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Foundations III GI (Cholley) > Liver > Flashcards

Flashcards in Liver Deck (109):
1

What is acute liver failure?

Liver injury, hepatic encephalopathy, & coagulopathy

2

What causes acute liver failure?

Hepatocyte necrosis due to:
- Viral hepatitis
- Drug induced
- Toxins
- Metabolic
- Vascular
- Wilson's disease, autoimmune, tumor, transplant

3

What is the #1 cause of acute liver failure?

Acetaminophen overdose

4

What are s/s of acute liver failure?

AMS
Cerebral edema
Coagulopathy
Organ failure
Ascites & anasarca
Shrinking liver

5

What are clinical features of acute hepatic failure?

Coagulopathy & jaundice
Encephalopathy within 1-4 wks

6

What are clinical features of subacute hepatic failure?

Encephalopathy within 12-24wks

7

What are lab findings w/ acute liver failure?

Increased PT/INR

Leukocytosis

Hyponatremia, hypokalemia, hypoglycemia

Elevated bilirubin, ALT/AST

8

How do you treat acute liver failure?

Transfer to liver transplant
Await for resolution
If no recovery --> transplant

9

Which type of hepatitis is transmitted fecal-orally & do not cause chronic infection?

A & E

10

How are hep B, C, & D transmitted?

Parenterally or MM contact

11

What does acute viral hepatitis look like on PE?

Enlargement/ tenderness of liver

Splenomegaly & posterior cervical lymphadenopathy

12

What are s/s of cholestatic hepatitis?

Severe jaundice for several month

Prominent pruritis

Persistent anorexia & diarrhea

13

What are s/s of relapsing hepatitis?

Arthritis, vasculitis, cryoglobulinemia

14

What are lab findings in acute viral hepatitis?

ALT/AST > 500, ALT > AST
Bilirubin: nl - 10mg
Alk phos: nl - mild elevation
Prolonged Pt/INR
Albumin: nl - mild decrease
WBC nl - mild leukopenia
Lymphocytosis

15

What are the lab findings in cholestatic hepatitis?

Bilirubin ≥ 20
Alk phos elevated
ALT/AST may decrease

16

What are the lab findings in relapsing hepatitis?

ALT, AST elevated
Bilirubin recurs

17

How do you treat cholestatic hepatitis?

Prednisone & urso

Cholestyramine for pruritis

18

What are RFs for hep A?

Living in endemic region
Contact w/ infected person
MSM
Foodborne outbreak

19

What are s/s of hep A?

Incubation = 28 days
Preicteric phase lasts 5-7 days
Fever, jaundice, RUQ TTP
Fulminant course

20

How do you dx hep A?

IgM antibody to HAV, which is then replaced by IgG anti-HAV

Elevated ALT/AST

21

How do you treat hep A? What is the prognosis?

Supportive
85% recover within 3 mos
nearly all recover within 6mos

10-20% can have relapsing course

22

How do you prevent hep A?

Handwashing
Disposal of wastes
Immunization
Avoid excessive APAP & Etoh

23

In hep A, when can children return to school?

1 week after the onset

24

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

25

In hep A, transmission usually precedes sx by...

2 weeks!

26

What are RFs for hep E?

Mexico, Cuba, Asia, Africa, Middle East

Consumption of undercooked pork, deer meat, shellfish

Contaminated water = MC

27

What are clinical features of hep E?

Abrupt onset of prodromal sx

Acute liver failure occurs in pregnant

28

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

29

How do you prevent hep E?

Good sanitation

Avoid unpurified H2O, boil & chlorinate

Avoid raw pork & venison

30

What are general characteristics of HAV & HEV?

Nonenveloped viruses

Linear RNA molecules

Survive when exposed to bile

Shed in feces

31

What are general characteristics of HBV, HDV, & HCV?

Enveloped

Disrupted by bile/detergents

A/w chronic liver disease

32

What are high prevalence areas w/ Hep B?

West Africa & South Sudan

33

What does the outer envelope of hep B contain?

HBsAg

34

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

35

What are strong RFs for Hep B?

Perinatal exposure
Multiple sex partners
MSM
Injection drug use
Asian, European, African
FHx of HBV or liver disease
FHx of HCC
Contact w/ HBV

36

What are weak RFs for Hep B?

Male
Hx of STDs
HIV, Hep C
Blood transfusion
HCW
Hx of incarceration
Hemodialysis

37

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

38

What are s/s of hep B in those that are chronically infected?

Asx

s/s of chronic liver disease:
- cirrhosis
- HCC
- failure

39

What are all the lab findings for hep B?

See page 149 in PANCE book

40

How do you treat hep B?

Acute --> self-limiting

Fulminant --> transplant

Chronic --> anti-viral (only if ALT elevated, which indicated active inflammation)

41

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

42

How do you prevent hep B?

Active immunization:
- Hep B vaccine

Passive immunization:
- Hep B immune globulin (used for postexposure prophylaxis)

43

When should you suspect HDV?

Fulminant HBV
Relapsing HBV
Progressive chronic HBV

44

How do you treat HDV?

High dose interferon alpha & PEG IFN

45

Who should be screened for hep C?

High risk

All people born btwn 1945-1965, all baby boomers

46

Hep C has how many genotypes & subtypes?

6 genotypes & > 50 subtypes

75% in US are genotype 1

47

What causes hep C?

MC = IVDU

Sex activity, perinatally, accidental blood contact

48

What are strong RFs for hep C?

IVDU
Blood transfusion
HIV

10% have no known RF.

49

How does hep C present?

Asx

30% have prodromal sx & jaundice

50

How do you dx hep C?

Hepatitis C antibody (anti-HCV)

HCV RNA needed to dx acute infection

51

Which genotype of hep C has more frequent spontaneous resolution vs less frequent?

More frequent = genotype CC

Less frequent = genotype CT & TT

52

What are characteristics of chronic Hep C?

HCV RNA in blood ≥ 6 months

Presents w/:
chronic liver disease
cirrhosis
HCC

53

What factors influence progression of chronic hep C liver disease?

Older age
Male
Concurrent chronic HBV
HIV
Alcohol

54

How do you screen for chronic HCV?

EIA (detects antibodies)

55

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

56

How do you treat HCV?

1st test for genotype, bc this determines the regimen

- PEGIFN weekly (no longer considered SOC)
- Ribavirin
- Oral antivirals = 1st line

57

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")

58

What is RVR?

Rapid viral response

HCV RNA undetectable by week 4 of tx

59

What is EOT?

End of treatment

HSV RNA undetectable at the end of tx

60

What is SVR?

Sustained virologic response

Undetectable HCV RNA at 12 weeks after tx

61

What is nonresponse?

Failure to attain undetectable HCV RNA at any point

62

What is relapse?

EOT response followed by return of HCV RNA after completion of tx

63

What are major offenders of drug-induced liver injury (DILI)/ toxic hepatitis?

Antimicrobials (MC)
CNS agents
Immunomodulators
Analgesics
Lipid-lowering

64

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

65

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

66

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%

67

How do you treat acetaminophen overdose?

IV N-acetylcysteine for serial doses

Charcoal within 1 hr

Gastric lavage within 4 hrs

68

What abnormalities are seen w/ alcoholic liver disease?

Steatosis
Steatohepatitis
Cirrhosis

69

What are clinical features of alcoholic liver disease?

Asx to advanced liver failure

Portal HTN

Fever, anorexia, nausea, RUQ pain, hepatomegaly, jaundice

70

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

71

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

72

What drug reduces 4wk mortality & frequency of hepatorenal syndrome in alcoholic liver disease?

Pentoxifylline

73

What is hepatic steatosis?

Accumulation of TG droplets in hepatocytes

Benign

74

What is non-alcoholic steatohepatitis (NASH)?

Necroinflammatory changes on liver bx, may progress to cirrhosis

75

What are RFs for NAFLD?

Insulin resistance
DM2
Obesity
Lipid abnormalities
Tamoxifen & corticosteroids

76

How does NAFLD present?

Usually asx

May have RUQ pain, hepatomegaly

77

What labs are seen in NAFLD?

Elevated aminotransferase levels

78

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

79

What does autoimmune hepatitis look like on liver bx?

Interface hepatitis w/out bridging necrosis & no cirrhosis

80

What are features of autoimmune hepatitis?

Young - middle aged females

Chronic hep w/ globulins

Positive ANA &/or SM antibody

Responds to corticosteroids

81

What are s/s of autoimmune hep?

Usually insidious

Fatigue, jaundice, hepatomegaly

May be severe/fulminant

82

How do you dx autoimmune hepatitis?

Autoantibodies (need at least 1 for dx): ANA or SM ≥ 1.4, anti-SLA, anti-LKM1 ≥ 1.4

83

How do you treat autoimmune hep?

Prednisone w/ or w/out azathioprine

84

What is the f/u like for autoimmune hep?

If remission achieved, f/u every 3-6mos due to high likelihood of relapse

85

How do you treat Wilson disease?

D-penicillamine

86

What are manifestations of hereditary hemochromatosis?

High serum iron or ferritin
Cardiac disease
DM
Joint disease
Infections

87

What gene mutation is typically found in hereditary hemochromatosis?

HFE gene

88

What is the pathogenesis behind primary biliary cirrhosis?

T cell attack on bile ducts --> bile duct loss & scarring --> cirrhosis

89

What are features/sx of primary biliary cirrhosis?

Middle aged

Asx, fatigue & pruritis

Jaundice, xanthelasma, xanthoma, steatorrhea

90

What are the lab findings in primary biliary cirrhosis?

Elevated alk phos
+ AMA
Elevated IgM
Increased cholesterol

91

How do you treat primary biliary cirrhosis?

Cholestyramine w/ water or juice 3 times daily for pruritis

Urso (slows progression)

Consider liver transplant

92

What is primary sclerosing cholangitis strongly a/w?

Cholangiocarcinoma
UC

93

What is the clinical presentation of primary sclerosing cholangitis?

M > F , 41 yo = average

Jaundice & pruritis MC

Fatigue, wt loss, RUQ pain

Hepatomegaly, splenomegaly

Hx of UC

94

What are the lab findings in PSC?

Elevated alk phos & bilirubin

Mild elevation of transferases

Positive p-ANCA

95

What procedures do use to dx PSC?

MRCP/ERCP

Liver bx

96

How do you treat PSC?

Stent

Recurrent ERCPs

Urso

97

What are complications of ESLD?

- Jaundice
- Palmar erythema
- Spider angioma
- Encephalopathy w/ asterixis
- Portal HTN
- Portal vein thrombosis
- Ascites, muscle wasting
- Spontaneous bacterial perotinitis

98

What does hepatic encephalopathy lead to?

Increased ammonia --> neuropsychiatric abnormalities

99

How do you treat hepatic encephalopathy?

Lactulose: removes ammonia from gut

100

What imaging do you use to dx portal vein thrombosis?

Doppler US, CT, MRI

101

How do you treat portal vein thrombosis?

Anticoag w/ heparin or LMWH

102

How do you treat ascites, LE edema, or pleural effusion?

1st line = diuretics (furosemide & spironolactone)

2nd = paracentesis/thoracentesis

3rd = transjugular shunt

103

How do you treat spontaneous bacterial peritonitis?

IV cefotaxime
IV albumin

Post infection bactrim

104

How do you assess degree of ESLD?

MELD

Bilirubin + INR + Cr

Mortality decreases at 15

105

What is the MC RF for HCC?

Cirrhosis

106

What imaging/lab should you perform for HCC?

CT/MRI every 6 mos

AFP

107

How do you treat HCC?

Transplant

Monitor via imaging

Ablation & TACE

108

Klatskin tumors

Perihilar tumors involving the bifurcation of biliary ducts

Intrahepatic

109

What is the MC age range for dx of cholangiocarcinoma?

50-70!!! (2/3)