MTB 2

Question 1

Tx for ascites

Answer 1

1. Na+ and H2O Restriction
2. Spironolactone
3. Loops - no more than 1 L/day if renal fnc OK
4. Frequent abdominal paracentesis

Question 2

What is the SAAG?

Answer 2

Serum ascites albumin gradient

Question 3

SAAG < 1.1 g/dL in what dz?

Answer 3

Infxn - NOT SBP
Cancer
Nephrotic syndrome

Question 4

SAAG > 1.1 g/dL in what dz?

Answer 4

Portal HTN
CHF
Hepatic vein thrombosis
Constrictive pericarditis

Question 5

Spontaneous Bacterial Peritonitis (SBP)
What is it?
Ass’d bugs?

Answer 5

Infxn w/out perforation of bowel

E.coli, anaerobes, pneumococcus

Question 6

Best initial test for SBP?

Answer 6

Cell count with > 250 Neutrophils - start tx

>500 WBCs

Question 7

TX for SPB?

Answer 7

Cefotaxime, Ceftriaxone

Question 8

What is the most accurate test for SBP?

Answer 8

Fluid culture

Question 9

Presentation of SBP?

Answer 9

Pt presents with fever, abdominal pain, AMS

Question 10

How does hepatopulmonary syndrome present?

Answer 10

Liver failure causes lung disease and hypoxia

Orthodexia - hypoxia sitting upright

Question 11

Most accurate test for alcoholic liver dz?

Answer 11

Liver Bx

Question 12

How does Primary Biliary Cirrhosis present?

Answer 12

Women
40's-50's
Fatigue and itching
Normal BR
Elevated Alk Phosph
Xanthelesma/xanthoma
Osteoporosis

Question 13

Most accurate test for PBC?

Answer 13

Liver Bx

Question 14

Most accurate blood test for PBC?

Answer 14

Antimitochondrial Ab

Question 15

Tx for PBC?

Answer 15

Ursodeoxycholic acid

Question 16

How does Primary Sclerosing Cholangitis present?

Answer 16

Women
40's-50's
Pruritis
Elevated Alk Phosph and GGTP
Elevated BR
UC in 80%

Question 17

Most accurate test for PSC?

Answer 17

ERCP shows beading, narrowing, strictures

Question 18

Tx for PSC?

Answer 18

Cholestyramine

Ursodeoxycholic acid

Question 19

Alpha 1 Antitrypsin Deficiency

Answer 19

Liver dz
Emphysema (COPD)
Young pt < 40
Nonsmoker

Question 20

Hemochromatosis Pathophysiology?

Answer 20

Genetic disorder - mutation C282y gene

Overabsorption of iron in duodenum

Question 21

Presentation of hemochromatosis?

Answer 21

Male earlier than female (menstruation delays)
50's
mild elevation in AST and Alk Phos
Fatigue
Pseudogout = joint pain
ED men, Amenorrhea women
Skin darkens
DM
Cardiomyopathy - restrictive, dilated, conduction abnormalities
Hypothyroidism

Question 22

Best initial test for hemochromatosis?

Answer 22

Iron studies
Increased serum Iron and Ferritin and Transferrin saturation
Decreased TIBC

Question 23

Most accurate test for hemochromatosis?

Answer 23

Liver Bx

Question 24

When is iron chelation used in hemochromatosis?

Answer 24

Pt cannot be managed w/phlebotomy

Anemic and have hemochromatosis from overtransfusion (thalassemia)

Question 25

Wilson Disease pathophysiology?

Answer 25

Abnormally decreased Copper excretion Genetic = ATP 7B Dysfunction Decrease in ceruloplasmin, copper accumulates in liver, kidney, RBCs and CNS

Question 26

Pt presents w/cirrhosis, hepatic insufficiency, neuro sx's, Coombs Negative HA, RTA or nephrolithiasis?

Answer 26

Wilson Disease

Question 27

Neuro sx's in Wilson?

Answer 27

``` psychosis tremor dysarthria ataxia seizures rigidity catatonia ```

Question 28

Best initial test for Wilson?

Answer 28

Slight-light exam for Kayser Fleischer rings = brownish ring around eye

Question 29

What test is used for staging Wilson?

Answer 29

Liver Bx

Question 30

Most specifid blood test for Wilson

Answer 30

Low Ceruloplasmin

Question 31

Most accurate dx test for Wilson?

Answer 31

Increased amt of copper excretion into urine after penicillamine administration?

Question 32

Tx for Wilson Dz?

Answer 32

Penicillamine = chelates copper, removes from body Zinc - interferes w/intestinal copper absorption Trientine - alternative copper-chelating compound

Question 33

What is seen on liver Bx in hepatic failure w/Wilson?

Answer 33

``` Inflammation Portal fibrosis hepatocyte necrosis macrovesicular steatosis vacuolated hepatocellular nuclei Mallory bodies ```

Question 34

Autoimmune hepatitis presentation

Answer 34

Young woman Liver inflammation + ANA microsomal abs

Question 35

Anti-smooth muscle abs in what dz?

Answer 35

AI hepatitis | These are anti liver kidney microsome abs

Question 36

Most accurate test for AI hepatitis?

Answer 36

Liver Bx

Question 37

Tx for AI hepatitis

Answer 37

Prednisone | Azathiorpine

Question 38

Labs with AI hepatitis?

Answer 38

Elevated AST, ALT in thousands Elevated AP Ass'd with other AI dz - elevated IgG 1.5X Normal, Protein elevated, Albumin decreased

Question 39

Nonalcoholic Fatty Liver Dz or Nonalcoholic Steatohepatitis

Answer 39

``` Ass'd with metabolic syndrome TPN Cushings Steroid use DM ```

Question 40

Most accurate test for NASH?

Answer 40

Percutaneous liver Bx shoes microvesicular fatty deposits

Question 41

Si/Sx's in NASH?

Answer 41

Hepatomegaly | Labs: mild increase in AP, AST/ALT <1

Question 42

What is Reye syndrome?

Answer 42

ASA in children | Hepatic encephalopathy

Question 43

Presentation of Reye?

Answer 43

Children N/V, HA, delirium, hypoglycemia, liver failure, CNS

Question 44

Sudden onset of mental status changes, emesis, liver dysnfunction, taking aspirin?

Answer 44

Reye syndrome

Question 45

Labs seen with Reye syndrome?

Answer 45

Elevated LFTs Elevated ammonia Elevated PT Metabolic Acidosis

Question 46

Treatment for Reye syndrome?

Answer 46

Glucose with FFP | Mannitol to decrease cerebral edema

Question 47

Rapid, massive increase in liver enzymes (thousands) with modest elevation in total BR and AP

Answer 47

Ischemic Hepatic Injury/Shock Liver