Liver Flashcards
(543 cards)
1
Q
Adenovirus, Influenza, Ebola, Zika, EBV, CMV, HSV, SARS-CoV-2 (COVID) and Parvovirus all have this in common.
A
ALL can cause significant liver injury and jaundice however 80% of adults have been exposed to EBV and CMV and have immunity in the form of IgG and therefore infections affecting the liver with these viruses would be uncommon UNLESS IMMUNOCOMPROMISED (HIV, chemotherapy, transplant) or YOUNG individuals (EBV - mononucleosis).
2
Q
Which VIRUS is the most COMMONLY REACTIVATED virus in IMMUNOCOMPROMISED patients that affects the liver?
A
CMV
3
Q
What is the MOST COMMON cause of ACUTE HEPATITIS in the USA?
A
HBV
4
Q
Which viruses CAN be transmitted from person to person via “CASUAL CONTACT”?
A
HAV, Adenovirus, Influenza, Ebola, Zika, EBV, CMV, HSV and Parvovirus
5
Q
Modern-day blood transfusions carry the risk of infection with which VIRUSES that can cause acute hepatitis?
A
Adenovirus, Influenza, Ebola, Zika, EBV, CMV, HSV and Parvovirus (NOT HAV,HBV, HCV, etc.)
6
Q
HOMOSEXUAL activity can bring about the transmission of which HEPATITIS VIRUSES?
A
HAV, HBV (HCV is rare)
7
Q
HETEROSEXUAL activity can bring about the trnasmission of which HEPATITIS VIRUSES?
A
HBV (HVA is rare, HCV is very rare)
8
Q
Which HEPATITIS VIRUSES can be trnasmitted VERTICALLY?
A
HBV, CMV, HSV (HCV is very rare)
9
Q
During this PHASE of clinical HEPATITIS a patient has NO SYMPTOMS and is POSITIVE serologically?
A
INCUBATION PHASE (phase 1) from entry of virus to presence of first symptoms.
10
Q
What is the LENGTH of the INCUBATION phase for HAV, HBV, HCV and HEV?
A
HAV: 2-6 WEEKS
HBV: 2-6 MONTHS
HCV: 2-20 WEEKS
HEV: 2-9 WEEKS
11
Q
Flu-like symptoms (myalgias, arthralgias, fatigue, loss of appetite, nasuea and vomiting, loss of sense of smell and taste) and mild tenderness over the liver for 3-5 days after INFECTION with HAV, HBV or HCV?
A
PRODROME PHASE
12
Q
What are the 4 PHASES of ACUTE HEPATITIS INFECTION?
A
- INCUBATION PHASE (asymptomatic but serologically positive) weeks to months.
- PRODROME PHASE (flu-like illness) 3-5 days.
- ICTERIC PHASE (total bilirubin >2.5 mg/dL and fatigue - <25% pts) several weeks.
- RESOLUTION PHASE (symptoms resolve, LFTs normalize, Ab’s present).
13
Q
This is a SERIOUS complication that is seen with HAV, HBV, HDV and HEV, (NOT WITH HCV) in older adults and those with CHRONIC LIVER DISEASE, is 50% FATAL and if diagnosed, MUST BE REFERRED to a liver TRANSPLANT CENTER.
A
ACUTE LIVER FAILURE (ALF)
14
Q
PROGRESSIVE worsening of JAUNDICE, COAGULOPATHY and MENTAL STATUS CHANGES in a patient with ACUTE HEPATITIS INFECTION?
A
ACUTE LIVER FAILURE (ALF) - 50% fatal - refer to transplant center ASAP.
15
Q
PREGNANT WOMEN, ELDERY, those with CHRONIC LIVER DISEASE when contracting HAV, HBV or HEV (preg women) are at an INCREASED RISK of what?
A
ACUTE LIVER FAILURE (ALF)
16
Q
What is the central theme driving the EXTRAHEPATIC MANIFESTATIONS of viral hepatitis (even after the virus has resolved)?
A
CRYOGLOBULINEMIA
17
Q
Unlike as seen with ACUTE infection, anti-HBVcore IgM can be positive in what other scenario?
A
Inactive chronic HBV FLARE
18
Q
WHAT is a prime TRIGGER for transient lower esophageal sphincter relaxation (TLESR), the most frequent mechanism for GERD in a patient who’s symptoms occur following the evening meal, and the pH monitoring demonstrates clustering of reflux episodes around postprandial periods?
A
Following a meal, PROXIMAL GASTRIC DISTENTION can cause increased TLESR frequency and is an important mechanism for persisting reflux symptoms.
19
Q
In the post prandial state, gastric acid produced by the stomach layers on top of the ingested meal. This pool of acidic gastric content, termed an ACID POCKET, is in close proximity to the GEJ, and can extend into a hiatus hernia or even the distal most part of the esophagus. Therefore, when an acid pocket exists, what occurs during a transient LES relaxation?
A
The VOLUME of acidic reflux is INCREASED during a transient LES relaxation (TLESR).
20
Q
In what way does a HIATUS HERNIA and GASTRIC FUNDIC DISTENTION INFLUENCE the transient LES relaxation (TLESR)?
A
These can INCREASE TLESR frequency (thereby increasing reflux and related GERD symptoms).
21
Q
Cryoglobulinemia (HBV, HCV, HEV) has which common positive serologic factor?
A
Rheumatoid Factor (always positive)
22
Q
Besides in an acute or resolving infection with HBV, when else can HBV IgM antibodies be positive?
A
HBV Reactivation
23
Q
PAS-positive, diastase-resistant globules in periportal hepatocytes represent what?
A
The hallmark of Z-type α1-AT
24
Q
Patient with positive HBsAg, HBeAg, positive viral load but asymptomatic and normal LFTs?
A
Immune Tolerant Phase
25
Alternative therapy for AIH when pt has reaction to prednisone or azathioprine (pancreatitis)
Mycophenolate Mofetil
26
Hepatic Caudate Lobe Hypertrophy
Feature associated with Budd Chiari Syndrome
27
What is used for intrahepatic cholestasis of pregnancy?
Ursodeoxicholic acid
28
Pt s/p transplant with elevated LFTs & INR in the thousands and Doppler shows no flow through the hepatic artery.
List for re-transplant status 1A (highest priority)
29
C282Y homozygote
Highest risk genetic genotype to develop severe iron overload in hereditary hemochromocytosis
30
In vertical transmission risk of HBV, what is the most significant factor?
HBVe AG positivity
31
Trip to India, otherwise healthy, LFTs in the thousands, pregnant, HAV, HBV, HCV neg?
HEV
32
Vinyl Chloride causes what disease with what feared complication? How is it treated?
Hepatic Angiosarcoma - local excision/TACE
33
Best treatment for patient with HepB and hepatocellular carcinoma with one to two lesions, well circumscribed without vascular invasion or mets?
Liver transplant.
34
What is the BEST predictor of survival in Primary Biliary Cirrhosis (AMA+)?
Total BILIRUBIN level
35
Recommended DIET for patients with chylous ascites?
HIGH protein, LOW fat and rich in MEDIUM chain triglycerides (long-chain triglycerides are absorbed by the lymphatics)
36
Maximum recommended dose of CARVEDILOL for patients with esophageal varices?
12.5 mg Daily
37
What parameter is monitored to determine need for phlebotomy in a patient with hereditary hemochromatosis?
FERRITIN 50-100 ug/L
38
What SLOWS progression of liver injury in patients with cystic fibrosis?
Ursodeoxycholic acid
39
What is the best way to treat a pregnant mother who is HepB positive in order to minimize risk of transmission?
Tenofovir (give child immune globulin and vaccine upon birth)
40
Patient transplanted for HepC cirrhosis has elevated liver enzymes and obviously HepC if not treated, they are on steroids and tacrolimus. What is the next step if US is normal as far as ducts and vascular?
Liver biopsy
41
What is the indication to start PROPHYLAXIS in a patient with cirrhosis, no SBP and PHG with oozing of blood?
The GI bleed
42
A patient needs treatment with chemotherapy and steroids for a cancer such as leukemia in the setting of dormant or treated HepB. What is essential to do?
Receive PROPHYLAXIS against HepB reverse seroconversion throughout his chemotherapy and for 12-18 months thereafter.
43
Patient with alcohol/HCV cirrhosis, well compensated, presents with liver US showing a 1.6 cm mass. What’s the next step?
TRIPHASIC CT of the liver
44
anti-HBcore IgM can be positive in ACUTE HBV infection and when else?
With REACTIVATION and FLARE of HBV in patients with inactive, chronic HBV
45
What is the significance of the **anti-HAV** IgG and **anti-HBV**surface antibodies?
These are the **ONLY** antibodies that actually confer **IMMUNITY** against future infection
46
A small portion of people (\>50, chronic liver disease) infected with this HEPATITIS virus can develop ACUTE LIVER FAILURE and require LIVER TRANSPLANT. This virus is transmitted casually from person to person mainly via STOOL contamination but can be through saliva and blood contact?
HAV
47
What can occurr in 3-20% of patients with HAV?
Have a **RELAPSE**
48
Asians, Blacks, Vertical Transmission, which HEPATITIS virus?
HBV
49
What confers **RISK** of **HCC** in patients with **HBV**?
HBV **DNA** (viral load)
in Immune **Tolerant** Phase (\>1,000,000)
in Chronic **Active** Phase (\>20,000)
in Chronic **Inactive** Phase (\<20,000)
50
What does E-antigen Negative chronic HBV mean?
Inactive HBV with positive E-antibody
51
In what TWO scenarios can a patient with HBV have E-antigen NEGATIVE?
Inactive Chronic HBV with E-abtibody POSITIVE
and
When there is a E-antigen PRE-CORE mutation in ACTIVE HBV
52
Which HBV patients CANNOT develop the INACTIVE HBV phase?
Those with an E-antigen PRE CORE mutation as the cannot develop the E-antibody
53
Can mothers with CHRONIC HCV (80% of people with HCV) breastfeed?
YES
54
When HCV and HBV coexist, what can happen when HCV is treated and eradicated as these two viruses compete?
Patient can have an HBV FLARE
55
This HEPATITIS VIRUS is almost EXCLUSIVELY contracted via IVDA and what is HIGH-RISK about these patients?
HDV, can only occurr with HBV and HBV-HDV infection can cause Acute Liver Failure
56
What is the RISK when a PREGNANT woman acquires acute HEV infection?
Acute Liver Failure
57
The presence of **anti-HBVsurface** (Ab) means what?
Person has been **VACCINATED** against HBV
58
Patients at risk for contracting HBV should be given what if they were vaccinated many years ago?
What should they be checked for?
What should be done if after being checked, the result is suboptimal?
HBV **BOOSTER** (one dose of the HBV vaccine)
Response to mounting an immunity against the BOOSTER
If poor or no response, give HBV **IVIG** and the remaining two vaccines (1mo, 1 mo, then 6 mo)
59
Which patients with HBV (phase) should be treated?
ONLY those with **ACTIVE HBV** (immune tolerant or inactive should be monitored) - this includes **CHRONIC ACTIVE** and **ALL** **CIRRHOSIS** (active or inactive)
60
HBV DNA **\>2,000-20,000** IU/mL **REGARDLESS** of **LFTs**
**ACTIVE HBV**
61
62
What is the **GOAL** of HBV treatment?
**SEROCONVERSION** (absence of the HBE-antigen and formation of the anti-HBE)
63
How do you treat HBE-antigen NEGATIVE patients (pre-core mutation)?
**Suppress** **HBV DNA** long term as they CANNOT seroconvert to inactive HBV
64
In which patients and why is **PEG-INF** not recommended?
In patients with **CIRRHOSIS**, because it can cause a **FLARE** and acute liver decompensation
65
Regardless of E-antigen status (positive or negative), which agents are used in treating **CHRONIC ACTIVE HBV** and HOW do they work?
**ORAL** antivirals (**TENOFOVIR** and **ENTECAVIR**) and these work by suppressing DNA replication resulting in undetectable viral loads.
66
**WHEN** CAN the ORAL antivirals (**TENOFOVIR** and **ENTECAVIR**) be stopped when treating HBV?
**ONLY** when **SEROCONVERSION** occurs (anti-HBE forms and HBE-antigen dissappears), otherwise they must be used long-term
67
How are patients with **BOTH** **CHRONIC INACTIVE HBV** and **CIRRHOSIS** treated?
ONLY with **ORAL** antivirals (**TENOFOVIR** or **ENTECAVIR**) and CANNOT use PEG-INF (causes flare)
68
When should **HBV** treatment be initiated in a **PREGNANT** patient to avoid **VERTICAL** trnasmission?
During the **THIRD TRIMESTER** if HBV DNA viral load is **\>200,000** IU/mL
69
In patients with **INACTIVE HBV**, in order to **PREVENT** a **FLAIR** during treatments such as **CHEMOTHERAPY**, **anti-TNF** agents (Crohn's, UC, etc.) and HIGH-DOSE **STEROIDS**, what must be used as **PROPHYLAXIS**?
**ORAL** antiviral agents (**TENOFOVIR** or **ENTECAVIR**) at the time of **INITIATION** of treatment and for **6 MONTHS** after.
70
What does it mean when a patient has **anti-HBcore** (Ab) and **anti-HBsurface** (Ab)?
They have **RESOLVED HBV** infection and are **NOT** at risk to develop HBV reactivation wehn immunosuppressed.
71
What constitutes a Sustained Virological Response (**SVR**) to HCV treatment?
**UNDETECTABLE HCV RNA** at **12-24 WEEKS** and is synnonimous to being **CURED**
72
The treatment of HCV requires how **MANY** agents to be used and why?
At least **TWO** agents because one has to be either a PROTEASE INHIBITOR (NS3-4) or a POLYMERASE INHIBITOR (NS5B) and one has to be a NS5A INHIBITOR (replication complex)
73
In patients with **HCV genotype 1A**, what can occurr when using ORAL antiviral agents and what can be done?
Can develop **NS5A** resistance and using **GRZ-EBV** therapy needs to be augmented with **RIBAVIRIN** (RBV) and extending therapy from **12** weeks to **16** weeks
74
Why are **SOF-LDV** and **SOF-VEL+/-RBV** the **ONLY** combination of ORAL antiviral therapies possible for patients with **DECOPENSATED CIRRHOSIS** (CHILD **CLASS** B)
Because **PROTEASE INHIBITORS** (**GRZ**, **VOX**) do not work in CIRRHOSIS
75
Which HCV oral antiviral agent **CANNOT** be used in patients with **RENAL FAILURE** (GFR \<30) and which combination IS USED in these patients?
**SOF CANNOT** be used (polymerase inhibitors)
Use **GRZ-EBV** in **RENAL** patients
76
**BEFORE** initiating therapy for **HCV**, what MUST be tested for first and why?
**HBV CO-INFECTION**, because it can cause HBV **FLAIR** and liver decompensation (test for **HBsurface antigen**, **anti-HBcore** and **anti-HBsurface**)
77
How do you treat the **HBV-HCV** co-infected patient whether the **HBV** is **ACTIVE** or **INACTIVE**?
**MUST** treat **HBV** with oral antiviral agents (**TENOFOVIR** or **ENTECAVIR**) up to 6 months after resolution of HCV as well as with **HCV** antivirals
78
What is developed when patients acquire HBV infection and what constitutes resolution of HBV?
ALL patients who contract HBV develop **HBsurface antigen**. When HBV is cleared and cured, **HBsurface antigen** is lost and if long enough after, so is the **anti-HBsurface antibody**.
79
A patient with **ISOLATED** **anti-HBcore** means what?
It means that they **HAD** been infected with HBV in the past and **RESOLVED** or were **NEVER INFECTED**
80
**ALL** patients with **CHRONIC HBV** have the pesistence of **WHAT**?
**HBsurface antigen**
81
A **PREGNANT** woman has HBV and has **DNA \>200,000** when should she start treatment?
During her **THIRD** trimester and for **ONE MONTH** post delivery will virtually **ELIMINATE** the risk for vertical transmission to her newborn
82
**HOW LONG** after **SEROCONVERSION** (anti-HBE) can oral (DAA) agents be stopped?
After **6 MONTHS**
83
For patients with chronic **HBV** who are **HBE-antigen negative** (cannot seroconvert), how long is oral antiviral therapy (DAA)?
**LIFE-LONG**
84
Which patients with HCV do not require **ANY** monitoring for **HBV**?
Those with **anti-HBsurface** (these patients **RESOLVED** their HBV)
85
**ALT \>10,000** IU/I, profound jaundice (**bilirubin \>10** mg/dL), elevated **INR**, hepatic **ENCEPHALOPAHTY**?
**ACUTE LIVER FAILURE** (**\>80%** mortality without transplant)
86
In a patient with HBV infection (was HBsurface antigen positive, anti-HBcore IgM) what does it mean when they **become HBsurface antigen negative** but are still **anti-HBsurface antibody negative**?
They are in the **WINDOW** period and will become anti-HBsurface antibody positive confering **SPONTANEOUS RESOLUTION**
87
**PERSISTANCE** of **HBsurface antigen** means?
**CHRONIC active HBV** infection
88
**anti-HBcore**, **HBsurface-antigen**, **HBE-antigen**, **NORMAL ALT,** **VERY HIGH HBV DNA**, **NO INFLAMMATION**, minimal fibrosis?
**HBV IMMUNE TOLERANT** state, **NO TREATMENT NEEDED**
89
At what **DNA** load is the reisk for development of **CIRRHOSIS** or **HCC** the greatest?
**\>20,000** IU/mL
90
What is the **DIFFERENCE** with respect to **RISK** of **HCC** in patients with **HBV** and those with **HCV**?
Only patients with **CIRRHOSIS** and **HCV** will develop **HCC**, whereas in **HBV** infection, patients with cirrhosis are more likely to develop **HCC** but those **WITHOUT** still **CAN**
91
How do you treat **NEWBORNS** to mothers who have **HBsurface-antigen**?
**HBIG + HBV VACCINE** within **12 HOURS** of **BIRTH**
92
What **AGENT** is used to prevent **VERTICAL** transmission of **HBV** if at the **THIRD TRIMESTER** mother's **HBV DNA is \>200,000**?
**TELBIVUDINE** (start third trimester and for **ONE MONTH** after birth)
93
Which formulation of **TENOFOVIR** is best (less toxicity, less drug, better delivery)?
Tenofovir **ALAFENAMIDE**
94
When are the **TWO** occassions in which **anti-HBcore IgM** is **POSITIVE**?
**ACUTE HBV** infection and **HBV REACTIVATION** (chemotherapy, imunosuppression)
95
If a patient is found to have **HBsurface-antigen**, what else **MUST** you test for?
**HBV DNA**, **HBE-antigen** and **anti-HBE**
96
**PRIOR** to treating **HCV** in a patient, **WHAT** must you test for?
Presence of **HBV** (**HBsurface-antigen**, **anti-HBsurface** and **anti-HBcore**)
97
**INH** and **HALOTHANE** can cause Drug Induced Liver Injury (**DILI**) mostly in whom?
Persons **\>60 yo**
98
Which patients are at most risk of **ALF** due to **Valproic Acid**?
**CHILDREN**
99
Anesthetic agents, INH (isonioazid), Acetaminophen, Cocaine, Vitamin A and Methotrexate can all cause an increased risk of **DILI** in patients that do what?
Consume **ALCOHOL** regulary
100
Is the risk for **DILI** elevated in patients with **CIRRHOSIS**?
**NO**
101
**Erythromycin**, **Ketoconazole**, **Fluconazole, Cimetadine** and **Quinidine** are significant in hepatic metabolism because?
**INHIBIT CYP** (cytochrome P450) and **REDUCE** hepatic metabolism of other drugs
102
**Carbon Tetrachloride** and **Amanita Mushrooms**
**Intrinsic Hepatotoxicity** (centrolobular necrosis)
103
What is significant about the **METABOLITES** of **ACETAMINOPHEN** and **INH**?
They are **HEPATOTOXIC**
104
**Phenytoin**, **Sulfonamides**, **Dapsone** and **Halothane** can all cause what type of hepatotoxicity?
Idiosyncratic hypersensitivity (differs in each person) and an **ALLERGIC** reaction (eosinophillia, fever, rash)
105
Up to **3X ASYMPTOMATIC** elevation in **AST/ALT** and **ALK PHOS** is considered what type of **DILI**?
**MILD DILI**, no need to stop the medications
106
What is it called when **LFTs** are raised **WITHOUT JAUNDICE** and can stay elevated up to **6 MONTHS** after starting a medicaion and only require **MONITORING**?
**ADAPTATION**
107
What can occurr in patients with **5X LFTs** and **JAUNDICE** after starting a **MEDICATION**?
Acute Liver Failure (**ALF**)
108
What is the **TYPICAL** time frame for a drug to cause **DILI** from when it is **INITIATED**?
**1-3 MONTHS**
109
Which **DRUG CLASS** is the most common cause of **DILI** and which medication in particular?
**ANTIBIOTICS**, **AUGMENTIN**
110
**PORTAL HTN** and **STEATOSIS** with elevated **LFTs** can be caused by these medications?
**HAART** (all antiretrovirals)
111
The initiation of which **MEDICATION** requires a **LIVER BIOPSY** to check for **FIBROSIS** and **REPEAT** biopsy after evey 2g increase or every 2 years? (causes STAGE 1 steatosis, STAGE 2 portal fibrosis, STAGE 3 bridging fibrosis and STAGE 4 cirrhosis)
**METHOTREXATE** (psoriasis, cancers, etc.)
112
What is one of the most **COMMON** adverse effects of **CHECK POINT INHIBITORS** (**CHI**)?
**HEPATOTOXICITY**
113
What causes the metabolism of **ACETAMINOPHEN** in the liver to be ramped up thereby causing rapid buildup of the toxic metabolite **NAPQI** which depletes **GLUTATHIONE** and causes hepatotoxicity?
Regular **ALCOHOL** consumption (2-4 drinks per day), **PHENYTOIN** and **RIFAMPIN**
114
Which medications should **NOT BE USED** in patients with **CIRRHOSIS** as they can cause bleeding due to exacerbated renal insufficiency and thrombocytopenia?
**NSAIDS**
115
What medication should **NOT BE USED** in treatment of **DILI**?
**STEROIDS** (only use N-acetylcysteine)
116
Is **ACETAMINOPHEN** safe to use in patients with **CIRRHOSIS**?
**YES**, very (less likely to cause hepatotoxicity in these patients due to poor metabolism)
117
What is a **PHASE-I** reaction when talking about **LIVER METABOLISM** of drugs? What is **PHASE-II**?
The creation of an **ACTIVE** **METABOLITE**, phase-II is detoxifocation of the metabolite.
118
What constitutes 3X elevation of AST, ALT and ALP? 5X?
3X AST - 120
3X ALT - 170
3X ALP - 441
5X AST - 200
5X ALT - 280
5X ALP - 735
119
What underlying liver issue can commonly cause **SLOW ADAPTATION** of drugs with elevated liver enzymes such as with **STATINS**?
**NAFLD**
120
What is the **COMPONENT** of **DILI** (3X ULN of LFTs to 5X ULN of LFTs) that determines the risk of development of **ALF**?
Presence of **JAUNDICE** (bilirubin \>2.5)
121
What is the most **COMMON** type of **HEPATIC INJUY** with **DILI** and what is mostly elevated?
**CHOLESTASIS** (elevated **ALP**) and **JAUNDICE**
122
Pt took **ACETAMINOPHEN**, **10-15g** and presented **\>24 hours** after with elevated **INR** and signs of **HEPATIC ENCEPHALOPATHY**, what do you do?
Immediately give **N-acetylcysteine** and transfer to **LIVER TRANSPLANT CENTER**
123
What are the **THREE** main **IMMUNE LIVER DISEASES?**
AutoImmuneHepatitis (**AIH**) - immune response directed agaisnt **HEPATOCYTES**
PrimaryBiliaryCholangitis (**PBC**) - immune against **SMALL** bile ducts
PrimarySclerosingCholangitis (**PSC**) - immune against **LARGE** bile ducts
124
What are the **COMMON** serologic markers for AutoimmuneLiverDisease (**ALD**)?
anti-Nuclear Ab (**ANA**), anti-Smooth Muscle Ab (**ASMA**) - **AIH**
anti-Mitochondrial Ab (**AMA**) - **PBC**
anti-Nuclear Cytoplasmic Ab (**ANCA**) - **PSC**
125
What does it mean when a patient has **POSITIVE** ASMA or AMA, or ANCA but no evidence of any liver disease?
It means that they ae **GENETICALLY** **PREDISPOSED** to AIH, or PBC or PSC but have not yet bee **TRIGGERED** to express the immune disease
126
What serological marker is **ELEVATED** in a patient with **AUTOIMMUNE LIVER DISEASE** and the higher it is the more rapid progreession to **CIRRHOSIS**?
**IgG** (levels correlate with histologic severity)
127
What are the liver injury patterns seen in AIH, PBC and PSC?
**AIH** - elevated **AST** and **ALT** (when severe, ALP can also be elevated) - **hepatocellular**
**PBC** - elevated **ALP** (when severe, AST and ALT can also be elevated) - **cholestatic**
**PSC** - elevated **AST**, **ALT** and **ALP** (**MIXED**)
128
What is **REQUIRED** **BEFORE** initiating **THERAPY** for all patients with **AIH** or **PBC**?
**LIVER BIOPSY**
129
Loss of liver function, Coagulopathy and Hepatic Encephalopathy are **ALL** indicative of what process?
Acute Liver Failure (**ALF**)
130
What is the **GREATEST RISK** of treating **ALF** with **IMMUNOSUPPRESSION**?
**INFECTION**
131
What are the indications to **NOT TREAT ALF** with immunosuppression (risk of infection) and proceed **DIRECTLY** to **TRANSPLANT** to avoid delay?
**HEPATIC ENCEPHALOPATHY** and **MELD \>25**
132
Patient with **CHRONIC AIH** (normal **LFTs**, **NO INFLAMMATION** on liver biopsy) with or without cryptogenic **CIRRHOSIS** get treated how?
**NO TREATMENT** necessary without inflammation on liver biopsy.
133
What MARKERS are positive in TYPE 1 AIH, TYPE 2 and 3?
TYPE 1 - **ANA**, **ASMA** - USA
TYPE 2 - **anti-LKM** (liver, Kidney, Microsomal) - Southern Europe - more agressive
TYPE 3 - **NO** POSITIVE **MARKERS**
134
Portal Tract Infmallation (**WITHOUT bile duct injury**), Interface Hepatitis, Piecemeal Necrosis, some Eosinophils and Lobular Inflammation are **ALL** histologic factors associated with what?
AutoImmuneHepatitis (**AIH**)
135
What is the **MAINSTAY** treatment of **AIH**?
**Prednisone** + **Azathioprine** (immunosupression)
136
At what **DOSE** of **PREDNISONE** should this **NOT** be tapered further until **LFTs** have **NORMALIZED**?
At **20 mg** (maintained at 5-10 mg for 6 months once LFTs are normal)
137
What can be used to treat patients with **AIH** if they do not **RESPOND** or **TOLERATE** Prednisone + Azathioprine?
**Cyclosporine**, **Tacrolimus** or **Mycophenolate Mofetil**
138
What can be used **INSTEAD** to **TREAT** **AIH** if a patient cannot tolerate prednisone?
**BUDESONIDE**
139
What is the **GREATEST RISK** for women who become **PREGNANT** while **CIRRHOTIC**?
**BLEED** from Esophageal **VARICES**
140
In pregant women with **AIH**, do **PREDNISONE** and **Azathioprine** need to be stopped?
**NO**
141
**Asymptomatic** or **PRURITUS** or **INTERMITTENT JAUNDICE** and associated with **HLA-DRW8**?
Primary Billiary Cholangitis (**PBC**)
142
What is observed with **PBC** in advanced disease that is similarly seen in Wilson's Disease?
Elevated **SERUM** and **URINARY** copper (causes renal disease)
143
**Xanthelasma** caused by **HYPERCHOLESTEROLEMIA** (without cardiovascular effect) is seen in which liver disease associated with **CHOLESTASIS** and treatment for the cholesterol is not necessary?
**PBC**
144
**PRURITUS** and **Osteoporosis** are the presenting complaints of this disease process?
**PBC**
145
What is the time at which patients with **PBC** should be considered for liver transplantation?
When **BILIRUBIN is \>10** (50% 2-year mortality risk)
146
What are the **TWO** available treatments for **PBC**?
**URSODEOXYCHOLIC ACID** and **OBETICHOLIC ACID**
147
In patients who cannot tolerate **URSO** for the treatment of **PRURITUS** in **PBC**, what else is available that works very well?
**RIFAMPIN** (Naltrexone and cholestyramine also can help)
148
Due to **CHOLESTASIS**, **ALL** patients with **PBC** should receive what supplements?
Vitamins **A**, **D** **E** and **K** as well as **CALCIUM + Vit D** and **ESTROGEN** (if post-menopausal) for osteoporosis
149
Which part of **HYPERCHOLESTEROLEMIA** is elevated in patients with **PBC** and thus does **NOT** require treatment?
**HDL**
150
Which is more prevalent in **FEMALES** and **MALES**, **PBC**, **PSC**?
**PBC** - **FEMALES** (95%)
**PSC** - **MALES** (75%)
151
Which **LIVER** disease process is **HIGHLY** associated with IBD (**Ulcerative Colitis**, much less Crohn's)?
**PSC**
152
**BEADED BILE DUCT** appearance, with multiple strictures with normal intervening segments of bile duct, BEST seen on **MRCP** (**cholangioscopy**) and is often **POSITIVE** for **ANCA** and **NEGATIVE** for **AMA**?
**PSC**
153
What test can cause **CHOLANGITIS** and should **NOT** be performed **DIAGNOSTICALLY** for a patient with **PSC**?
**ERCP**
154
What is the **SINGLE** highest risk factor for **CHOLANGIOCARCINOMA** (elevated CA 19-9 and CEA)?
**PSC**
155
What is the **ONLY** effective treatment for **PSC**?
**LIVER TRANSPLANTATION**
156
What should be done in elderly patients diagnosed with **MILD AIH** (low stage elastography, mild biopsy findings)?
**OBSERVATION** only (takes decades to advance), do **NOT** treat MILD AIH with DIABETES by giving prednisone and azathioprine is NOT used alone to INITIATE therapy
157
If **URSO** does not aleviate symptoms of **PBC** (pruritus, elevated ALP), what should be **ADDED**?
**OBETICHOLIC ACID**
158
Which **AUTOIMMUNE** disorders are **MOST** commonly seen with **PBC**?
**Sjogren's**, **RA**, **Thyroid Disease**
159
Which **AUTOIMMUNE** disorders are most commonly seen with **PSC**?
**ULCERATIVE COLITIS** and Crhon's
160
What is the **TYPICAL HISTOLOGY** noted in **AIH**?
**PIECEMEAL NECROSIS**
161
Why do patients with **PBC** have **HYPERCHOLESTEROLEMIA**?
Because **BILE** is the **ONLY** exit of cholesterol from the body
162
**Telangiectasias** and **Palmar Erythema** are what findings in **PREGNANT** women?
**NORMAL** and not indicative of liver disease
163
What is increasingly released by the placenta during **PREGNANCY** causing gradual elevation in this **LIVER** test serologically?
**ALP**
164
When is it safe to treat a **PREGNANT** mother for **HCV**? Her positive child?
**OLNY AFTER DELIVERY**
Once the child is **\>2 years old**
165
**VERY HIGH LFTs** but **NORMAL** to **LOW BILIRUBIN** in a **PREGNANT** mother?
**HSV** (treat with acyclovir)
166
Hepatic Venous Outflow Obstruction in a **PREGNANT** patient due to increased estrogens presenting with new onset **ASCITES**, **RUQ** pain and **HEPATOMEGALY**?
**Budd-Chiari** Syndrome
167
What **PARASITIC** disease worsens during **PREGNANCY** and can cause liver **ABSCESS**?
**Schistosomiasis**
168
What is the **RISK** to a **PREGNANT** woman with **CIRRHOSIS** for which she must be screened for?
Esophageal **VARICES**
169
What should be done in **PREGNANT** women being treated for **AIH** with prednisone and azathioprine?
**CONTINUE** treatment during pregnancy (small risk of cleft palate with prednisode)
170
How is **Wilson's Disease** treated during **PREGNANCY**?
With **ZINC** or **PENICILLAMINE** chelation
171
What should be done with increasing hepatic **ADENOMAS**, Focal Nodular Hyperplasia (**FNH**) and **HEMANGIOMAS** during pregnancy?
**Monitored** with **US** (to avoid rupture)
172
Intrahepatic Cholestasis of Pregnancy (40-60% chance of recurrence with subsequent pregnancies) is treated how?
**UCDA** (rpruritus) + **Vitamin K**
173
Nulliparity, Maternal Age \>40, Family Histroy of Pregnancy Induced HTN, CRF and DM are all **RISK** factors for what condition of pregnancy?
**Pre-Eclampsia** (HTN, proteinuria, edema, elevated LFTs, thrombocytopenia) - when seizures and coma present, it's ECLAMPISA
174
This condition in **PREGNANCY** occurs **BEFORE DELIVERY**, manifests with **HEMOLYSIS** (elevated LDH), elevated **LFTs**, and **LOW PLATELETS**?
**HELLP** Syndrome (treatment is **SUPPORTIVE**)
175
Thic **COMPLICATION** can occur during **PRE-ECLAMPSIA**, **ECLAMPSIA** and **HELLP** **SYNDROME** and presents with **SUDDEN** abdominal pain and **MARKEDLY** elevated **LFTs** (3,000-6,000) with **FEVER** and **ANEMIA**?
Hepatic **INFARCTION** and **RUPTURE** (fluids, treat shock, surgery)
176
This liver condition is associated with **PRE-ECLAMPSIA** and occurs in the **THIRD TRIMESTER**, elevated **AST/ALT** and **WBCs**, elevated **BILIRUBIN**, **HYPOGLYCEMIA**, **RENAL INSUFFICIENCY**, **COAGULOPATHY** with nausea and vomiting, abdominal pain?
Acute Fatty Liver of Pregnancy (**AFLP**) - microvesicular steatosis
177
HTN, Renal Failure, Edema, Increase in Body Weight, Blurry Vision, N/V, RUQ Abdominal Pain, Shock in **THIRD TRIMESTER**?
**PRE-ECLAMPSIA**
178
In Acute **CHOLESTASIS** of **PREGNANCY**, what serologic marker determines **WORSE** **OUTCOMES** (fetal morbidity)?
Serum **BILE ACIDS \>40µmol**
179
**Ground Glass Cells** are seen inside hepatocystes of patients with what liver disease?
**CHRONIC HBV**
180
**PATCHY NECROSIS** with **LITTLE INFLAMATION** and **VIRAL INCLUSIONS** are seen histologically in the liver biopises of which patients?
Those with **HSV**
181
Which are the **ONLY TWO** drugs that can be **SAFELY** (class B) used to treat **HBV** in a **PREGNANT** mother in her **THIRD TRIMESTER** to avoid vertical transmission?
**TENOFOVIR** and **TELBUVUDINE**
182
Which medication **CANNOT** be used safely in pregnancy to treat **HBV**?
**ENTECAVIR**
183
**PRE-ECLAMPISA** is associated with what comlication of pregnancy?
**ABRUPTIO PLACENTA** (also HELLP, infactrion, rupture)
184
Nausea, Jaundice, Abdominal Pain, Renal Failure (**THIRD TRIMESTER**)?
**AFLP**
185
Abdominal Pain, HTN, Edema, Proteinuria (**THIRD TRIMESTER**)?
**HELLP**
186
Increased **ALP** and **GGT** in **PREGNANCY**?
**Gallstones**
187
Increased **ALP** but **NORMAL GGT** in **PREGNANCY**?
Acute **CHOLESTASIS** of Pregnancy (UDCA + Vit K)
188
A significant proprotion of **ASIAN** people lack this enzyme for processing of **ALCOHOL**?
**ALDEHYDE DEHYDROGENASE**
189
How does **ALCOHOL** increase the risk of **LIVER TOXICITY** with use of **ACETAMINOPHEN**?
It **DEPLETES GLUTATHIONE** and upregulates **CYTP450** (more repid conversion of acetaminophen into toxic compound in PHASE-I)
190
**Macrovesicular Steatosis**, **NO INFLAMMATION** or **FIBROSIS**, may or may not have **ABDOINAL PAIN**?
**ALCOHOLIC FATTY LIVER**
191
**ANOREXIA**, **FEVER**, **JAUNDICE**, **HEPATOMEGALY**, **MALAISE** in alcoholic liver disease?
**ALCOHOLIC STEATOHEPATITIS** (balooning degeneration, Mallory Bodies, fibrosis, necrosis)
192
When there is the presence of **REGENERATIVE NODULES** in the histology of alcoholic liver disease this usually means what?
**CIRRHOSIS**
193
What **MEDICATIONS** can be used to treat moderate to severe **ALCOHOLIC STEATOHEPATITIS**?
**CORTICOSTEROIDS** or **PENTOXYFILLINE** (MADDREY discriminant function) - **EXCLUDE** infection or active **GIB** prior to treating
194
4.6 X [(PT-control) + total bilirubin] if \>32, adde corticosteroids
Maddrey Discriminant Function
195
**MACROVESICULAR** steatosis, **MALLORY** bodies, **BALOONING** degeneration, **NECROSIS** and **FIBROSIS**?
**NASH**
196
Central **OBESITY**, **DM**, **HTN** and **HYPERLIPIDEMIA** constitute what important connection to **NAFLD**?
**METABOLIC** Syndrome
197
What are **SECONDARY** causes of **STEATOHEPATITIS** aside from **ALCOHOL**, **MEDS** and **DISEASES**?
**JEJUNO-ILEAL BYPASS**, **TPN**
198
The **HETEROZYGOUS MZ** Phenotype of **apha-1 antitrypsin**, **ANA**, **ASMA** and **CRP** are all elevated in this disease process of the **LIVER**?
**NASH**
199
What is found on **LIVER US** in a patient with **NASH**?
**HEPATOMEGALY** and **HYPERECHOIC** liver
200
What do you HAVE to use to distinguish **FATTY LIVER** from **NASH** and from **CIRRHOSIS**?
Liver **BIOPSY**, no radiologic study can do this
201
What are the **MEDICATIONS** used to treat **NASH, ONLY when DM-2 is ALSO PRESENT** when **DIET** and **EXERCISE** are not sufficient and **BARIATRIC SURGERY** is not yet recommended?
**Thiazolidinediones** (TZD) "**GLITAZONE**" (rosiglitazone, pioglitazone) - this CLASS of meds causes **WEIGHT GAIN** but treats NASH
202
If a patient is treated with **CORTICOSTEROIDS** for elevated **MDF** (\>32) and after several days does not respond with **INCREASE in MDF**, what do you do?
**STOP STEROIDS** (adding pentoxyfiline does **NOTHING**) - pt **NOT** likely to respond (**Lille Score** **\>0.45**)
203
In **ALCOHOLIC** patient with abdominal **PAIN** where **AST:ALT NOT \>2** and **AST/ALT \>300-400**, what else should be considered and tested for?
**ACETAMINOPHEN TOXICITY**
204
Amiodarone, Methotrexate, Diltiazem, Corticosteroids, Tamoxifen, HAART can all cause what liver condition?
**MACROVESICULAR** Fatty Liver Infiltration (**NAFLD**, NOT NASH)
205
Valproate, Rye's Syndrome, Antivirals, HELLP, can all cause what liver condition?
**MICROVESICULAR** Fatty Liver Infiltration (**NAFLD**, not NASH)
206
How **MUST** alcoholic hepatitis be treated besides **CORTICOSTEROIDS** (if doesn't tolerate due to infection or GIB, use **PENTOXYFILLINE**) depending on MDF?
**Nutrition**, Adequate Protein, **THIAMINE**, **GLUCOSE**, Vit K, Electrolytes
207
What is considered **SIRS** in patient with Alcoholic Hepatitis?
**HR** \>100, **TEMP** \<36C or \>38C, **RR** \>12, **WBC** \>12
208
What constitutes **TREATMENT** of **ACUTE ALCOHOLIC HEPATITIS** besides **MDF**?
**MELD \>20**, Hepatic **ENCEPHALOPATHY**
209
Elevated **ANA** and **FERRITIN** are seen in this fatty liver disease?
**NAFLD** (weight loss, Vit E)
210
**HFE** gene with mutations at the **C282Y** or **H63D** are linked to what hereditary disease?
**Hereditary Hemochromatosis**
211
Thalassemia, Sideroblastic Anemia, Cirrhosis and Alcoholism can all result in this condition?
**Secondary Iron Overload**
212
People of **NORTHERN EUROPEAN** descent (Spain, etc.) are at **HIGH PREVALENCE** for this generic liver disease?
**Hereditary Hemochromatosis**
213
Abdominal pain, Hepatomegaly, Cirrhosis, Fatigue, Impotence, Diabetes, Cardiomyopathy and Arthralgias are all seen in this disease process of the liver?
**Hemochromatosis** due to **IRON DEPOSITION**
214
What **MUST** be done once **SERUM TESTS** suggest **Hemochromatosis** (TS \>45%, Ferritn \>200, TIBC)?
**LIVER BIOPSY** or quantitative **PHLEBOTOMY**
215
What are the **SCREENING TESTS** for hemochromatosis?
Serum **Transferrin**-Iron Saturation (TS \>45%), **Ferritin**, Unsaturated **Iron Binding Capacity**
216
**Serum Iron/TIBC = TS** (transferrin saturation) if this is **\>45%**, what is the likely diagnosis?
**IRON OVERLOAD**
217
Which **HOMOZYGOUS** or **HETEROZYGOUS** for the **C282Y HFE** mutation, will develop **Hemochromatosis**?
**HOMOZYGOUS** (heterozygous only if with other liver disease such as HCV, ALD) **COMPOUND** **HETEROZYGOUS** for **C282Y/H63D** also can
218
What are the two **END-DISEASE** processes in **Hereditary Hemochromatosis** which lead to **MORTALITY**?
**CIRRHOSIS** and **Hepatocellular Carcinoma**
219
How is **Hereditary Hemochromatosis** and **IRON OVERLOAD** treated?
**PHLEBOTOMY** (Weekly and until development of **MILD ANEMIA** with ferrtin \<50)
220
Which **VITAMIN** supplement must patients with **HEMOCHROMATOSIS/IRON OVERLOAD** avoid?
**VITAMIN C**
221
In **WHICH** individuals should there be **SCREENING** for **HEMOCHROMATOSIS**?
**Family Members** of those with **HEMOCHROMATOSIS**, those with **ABNORMAL LFTs** and those with end-organ damage (**DM**, **Cardiomyopathy**, **Pituitary Disfunction** and **Arthropathy**)
222
This A**UTOSOMAL RECESSIVE** genetic disease causes progressive **CIRRHOSIS** in adults and **LUNG DAMAGE** through **EMPHYSEMA**?
**alpha-1-antitrypsin deficiency** (homozygous for the PiZZ allele)
223
What is **POSITIVE** on the liver **BIOPSY** of patients with alpha-1-antitrypsin deficiency?
**PAS+** diastase resistent **globules** within hepatocytes
224
What does **PERSISTENT JAUNDICE** in the **NEWBORN** suggest?
**alpha-1-antitrypsin deficiency** (homozygous)
225
What is the **ONLY** treatment for alpha-1-antitrypsin deficiency?
Orthotopic **LIVER TRANSPLANTATION**
226
Autosomal **Recessive**, **Chromosome 13**, Billiary Excretion of this compound is affeted, product is accumulated in the **LIVER**, **BRAIN**, **CORNEA**, kidneys, joints, heart and pancreas?
**Wilson's Disease** (Kayser-Fleischer Rings)
227
Pt's present between the ages of **10 to 22**, almost **NEVER \>40** and with **LIVER** or **NEUROLOGICAL** symptoms?
**Wilson's Disease**
228
COOMB'S NEGATIVE HEMOLYTIC ANEMIA, LOW ALP, HIGH BILIRUBIN, progressive RENAL FAILURE, AST\>ALT, DEPRESSION, MOOD DISORDERS, PERSONALITY CHANGES, TREMMORS, PARKISON'S-LIKE features?
**Wilson's Disease**
229
How do you **diagnose** **WILSON'S** DISEASE?
**SLIT-LAMP** examination (**Kayser-Fleischer** Rings and **Sunflower** Cataracts) and serum **CERULOPLASMIN** (\<20) levels
230
In which patients is **SCREENING** for **WILSON'S** disease appropriate?
**ONLY** in **1st DEGREE** relatives of those affected
231
What is the **TREATMENT** for **WILSON'S** disease?
**CHELATION** with **PENICILLAMINE** (with **PYRIDOXINE** supplementation) or **TRIENTINE** as well as **ZINC** and **LOW-COPPER diets** (avoid shellfish, chocolate, nuts and liver)
232
What should be used **INSTEAD** of **PENICILLAMINE** in patient's with **WILSON'S** disease and **NEUROPHYCHOLOGICAL** symtoms as these may worsen?
**TRIENTINE** (also a copper chelator)
233
This compound **PREVENTS** copper **ABSORPTION** from the intestine and promotes **FECAL** **EXCRETION**?
**ZINC**
234
What is considered **CURATIVE** in **WILSON'S** disease?
**LIVER TRANSPLANTATION**
235
**FOCAL BILIARY CIRRHOSIS**, **FATTY LIVER**, **PIGMENTED GALLSTONES**, Diarrhea, Pancreatitis, Hearing Loss, Short Stature, Chromosones 18, 2 and 7?
**CYSTIC FIBROSIS**
236
Which **PROTEIN** does **HEPCIDIN** regulate in liver iron storage?
**FERROPORTIN**
237
In a patient with **AST:ALT \>1.5-2**, as well as **ELEVATED FERRITIN**, what would be the diagnosis if they were found to be **HFE NEGATIVE**?
**ALCOHOLIC LIVER DISEASE**
238
Of **CIRRHOSIS**, **ARTHROPATHY**, **HYPOGONADISM**, **DM** which can be **IMPROVED** with **PHLEBOTOMY** in a patient with **HEMOCHROMATOSIS** or **IRON OVERLOAD?**
**DIABETES MELLITUS** only
239
Which **GENOTYPE** is associated with **MILD** a**lpha-1-antitrypsin defficiency** with a **level \>40** and a serrum **ferritin \<1,000?**
**PiMZ** (vs PiZZ in which alpha-1-antitrypsin is \<40 and ferritin \>1,000)
240
What are the **SEROLOGICAL** tests to perform in a patient with **SUGGESTED WILSON'S** disease in an **ASYMPTOMATIC** patient with a **NORMAL** physical exam?
**24-HOUR URINE** for TOTAL **COPPER** CONTENT (\>100 µg/24 hours); **TOTAL** **SERUM** **COPPER** (\>80 µg/dL); **INCREASED SERUM FREE-COPPER** (\>200 µg/dL)
241
Patient with Hemochromatosis is \>40 yo, has Thrombocytopenia (\<200,000), Ferritin \>1,000, elevated LFTs, Hepatomegaly, what should be done **NEXT**?
**LIVER BIOPSY** (determine if there is **CIRRHOSIS**)
242
Is **FERRITIN** elevated only in Hemochromatosis and Iron Overload?
**NO**! It is an **ACUTE PHASE REACTANT** and is elevated in many scenarios. ONLY biopsy liver if ALT is elevated and so is TS (transferrin saturation)
243
**FANCONI** syndrome (GLYCOSuria, AMINOACIDuria, URICOSuria, HYPORURICemia, HYPERCALCIuria, PHOSPHATuria) is associated with this **GENETIC LIVER DISEASE**?
**WILSON'S** disease
244
What tests should be performed on patients with **NEW**-**ONSET** **ASCITES**?
Diagnotic **PARACENTESIS** and **ULTRASOUND** with Doppler
245
What should the **NEW**-**ONSET** **ASCITES** be sent for in a diagnostic **PARACENTESIS**?
**TOTAL PROTEIN** (VERY LOW **\<1 g/dL in cirrhosis** and HIGH in heart failure, etc.); **ALBUMIN** (SAAG \>1.1 g/dL is suggestive of ascites due to portal HTN i.e. cirrhosis); **CELL COUNT** (PMN \>250 - SBP), high RBCs may mean malignancy or bleed, leukocyts possible tuberculosis; **CULTURE**; **TRIGYCERIDES** (elevated in chylous ascites as in lymphoma); **CYTOLOGY** (malignancy); **AMYLASE** (pancreatitis with duct leak) - NO NEED for pH, lactate, LDH or glucose
246
When do you **RESTRICT** fluids in **ASCITES**?
**ONLY** if there is **HYPONATREMIA**
247
If a patient using **SPIRONOLACTONE** for ascites control and develops **GYNECOMASTIA**, what diuretic can be used instead?
**AMILORIDE**
248
What can be done for **REFRACTORY ASCITES** (poor response to therapy, adverse reaction to therapy, low GFR, hyponatremia)?
**TIPS**
249
Liver Faiure (high MELD \>18-20), Elevated Bilirubin (3-5), Elevated INR (\>2.5), Hepatic Encephalopathy, CHF, Pulmnary HTN are all **CONTRAINDICATIONS** for this method of **ASCITES** management?
**TIPS**
250
What can be done for patients with a **SHORT LIFE EXPECTANCY** (palliative) that are **NOT TIPS** candidates and have **REFRACTORY ASCITES**?
Peritoneal Venous shunt (**PV** shunt)
251
252
A patient with **CIRRHOSIS** and **ASCITES** presents with abdominal **PAIN**, **FEVER** and **ENCEPHALOPATHY**. What is the likely scenario?
Spontaneous Bacterial Peritonitis (**SBP**)
253
**ASCITES** with very **HIGH PMNs**, **LDH**, **Alk Phos**, **CEA**, high **ANAEROBES** suggests what type of **SBP**?
**SECONDARY** (PUD, perforated diverticulitis)
254
What is the **COMPLETE** treatment of **SBP**?
**5 DAYS** of **IV CEPHALOSPORIN** followed by **PO ANTIBIOTICS** to complete **7-10 day** course followed by **INDEFINITE DAILY PROPHYLAXIS** (fluoroquinolone or TMP/SMX) if LOW total protein (\<1.5), BUN \>30 and HYPOnatremia
255
What is part of the treatment for **SBP** that **PREVENTS HEPATORENAL SYNDROME** and should be administered within **6 HOURS** of presentation?
IV **ALBUMIN**
256
Which **CIRRHOTIC** patients should **NEVER** be treated with non-selective **ß-BLOCKERS**?
Those with **HEPATORENAL SYNDROME** or **HYPOtension**
257
What can **OCCUR** in patients with **CIRRHOSIS** and **ASCITES** if the have **DIAPHRAGMATIC BLEBS**?
**HEPATIC** **HYDROTHORAX** - treat with Pleuro-Venous Shunt (if infected, Spontaneous Bacterial Empyema)
258
Microscopic examination of **URINE** in patients with **CIRRHOSIS** shows **CELL** **DEBRIS** and spot urine **SODIUM** is **HIGH**?
**ATN** (Acute Tubular Necrosis) - cannot CONCENTRATE urine
259
Microscopic examination of **URINE** in patients with **CIRRHOSIS** shows **CLEAN URINE** and spot urine **SODIUM** is **LOW**?
**HRS** with **Pre-Renal Azotemia**
260
**LOW GFR** (**\<20 mL/min**), **Cr \>2.5**, **Oliguria**, **LOW** urine **SODIUM** and no improvement with IVF challenge
**HRS**
261
What is the **CURE** for **HRS**?
**PROMPT LIVER TRANSPLANT**
262
What is the **TREATMENT** for **HRS**?
**MIDODRINE**, **OCTREOTIDE**, **IV ALBUMIN** and **TERLIPRESSIN** (can reverse HRS)
263
What **MEDICATIONS** should **NEVER** be given to patients with **CIRRHOSIS** and **ASCITES**?
**NSAIDs** and AMINOGLYCOSIDES (-**mycin**)
264
What is a **POOR** prognostic marker in a patient with **CIRRHOSIS**?
**HYPOnatremia** (Na \<130) (exacerbates hepatic encephalopathy, reduce or STOP diuretics in these patients)
265
What should be done **AFTER** endoscopy confirms **ESOPHAGEAL**, **GASTRIC VARICES** or Portal Hypertensive Gastropathy (**PHG**)?
Doppler **US** to look for **Portal Vein Thrombosis** or **Hepatic Vein Thrombosis**
266
When obtaining a **Trans-Jugular LIVER BIOPSY**, what can be **MEASURED** and what constitures **PORTAL HTN**?
Hepatic Venous Pressure Gradient (5-**12 mm Hg** GRADIENT is positive for **PHTN** and high rish for **VARICES**)
267
How **OFTEN** should **EGD** be performed in patients with **ACTIVE CIRRHOSIS** (Hep C, EtOH, etc.) and in patients with **INACTIVE CIRRHOSIS** (cured Hep C)?
Every **2 YEARS** for **ACTIVE** and **3 YEARS** for **INACTIVE**; If **SMALL** **VARICES** are prenset, then its every 1 YEAR (active) and every 2 YEARS (inactive)
268
What patients with esophageal **VARICES** should receive **PP** (Primary Prophylaxis - treatment **BEFORE** any bleeding has occurred)?
Those with **GRADE \>2** esophageal **VARICES** (non-selective **ß-BLOCKER** **OR** variceal **BANDING** but **NEVER BOTH**)
269
270
Once **PP** (Primary Prophylaxis) has been initiated with a **ß-BLOCKER** (HR 50-60 bpm), how often do you repeat **EGD** for surveillance?
You **DON'T**, can stop
271
Once **PP** (Primary Prophylaxis) has been initiated with **Esophageal Varix Band Ligation**, how often do you repeat **EGD** for surveillance?
Every **1-2 WEEKS** until varices are **GONE**
272
What should be done **PRE-TREATMENT** of **BLEEDING** esophageal **VARICES**?
**TRANSFUSION** (\<7 Hb), **ANTIBIOTICS**, IV **OCTREOTIDE**, endotracheal **INTUBATION**
273
What can be done for **BLEEDING** esophageal **VARICES** if there is **FAILURE** of **BOTH** endoscopic and medical managemen and **RECURRENT** **BLEED** in spite of treatment, **REGARDLESS** of presence of hepatic encephalopathy or high MELD?
**TIPS**
274
Which are the MOST COMMON types of gastric varices and what is the treatment?
**GOV1** (in continuity with esophagus and lesser curvature) - **BANDING** (GOV2 are same but with greater curvature; IGV1 - rule out spelnic vein thrombosis - are in the fundus, and IGV2 in the antrum, neither in continuity with the esophagus)
275
What can cause **SPLENIC VEIN THROMBOSIS** and what **GASTRIC VARIX TYPE** is associated with this?
**PANCREATITIS** or Pancreatic **CANCER**, **IGV1** (**fundus**)
276
What is the treatment for **SPLENIC VEIN THROMBOSIS** and what is the **TESTING** modality?
**SPLENECTOMY**, **CT/MRI**
277
What is the **EMERGENCY** treatment of **CHOICE** (if glue with coils not available) for **IGV2** or **GOV**?
**TIPS**
278
What are the treatments of choice for **BLEEDING** from Portal Hypertensive Gastropathy (**PHG**)?
IV **OCTREOTIDE** and **APC**
279
Which **MEDICATIONS** can cause **Hepatic Encephalopathy** in patients with **CIRRHOSIS**?
**benzodiaAZEPINES** (-azepam, -zolam)
280
Hepatic Venous Portal Gradient (**HVCG** normal is \<5 mmHg) is the difference between?
Wedged Hepatic Venous Pressure (**WHVP**) - Free Hepatic Venous Pressure (**FHVP**)
- **NORMAL WHVP** (**\<5 mmHg**) is slightly higher than FHVP (same as IVC and RIGHT atrial pressure)
- **HVPG 5-10 mmHg** is **PORTAL** **HTN**
**HVPG \>12 mmHg** indicates **VARICES** with risk for **BLEED**
PRE-SINUSOIDAL (BOTH WHVP & FHVP are low, HVPG is normal)
SINUSOIDAL (WHVP is HIGH, FHVP is normal and HVPG is HIGH)
POST-SINUSOIDAL (BOTH WHVP & FHVP are HIGH and thus HVPG is normal)
281
In a patient on a non-selevtive **ß-BLOCKER** with **LOW BP** and rising **CREATININE** and **FALLING SERUM ALBUMIN**, what should be done **NEXT**?
**STOP** the **ß-BLOCKER** (to improve renal perfusion)
282
The **ABSENCE** of **N/V**, **HEPATIC ENCEPHALOPATHY, SHOCK** and **KIDNEY** **INJURY** is suggestive that **SBP** can be treated how?
On an **OUTPATIENT** basis
283
In BOTH RIGHT HEART FAILURE and Budd-Chiari ASCITES is the expected result NOT VARICEAL BLEEDS, why?
They cause POST-Hepatic PORTAL HTN (both the WHVP and FHVP wou;d be elevated and thus HVPG would be normal)
284
What would the **WEDGE** pressure (**WHVP** - wedged hepatic venous pressure) be in a patient with **ALCOHOLIC CIRRHOSIS**?
**ELEVATED** (because the damage is **HEPATIC**, ie at the **sinusoidal** level)
285
In what condition causing **CHYLOUS** **ASCITES** (high trigltcerides in ascitic fluid can also occurr in alcoholic cirrhosis) is the **SAAG LOW** and the **PROTEIN HIGH**?
**LYMPHOMA**
286
In a patient with **CIRRHOSIS** with **ACITES** and **SBP**, if the Cr and Albumin begin to approach **HRS** levels, what should be done to treat **FIRST** besides **LVP**?
**IV ALBUMIN** (BEFORE starting midodrine and octreotide)
287
What is the **URINE OUTPUT** goal on **DIURETICS** for **ASCITES** and when should **DIURETICS** be **STOPPED**?
Urnine putput **500 mL -1 L more per day**
If **Cr \>1.5** or **low BP** and **low HR**
DO NOT USE ß-BLOCKERS in COPD patients
288
What should be **AVOIDED** when treating **SBP** in a patient with **CIRRHOSIS** with **ASCITES**?
**LVP**, **IV CONTRAST** studies and **AGRESSIVE DIURESIS**
289
**RENAL FAILURE** in patients with **LIVER** **FAILURE** associated with **LOW URINE SODIUM** (\<20) in the **ABSENCE** of renal pathology and in spite of **VOLUME REPLETION**?
**HRS**
290
Median **SURVIVAL** is **2 WEEKS**, **RAPIDLY** progressing **RENAL FAILURE**, **DOUBLING** of **SERUM Cr** (**\>2.5**) in **\<2 WEEKS**?
**HRS-I**
291
Median **SURVIVAL** is **6 MONTHS**, **SLOW** and **CHRONIC** progressing **RENAL FAILURE**, and **SERUM Cr** (**\>1.5**)?
**HRS-II**
292
What **MAP** in **HRS** is associated with **IMPROVED SURVIVAL**?
**\>82 mmHg** (Midodrine, Octreotide, Norepinephrine)
293
In a patient with **ACTIVE CIRRHOSIS** (continued alcohol, untreated HCV, etc.) and **small**, **grade-1** esophageal **VARICES**, **WHEN** do you repeat surveillance?
Every **1-YEAR**
294
**WHEN** should **EGD** be performed for **BLEEDING** esophageal **VARICES** or **GOV-1/2**?
**WITHIN 12 HOURS**
295
Are **PPIs** recommended **LONG-TERM** (beyond the 10-14 days post treatment) for **VARICEAL** **BLEED**?
**NO**
296
What is the **DANGER** when **SERUM AMMONIA** levels are **\>200**?
**CEREBRAL EDEMA**
297
Why is the **CAUDATE** **LOBE** of the liver enlarged in **BUDD-CHIARI** syndrome?
Because it surrounds the **VENA CAVA** and drains **DIRECTLY** into the **IVC** via small perforating veins
298
What agent **REGULATES** blood flow to the hepatic lobule and adjusts it depending on variations of **PORTAL** and **ARTERIAL BLOOD FLOW**?
**ADENOSINE** (constantly secreted into the liver)
299
What is indicated for **TREATMENT** when **PVT** is **ACUTE**, **SYMPTOMATIC** (nausea, RUQ or diffuse abdominal pain from bowel congestion), **PROGRESSIVE** toward **SMV** and occurs in the **ABSENCE** of **CIRRHOSIS** and **NO GIB**?
**ANTICOAGULATION** for **6 MONTHS** (do not used in cirrhosis Child classes B and C) if hypercoagulable state, anticoagulation is life-long
300
What hepatic **VASCULAR** issue can **PANCREATITIS**, **INFECTION**, liver **ABSCESS**, **CHOLANGITIS**, and **CHOLECYSTITIS** cause?
Portal Vein Thrombosis (**PVT**)
301
In the **ABSENCE** of **CIRRHOSIS**, what are the most **COMMON** causes of **PVT**?
**MYELOPROLIFERATIVE** disorders (**JAK-2** mutations), Factor V Leiden, Antiphospholipid Syndrome, Antithrombin III deficiency, Protein C and S deficiency, and Paroxysmal Nocturnal Hemoglobinuria (PNH) - CD 55 and CD 59 flow cytometry
302
What causes **CAVERNOUS TRANSFORMATION** (collaterals) of the **PORTAL** **VEIN**?
**CHRONIC PVT** (post-partum infection of the ubilical vein, etc.)
303
Should patients with **PVT** due to **HCC** be anticoagulated?
**NO**
304
A syndrome caused by **CHEMOTHERAPY** (platinic drugs, myeloablative therapy) wherein **THROMBI** obstruct the **CENTRAL** **HEPATIC** **VENULES**?
Sinusoidal Obstructive Syndrome (**SOS**)
305
What is recommended as **PROPHYLAXIS** to avoid Sinusoidal Obstructive Syndrome (**SOS**) when undergoing **CHEMOTHERAPY**?
**URSODIOL**
306
This is NOT cirrhosis but may look that way on imaging, it is caused by **VASCULAR** **INJURY** (**VASCULITIS**) and can cause **PRE-SINUSOIDAL PORTAL HTN**?
Nodular Regenerative Hyperplasia (**NRH**)
307
If **WITHIN 20 DAYS** of **CHEMOTHERAPY** or **BONE MARROW TRANSPLANT**, a patient develops total **BILIRUBIN \>2**, **HEPATOMEGALY**, **WEIGHT GAIN**, what has occurred?
Sinusoidal Obstructive Syndrome (**SOS**)
308
What can be done to treat **ACUTE HEPATIC VEIN THROMBOIS** causing liver dysfunction and ascites?
**ANGIOGRAPHY** with **BALLOON DILATION**, **TIPS**
309
What **CARDIOPULMONARY** conditions can cause **CIRRHOSIS** with **ASCITES**?
**RIGHT HEART** failure (tricuspid regurgitation), **PULMONARY HTN**
310
What **LIVER** injury is required for **ASCITES** to form?
**SINUSOIDAL** HTN
311
What are some examples of Extrahepatic Portal Vein Obsruction (**EHPVO** - non-cirrhotic, no ascites but positive **VARICES**)?
Umbilical Vein Thrombosis, **HCC**, **Pancreatitis**, **Abdominal Trauma**, **ARSENIC**, **VINYL CHLORIDE**, **SCHISTOSOMIASIS**
312
**Acute Mesenteric Thrombosis** (such as in extention of PVT) is treated how?
**SURGERY**, cannot use anticoagulants due to HIGH risk of bleed
313
What are the **CONTRAINDICATIONS** to **TACE** (tansarterial chemoembolization used for HCC)?
**PVT**, **CAVERNOUS** transformation of the portal vein
314
**SHOCK LIVER** (acute hepatic artery hypoperfusion) can recover, however in the setting of what other conditions, can this cause **ACUTE LIVER FAILURE**?
**PVT**, **CIRRHOSIS** (dual blood supply is compromised)
315
What is the prognosis of **SHOCK LIVER** if after restoration of blood flow and pressure, the **LFTs** and **INR** remain elevated and don't normalize?
**POOR PROGNOSIS**, **HIGH MORTALITY RISK**
316
What should be done with a **COMPLEX** **CYST** in the liver?
**RESECT** (15% can become malignant from biliary cystadenomas)
317
What should be suspected if a hemangioma undergoes interval increase in size?
**HEMANGIOSARCOMA**
318
What **HEPATIC LESION** is associated with **ORAL CONTRACEPTIVE** use?
Hepatic **ADENOMA**
319
What should be done for surveillance for those with **CIRRHOSIS** and those withoiut cirrhosis but with **Hep B**?
Liver **US** and **AFP** every **6-12 months**
320
**\>2 cm** lesion in a **CIRRHOTIC LIVER** with **ARTERIAL ENHAMCEMENT** on **MRI** (derives blood supply ONLY from hepatic artery) and with **EARLY WASHOUT** (no blood supply for portal vein) is what?
**HCC** (no biopsy needed unless those characteristics are absent)
321
A **SOLITARY** lesion **\<6.5 cm** OR **≤3 NODULES**, the largest of which **\<4.5 cm** OR total tumor diameter **\<8.5 cm WITHOUT** vascular invasion
322
Which patients are candidates for **HCC** **SURGERY**?
**Child** Class **A** Cirrhosis, **NO Portal HTN**, **No Metastatic disease**
323
Onset of **HEPATIC ENCEPHALOPATHY** within **8 WEEKS** of onset of **JAUNDICE** in a patient without previously known liver disease?
Acute Liver Failure (**ALF**)
324
**ACIDOSIS** (**pH \<7.30**), severe **COAGULOPATHY** (**PT \>100**), **RENAL FAILURE** (**Cr \>3.4**) and **HIGH-GRADE HEPATIC ENCEPHALOPATHY** indicate the requirement for what?
**LIVER TRANSPLANT**
325
A patient with **PHTN** and **HYPOXEMIA** (positional dyspnea, cyanosis, clubbing), **PaO2 \<60 mmHg** and **NORMAL** **CXR** and **SPIROMETRY**, **CONTRAST-ECHO** with **BUBBLES** in **LEFT** **HEART** is confirmatory?
Hepato-Pulmonary Syndrome (**HPS**)
326
How is Hepato-Pulmonary Syndrome (**HPS**) treated?
Supplemental **O2** and **LIVER TRANSPLANT**
327
**Pulmonary** **HTN** with a **NORMAL PCWP** in a patient with **PHTN** - **ECHO** with **RIGHT** heart enlargement?
Pulmonary-Portal HTN (**PPH**)
328
When is **ACUTE CELLULAR REJECTION** of a **TRANSPLANTED** liver the greatest?
The **FIRST 6 MONTHS** post-op (diagnose by **BIOPSY** - lymphocyte inflammation in portal areas, bile duct injury, central venulitis)
329
What is the most **COMMON** cause of **POST-TRANSPLANT DEATH** in patients post liver transplant (first **30 DAYS**)?
Bacterial and Fungal **INFECTIONS**
330
If Acute Cellular Rejection of a transplanted liver doens **NOT RESPOND** to increase in **STEROIDS** or increased **IMMUNOSUPPRESSION**, what can be done besides re-transplant for **SEVERE** acute rejection?
**ANTI-THYMOCYTE GLOBULIN**
331
**PROGRESSIVE CHOLESTASIS** years after liver transplant is due to?
**CHRONIC REJECTION**
332
What is the **MAJOR** cause of **RENAL FAILURE** (acute or chronic) after liver transplant?
The **CALCINEURIN INHIBITORS** (cyclosporin, tactrolimus)
333
How **OFTEN** should a patient who received a **LIVER TRANSPLANT** for **PSC** be screened with a **COLONOSCOPY**?
**YEARLY**
334
What are the most **COMMON** malignancies that occurr post liver **TRANSPLANT**?
**SKIN** cancers, **COLON** cancer, **LYMPHOMA** (EBV)
335
What is given to **HBV** patients who receive liver transplants to prevent reinfection?
**HBIgG** and possibly entecavir or tenofovir
336
In a patient with CIRRHOSIS and ASCITES with HIGH AFP, what is the BEST way to exclude HCC?
**Tripple Phase CT** (better than MRI especially with ascites present)
337
In a patient with **KNOWN CIRRHOSIS** who presents with diuretic-refractory **ASCITES**, what must still be done?
EVEN if SAAG is \>1.1, if the TOTAL PROTEIN of the ascites is high, it is RIGHT HEART FAILURE that caused the ascites not the cirrhosis, and TIPS is contraindicated
338
In a patient with resolving **SHOCK LIVER**, bilirubin starts increasing and serum albumin decreasing, what could be happening when all the other LFTs are normalizing?
**PVT**, do **US**
339
340
When does the **BILIRUBIN** typically **PEAK** after the **LFTs** peak in **SHOCK LIVER**?
**3-5 DAYS after** (they lag)
341
A **NODULAR LIVER** on imaging in the **ABSENCE** of **CIRRHOSIS**, is what and what causes it?
**Nodular Regenerative Hyperplasia** (usually autoimmune **VASCULITIS**), check for PHTN (\>10 mmHg)
342
Sudden-onset abd pain and distention in a young patient, with ascites and hepatomegaly and **PVT**?
**Budd-Chiary** Syndrome (Rotterdam Class II) - treat with **ANTICOAGULATION** (if decompensation is present ie elevated LFTs, INR - do **TIPS** which is less invasive than surgical shunt)
343
**LESION** in the **LIVER** with a **CENTRAL SCAR** (MRI isointense T1, hyperintense T2)?
Focal Nodular Hyperplasia (FNH) - **NO TREATMENT NEEDED**
344
Most common causes of Portal Vein Thrombosis (**PVT**) are?
**Malignancy** (liver, cholangio, pancreas), **MYELOPROLIFERATIVE** disorder (hypercoagulable as well), **Cirrhosis**, **Infection**, **IBD**, **Surgery**, **Pancreatitis**
345
How do you treat **CHRONIC PVT** (cavernous transformation of the PV?
**DO NOT ANTICOAGULATE** unless **EXTENDS** to the **SMV**
346
Do you treat **PVT** secondary to **CANCER** with anticoagulation?
**NO!**
347
Compression of the **IVC** by the **CAUDATE LOBE** of the liver (which encircles the IVC) is called what?
**Budd-Chiari Syndrome** (acute abdominal pain, ascites, GIB, fever, encephalopathy) ASCITES protein just as high as with RIGHT heart falilure
348
Recurrent **EPISTAXIS** (**MOST COMMON**), also **GI**, **LUNGS**, **BRAIN**, **1st DEGREE RELATIVES**?
Hereditary Hemorrhagic Telangiectasias (**HHT**) - **Osler-Rendu-Weber** (shortness of breath, edema, ascites, PHTN, biliary cysts, cholangitis)
349
Reorganization of **NORMAL** hepatocytes into a **NODULE** caused by vascular injury such as in (**VASCULITIS**, **CHEMO**)
Nodular Regenerative Hyperplasia (**NRH**) - appears as a "mass" on imaging or **MANY NODULES** and **MIMIC CIRRHOSIS** (only on imaging and gradient, no fribrosis on biopsy)
350
Abdominal pain, randomly distributed **BLOOD FILLED CAVITIES** without endothelium caused by various cancers, infections (**BARTONELLA**), medications (**AZATHIOPRINE**, anabolic **STEROIDS**) and renal disease?
**PELIOSIS HEPATITIS**
351
**JAK-2 MUTATION** (myeloproliferative disorders) is **ASSOCIATED** with this **LIVER** issue that affects the **CAUDATE LOBE**?
**Budd-Chiary Syndrome**
352
How do you **TREAT** Budd-Chiary?
**ANTICOAGULATE** (PVT) and evaluate for **TIPS**
353
In a patient with abdominal pain and **ACUTE PVT,** without phlebitis and **WITHOUT** identifiable **HYPERCOAGULABLE** state, what is the treatment?
**ANTICOAGULATION** for **3 MONTHS** (if hypercoagulable state identified, **LIFELONG** anticoagulation)
354
**MRI** shows (**CENTRIPETAL ENHANCEMENT**) without high-output heart failure, what is this and how do you treat?
**HEMANGIOMA**, **NO TREATMENT** needed unless painful (then surgery)
355
**BENIGN** tumor, has **NO BILE DUCTS**, **RIGHT LOBE**, associated with oral **CONTRACEPTIVES**, risk of **HEMORRHAGE** and malignant degeneration with **SIZE**, treated by **STOPPING OCPs**, **OBSERVATION** and **SURGERY** as needed?
Hepatic **ADENOMA**
356
**ASIAN** male/female **HepB CARRIERS** (\>40/\>50), **AFRICAN**, **North American Blacks** with Hep B all need what?
**HCC** surveillance with **US** and **AFP** every **6 MONTHS** regardless of Hep B DNA levels
357
If **MRI** shows a **LIVER** lesion \>2 cm in a **CIRRHOTIC** liver, with **LATE ARTERIAL** **ENHANCEMENT** and **PORTAL VENOUS WASHOUT**, what is the diagnosis and what more is needed?
**HCC**, **NO BIOPSY** needed unless **MRI** features are not there
358
**HSV** with **AST/ALT \>1,000** with **ALF**, what do you do?
Evaluate for **LIVER TRANSPLANT**
359
At what **MELD** score should **LIVER TRANSPLANT** be considered?
**MELD ≥15**
360
Patient with **LIVER TRANSPLANT \<1 YEAR** presents with elevated **LFTs**, diffuse abdominal pain, **FEVER**, **NAUSEA**, **DIARRHEA**. What is the **MOST COMMON CAUSE**?
**CMV** (get PCR)
361
**Skin** Cancers, **Kaposi** Sarcoma, **EBV** Lymphoproliferative Disease, **COLON** CANCER (if PSC with UC), **Oropharyngeal** Cancers are all seen in these patients?
Post **LIVER TRANSPLANT** (due to meds)
**ANNUAL COLONOSCOPY** in liver transplant for pts with **PSC/UC**
362
When a **DISCREPANCY** exists between **ELASTOGRAPHY** and **FIBROSURE** (serum) regarding fibrosis and whether cirrhosis exists or not, what should be done next?
**LIVER BIOPSY**
363
It a patient is either **HBsurface-antigen POSITIVE** or **anti-HBcore POSITIVE**, what can occurr when treating **HCV** with **DAAs**?
**REACTIVATION** of **HBV**
364
In a patient who **FAILED** treatment for **HCV GENOTYPE 1a**, what must be tested for and how must they be treated?
Test for **NS5A** if previously treated with **elbasvir/grazoprevir** or any other **NS5A INHIBITOR**
365
If a patient is **HCV** positive and will be undergoing **DAA** therapy, and is on a **TRANSPLANT LIST** for an organ, what is to their **ADVANTAGE**?
If they are **CONSENTING** to receiving a **HCV** positive **ORGAN** donation (much faster!)
366
What is the **SINGLE**, most frequently identified **NSAID** associated with **DRUG-INDUCED** liver injury with **AUTOIMMUNE HEPATITIS PHENOTYPE** pattern (positive **ANA**)?
**DICLOFENAC**
367
What **MUST** be done for a patient who **DEVELOPS** elevated **LFTs** while on **AIH** therapy with **AZATHIOPRINE**?
**STOP** azathioprine and check for **TOXIC** metabolites **THIOGUANINE** and **6-MMP**
368
Pt s/p **\>1 year** **LIVER TRANSPLANT** who develops **PRURITUS** with elevated **ALP**, no symptoms, negative serologies and normal US?
**ANASTOMOTIC BILIARY STRICTURE**, do **ERCP** with stent
369
HEPATO-PULMONARY SYNDROME (**HPS**) with a **ROOM AIR PO2 \>60 mmHg**; PORTO-PULMONARY HTN (**PPH**) with a mean **PULMONARY ARTERY PRESSURE \>35 mmHg** affect **LIVER TRANSPLANT** how?
**CONTRAINDICATED**
370
ALT:AST \>2.2 and ALP:T.Bili \<4?
**100% SPECIFIC** for **WILSON's** disease
371
Besides acute **ALCOHOLIC HEPATITIS**, where else is the **AST:ALT \>2**? What other ratio makes it 100% SPECIFIC?
**WILSON's** disease (**ALP:T.Bili \<4**)
372
What **LIVER LESION** can **OCPs** cause or need to be stopped for as these are **HORMONALLY** responsive?
Hepatic **ADENOMAS**
373
Past history of **PSC** with **UC**, received liver **TRANSPLANT** **\<1 YEAR** ago, presents with **BLOODY DIARRHEA**, **FEVER** and **ABDOMINAL PAIN**, what shoud you do **NEXT**?
Check **CMV PCR** first, BEFORE considering invasive colonoscopy
374
In an **ASYMPTOMATIC** patient with **GENETIC** **HEMOCHROMATOSIS** with serum **FERRITIN \<1,000** what should be done **NEXT**?
NO liver biopsy necessary at this point, should just do THERAPEUTIC PHLEBOTOMY (serum ferritin levels dictate this)
375
What is the **GOAL** serum **FERRITIN LEVEL** that **GUIDES PHLEBOTOMY** in a patient with genetic **HEMOCHROMATOSIS** or **IRON OVERLOAD**?
SERUM FERRITIN of **50-100 µg/L**
376
If a patient presents with **CIRRHOSIS** and also has positive markers for other disease such as **AIH** (ANA, ASMA, etc.), what **MUST** be done **PRIOR** to starting treatment (prednisone + azathioprine)?
**US** of LIVER to check for **HCC**
377
**WHEN** do you start **TREATMENT** in a patient with **AIH**?
1. **INCAPACITATING** symptoms (arthralgia and fatigue)
2. **AST/ALT \>10 X** normal values
3. **BRIDGING** or **NECROSIS** on liver BIOPSY
Patients with INACTIVE CIRRHOSIS do NOT require CORTICOSTEROIDS
378
What can occur in a patient being treated with **LAMIVUDINE** for **Hep B** and what do you do if suspected (has not seroconverted, ie anti-HBe negative)?
50% develop RESISTANCE (after years) and should be tested for this
Can **ADD** **TENOFOVIR** or **ENTECAVIR** or adefovir
379
What should be **TESTED** for if suspecting **ACUTE** **Hep C** infection (IVDA), with **AST/ALT** in the **THOUSANDS** (can be \>2,000)?
**HCV RNA** (because antibodies take a while to form)
380
**WHEN** should **PO CHARCOAL** be included in the treatment of an **OVERDOSE** (tylenol, etc.)?
ONLY if **\<4 HOURS** since ingestion
381
What is the most **COMMON** cause of **DEATH** in a patient with **NAFLD** (not NASH)?
**CARDIOVASCULAR** disease
382
What is recommended for patients with **PSC** who undergo **ERCPs** to relieve dominant strictures causing pruritus?
Prophylactic **ANTIBIOTICS**
383
In a patient with **CRRHOSIS** and with **NORMAL AMMONIA** levels, what is **NOT** causing mental stateus changes?
**HEPATIC ENCEPHALOPATHY**
384
How should a patient with **CRYOGLOBULINEMIC** **VASCUITIS** with **RENAL FAILURE** be treated?
**DAA**
385
Pt with **HCV**, **FATIGUE**, **JOINT PAIN**, **WEAKNESS**, mild **ANEMIA**, **RENAL** **INSUFFIEICENCY**, **LOW GFR**, how do you **TREAT**?
**DAA**
386
Pt with chronic **CHOLESTASIS**, **CROHN's** disease, mild **PRURITUS**, **NEGATIVE MRCP**, what could this be and what should be done?
**SMALL DUCT PSC** (more common in PSC with CROHN's as 10% have negative MRCP), **BIOPSY**
387
Which **PSC** patients have the **WORST PROGNOSIS**?
Those with **LARGE DUCT PSC** - **CHOLANGIOCARCINOMA** (10% with small duct progress to large duct)
388
Drugs such as **NITROFURANTOIN** can cause **HEPATOTOXICITY** that mimics what?
**AIH** (elevated ANA)
389
In patients who developed **RESISTANCE** to **LAMIVUDINE**, what medication **CANNOT** be used to treat HBV and what medication should be used?
Cannot use **ENTECAVIR** (will also be resistant), must use TENOFOVIR
390
In a patient with acute **ALCOHOLIC HEPATITIS** with an **ACTIVE INFECTION** (PNA, etc.) would you start **STEROIDS** if MDF was \>32?
**NO**
391
In a patient with **VARICEAL BLEED**, besides **INDEFINITE** **non-selective ß-Blockers**, after EGDs no longer show varices, how **OFTEN** do you repeat them after the **FIRST NEGATIVE EGD**?
Repeat in **1-3 MONTHS**, if negative again, repeat **every 6 MONTHS**
392
What would **INCRESING DIURETICS** cause in a patient with **WORSENING ASCITES** with **HYPOnatremia**?
It would further **WORSEN** the **HYPOnatremia**
393
What is the **BEST** treatment for **REFRACTORY ASCITES** when pt is **NOT** a **TIPS** candidate (HE, T.Bili \>3, high MELD score)?
Serial **PARACENTESIS** with **ALBUMIN** replacement
394
What should be done for a patient presenting with **CHRONIC INDETERMINATE CHOLESTATIC LIVER DISEASE**?
**LIVER BIOPSY (AMA-neg livefr disease or infiltrative process such as sarcoid, etc.)**
395
What **antibodies** are a feature of **TYPE-II AIH** (hepatocellular not cholestatic)?
**LKM1** autoantibodies
396
For **NAFLD**, what is a way to monitor for improvement?
Weight loss with **SERIAL** monitoring of **LFTs**
397
**FEVER, SOMNOLENT**, **VERY HIGH AST/ALT** (thousands) and imaging showing **TEMPORAL LOBE CHANGES** (encephalitis)?
**HERPES HEPATITIS** - acyclovir
398
What is **RECOMMENDED** after the initiation of **STATINS** when **LFTs** rise after starting this therapy?
**OBSERVATION** with serial **LFT** monitoring
399
Liver biopsy demonstrating **LYMPHOCYTIC INFILTRATES**, **LYMPHOCYTIC CHOLANGITIS**, STEATOSIS, **AMA-negative** in a patient with steady and chronic **LFT** elevation and hepatomegaly?
**AMA-negative PBC** (can have positive ANA and SMA)- treat with **URSODIOL**
400
What needs to be excluded in a **YOUNG** patient with **CIRRHOSIS** (thrombocytopenia, elevated INR, low albumin, coarse liver echotexture, splenomegaly, lymphoplasmacytic portal inflammation, septal **FIBROSIS** and **NODULAR REGENERATION**)?
Must exclude **WILSON's** disease (hepatic **COPPER** quantitation)
401
In a patient with minimally elevated **LFTs** and a normal Ŷ-globulin level, would **AUTOIMMUNE** hepatitis be likely?
**NO**
402
**STEATOSIS** in a patient **WITHOUT** obesity or **DM** is suggestive of what?
**WILSON's**, **HEP C**, **DRUGS** or **CELIAC DISEASE**
403
Patient presents with **FEVER**, elevated **ALK PHOS** and liver biopsy shows **NON-CASEATING GRANULOMAS AFTER** receiving intra-**VESICAL** **BCG** for **BLADDER CANCER**?
**MYCOBACTERIUM BOVIS** (non-TB mycobacterial infection)
404
In a **YOUNG** patient with **Hep B**, **POSITIVE** **HBeAg** and **VERY HIGH HBV DNA** level but with **NO ELEVATION of LFTs**, what **NEEDS** to be **DONE**?
Repeat **LFTs** in **6 months** (**INACTIVE CARRIER STATE**)
405
**WHEN** is the monitoring of the liver with **US** and **AFP** **NEEDED**?
When the patient has **CIRRHOSIS** (**OR asian men \>40**, **asian women \>50**, **blacks \>20** and pts with **family history of HCC**)
406
In **WHICH PATIENTS** with **Hep B** and **WITHOUT CIRRHOSIS** is an **US** every **6 MONTHS** and an **AFP** level **NEEDED**?
**BLACKS \>20**, ASIAN MEN \>40, ASIAN WOMEN \>50 and patients with a **FAMILY HISTORY of HCC**
407
Do **Hep B** patients with **INACTIVE CARRIER STATE** require **LIVER BIOPSY**?
**NO**
408
What is **RECOMMENDED** for **ALL PATIENTS** with **Hep B** and **DECOMPENSATED CIRRHOSIS** with **ANY DETECTABLE HBV DNA**?
**TREATMENT** (tenofovir or entecavir)
409
Can you **TREAT** a patient with **DECOMPENSATED** **CIRRHOSIS** with **PEGINTERFERON**?
**NO** (precipitates a **FLARE** of hepatitis)
410
In a patient with **Hep C** who develops **CRYOGLOBULINEMIA** **WITH** **SYSTEMIC** **EFFECTS** (**RENAL FAILURE**), how do you treat?
**RITUXIMAB** FIRST, then **HCV THERAPY** (plasmapharesis and corticosteroids as well as needed)
411
What is special about **HEPATITIS C IL28B** genotype **CC**?
**HIGH** chance for **SPONTANEOUS CLEARANCE** in **ACUTELY INFECTED PATIOENT** (**OBSERVE** for **3 months** and only treat if still positive)
412
In a patient with **CHRONIC HBV** and **CIRRHOSIS**, **MRI** shows a new mass with **ARTERIAL ENHANCEMENT** and **PORTAL VENOUS WASHOUT**?
**HEPATOCELLULAR CARCINOMA**
413
In an **OTHERWISE** healthy patient with **Hep B CIRRHOSIS** and a **LOCALIZED LIVER MASS**, what is the best treatment?
**ORTHOPIC LIVER TRANSPLANT** (RFA ablation or ethanol only if comorbidities preclude surgery)
414
How do you **TREAT ADVANCED STAGE INTRA-HEPATIC CHOLANGIOCARCINOMA**?
**GEMCITABINE + CISPLATIN**
415
**LIVER MASS** with **RAPID HOMOGENEOUS ENHANCEMENT** in the **ARTERIAL PHASE** and return to **ISOINTENSITY** in the **PORTAL VENOUS PHASE** with a **CENTRAL SCAR** and **CONTRAST RETENTION** in the **DELAYED HEPATOBILIARY PHASE**?
**FOCAL NODULAR HYPERPLASIA** (bening, no treatment needed)
416
What is the **BEST** way to **ABLATE** an intra-hepatic **SEROUS CYST** after drainage?
**ALCOHOL INSTILLATION** (fenestration if alcohol fails)
417
What is the **RECOMMENDATION** for **₿-catenin-activated inflammatory hepatocellular adenoma**?
**SURGICAL RESECTION** (risks malignant transformation)
418
What does the presence of **₿-catenin** signify when a heaptic lesion stains **POSITIVE**?
**HIGH RISK** for **MALIGNANT TRANSFORMATION**
419
A **MADDREY DISCRIMINANT FUNCTION SCORE** of what would **SUGGEST** use of **PRENDISOLONE OR PENTOXIFYLLINE** (not both)?
**\>32**
420
What is the **KEY** to **INTERVENTION** in **ALCOHOLIC CIRRHOSIS**?
**ABSTINENCE** and **MANAGEMENT** of **ALCOHOLISM**
421
**SHOULD** patients with **CHRONIC HEPATITIS** of **ANY KIND** (**Hep C**, etc.) consume **ALCOHOL**?
**NO** (synnergistic effect and causes more damage)
422
What can occur in a patient who drinks **ALCOHOL** and takes normal amounts of **ACETAMINOPHEN**?
**DILI** ith elevated AST adn ALT
423
What causes **MACROVESICULAR STEATOSIS**?
**ALCOHOL**
424
Where do you see **BALLOONING DEGENERATION** and **MALLORY** **BODIES**?
**ALCOHOLIC HEPATITIS**
425
Where do you see INTERFACE HEPATITIS with PLASMA CELLS?
**AUTOIMMUNE HEPATITIS**
426
Can you treat **PORTAL VEIN THROMBOSIS** or **TUMOR THROMBOSIS** of any kind with anticoagulation or anti-thrombotic therapy?
**NO**, no role for that
427
What is the **BEST RECOMMENDATION** for an **ELDERLY** patient with **CHRONIC Hep B** with **HCC** and tumor-related **PVT** (arterial enhancement of the clot)?
**POOR PROGNOSIS** (2-3 months) - **HOSPICE**
428
What do **ISOLATED** gasric **FUNDUS** **VARICES** suggest in the **ABSENCE** of liver disease?
**SPLENIC VEIN THROMBOSIS** (pancreatitis, etc.)
429
What should be done for a patient with **SPLENIC VEIN THROMBOSIS** and **FUNDUS VARICES** with bleed?
**SPLENECTOMY**
430
**ASCITES** due to **BUDD-CHIARI** syndrome (hepatic veins are not well visualized on doppler US) is treated how?
**DIURESIS** and **ANTICOAGULATION**
431
When is **THROMBOTIC** **THERAPY** appropriate for **HEPATIC VEIN THROMBOSIS**?
When it is **ACUTE** (catheter-directed therapy, NOT SYSTEMIC)
432
How is **ACUTE PVT** due to **INFLAMMATION** (diverticulitis) **TREATED**?
**ANTICOAGULATION** (**WARFARIN** for **6 MONTHS**)
433
Post **LIVER TRANSPLANT**, pt develops **FEVER**, **ABDOMINAL PAIN**, **N/V**, **RAPID DETERIORATION**, **HYPOTENSIVE**, **TOXIC**, **TACHYCARDIA**, **RESPIRATORY DISTRESS**, **VERY HIGH AST/ALT**, **ACUTE KIDNEY INJURY**, **HIGH INR**, **US** shows **PNEUMOBILIA**, **HEPATIC ARTERY NOT VISUALIZED**?
**ACUTE HEPATIC ARTERY THROMBOSIS** (usually within **7 DAYS**)- severe ischemic necrosis - **LIST FOR RETRANSPLANT**
434
**IN** a patient with **BLEEDING** gastric **FUNDUS** **VARICES** due to **LIVER** **CIRRHOSIS** (not pancreatitis), what is the **RECOMMENDED TREATMNET**?
**TIPS** (NOT band ligation)
435
In a patient with **UGIB** with **CIRRHOSIS** and **ANY SIZE ESOPHAGEAL VARICES**, **WHERE** should the bleeding be suspected to have originated even if **NO STIGMATA** are noted on the esophageal varices?
The **ESOPHAGEAL VARICES** - so **BAND THEM**
436
In a patient with **DIFFUSE GAVE**, **NOT AMENABLE** to **ENDOSCOPIC** **THERAPY**, what is the **RECOMMENDED TREATMENT**?
Estrogen therapy
437
In a patient with **CHRONIC BLEEDING** from **PORTAL HYPERTENSIVE GASTROPATHY** which is **NOT** amenable to endoscopic therapy (most cases), what is the recommended **TREATMENT**?
**TIPS**, **B-blockers** and **Iron** supplementation
438
What should be done for a patent on **B-blocker** (nadolol) as primary variceal prophylaxis if they develop side effects (fatigue, sexual dysfunction, orthostatic hypotension)?
**STOP** the **NADOLOL** and perform **EGD** with variceal **BANDING** as primary prophylaxis
439
What is the **BEST** antibiotic **CHOICE** for a patient with **ASCITES** and **GIB**?
**IV CEFOTAXIME** (gm-negative bacilli coverage)
440
What would a patient's **TRANSFERRIN SATURATION** be in **HEMOCHROMATOSIS**?
**HIGHLY ELEVATED** (**\>50%**)
441
**OBESITY**, **HTN** & **IMPAIRED FASTING GLUCOSE** are all components of what **LIVER CONDITION**?
**NAFLD**
442
**WHEN** should phlebotomy be started in a patient with **HEMOCHROMATOSIS** (2 abnormal copies of the **C282Y** mutation)?
**ONLY** when there is evidence of **IRON** **OVERLOAD** (elevated serum **FERRITIN \>300**)
443
Patients with **CIRRHOTIC-STAGE HEMOCHROMATOSIS** are at **HIGH RISK** for **HCC**, and if they develop **PVT**, what **MUST BE DONE**?
**MUST EXCLUDE** thrombus due to tumor, **DO NOT** start anticoagulation (TRIPPLE PHASE **CT** of the **ABDOMEN** or **MRI**)
444
**ALL** patients with **CIRRHOSIS** presenting with **PVT**, what must be ruled out **FIRST** before starting anticoagulation?
**HCC** (**CT** or **MRI**)
445
In **ONE** parent with **HEMOCHROMATOSIS**, **HOW MANY MUTANT HFE** **GENE** copies can that parent's chilren **INHERIT**?
JUST **ONE** (which is why you **MUST TEST THE WIFE** to know whether the children will also have **HEMOCHROMATOSIS** or just be **CARRIERS**)
446
In a patient with **POSTIVE AMA** (**PSC**) and being treated with **URSODIOL**, what is the **BEST NEXT TEST** to use to gauge respone to therapy?
**ALK PHOS** (**ALP**)
447
In an **ADVANCED** **STATE** of **LIVER DISEASE** (**CIRRHOSIS**), what complication commonly occurs **METABOLICALLY**?
**FAT**-**SOLUBLE** **VITAMIN DEFICIENCIES** (**DEKA**)
448
In a **NEWLY**-**DIAGNOSED** patient with **PSC**, what is **RECOMMENDED** to be done diagnostically when **BILIARY** **STRICTURES** are noted?
**ERCP** with **BILIARY** **BRUSHING** (NOT LIVER BIOPSY)
449
What is it called when a patient meets criteria for **BOTH** **AIH** and **PBC** (positive **AMA** and biopsy showing **LYMPHOCYTIC CHOLANGITIS** and **PLASMA CELLS**, positive **SMA** and **ANA**)?
**OVERLAP SYNDROME**
450
Patients with this **TYPE** of **PSC** **DO NOT** have positive **AMA** and have normal **Ŷ-globulin** results?
**SMALL-DUCT PSC**
451
**NON**-**CASEATING** **GRANULOMAS** involving the **PROTAL TRACTS** are found in the liver of patients with what?
**SARCOIDOSIS** and **MYCOBATERIA** (**TB** or **BOVIS**)
452
**WHICH** **LIVER** disease is **UCDA** used for?
**PRIMARY BILIARY CIRRHOSIS** (not PSC)
453
Is biliary duct **DILATION** and **BEADING** on **MRCP** sufficient for a diagnosis of **PSC**?
**YES**
454
What **MUST** be done for patients with **BOTH** **UC** and **PSC**?
**ANNUAL SURVEILLANCE COLONOSCOPY** (increased risk of COLON CANCER over UC alone)
455
**PAINLESS JAUNDICE**, elevated **BILIRUBIN**, **NODULAR PANCREAS** and **LONG TAPERING EXTRAHEPATIC CBD STRICTURE**?
**AUTOIMMUNE PANCREATITITS** (**IgG4**)
456
Most **COMMON MEDICATION** causing **IDIOSYNCRATIC DILI**?
**AUGMENTIN** (**AMOXICILLIN**-**CLAVULANATE**)
457
What medication is **HELPFUL** with **ACUTE LIVER FAILURE** (jaundice, pruritus, confusion, elevated INR and LFTs) whether caused by acetaminophen or not?
**N-acetylcysteine**
458
In a patient who is a **HUNTER** and eats **RAW PORK** or **DEER** **MEAT**, what are they at **RISK** for (elevated LFTs, nausea, vomiting, malaise and abdominal pain)?
**Hepatitis E** (check **IgM**)
459
**CHRONIC ALCOHOL** abusers who take **ACETAMINOPHEN** are at **INCREASED RISK** of acetaminophen **TOXICITY** by what **MECHANISM**?
**ALCOHOL INDUCTION** of **CYP2E1** resulting in **INCREASED HEPATOTOXIC METABOLITE** **N-acetyl-p-benzoquinone imine**
460
**CHRONIC ALCOHOL INGESTION** and **MULTIPLE SUPRATHERAPEUTIC DOSES** of **ACETAMINEOPHEN**?
**HIGHEST RISK** for **ACETAMINOPHEN**-**RELATED** **HEPATOTOXICITY** (CYP2E1 induction with production of more toxic N-acetyl-p-benzoquinone imine)
461
What is the **TREATMENT** of **CHOICE** for **VALPROATE HEPATOTOXICITY** with features of **HEPATIC ENCEPHALOPAHTY**?
**CARNITINE**
462
**MIDDLE-AGED** **WOMAN** with **FATIGUE** and **PRURITUS**, **XANTHELASMAS** (from **HIGH-LIPIDS**) is **HIGHLY**-**SUSPICIOUS** for what condition and how should you test?
**PRIMARY BILIARY CIRRHOSIS** (**PBC**) - check **AMA**
463
**PERIDUCTAL ONION SKIN FIBROSIS** with edema and mild **INFLAMMATORY INFILTRATE** in a patient with **UC** and abnormal **LFTS** including **ALP**, AST and ALT?
**PSC**
464
What is the **ONLY MEDCIATION** shown to **DELAY** time to **LIVER TRANSPLANT** in a patient with (hypercholesterolemia, elevated ALP, AST ALT, GGT, BILIRUBIN, INR, ANA, AMAand IgG)?
**URSODIOL** at **13-15 mg/kg DAILY** (**PBC**)
465
POSITIVE **ANA**, **SMA** very HIGH **IgG**, with **FATIGUE**, **SOB**, **RUQ** pain with elevated **ALP**, **ALT**, **AST**, **BILIRUBIN** and **FERRITIN** (acute phase reactant)?
**AIH** (treat with **STEROIDS** +/- azathioprine) - **90% BIOCHEMICAL** improvement in **2 weeks** and **60% HISTOLOGIC** improvement in **18 MONTHS** and **85% in 3 YEARS** (in the 10% who don't respond, consider OVERLAP SYNDROME or WILSON's disease)
466
**WHAT** **HISTOLOGIC** **FEATURE** can distinguish **NASH** (Non-Alcoholic Steato-Hepatitis) from **ASH** (Alcoholic Steato-Hepatitis)?
**NONE** (diagnosis is made by **HISTORY** and **CLINICAL EXAM**)
467
Approximately what **PERCENTAGE** of patients with **ALCOHOLIC FATTY LIVER** will **PROGRESS** to more **ADVANCED LIVER DISEASE** with either **ABSTINENCE** or **CONTINUED EXCESS DRINKING**?
With **ABSTINENCE** - **0%**
With continued **EXCESS DRINKING** - **25%**
**FATTY LIVER DISEASE** from **ALCOHOL** is **REVERSIBLE**
468
Which are the **IMPORTANT** **CLINICAL** and **LABORATORY** features of **ALCOHOLIC HEPATITIS** which predict **SURVIVAL**?
Those used in calculating the **MELD** **SCORE** and **MADDREY** **DISCRIMINANT** **FUNCTION** (bilirubin, PT, INR, Na, Cr, hepatic encephalopathy) - NOT albumin
469
**ALCOHOLIC** patient **WALKS** into clinic and complains of **PAIN** and is found to have **ALT/AST** in the **THOUSANDS**?
**ACETAMINOPHEN** **TOXICITY** most likely diagnosis
470
What is the **FIRST** **LINE** of therapy for **FATTY LIVER** (ANA and FERRITIN are usually elevated)?
**WEIGHT LOSS** (at least **10%** of **EXCESS** body weight)
471
In the **EARLY SECOND TRIMESTER** (weeks 13-24) and having a **CHILD** in **DAY CARE**, is a **RISK FACTOR** for what **LIVER DISEASE**?
**ACUTE** **Hep A** (**AST/ALT** in the **thousands**)
472
**ASCITES**, **HEPATOMEGALY**, **VENOUS COLLATERALS** in the **POST**-**PARTUM** period?
**ACUTE** **BUDD**-**CHIARI** **SYNDROME** (history of thromboembolism, etc.)
473
This **CONDITION** develops in the **SECOND** or **THIRD** **TRIMESTER**, with **ELEVATED** **AST/ALT** and **ALP** with **BILIRUBIN** and **SEVERE** **PRURITUS**, **HOW** is it **TREATED**?
**INTRAHEPATIC CHOLESTASIS** of **PREGNANCY** (**ICP**) - **UDCA**
474
**WHEN** is **PREGNANCY** **SAFEST** after **LIVER TRANSPLANT**?
**2**-**YEARS POST TRANSPLANT**
475
Is **PREGNANCY** **ASSOCIATED** with **TRANSPLANT REJECTION**?
**YES**, only **ACUTE** CELLULAR REJECTION, **NOT CHRONIC**
476
Is **MYCOPHENOLATE MOFETIL SAFE** in **PREGNANCY**?
**NO! ABSOLUTELY NOT!** (known **TERATOGEN**)
477
**THIRD TRIMESTER**, with **ACUTE LIVER FAILURE** represented by **ANOREXIA**, **MALAISE**, **N/V**, **DISORIENTED**, **TREMMOR**, **JAUNDICE**, **HYPERTENSION**, **LE EDEMA**, **LEUKOCYTOSIS**, **ELEVATED AST/ALT**, **ALP**, **BILIRUBIN**, **INR** and **Cr**?
**ACUTE FATTY LIVER** of **PREGNANCY**
478
**THIRD TRIMESTER**, with **ACUTE LIVER FAILURE** represented by **ANOREXIA**, **MALAISE**, **N/V**, **NO** **JAUNDICE**, **HYPERTENSION**, **LOW PLATELETS**, **LE EDEMA**, **LEUKOCYTOSIS**, **ELEVATED AST/ALT**, **ALP**, **BILIRUBIN**, **INR** and **Cr**?
**H**(hemolysis)**EL**(elevated LFTs)**LP**(low platelets) **SYNDROME**
479
**WHEN** is **HEPATECTOMY** and **LIVER** **TRANSPLANTATION** **CONTRAINDICATED** in a **CIRRHOTIC** with **LOCALIZED** **HCC**?
When there is **PORTAL HYPERTENSION**
480
What is the **MILAN CRITERIA** for **LIVER TRANSPLANTATION** in **HCC**?
**ONE LESION ≤5 cm**
or
**UP TO 3 LESIONS** that are **EACH ≤3 cm** with **NO MACROVASCULAR INVASION** or **EXTRAHEPATIC SPREAD**
481
In a **HIGHLY**-**SYMPTOMATIC** patient with **PSC** and a **LOW MELD** (**\<28**) **HOW** could they **QUALIFY** for a **LIVER TRANSPLANT**?
**LIVING DONOR TRANSPLANT**
482
Pt post **RECENT LIVER TRNSPLANT** presents with **PRURITUS**, **JAUNDICE** without fever or pain and **ELEVATED** **ALP** and **BILIRUBIN** with **MILD** **AST/ALT ELEVATIONS**, **NON**-**DILATED** **INTRAHEPATICS** and **NORMAL** **ARTERIAL** and **VENOUS FLOW**?
**ANASTOMOTIC BILIARY STRICTURE**
483
**FEVER**, malaise, **N/V**, abdominal pain and **PROFUSE DIARRHEA** **3-12 MONTHS** post **LIVER TRANSPLANT**?
**CMV INFECTION**
484
**FEVER**, malaise, **N/V**, abdominal pain and **PROFUSE DIARRHEA** **3-12 MONTHS** post **LIVER TRANSPLANT**?
**CMV INFECTION**
485
Are patients with **METASTATIC** **DISEASE** to the **LIVER** (as in colon metastatic to liver) **CANDIDATES** for **LIVER TRANSPLANT**?
**NO**
486
What is the **MOST COMMON** viral hepatitis etiology especially in **IMMUNOCOMPROMISED** and **YOUNG** individuals?
**EBV**
487
Which HEP virus has shown the greatest **INCREASE** in incidence over the past 10 years?
**HAV** (narcotic abuse, homelessness)
488
Where is the **HDV** DNA located?
Inside the **HBsAg**
489
Acute **FULMINANT** hepatic failure is associated with what infection?
**HBV** + **HDV** CO-INFECTION
490
Patients with **HBV + HDV** superinfection have **~100%** risk of what?
**CHRONICITY** (HDV is found in **40%** of patients with HBV)
491
For either **MALEs** or **FEMALEs**, acute hepatitis infection negative for HBV, HCV, HAV, and especially from **EGYPT**, what is the likely acute viral infection?
**HEV** (highest prevalence in 60-80 yo, meat eaters, immigrants, hunters, fishermen)
492
Do Hepatitis C or D develop **PROTECTIVE** Ab's?
**NO**
493
Does **HAV** develop **CHRONIC** hepatitis?
**NO**
494
Does **HEV** develop **CHRONIC** hepatitis?
**YES**, ONLY in **IMMUNOCOMPROMISED**
495
What is the % of individuals in which **HBV** develops **CHRONICITY**? **HCV**?
**HBV** - **15%**
**HCV** - **85%**
496
An **ALT** OF **>10,000**, jaundice with **bilirubin** of **>10** is an idication of what?
**Acute Liver Failure** (prolonged INR, hepatic encephalopathy)
497
What are the **3 types** of **HAV** infection presentation?
1. **Acute** (**4 weeks**, T.bili <10, NL alk phos)
2. **Cholestatic** (up to **12 weeks**, T.bili >10, Elev alk phos)
3. **Relapsing** (up to **1 year**, every 4-15 wks, **IgM** stays **POSITIVE**)
498
When do you see **HBeAg-NEGATIVE** **active** hepatisis B?
When there is an **HBeAg MUTATION** in the e-GENE
499
What is the **TARGET** of the immune response to **INACTIVATE** **HBV**?
The **eAg** (thus, when this is mutated, an eAb cannot be formed and this cannot inactivte HBV ("e-nagative, active hepatitis - chronic)
500
**Cirrhosis** and **HCC** are directly related to what feature of HBV infection?
Amount of **HBV DNA** present (risk starts increasing significantly at **2-20,000 IU** of HBV DNA ie 10x4 - 10x5 copies) so, **TREAT at >20,000**
501
What pts with HBV do you **screen** for **HCC**?
US (+/- AFP) EVERY 6 months in those with ACTIVE (20%) (HBeAG +/-) and those with INACTIVE (80% of HBV ps) (HBeAG -)
## Footnote
essentially, there are so many more inactive HBV patients than active (80%/20%) that HCC is higher collectively in inactive patients
502
What is the **difference** in development of **HCC** in patients with **HBV** vs **HCV**?
In **HBV**, **both** pts with and without CIRRHOSIS will develop HCC whereas in **HCV ONLY CIRRHOTIC** patients will develop HCC
503
What hepatitis **VACCINE** is recommended in ALL children?
**HBV**
504
For whom is the **HAV vaccine** recommended?
ALL those traveling to **endemic** areas (Caribbean, Mexico, Egypt, etc. and individuals at **RISK**) - all **household** or **intimate** contacts of an HAV patient must receive **IVIGg**
505
Do you need to get re-boosted every time you have a needle-stick exposure once you got your HBV vaccine or booster 10 years later?
**NO** (even if Ab levels wane and decreased over 6-12 months)
506
**CHRONIC HBeAg POSITIVE** patients are treated with what and how long?
**TENOFOVIR** or **ENTECAVIR** (**6 MONTHS** after **HBeAb** forms - seroconversion (20%), LFT normalization and DNA <2,000 IU)
507
Which **HBV** Direct Antiviral Agent (**DAA**) is the most potent?
**TENOFOVIR** ALAFENAMIDE (less drug, less toxicity)
508
When treated with **PEG-INTERFERON**, which **GENOTYPE** of **HVB** will experience a 50% **SEROCONVERSION** (HBeAb)?
Genotype **A**
509
Can **PEG-INTERFERON** be used in **HBeAg** **NEGATIVE** pts?
**NO** (only tenofovir or entecavir)
510
What does **HBV SEROCONVERSION** (HBeAg to HBeAb) mean?
**INACTIVE** STATE
511
When can **DAA** be stopped in **HBeAg** **NEGATIVE** pts?
**NEVER**
512
In a patient with **UC** needing treatment, who has **normal LFTs** BUT is **HBsAg positive** (immune tolerant phase) and **HCV-Ab positive**, how do you treat?
Start treatment for **UC** AND **HBV** AND **HCV**
513
Which **CIRRHOTIC** patients CANNOT use **PROTEASE** INHIBITORS (NS3-4A) to treat **HCV**?
**CTP** (Child-Turcotte-Pugh) classes **B** or **C**
514
A patient with **LIMITED** life expectancy and mild fibrosis; **ADVANCED** stage 3-4 HCC; CPT class **C** with HIGH MELD who are **transplant** candidates; **ACTIVE** drug users ALL have this in common?
NON-HCV therapy candidates
515
**BEFORE** starting a patient on **immunotherapy**, **antibiologics**, **HCV** treatment, **chemotherapy**, ALWAYS **screen** for?
**HBV** (HBsAg, HBsAb, HBcAb)
516
While treating an **HCV** pt who had **inactive HBV**, **WHEN** after **curing HCV** do you **STOP HBV**prophylaxis?
SEVERAL **MONTHS** later
517
In treating a patient with **HCV** and **ONLY HBcAb** (NO HBsAG or HBsAb) what do you do for the HBV exposure?
**MONITOR ONLY**
518
In treating a patient for **HCV** with **HBsAb** (seroconverted), what is required for HBV?
**NOTHING** (no monitoring nor prophylaxis)
519
IF a pt is tested for **HBsAg** and is **POSITIVE**, what do you test for **NEXT**?
HBV DNA, HBeAg and HBeAb
520
**LYMPHOMA**, **DM** and **ESLD** are all significantly **REDUCED** when treating what?
**HCV**
521
**ALL HBV** pts and **ALL** **CIRRHOTIC** pts who have been **successfully** treated for **HCV** must be **SCREENED** for?
**HCC** every 6 months with US +/- AFP
522
**60%** of **ACUTE LIVER FAILURE** cases are caused by?
**DILI** (drug induced liver injury)
523
Does **CHRONIC LIVER DISEASE** or **CIRRHOSIS** increase the risk of **DILI**?
**NO** (but if does occur, it **increases** the **severity** and chance of developing **ALF**)
524
**Elevated AST/ALT sometimes AlkPhos as well, up to 3xNL then adapts?**
**DILI** (when no adaptation occurs, may have underlying NAFLD)
525
LFT elevations of **3-5 x ULN** after taking **MEDS** with **JAUNDICE** and **>5x ULN** may result in what?
**10% - 50%** risk of **ACUTE LIVER FAILURE**
526
When someone is taking a med that results in elevated **LFTs** (AST, ALT and sometimes AlkPhos) what **change** besides elevation in LFTs (3-5x) signals risk for **ACULE LIVER FAILURE**)?
**JAUNDICE** (STOP med immediately)
527
Pt is on a new **MED**, **LFTs 3-5X ULN**, then **plateus**. **WHEN** must you **STOP** the drug?
If **JAUNDICE** develops
528
When **AlkPhos** is mainly **ELEVATED** more so than AST/ALT, mostly with associated itching, what is the **pattern** of this liver **INJURY**?
**CHOLESTATIC** (when **jaundice** is seen in this situation, it is **LESS OMINOUS** than with hepatocellular pattern) - in JAUNDICE, AlkPhos & T.bili are up while AST/ALT are low high or normal
529
What type of **ISOLATED** liver injury results from **METHOTREXATE** or **Vitamin A**?
**FIBROSIS**
530
**SAAG** (serum Alb - ascites Alb) >1.1 gm/dL?
**Portal HTN** (**CIRRHOSIS**, hepatic failure, veno-occlusive, Budd-Chiari, CHF, malignancy, malnutrition)
531
**SAAG** (serum Alb - ascites Alb) <1.1 gm/dL?
Mesothelioma, peritoneal carcinomatosis, TB, sarcoidosis, SLE, Whipple Disease, Endometriosis
532
533
**HVPG** (hepatic vein pressure gradient) = **Wedged HVP** - **Free HVP**. What is normal and elevated?
HVPG **WNL 1-5**
HVPG ≥10 Portal HTN
HVPG ≥12 Varices
534
What can cause **stiff liver sinusoids**, **non-cirrhotic portal HTN**, **ascites**, **varices** with **normal liver on imaging and biopsy**?
**CHEMOTHERAPY**
535
Pt receives **CHEMOTHERAPY** and develops a **NODULAR** liver, non-cirrhotic portal HTN, liver synthetic function normal, HVPG normal, normal biopsy?
**Nodular Regenerative Hyperplasia** (NRH)
536
Pt receives **CHEMOTHERAPY** with another **DRUG** and AST, ALT and AlkPhos are high with 5% developing **JAUNDICE** in about **60 DAYS** after initiation, what did they get?
**CHECKPOINT INHIBITOR** (pembrolizumab, etc.) treat with steroids+mycophenolate mofetil or just stop the drug, does recurr with restart (17-28%)
537
**ACETAMINOPHEN TOXICITY** is **INCREASED** by what?
**ALCOHOL** (not liver disease or cirrhosis)
538
**Acetaminophen** toxicity **>24 hours**, elevated **INR** or Hepatic **Encephalopahty**?
Immediate transfer to **Liver Transplant Center**
539
What are the **serologic** markers usually positive in **AIH I**, **II**?
**AIH I** - **ANA**, **ASMA**
**AIH II** - **anti-LKM** or **anti-LC1** (European, more severe)
540
What should be done when suspecting **AIH**, what is found?
**Liver Biopsy** - **PIECEMEAL** & **LOBULAR NECROSIS**
541
What is the **TREATEMENT** for **AIH** when its **CRYPTOGENIC CIRRHOSIS** (stable or decompensated cirrhosis, **normal LFTs**, **no inflammation on biopsy**, positive serologic markers for AIH)?
**NO TREATMENT**
542
In patients with **AIH** with liver **decompensation**, what should be considered?
**Liver Transplant**
543
