MET3 Revision: Hepatology II Flashcards

Question

Name 3 drugs that are associated with increasing risk factor for NAFLD [3] Name a surgery that is associated associated as a risk factor for NAFLD [1] Describe nutrition that is associated with increasing risk factor for NAFLD [2]

Answer 1

Drugs: - **Steroids** - **Amiodarone** - **Methotrexate** Weight reducing surgery: - **jejuno-ileal by pass** Nutrition * **Protein calorie malnutrition & TPN**

Answer 2

- **Weight loss**: diet & exercise - Consider **vitamin E** - Consider **pioglitazone** (reduces peripheral insulin resistance) - Consider weight loss medication: **orlistat** - Consider **bariatric surgery** if BMI > 35 and one other obesity co-morbid / BMI > 40. - **Liver** **transplant** | BMJ BP

Answer 3

The diagnosis requires the presence of - **ultrasound** findings of a **fatty** **liver** - **risk factors** - **excluding** other causes of liver disease with a careful alcohol history and full non-invasive liver screen. - **Liver biopsy is the gold standard test.**

Answer 4

Acute: - Hepatitis **A** - Hepatitis **E** Chronic: - Hepatitis **B** - Hepatitis **C** - Hepatitis **D**

Answer 5

Faecal-oral:: - Hepatitis **A** - Hepatitis **E** Bodily fluids:: - Hepatitis **B** - Hepatitis **C** - Hepatitis **D**

Answer 6

**Hep B**: requires Hep B surface antigens

Answer 7

- **Majority** (**65**%) exposed to acute HBV infection have **asymptomatic** **recovery** - **25%** have **acute** hepatitis but **recover** - **10%** have **chronic** infection (HBV antigens >6months) i) **90%** these: **asymptomatic** ii) **10%** lead to **chronic** hepatitis; cirrhosis; HCC

Answer 8

**Hepatitis B surface antigen (HbsAGs):** - will only be positive in current infection, whether acute or chronic. **Hepatitis B surface antibody (Anti-HBs):** - Confers immunity (can be after infection or vaccination) **Hepatitis B core antigen (HBcAg):** - expressed by infected hepatocytes, not used in the vaccination - **anti-HBc** will only be present in a previous or current infective state (never post-vaccination). - **IgG**: past exposure / chronic infection - **IgM**: acute infection **HBV DNA:** - used to confirm virus - used to monitor treatment (undetectable?) **HDV IgG**: in case of also Hep D infection **HbeAg/Ab**: level correlates to replication level & therefore infectivity

Answer 9

solely having antibodies to HBsAG: **HBsAB** ## Footnote Surface AB: Safe

Answer 10

Acute HBV: **IgM** Chronic HBV: **IgG**

Answer 11

**E antigen (HBeAg)**: marker of viral **replication** and implies **high infectivity:** Where the HBeAg is present it **implies the patient is in an acute phase of the infection** where the virus is **actively** **replicating**. The **level** of **HBeAg** **correlates** with their **infectivity** If the HBeAg is higher, they are highly infectious to others

Answer 12

Nucleoside analogues: - **Entecavir** - **Tenofovir** **PEG-IFN** (peginterferon alfa 2a)

Answer 13

Asymptomatic (majority) Jaundiced RUQ pain N&V Arthralgia urticaria (hives)

Answer 14

- most people with chronic HBV are also **asymptomatic** - symptoms of chronic liver disease: **palmar erythema; spider angiomas** (the number and size of spider angiomata correlate with increasing severity of liver disease); **asterixis; easy bruising** - symptoms of cirrhosis and portal hypertension: **ascites**; **hepatomegaly**; **splenomegaly; caput medusae** Extra-hepatic manifestations (10-20%): **serum sickness-like syndrome** (fever, arthralgia, malaise, lethargy); **Polyarteritis nodosa; Glomerular disease** (membranous nephropathy)

Answer 15

HBV: low HBC: 80% develop risk of chronicity (therefore higher risk of cirrohosis & HCC) | C = Chronic

Answer 16

* 1 in 4 fight off the virus and make a full recovery * 3 in 4 develop chronic hepatitis C: chronic hepatitis; cirrhosis; HCC

Answer 17

Test for: - **HCV antibody IgG** - **HCV RNA** (6 genotypes; can change treatment strategies) - **LFTs** - **HCC** **screen** (given higher risk): USS and AFP - **Liver biopsy** (rare) or Fibroscan to investigate stage of fibrosis}

Answer 18

HCV PCR [1] Procede to have biospy to see extent of damage

Answer 19

**8-12 weeks** **Therapies**: - ARVs: aim sustained virological response (SVR; undetectable serum HCV RNA six months after the end of therapy) - Combination dependent on genotype and stage of fibrosis - currently a combination of **protease** **inhibitors** (e.g. **daclatasvir + sofosbuvir or sofosbuvir + simeprevir**) with or without **ribavirin** are used

Answer 20

an **iron storage disorder in which** iron depositions in multiple organs (such as the liver, skin, pituitary, heart and pancreas) **leading to oxidative damage.** It is the most common genetic condition in the UK but may initially present with non-specific symptoms, leading to under-diagnosis.

Answer 21

- **human haemochromatosis protein (HFE) gene** - **autosomal** **recessive** - HFE mutation causes **decreased hepcidin activity** (regulates iron stores); **increased duodenal/jejunal iron absorption** AND **release of iron from bone marrow macrophages** → iron deposition in cells → Fenton reaction and hydroxyl free radicals → DNA, lipid and protein damage → organ dysfunction *Fenton reaction*: Iron freely undergoes oxidation in cells from Fe2+ to Fe3+ as part of the Fenton reaction In this process, hydroxyl free radicals are generated which then cause oxidative damage

Answer 22

menstruation acting to eliminate iron from the body

Answer 23

* Chronic tiredness * Joint pain * Pigmentation (bronze skin) * Testicular atrophy * Erectile dysfunction * Amenorrhoea (absence of periods in women) * Cognitive symptoms (memory and mood disturbance) Later: - Slate-grey skin pigmentation - Hepatomegaly - Dilated cardiomyopathy

Answer 24

- **Raised serum ferritin** - **Elevation** **transferrin** **saturation** - Raised AST & ALT (not more than 2x) - Test for HFE gene - Liver bx / Fibroscan - MRI (Ferriscan)}

Answer 25

**Venesection** (regularly removing blood to remove excess iron – initially weekly) **Iron chelation therapy** (iron chelator) works by binding to the extra iron so that it can be removed from the body): Oral: **Deferasirox** and parenteral agents **Desferrioxamine**.

Answer 26

**Chondrocalcinosis**: causes stressed joints to deteriorate faster than resting joints

Answer 27

Wilson's disease is an autosomal recessive disorder characterised by **excessive copper deposition in the tissues**

Answer 28

Liver: **hepatitis, cirrhosis** neurological: **basal ganglia degeneration, speech, behavioural and psychiatric problems** are often the first manifestations. Also: **asterixis, chorea, parkinsonism, dementia** **Kayser-Fleischer rings** **renal tubular acidosis** (esp. Fanconi syndrome) **haemolysis** **blue nails**

Answer 29

* **reduced serum caeruloplasmin** * **reduced** **serum copper**(counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin) * Liver bx * MRI brain * increased 24hr urinary copper excretion * haemolytic anaemia

Answer 30

**Copper chelation** using either: * **Penicillamine** * **Trientine** **Zinc salts** (inhibit copper absorption in the gastrointestinal tract) **Liver transplantation**

Answer 31

- **USS**: 6 months - test for **AFP** - tumour marker

Answer 32

**Cirrhosis** The Model of End-Stage Liver Disease (MELD) Score measures the severity of cirrhosis based on five parameters: serum bilirubin, INR, sodium, creatinine and need for dialysis.

Answer 33

NICE recommend **lactulose first-line** **rifaximin for the secondary prophylaxis of hepatic encephalopathy**

Answer 34

**Venesection** is the first line treatment for hereditary haemochromatosis. **Desferrioxamine** may be used second-line (medicine that removes excess iron that builds up after having regular blood transfusions)

Answer 35

**Corticosteroids** are used in the management of severe alcoholic hepatitis

Answer 36

How do you determine if a patient is acutely suffering from HBV? [1] - **HBsAg** How you determine if a patient has immunisation from vaccination? [1] - **A vaccine would only lead to anti-HBs antibodies** How you determine if a patient has immunisation from previous infection? [1] - immunity due to natural infection also leads to the **presence of anti-HBc antibodies** & **anti-HBs antibodies** *Anti-HBs = Safe (Have immunity so either immunised or previously exposed, -ve in chronic disease)* *Anti -HBc = Caught (acquired infection at some point rather than immunised)*

Answer 37

**ABCDE** A - albumin B - bilirubin C - clotting D - distention (ascites) E - encephalopathy

Answer 38

1st line: **prednisolone** 2nd line: **aziothropine** **Continue treatment for 2 years**

Answer 39

**Cirrhosis** **Ascites** **AKI not attributable to any other cause.**

Answer 40

**terlipressin**, have a growing evidence base supporting their use. They work by causing vasoconstriction of the splanchnic circulation **volume expansion with 20% albumin** **transjugular intrahepatic portosystemic shunt** (still have a v poor prognosis)

Answer 41

Budd–Chiari syndrome of **hepatic vein thrombosis** Associated with **pregnancy** and **being postpartum**

Answer 42

RUQ pain (hepatosplenomegaly) and ascites

Answer 43

The oral contraceptive pill

Answer 44

**Anti-HBsAg +ve only**

Answer 45

HBsAg +ve Anti-HBcAg IgM +ve

Answer 46

HBsAg +ve Anti-HBcAg IgG +ve

Answer 47

Anti-HBcAg IgG +ve Anti-HBsAg +ve ## Footnote NB: vaccine = **Anti-HBsAg +ve only**

MET3 Revision: Hepatology II Flashcards

(73 cards)