Chronic Hepatitis

Question 1

Define Chronic Hepatitis

Answer 1

chronic inflammation of more than 6 months

Question 2

Common symptoms of chronic hepatitis

Answer 2

Fatigue
Malaise
Jaundice
Fever

Question 3

What do Serum Fibrosure and US elastography evaluate?

Answer 3

Non-invasive way to evaluate fibrosis of the liver

Question 4

Cirrhosis due to HCV risk factors

Answer 4

Male
More than 5 drinks daily (shit...)
Infection after 40 
Immunocompromised
Tobacco and Cannabis use

Question 5

Autoimmune Hepatitis

Answer 5

Type I: Anti-smooth muscle + ANA
Type II: Anti-liver/kidney microsomal (LKM)

Mainly Female 30-50’s
Progressive jaundice, epistaxis, amenorrhea
Hepatocellular type chemistry (elevated AST/ALT)

Question 6

Treatment for autoimmune hepatitis

Answer 6

Symptomatic

Glucocorticoids can potentially help

Question 7

What can excessive EtOH intake cause?

Answer 7

A good time

Fatty liver
Hepatitis
Cirrhosis

Question 8

What is defined as excessive EtOH intake

Answer 8

Males: >80g/day
Females: >30-40g/day

4 oz whiskey
15 oz wine
4 beers

Question 9

Symptoms of Alcoholic Liver Disease

Answer 9

Asymptomatic hepatosplenomegaly
Elevation of Liver tests (Bilirubin and ALP)
2:1 increase of AST:ALT
Hypoalbuminemia

Question 10

CBC findings of Alcoholic Liver disease

Answer 10

Leukocytosis with left shift
Anemia (Macrocytic/Megaloblastic)
Thrombocytopenia
Elevated PT time

Question 11

What is the treatment for Alcoholic Liver disease

Answer 11

stop drinking
Nutrition support including Thiamine to prevent Wernicke-Korsakoff

*GIVE THIAMINE WITH OR PRIOR TO GLUCOSE

Question 12

Wernicke-Korsakoff Syndrome

Answer 12

“Wet, Wobbly, Wacky”

• Saccadic eye movement
• Confabulation
• Incontinence

Question 13

Severe Alcoholic Hepatitis lab findings

Answer 13

Total bili >8-10 mg/dL and PTT > 6 sec

Question 14

What are the cutoff numbers for the Maddrey’s Discrimination Function, Glasgow Alcoholic Hepatitis Score, and MELD Scores that indicate glucocorticoid use and poor prognosis?

Answer 14

DF: >32
Glasgow: >9
MELD: >21 (>14 are put on liver transplant list)

Question 15

What is the most common cause of chronic liver disease in the US?

Answer 15

Non-Alcoholic Fatty Liver Disease

Question 16

What are the main causes of NAFLD and what can patient’s develop?

Answer 16

Metabolic syndrome:

• Obesity
• the bedis
• High Triglycerides

Increased risk for CVD, CKD, CRC

Question 17

Alpha 1 AntiTrypsin Deficiency

Answer 17

AR disorder
low levels of a1-antitrypsin leads to loss of inhibition of proteases which leads to liver damage.
- Pulmonary emphysema in lower lobes in young people
- MOST COMMON diagnosed hepatic disorder in children and infants

Question 18

What genotype is associated with alpha-1 antitrypsin deficiency?

Answer 18

PiZZ on Chr. 14

Question 19

Primary Biliary Cholangitis

Answer 19

autoimmune destruction of intrahepatic bile ducts and cholestasis

• Female predominance median age of 50
• Isolated elevation in ALP
• AMA Ab’s
• Increased IgM levels

Question 20

Risk factors and PE findings for Primary Biliary Cholangitis

Answer 20

Recurrent UTI’s
Smoking
HRT
Hair dye?

PE: Pruritis, jaundice, xanthelasmas

Tx: Ursodeoxycholic Acid

Question 21

Classic tetrad of Hemochromatosis

Answer 21

1. Cirrhosis with HSM
2. Abnormal pigmentation
3. DM
4. Cardiac Dysfunction

Question 22

Hemochromatosis etiology

Answer 22

AR
HFE gene mutation on Chr. 6 resulting in abnormal sequestration of Iron in the liver, pancreas, heart, kidneys, balls, pituitary

Question 23

Lab findings in Hemochromatosis

Answer 23

> 45% transferrin saturation with elevated serum ferritin

Question 24

Treatment for Hemochromatosis

Answer 24

1. Phlebotomy
2. PPI to reduce intestinal iron absorption
3. Deferoxamine

Question 25

What 3 infectious agents are hemochromatosis patients at risk for?

Answer 25

Vibrio Vulnificus Listeria Monocytogenes Yersinia

Question 26

Wilson Disease

Answer 26

``` AR disorder in ATP7B protein Impaired copper excretion and failure to incorporate it into ceruloplasmin - Hemolytic Anemia - Psychiatric problems - Kayser-Fleischer rings ``` Tx: Oral Penicillamine

Question 27

What is seen on liver biopsy in patients with right-sided heart failure?

Answer 27

Nutmeg Liver- Chronic venous congestion causing stasis

Question 28

What is "shock liver"

Answer 28

hepatitis caused by ischemia | - rapid elevation in AST/ALT greater than 5000 with a rapid rise in LDH

Question 29

3 most common causes of cirrhosis

Answer 29

1. Hep C 2. EtOH 3. NAFLD

Question 30

Pathophysiology of cirrhosis

Answer 30

Liver cell injury--> Fibrosis--> diminished blood flow--> nodule formation

Question 31

What is protective from cirrhosis?

Answer 31

Coffee and tea consumption

Question 32

Common findings on PE of cirrhosis

Answer 32

``` Jaundice telangiectasias Gynecomastia Ascites Palmar Erythema Asterixis (Liver flap) Dupuytran's Contracture ```

Question 33

What infection is Cryoglobulinemia seen in?

Answer 33

HCV

Question 34

Nail changes associated with cirrhosis

Answer 34

Muehrcke lines- what lines separated by normal nail color | Terry Nails- darkening close to the distal nail secondary to hypoalbunemia

Question 35

What must you rule out in a patient with ascites via an abdominal paracentesis?

Answer 35

Spontaneous Bacterial Peritonitis (SBP)

Question 36

Primary biliary cholangitis Ab

Answer 36

Anti-mitochondrial (AMA)

Question 37

Autoimmune hepatitis Ab

Answer 37

Type I: SMA (Anti-smooth muscle) | Type II: anti Liver-kidney (LKM)

Question 38

If serology shows >250 PMN/mL what is the Ddx?

Answer 38

SBP

Question 39

Treatment for HCC

Answer 39

Ablation or partial resection | Liver Transplant

Question 40

Management of decompensated cirrhosis

Answer 40

No EtOH, drugs, or Tobacco Acetaminophen Monitor AFP and perform US every 6m looking for HCC

Question 41

What are ascites?

Answer 41

accumulation of fluid in peritoneal cavity secondary to portal hypertension (most common cause)

Question 42

SAAG score

Answer 42

Serum Albumin - Ascites Albumin >1.1 is Liver issue <1.1 is something else (Biliary, Nephrotic, Pancreatitis)

Question 43

Hepatic Encephalopathy

Answer 43

Alteration in mental status in the presence of liver failure. Ammonia typically elevated but NOT correlated with severity (don't monitor) Tx: Lactulose (acidifies colon to trap basic ammonia in it to be excreted)