Liver

Question 1

Hepatitis B/C:

Know the various causes of the elevated transaminases.

Answer 1

Alcoholic steatohepatitis, 
NASH (Nonalcoholic steatohepatitis)
Toxic hep., 
Viral hep., 
Celiac, 
Wilson’s, 
Primary sclerosing cholangitis, 
Primary biliary cirrhosis

→ all cause cirrhosis and thus in the process elevated transaminases

Question 2

Hepatitis B/C:

Know the relationship between celiac disease and elevated transaminases.

Answer 2

Common for pt to be dx w NASH then later find they have Celiac dz

Overall, elevation of transaminases is assoc w celiac dz

Question 3

Hepatitis B/C:

Have an understanding of seroconversion of acute HBV and chronic HBV, which antigen is persistent in carrier status?

Answer 3

HBsAg is the main antigen present in both acute and chronic ie Carrier Status

HBeAg will be present in both acute and chronic if there is active replication

… remember, s = sick

Question 4

Hepatitis B/C:

What are signs and symptoms of HBV & HCV

Answer 4

flu-like

HBV -> Jaundice
HCV -> Asx & mental Sx’s

PE: LR enlargement and T (mb SP, too)

Question 5

Hepatitis B/C:

Conventional treatment of Acute HBV? Chronic HBV? HCV?

Answer 5

INTERFERON ALFA

for HCV interferon + Ribavirin

(Ribavirin used to stop viral RNA synthesis and viral mRNA capping, thus, it is a nucleoside inhibitor)

Question 6

Hepatitis B/C:

Know the appropriate diet and nutritional therapies for HBV and HCV

Answer 6

No alcohol,
low sodium,
high protein (white meat),
low water

***pt w cirrhosis and (hyponatremia for water restriction)

Question 7

Hepatitis B/C:

Role of antioxidants, mechanism of action?

Answer 7

ALT levels decrease,
HCV-RNA levels decrease

Mitoquinone may decrease inflamm. in the LR
(bc study done w mitochondria-targeted anti-oxidant mitoquinone)

Question 8

Hepatitis B/C:

How does Silymarin (Milk thistle) and Silybin-Phosphatidylcholine Complex help in the treatment of HBV/HCV?

Answer 8

Silymarin is anti-inflamm., anti-viral… decreases serum transaminases

Question 9

Hepatitis B/C:

Glycyrrhiza glabra – the role it plays in the treatment of HBV/HCV

Answer 9

• Antioxidant
• Anti-viral (but mb does not lower HCV RNA)
• Lowers transaminases
• May prevent CA (LR)

*Reduces long-term complications in Chronic Hep C who did not respond to INTERFERON ALFA
(in a study…)

Question 10

Hepatitis B/C:

The role of Low-Dose Naltrexone in the treatment of HBV, HCV? Mechanism of action?

Answer 10

1. blocks beta endorphin (4 hour)
2. Stims. prod. of beta endorphins
3. Triggers prolonged upregulation of immune system (via increase in endorphins and enkephalins which act on opioid receptors of immune cells.)

LDN provides a 4 hour blockade of beta endorphin receptors (best time is 2 am to 4 am, so taking around 10 pm is ideal)

Stimulates the endogenous production of beta endorphin

Question 11

Hepatitis B/C:
Be able to identify the homeopathic picture for the various remedies as it relates to the
case/question format.

Answer 11

Aconite – sudden inflammation at onset of acute hepatitis. Tearing, burning pains, restless, anxious, moving constantly, fear of death, great thirst.

Arsenicum – Enlarged liver with pressing pain. Violent burning in epigastrium (like red hot coals.) Burning thirst without desire to drink or thirst for small quantities often. Burning pain relieved by heat/hot drinks. Pt is restless and anxious and fearful of death.

Bryonia – heavy feeling in the liver; breathing, motion and touch cause agg. of stitching, burning pain. When coughing – feels the liver will burst.

Chamomilla – Intense irritability. Hepatitis after anger; Jaundice after anger (Nux.)

Chelidonium – very specific for the liver; acute and semi-acute congestion, fullness, enlargement. Stitching shooting pains from liver through to the back. Pain below the right scapula. Better from hot drinks, hot milk and eating.

Corpus circinata – Chronic hepatitis with frequent stools and a sensation that “she would break in two at the waist.”

Lycopodium – tension like a cord in the liver region; cannot stretch or stand upright. Soreness as if from a blow in RUQ; worse from touch. Jaundice with flatulence; must loosen clothes. Worse 4-8 PM. Full from one mouthful of food; better warm drinks.

Mercurius - pressing pain or stitching in liver; cannot lie on right side. Bitter taste in mouth with thirst and little appetite. Liver swollen and hard with abdominal distention. Desire for beer, ice water, milk, sweets, bread and butter.

Nat Sulph – hepatitis, depression or headaches after head injuries; worse from wet weather and lying on the left side.

Nux vomica – Liver swollen, indurated, sensitive; must loosen clothing. Pain in the right shoulder. Chilly, irritable and hypersensitive to light, noise and drafts of air.
Hepar sulph – hepatitis with jaundice; white or greenish stools. Useful in hepatic abscess in cirrhotic pts. Hepar is sensitive, quarrelsome, angry, abusive, impulsive. Oversensitive to cold and drafts. Desires vinegar.

Phosphorus – Liver enlarged, hard – later atrophied. Fever and night sweats with soreness of the liver. Pale stools; abdomen tympanic; stool may be bloody. Craves cold food and drink: ice cream. As soon as water becomes warm in stomach it is vomited.

Podophyllum – congestion and enlargement in acute and chronic hepatitis. Stuffed, distended feeling in the liver. Slimy tooth-notched tongue as if spread with mustard. Fidgety – cannot sit still.

Question 12

HBV summary:

Spread?

Answer 12

Spread via IV drug use, vertical transmission, M-M sex, hemodialysis, exposure to blood/blood products

Incubation period: ~100d

Question 13

HBV summary: S/Sx’s

Answer 13

RANGE WIDELY: (asx -> fatal) // insidious onset
mild in children
adults - 30-40% have jaundice
N/V, anorexia, malaise/fatigue, flulike (pharyngitis, cough, coryza, photophobia, HA, myalgias) …

Question 14

HBV summary: PE

Answer 14

nonspecific
mild enlargement of LR, SP (mb T)
post. cervical LA in 15-20%

Fulminant Dz aka Acute LR Failure Sxs: —> change in mental status dt encephalopathy and coagulopathy

Carrier State/Chronic Infx:

• HBsAg in blood for more than 6 mo.
• bad for newborns (90% progress to carrier state)
• 10% adults
• (those infected will clear surface ag 0.5%/yr)

-15-40% develop Sequelae:
Arthralgia, mucocutaneous vasculitis, glomerulonephritis (more children), Polyarteritis

Nodosa (more in adults)

Question 15

HBV summary: Dx

Answer 15

viral & immune markers in blood

-HBsAg (+) 
is first (those who clear the virus, will lose this and develop the Ab)

-HBeAg (mb + -)
(begin to fall at onset of illness, correlates w active viral replication)

-HBV DNA (usu +) (begin to fall at onset of illness)

-IgM core antibody (+)
(gone within 6-12mo of onset)

-anti-HBc (+) (w onset of sxs)

-ALT, AST 500-5000 U/L
(then fall after acute phase)

Chronic Hep B Dx:
HBsAg for 6mo in serum

Chronic Hep B → HCC (hepatocellular carcinoma)

Question 16

HBV summary: Tx

Answer 16

Preventative: vaccine

1. Engerix-B
2. Recombivax HB
   adults: 3 injections IM at 0, 1, 6 mo

Post-exposure Prophylaxis:
1. HBIG (hep B immune globulin)
single dose IM
followed by vaccine

Acute:
supportive… most recover

Chronic: therapy is for those w active damage to LR

• suppress viral replication & prevent progression of LR Dz
• normalize enzymes levels, decrease viral DNA, seroconversion from e Ag-pos → e Ab-neg

**Interferon alfa (antiviral injected subQ)
long-acting interferon also avail

Nucleoside [analogues] (interfere w viral replication)
others: adefovir, entecavir, telbivudine

Question 17

HCV summary:

Spread?

Answer 17

HCV infx → Chronic in 60% of pt → Cirrhosis in 20% over ~20 yrs → HCC
(screening done w US and alpha-fetoprotein)

MC indication for LR transplantation in US

IV drug use, blood transfusion (less common these days)

Question 18

HCV summary:

Sxs:

Answer 18

Acute:
usu asx, can be flu-like in 2-26 wk incubation period
usu find abN hepatic transaminase levels on routine testing

Chronic:
fatigue, depression, N, anorexia, abd discomfort, difficulty w concentration

Extrahepatic manifestations:
mixed cryoglobulinemia, porphyria cutanea tarda, membranoproliferative glomerulonephritis, leukocytoclastic vasculitis, focal lymphocytic sialadenitis, idiopathic pulmonary fibrosis

Question 19

HCV summary: Dx

Answer 19

HCV ab via ELISA (enzyme-linked immunosorbent assay)
but will be positive in those who’ve cleared the virus

HCV RNA via PCR
some pt can’t mount an immune response so need this to detect HCV presence and viral load

ALT increased (but mb normal in infected pts)

Question 20

HCV summary: Tx

Answer 20

1. Interferon alfa
2. • ribavirin
3. Vaccination for hep A and if at high risk, hep B

Question 21

NAFLD/NASH Meaning:

Answer 21

NASH is the inflammatory version of NAFLD → Cirrhosis → HCC

NASH = nonalcoholic steatohepatitis

NAFLD = nonalcoholic fatty LR dz

Question 22

NAFLD/NASH:

Know the risk factors

Answer 22

• Obesity
• Dyslipidemia
• Glucose intolerance
• Insulin resistance
• Metabolic syn
• F
• Excess fructose consumption

Question 23

Fructose metabolized mainly by?

Answer 23

The LR w rapid conversion to glucose, glycogen, lactate and fat.

Question 24

Understand the outcome of continual fructose consumption on uric acid levels

Answer 24

Uric acid will be increased due to ATP breakdown to peptides in an effort to maximize phosphate groups for fructose metabolism

Question 25

Which pharmaceuticals are risk factors for NASH?

Answer 25

``` ◦Calcium channel blockers ◦Tamoxifen ◦Corticosteroids ◦Synthetic estrogens ◦Aspirin ◦Methotrexate ◦Valproic acid ◦Cocaine ◦AZT (Aids->Zidovudine, Retrovir) ◦amiodarone ```

Question 26

How does MSG consumption influence NASH?

Answer 26

In a study w mice, MSG elevates FFAs, TGs, HDL-C, and insulin. MSG also increased expression of hepatic genes involved in lipid metabolism and bile synthesis

Question 27

Basic treatment protocol of NASH:

Answer 27

1. Weight loss 2. Lipid, insulin, glucose normalization 3. Diet - high protein - high fresh veggies - lower glycemic index/load - no alcohol - smaller freq. meals - gluten free 4. Choleretics 5. Betaine 6. NAC 7. Vit E 7. ALA 8. B complex 9. Cr, Zn, Mg, Mn, Va 10. Balance cortisol/DHEA 11. Probiotics