Flashcards in Liver Deck (63):
Most common cause of acute liver failure
Acute liver failure signs and symptoms
- Encephalopathy/altered mental status (1-4 weeks after jaundice)
Acute liver failure labs
-ALT and AST, bilirubin elevated
-Leukocytosis (high WBCs)
-Hyponatremia, hypokalemia, hypoglycemia
Acute liver failure: TX
hospitalize, may need transplant
Hepatitis: acute and chronic
Viral is most common cause of both
Which hepatitis viruses are transmitted fecal oral
A and E
How are hepatitis B, C, D transmitted?
-IV drug use
Which hepatitis virus most commonly causes cholestatic hepatitis?
-prominent jaundice and itching
-elevation in bilirubin, ALK phos
Which hepatitis virus is the most common cause of relapsing hepatitis?
-symptoms recur in weeks/months
-may see arthritis, vasculitis, excess protein in the blood
Acute viral hepatitis: physical exam
-mild hepatomegaly with tenderness
-posterior cervical lymphadenopathy
Acute Viral hepatitis (self-limited disease and relapsing hepatitis) treatment
outpatient (unless super dehydrated)
Cholestatic hepatitis: tx
2. Ursodeoxycholic acid
3. Cholestyramine (for itching, binds to cholesterol)
Hep A: signs/sx
-fever (uncommon in other viral hepatitis)**
-icteric phase: jaundice peaks at 2 weeks
How long does IgM antibody to HAV stay elevated?
IgM is test of choice***
How long does IgG anti-HAV stay elevated?
Which hepatitis viruses have vaccines?
When should the Hep A vaccine be given?
-at 1 year old
-IV drug user
Post exposure Hep A prophylaxis?
Vaccine for 1 -40 years
Immunoglobulin for <1 yr, >40 yr, or immunocompromised
In whom is hepatitis E often more severe and fulminant?
**acute liver failure esp if in 3rd trimester**
-longer incubation than Hep A**
-Spread by swine/undercooked meat
Hepatitis E: labs
-HEV RNA test confirms and quantifies HEV presence*** (stool or serum)
Hepatitis E: prevention
Hep A and E: non-enveloped, not affected by bile/detergents
Hep B, C, D: enveloped, disrupted by bile/detergents
Hep B: general
-transmission via percutaneous and permucosal routes
-May result in chronically infected state-->esp infants, kids
-Adults more likely to get asymptomatic/self-limited disease
What does HBeAg tell you?
marker of active infection
What does antibody to HBsAg tell you?
immunity to the surface antigen
If the patient has anti-HBs and anti-HBc what does that tell you?
Prior HBV infection
What labs would indicate chronic Hepatitis B infection?
HBsAg for >6 months
If patient has Hep B infection, is young, non-cirrhotic, low HBV DNA level what is the treatment?
(SQ injections for 48 weeks)
-greater chance of seroconversion
Nucleoside analogues (ex. entecavir, tenofovir)
-inhibit HBV replication, don't eradicate HBV
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
Who should be screened for Hepatitis C?
-Born between 1945-1965 [BABY BOOMERS]
Most common Hepatitis C genotype in US?
note: genotype 3 is hardest to treat
Hepatitis C: etiology/risk factors
-transmitted MC between IV drug users**
-Blood transfusion before 1992
-HIV (less likely to clear virus)
Hepatitis C: clinical presentation
-young women more likely to clear the virus (blacks less likely to clear)
-majority will develop chronic infection
Which lab is needed to diagnose acute Hep C infection?
HCV RNA test***
-if present >6 months =chronic infection
Hep B vs. Hep C in kids
Hep B - kids more likely to become chronic
Hep C - kids more likely to resolve spontaneously
In a patient with chronic Hep C, how do you tell if there is active infection?
+ screening test by EIA (antibodies against the virus)
If your patient has hepatitis C, what other things are important to do?
-screen for HIV
-vaccinate for Hep B, and Hep A
What determines the treatment regimen for hep C?
What are the new Hep C drugs?
-NS3-4 protease inhibitors (ex. Simeprevir)
-NS5B polymerase inhibitors (ex. Sofosbuvir)
What is the main offender for drug-induced liver injury?
-antibioticss (esp. Augmentin, Sulfonamides)***
-Antituberulous Agents (Isoniazid and Rifampin)
What does Maddrey's discrimination function help you determine?
mortality during current hospitalization for alcoholic hepatitis
Tx: methylprednisolone and pentoxifylline help
Non alcoholic fatty liver disease, and nonalcoholic steatohepatitis: general
-asymptomatic, maybe RUQ pain
-<4 alcoholic drinks a day
Autoimmune hepatitis: general
-young to middle aged women
-high serum gamma-globulin level
+smooth muscle antibody
Autoimmune hepatitis: Tx
Tx: Prednisone 30mg (taper over month) +/- azathioprine
Autoimmune hepatitis: prognosis/follow up
hepatologist every 3-6 months due to high relapse rate
-impaired biliary copper excretion
-decreased serum ceruloplasmin
Wilson disease: tx
Which organs are affected by Alpha-1 antitrypsin deficiency
Lung and Liver
Primary Sclerosing Cholangitis
-Elevated: Alk Phos, Bilirubin
Primary Biliary Cirrhosis
-middle aged women
-fatigue and pruritis**
Primary Biliary Cirrhosis: Tx
1. Urodeoxycholic acid*
2. Cholestyramine (bile acid resin)
Primary Sclerosing Cholangitis: Dx
ERCP with stenting
-Ursodiol (reduces secretion of cholesterol)
Definitive -->most will need transplant
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
ESLD: Tx for high ammonia in the blood
Lactulose and/or Rifaximin`
What happens to albumin in end-stage liver disease?
-more difficulty maintaining osmotic pressure of blood
-less carrying ability for small hydrophobic molecules
End Stage Liver disease: Sodium
-Chronically low - fluid overload
-Indirect marker of portal hypertension
-hyponatremia - risk of cerebral edema and neurologic changes
Model of End-Stage Liver Disease (MELD)
determines transplant eligibility
>15 MELD score is where 3 month survival starts dropping = consider for transplant
What are strong predictors of 3 month mortality
1. Total Bilirubin
Hepatocellular Carcinoma (HCC)
MC risk factor = cirrhosis
Image every 6 months = alternating CT/MRI
Serum cancer marker = Alpha feto-protein
-cancer from bile duct epithelium
-Klatskin tumor --> if near bifurcation of the ducts
-MOST are adenocarcinomas
-Males, between ages 50-70
Cholangiocarcinoma: history and exam
-fever, jaundice, RUQ pain (Charcots)