Liver

Question 1

Which 3 groups of patients with cirrhosis, do not need variceal screening with EGD?

Answer 1

Upper endoscopy should be performed in any
patient with cirrhosis to screen for varices, with
the exception of those with compensated cirrhosis,
a platelet count above 150,000 platelets/μL, and
a liver stiffness measurement below 20 kPa.

Question 2

Under what level kPa for liver stiffness do you not have to get an EGD for variceal screening?

Answer 2

liver stiffness measurement below 20 kPa does not require EGD

Question 3

If no varices are seen on EGD, how often should patients with compensated cirrhosis have an EGD (ongoing liver disease/injury vs not having ongoing liver insult)?

Answer 3

If no varices are found in a patient with compensated
cirrhosis, recommendations are for a screening
endoscopy to be repeated every 2 years in those
with ongoing liver injury and every 3 years in
those without ongoing liver injury.

Question 4

Under what platelet number, are patients at increased risk of varices and should have an EGD?

Answer 4

Under 150k

Question 5

In individuals with cirrhosis and varices that have not bled, who are taking nonselective BB, how often should endoscopy be done?

Answer 5

In addition, in individuals with varices
that have not bled, endoscopy does not need to
be repeated in patients who are taking NSBBs.

Question 6

Patients with HCC with should be referred for liver transplantation, if they are within Milan criteria? what is Milan criteria

Answer 6

Milan criteria (single mass <5 cm or up to 3 masses <3 cm each, in the absence of vascular invasion or metastatic disease). Liver
transplantation will provide him his best chance for
long-term survival. While awaiting transplantation,
he can undergo locoregional therapies to control
his tumor burden.

Question 7

what are some of the cirrhotic related clinical manifestations that make a cirrhotic patient with HCC a poor surgical candidate?

Answer 7

underlying clinically significant portal hypertension (as evidenced by his large esophageal varices, thrombocytopenia, and splenomegaly) make a pt a poor resection candidate.

Question 8

what is the likelihood of a patient with AIH, having recurrent disease after transplantation?

Answer 8

Patients with AIH usually require higher doses
of baseline immunosuppression after transplantation. Individuals with AIH have an approximately 20% chance of recurrent disease after transplantation. This risk is higher if immunosuppression is rapidly tapered after transplantation, and most centers manage patients with a higher baseline level of immunosuppression compared with recipients with other etiologies of liver disease.

Question 9

Should pts with new decomp cirrhosis 2/2 HCV, have treatment of HCV prior to traplsant?

Answer 9

All patients with HCV infection should be considered for therapy, given the tolerability and efficacy of direct-acting antiviral therapies. In those awaiting transplantation, however, treatment decisions need to be made on a case-by-case basis, as there are a variety of potential risks and benefits with each treatment strategy. Potential benefits of
treatment before transplantation include stabilizing or improving liver function before surgery and preventing liver graft infection at transplantation. Potential risks of treatment before transplantation include having higher rates of treatment failure with decompensated liver disease and
that successful treatment may leave patients with
a diseased liver but improve their MELD score
enough to limit access to organs (often referred
to as “MELD purgatory”).

Question 10

what 3 findings can you see in patients with hepatopulmonary syndrome?

Answer 10

hepatopulmonary syndrome
based off the presence of underlying liver disease,

impaired oxygenation, and evidence of intrapul-
monary vascular shunting.

Question 11

in patients with hepatopulmonary syndrome, what can be expected to be seen on ABG?

Answer 11

When present, an arterial blood gas should be obtained with the expectation of an elevated alveolar-arterial gradient and a reduced PaO2. aFTER liver transplantation , pts can expect gradual improvement in his hypoxia over
the next 6 to 12 months.

Question 12

Does TIPS help to improve hepatopulmonary syndrome?

Answer 12

Response to medical therapies is overall ineffective and response to transjugular intrahepatic portosystemic shunt
has been reported with variable results and is not generally recommended.

Question 13

Muscle cramps in cirrhotic patients are common. Can muscle cramps in cirrhotic patients be treated?

Answer 13

The cramps related to her liver disease can be improved with multiple different supplements including the use of agents such as baclofen, vitamin E, and taurine.

Question 14

can pts with acute liver failure receive urgent liver transplant? what is the major exclusion criteria to getting a transplant in this situation?

Answer 14

One of the most feared
outcomes of transplantation, however, is failing to
recover neurological function. Objective evidence
of brainstem injury (with fixed and dilated pupils a) should preclude transplantation as it is likely to be futile.

Question 15

are Bacterial infection or psychiatric disease contraindications to liver

transplantation?

Answer 15

Bacterial infection and psychiatric disease are
relative contraindications but should not preclude

transplantation.

Question 16

Which cirrhotic variceal patients need early TIPS?

Answer 16

Several studies have suggested benefit with early TIPS for individuals who present with variceal hemorrhage. TIPS placement should be reserved for individuals who meet inclusion criteria of studies that have shown benefit. The population that is often referenced in this setting are those who present with a variceal hemorrhage and are Child-Pugh class C (score 10-13) or Child-Pugh class B (score 7-9) with active hemorrhage on endoscopy.

Question 17

What are 3 exclusion criteria for early TIPS for variceal bleed?

Answer 17

Notably renal disease, age above 75 and Child-Pugh class A cirrhosis were exclusion criteria for TIPS.

Question 18

how can liver massHCC be diagnosed on imaging? whats the best imaging for this?

Answer 18

liver mass on ultrasound, which is highly concerning for HCC if baseline cirrhosis.
Diagnosis can often be made without biopsy, when
dynamic imaging of the liver (either CT with contrast or MRI)
reveals the typical features of HCC (arterial
hypervascularity and early washout in the portal
venous phase).

Question 19

Radiologically, what are the typical features of HCC?

Answer 19

The typical features of HCC (arterial
hypervascularity and early washout in the portal
venous phase)

Question 20

Which CT imaging is best to radiographically diagnoise HCC?

Answer 20

CT imaging is not adequate to evaluate for HCC IF done without contrast. HCC would not be evident on noncontrast CT imaging of the liver and could easily be missed on a single-
phase CT of her abdomen (which would have onlyobtained a venous phase).

Question 21

in cirrhotic patients, whats the max daily Tylenol dose you can give?

Answer 21

When systemic medications are needed, acetaminophen is considered safe and is the recommended first-line
pharmacologic therapy for pain in this population,
at a dose of up to 2000 mg daily.

Question 22

In alcoholic hepatitis, if patients do not have improvement in Lille score and score is consistent with nonresponse to
medical therapy, should they continue steroids with Prednisolone?

Answer 22

Pts should stop prednisolone and be referred to a tertiary center for considerations of early transplantation as
individuals with severe alcoholic hepatitis that did not respond to
glucocorticoid therapy were found to have a markedly improved 6-month survival if
they underwent early liver transplantation,

Question 23

Does older age necessarily prevent you from being a liver transplant candidate?

Answer 23

It is generally accepted that physiological, not chronological, age should determine who is a
candidate for liver transplantation. Older patients can be listed for liver transplantation after careful considerations of their comorbidities and
functional status.

Question 24

Under what circumstance should patients with CKD and liver disease, be listed for liver and kidney transplant?

Answer 24

If kidney disease worsens after liver transplantation, the patient can be listed for kidney transplantation and will be prioritized on the list/ If the patient has underlying chronic kidney disease it may very likely worsen after transplantation related to the acute stressors of
surgery and side effects of medications he will
likely receive. The Organ Procurement and Transplantation Network established medical eligibility for those who are candidates for simultaneous liver kidney transplantation (SLK)
that included a “safety net” allocation priority for
individuals who undergo liver transplantation
alone and develop new or ongoing progressive
renal impairment.

Question 25

Which liver transplant patients, are eligible for an SLK?

Answer 25

Individuals are eligible for an SLK if they have a sustained acute kidney injury (≥6 weeks of requiring ≥once-weekly dialysis or a GFR of ≤25 mL/min tested weekly) or chronic kidney disease (GFR ≤60 mL/min for >90 days and a subsequent worsening of renal function of GFR ≤30 mL/min or need for regular dialysis). The hope in those not meeting these criteria is that their renal function may recover, minimizing the transplantation of kidneys into individuals who may not need them.

Question 26

what is the treatment for pts with patient has evidence of portal hypertensive gastropathy (PHG)?

Answer 26

If patient has evidence of portal hypertensive gastropathy (PHG), First-line therapy consists of iron supplementation for anemia and nonselective beta-blockers. Transjugular intrahepatic portosys- temic shunt can be considered if first-line measures fail, although its overall efficacy is not clear.

Question 27

what is the recommended caloric intake for cirrhotics with sarcopenia?

Answer 27

In this setting, specific recom- mendations should be given regarding total caloric (30-35 kg/kg daily) and protein (1.2-1.5 g/kg daily) intake for any individual with cirrhosis.

Question 28

In cirrhotic patients, what is the negative effect of patients fasting on muscle mass?

Answer 28

This patient is fasting for prolonged periods of time (roughly 16 hours a day between meals), which will lead to worsening of his sarcopenia.

Question 29

if cirrohtic pts with variceal bleed, what tx is recommended to prevent rebleeding in this population?

Answer 29

Individuals who survive an episode of acute vari- ceal hemorrhage have a bleeding risk of around 60% if untreated. Current recommendations are for a combination of EVL and NSBB to prevent rebleeding in this population. as combination therapy has been shown to be superior to EVL alone at preventing re- bleeding. TIPS is incorrect and recommended as a rescue therapy in those who experience recur- rent bleeding despite management with EVL and NSBB combination therapy.

Question 30

when is TIPS used for variceal bleed?

Answer 30

TIPS is recommended as a rescue therapy in those who experience recurrent bleeding despite management with EVL and NSBB combination therapy.

Question 31

can pts with early-stage unresectable hilar cholangiocarcinoma be candidates for liver transplant?

Answer 31

Transplantation is now considered an option in many centers in those with early-stage unresectable hilar cholangiocarcinoma after data published from the Mayo Clinic showed acceptable outcomes in a highly selected cohort of patients. In those who were candidates, patients received neoadjuvant therapy that included both radiation and sys- temic chemotherapy

Question 32

Which is the main reason patients with would not be a candidate for liver transplant?

Answer 32

Transplantation centers have since developed individualized protocols for transplantation for early-stage hilar cholangiocarcinoma. In addition to a requirement for neoadjuvant therapy and repeat staging after treatment, the Organ Procurement and Transplantation Network mandates that transperitoneal biopsy (either by endoscopic ultrasound or percutaneous approaches) be an exclusion criterion in any institutional protocol.

Question 33

How does portal hypertensive gastropathy appear described on endoscopy?

Answer 33

This patient has evidence of portal hypertensive gastropathy (PHG). Upper endoscopy reveals a mosaic mucosal pattern with a “snake-skin” appearance.

Question 34

If first line therapy for PHG (NSBB) fails, what can be considered next?

Answer 34

TIPS

Question 35

WHICH clinical phenomenon is asociated with upper endoscopy reveals multiple red spots and linear areas of erythema converging on the pylorus?

Answer 35

First-line therapy consists of endoscopic electrocoagulation or laser therapy and multiple sessions are often needed. For refractory cases, surgical antrectomy can be performed, albeit with significant morbidity.

Question 36

what is the first line treatment for GAVE? Then what is treatment if refractory

Answer 36

First-line therapy consists of endoscopic electrocoagulation or laser therapy and multiple sessions are often needed. For refractory cases, surgical antrectomy can be performed, albeit with significant morbidity.

Question 37

What is the one treatment that have shown to help resolve GAVE?

Answer 37

A variety of case reports and case series have shown that GAVE can resolve after liver transplantation. No medication has been clearly shown to be beneficial for the treatment of GAVE.

Question 38

In terms of therapies, does bleeding from GAVE respond to measures that reduce portal pressure?

Answer 38

Unlike portal hypertensive gastropathy and varices, bleeding from GAVE does not respond to measures that reduce portal pressure.

Question 39

For cirrhotic pts with sleep problems, what 3 meds can be used for the short term?

Answer 39

Sleep disturbances are relatively common in individuals with cirrhosis. When present, clinicians should consider inadequately treated hepatic encephalopathy (which can lead to sleep-wake reversal) as well as sleep hygiene, which includes ensuring lactulose and diuretics are timed to avoid nocturnal awakenings. Medications that have been studied in small randomized controlled trials for sleep disturbances in cirrhosis include melatonin, zolpidem, and hydroxyzine.

Question 40

How is bleeding from GOV type 1 gastric varices managed compared to esophageal varices?

Answer 40

type 1 gastric varices (GOV1) are located along the lesser curvature of the stomach. Bleeding from GOV1 should be managed similarly to bleeding from esophageal varices.

Question 41

Where are type 1 gastric varices (GOV1) located?

Answer 41

type 1 gastric varices (GOV1) are located along the lesser curvature of the stomach. Gastroesophageal varix (GOV) type 1: Extension of esophageal varices along lesser CURVATURE OF STOMACH

Question 42

in the setting of cirrhosis and variceal bleed, with type 2 or 3 GOV varices, when is splenectomy considered?

Answer 42

Splenectomy can be considered in the presence of splenic vein thrombosis.

Question 43

Where are GOV2 varices located?

Answer 43

Gastroesophageal varix type 2: Extension of esophageal varices along great curvature

Question 44

In patients with alcohol cirrhosis, who have improvement in clinical status and go from decompensated to compensated status, with a low MELD and low (class A child pugh), is liver transplant indicated?

Answer 44

Although transplantation is clearly beneficial in individuals with advanced liver disease with high MELD scores, a survival advantage with transplantation is only seen after MELD scores are greater than 17.

Question 45

Are patients with end-stage hepatocellular carcinoma (Barcelona Clinic Liver Cancer stage D), poor functional status and poor liver function (Child-Pugh class C) candidates for chemo or liver transplant?

Answer 45

This patient has end-stage hepatocellular carcinoma (Barcelona Clinic Liver Cancer stage D) given his poor functional status and poor liver function (Child-Pugh class C). This corresponds to a poor survival (<3 months) and treatment should be supportive. He is not a transplantation candidate based off tumor burden and vascular invasion (outside of “Milan criteria”).

Question 46

Which set of criteria refer to a single tumor of 5 cm or less or three tumors that are each 3 cm or less, no macrovascular invasion, and no metastasis?

Answer 46

The Milan criteria state that transplantation should be performed in those with a single tumor of 5 cm or less or three tumors that are each 3 cm or less, no macrovascular invasion, and no metastasis. Patients who do not meet the Milan criteria are not considered eligible candidates for liver transplantation.

Question 47

What is the milan criteria used for? what are the components of milan criteria?

Answer 47

The Milan criteria state that transplantation should be performed in those with a single tumor of 5 cm or less or three tumors that are each 3 cm or less, no macrovascular invasion, and no metastasis. Patients who do not meet the Milan criteria are not considered eligible candidates for liver transplantation.

Question 48

In evaluating a patient for transplant, if they have evidence of pulmonary hypertension (with right ventricular systolic pressure [RVSP] > 45 mmHg), is this a deal breaker for transplant?

Answer 48

If the right heart catheterization is consistent with severe pulmonary hypertension (mean pulmonary artery pressure [MPAP] > 45 mmHg), should be considered a contraindication to transplantation if this cannot be improved. A Mayo Clinic case series showed a 100% mortality in those who received a transplant with an MPAP greater than 50 mmHg, and current guidelines only recommend pursuing transplantation if these patients achieve an adequate response to medical therapy.

Question 49

What are the 3 different nonselective beta-blockers that can be recommended for primary prophylaxis in individuals with cirrhosis and medium/large varices that have not bled?

Answer 49

(nadolol, propranolol, and carvedilol)

Question 49

Above what number BMI, is a relative contraindication to transplantation (but not an absolute contraindication)?

Answer 49

Body mass index greater than 40 kg/m2 is a relative contraindication to transplantation (but not an absolute contraindication).

Question 49

In cirrhotic variceal patients, WHO HAVE NEVER BLED, is it better to band them or give them NSBB?

Answer 49

dO ONE OR THE OTHER. Endoscopic variceal ligation has been shown in randomized controlled trials to be as effective as nonselective beta-block-ers for primary prophylaxis. The combination of NSBB and variceal ligation has been associated with more side effects without reduction in variceal hemorrhage risk in this population that has not had active bleeding.

Question 49

What is The most important predictor of variceal hemorrhage?

Answer 49

The most important predictor of variceal hemorrhage is the size of the varices, with individuals with large varices experiencing their first hemorrhage at a rate of 15% per year.

Question 50

Aside from the size of varices, what two other factors are important risk factors for re-bleeding from varices in cirrhotic with varices?

Answer 50

Other predictors of bleeding are the presence of red wale signs on endoscopy and Child-Pugh class B or C cirrhosis.

Question 51

Can TIPS be used for the primary prophylaxis for prevention of variceal bleed?

Answer 51

TIPS placement is not recommended for the primary prophylaxis based off trials of prophylactic surgical shunts showing a higher rate of encephalopathy and a trend toward higher mortality.

Question 52

In treating ascites, which diuretic is usually started first?

Answer 52

Starting spironolactone 50–100 mg orally daily is the initial approach to treat ascites (and thus, hepatic hydrothorax). Furosemide 40 mg orally daily is incorrect given the recommended diuretic to start in patients with ascites is monotherapy with spironolactone.

Question 53

How are ascites and hepatic hydrothorax treated different/y medically?

Answer 53

They aren't, The management of hepatic hydrothorax is similar to the management of ascites. Starting spironolactone 50–100 mg orally daily is the initial approach to treat ascites (and thus, hepatic hydrothorax).

Question 54

Can you place a chest tube in the setting of hepatic hydrothorax, in diuretic refractory cases/

Answer 54

Chest tube placement should never be performed in the setting of hepatic hydrothorax, even in diuretic refractory cases.

Question 55

If the cause of portal hypertension is Hepatic, will the ascitic protein be high or low?

Answer 55

Hepatic causes of portal hypertension will have a low total protein in the ascites fluid (<2.5 g/dL).

Question 56

what is the main clinical significance of the serum-ascites albumin gradient (SAAG) greater than 1.1?

Answer 56

The patient has evidence of portal hypertension given the serum-ascites albumin gradient (SAAG) greater than 1.1.

Question 57

Should you transfused cirrhotic variceal pts to a high goal?

Answer 57

Conservative transfusion strategy should be implemented in the setting of cirrhosis so that portal hypertension is not worsened.

Question 58

what is the goal number of BMs for Patients with Hepatic encephalopathy ?

Answer 58

Patients with encephalopathy should have 2-3 soft (not liquid) BMs daily. Careful, as the patient may develop dehydration from frequent BMs, and this could be precipitating encephalopathy.

Question 59

What does having gastric varices (GOV2) tell you about the source of portal hypertesion?

Answer 59

This patient has GOV2 suggesting portal hypertension that is from an intrahepatic source.

Question 60

What is the main cause of this constellation of symptoms: - prehepatic portal hypertension - isolated gastric varices - splenomegaly

Answer 60

Splenic vein thrombosis would cause pre-hepatic portal hypertension and isolated gastric varices in addition to splenomegaly.

Question 61

Is surgical resection of a liver mass feasible in patient with ascites/ portal hypertension?

Answer 61

Surgery is not recommended given her ascites/ portal hypertension.

Question 62

In patients with HCC mass and normal labs, should systemic therapy OR locoregional therapy be pursued?

Answer 62

She would be a candidate for systemic therapy if locoregional therapy was not an option, but her laboratory tests results are normal so locoregional therapy should be considered first.

Question 63

WHATS THE BEST way to screen for HCC in cirrhotic pts and how often>?

Answer 63

Ultrasound with AFP every 6 months indefinitely. Patients with cirrhosis have an increased risk of HCC. Screening patients routinely allows for earlier detection and provides the greatest number of treatment options. Studies demonstrate that a com- bination of serum alpha fetoprotein levels along with ultrasound every 6 months provides earlier detection of HCC and reduces mortality.

Question 64

Whati s the main treatment benefit of early detection of HCC?

Answer 64

There are benefits to early detection of HCC which include offering locoregional therapy). So screen with US for HCC q6 months for ever

Question 65

HBV recurs after transplantation, how medically can the risk be reduced?

Answer 65

HBV recurs after transplantation, and the risk is modified by oral nucleos(t)-ide analogues (NAs) used daily. use IV HBV immunoglobulin and entecavir daily

Question 66

When is the risk of HBV reactivation after transplantation greatest?

Answer 66

Given the risk of HBV reactivation is highest in the early days after transplantation when immunosuppression is greatest, it is recommended to also treat patients with IV HBV immunoglobulin in addition to a NA such as entecavir. This is especially true when patients have detectable HBV DNA at the time of transplantation and are at increased risk of HCC

Question 67

How often does HCV recur after liver transplantation ?.

Answer 67

HCV recurs after transplantation in the new graft 100% of the time. Rates of graft failure were higher before the discovery of direct-acting antiviral agents.

Question 68

Should you use the ammonia level to guide therapy in HE?

Answer 68

The ammonia level should not be used to guide therapy in HE.

Question 69

If treating cirrhotic patients for HE who have persistent sleep wake cycle issues despite BM goal with Lactulose and Rifaximin. what imaging can be ordered to further evaluate? and what are you looking for as a cause of HE?

Answer 69

Ordering imaging to evaluate for splanchnic vessel shunts is correct since investigating for shunts can be a treatable cause of HE. If present, the shunts could be embolized to help with HE.

Question 70

What would be the next reasonable step in treatment for cirrhotic patients with TIPS, who have developed HE that is refractory to medical therapy?

Answer 70

TIPS can precipitate HE and in cases where standard medical treatments do not control symptoms, there may be a need to embolize or reduce the size of the shunt.

Question 71

Which type of Hepatic encephalopathy is associated with acute liver failure?

Answer 71

Type A is associated with acute liver failure,

Question 72

Which type of Hepatic encephalopathy is associated with bypass shunts in the absence of cirrhosis?

Answer 72

Type B is associated with bypass shunts in the absence of cirrhosis.

Question 73

Which type of Hepatic encephalopathy is associated with gradual onset, rarely fatal, and associated with cirrhosis and portosystemic shunting.

Answer 73

Type C is gradual onset, rarely fatal, and associated with cirrhosis and portosys- temic shunting.

Question 74

for Patients with cirrhosis and ascites, at what protein level do you start prophylaxis for SBP?

Answer 74

Patients with cirrhosis and ascites if the ascitic fluid protein is <1.5 g/dL (15 g/L) along with either impaired renal function or liver failure, give antibiotic prophylaxis

Question 75

For cirrhotic patients who come in with decompensation, whats the most important and early thing to do?

Answer 75

It is vital to perform a diagnostic paracentesis in patients who present with decompensation. Spontaneous bacterial peritonitis can precipitate acute-on-chronic liver failure and so early diagnosis is critical.

Question 76

After transplant, can recurrent primary biliary cholangitis occur?

Answer 76

Recurrent primary biliary cholangitis (PBC) can occur after transplantation.

Question 77

What is the most likely cause of the elevated alk phos in a patient with history of PBC who has had transplant?

Answer 77

rise in alkaline phosphatase represents a florid bile duct lesion, which is a classic finding in patients with PBC

Question 78

In a patient with AIH, who has a liver transplant, and they have worsening LFTs after that continue to worsen within 24 hours, what diagnosis should come to mind as the most likely cause?

Answer 78

Primary graft nonfunction is a serious and rare complication that occurs after transplantation. The patient’s clinical worsening within 24 hours suggests this diagnosis. She has a history of auto-immune hepatitis (AIH); however, in the setting of high-dose steroids, it would be unusual to have her numbers continue to rise as it would in severe AIH.

Question 79

Which type of hepatic encephalopathy is associated with acute liver failure?

Answer 79

type A

Question 80

In a liver transplant patient, what are the three CARDINAL Features of acute rejection on liver biopsy histology?

Answer 80

1. Central endotheliitis 2. Mixed inflammatory infiltrate in the portal triad (primary lymphocytic) and destructive 3. nondestructive nonsuppurative cholangitis involving interlobular bile duct epithelium

Question 81

How is acute rejection from liver transplant treated?

Answer 81

boluses of high-dose steroids.

Question 82

In patients taking Tacrolimus after liver transplant, what should be doine with TAC in the setting of kidney injury?

Answer 82

first step to possible calcineurin inhibitors renal toxicity is to lower the dose of tacrolimus while following the transaminase levels.

Question 83

Liver transplant patients on immunosuppression with TAC and MMF, who have increased sun exposure are at highest risk of what condition?

Answer 83

Nonmelanomatous skin cancer is correct. Given his immunosuppression and sun exposure by living and exercising in Florida, he is at increased risk for skin cancer.

Question 84

Liver patients with PSC should be screened annually for what?

Answer 84

Colonoscopy yearly for colon cancer detection is correct based on the increased risk of colon cancer in patients with PSC who have received a liver transplant. This is also true of patients with ulcerative colitis.

Question 85

Can you treat a pregnant mom with Hep C with antivirals? can the the newborn be treated? Can she breastfeed?

Answer 85

antiviral therapy is not currently approved for the mother while pregnant or breastfeeding or for newborn infants.

Question 86

What is one major thing that should be avoided in pregnant moms to reduce risk of hep c transmission to baby?

Answer 86

Invasive monitoring (fetal scalp monitoring) should be avoided to reduce risk of transmission.

Question 87

For acute hepatitis C, will you see antibodies in the acute setting?

Answer 87

Antibodies to hepatitis C virus are not typically detectable until 8 weeks from exposure, and an evaluation of viral load is essential to establish the diagnosis.

Question 88

For patients with evidence of cryoglobinemia related to hep c , whats the treatment?

Answer 88

treat underlying hepatitis C virus infection with a regimen approved for patients with renal dysfunction, Elbasvir/grazoprevir (Zepatier)

Question 89

Before treating a patient for hep c, what other virus should be checked and why?

Answer 89

Patient's at high risk of coinfection with hepatitis B and C viruses and should be evaluated for hepatitis B virus infection before initiating therapy for Hep C because treatment with direct-acting antiviral therapy in the setting of coinfection with hepatitis B and C viruses might increase risk of reactivation and hepatitis.

Question 90

How are patients with both hep b and c hepatitis managed in active infection?

Answer 90

Patients coinfected with positive surface antigen and evidence of active replication should receive HBV therapy during treatment for HCV and at least 12 weeks after therapy with close monitoring.

Question 91

Is active use of intravenous drugs a contraindication to HCV therapy?;

Answer 91

Active use of intravenous drugs is not a contraindication to therapy;

Question 92

How should you treat a patient who received a HCV posiitve liver transplant and thy were HCV negative ?

Answer 92

Due to organ shortages and the advent of direct-acting antiviral therapy, centers are increasingly using HCV viremic donors for transplantation into HCV-negative recipients. Experience thus far indicates excellent out- comes; however, informed consent and coun- seling is essential. Early therapy within the first month is recommended when the patient is stable.

Question 93

For pts who are receiving a solid organ transplant (other than a liver) from a HCV donor, when should they get treated for HCV?

Answer 93

Treatment for HCV-negative recipients of nonliver organs from HCV-positive patients should begin immediately in the perioperative period at day 0 without waiting to confirm viral load positivity. Early therapy started preemptively with direct-acting antiviral therapy prevents development of chronic HCV infection and possible complications.

Question 94

In patients with decompensated Child-Pugh B/C cirrhosis, who have Hep C, can they be treated with typical Hep C regimens ?

Answer 94

For patients with decompensated Child-Pugh B/C cirrhosis regimens containing protease inhibitors are contraindicated due to hepatic metabolism and risk of drug-induced liver disease. dipasvir. Treatment regimens should be based on a combination of sofosbuvir and an NS5A inhibitor (sofosbuvir/ledipasvir or sofosbuvir/ velpatasvir) like Epclusa

Question 95

what class of meds do cyclosporine have bad interactions with mostly?

Answer 95

After liver transplantation, patients are often taking multiple medications, which may complicate HCV therapy. Cyclosporine has multiple interactions with direct-acting anti-viral therapies; thus, careful consideration is essential when selecting regimens.

Question 96

which pattern of liver injury is associated with elevation of ALT and AST more than Alk Phos?

Answer 96

Hepatocellular

Question 97

which pattern of liver injury is associated with elevation of ALKP more than ALT/AST (R <2)

Answer 97

Cholestatic

Question 98

which pattern of liver injury is associated with elevation of both ALT/AST and ALKP?

Answer 98

Mixed pattern: elevation of both ALT/AST and ALKP (R = 2 to 5)

Question 99

What are the 4 causes of liver injury that lead to high ALT and AST levels >1000 IU/L?

Answer 99

1. Drug induced liver injury 2. Acute viral hepatitis 3. Ischemic hepatitis, 4. Mushroom poisoning.

Question 100

In addition to High ALT and AST levels >1000, what other lab is elevated in ischemic hepatopathy?

Answer 100

LDH is elevated in ischemic hepatopathy.

Question 101

What condition is suggested by an elevated AST/ALT ratio ?

Answer 101

Elevated AST/ALT ratio is suggestive of advanced alcoholic liver disease, rather than heavy alcohol drinking without liver disease

Question 102

Aside from alcohol use, what are the other conditions that can cause an elevated AST/ALT ratio ?

Answer 102

Other causes of this pattern are cirrhosis, ischemic hepatitis, congestive hepatopathy, Budd Chiari syndrome and TPN !

Question 103

In patients with mild mild elevation of liver enzymes, what diagnosis should be considered?

Answer 103

* Celiac disease can present with mild elevation of liver enzymes. * Test for celiac disease in patients with elevated liver enzymes of unclear etiology

Question 104

what is the most common cause of mild unconjugated hyperbilirubinemia?

Answer 104

Gilbert syndrome

Question 105

Aside from Gilbert syndrome, what other two conditions can lead to unconjugated hyperbilirubinemia ?

Answer 105

Fasting and stress can lead to unconjugated hyperbilirubinemia (usually < 3 mg/dL, up to 6-8 mg/dL).

Question 106

In assessing post op jaundice, what is one of the most important things to rule out?

Answer 106

Rule out intra- or extra-hepatic obstruction with an ultrasound, CT, or MRI. Investigate the presence of previous chronic liver disease. Consider drug induced liver injury.

Question 107

Aside from intra- or extra-hepatic obstruction, what other 4 causes of post op jaundice should be considered?

Answer 107

* Other etiologies to consider: 1. TPN 2. Resorption of a large hematoma 3. Multiple blood transfusions (unconjugated hyperbilirubinemia) 4. congestive hepatopathy

Question 108

How can sepsis lead to Sepsis induced cholestasis?

Answer 108

Sepsis due to any cause can lead to conjugated hyperbilirubinemia. * Sepsis results in changes in bile transport such as decreased clearance of conjugated bilirubin, decreased basolateral and canalicular transport of bile acids. These changes can lead to hyperbilirubinemia.

Question 109

Sepsis induced cholestasis is usually associated with which type of bacteria?

Answer 109

* Most associated with gram-negative bacteremia and intraabdominal infection.

Question 110

Should ERCPs be done in post op jaundice with no cholangitis?

Answer 110

*Avoid ERCPs if there are no clues for cholangitis (no abdominal pain, normal bile ducts).

Question 111

which clinical condition is associated with progressive increase in conjugated bilirubin starting within 2 to 10 days after surgery?

Answer 111

Benign post-operative jaundice. Bilirubin levels range between 10 to 40 mg/di, while AST, ALT and ALKP are < 5 times ULN.

Question 112

what is the most common cause of liver disease in pregnancy?

Answer 112

Liver disease in pregnancy is commonly due to etiologies not specific to pregnancy. Viral hepatitis (A, B, C, D, and E) is the most common cause of liver disease in pregnancy,

Question 113

which type of hepatitis is associated with HIGH mortality in pregnancy?

Answer 113

Acute hepatitis E has a high mortality in pregnancy (up to 20%).

Question 114

which type of hepatitis in pregnancy, associated with a rash, , can progress to fulminant hepatic failure? And what should be the empiric treatment while awaiting serology?

Answer 114

* HSV hepatitis Consider empiric treatment in patients with fulminant hepatic failure while awaiting the results of HSV serologics Treatment of choice is with acyclovir.

Question 115

Aside from viral hepatitis, what is the next most common cause of liver enzyme elevation in pregnancy?

Answer 115

Gallstones are a common cause of liver enzyme elevation in pregnancy.

Question 116

why are pregnant women at an increased risk of developing gallstones ?

Answer 116

Pregnant women are at an increased risk of developing gallstones due to decreased gallbladder contractilty combined with increased cholesterol saturation in the bile.

Question 117

In pregnant patients who are symptomatic with gallstone disease, what should be the management?

Answer 117

* Most patients with gallstones remain asymptomatic, and they should be managed conservatively. Symptomatic patients (biliary pain, choledocholithiasis, cholecystitis, and pancreatitis) should be strongly considered for cholecystectomy (+/- ERCP) during pregnancy to decrease the rate of recurrent symptoms and hospitalizations.? 1º The ACG recommends that symptomatic cholecystitis should be managed with early surgical intervention with laparoscopic cholecystectomy

Question 118

In pregnant patients who are symptomatic with gallstone disease, when should Laparoscopic cholecystectomy safest to be performed?

Answer 118

Laparoscopic cholecystectomy is safest in the second trimester. Patients who develop gallstone complications in the third trimester should undergo cholecystectomy in the early postpartum period.

Question 119

which clinical syndrome is associated with persistent nausea and vomiting with weight loss of > 5% of pre-pregnancy body weight in preggo pts?

Answer 119

Hyperemesis gravidarum

Question 120

Which clinical condition is associated with

Question 121

During which trimester is Hyperemesis gravida normally present?

Answer 121

>. It presents early in the first trimester. Patients may have a mild elevation of liver enzymes.

Question 122

Which clinical condition is associated with new onset pruritus in the second or third trimester, and elevated bile acid levels >10?

Answer 122

Intrahepatic cholestasis of pregnancy (ICP)

Question 123

During what trimester does Intrahepatic cholestasis normally present?

Answer 123

in the second or third trimester

Question 124

what is the most common liver disease specific to pregnancy?

Answer 124

Intrahepatic cholestasis of pregnancy

Question 125

Which liver disease specific to pregnancy (hyperemesis gravidum, intrahepatic cholestasis of pregnancy, HELLP, acute fatty liver of pregnancy) has the highest mortality?

Answer 125

acute fatty liver of pregnancy

Question 126

Which liver disease specific to pregnancy (hyperemesis gravidum, intrahepatic cholestasis of pregnancy, HELLP, acute fatty liver of pregnancy) causes pruritus?

Answer 126

intrahepatic cholestasis of pregnancy

Question 127

what is the treatment for pre-eclampsia?

Answer 127

ASPIRIN AND HTN Management

Question 128

For patients with severe pre-eclampsia (really high BP, end organ damage), when should delivery occur compared to those without severe pre-eclampsia?

Answer 128

34 weeks for severe and 37 weeks for non severe

Question 129

Where is Iron is mainly absorbed ?

Answer 129

Iron is mainly absorbed in the proximal small intestine,

Question 130

How is iron absorbed in the small intestine?

Answer 130

Ferric iron is reduced to ferrous iron (Fe}) by duodenal cytochrome B (DeytB). It is then absorbed by the mucosal transmembrane protein DMTI into the enterocyte. * Ferroportin (FPN) exports iron across the basolateral membrane into the circulation. This also requires the iron oxidase hephaestin (Hp) that converts Fe* to Fe* (requires copper). Fe* then binds to transferrin (Tf).

Question 131

Loss of function mutation in what gene leads to "ferroportin disease?

Answer 131

Loss of function mutation in ferroportin gene SLC40A1

Question 132

what effect does Hepcidin have on iron absorption?

Answer 132

Hepcidin is a negative regulator of iron absorption. It is synthesized in the liver in response to excess iron. It downregulates ferroportin, which leads to decreased iron absorption.

Question 133

What is the important protein involved in the molecular pathway leading to the expression of hepcidin? A defect in this leads to very low hepcidin levels and increased iron absorption.

Answer 133

Hemojuvelin (HJV) is an important protein involved in the molecular pathway leading to the expression of hepcidin. A defect preventing JV expression leads to very low hepcidin levels and increased iron absorption.