Liver Disorders

Question 1

What is hemoglobin brokendown into?

Answer 1

Heme and globin

Question 2

Heme is converted to what by-product?

Answer 2

Bilivirdin

Question 3

Bilivirdin becomes what?

Answer 3

Unconjugated bilirubin

Question 4

What is unconjugated bilirubin?

Answer 4

Indirect bilirubin in labs

*Non-functional, fat soluble, bound to albumin

Question 5

Where is unconjugated bilirubin conjugated?

Answer 5

Hepatocytes

Question 6

What are the four phases of bilirubin metabolism?

Answer 6

• Production of bilirubin
• Uptake via liver cells
• Conjugation with glucuronic acid
• Transport via bile/urobilinogen

Question 7

Where is jaundice typically first seen?

Answer 7

Sclera or darkening of urine

Question 8

What is hyperbilirubinemia?

Answer 8

Accumulation of bilirubin in body tissues

Question 9

What is a normal bilirubin level in newborns (total)?

Answer 9

1.0 - 12.0 mg/dL

Question 10

What is a normal direct bilirubin?

Answer 10

0.1 - 0.3 mg/dL

Question 11

What is the normal indirect bilirubin?

Answer 11

0.2 - 0.8 mg/dL

Question 12

At what lab value is jaundice apparent around?

Answer 12

2.5-3 mg/dL

Question 13

Impaired uptake leading to hyperbilirubinemia is primary the result of

Answer 13

Certain drugs, can be treated by removing drug

Question 14

Is stool color normal in impaired conjugation caused hyperbili?

Answer 14

Light to normal

Question 15

What enzyme is immature in physiologic neonatal jaundice?

Answer 15

GT

Question 16

Why do we use UV light to treat physiologic neonatal jaundice?

Answer 16

UV light makes unconjugated bilirubin water soluble –> dissolves in bile

Question 17

What is Gilbert Syndrome?

Answer 17

Hereditary disorder –> reduced function of GT (evident with hemolysis)

Presents later in puberty or adulthood, episodic jaundice and hyperbili (worse with stress, ETOH)

Question 18

What is conjugated (direct) hyperbilrubinemia primary the result of?

Answer 18

Obstruction or hepatocellular dysfunction

Question 19

Is bilirubin itchy?

Answer 19

Yes, patients will be itchy

Question 20

What symptoms are found in conjugated (direct) hyperbilirubinemia?

Answer 20

Dark urine, jaundice, light stools

Question 21

What are the etiologies causing elevated indirect/unconjugated bilirubin?

Answer 21

Hemolysis
Drugs
GT dysfunction

Question 22

What are the etiologies causing elevated direct/conjugated bilirubin?

Answer 22

Liver dysfunction or obstruction

Question 23

Most liver studies are included in what lab?

Answer 23

CMP

Question 24

Elevations in AST/ALT reflect what hepatic problem?

Answer 24

Hepatocellular injury

Question 25

What is the most common cause of AST/ALT elevations?

Answer 25

Non-alcohol related fatty liver disease

Question 26

If the AST > ALT the liver injury is more related to what?

Answer 26

Alcohol related livery injury or cirrhosis

Question 27

What conditions is a livery biopsy better for

Answer 27

Diffuse disorders

Question 28

How is fulminant acute liver failure defined?

Answer 28

Development of hepatic encephalopathy within 8 weeks

Question 29

How is subfulminant liver failure defined?

Answer 29

hepatic encephalopathy 8 weeks to 6 months after onset

Question 30

What medication most commonly will lead to acute liver failure?

Answer 30

Rifampin

Question 31

What is the presentation of acute liver failure?

Answer 31

Jaundice Bleeding disorders Encephalopathy/AMS

Question 32

What is the cause of systemic inflammatory response syndrome (SIRS)?

Answer 32

Death or hepatocytes *patients are SICK! Multisystem organ dysfunction

Question 33

What is the treatment for acute liver failure?

Answer 33

Admit to ICU *Lots of things to be done

Question 34

Non-alcohol related liver disease exists on a continuum, what are the different stages?

Answer 34

Normal liver --> NAFLD --> NASH --> Cirrhosis

Question 35

What liver disease stage is irreversible?

Answer 35

Cirrhosis

Question 36

Non-alcohol related fatty liver disease has a significant correlation to what resistance?

Answer 36

Insulin resistance

Question 37

What is the presentation of NAFLD?

Answer 37

**Primarily asymptomatic +/- RUQ discomfort +/- Non-specific constitutional symptoms +/- isolated hepatomegaly

Question 38

What is the most reliable treatment for NAFLD?

Answer 38

Lifestyle modifications including GRADUAL weight loss

Question 39

What are the causes of cirrhosis?

Answer 39

- Viral hepatitis (C&B) - Alcohol - NAFLD - Drug toxicity - Autoimmune - Metabolic liver disorders

Question 40

What are the three stages of cirrhosis?

Answer 40

1. Compensated 2. Compensated with varices 3. Decompensated

Question 41

Are the symptoms of cirrhosis specific?

Answer 41

No, wide array of vague presenting symptoms

Question 42

When does the first liver positive physical exam finding appear in cirrhosis?

Answer 42

Late stage; will have a firm, palpable, nodular liver

Question 43

What imaging modality is good in assessing liver size?

Answer 43

US

Question 44

How do you assess for varices?

Answer 44

EGD

Question 45

What vaccines should be given to cirrhosis patients?

Answer 45

HAV, HBV, pneumococcal and annual flu

Question 46

What does portal hypertension lead to?

Answer 46

Third spacing

Question 47

What are the symptoms of hepatocellular carcinoma (HCC)?

Answer 47

Cachexia, weight loss, weakness Sudden development of ascites Enlarging liver with palpable mass

Question 48

What is the diagnostic test of choice in working up hepatocellular carcinoma (HCC)?

Answer 48

Biopsy

Question 49

What is the definitive treatment for chirrhosis and associated complications?

Answer 49

Transplant

Question 50

In order to be eligible for a liver transplant how long must you have sustained from alcohol?

Answer 50

6 months

Question 51

Is HIV and Hepatitis a contraindication for a liver transplant?

Answer 51

No

Question 52

Patients on the liver transplant list are prioritized by what score?

Answer 52

MELD score (eligible if 15+)

Question 53

True or False: Nearly everyone (90%) with harmful alcohol use develops some liver dysfunction

Answer 53

True

Question 54

Is there a dose effect associated with ETOH?

Answer 54

Yes

Question 55

What is the spectrum of alcohol related liver disease?

Answer 55

Alcohol related steatosis --> alcohol related hepatitis --> cirrhosis

Question 56

What is the primary treatment in alcohol related liver disease?

Answer 56

Abstinence from ETOH

Question 57

What are the two pharmacological agents that can be used to help abstain from alcohol?

Answer 57

Naltrexone (Vivitrol) Disulfram (Antabuse)

Question 58

Can you use disulfram in the treatment of alcohol related cirrhosis?

Answer 58

No, it should be avoided. Can use Naltrexone.