Flashcards in Liver Deck (109):
What is acute liver failure?
Liver injury, hepatic encephalopathy, & coagulopathy
What causes acute liver failure?
Hepatocyte necrosis due to:
- Viral hepatitis
- Drug induced
- Wilson's disease, autoimmune, tumor, transplant
What is the #1 cause of acute liver failure?
What are s/s of acute liver failure?
Ascites & anasarca
What are clinical features of acute hepatic failure?
Coagulopathy & jaundice
Encephalopathy within 1-4 wks
What are clinical features of subacute hepatic failure?
Encephalopathy within 12-24wks
What are lab findings w/ acute liver failure?
Hyponatremia, hypokalemia, hypoglycemia
Elevated bilirubin, ALT/AST
How do you treat acute liver failure?
Transfer to liver transplant
Await for resolution
If no recovery --> transplant
Which type of hepatitis is transmitted fecal-orally & do not cause chronic infection?
A & E
How are hep B, C, & D transmitted?
Parenterally or MM contact
What does acute viral hepatitis look like on PE?
Enlargement/ tenderness of liver
Splenomegaly & posterior cervical lymphadenopathy
What are s/s of cholestatic hepatitis?
Severe jaundice for several month
Persistent anorexia & diarrhea
What are s/s of relapsing hepatitis?
Arthritis, vasculitis, cryoglobulinemia
What are lab findings in acute viral hepatitis?
ALT/AST > 500, ALT > AST
Bilirubin: nl - 10mg
Alk phos: nl - mild elevation
Albumin: nl - mild decrease
WBC nl - mild leukopenia
What are the lab findings in cholestatic hepatitis?
Bilirubin ≥ 20
Alk phos elevated
ALT/AST may decrease
What are the lab findings in relapsing hepatitis?
ALT, AST elevated
How do you treat cholestatic hepatitis?
Prednisone & urso
Cholestyramine for pruritis
What are RFs for hep A?
Living in endemic region
Contact w/ infected person
What are s/s of hep A?
Incubation = 28 days
Preicteric phase lasts 5-7 days
Fever, jaundice, RUQ TTP
How do you dx hep A?
IgM antibody to HAV, which is then replaced by IgG anti-HAV
How do you treat hep A? What is the prognosis?
85% recover within 3 mos
nearly all recover within 6mos
10-20% can have relapsing course
How do you prevent hep A?
Disposal of wastes
Avoid excessive APAP & Etoh
In hep A, when can children return to school?
1 week after the onset
When should you give someone postexposure prophylaxis for hep A?
If recently exposed & not vaccinated
Give ASAP/within 2 wks
12mos-40yo --> HAV vaccine
< 12mos or > 40, immunocompromised, liver disease --> immune globulin
In hep A, transmission usually precedes sx by...
What are RFs for hep E?
Mexico, Cuba, Asia, Africa, Middle East
Consumption of undercooked pork, deer meat, shellfish
Contaminated water = MC
What are clinical features of hep E?
Abrupt onset of prodromal sx
Acute liver failure occurs in pregnant
How do you dx Hep E?
IgM anti-HEV detectable for at least 6wks, then replaced by IgG anti-HEV (detectable for 12-20 mos)
HEV RNA confirms & quantifies
How do you prevent hep E?
Avoid unpurified H2O, boil & chlorinate
Avoid raw pork & venison
What are general characteristics of HAV & HEV?
Linear RNA molecules
Survive when exposed to bile
Shed in feces
What are general characteristics of HBV, HDV, & HCV?
Disrupted by bile/detergents
A/w chronic liver disease
What are high prevalence areas w/ Hep B?
West Africa & South Sudan
What does the outer envelope of hep B contain?
What does the inner envelope of hep B contain?
HBcAg (structural protein): induces response against HBV
HBeAg (non-structural): marker for active replication
DNA polymerase: reverse-transcriptase
What are strong RFs for Hep B?
Multiple sex partners
Injection drug use
Asian, European, African
FHx of HBV or liver disease
FHx of HCC
Contact w/ HBV
What are weak RFs for Hep B?
Hx of STDs
HIV, Hep C
Hx of incarceration
What are s/s of hep B?
Insidious onset of prodromal sx
Serum sickness-like syndrome in 10%: F/C, malaise, maculopapular or urticarial rash, N/V, arthralgia/arthritis
What are s/s of hep B in those that are chronically infected?
s/s of chronic liver disease:
What are all the lab findings for hep B?
See page 149 in PANCE book
How do you treat hep B?
Acute --> self-limiting
Fulminant --> transplant
Chronic --> anti-viral (only if ALT elevated, which indicated active inflammation)
What are 1st line pharmocological options for chronic hep B?
Peginterferon alpha-2a SQ x 48wks
Nucleoside analogues PO QD (may be indefinitely): Entecavir & tenofovir
How do you prevent hep B?
- Hep B vaccine
- Hep B immune globulin (used for postexposure prophylaxis)
When should you suspect HDV?
Progressive chronic HBV
How do you treat HDV?
High dose interferon alpha & PEG IFN
Who should be screened for hep C?
All people born btwn 1945-1965, all baby boomers
Hep C has how many genotypes & subtypes?
6 genotypes & > 50 subtypes
75% in US are genotype 1
What causes hep C?
MC = IVDU
Sex activity, perinatally, accidental blood contact
What are strong RFs for hep C?
10% have no known RF.
How does hep C present?
30% have prodromal sx & jaundice
How do you dx hep C?
Hepatitis C antibody (anti-HCV)
HCV RNA needed to dx acute infection
Which genotype of hep C has more frequent spontaneous resolution vs less frequent?
More frequent = genotype CC
Less frequent = genotype CT & TT
What are characteristics of chronic Hep C?
HCV RNA in blood ≥ 6 months
chronic liver disease
What factors influence progression of chronic hep C liver disease?
Concurrent chronic HBV
How do you screen for chronic HCV?
EIA (detects antibodies)
How do you use qualitative vs quantitative studies?
Qualitative: confirms viremia, low limits of detection
Quantitative: give wide dynamic range of viral loads, best way to confirm response to tx
How do you treat HCV?
1st test for genotype, bc this determines the regimen
- PEGIFN weekly (no longer considered SOC)
- Oral antivirals = 1st line
What are examples of direct acting antivirals (DAAs) used for the tx of HCV?
NS3-4 protease inhibitors: genotype 1 & 4 ("previr")
NS5B polymerase inhibitors: all genotypes ("buvir")
NS5A replication complex inhibitors: ("asvir")
What is RVR?
Rapid viral response
HCV RNA undetectable by week 4 of tx
What is EOT?
End of treatment
HSV RNA undetectable at the end of tx
What is SVR?
Sustained virologic response
Undetectable HCV RNA at 12 weeks after tx
What is nonresponse?
Failure to attain undetectable HCV RNA at any point
What is relapse?
EOT response followed by return of HCV RNA after completion of tx
What are major offenders of drug-induced liver injury (DILI)/ toxic hepatitis?
How does drug-induced liver injury (DILI)/ toxic hepatitis present?
Ranges from subclinical LFT elevation to acute liver failure
Liver injury may develop in days or within several wks of ingestion
Labs may reveal hepatoxic injury, cholestatic, or mixed
How does acetaminophen overdose present?
30mins-24 hrs: GI sx
2 days after: R abd pain & oliguria, elevated LFTs & prolonged PT/INR
3-5 days: hepatic necosis w/ elevated aminotransferases, renal failure, & ALF
5-10 days: recovery phase
What determines the likelihood of death or need for transplant?
pH < 7.3
Stage 3-4 encephalopathy w/ PT/INR > 6.5 & Cr > 3.4
Factor V level ≤ 10%
How do you treat acetaminophen overdose?
IV N-acetylcysteine for serial doses
Charcoal within 1 hr
Gastric lavage within 4 hrs
What abnormalities are seen w/ alcoholic liver disease?
What are clinical features of alcoholic liver disease?
Asx to advanced liver failure
Fever, anorexia, nausea, RUQ pain, hepatomegaly, jaundice
What are the lab findings found in alcoholic liver disease?
AST elevated (but not above 300) > ALT
Elevated alk phos
Elevated TG, glucose
K, phosphate, Mg deficient
How do you determine the short-term px in pts w/ worsening alcoholic hepatitis?
Maddrey's discrimination fuction (DF)
DF = 4.6 x (the difference btwn the patient's & control prothrombin time) + bilirubin
If DF > 32 --> pt has 50% mortality
What drug reduces 4wk mortality & frequency of hepatorenal syndrome in alcoholic liver disease?
What is hepatic steatosis?
Accumulation of TG droplets in hepatocytes
What is non-alcoholic steatohepatitis (NASH)?
Necroinflammatory changes on liver bx, may progress to cirrhosis
What are RFs for NAFLD?
Tamoxifen & corticosteroids
How does NAFLD present?
May have RUQ pain, hepatomegaly
What labs are seen in NAFLD?
Elevated aminotransferase levels
What are the lab results seen in autoimmune hepatitis?
ALT elevated 8 fold
AST elevated 7 fold
Bilirubin elevated 2 fold
Gamma-globulin elevated 1.5 fold
Alk phos elevated 1.5 fold
What does autoimmune hepatitis look like on liver bx?
Interface hepatitis w/out bridging necrosis & no cirrhosis
What are features of autoimmune hepatitis?
Young - middle aged females
Chronic hep w/ globulins
Positive ANA &/or SM antibody
Responds to corticosteroids
What are s/s of autoimmune hep?
Fatigue, jaundice, hepatomegaly
May be severe/fulminant
How do you dx autoimmune hepatitis?
Autoantibodies (need at least 1 for dx): ANA or SM ≥ 1.4, anti-SLA, anti-LKM1 ≥ 1.4
How do you treat autoimmune hep?
Prednisone w/ or w/out azathioprine
What is the f/u like for autoimmune hep?
If remission achieved, f/u every 3-6mos due to high likelihood of relapse
How do you treat Wilson disease?
What are manifestations of hereditary hemochromatosis?
High serum iron or ferritin
What gene mutation is typically found in hereditary hemochromatosis?
What is the pathogenesis behind primary biliary cirrhosis?
T cell attack on bile ducts --> bile duct loss & scarring --> cirrhosis
What are features/sx of primary biliary cirrhosis?
Asx, fatigue & pruritis
Jaundice, xanthelasma, xanthoma, steatorrhea
What are the lab findings in primary biliary cirrhosis?
Elevated alk phos
How do you treat primary biliary cirrhosis?
Cholestyramine w/ water or juice 3 times daily for pruritis
Urso (slows progression)
Consider liver transplant
What is primary sclerosing cholangitis strongly a/w?
What is the clinical presentation of primary sclerosing cholangitis?
M > F , 41 yo = average
Jaundice & pruritis MC
Fatigue, wt loss, RUQ pain
Hx of UC
What are the lab findings in PSC?
Elevated alk phos & bilirubin
Mild elevation of transferases
What procedures do use to dx PSC?
How do you treat PSC?
What are complications of ESLD?
- Palmar erythema
- Spider angioma
- Encephalopathy w/ asterixis
- Portal HTN
- Portal vein thrombosis
- Ascites, muscle wasting
- Spontaneous bacterial perotinitis
What does hepatic encephalopathy lead to?
Increased ammonia --> neuropsychiatric abnormalities
How do you treat hepatic encephalopathy?
Lactulose: removes ammonia from gut
What imaging do you use to dx portal vein thrombosis?
Doppler US, CT, MRI
How do you treat portal vein thrombosis?
Anticoag w/ heparin or LMWH
How do you treat ascites, LE edema, or pleural effusion?
1st line = diuretics (furosemide & spironolactone)
2nd = paracentesis/thoracentesis
3rd = transjugular shunt
How do you treat spontaneous bacterial peritonitis?
Post infection bactrim
How do you assess degree of ESLD?
Bilirubin + INR + Cr
Mortality decreases at 15
What is the MC RF for HCC?
What imaging/lab should you perform for HCC?
CT/MRI every 6 mos
How do you treat HCC?
Monitor via imaging
Ablation & TACE
Perihilar tumors involving the bifurcation of biliary ducts