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Flashcards in Liver Diseases CIS Deck (69):
1

hepatocellular- labs

-ALT and AST

2

cholestasis

-ALK phos

3

IgM and IgG

-IgM- acute
-IgG- chronic

4

liver fxn tests

PT and serum albumin

5

ascites- caused by? risk factors?

-portal HTN from chron liver dz
-ETOH, transfusions, tattoos, IVDU, viral hepatitis

6

fatty liver (hepatic steatosis)- caused by

-NAFLD
-alcoholic related fatty liver dz
-vinyl chloride

7

NAFLD- sx, etiology

-usually asymptomatic- RUQ pain, hepatoemgaly
-obesity, DM, hypertriglyceridemia, metabolcic syndrome
-coffee reduces risk of fibrosis and cirrhosis
-protective- physical activity

8

NAFLD- histology

-macrovesicular steatosis
-NASH (nonalcoholic steatohepatitis)- macrovesicular steatosis and focal infiltration by PMN's and Mallory hylain

9

NAFLD- imaging, tx

-US- can see macrovascular steatosis
-liver bx- diagnostic
-tx- weight loss, dietary fat restriction, exercise, vit E, gastric bypass

10

do what test for ascites?

-US

11

if abd pain, ascites, and fever- must rule out what? via?

spontaneous bacterial peritonitis
-via Paracentesis!!- run WBC count with differential!
-if malnourished- run adenosine deaminase- for tb!!

12

spontaneous bacterial peritonitis- caused by? presentation?

-ascitic fluid infection w/o an apparent source
-translocation of gut bacteria- gram neg (E coli or Klebsiella) or gram + (strep pneumo, viridans, enterococcus)
-10-20% of known cirrhotic pts- present with decompensation- encephalopathy, fever, abd pain, worsening renal fxn!!!!

13

spontaneous bacterial peritonitis- lab test

-paracentesis- WBC count with diff
-PMN > 250 with 75% of all white cells!!!- highly suggestive
-if elevated WBC count and lymphocyte predominance- think TB or peritoneal carcinomatosis

14

calculate SAAG

-serum albumin - ascitic fluid albumin
->1.1 = a portal HTN cause
-<1.1= non portal HTN cause!!

15

causes for ascites

Portal HTN (SAAG >1.1)- most common
-hepatic congestion
-liver dz
-portal v occlusion
Hypoalbuminemia (SAAG <1.1)

16

alcoholic- follow up for?

EGD- esophageal varices

17

Hepatitis A- Dx, Tx

-RNA hepatovirus
-acute
-inc aminotransferases- inc Alk phos and bilirubin
-fecal-oral transmission- international travel is a risk factor!!
-Dx- IgM anti-HAV
-Tx- self limited

18

Had Hep A but not anymore

-Anti-HAV IgG

19

Had Hep C but not anymore

-Anti-HCV with neg HCV RNA

20

acute HBV infection- window period

-b/w HBsAg disappearing and HBsAb appearing
-ACUTE HBV!!
-only detectable with HBcAb IgM
*important for screening blood donations

21

Hepatitis B

-acute or chronic
-dsDNA genome
-inc aminotransferases- elevated Alk phos and billirubin
-transmitted- infected blood, sexual contract, mother to baby at delivery!!- asia!
-HBV vaccine

22

Acute HBV- presentation

-variable
-asymptomatic-> fulminant dz and death (<1%)
-aminotransferase levels > HAV
-can become chronic

23

HBV- window period- lab

-Anti-HBc IgM +

24

HBV-Acute Infx- lab

-HBsAg +
-HBeAg +
-Anti-HBc IgM +
-HBV DNA +

25

HBV- prior infection- lab

-Anti-HBs +!!!!
-Anti-Bc IgG +
-Anti-Hbe +/-
(ASIA- maternal transmission)

26

HBV- chronic infection- lab

-HBsAg +
-HBeAg +
-Anti-HBc IgM +
-Anti-HBc IgG +
-Anti-HBe +/-
-HBV DNA +

27

HBV- immunization- lab

-Anti-HBs +

28

Chronic HBV- where?

Asia!
-90% of infants with maternal transmission
-risk of HCC and cirrhosis

29

HDV (delta agent)

-acute or chronic
-only in assoc with HBsAg
-percutaneous exposure
-immigrants from endemic areas

30

HDV- dx

-anti-HDV
-HDAg
-HDV RNA

31

HCV

-ssRNA
-50% by IV drug use
-risk factors- body piercing, tattoos, hemodialysis
-sexual and maternal-fetal transmission is LOW
-80% chronic
-no vaccine!!

32

HCV- dx

-enzyme immunoassay for Anti-HCV
-confirmed by HCV RNA
-+anti-HCV in serum but neg HCV RNA = recovery from past infection

33

HCV complications

-mixed cryoglobulinemia
-membranoproliferative GN
-lichen planus, autoimmune thyroiditis, idiopathic pulm fibrosis
-inc risk for Non-Hodgkin lymphoma!
-HCV genotype 3- hepatic steatosis
-dec in serum chol and LDL
-cirrhosis and HCC

34

HCV- recommendations

-screen ppl born b/w 1945-1965
-vaccinate against HAV and HBV
-check for co infection with HBV and HIV
-safe sex practice
-CURABLE

35

Chronic HCV- cirrhosis progression inc in?

-after 20 yrs of dz
-men
-drink > 50g of ETOH daily
-acquire infx after 40 yo
-immunocompromised
-tobacco and cannabis smoking
*Af Am- higher rate of chronic HCV but lower fibrosis
-coffee- slows progression
-risk of cirrhosis and HCC
-HCV is curable!

36

HEV- in who? dx?

-acute hepatitis in Asia, Africa
-waterborne- pets, swine
-self-limited
-transplant recipients- those treated with tacrolimus!!!
-Dx- IgM anti-HEV

37

Acute Liver Failure- causes

-Acetaminophen
-idosyncratic drug rxn
*risk inc with DM, outcome worse in the obese

38

acute liver failure- sx

-fulminant = hepatic encephalopathy within 8 wks and coagulopathy
-labs= severe hepatocellular damage!
-acetaminophen toxicity- AST/ALT > 5000
-ammonia level elevated- encephalopathy and intracranial HTN

39

Tylenol OD

-treat with NAC if in toxicity area
-get a 4 hr acetaminophen level!!
-empiric treatment if ingestion is unknown- acetylcysteine

40

Autoimmune hepatitis- who? labs?

-young-mid age women
-+ANA and/or smooth m AB (type I)
-Anti-LKM1 (type II)
-AST/ALT can be >1000
-inc risk of cirrhosis and HCC

41

Autoimmune hepatitis- tx

steroids +/- azathioprine

42

alcoholics- what vit def?

-thiamine (B1)- wernicke korsakoff syndrome

43

wernicke encepalopathy

-encephalopathy- confusion, ataxia, involuntary abnormal eye movements
-syndrome- memory issues, confabulate/make up stories

44

Alcoholic Liver Disease- labs

-AST 2x > ALT
-when total bili > 10 and PTT > 6 sec = severe alk hep with 50% mortality; susceptible to infections

45

Alcoholic Liver Disease- effects

-dec platelets- direct effect on megakaryocytes prod or hypersplenism
-inc hepatic iron stores
-reversible!
-most common precursor to cirrhosis in US!
-risk of HCC

46

Alcoholic Liver Disease- Bx, Tx

-polymorphonuclear infiltration with hepatic necrosis (Mallory bodies) and perivenular/perisinusoidal fibrosis
-abstinence from alcohol!!
-nutritional support for anorectic pts- glucose admin increases the thiamine requirement!!
-6 month abstinence before liver transplant

47

Risk of alcoholic cirrhosis

->50 grams daily for over 10 yrs

48

Maddrey Discriminant function- used for?

-disease severity and mortality risk in pts with alcoholic hepatitis
->32 = high short-term mortality- may benefit from tx with glucocorticoids!!

49

Glascow alcoholic hepatitis score (GAH)

-predicts mortality in alcoholic hepatitis
->9 who received glucocorticoids- higher survival rates than those who didnt receive glucocorticoids!!
-no survival benefit with glucocorticoids <9

50

Cirrhosis- who? caused by? risk factors?

-fibrosis and regenerative nodules
-Mex Ams and Af Ams > whites
-causes- alcohol, chronic HCV, HBV, NAFLD, hemochromatosis
-risk factors- heavy alcohol use, obesity, iron overload
-coffee and tea consumption reduces risk
-methotrexate and vit A assoc with fibrosis and cirrhosis

51

Cirrhosis- signs/sx

-asymptomatic for a long time
-fatigue, disturbed sleep, m cramps, weight loss
-portal HTN
-others- gynecomastia, spider telangiectasias, palmar erythema, dupuytren contractures, asterixis

52

Cirrhosis- effects

-portal HTN- varices, ascites, hyperdynamic circulatory state
-liver insufficiency- cant syn albumin, coag factors, and cant excrete bilirubin
-portosystemic shunts

53

Cirrhosis- labs

-macrocytic anemia- folic acid def, hemolysis (hypersplenism)
-dec WBC (hypersplenism)
-inc infection
-thrombocytopenia- marrow suppression, sepsis
-prolongation of prothrombin time
-elevation of AST, Alk phos, T bilirubin
-dec in albumin
-inc risk of DM!!
-vit D def

54

Cirrhosis- imaging

-US- liver size, ascites, nodules
-contrasted CT- nodules- biopsy
-fibrosure- low/high excludes/predicts advanced fibrosis
-liver bx
-EGD
-detect varices or causes of bleeding in esophagus, stomach, duodenum

55

Cirrhosis- complications

-Upper Gi bleeding- portal HTN gastropathy, gastroduodenal ulcer, varices
-liver failure
-hepatic encephalopathy
-SBP (spontaneous bacterial peritonitis)
-hepatorenal syndrome
-coagulopathy
-HCC
-osteoporosis

56

Ascites- caused by?

-secondary to portal HTN!
-found in 50% of pts with cirrhosis
-1/3 will develop upper GI bleeding
-upper endoscopy- dx!

57

Child Pugh score

estimates cirrhosis severity!
-ascites, encephalopathy, bilirubin, albumin, PT time
-Class A- 5-6
-class B- 7-9
-Class C- 10-15

58

MELD score

(model for end-stage liver dz)
-predict survival in pts with cirrhosis
-serum bilirubin, creatinine, INR
-inc of 2 in first wk- predict in-hospital mortality

59

PBC (primary biliary cholangitis)- lab, assoc with? risk factors? tx

-autoimmune destruction of small intrahepatic bile ducts and cholestasis
-W>M
-isolated elevated Alk phos!!!
-antimitochondrial ab!!!
-IgM elevated, inc chol
-assoc HLA DRB1 and DQB1
-asoc with Sjogren, autoimmune thyroid, raynaud, scleroderma, celiac
-risk factors- smoking
-TX- ursodeoxycholic acid

60

Absorption- colon, duodenum, ileum

-colon- water
-duodenum- iron
-ileum- vit B12, bile salts

61

Hemochromatosis- caused by?

-autosomal recessive
-HFE mutation- C282Y
-iron accum- liver, pancreas, heart, adrenals, testes, pituitary, kidneys

62

Hemochromatosis- sx

-usually not until fifth decade!!
-cirrhosis, HF, hypogonadism, arthritis, skin pigmentation, DM

63

hemochromatosis- tx?


-avoid food rich in iron (Red meat), alcohol, vit C, raw shellfish, supplemental iron
-phelbotomies
-PPI- reduces intestinal iron abs
-Deferoxamine- chelating agent

64

Wilson disease- sx, tx

(hepatolenticular degeneration)
-autosomal recessive, <40
-N european
-copper deposition- brain, kidney, liver
-neuropyschiatric disease
-kayser-fleischer rings
-tx- oral penicillamine, liver transplant

65

Wilson dz- lab findings

-serum ceruloplasmin- low
-urinary excretion of copper- high
-hepatic copper- high

66

Budd-Chiari

-RUQ pain, painful hepatic enlargement, ascites, HSCM, jaundice
-occlusion of hepatic v or ICV
-hypercoagulable state!!
-complicated by HCC!

67

Budd-Chiari- Dx

-prominent caudate lobe!!
-screening- Doppler ultrasonography
-direct venography- "spider web" pattern!
-Bx- centrilobular congestion! (nutmeg liver)

68

assoc with oral contraception

-hepatocellular adenoma

69

Alpha-1 antritrypsin def

-autosomal recessive
-defective alpha1-AT accum in hepatocytes
-chrom 14- PIZZ
-micronodular cirrhosis- risk of HCC
-panacinar emphysema
-TX- smoking abstinence, liver transplant