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Summer FDTN Exam 5 > Liver > Flashcards

Flashcards in Liver Deck (185):
1

What is acute liver failure

Onset of liver injury, hepatic encephalopathy, and coagulopathy (INR >1.5) in patients w/ no prior h/o liver disease

2

Most acute liver cases arise from

massive hepatocyte necrosis; *APAP overdose*
-viral hepatitis, drugs, toxins, metabolic, vascular events, misc.

3

What are S/Sx of acute liver failure

AMS (encephalopathy)
cerebral edema
coagulopathy
multiple organ failure
ascites, anasarca, shrinking liver on PE

4

What are the stages of encephalopathy (AMS)

Early: personality change, reverse sleep pattern
Progressing: lethargy
Late: coma

5

What is acute hepatic failure

acute onset liver failure with coagulopathy (INR >1.5) and jaundice
Encephalopathy w/in 1-4 weeks of liver injury!

6

What is subacute hepatic failure

Acute liver failure with encephalopathy developing 12-24 weeks after onset of liver injury

7

What are lab findings in acute liver failure

Severe coagulopathy (high PT/INR)- bleed easy
CBC: leukocytosis
BMP: hyponatremia, hypokalemia, hypoglycemia
LFT: marked elevation of bilirubin, ALT, AST

8

How do you treat acute liver failure

Hospitalization
Continuous monitoring
Supportive care
If recovery seems unlikely, prep for liver transplant

9

What is hepatitis

Acute or chronic hepatocellular damage

10

What causes acute vs chronic hepatitis

Acute: Viral!
Chronic: Viral!
so basically... VIRAL!!

11

How are different hepatitis forms contracted

A&E: fecal oral route (E from Mexico). But they are self limited!
B, C, D: parenterally, mucous membrane (IVDU, tattoos, infected mom, transfusion). these progress to chronic

12

What are categories of acute hepatitis

Self limited
Acute liver failure
Cholestatic hepatitis (HAV)
Relapsing hepatitis (HAV)

13

What is the pathophys of acute viral hepatitis

Cell mediated mechanisms cause hepatocyte injury by degeneration or apoptosis; CD8 and CD4 respond, and cytokines are produced

14

What are S/Sx of acute viral hepatitis (self limited)

Prodrome: malaise, anorexia, N/V, flu-like Sx. Abrupt onset in A&E, insidious in B-D
Wen prodromal Sx subside, jaundice sets in w/ dark urine and pruritis

15

What will self limited acute viral hepatitis show on PE

mild enlargement and ttp of liver
mild splenomegaly

16

What are S/Sx of cholestatic hepatitis (HAV acute)

severe jaundice
pruritis
anorexia and diarrhea
-BUT a good prognosis

17

What are S/Sx of relapsing hepatitis (HAV acute)

Sx recur for wk-months
arthritis
vasculitis
cryoglobulinemia
-BUT, prognosis is excellent eventually

18

What are lab findings in acute viral hepatitis (self limited)

ALT/AST >500
Total bili: normal
Alk Phos: normal
Prolonged PT/INR: normal
Albumin: normal
WBC: normal
+/- lymphocytosis

19

What are cholestatic disease (acute viral) findings

Bilirubin 20+
Alk phos: high
ALT/AST: initially elevated, may decrease*

20

What are lab findings in relapsing acute viral hepatitis

ALT/AST: elevation after normalization
Bilirubin: elevation after normalization
-relapses usually don't exceed previous levels

21

How do you treat acute viral hepatitis

Self limited and relapsing: outpt, unless severe dehydration. Plenty of fluids&kcal. No EtOH, rest, d/c non-essential drugs, if HCV doesn't resolve in 3 months use antiviral, if HBV use tenofovir or entecavir if severe

22

How do you treat cholestatis acute viral hepatitis

Prednisone
Ursodeoxycholic acid
Cholestyramine for pruritis

23

Are HAV and HEV chronic

No, the virus can survive in bile and is shed in feces, but does NOT result in prolonged viremic or intestinal carrier states

24

What is the pathophys of hep A&E

Virus ingested, transported across intestinal epithelium, through mesenteric veins to liver
It enters hepatocytes, replicates, causes cell mediated injury, and is then shed into bile and travels to intestine

25

What are RF for Hep A

Live in Africa, Asia, or Latin America (poor sanitation, developing countries)
Close contact with infected person
MSM
Food outbreak (contaminated water, ice, shellfish)

26

What are S/Sx of HAV

28 day incubation: Fever, jaundice (2 weeks)
Cholestatic and relapsing hepatitis are common manifestations
Fulminant course NOT common

27

How can you diagnose Hepatitis A

IgM antibody to HAV (anti-HAV) 5-10 days before Sx. Stay high for 3-6 months
Lifelong IgG anti-HAV elevation means immunity**!

28

Positive anti-HAV IgG can indicate

Prior infection or recent disease

29

How do you treat Hep A

Supportive care
Nearly all will recover fully in 6 months

30

What info do you send the patient with Hep A home with

Wash hands after pooping and changing diapers
Dispose waste sanitarily
Safe food handling practices
Immunization if you are high risk
Avoid excess APAP and alcohol, eat a balanced diet
Kids: don't go back to school until 1 week after illness onset

31

How can you prevent Hep A

HAV vaccination (inactive) for:
**All kids 1 y/o (CDC says healthy ppl 1-40)
kids 2-18 in high risk areas
Traveling to endemic area
MSM
IVDU
Occupational risk
Hx of chronic liver dx
Clotting factor disorder
Household member has Hep A

32

What is Hep A prophylaxis

If you have been exposed to Hep A and are not vaccinated, Give prophylaxis w/in TWO WEEKS* of exposure
If <1 or >40, or immunocompromised, give immunoglobulin*

33

Key highlight on slide 42

Do it

34

What is the epidemiology of Hep E (where it's found, how it's spread, etc)

Endemic in: mexico*, cuba, asia, africa, middle east
Spread by animals, MC swine* and deer
Contaminated drinking water

35

What are Sx of Hep E

Abrupt onset prodromal Sx
Acute liver failure is common in pregnant ladies (esp in 3rd trimester)

36

How do you diagnose HEV

IgM anti-HEV detectable for 6 weeks
IgM replaced by IgG anti-HEV, detectable for 12-20 months (NOT immune longterm)
HEV RNA confirms presence of Hep E in serum or stool

37

How do you prevent Hep E

NO vaccine!! or immunoglobulin for prophylaxis! So:
Good sanitation
Avoid unpurified H2O
Avoid raw pork and venison (deer)

38

What is Hep B

a DNA virus that is transmitted by sex or mucosal route
Can develop limited (MC in adults) or chronically infected (MC in kids and perinatal) disease

39

Where is Hep B prevalent

West africa
South sudan

40

What are characteristics of Hep B

Outer envelope has: Hep B surface antigen (HBsAG)
In envelope: structural protein (HBcAg), non-structural (HBeAg), DNA polymerase (reverse transcriptase)

41

Hep B infection is influenced by

age
genetic factors
presence of other viruses
HBV mutation
level of immunosuppression

42

How does Hep B manifest in different individuals

Neonates: 95% become chronic ASx carriers
Adult primary infection: 70% are ASx and self limited
Chronic HBV: risk of cirrhosis esp in older pts, or if co-infected with HCV, HDV, or HIV

43

What is the pathophys of Hep B

Liver injury occurs 2/2 host immune response to Hep B virus
Immune response is against Hep B structural protein (HBcAg)

44

Strong RF for Hep B are

Perinatal exposure to Hep B mom
Multiple sex partners
MSM
IVDU
Asian, Eastern European, African
FHx of HBV
FHc of HCC
Household contact with HBV

45

In order to diagnose Hep B you need

elevated clinical suspicion* in high risk individual

46

What are Sx of Hep B

Insidious onset
Serum sickness like syndrome: fever, chills, malaise, rash, n/v, arthralgias, arthritis

47

How does Chronic Hep B present

May be ASx OR signs of chronic dz:
Cirrhosis
HCC
liver failure

48

how do you diagnose acute Hep B

IgM antibody to Hep B core antigen (HBcAg) w/ Sx and elevated ALT
HBsAg and IgM anti-HBc 2wk-6mo after exposure

49

How do you know Hep B has resolved

ALT normalizes
No HBV DNA
Seroconversion to Anti-HBe and Anti-HBs, and IgG anti-HBc

50

How can you tell if someone has had a prior HBV infection

Will have both surface and core proteins!
anti-HBs, IgG anti-HBc, and anti-HBe

51

How do you diagnose chronic Hep B

HBsAg present for >6 months
HBeAg and HBV DNA persistence
Inactive carrier: ASx, normal ALT, low HBV DNA, anti-HBe

52

How do you treat chronic Hep B

Acute: self limiting
Fulminant: liver transplant
Chronic: anti-viral therapy

53

What are first line therapy options for chronic viral Hep B

*Peginterferon alfa-2a: weekly subQ injection for 48 weeks (best for young, non-cirrhotic, low HBV-DNA level)
Nucleoside analogues (Entacavir, Tenofovir) to inhibit HBV replication: daily PO indefinitely

54

Goal of Hep B antiviral Tx is

Sustain low or undetectable HBV DNA
Seroconvert HBeAg and HBsAg and normalize ALT

55

How can you prevent Hep B

Hep B vaccine given once, then repeat 6 months later
Part of universal infant immunization, and for high risk individuals

56

What Hepatitis has vaccines

A and B!!!
NONE OTHERS

57

How can you prevent Hep B

Hep B immunoglobulin
Postexposure prophylaxis then HBV vaccine if sex w/ casual partner with HBV
Newborn w/ Hep B + mom: HBIG and HBV vaccine immediately after birth

58

What is secondary prevention of Hep B

Chronic HBV not immune to Hep A: Hep A vaccine
Chronic HBV: Avoid heavy alcohol
HBsAg positive: use barrier protection, don't share toothbrush or razor, cover open cuts, clean blood with bleach, no blood, organ, or semen donation

59

What is the prognosis of Hep B

5 year risk for:
Cirrhosis= 10-20%
HCC= 5-10%
decompensated cirrhosis= 15%

60

Key highlights on slide 78

Go look

61

When should you suspect Hep D

Fulminant Hep B infection
Acute Hep B infection that improves then relapses
Progressive chronic HBV w/o active HBV replication

62

How do you get Hep D

You can only get it if you also have Hep B!
HDV is specific only in the presence of HBsAg

63

What do Hep D labs show

anti-HDV and HDV RNA
Co-infection: IgM anti-HBc
Superinfection: IgG anti-HBc

64

How do you treat Hep D

High dose interferon alpha and PEG IFN
therapy is not optimal 2/2 high risk of relapse

65

What is Hep C

a flavivirus

66

Per CDC, when should you screen for Hep C

If high risk for infection
If born between 1945-1065 regardless of risk

67

What is the pathophys of Hep C

Acute: self limited, most develop antibodies
Persistent viremia: hepatic inflammation and fibrosis. weak CD4 and CD8 cells can't control viral replication
Chronic: liver damage 2/2 local immune response (inflammation) by hepatic stellate cells

68

In Hep C, cirrhosis is accelerate by

Chronic alcohol consumption
Coincidental viral infection

69

What are the types of Hep C

6 genotypes!
U.S.: Genotype 1
Middle east: genotype 4
South africa/asia: genotype 5&6

70

How is Hep C transmitted

Blood exposure, MV in IVDU
less common but still possible: sex, perinatal, accidental blood contact

71

Strong RF to Hep C are

IVDU
Blood transfusion before 1992
Clotting factor transfusion before 1987
HIV (more likely to progress to liver dz, esp w/ low CD4)

72

What is literally the worst news a hypochondriac could receive about Hep C

It can live outside the body for 3 weeks
YOU CAN GET HEP C FROM DRIED BLOOD!!!
So watch the damn tamp box in the bathroom, ya nasty

73

How does Hep C present

MC: ASx
Prodromal jaundice
Young women can spontaneously clear, but most develop chronic infection
Black are least likely to clear infection

74

What are acute function tests for Hep C

8 wks after exposure: HCV RNA (needed to Dx acute infection)
6-12 wks after: ALT and AST elevated
8 wks-months after: anti-HCV (hep C antibody) detectable

75

Who is more likely to spontaneously clear hep C (self limited dz)

IL28B genotype CC
IL28B CT&TT are LESS likely

76

How can you diagnose chronic infection of HCV

HCV RNA in blood for min 6 months
Screening test by EIA detects Abs against virus. If +, it's active
ASx
Likely have chronic liver disease, decompensated cirrhosis, and HCC

77

What factors influence development of chronic progressive liver disease 2/2 HCV

Older age
Male
Concurrent Hep B
HIV
high alcohol intake

78

How do you use Hep C tests

Qualitative studies confirm viremia and have low limits of detection (RT-PCR detects 40-50 IU, TMA lower limit is 5IU)
Quantatitave tests give a wide dynamic range of viral loads

79

What is a baseline HCV workup

Confirm HCV viremia (quantitative)
Eval for coexisting liver disease and HIV
Vaccinate for Hep A and B
Get viral genotype

80

Goal in treating Hep C is

Clear virus from blood stream
Stabilize or improve liver histology
Sx control
Prevent complications (HCC, cirrhosis, decompensated dz)
If already cirrhotis: avoid passing to new liver, haver fewer complications, have less mortality

81

What is NEW Hep C treatment

Telaprevir and Boceprevir: protease inhibitors that bind protease of HCV genotype 1 and inhibit replication
Sofosbuvir was more effective than any other medications
Direct acting antivirals: Simeprevir, Paritaprevir, Grazoprevir (second gen NS3-4 inhibitors)
-Can use ribavirin

82

What determines Tx regimen for Hep C

HCV genotype
Has the patient been treated before
Do they have cirrhosis
(she said basically Sofosbuvir + another med)

83

How can you tell Hep C is responding to Tx

RVR: HCV DNA undetectable by week 4 of Tx
EOT response: HCV DNA undetectable by end of Tx
SVR: sustained virologic response (best) means no HCV RNA 12 weeks after Tx is over
(Non-response means you have detectable RNA, Relapse means you were undetectable and now you are again)

84

What reduces likelihood of achieving SVR

Cirrhosis
Previous nonresponse
HCV genotype 3
-In these, continue Tx by 24 weeks and add Ribavirin

85

Hep C patient education is

Dont share toothbrush or razors
Cover bleeding wounds
Don't donate organs or blood
Use barrier protection
Avoid IVDU

86

Go over key highlights slide 128

do it
this was a shit show

87

What drug classes are known to cause toxic hepatitis

Antimicrobials*
CNS agents
Immunomodulators
Analgesics
Lipid lowering meds

88

What specific drugs are known to cause toxic hepatitis

APAP
NSAIDs, ASA
Augmentin, Sulfonamides
Isoniazid, Rifampin
Interferon, antiretrovirals for HIV
OCP
Carbamazepine, phenytoin, valproic acid
Amiodarone
TZD, Metformin
Statins
Methotrexate, Azathioprine
Chemo
Herbals
Mushrooms
Cocaine

89

How does toxic hepatitis present

LFT elevation +/- acute liver failure
Liver injury w/in days-weeks of ingestion
Labs can look like hepatotoxic injury, cholestatic, or mixed

90

How do you diagnose toxic hepatitis

H&P!
Exclude other causes

91

How do you treat toxic hepatitis

Remove causative agent
+/- liver transplant for severe acute liver failure

92

What is the MCC of acuute liver failure and drug induced liver injury

Tylenol!!!
Toxic dose is 10-20g (lower in alcoholics)

93

How does APAP toxic hepatitis present

30 min-24 hours after ingestion: GI Sx
2 d after: R side abd pain and oliguria, elevated LFT, prolonged PT/INR
3-5 d after: hepatic necrosis w/ elevated aminotransferase, renal failure or acute liver failure
5-10 d after: recovery phase

94

What increases the likelihood of death or need for liver transplant in an APAP OD

pH <7.3
Stage 3-4 encephalopathy w/ PT/INR >6.5 and Cr >3.4
Factor V level 10% or less

95

How do you manage APAP OD

Get a serum APAP level
IV NAC
Charcoal w/in 1 hr of ingestion
Gastric lavage w/in 4 hours

96

What are the types of alcoholic liver disease

Steatosis: fatty liver
Steatohepatitis: alcoholic hepatitis
Cirrhosis: fibrogenesis/scarring

97

What are Sx of alcoholic liver disease

Portal HTN
Fever, anorexia, nausea, RUQ pain, tender hepatomegaly, jaundice

98

What are lab findings in alcoholic liver disease

AST high (AST>ALT)
Alk phos: high
Other LFT: normal
Tg: high
K, Phos, Mag: deficient
Glucose: high

99

How do you diagnose alcoholic liver disease

Hx of significant alcohol abuse
Exclude other forms
Liver biopsy

100

How do you manage alcoholic liver disease

Abstinence can stop progression +/- reverse damage!

101

What is Maddrey's Discrimination function

A way to calc short-term prognosis in pts w/ worsening alcoholic hepatitis:
4.6 x (diff btwn pt's PTT and control PTT) + SrBili
If DF >32, pt has 50% mortality during current hospitalization

102

How do you manage acute worsening of alcoholic hepatitis

Stop drinking EtOH
Naltrexone, Acamprosate, or Baclofen lessen effects of withdrawal and decrease desire to drink
Counseling
Give carbs and calories (promote gluconeogenesis, prevent hypoglycemia)
Ntr support
Give folic acid, thiamine (prevent werneke's), and zinc
Methylprednisolone PO x 1 month (reduce DF)
Pentoxifylline: PDE inhibitor to enhance circulation, reduce 4 week mortality

103

What is NAFLD (hepatic steatosis)

Accumulation of Tg droplets in hepatocytes.
Can be benign if no significant inflammation or fibrosis on biopsy

104

What is NASH

necroinflammatory change on liver biopsy, can progress to cirrhosis
Lipotoxic injury to hepatocytes

105

RF for NAFLD are

Insulin resistance
Obesity
DM2
Lipid abnormalities
Meds like Tamoxifen, and corticosteroids

106

What increases the likelihood of death or need for liver transplant in an APAP OD

pH <7.3
Stage 3-4 encephalopathy w/ PT/INR >6.5 and Cr >3.4
Factor V level 10% or less

107

How do you manage APAP OD

Get a serum APAP level
IV NAC
Charcoal w/in 1 hr of ingestion
Gastric lavage w/in 4 hours

108

What are the types of alcoholic liver disease

Steatosis: fatty liver
Steatohepatitis: alcoholic hepatitis
Cirrhosis: fibrogenesis/scarring

109

What are Sx of alcoholic liver disease

Portal HTN
Fever, anorexia, nausea, RUQ pain, tender hepatomegaly, jaundice

110

What are lab findings in alcoholic liver disease

AST high (AST>ALT)
Alk phos: high
Other LFT: normal
Tg: high
K, Phos, Mag: deficient
Glucose: high

111

How do you diagnose alcoholic liver disease

Hx of significant alcohol abuse
Exclude other forms
Liver biopsy

112

How do you manage alcoholic liver disease

Abstinence can stop progression +/- reverse damage!

113

What is Maddrey's Discrimination function

A way to calc short-term prognosis in pts w/ worsening alcoholic hepatitis:
4.6 x (diff btwn pt's PTT and control PTT) + SrBili
If DF >32, pt has 50% mortality during current hospitalization

114

How do you manage acute worsening of alcoholic hepatitis

Stop drinking EtOH
Naltrexone, Acamprosate, or Baclofen lessen effects of withdrawal and decrease desire to drink
Counseling
Give carbs and calories (promote gluconeogenesis, prevent hypoglycemia)
Ntr support
Give folic acid, thiamine (prevent werneke's), and zinc
Methylprednisolone PO x 1 month (reduce DF)
Pentoxifylline: PDE inhibitor to enhance circulation, reduce 4 week mortality

115

What is NAFLD (hepatic steatosis)

Accumulation of Tg droplets in hepatocytes.
Can be benign if no significant inflammation or fibrosis on biopsy

116

What is NASH

necroinflammatory change on liver biopsy, can progress to cirrhosis
Lipotoxic injury to hepatocytes

117

What is Wilson's disease

Auto recessive genetic abnormality leads to impaired copper transport
Results in hepatolenticular degeneration and cirrhosis, impaired biliary copper excretion, neuro complications

118

How does NAFLD/NASH present

ASx!
+/- RUQ pain, hepatomegaly
Elevated eminotransferase levels

119

How do you diagnose NASH/NAFLD

Macrovesicular steatosis w/ or w/o inflammation and fibrosis on liver bx
4 or less EtOH drinks x day

120

How do you treat NASH/NAFLD

Weight loss
Dietary fat restriction
Exercise

121

What is autoimmune hepatitis

Chronic hepatitis w/ high serum globulins
Presents w/ + ANA or amooth muscle antibosy

122

What does autoimmune hepatitis respond to

Corticosteroids!
Prednisone and Azathioprine improve Sx and decrease:
Sr bili, Aminotransferases, gamma-globulin levels, reduce hepatic inflammation

123

What are S/Sx of autoimmune hepatitis

Insidious onset
Fatigue, jaundice, hepatomegaly
+/- acutely severe or fulminant

124

What lab findings indicate autoimmune hepatitis

Aminotransferase >1000
Total bili: increased
Alk Phos: increased
Sr gamma globulin: increased

125

What do you need to diagnose autoimmune hepatitis

Autoantibodies: ANA or smooth muscle >1:40- anti-LKM1 if >1:40- anti-SLA +
High gamma globulin
No evidence of viral hepatitis
Liver bx

126

Standard Tx for autoimmune hepatitis is

Prednisone taper from 30mg to 10mg in 1 month PLUS Azathioprine 50mg
or
Prednisone taper from 60mg to 20mg in 1 month, then 20mg maintenance

127

When do you stop treating autoimmune hepatitis (end point for steroids)

Remission ideally: No Sx, nl AST/ALT, ULN), nl liver tissue (no hepatitis)
BUT- Tx can fail, you can have incomplete response, or drug toxicity

128

When do you follow up on autoimmune hepatitis if remission is achieved

Hepatologist q3-6 months 2/2 high likelihood of recurrence

129

Where does copper tend to accumulate in Wilson's disease

Liver
Brain
Cornea (Kayser-Fleischer rings)

130

Wilson's disease has what specific lab findings

Decreased ceruloplasmin

131

How do you treat Wilson's disease

D-Penicillamine
Liver transplant if: fulminant hepatitis, hepatic insufficiency unresponsive to medical therapy, severe neuro Sx

132

What is hereditary hemochromatosis

Inherited disorder w/ impaired intestinal iron absorption causing iron to deposit in multiple organs
GFE gene mutation
Suspected 2/2 FHx ot Hx of elevated iron saturation or Sr ferritin

133

What is primary sclerosing cholangitis

Chronic thickening of bile duct walls leading to cholestatic liver disease
Inflammation, fibrosis, and stricturing of intra- and extra-hepatic bile ducts
Unknown pathogen, may be autoimmune
M>F, avg age 41

134

How do you treat hemochromatosis

Serial phlebotomy to achieve iron depletion
If not Tx, can cause cirrhosis and HCC

135

What is alpha-1 antotrypsin (AAT) deficiency

AAT is a protease inhibitor of proteolytic enzyme elastase
Deficiency manifests in lungs, liver, and rarely, skin

136

How does AAT present in kids

Liver disease (elevated LFT, cholestasis)

137

How do you diagnose AAT deficiency

Decreased AAT level
Genotypic Z protein (PiZZ is severe, PiMZ is intermediate)

138

How do you treat AAT deficiency

No Tx!

139

What is primary biliary cirrhosis

T cell attack on bile ducts causes gradual bile duct loss and portal scarring= cirrhosis
Commin in middle aged women

140

How does primary biliary cirrhosis manifest

ASx
+/- fatigue and pruritis
Jaundice, cirrhosis, xanthelasma, xanthoma, steatorrhea

141

What will primary biliary cirrhosis labs show

Alk phos: elevated
+ AMA
IgM: elevated
Cholesterol: elevated

142

How do you diagnose primary biliary cirrhosis

Normal biliary imaging
Characteristic liver biopsy

143

What are complications of ESLD

Jaundice
Fibrosis- then cirrhosis
Palmar erythema
Spider angioma
Encephalopathy w/ asterixis (hands tremor when pointed up)
Portal HTN
Ascites, muscle wasting

144

What is hepatic encephalopathy

Neuropsych abnormalities (I-short attention, II-personality change, III-confusion, IV-coma) 2/2 hepatocellular dysfxn causing increased ammonia levels (liver can't convert ammonia to urea so ammonia crosses the BBB)

145

How does PSC present

*Pruritis, jaundice*
Fatigue, weight loss, RUQ pain
Hepatomegaly, splenomegaly

146

What do PSC labs look like

Cholestatic pattern: elevated alk phos and bilirubin, mild ALT/AST elevation (<300)
Atypical P-ANCA +

147

How do you diagnose PSC

MRCP/ERCP: multifocal stricturing and dilation of intra/extrahepatic bile ducts (ERCP can also retrieve stones and place stents!)
Liver bx: support Dx and tells you level of cirrhosis

148

How do you manage PSC

Stent for strictures (ERCP)
Ursodiol: reduce secretion of cholesterol from liver, may help Sx

149

What is spontaneous bacterial peritonitis

Infection in abd ascites fluid or pleural fluid
Presents w/ fever, abdominal pain, AMS, or can be ASx

150

What is the prognosis of PSC

Progress to cirrhosis, require liver transplant
10-12 year survival w/o transplant
Screen for cholangiocarcinoms q6-12 mo (CA 19-9, CT, or MRI)
If pt has UC: screen for colon cancer (CEA, colonoscopy)

151

What diseases can lead to ESLD (cirrhosis) that have elevated ALT/AST

HCV, HBV
EtOH
Steatohepatitis/NASH/NAFLD
Autoimmune hepatitis
Hemochromatosis
Wilsin's disease
AAT deficiency

152

What diseases can lead to ESLD that have elevated Alk phos and Bili

PSC
primary biliary cirrhosis

153

What are complications of ESLD

Jaundice
Fibrosis- then cirrhosis
Palmar erythema
Spider angioma
Encephalopathy w/ asterixis (hands tremor when pointed up)

154

What is hepatic encephalopathy

Neuropsych abnormalities (short attention, personality change, coma) 2/2 hepatocellular dysfxn leading to increased ammonia levels

155

How do you treat hepatic encephalopathy

Grade I-II: Lactulose (want 2 BM/d) or Rifaximin
Grade III-IV: admit for Lactulose via NG tube until mental status improves

156

What is portal vein thrombosis

Diminished blood flow in portal vein and changes in clotting factors that are normally cleared by liver causes thromboembolism

157

How do you diagnose and treat portal vein thrombosis

Doppler US, CT, or MRI
Tx with anticoags (heparin or LMWH)

158

How do you treat ESLD

1st line: Furosemide&Spironalactone (40mg:100mg)- compression stockings for LE edema
2: Paracentesis, thoracentesis
3: Transjugular intrahepatic Portosystemic Shunt (TIPS) creates channel between hepatic and portal vein to reduce portosystemic pressure to <12

159

What is MELD (model of ESLD)

Determine transplant eligibility
3.8 (Srbili) + 11.2 (INR) + 9.6 (SrCr) + 6.4
MELD - Na - (0.025 x MELD x [140-Na]) +140
Total bili, INR, Cr, and Na are used bc they are strong predictors of 3 month mortality
Mortality decreases starting at MELD 15 (0 is least likely to die)

160

What serology indicted ESLD

Low Albumin and globulins (<6.3)
High PT/INR
Low Sodium
High Creatinine
Thrombocytopenia

161

What is albumin

60% of protein in serum! Should be 3.5-5
Carries small hydrophobic molecules (fatty acids, bili, drugs) and maintains osmotic pressure of blood
If low, think: nephrotic syndrome, malntr, chronic liver dz

162

What is PTT

Thromboplastin +CaCl added to plasma to measure time to clot
Norm is 12-15 seconds
Need vitamin K for liver synthesis of thromboplastin!
If high think: chronic liver dz, acute liver failure, obstructive jaundice, vitamin K deficiency

163

What is INR

Used to standardize PT

164

Why is sodium low in ESLD

Indirect marker of portal HTN (chronically overloaded)! Marker of mortality
If w/ hyponatremia may lead to cerebral edema and neuro changes
Added to MELD score

165

Why is Creatinine high in ESLD

Indicates worsening renal fxn
Vasodilation 2/2 portal HTN decreases blood flow to kidneys

166

Why is thrombocytopenia present in ESLD

Coagulopathy of liver, TPO is dependent on liver function
Splenomegaly 2/2 portal HTN

167

Score the progression of fibrosis

0: none
1: portal fibrous expansion
2: Thin fibrous septa
3: Septa bridge central veins
4: Cirrhosis

168

What is MELD (model of ESLD)

Determine transplant eligibility

169

How do you screen for cirrhosis complications

EGD to r/o varicies
Abdominal imaging to r/o HCC

170

What is the serum marker for HCC

AFP!
Imaging you can do are CT/MR every 6 months

171

MC RF for HCC is

Cirrhosis**
Other: chronic HBV, hereditary tyrosemia, Aflatoxin, Thorotrast

172

How do you decide to transplant

MELD >15 is on the list
Ensure disease is not amenable to meds/surgery
Must have diminished QoL
Non-hepatic disease that would benefit from transplant (Amyloidosis)

173

What is the epidemiology of HCC

one of MC malignancies worldwide
Highest in Asia an sub-saharan africa
Median age is 40
M>F

174

How do you diagnose HCC

Screen: US or CT, AFP
confirm: Liver biopsy

175

how do you manage HCC

No mets: liver transplant
Monitor growth w/ CT/MRI q6 months
Prevent growth w/ radiofrequency ablation and TACE

176

What is cholangiocarcinoma

Cancer arising from bile duct epithelium
Intrahepatic (Klatskin tumors, perihilar) or Extrahepatic (distal)
Most are adenocarcinomas**

177

What is the epidemiology of cholangiocarcinoma

MC in 50-70 y/o*
M>F

178

What are some causes of cholangiocarcinoma

chronic liver disease
alcoholic liver dz
Cirrhosis
bile duct disease
UC
Choledocolithiasis
HIV
PSC
chronic typhoid carrier
heavy drinking
exposure to: OCP, radionuclide, isoniazid

179

How does cholangiocarcinoma present

Painless jaundice
weight loss
abdominal pain
pruritis
palpable gallbladder
hepatomegaly
dark urine
pale stools
Triad*: fever, jaundice, RUQ pain

180

How do you treat cholangiocarcinoma

Resect if candidate
If non-resectable: liver transplant w/ chemo +/- radiation
Chemotherapy +/- radiation, palliative care (if not transplant candidate)

181

How do you decide to transplant

MELD >15 is on the list

182

What are some post-transplant issues

Can pt survive post-op?
Can pt comply w/ complex med regimen s/p transplant?
Does pt have other comorbidities that will compromise the donor liver?

183

Contraindications to liver transplant arw

Active EtOH or drug abuse
extrahepatic HCC
Mets bile duct cancer
non-hepatic malignancy
Severe cardiopulmonary disease
Co-morbidities reducing chance of survival (BMI >35)
Unfavorable psych issues

184

Who needs to eval patient for transplant

Hepatology
Social worker
Psych
ID, cardiology
Transplant surgery
Selection committee

185

Who gets the liver first

Patient with most severe disease get it sooner than those w/ less severe disease!