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Flashcards in Liver Deck (63):
1

Most common cause of acute liver failure

Acetaminophen overdose

2

Acute liver failure signs and symptoms

- Ascites
- Coagulopathy
-Jaundice
- Encephalopathy/altered mental status (1-4 weeks after jaundice)
-

3

Acute liver failure labs

-ALT and AST, bilirubin elevated
-INR elevated
-Leukocytosis (high WBCs)
-Hyponatremia, hypokalemia, hypoglycemia

4

Acute liver failure: TX

hospitalize, may need transplant

5

Hepatitis: acute and chronic

Viral is most common cause of both

6

Which hepatitis viruses are transmitted fecal oral

A and E

-self limited
-abrupt onset

7

How are hepatitis B, C, D transmitted?

-IV drug use
-tattoos
-infected mother
-blood transfusion

8

Which hepatitis virus most commonly causes cholestatic hepatitis?

hepatitis A

-prominent jaundice and itching
-elevation in bilirubin, ALK phos

9

Which hepatitis virus is the most common cause of relapsing hepatitis?

hepatitis A

-symptoms recur in weeks/months
-may see arthritis, vasculitis, excess protein in the blood

10

Acute viral hepatitis: physical exam

-mild hepatomegaly with tenderness
-mild splenomegaly
-posterior cervical lymphadenopathy

11

Acute Viral hepatitis (self-limited disease and relapsing hepatitis) treatment

outpatient (unless super dehydrated)

12

Cholestatic hepatitis: tx

1. Prednisone
2. Ursodeoxycholic acid
3. Cholestyramine (for itching, binds to cholesterol)

13

Hep A: signs/sx

-fever (uncommon in other viral hepatitis)**
-icteric phase: jaundice peaks at 2 weeks

14

How long does IgM antibody to HAV stay elevated?

3-6 months

IgM is test of choice***

15

How long does IgG anti-HAV stay elevated?

lifelong

16

Which hepatitis viruses have vaccines?

Hep A
Hep B

17

When should the Hep A vaccine be given?

-at 1 year old
-MSM
-IV drug user

18

Post exposure Hep A prophylaxis?

Vaccine for 1 -40 years

Immunoglobulin for <1 yr, >40 yr, or immunocompromised

19

In whom is hepatitis E often more severe and fulminant?

pregnant lady

**acute liver failure esp if in 3rd trimester**

20

Hepatitis E

-longer incubation than Hep A**
-Spread by swine/undercooked meat

21

Hepatitis E: labs

-IgM first
-IgG second
-HEV RNA test confirms and quantifies HEV presence*** (stool or serum)

22

Hepatitis E: prevention

-no vaccine
-no immunoglobulin

23

Viral differences

Hep A and E: non-enveloped, not affected by bile/detergents

Hep B, C, D: enveloped, disrupted by bile/detergents

24

Hep B: general

-DNA virus
-transmission via percutaneous and permucosal routes
-sexually transmitted
-May result in chronically infected state-->esp infants, kids
-Adults more likely to get asymptomatic/self-limited disease

25

What does HBeAg tell you?

marker of active infection

26

What does antibody to HBsAg tell you?

immunity to the surface antigen

27

If the patient has anti-HBs and anti-HBc what does that tell you?

Prior HBV infection

28

What labs would indicate chronic Hepatitis B infection?

HBsAg for >6 months

29

If patient has Hep B infection, is young, non-cirrhotic, low HBV DNA level what is the treatment?

Peginterferon alfa-2a
(SQ injections for 48 weeks)
-greater chance of seroconversion

Nucleoside analogues (ex. entecavir, tenofovir)
-inhibit HBV replication, don't eradicate HBV
-Oral medication

30

Hep B: passive immunization (ex. newborns of HBsAg moms)

1. Immunoglobulin (HBIG)
-give postexposure prophylaxis to casual sexual partners

2. HBV vaccine series
-2 shots, 6 months apart

31

Who should be screened for Hepatitis C?

-high risk
-Born between 1945-1965 [BABY BOOMERS]

32

Most common Hepatitis C genotype in US?

genotype 1

note: genotype 3 is hardest to treat

33

Hepatitis C: etiology/risk factors

-transmitted MC between IV drug users**
-Blood transfusion before 1992
-HIV (less likely to clear virus)

34

Hepatitis C: clinical presentation

-usually asymptomatic
-young women more likely to clear the virus (blacks less likely to clear)
-majority will develop chronic infection

35

Which lab is needed to diagnose acute Hep C infection?

HCV RNA test***

-if present >6 months =chronic infection

36

Hep B vs. Hep C in kids

Hep B - kids more likely to become chronic

Hep C - kids more likely to resolve spontaneously

37

In a patient with chronic Hep C, how do you tell if there is active infection?

+ screening test by EIA (antibodies against the virus)

38

If your patient has hepatitis C, what other things are important to do?

-screen for HIV
-vaccinate for Hep B, and Hep A

39

What determines the treatment regimen for hep C?

genotype

40

What are the new Hep C drugs?

Direct-acting antivirals
-NS3-4 protease inhibitors (ex. Simeprevir)

-NS5B polymerase inhibitors (ex. Sofosbuvir)

41

What is the main offender for drug-induced liver injury?

-antibioticss (esp. Augmentin, Sulfonamides)***
-Acetaminophen
-Antituberulous Agents (Isoniazid and Rifampin)

42

What does Maddrey's discrimination function help you determine?

mortality during current hospitalization for alcoholic hepatitis

Tx: methylprednisolone and pentoxifylline help

43

Non alcoholic fatty liver disease, and nonalcoholic steatohepatitis: general

-asymptomatic, maybe RUQ pain
-elevated ALT
-<4 alcoholic drinks a day

44

Autoimmune hepatitis: general

-young to middle aged women
-high serum gamma-globulin level
+ANA
+smooth muscle antibody

45

Autoimmune hepatitis: Tx

Tx: Prednisone 30mg (taper over month) +/- azathioprine

46

Autoimmune hepatitis: prognosis/follow up

hepatologist every 3-6 months due to high relapse rate

47

Wilson disease

-impaired biliary copper excretion
-Autosomal recessive
-decreased serum ceruloplasmin
-Kayser-Fleicher rings

48

Wilson disease: tx

D-penicillamine

49

Which organs are affected by Alpha-1 antitrypsin deficiency

Lung and Liver

50

Primary Sclerosing Cholangitis

-Men 20-40
-Ulcerative colitis
-cholangiocarcinoma
+ P-ANCA
-Elevated: Alk Phos, Bilirubin

51

Primary Biliary Cirrhosis

-middle aged women
-fatigue and pruritis**
-xanthelasma/xanthoma
+Anti-mitochondrial antibody****

52

Primary Biliary Cirrhosis: Tx

1. Urodeoxycholic acid*

2. Cholestyramine (bile acid resin)

53

Primary Sclerosing Cholangitis: Dx

ERCP with stenting

-Ursodiol (reduces secretion of cholesterol)


Definitive -->most will need transplant

54

ESLD hepatic encephalopathy

-hepatocellular dysfunction leads to increased serum ammonia levels
-Neuropsychiatric abnormalities (grade1: short attention span, grade2: personality change, grade3: confusion disorientation, grade4: coma

55

ESLD: Tx for high ammonia in the blood

Lactulose and/or Rifaximin`

56

What happens to albumin in end-stage liver disease?

decreases

-more difficulty maintaining osmotic pressure of blood
-less carrying ability for small hydrophobic molecules

57

End Stage Liver disease: Sodium

-Chronically low - fluid overload
-Indirect marker of portal hypertension
-hyponatremia - risk of cerebral edema and neurologic changes

58

Model of End-Stage Liver Disease (MELD)

determines transplant eligibility

>15 MELD score is where 3 month survival starts dropping = consider for transplant

59

What are strong predictors of 3 month mortality

1. Total Bilirubin
2. INR
3. Cr
4. Na+

60

Hepatocellular Carcinoma (HCC)

MC risk factor = cirrhosis
Image every 6 months = alternating CT/MRI

Serum cancer marker = Alpha feto-protein

61

Cholangiocarcinoma: etiology

-cancer from bile duct epithelium
-Klatskin tumor --> if near bifurcation of the ducts
-MOST are adenocarcinomas

-Males, between ages 50-70

62

Cholangiocarcinoma: history and exam

-Painless jaundice
-pruritus
-fever, jaundice, RUQ pain (Charcots)
-palpable gallbladder
-hepatomegaly
-dark urine
-pale stools

63

Contraindications for liver transplant

-active EtOH or drug abusee
-HCC outside the liver
-Metastatic bile duct cancer
-Non-hepatic malignancy
-Severe cardiopulmonary disease
-Comorbidities (BMI>35)
-Psych/social issues