (for which there is no treatment)?
**SYMPTOMATIC** disease (jaundice)
134
What is the **MEAN** survival time in **YEARS** from **DIAGNOSIS** to **CIRRHOSIS** (needing transplantation) for patients with **PSC**?
**20** years
135
**WHEN** is the **ONLY** time **PSC** patients require **ENDOSCOPIC** management (**ERCP**) ? NO EFFECT ON SURVIVAL
When they develop **SYMPTOMATIC PERSISTENT JAUNDICE** or develop **CHOLANGITIS** due to **BILIARY SEPSIS** due to **HIGH-GRADE CBD STRICTURES**
136
What are the **RISKS** of **ERCP** in **PSC** patients who do **NOT** have symptomatic **CBD** strictures (persistent jaundice, cholangitis)?
**CHRONIC** cholangitis, liver **ABSCESS**, acelerated need for liver **TRANSPLANT**
137
What is the ONLY **TRIAL** drug that shows promise in **PSC**?
**CILOFEXOR** (decreased ALP)
138
What is the single greatest **RISK** factor for **CHOLANGIOCARCINOMA** (progressive jaundice and weight loss)?
**PSC** (check CA19-9 and CEA)
139
What are the **ONLY** tests useful for **SCREENING** for **CHOLANGIOCARCINOMA**?
**CT or MRCP** every **6-12 MONTHS**, **CA19-9**, **CEA**
140
In a patient with **STRONG** suspicion for **PSC** with **NORMAL** imaging, what do you treat for?
**SMALL-DUCT PSC**
141
If **LFTs** are **OFF** (as in **OVERLAP** syndromes) what do you use as guide for **TREATMENT**?
**SEROLOGIES** and **HISTOLOGY**
142
Elevated **IgG4**, biopsy with **INFLAMMATION** and **FIBROSIS** (**pancreas**, **bile ducts**, **LNs**, **salivary glands**, **retroperitoneum**) and if biliary, elevated LFTs with biliary strictures?
**IgG4-ASSOCIATED CHOLANGITIS**
143
How is **IgG4-ASSOCIATED CHOLANGITIS** treated?
**PREDNISONE** + **MMF** or **RITUXIMAB**
144
**IgG4** or **SAUSAGE**-LIKE biliary dilation, elevated **LFTs**, **INFLAMMATORY** masses in **PANCREAS** or **LNs** or **BILE DUCTS** or **SALIVARY** glands or **RETROPERITONEUM**?
**IgG4-ASSOCIATED CHOLANGITIS**
145
What should you **ALWAYS** check for in a patient with **PSC** and why?
**IgG4-ASSOCIATED CHOLANGITIS** (because its **TREATABLE**)
146
Decreased serum **ALBUMIN**, increased **CHOLESTASIS** and **TELANGIECTASIAS** (spider angiomas, palmar erythema, small varices) are all **NORMAL** during this process?
**PREGNANCY**
147
Are chnages in **AST/ALT**, **GGT**, **PT** or **BILIRUBIN** normally expected in **PREGNANCY**?
**NO**
148
What is the safest time during **PREGNANCY** to have **SURGERY** or an **ERCP** for gallstones, etc.?
**2nd Trimester**
149
In a **PREGNANT** patient, when traveling **ABROAD**, what **VIRUS** affords the highest **RISK** of **FULMINANT HEPATIC FAILURE**?
**Hep E**
150
Are treatments such as **INF** and **RIBAVIRIN** ok to use in **PREGNANCY** to treat **Hep E**?
**NO**
151
This hepatitis **VIRUS** is associated with **PRE-TERM** labor and premature **RUPTURE** of **MEMBRANES** and **IgG MUST** be given to neonate if infection occurs within **2 WEEKS** of pregnancy?
**Hep A**
152
Having this **VIRUS** can cause **SEVERE HEPATITIS** (**74% mortality**) in the **2nd/3rd TRIMESTER** with **VERY HIGH LFTs**, present with **FEVER** and **UPPER RESPIRATORY INFECTION**, **NO JAUNDICE** with near-normal bilirubin?
**HSV**
153
What is seen on **LIVER BIOPSY** in patients with **HSV** hepatitis (pregnant women in 2nd/3rd trimester)?
Patchy **NECROSIS** and **VIRAL INCLUSION BODIES**
154
What is the **ONLY** acceptable wat to **DIAGNOSE HSV HEPATITIS** in pregnancy and how do you **TREAT**?
Diagnose: **HSV PRC**
Treat: **ACYCLOVIR** (can **suspect**, don't need to have diagnosis)
155
What hepatitis **VIRUSES** should be screened for in **ALL PREGNANT** women?
**HBV/HCV**
156
What **FACTOR** determines **RISK** of **TRANSMISSION** of **HBV** from mother to **CHILD**?
HBV **DNA**
157
Besides DNA VIRAL LOAD, what **THREE FACTORS INCREASE** the risk of **TRANSMISSION** of **HBV** from pregnant mother to **CHILD**?
1. Presence of **HBeAg** (90%)
2. Anti-partum **HEMORRHAGE**
3. **MECONIUM**-stained amniotic fluid
158
At what **HBV VIRAL DNA LOAD** should a pregnant woman in her **3rd TRMIESTER** be given **PROPHYLAXIS** (**TENOFOVIR**) to prevent vertical **TRANSMISSION**?
>**2 x 10^5** (>200,000 copies)
159
What medical **PROCEDURES** whould be **AVOIDED** for a **PREGNANT** patient with **HBV or HCV**?
**AMNIOCENTESIS**, **INVASIVE** fetal monitoring or **EPISIOTOMY**
160
# [](http://)
Is a **C-Section** recommended over vaginal delivery for **PREGNANT** mothers with **HBV**?
**NO**
161
Is it **OK** to **BREASTFEED** for a woman with **HBV**?
**YES** (HBV is NOT found in breast milk)
162
What is the **TREATMENT** of a **PREGNANT** mother with **HBV** (viral load **>200,000** and **HBeAg+**) and **CHILD**?
Mother: **TDF** (not TAF) a **28-32 WEEKS**
Child: **HBV IgG** at **BIRTH**, **VACCINE** **within 12 hrs**, **MONTH 1** and **MONTH 6**
163
What is the **TREATMENT** of a **PREGNANT** mother with **HBV** (viral load **< 200,000** and **HBeAg-**) or **PRE-TERM** and **CHILD**?
Mother: **NOTHING**
Child: **HBV IgG** at **BIRTH**, **VACCINE** **within 12 hrs**, **MONTH 1** and **MONTH 6**
164
Can **HCV VERTICAL TRANSMISSION** be **PREVENTED**?
**NO** NOT even by C-Section (but low, 3-10%)
165
What **CO-INFECTION** with **HCV** makes **VERTICAL TRANSMISSION** higher **RISK** in **PREGNANT** women?
**HIV** (11-19%)
166
**WHEN** do you **TEST** an infant for **HCV** if born to a **POSITIVE** mother?
On **TWO** occasions between **2-6 MONTHS**
And/Or **AFTER 18 MONTHS**
167
**WHEN** is **BREASTFEEDING** ok for a mother with **HCV**?
If no **NIPPLE TRAUMA** and no **HIV CO-INFECTION**
168
With which hepatitis **VIRUS** can you see **POST-PARTUM FLARES**?
**HBV**
169
**PREGNANT** women have a **20X** increased **RISK** of **INTRAHEPATIC CHOLESTASIS of PREGNANCY** if infected with which **VIRUS**?
**HCV**
170
Why should **PREGNANT** women have their **HCV** status re-evaluated **POSTPARTUM**?
Because **10% SPONTANEOUSLY** clear the virus
171
**WHEN** should a **HCV** positive **WOMAN** who wants children be treated for **HCV**?
**BEFORE CONCEPTION** or **AFTER DELIVERY**
If wants to breastfeed, **AFTER** done **BREASTFEEDING**
172
How **LONG** should a woman **WAIT** to become **PREGNANT** and **MUST** use **DUAL CONTRACEPTION** after **LAST DOSE** of **RIBAVIRIN** (TERATOGEN)?
**6 MONTHS**
173
What is the **ONLY SAFE** treatment of **AIH** in **PREGNANCY**?
**PREDNISONE + AZATHIOPRINE** (cannot use MMF, etc.)
174
What are the risks to **PREGNANCY** with **AIH**?
**PREMATURITY** and **FETAL LOSS**
175
What can happen to **AIH** with **PREGNANCY**?
**FLARE** (monitor **LFTs** but **LIMIT CHANGING** therapy) **INTRAPARTUM** and **POSTPARTUM** (check every 2-4 weeks for 6 months)
176
What needs to **CHANGED** about treating **WILSON's DISEASE** in pregnancy if treating with chelation therapy with **D-Penicillamine or TRIENTENE**?
**REDUCE** dose in **3rd TRIMESTER** by **25-50%**
177
What needs to **SUPPLEMENTED** when treating **WILSON's DISEASE** in pregnancy with chelation therapy with **TRIENTENE**?
**IRON** (chelates IRON besides copper)
178
Can a woman **BREASTFEED** if being treted for **WILSON's DISEASE** with **CHELATION** therapy (D-Peniciliamine or Trientene)?
**NO** (causes copper deficiency to child)
179
**Hepatocellular Adenomas (HCA)** **>5 cm** in size are at an increased **RISK** for what in **PREGNANCY** and **WHY**?
**RUPTURE** with **HEMORRHAGE**
**ESTROGEN** DEPENDENT
180
If **BEFORE PREGNANCY** a hepatocelluar adenoma is found to be **< 5 cm**, what needs to be **DONE**?
**MONITOR** every **TIMESTER** and **12 WEEKS POSTPARTUM**
181
If a **hepatocelluar adenoma** is found to be **>5 cm BEFORE PREGNANCY**, what can be **done**?
**EMBOLIZATION** or **RESECTION**
182
If a **hepatocellular adenoma BECOMES >5 cm DURING PREGANANCY**, what is **done**?
Bland **EMBOLIZATION**
183
A patient presents at 30 weeks gestation with intense **pruritus**, her **ALT/AST** **ALP** and **T.bili** are all elevated. US shows no gallstones of duct dilation, what's the **NEXT** step for **THIS** diagnosis?
Measure **SERUM BILE ACID LEVELS**
**Intrahepatic Cholestasis of Pregnancy**
184
How do you **TREAT** hyperemesis gravidarum (1-20 weeks of pregnancy)?
**IVFs, Vit B6, Antiemetics (ondansetron, promethazine, metoclopramide)**
185
How do you **TREAT** Intrahepatic Cholestasis of Pregnancy (2nd and 3rd trimesters)?
**URSO** 15 mg/kg
EARLY **DELIVERY** (37 weeks)
186
How do you **TREAT ACUTE FATTY LIVER OF PREGNANCY** (3rd trimester)?
**PROMPT DELIVERY** (monitor infant for LCHAD deficiency)
187
**ECLAMPSIA**, **PRE-EXCLAMPSIA** and **HELLP** syndromes occur at 20-22 weeks of pregnancy, what is **PARAMOUNT** to treatment?
**IMMEDIATE DELIVERY** (if after **34-36 weeks**)
188
Besides prompt **DELIVERY** (after **34-36 weeks**) for a patient with **HELLP**, what **ELSE** must you **TREAT** the mother with?
**PLATELET TRANSFUSION** to 40K-50K platelets
189
**Nulliparity**, **DM**, **OBESITY**, **HYPOthyroidism**, **TWIN** pregnancy are all **RISK** factors for what **PRENGNANCY**-associated **syndrome**?
**HYPEREMESIS GRAVIDARUM** (elevated LFTs, unconjugated bilirubin)
190
What **PREGNANCY SYDROME** are **Scandinavians** and **Chilean Indians** more prone to?
**Intrahepatic Cholestasis of Pregnancy**
191
**PREGNANT** woman with persistent **PRURITUS** (palms and soles, nocturnal), **BILE ACIDS >10 mmol/L**?
**Intrahepatic Cholestasis of Pregnancy**
192
What are the **TWO** most common **DEFICIENCIES** noted in women who develop **intrahepatic cholestasis of pregnancy**?
**Vit D** & **SELENIUM**
193
Elevated maternal **AGE**, history of **CHOLESTASIS** with **OCPs**, **CHRONIC HCV** (20 X the risk) or **FAMILY HISTORY** of this condition are the **RISK** factors for?
**Intrahepatic Cholestasis of Pregnancy**
194
What special **TESTING** is recommended in a patient with **RECURRENT Intrahepatic Cholestasis of Pregnancy**, **early** onset of this or **severe** case with **bile acids >100 mmol/L**?
**GENETIC TESTING**
195
This condition usually occurs in the 2nd-3rd trimester (**25-32 weeks**) with **PRURITUS** of the **PALMS** and **SOLES** at night, **STEATORRHEA**, **ELEVATED ALP**, mild **GGT** elevation, **HIGHLY ELEVATED BILE ACIDS** (10-100 ULN), **ELEVATED LFTs** and **MILD BILIRUBIN** elevation?
**Intrahepatic Cholestasis of Pregnancy**
196
What **SEROLOGIC** factor is the **KEY** to diagnosis of **Intrahepatic Cholestasis of Pregnancy**?
**ELEVATED BILE ACIDS**
197
What is the **TREATMENT** for **Intrahepatic Cholestasis of Pregnancy**?
**URSO**, **Vit K**, **Delivery** at **37 WEEKS**
198
Can **Intrahepatc Cholestasis of Pregnanc**y **RECCUR** with subsequent pregnancies?
**YES** (65%)
199
**Pregnant** woman presents with **HTN**, **SUDDEN WEIGHT GAIN**, **BLURRY VISION**, **EDEMA**, **PROTEINURIA** (>300 mg/24h), **ELEVATED LFTs**?
**PREECLAMPSIA**/**ECLAMPSIA**
200
**Nulliparity**, maternal **Age >40**, **FH**, **Chronic HTN**, **CKD**, **DM** are all **RISK** factors forthis condition which can result in liver **HEMATOMAS**, **RUPTURE** (sudden onset abdominal pain with radiation to shoulder, shock, fever)?
**PREECLAMPSIA**/**ECLAMPSIA**
201
When do you DELIVER a patient with **PREECLAMPSIA**/**ECLAMPSIA**
**34 WEEKS**
202
If a **PREGNANT** woman presents with symptoms of **HEMOLYSIS**, elevated **LFTs** and **LOW PLATELETS**, when do you **DELIVER**?
**ASAP** (especially if >34 weeks)
203
**WHEN** can **HELLP** syndrome occur?
**2nd-3rd trimester** (28-36 weeks)
and up to **1 WEEK POSTPARTUM**
204
In a **PREGNANT** woman with **HIGH LFTs** (AST/ALT **>1,000**) with **ABDOMINAL PAIN RADIATING TO SHOULDER**? **NEXT STEP**?
**HEPATIC INFARCTION**, **SUBCAPSULAR BLEED** or **RUPTURE**
**CALL SURGERY** or **IR**, **CORRECT COAGULOPATHY**
205
**HOW** do you treat **PREGNANT** woman with **HELLP** at **DELIVERY** or for **PROCEDURES**?
**TRANSFUSE PLATELETS** to **>40K**
206
This condition typically ocurs during the **THIRD** trimester (around **week 36**) as well as **POST PARTUM** with **MICROVESICULAR FATTY LIVER** (not well seen on US) especially with **HOMOZYGOUS LCHAD** babies (spill and accumulate in liver)?
**ACUTE FATTY LIVER** of **PREGNANCY**
207
**Pregnant** woman at **36 WEEKS** gestatio presents with **ENCEPHALOPATHY**, elevated **LFTs**, **HYPOglycemia**, **LEUKOCYTOSIS**, **ASCITES**, elevated **Cr**, **COAGULOPATHY**? **TREAT**?
**AFLP** (acute fatty liver of pregnancy)
**DELIVER** and **SUPPORTIVE** therapy for liver (may need **TRANSPLANT** if does not improve)
208
What is the **SAFEST CONTRACEPTIVE** for women with **CHRONIC LIVER DISEASE** (besides condom)?
**IUD**
209
Women with chronic liver disease with **THROMBOSIS**, **ADENOMAS**, decompensated **CIRRHOSIS** and **NAFLD** should **AVOID** which contraceptives?
**COMBINED** **HORMONAL** CONTRACEPTIVES
210
Do women with **CHRONIC LIVER DISEASE** have **DIFFICULTY** with **REPRODUCTION**?
**YES**
211
Is **ASSISTED REPRODUCTION SAFE** in women with **CIRRHOSIS**?
ONLY **CHILD's A** (bilirubin, albumin, INR, ascites)
212
Is **REPORDUCTION** affected in **MEN** with **chronic liver disease**?
**YES** (feminization, low testosterone, elevated **estrogen** with **ED**, testicular **atrophy**, **oligospermia**)
213
Women with **CIRRHOSIS** (compensated or not) who become **PREGNANT**, are a **HIGH-RISK** of what on **US**?
**SPLENIC ARTERY ANEURYSM** wich can rupture especially if **>2 cm** (due to INCREASED **portal HTN**)
214
In women with **CHRONIC LIVER DISEASE**, the **PHYSIOLOGIC** changes of **PREGNANCY** cause what?
**INCREASED PORTAL HTN** (ascites, varices, HE)
215
In women with **CIRRHOSIS**, if become **PREGNANT**, most complications will occur because of what condition?
**PORTAL HTN** (splenic artery aneurysm, bleeding varices, ascites)
216
In a woman who is **CIRRHOTIC** and **PREGNANT** with **PORTAL HTN**, the risk of **RUPTURE** of a **SPLENIC ARTERY ANEURYSM** is **VERY HIGH** if how **LARGE**?
**>2 cm**
217
What is the **RECOMMENDATION** for a woman with **CIRRHOSIS** who has had **VARICEAL SURVEILLANCE** within **1 YEAR PRIOR** to conception and had **SMALL** to **LARGE** varices?
Non-selective **beta blocker** or **EGD** with **BANDING**
218
What is the **RECOMMENDATION** for a woman with **CIRRHOSIS** who has **NOT** had **VARICEAL SURVEILLANCE PRIOR** to conception and has **SMALL** to **LARGE** varices?
**SECOND TRIMESTER ONLY**: non-selective **beta blocker** or **EGD** with **BANDING**
219
Which non-selective **BETA BLOCKER** do you use for **PREGNANT** women who have **VARICES**?
**PROPRANOLOL** (NOT nadolol)
220
In **PREGNANT** women with **CIRRHOSIS**, what is a **PREDICTOR** of **COMPLICATIONS** (most occur 2nd-3rd trimester)?
**MELD >10**
221
In **PREGNANT** women whom received a liver **TRANSPLANT**, what are two commonly seen **ISSUES**?
**GESTATIONAL DIABETES**
**HYPERTENSIVE** disorders
222
In **PREGNANT** women whom received a liver **TRANSPLANT** there is a **HIGH RISK** of **REJECTION** if conception occurs **WHEN**?
**WITHIN 6 MONTHS** of TRANSPLANT
223
In a **CIRRHOTIC PREGNANT** woman with **ACTIVELY BLEEDING** varices, what **MEDS** are **OK** to use?
**OCTREOTIDE** and **CEPHALOSPORINS** (prophylaxis) - do NOT use vasopressin or terlipressin
224
In women whom received a liver **TRANSPLANT**, **WHEN** should **CONCEPTION** be **ATTEMPTED**?
**ONE** (**1**) **YEAR** post **TRANSPLANT**
or **ONE** (**1**) **YEAR** post **REJECTION** episode
225
In women whom received a liver **TRANSPLANT**, which **CONTRACEPTIVES** are **SAFE**?
**PROGESTERONE** or **IUDs** (estrogen increases risk of thromboembolism and HTN)
226
In women whom received a liver **TRANSPLANT**, and are thinking of **PREGNANCY**, what is **IMPERATIVE**?
**CONTRACEPTION** and **PRECONCEPTION** **COUNSELING**
227
Which **IMMUNOSUPRESSION** drugs are **OK** to use (liver transplant, etc.) during **PREGNANCY** and how often do you monitor labs for **LEVELS**?
**Tacrolimus**, **Cyclosporine**, **Azathioprine**, **Prednisone**
(NEVER use mycophenolate mofetil, sirolimus/everolimus)
Monitor **LEVELS** every **2-4 weeks** because levels will decrease with increased blood volume
228
How **LONG** after using **Mycophenolate Mofetil** is it **OK** for **BOTH MEN & WOMEN** to plan **PREGNANCY** (BLACK BOX WARNING)?
**6 MONTHS**
229
Can you **BREASTFEED** if on **Mycophenolate Mofetil**, **EVEROLIMUS** or **SIROLIMUS**?
**NO**
230
Which **IMAGING** studies are helpful for **CHOLESTATIC LIVER DISEASES**?
**US** or **MRPC**
231
**Fatty** liver infiltration with LOBULAR **INFLAMMATION**, CYTOLOGIC **BALOONING**, +/- **MALLORY** BODIES, +/- **FIBROSIS**?
**STEATOHEPATITIS**
232
What **TYPE** of **STEATOSIS** do **PREDNISONE**, **ALCOHOL** and **METABOLIC SYNDROME** cause?
**MACRO**vesicular steatosis
233
**WILSON** disease, **TPN**, **ESTROGEN**, **AMIODARONE**, **METHOTREXATE**, **TAMOXIFEN**, **HCV**, **PCOS**, **CELIAC** disease, **OSA**, **HYPO**/**HYPER**thyroidism and post **WHIPPLE** procedure all cause what **TYPE** of **STEATOSIS**?
**MACRO**vesicular
234
**VALPROIC ACID**, **HIV**-DRUGS, **AFLP** and **HELLP** syndrome, **LIPOSOMAL ACID LIPASE** deficiency all cause this **TYPE** of **STEATOSIS**?
**MICRO**vesicular
235
What is the **RISK** of progressing to **HCC** in patients with **CIRRHOSIS**?
**10%**
236
**Female** gender, **obesity**, **viral** hepatitis, **Iron** overload, **smoking** are all **RISK** factors for **INCREASED LIVER INJURY** with this activity?
Drinking **ALCOHOL**
237
What is known to be **PROTECTIVE** against **LIVER INJURY** in those who drink **ALCOHOL**?
**COFFEE**
238
Besides spider angiomas, what is another **PHYSICAL** sign of **CHRONIC LIVER DISEASE**?
**DUPUYTREN CONTRACTURE**
239
**LEUKOCYTOSIS** (RULE OUT INFECTION) and an **AST:ALT** ratio of **WHAT**, is seen with **ALCOHOLIC HEPATITIS**?
**1:2**
240
**ALCOHOLIC HEPATITIS** will **RARELY** present **ALONE** with **LFTs >**?
**350** (look for concomitant disease)
241
Besides alcohol cessation, what is one of the **MOST IMPORTANT** treatments of a patient with **ALCOHOLIC HEPATITIS**?
**HIGH-PROTEIN** NUTRITION (1.5 g/kg/day) with ~**3,000 calories**/day
242
What **VITAMINS** and **MINERALS** must be **SUPPLEMENTED** in patients with **ALCOHOLIC HEPATITIS**?
**Vit K**, **Thiamine** (prevent Wernicke's), **Glucose**, **Folate**, **Mg**, **Phos**, **Potassium** (may have elevated INR), **Zinc**
243
What is the **EQUATION** for **Maddrey's** discriminant function?
**4.6 x (PT-control) + T.Bili**
If **>32**, start **steroids +/- NAC**
Can use **MELD**, and if **>20**, start **steroids +/- NAC**
244
# [](http://)
This **SCORE** stratifies patients **ALREADY RECEIVING** steroids for **ALCOHOLIC HEPATITIS** for **7 days** and predicts which will improve and which need other management?
**Lille** Score
**< 0.45** - **RESPONDING** (85% 6 month survival)
**> 0.45** - **NOT** RESPONDING (25% 6 month survival)
245
In a patient with a **FIRST EVENT**, good **SUPPORT** system, **INSIGHT** into alcohol use disorder, no **ILLICIT** substance use, no prior **FAILED REHAB**, who presents with **ALCOHOLIC HEPATITIS** with **Lille Score >0.45**, what is the **NEXT STEP**?
**TRANSFER** to liver **TRANSPLANT** center
246
When the **DIAGNOSIS** of **ALCOHOLIC HEPATITIS** is **POSSIBLE** (could be alpha-1 antitrypsin, UGIB, HTN, cocaine - 7 days, DILI - 30 days, atypical lab tests) but **NOT PROBABLE**, what should you do?
Liver **BIOPSY**
247
Onset of **JAUNDICE** within **PAST 8 WEEKS**, ongoing **ALCOHOL** consumption for **>6 MONTHS** with < 60 days abstinence, **AST/ALT both < 400**, **AST:ALT 1:2** and **T.bili >3**, what is this?
**Alcoholic Hepatitis**
248
**HOW** do you check **ALCOHOLIC HEPATITIS** patients for **INFECTION**?
**Blood**, **Urine**, **Ascites**
249
Is **PENTOXIFYLINE** still used to treat appropriate (high MDF score) alcoholic hepatitis patients?
**NO** (only steroids) - **PREDNISONE 40 mg/day** for **28 days +/- NAC** - check **LILLE score** in 5-7 days
250
Uncontrolled **INFECTIONS**, **AKI Cr >2.5**, uncontrolled **GIB**, **HBV**, **HCV**, **HIV**, **HCC**, **DILI**, **TB** and **ACUTE PANCREATITIS**, **SHOCK**, **MULTIORGAN FAILURE** are all **CONTRAINDICATIONS** to using which treatment for **ALCOHOLIC HEPAITITS**?
**STEROIDS** (consider TRANSPLANT)
251
What **TWO** tests are available to check if a patient has **CHRONICITY** to their **ALCOHOLIC HEPATITIS** and not **ACUTE**?
**Ethyl Glucoronide**
**Phosphatidylethanol**
252
Which mediations **HELP** with **REHAB** of **ALCOHOLIC HEPATITIS**?
**NALTREXONE**, **DISULFIRAM**, acamprosate, baclofen
253
At what **MELD-Na** score should you **REFER** a patient to a liver **TRANSPLANT** center?
MELD-Na **>21**
254
This disease is **diagnosed** by **EXCLUSION**, serum **FERRITIN** is mildly elevated **< 1.5 x ULN** (but not transferrin), ANA < 1:160, AMA < 1:40?
**NAFLD**
255
Elevation in **FERRITIN**, **TRANSFERRIN** and **IRON SATURATION**, how to dignose?
Liver **BIOPSY** (**hemochromatosis**)
256
If there is **CONFUSION** between A**UTOIMMUNE LIVER DISEASE** and **NAFLD**, what should you do?
Liver **BIOPSY**
257
What is the natural **PROGRESSION** of **NAFLD**?
**NAFLD** (20%) to **NASH** (25%) to **CIRRHOSIS** (10%)
258
What finding in **LIVER INJURY** predicts need for **TRANSPLANT** or risk of **DEATH**?
**FIBROSIS** stage
259
How can you differentiate **NASH** vs **NAFLD**?
**BIOPSY**
260
What is **NAFLD**? **NASH**?
**NAFLD**: fatty **deposition** in liver
**NASH**: fatty **deposition** in liver with **INFLAMMATION**
261
Greater **duration of NAFLD**, age **>50**, postmenopausal **WOMEN**, **HISPANICS/ASIANS**, **METABOLIC SYNDROME**, persistent **ALT** elevation?
Greater risk for progression to **NASH** (metabolic syndrome is TOP risk predictor)
262
What **CLINICAL** parameters can be looked at to predict **NASH** from **NAFLD**?
**FIBROSIS** studies (imaging - elastography), APRI, **FIB-4** and ELF panel)
263
Which **CLINICAL** test detects liver **FIBROSIS** by assessing **AGE**, **Plt**, **AST/ALT**?
**FIB-4** (**< 1.4**5 unlikely; **>3.25** advanced)
264
**Non-FASTING**, liver **CONGESTION**, **AST/ALT** fllare with **HEPATITIS**, and **EXTRAHEPATIC BILIARY OBSTRUCTION** are can all **OVERESTIMATE** results with this **FIBROSIS** test?
**ELASTOGRAPHY** (Fibroscan)
265
What is the **RATE** of **FIBROSIS** progression in **NAFLD/NASH**?
**NAFLD:** 1 stage in **14 years**
**NASH:** 1 stage in **7 years**
266
What should be done in a patient with **NASH** who has elevated **LDL**, **triglycerides** and **ALT/AST**?
Start **STATINS** (avoid CAD and cardiac death) - **decreases ALT/AST** in these patients
267
**Obese** pt with **METABOLIC** syndrome, elevated **LFTs**, **FERRITIN**, **LIPIDS**, mild **ANA**, should be treated **HOW** if wt loss isn't working?
**Vitamin E** (< 800 IU/day) - watch for prostate cancer and hemorrhagic stroke
268
What **FOOD** item is **BENEFICIAL** in **NAFLD**?
**COFFEE**
269
What is the **MOST EFFECTIVE** for **FIBROSIS REGRESSION** in **NASH**?
**WEIGHT LOSS** (at least **10%** of body weight)
270
At what **BMI** is **BARIATRIC** surgery recommended?
BMI **>40**
BMI >**35 with** obesity-related **COMORBIDITIES**
271
Besides **Vitamin E**, what other medications are **RECOMMENDED** in patients with **NASH** and **DM**?
**PIOGLITAZONE** (edema, weight gain, bladder cancer and heart failure)
**GLP-1** agonists ("utide/atide")
272
A **DECREASE** in **ALT** of what, is associated with **HISTOLOGIC** improvement of **NALFD/NAS**H disease activity?
**>17** U/L
273
How does the **HFE GENE** (anomaly in **HEMOCHROMATOSIS**) regulate **IRON**?
By regulating **HEPCIDIN** which is what the liver uses to increase or decrease **IRON ABSORPTION** from the gut (**enterocytes**) via the ferroportin transporter
274
Which **TWO** **HFE** genes are associated with hereditary **HEMOCHROMATOSIS**?
**C282Y**
H63D
275
**HIGH TRANSFERRIN** saturation and **HIGH** serum **FERRITIN**, **LOW HEPCIDIN** age **40-50**?
Hereditary **HEMOCHROMATOSIS** (C282Y/H63D) - Autosomal **Recessive**
276
**ANEMIA**, parenchymal and **SPLENIC** IRON, **HIGH HEPCIDIN** (reduced iron export by **MACROPHAGES**)
**FERROPORTIN** disease (**FPN** gene - a type of hemochromatosis)
277
Anemias such as **Thalassemia**, **Sideroblastic**, **Sickle** cell, **Hemolysis**, **Spherocytosis**, **CHRONIC INFLAMMATION**, **EXCESS VIT C** can lead to what condition?
Secondary **IRON OVERLOAD**
278
Which **genotype** mutation is at **HIGHEST RISK** for developing an **IRON OVERLOAD** syndrome?
**C282Y HOMOZYGOTE** (**TWO** identical copies of a gene as in **C282Y/C282Y**)
279
279
Which **POPULATIONS** is **HEREDITARY** **HEMOCHROMATOSIS** highest in?
**IRISH** and **SCANDINAVIANS**
280
Compound **HETEROZYGOTE Hereditary Hemochromatosis** such as **C282Y/H63D** can become **IRON OVERLOADED** when?
If **COFACTOR** present (**alcohol**, **HCV**, etc.)
281
Do **HETEROZYGOTE** mutations of **hereditary hemochromatosis** or the **H63D/H63D HOMOZYGOTE** develop **IRON OVERLOAD**?
**NO** (only if cofactors present - alcohol, HVC, etc)
282
Why does **IRON OVERLOAD** show up **LATER** in life in **women**?
Iron loss through **MENSTRUATION**
283
Liver **DISEASE**, **FATIGUE**, in **BRONZING**, **DM**, **GONADAL** dysfunction, **ARTHROPATHY** (chondrocalcinosis), **ARRHYTHMIAS**, dilated **CARDIOMYOPATHY** are seen in this liver disroder?
**Hereditary Hemochromatosis** with **IRON OVERLOAD**
284
How do you **INITIALLY** screen a **SYMPTOMATIC**, **ASYMPTOMATIC** (mildly elevated **LFTs**) or adult with **1st degree relative** for **HEREDITARY HEMOCHROMATOSIS**?
Serum **TRANSFERRIN** (**>45%**), **FERRITIN** (**>1000**) and **IRON SATURATION**
285
If a patient suspected of hereditary hemochromatosis has a **TRANSFERRIN SATURATION >45%**, what is the **NEXT** step?
Assess **HFE GENOTYPE**
286
If **HFE C282Y/C282Y HOMOZYGOTE**, what do you **ASSESS** next?
**FERRITIN** and **LFTs**
If **FERRITIN >1,000** and **abnormal LFTs** - **BIOPSY** staging
If **FERRITIN < 1,000** and **normal LFTs** - **PHLEBOTOMY**
287
If **TRANSFERRIN** saturation **>45%** **BUT HFE** genotype **HETEROZYGOUS** or **COMPOUND HERETOZYGOUS** (C282Y/H63D), what do you do next?
Assess serum **FERRITIN**
If **FERRITIN >1,000** - **PHLEBOTOMY**
If **FERRITIN normal** - evaluagte for **OTHER LIVER DISEASES/HEMATOLOGICAL** disorders - **BIOPSY**
288
# ```
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If a patient with **HFE** mutation **C282Y/C282Y HOMOZYGOUS** presents with signs of **CIRRHOSIS**, what do you do?
Liver **BIOPSY**
289
At what serum **FERRITIN** level do you sart **TREATING** (**PHLEBOTOMY** every **1-2 WEEKS**) patients with **HEREDITARY HEMOCHROMATOSIS** with the **C282Y/C282Y HOMOZYGOTE**?
**Women** **>200** ng/mL
**Men** **>300** ng/mL
290
What do you do for patients with **HEREDITARY HEMOCHROMATOSIS** with the **C282Y/C282Y HOMOZYGOTE** but with **FERRITIN** levels **BELOW** treatment (**W < 200**, **M < 300**)?
**MONITOR** **LFTs** and **FERRITIN levels YEARLY**
291
What is the **GOAL FERRITIN** level for patients with **HEREDITARY HEMOCHROMATOSIS** with the **C282Y/C282Y HOMOZYGOTE**?
**50 -100** ng/mL (once acieved, only need phlebotomy 3-4 x/yr)
292
What **VITAMIN** should patients with **HEREDITARY HEMOCHROMATOSIS** with the **C282Y/C282Y HOMOZYGOTE** avoid?
**Vit C** (this vitamin helps ABSORB iron)
293
Which **FOOD** can cause serious liver disease in a patient with **HEREDITARY HEMOCHROMATOSIS** with the **C282Y/C282Y HOMOZYGOTE** and should be **AVOIDED**?
**SHELLFISH** (VIBRIO)
294
If **PHLEBOTOMY** is not possible for patients with **HEREDITARY HEMOCHROMATOSIS** with the **C282Y/C282Y HOMOZYGOTE** due to **LIVER** and **RENAL TOXICITY**, what can **ONLY THEN** be used instead?
**Chelation** agents (deferoxamine)
295
What is **CORRECTED** with **PHLEBOTOMY** in patiens with **HEREDITARY HEMOCHROMATOSIS** with the **C282Y/C282Y HOMOZYGOTE**?
**EARLY HEPATIC FIBROSIS**, **cardiac** dysfunction, skin **pigmentation**, **hepatomegaly**, **porphyria** cutanea tarda (not the arthropathy, not DM, not hypogonadism)
296
What is the amino acid substitution in patients with **Alpha-1 Antitrypsin Deficiency** (emphysema - COPD, liver disease in infants and children)
**Glutamic Acid** - to - **Lysine** in serine protease inhibitor A1 (SERPINA1) **Z-ALLELE** - autosomal dominant (**M**-allele is the normal one)
297
What leads to the **LIVER INJURY** seen in patiens with **Alpha-1 Antitrypsin Defficiency**?
**Abnormal POLYMERIZATION** of Alpha-1 Antitrypsin molecules (can't be excreted by the liver causing cell death)
298
What is made if a patient has the **NULL/NULL** phenotype for **Alpha-1 Antitrypsin**?
**NOTHING**, no product also **no liver** disease (its only the poorly polymerized type that makes product tht cant be excreted out of the liver that caauses cell death) - only **lung** injury
299
How do you **CHECK** for **Alpha-1 Antitrypsin Defficiency**?
**PHENOTYPE** (not the AT level as this changes with inflammation, underlying liver disease, etc.) MM normal, SS moderate **ZZ** severe and most COMMON
300
Liver **BIOPSY**: **PAS** positive **DIASTASE** resistent globules?
**Alpha-1 Antitrypsin Deficiency**
301
What is **PRUSSIAN STAIN** used for?
**IRON OVERLOAD** such as liver biopsy in patient with hereditary hemochromatosis
302
Liver disease beginnign in **INFANCY** and **CHILDHOOD** with **MILD AST/ALT** elevation, **ASCITES**, **CONJUGATED** **JAUNDICE**, **HEPATOMEGALY**, **VARICES**?
**Alpha-1 Antitrypsin Deficiency**
303
**ALL** patient who present with liver disease (abn LFTs, cirrhosis, PHTN, HCC) should be suspected to have **A1AT** and if **ZZ** allele positive, **HOW OFTEN** do you monitor (serology, imaging, elastography?
**YEARLY**
304
What is the **EXPRESSED** state of **A1AT** (levels **< 10**)? **CARRIER** state (levles **50-100**) - no disease unless concomitant liver disease? **Normal** levels **80-220**
**Expressed** state: **ZZ**
**Carrier** state: **MZ**
305
What is **RECOMMENDED** to patients with **A1AT** **CARRIER** state (**MZ**)?
**Alcohol** avoidance, reduction of **metabolic** risk factors, **vaccines** for HAV/HBV, **smoking** cessation
306
This **CLASS** of drug should be **AVOIDED** in patients with **A1AT** Deficiency because it **INCREASES** production of the **POORLY POLYMER MOLECULES**?
**NSAIDs**
307
What **SCREENING** is necessary for patients with **A1AT Defficiency** (**ZZ** allele)?
Screen for **CIRRHOSIS**, **HCC**, **VARICES**, **PFT** (lungs) and if decompensated, refer for **TRANSPLANT**
308
**YOUNG** (**< 45 yo**), **ACUTE** liver failure, **HIGH T.bili with LOW ALK PHOS**, **ANEMIA**, **ACUTE KIDNEY INJURY**?
**WILSON DISEASE**
309
**Liver disease** preceeds **neurologic disease** by **10 years**, affects **BRAIN**, **KIDNEY**, **HEART**, **CORNEA**, **ERYHTROCYTES**, **JOINTS**?
**WILSON** DISEASE (hepatolenticular degeneration)
310
Autosomal **RECESSIVE**, affects **CHROMOSOME 13 ATP7B** mutation and necesary for **CERULOPLASMIN** synthesis (**LOW < 20 mg/dL**)?
**WILSON** DISEASE (hepatolenticular degeneration)
311
**LIVER** disease (LFTs, hepatitis, hepatomegaly, cirrhosis, ALF) + **NEUROLOGIC** disease (mania, psychosis, **DEPRESSION**, rigidity, seizures), **COOMB's negative HEMOLYTIC ANEMIA**, **INFERTILITY**, **OSTEOPOROSIS** is suspicious for what?
**WILSON** DISEASE (hepatolenticular degeneration)
312
**Kaiser-Fleisher Rings** & **SUNFLOWER CATARACTS** in the cornea suggest?
**WILSON** DISEASE (hepatolenticular deneneration) - slit lamp to visualize
313
What **CONFUSING** findings are often seen on liver **BIOPSIES** of patients with **WILSON** DISEASE?
Features of **FATTY** liver and **AIH**
314
What **RENAL** conditions does **WILSON DISEASE** cause besides **AKI**?
**FANCONI** syndrome (excessive drinking and urination), distal **RTA** and **NEPHROTIC** syndrome
315
Coomb's NEGATIVE **hemolytic anemia**, **LOW alk phos**, **HIGH T.bili**, **AST>>ALT**, **RENAL** failure, **< 45 yo**, **NEUROLOGIC** disorders, **LIVER TRANSPLANT** is life saving?
**WILSON** DISEASE (hepatolenticular degeneration)
316
Are **NEUROLOGIC** disorders **REVERSIBLE** in a patient with **WILSON** disease (liver transplant or otherwise)?
**NO**
317
Serum **CERULOPLASMIN < 20** mg/dL and 24-hour **URINE COPPER >40** mcg are suggestive of?
**WILSON** DISEASE (if unsure, do LIVER **BIOPSY**)
318
What **COPPER-RICH** foods should patients with **WILSON** disease avoid?
**SHELLFISH**, **NUTS**, **CHOCOLATE**, MUSHROOMS, **ORGAN MEATS**, **PEAS**, DRIED FRUIT
319
How do you **TREAT WILSON** disease with meds?
Chelation (**D-PENICILLAMINE + pyridoxine**, **TRIENTINE**)
Decrease intestinal absorption: **ZINC** (nausea/vomiting/diarrhea)
**SCREEN FAMILY**
320
When treating **WILSON** disease with chelator **D-PENICILLAMINE**, what can you see?
**WORSENING** of **NEUROLOGIC** symptoms (switch to **TRIENTINE** - also chelates iron so CAREFUL)
321
When treating **WILSON** disease with chelator **TRIENTINE**, what can you **NOT** take with it as it forms a **TOXIC** complex?
**IRON** supplementation (trientine also chelates iron)
322
**CHILDHOOD**, Autosomal **DOMINANT**, severe **PRURITUS**, **HIGH GGT**, **JAG1** gene, abnormal **FACE**, **BUTTERFLY** vertebrae and **PULMONIC** stenosis?
**ALLAGILE** syndrome
323
Focal or multilobular **CIRRHOSIS**, **LUNG** disease, can use **URSO** for cholestasis and optimize **NUTRITION**?
**Cystic Fibrosis**(CF)
324
Genetic liver disease with either **LOW GGT** (types 1 & 2) - normal is 5-40 U/L or very **HIGH GGT** (type 3), **HCC** (type 2) **INTRAHEPATIC GALLSTONES** and massive **BILE DUCT PROLIFERATION**?
**Progressive Familial Intrahepatic Cholestasis** (PFIC)
If **RELENTING** and **RELAPSING** then (Benign Recurrent Intrahepatic Cholestasis) - BRIC
325
**Congestion/Cirrhosis** in the liver causes back-up of blood in which **VEIN** reulting in **ESOPHAGEAL/GASTRIC** varices and **splenomegaly**?
**PORTAL VEIN**
326
How is **PRESSURE** in the **HEPATIC VEIN** measured?
**Wedge** pressure
327
**CIRRHOSIS** causes what **KIND** of **PORTAL HTN**?
**SINUSOIDAL** (therefore **INCREASED** Hepatic Vein Wedged Pressure) - normal Free HV pressure and **INCREASED** gradient
**HVPG = WHPV - FHVP**
328
Does **PORTAL VEIN THROMBOSIS** affect the Hepatic Vein Pressure Gradient?
**NO** (the hepatic vein is wedged not the portal)
329
What is considered **CLINICALLY-SIGNIFICANT** portal HTN (development of ascites or beeding varices)?
Hepatic Vein Pressure Gradient (**HVPG >10 mmHg**)
330
How do you **NON-IVASIVELY** determine presence or portal HTN?
Vibration **ELASTOGRAPHY** with **>20 kPa & Plt < 150K**
331
**Portosystemic COLLATERALS** found on imaging or **UMBILICAL VEIN** (round ligament of liver) mean what?
**Portal HTN**
332
How do you **PROPHYLACTICALLY** treat a patient with **CLINICALLY-SIGNIFICANT** portal HTN (**HVPG >20 mmHg**)?
**NON-SELECTIVE** beta-blockers (propranolol, nadolol, carvedilol) - prevents ascites, variceal BLEEDING, encephalopathy
332
333
What is the most **COMMON** complication of **cirrhosis**?
**ASCITES** (5-year 44% mortality)
334
What **MAP** is assocciated with increased **SURVIVAL** for patients with **ASCITES**?
**MAP >82 mmHg**
335
335
Calculate **SAAG**?
**SAAG = Serum Alb - Asctites Alb**
If **>1.1** g/dL can be **cirrhosis** or **RIGHT HEART / Budd Chiari** (if < 1.1 - likely peritoneal cancer, TB, etc.)
If **Ascites Protein < 2.5 g/dL = CIRRHOSIS** if >2.5 g/dL do HV doppler or ECHO
336
Do you **REPEAT** a **SAAG** after it has been obtained?
**NO** (same result)
337
What do you **ALWAYS** order on a patient with **FIRST ONSET ASCITES**?
**SAAG**, **PMN**, **CULTURE**, **PROTEIN**
338
What do you **ALWAYS** order for a patient with **ASCITES** wheter first episode or recurret or whetehr inpatient or outpatient?
**PMN** (rule out **SBP >250**)
339
What do you order for an **INPATIENT ONLY**, with **ASCITES** whetehr first episode or recurrent?
**CULTURE**
340
When do you order **CYTOLOGY** in a patient with **ASCITES**?
If **SAAG < 1.1** and **suspect cancer**
341
When do you order **TRIGLYCERIDES** in a patient with **ASCITES**?
If **ASCITES** is **MILKY WHITE** (chylous, **>110** mg/dL)
342
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If **ASCITES** is found on **CULTURE** to be **POLYMICROBIAL**, **CEA >5** ng/mL, **ALK PHOS >240** U/L, what does this indicate?
Gut **PERFORATION**
343
If **AMYLASE >100** is found in **ASCITES**, what is it from?
**PANCREATIC ascites** (needs imaging/ERCP)
344
**SAAG >1.1** **Ascites TP >2.5** what **ELSE** can you check before commiting to **CARDIAC** source instead of **Budd-Chiari**?
**pro-BNP >6,100 pg/m**
(its only 166 pg/mL in cirrhosis)
345
Is **CA-125** test helpful for **ASCITES**?
**NO**
346
**ASCITES** that is **RESPONSIVE** to **LOW-SODIUM** diet and **DIURETICS**?
**GRADE-1** (does not require paracentesis)
346
**RECURRENT ASCITES** (3 or more times/year) in spite of SODIUM RESTRICTION ans DUIRETICS with **MODERATE** abdomina distension?
**GRADE-2** (consider LVP/TIPS)
347
**RECURRENT LARGE-VOLUME ASCITES** with **SEVERE** abdominal distention, refractory to sodium restriction and diuretics and recurrs **EARLY** post **PARACENTESIS** (requires frequent paracentesis)?
**GRADE-3** (refractory) - **TIPS**
348
**INITIAL** considerations and treatment of **ASCITES**?
**Sodium-restric** diet (< 2 g/day)
**AVOID ACE-I & ARBs** (increase renal failure and HYPOtension
**Spironolactone 100** mg/day + **Furosemide 40** mg/day (increase as needed 2.5:1 ratio)
349
In a patient with **ASCITES** who is treated with **SPIRONOLACTONE** and develops **GYNECOMASTIA**, what do you replace with?
**Eplerenone** or **Amiloride**
350
At what **Cr** level do you **REDUCE** or **STOP DIURETICS** for **ASCITES**?
**>1.5** mg/dL
351
A **SPOT** **Urine Na:Urine K >1** means what in patients with **ASCITES**?
**DIETARY** non-compliance
352
When should **ALBUMIN** be given to patients whom undergo **LVP** for **ASCITES**?
When removing **>5 L**
353
In patients requiring recurrent **LVP** (weekly) with evidence of **KIDNEY INJURY** (**Cr >1.5**), what should be considered?
**TIPS**
354
What is the preferred medication for treatment of **MUSCLE CRAMPS** in patients with **ASCITES**?
**BACLOFEN**
355
**REFRACTORY** ASCITES, HEPATIC **HYDROTHORAX** (ascites that migrates to become pleural fluid) and ACUTE **UNCONTROLLED** or **RECURRENT** VARICEAL **BLEEDING** are all indications for what?
**TIPS**
356
**Pulmonary HTN**, **PRIMARY** prevention of **variceal bleeding**, SEVERE **CHF** (stage C, D), **SEPSIS**, active **BILIARY OBSTRUCTION**, **TUMOR** preventing placement, **REFRACTORY HE** are all **ABSOLUTE CONTRAINDICATIONS** to what?
**TIPS**
357
What are the three (3) **RELATIVE** contraindications to **TIPS**?
Decompensated **CIRRHOSIS** (liver won't handle the shunt well):
1. **MELD >18**
2. **T.bili >4**
3. **INR >5**
358
Pt s/p **TIPS**, presents with **PERSISTENT ASCITES** **>6 weeks** after TIPS placement, whats the issue?
**TIPS** dysfunction
359
If a patient has had **>3 LVP** in **ONE YEAR**, what is recommended?
**TIPS**
360
Pt comes in with **ASCITES**, **PMN < 250** but **blood cultures positive**, **NO SIGNS** of infection otherwise, how do you **TREAT**?
**NO ANTIBIOTICS**, **repeat** diagnostic **paracentesis** (contamination)
361
Is **PRIMARY PROPHYLAXIS** (BEFORE it occurs) for **SBP** standard of care for pts with **ASCITES**?
**NO** (risk of developing resistent infection)
362
What is the **TREATMENT** of **SVP**?
**IV ANTIBIOTICS** (cephalosporins, quinolones) + **IV ALBUMIN** (3 days) - **19% MORTALITY REDUCTION** with combination therapy
363
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In a patient with **ASCITES** and **SBP**, what treatments should be **AVOIDED**?
Aggressive **DIURESIS**, **LVP**, **IV CONTRAST**, **HOLD beta-blockers** (hypotension, AKI)
364
How **LONG** is **SBP** treated for?
**7 DAYS** (repeat paracentesis on day 3 if fever/pain persist)
365
In a patient being **TREATED** for **SBP**, **PMNs** are found to be **>PRETREATMENT** value, what should be **SUSPECTED**?
**RESISTENT** organism or **SURGICAL** source
366
In a patient being treated for **SBP**, the **PMNs** are found to still be **ELEVATED**, but **< PRETREATMENT** value, what do you do?
**CONTINUE** treatment for an additional 48 HOURS, then **REPEAT PARACENTESIS**
367
**WHEN** is **PROPHYLAXIS** for **SBP** considered **STANDARD** of care?
**ONLY** after **FIRST EPISODE** of **SBP** (otherwise **recurrence is 70%**)
368
What is appropriate **prophylaxis** for **SBP**?
**DAILY** (not weekly) **CIPRO**, or **NORFLOXACIN**, or **BACTRIM**
369
# **
If a patient presents with **ASCITES**, **CIRRHOSIS** and **GIB**, what do you give for **SBP PROPHYLAXIS**?
**CEFTRIAXONE 1 g IV DAILY x 7 days**
370
Is treating **CIRRHOSIS** with **ALBUMIN** in inpatients helpful?
**NO** (not unless they have SBP or undergo LVP)
371
In **CIRRHOTICS** with **ASCITES**, **OVERDIURESIS**, dehydration due to **LACTULOSE** (HE), **LVP**, **SBP**, **GIB**, **beta-blockers**, **NSAIDs**, **INFECTION** all can **LEAD TO**?
**HEPATORENAL** SYNDROME (HRS-AKI/CKI)
372
What are the **HRS-AKI STAGES**?
Stage 1: **Increase** of **Cr** by **0.3 mg/dL/BASELINE** - **2xBASELINE**
Stage 2: **Increase** of **Cr** by **2-3xBASELINE**
Stage 3: **Increase** of **Cr** by **>3xBASELINE or >4.0 mg/dL**
373
What are the three (**3**) kinds of **AKI** in a patient with **CIRRHOSIS** with **ASCITES**?
**TRANSIENT** (returns to baseline)
**PERSISTENT** (**Cr** increase **>0.3** mg/dL over 48H, **no dialysis**)
**PROGRESSIVE** (persistent AKI requiring **dialysis**)
374
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How is **HRS** treated?
**STOP anti-hypertensives**, use **OCTREOTIDE + MIDODRINE + ALBUMIN**, NOREPINEPHRINE, TERLIPRESSIN (can cause resp failure)
375
Is **DOPAMINE** used to treat **HRS**?
**NO**
376
When using **TERLIPRESSIN** to treat **HRS**, what **MUST** you watch for?
**REPIRATORY FAILURE** (do not start on patients who have respiratory compromise)
377
What kind of **HYPONATREMIA** can a patient on **DIURETICS** and **LACTULOSE** have and how is it **TREATED**?
**HYPOVOLEMIC** (**NS** + **IV Albumin**) do NOT volume restrict
378
What are the three (**3**) stages of **HYPOnatremia** and how do you **TREAT**?
**MILD**: 126-135 mEq/L - monitor, water restrict if HYPERvolemic
**MODERATE**: 120- 125 mEq/L - water restrict to 1L/day, STOP diuretics
**SEVERE**: < 120 mEq/L - water restrict to 1L/day, stop diuretics, IV albumin
379
WHEN is **HYPERTONIC** (3% NS) **SALINE** (or RARELY satavaptan or tolvaptan) used to treat **HYPOnatremia**?
Short-term for **SYMPTOMATIC** or imminant liver **TRANSPLANT** (goal is **4-6 mEq/L in 24 hours**, NO MORE than 8 mEq/L in 24 hours)
380
A **CIRRHOTIC** patient presents with **SUSPICION** of esophageal **VARICES** but liver **STIFFNESS** is **< 20 kPa** and **Plt >150K**, how do you proceed?
**NO EGD** NECESSARY
381
What is the **5-YEAR mortality** risk of a patient with **CIRRHOSIS** with **VARICEAL BLEED**?
**20%**
382
What does **VARICEAL BLEED** (not the presence of varices) mean for pt's **CIRRHOSIS**?
**DECOMPENSATED** cirrhosis
383
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What is considered **NORMAL** **HVPG**?
**3-5 mmHg**
384
What is considered **CLINICALLY SIGNIFICANT** **HVPG**?
**>10 mmHg**
385
At what **HVPG** is there a risk of **VARICEAL BLEEDING**?
**>12 mmHg**
386
At what **HVPG** is there a risk of **DEATH**?
**>16 mmHg**
387
At what **HVPG** is there a risk of being **UNABLE** to **STOP VARICEAL BLEEDING**?
**>20 mmHg**
388
Do **NON-SELECTIVE** beta-blockers **PREVENT** formation of esophageal **VARICES**?
**NO**
389
Once esophageal **VARICES** are there, what is used for **PRIMARY PROPHYLAXIS**?
**NON-SELECTIVE beta-blockers** (nadolol, propranolol, carvedilol)
390
Once esophageal **VARICES BLEED**, what is used for **SECONDARY PROPHYLAXIS**?
Band **LIGATION** (60% recureence if not)
391
How **OFTEN** do you **SCREEN** for esopahgeal **VARICES** in a cirrhotic patient, that have **NEVER BLED** if **NO VARICES** on **FIRST EGD**?
Every **2 YEARS** if **ACTIVE** disease (drinks, active viral hep)
Every **3 YEARS** if **INACTIVE**
**IMMEDIATELY** if presents with **DECOMPENSATED CIRRHOSIS**
392
**WHEN** do you perform an **EGD** on **ANY** patient who presents with **DECOMPENSATED CIRRHOSIS** (variceal bleed, jaundice, ascites, HE)?
**IMMEDIATELY**
393
If a patient with **CIRRHOSIS** presents with variceal bleed, or jaundice, or ascites or HE, what **TYPE** of **CIRRHOSIS** do they have?
**DECOMPENSATED** cirrhosis
394
How **OFTEN** do you **SCREEN** for esopahgeal **VARICES** in a cirrhotic patient, that have **NEVER BLED** if **SMALL VARICES** on **FIRST EGD**?
Every **1 YEAR** if **ACTIVE** disease (drinks, active viral hep)
Every **2 YEARS** if **INACTIVE**
**IMMEDIATELY** if presents with **DECOMPENSATED CIRRHOSIS**
395
How **OFTEN** do you **SCREEN** for esopahgeal **VARICES** in a cirrhotic patient, that have **NEVER BLED** if **MEDIUM/LARGE VARICES** on **FIRST EGD**?
**NON-SELECTIVE beta-blockers** or **EGD with BANDING** (every 2 weeks until eradicated) but **NOT BOTH**
396
When do you start **PRIMARY PROPHYLAXIS** for esophageal **VARICES** with non-selective beta-blockers **OR** banding but **NOT BOTH**?
**MEDIUM-LARGE** varices or **SMALL** (**with red-whale sign**)
397
Should **Nitrates** or **Sclerotherapy** be used for primary prophylaxis of esophageal varices?
**NO**
398
**WHEN** is it **RECOMMENDED** to use **BOTH** non-selective beta-blockers and EGD with BANDING for esophageal variceal bleed prophylaxis?
For **SECONDARY PROPHYLAXIS** (already bled once)
399
What are the **REQUIRED** elements for management of **ACUTE** variceal **BLEEDING**?
1. Early **EGD** in **12 HOURS**
2. **OCTREOTIDE** x **72 HOURS**
3. **PPI** x **10-14 DAYS ONLY** (stabilizes clot)
4. Prophylactic Abx (**CEFTRIAXONE**) x **7 DAYS**
400
Do long-term **PPIs PREVENT** variceal **BLEEDING**?
**NO**
401
How **FREQUENTLY** do you **REPEAT EGDs** after initial variceal **BLEED**?
Every **2 WEEKS** until **eradicated**
Then screen again in **3 MONTHS**
If **NONE**, then in **6-12 MONTHS**
402
**WHEN** should **TIPS** be recommended in variceal **BLEEDING**?
**EARLY** - within **72 HOURS** (better survival and less bleeding episodes)
**10 mm** TIPS is better than larger, less complications
403
Which **GASTRIC** varices **CAN** be **BANDED**?
**G**astro**E**sophaeal**V**arices **1**&**2** (**GOV 1&2**)
404
Which **GASTRIC** varices **CANNOT** be **BANDED** (Minnesota tube, Octreotide, TIPS)?
**I**solated**G**astric**V**arices **1**&**2** (**IGV 1&2**)
405
What type of **IMMAGING** is recommended post esophageal variceal **HEMOSTASIS**?
**CROSS-SECTIONAL** (determine vascular anatomy)
406
What type of **ENDOSCOPIC** therapy is **RECOMMENDED** for **GASTRIC VARICES** (IGV 1&2)?
**EUS**-GUIDED **CYANOACRYLATE NON-LIPOIDAL**
407
In **GASTRIC VARICES**, if these are **MAINLY FED** by the **CORONARY VEIN**, what is the preferred mode of **TREATMENT**?
**TIPS**
408
In **GASTRIC VARICES**, if these are **MAINLY FED** by a **GASTRO-RENAL SHUNT**, what is the preferred mode of **TREATMENT**?
**BRTO** (**B**alloon-occluded **R**etrograde **T**ransvenous **O**bliteration) - as long as no ASCITES or HE
409
What medications can **PRECIPITATE HE**?
**Benzo**diazepines, **Narc**otics, **Gaba**pentin, Mirtazapine
410
Besides cleaning-up a pt's medication list, how do you **TREAT HE**?
**Lactulose** (titrate 1-3 soft BMs/day)
Add **RIFAXIMINE** if insufficient
Correct **HYPO**natremia
**HIGH-PROTEIN** diet (1.2-1.5 g/kg/day with late-night snack)
411
What can be **PRECIPITATED** after **TIPS** and how do you **TREAT** prophylactically?
**HE** - **RIFAXIMIN**
412
An **OUTPATIENT** with established cirrhosis and ascites presents for **LVP**, what shuld be sent?
**PMNs ONLY** (if inpatient, PMNs and culture)
413
If a **CIRRHOTIC** patient presents with **PVT**, what do you check for?
**CANCER** (liver, cholangio, pancreas) - CONTRAST CT
414
If a patient **WITHOUT** cirrhosis patient presents with **PVT**, what do you check for?
**SURGERY**, **MYELOPROLIFERATIVE** disorder, THROMBOPHILIA (**V617**, **JAK2**)
415
Is **PVT** caused by **MALIGNANCY** treated with **ANTICOAGULATION**?
**NO**
416
Clots caused by a **MALIGNANCY** are different on **IMAGING** than **NON-MALIGNANT** clots how?
These **ENHANCE** and look **whiter** than "bland clots" that look gray
417
How **LONG** do you **ANTICOAGULATE** a non-malignant **ACUTE PVT**?
**3-6 MONTHS**
418
How **LONG** do you **ANTICOAGULATE** a **CHRONIC PVT**?
You **DON'T** unless (extends to **SMV**, causes bowe **ISCHEMIA** or caused by a thrombophilia - **JAK2** or **V617**)
419
**COLLATERAL** formation around a **PVT** indicates what?
**CHRONIC** PVT (do **NOT** anticoagulate)
420
What **MUST** be done for **ALL CHRONIC PVT** pts?
**EGD** to rule out varices
421
**WHEN** are the **ONLY 2 OCCASIONS** where **PVT** is **NOT** anticoagulated?
**MALIGNANCY** and if causes **PARTIAL** obstruction
422
What part of the liver **ENARGES** with **BUDD-CHIARI** syndrome and why?
**CAUDATE LOBE** (segment 1) - due to **collaterals** formed - which can result in **compression** of the **IVC**
423
In which **CONDITION** do you see **ENHANCING** nodules in the liver that are **NOT HCC** but rather **REGENERATIVE** (should be **BIOPSIED**)?
**BUDD-CHIARY** syndrome
424
What is the **WORKUP** and **TREATMENT** of **BUDD-CHIARI** syndrome?
Evaluate for **THROMBOPHILIA** (JAK2 or V617) and start **HEPARIN**, **LMWH**, Direct Oral **Anticoagulants**, **WARFARIN**
425
426
When is **TIPS** or liver **TRANSPLANT** considered for a patient with **BUDD-CHIARI** syndrome?
**LIVER FAILURE**
427
This condition **APPEARS** as **BUDD-CHIARI** syndrome but is caused by occlussion of **SMALL** intrahepatic vessels not large ones (hepatic veins **PATENT** on imaging), presents with **PAIN**, **WEIGHT GAIN** and **ASCITES**, caused by **CHEMOTHERAPY**, **AZATHIOPRINE**. How is it **TREATED**?
**Sinusoidal Occlusive Syndrom**e (SOS)
**Prevent** with **URSO**
**Treat** with **DEFIBROTIDE**
428
Should you **CORRECT** thrombocytopenia or a coagulopathy (elevated INR) for **LOW-RISK** procedures (paracentesis, thoracentesis, EGD w/banding)?
**NO**
429
What can be used for **HEMOSTASIS** in patiets with **CIRRHOSIS** and **LIVER FAILURE**?
**DESMOPRESSIN** (DDAVP)
430
430
What is given to patients with **symptomatic DVT** or portal or mesenteric vein THROMBOSIS?
**IV HEPARIN**
431
What should raise **SUSPICION** of **CARDIAC** etiology of **ASCITES**?
SAAG >1.1 g/dL & ASCITES **PROTEIN >2.5** g/dL
432
Whar are the **CARDIAC** etiologies of **ASCITES** (protein >2.5)?
Constrictive **pericarditis** (need cardiac MRI to diagnose)
**RIGHT** heart failure
**Pulmonary** HTN
**TRICUSPID** insufficiency
433
How do you **TREAT** ascites caused by **CARDIAC** etiology?
Treat **underlying** heart disease (diuretics can result in hypotension and shock)
434
In **ISCHEMIC** hepatitis, why does the **BILIRUBIN** still rise for a week or more after **AST/ALT** decline?
**LAG** (but it will normalize ~2 weeks)
435
**RECURRENT**, spontaneous **nose bleed**s, **skin** telangiectasias, involves **GIT**, **LUNGS** & **BRAIN**, Family History, **HH1** MUTATION (endoglin **ENG**)?
**Hereditary Hemorrhagic Telangiectasia** (HHT) or Osler-Weber-Rendu syndrome
436
What do you do for a patient with HHT as far as **screening** and **treatment**?
Treat by REPLETING **IRON**, embolize SYMPTOMATIC **PULMONARY AVMs**, and **cerebral AVM** screening with **CT/MRI**?
437
How do you treat **SYMPTOMATIC HEPATIC AVMs**?
**BEVACIZUMAB**
438
**VASCULAR** injury to liver or casued by **AZATHIOPRINE**, **STENOSIS** of intrehepatic **VEINS**, appears like **CIRRHOSIS** on imaging but is not. **HPVG** is normal but with **portal HTN**?
**N**odular **R**egenerative **H**yperplasia (NRH)
439
Randomly distributed **BLOOD FILLED CAVITIES** in the liver caused by **AZATHIOPRINE**, **HIV**, **BARTONELLA**, **ANABOLIC STEROIDS**, multiple myeloma or Hodgkin's?
**PELIOSIS** Hepatitis
440
If a **THROMBUS ENHANCES** on arterial phase, it is most likely caused by what? How do you **NOT** treat?
**MALIGNANCY** - do **NOT** anticoagulate
441
**ASCITIC** fluid **PROTEIN >2.5** mg/dL?
**CARDIAC** or **Budd-Chiari** (NO DIURETICS)
442
Do hepatic **SIMPLE CYSTS** cause **SYMPTOMS**?
Only if **LARGE** and **COMPRESS** stomach or organs
443
If you find **>10-20** hepatic **CYSTS** in a patient, what should you **SUSPECT**?
**POLYCYSTIC** liver/kidney disease (AD **PRKCSH** or **SEC63** genes)
444
If a hepatic **CYST** sppears **NODULAR** or has internal **SEPTATIONS**?
**RESECT** (**15% cancer** risk - biliary cytadenomas)
445
When is the **ONLY** time **HEMANGIOMAS** require surgical intervention?
When they cause **SYMPTOMS** or **HIGH-OUTPUT HF**, or **THROMBOCYTOPENIA**, **DIC** and **SYSTEMIC BLEEDING**?
446
**CENTRIPETAL ENHANCEMENT** of a lesion on **MRI**?
**HEMANGIOMA** (bening regardless of size)
447
**FEMALE**, **SOLITARY LIVER LESION < 5 cm**, **CENTRAL SCAR**?
**FOCAL NODULAR HYPERPLASIA** (not associated with OCPs or estrogen) - **BENIGN**
448
**ISOINTENSE** lesion on **T2 MRI** phase with **CENTRAL SCAR**?
**FOCAL NODULAR HYPERPLASIA** (FNH)
449
These liver **TUMORS** (**HNF-apha**) are usually found in the **RIGHT** lobe, are **SOLITARY**, lack bile ducts or normal architecture, are associated with **OCPs** and **PCOS**, risk of **HEMORRHAGE** and **MALIGNANT** (**BETA-CATENIN**) transformation? Treatment?
Hepatic **ADENOMAS**
Stop **OCPs**, observe, **RESECT/ABLATE** (if found in men, or if enlarging)
450
ALL **ASIAN** men (**>40**), women (**>50**) and **ANY** individuals who are **Hep B CARRIERS** and have a **FAMILY HISTORY** of this, should undergo **SURVEILLANCE**?
**HCC** (US and AFP every 6 MONTHS)
451
What should **ALL BLACKS** with **HBV** undergo surveillane for?
**HCC** (US and AFP every 6 MONTHS)
452
ALL patients with **CIRRHOSIS** (HBV, HCV, PBC, hemochromatosis, alpha-1, etc) should undergo **SURVEILLANCE** for?
**HCC** (US and AFP every 6 MONTHS)
453
How is **HCC** **NON-INVASIVELY DIAGNOSED**?
**CT** or **MRI**, lesion **>2 cm** with **LATE ARTERIAL ENHANCEMENT & PORTAL VENOUS WHASHOUT** (**LIRADS-5**) no biopsy needed
454
Why are most patients with **HCC** **NOT** candidates for surgical **RESECTION**?
Because they are **CIRRHOTIC** and lack liver reserve
455
In patients with **HCC** not candidates for **LOCOREGIONAL** therapy, or **RESECTION** or due to **METASTATIC** disease ot **CIRRHOSIS**, what is the treatment?
**ATEZO**lizumab + **BEVA**cizumab (others are sorafenib, levatinib)
456
**BEFORE** treating for **HCC** or **HHT** with **BEVA**cizumab, what should be **DONE** first?
**EGD** to evaluate and treat **VARICES** (GIB risk)
457
Is **SORAFENIB** therapy preferred for treatment of **HCC** or for adjuvant therapy after resection or LocoRegionalTherapy?
**NO**
458
Decribe the **MILAN** criteria for **TRANSPLANT** eligibiltiy for a patient with **HCC**?
**ONE** lesion **< 5 cm** or Up to **THREE** lesions **< 3 cm EACH**
459
What is the **UCSF** criteria for **DOWNSTAGING** to **MILAN** criteria for liver **TRANSPANT** for a patient with **HCC**?
**ONE** lesion **>5 cm** but **< 8 cm**
**TWO-FIVE** lesions **each < 5 cm** but **COLLECTIVELY < 8 cm**
460
The **ONSET** of **HE** within **8 WEEKS** of **FIRST** symptoms of **LIVER DISEASE** suggests what?
**Acute Liver Failure** (ALF) - no pre-existing liver disease
461
What does the presence of **HEPATIC ENCEPHALOPAHTY** mean?
**LIVER FAILURE**
462
What is **REQUIRED CRITERIA** for a **STATUS 1A** (highest status for requirement of immediate **LIVER TRANSPLANT** for **ACUTE** (not acut on chronic) Liver Filure?
**ICU** care required
**VENTILATED**
On **DIALYSIS**
**INR >2**
463
In a patient with **ACETAMINOHEN OD**, what is the **KING's COLLEGE CRITERIA** for the **WORST PROGNOSIS** (**TRANSPLANT** IMPENDING)?
Arterial **pH < 7.30**
**INR >6.5** (PT >100)
**Cr >3.4**
**HE Grade 3-4**
464
Patient presents with **AST/ALT** in the **THOUSANDS** and **BILI** is **NORMAL**, no alcohol nor acetaminophen history, no ischemia?
**HERPES** Hepatitis (test with PCR, treat with acyclovir)
465
What is **BENEFICIAL** to start for **ANY** patient with **ACUTE LIVER FAILURE** (presence of **HE**) regardless of etiology?
**N-cetylcysteine**
466
What are the **INDICATIONS** for liver **TRANSPLANT**?
**MELD**-Na **>15**
**DECOMPENSATED CIRRHOSIS**
**MELD EXCEPTION** (HCC - MILAN or USCF downgraded)
467
468
What are the **MELD EXCEPTIONS** for liver **TRANSPLANT**?
**HCC** (MILAN or USCF downgrade)
**HepatoPulmonary** Syndrome
**Cholangiocarcinoma**
**Cystic Fibrosis**
Refractory **Cholangitis**
469
Which are the **TWO PULMONAR**Y conditions associated with **portal HTN** and **CIRRHOSIS**?
**Portopulmonary HTN** - **ECHO**, RIGHT heart **CATH**
**Hepatopulmonary Syndrome** - RIGHT to LEFT **SHUNT** (**bubble** ECHO)
470
What is the **MOST COMMON** infection after LIVER **TRANSPLANT**?
**CMV** (highest risk is **3 MO** post transplant)
FEVER, N/V/D - PCR
471
**MAJOR** Adverse Effect of **Cyclosporine** & **Tacrolimus**?
Chronic **KIDNEY** Injury
472
**MAJOR** Adverse Effect of **EVEROLIMUS**/**SEROLIMUS**?
**ANEMIA**, **HYPER**lipidemia
473
**MAJOR** Adverse Effect of **Mycophenolate Mofetil**?
**TERATOGEN**
ANEMIA, DIARRHEA, CMV
474
Which **MEDS** **INCREASE** levels of **TACROLIMUS/CYCLOSPORINE**?
**Antifungals** (ketoconazole, fluconazole)
**Metoclorpamide**
**HIV** drugs (protease inhibitors)
475
Which **MEDS** **DECREASE** levels of **TACROLIMUS/CYCLOSPORINE**?
**TB** drugs, anti-**SEIZURE**
476
What does **AMIODARONE + SOFOSBUVIR** (HAART) cause?
**Cardiac** Issues
477
What are the **COMMON** cancers seen post **LIVER** **TRANSPLANT**?
**SKIN** (squamous/basal cell)
**KAPOSI** Sarcoma HHV-8
**COLON** (if for PSC)
**OROPHARYNX** (if for EtOH cirrhosis)
478
Patient with EtOH **cirrhosis** comes in with a 50% occlusive **PVT** that arterially **enhances** on CT but no mass is shown, next step?
**AFP** (because if **>200** ng/mL its **HCC**)
479
How do you **MONITOR** a patient on **METHOTREXATE** (should ABSTAIN from alcohol) for development of liver disease?
Annual **ELASTOGRAPHY** (DILI and fibrosis)
480
What is the **PREFERRED** analgesic in pts with **CIRRHOSIS**?
**ACETAMINOPHEN**
481
When do you perform an **EGD** after a patient underwent **BRTO** for bleeding **VRICES**?
**2-4 WEEKS**
481
In a patient with **CIRRHOSIS** and a **VARICEAL BLEED**, what is the **PREFERRED** treatment where there is ANY "**TYPE b**" (gastro-renal shunt) anatomy?
**BRTO** (Balloon Retrograde Trans-Obliteration)
482
What does the presence of **ASCTIES** tell you about the pt's **CIRRHOSIS**?
**DECOMPENSATED** cirrhosis (Child B or C)
483
In an active **Hep C** (**G 1-6**) patient with **DECOMPENSARED** cirrhosis (ascites, etc), what is the treatment regimen?
**12 WEEKS** **SOFOS**buvir + **VEL**patasvir + **RIBA**virin (or **24 WEEKS** without RIBA)
484
Which **Hep C** drugs (protease inhibitors) **CANNOT** be used with **DECOMPENSATED CIRRHOSIS** (ascites, etc.)?
**VOX**ilaprevir and **GLE**caprevir
485
What is **IMPORTANT** to test for in a patient with **Hep C GENOTYPE 3**, **PRIOR** to initiating treatment?
**Y93H** mutation (reduced SVR)
486
In a patient with **DECOMPENSATED CIRRHOSIS** who presents with **PANCYTOPENIA**, **ATAXIA** and **HYPER**cholesterolemia, what is the **DEFFICIENCY**?
**COPPER**
487
**Night** **blindness** is associated with which **defficiency**?
**Vitamin A**
488
**Cardiomyopathy**, **myositis**, **cramps** and **alopecia** are associated with which **defficiency**?
**SELENIUM**
489
If a patient receiving treatment for **Hep C** and is doing well, but **LFTs** become **HIGHLY** elevated, what shoud you **SUSPECT**?
Re-activation of **Hep B** (check HBsAg, HBc IgM, DNA)
490
If a patient with **Hep C** presents and looks like he might clear the virus spontaneouslty, do you wait or do you treat?
**TREAT ASAP** (to clear viral load right away) do **NOT WAIT**
491
If a pt with **Hep C** requires **TRANSPLANT** (liver, kidney, etc) what **MUST** you check first before treatment?
If he **CONSENTED** to **Hep C POSITIVE** donor (because he would get the transplant much quicker then treat)
492
In a patient with **CHRONIC Hep B** treated with DAA with **HBsAg+** and **undetectable DNA** and **HBeAg-** who asks if they can **STOP** therapy, **WHAT** predicts **HBsAg LOSS** after stopping therapy?
**HBsAg** **QUANTITATIVE TITER** (not HBeAb)
If **< 100**, good chance for spontaneous clearance
493
494
In a patient with a **PVT** with **EXTENSION** into **SMV** who had their last **EGD >1 year** ago with **NO VARICES**, who is listed for **LIVER TRANSPLANT**, what do you do **BEFORE** starting **ANTICOAGULATION**?
**REPEAT EGD** to evalaute for varices **PRIROR** to **TRANSPLANT**
495
Acute **CHOLESTASIS** of **PREGNANCY** with **PRURITUS**, elevated **ALK PHOS**, elevated serum **BILE ACIDS** can safely be **TREATED** with what?
**URSO**
496
If a patient is foud to have **Focal Nodular Hyperplasia** (central scar) on imaging, what is the follow-up?
**NOTHING** else needs to be done
497
498
This **DRUG** causes **DILI** which looks like **AIH** (AST/ALT >> ALK PHOS), treatmet is **STOPPING** the drug.
**MINOCYCLINE**, **STATINS**, nitrofurantoin, methyldopa, hydralazine, **DICLOFENAC**, **MELOXICAM**, anendronate
499
If a patient is **HBsAG+** or **HBcAb+** and undergo **IMMUNOSUPPRESSIVE** or **CHEMOTHERAPY** require **WHAT**?
**ORAL** antiviral therapy while treated and for **12 MONTHS** after completion
500
If a **Hep B** patient is about to be started on **TENOFOVIR**, what **MUST** they be tested for **BEFORE** starting therapy and why?
**HIV** (because tenofovir can cause treatment to be ineffective for HIV)
501
If a patient responds well to prednisone and **AZATHIOPRINE** with **LFT** normalization then LFTs start going up again (**ALT/AST**), what do you need to check?
**THIOPURINE** **metabolities** from azathioprine **toxicity** - check **6-MMP**
502
Most **COMMON** reason for elevation of **ALK PHOS** and **PRURITUS** post liver **TRANSPLANT** (even **YEARS** later) and what do you do to diagnose?
Biliary **ANASTOMOTIC STRICTURE** - do **ERCP**
503
What is the most **CONSISTENT** and **REPRODUCIBLE** method used to quantfy **MUSCLE MASS** (such as in a patient with sarcopenia and fraily awaiting liver transplant)?
**CT** for **Skeletal Muscle Index**
504
In a **CIRRHOTIC** patient with **Mental Status Changes** and **Confusion**, if **BLOOD VENOUS AMMONIA** levels are **NORMAL**, whats the issue?
**NOT HE**, may be metabolic or different etiology
505
505
Patient with **CIRRHOSIS** and gastric bypass presents with **RASH**, **ALOPECIA**, **HE** and **MYOPATHY**, what is their **DEFFICIENCY**?
**ZINC**
506
507
**SELENIUM DEFFICIENCY** results in what condition?
**CARDIOMYOPATHY**
508
**COPPER DEFFICIENCY** results in what conditions?
**HYPER**lipidemia, **BONE MARROW** SUPPRESSION
509
**Hepatopulmonary** syndrome with a **RA SpO2 of < 60 mmHg** is considered **HOW** in terms of liver **TRANSPLANT** priority?
This is a **MELD EXCEPTION** and would be **PRIORITIZED**
510
511
Ptients with **ACUTE Liver Failure** should be **ROUTINELY TESTED** for what?
**HERPES** (HSV)
512
What is the **FIRST LINE TREATMENT** of **HCC** that is unresectable?
**ATEZ**olizumab + **BEV**acizumab
513
Patient presenting with bloody **DIARRHEA** and **FEVER** after a liver **TRANSPLANT** on immunosuppressive therapy needs to be checked for?
**CMV** (PCR)
514
Which is one of the **ONLY** scenarios in which **N-acetylcysteine** is NOT recommended?
**CHILDREN** with **non-acetaminophen** DILI (harmful)
515
# [](http://)
Which feature on **HISTOLOGY** is the most important in predicting **LIVER**-rlated outomes?
Stage of **FIBROSIS**
516
In a **CIRRHOTIC** patient with **HCC** about to start **CHEMOTHERAPY** (**ATEZ**olizumab + **BEV**acizumab), what **MUST** be done first?
**EGD** to rule out **VARICES** (because the **adeverse effects** of ATEZolizumab + BEVacizumab are **GI bleed**)
