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liver!! Flashcards

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1
Q

fatty liver patho

A

1st stage of liver disease d/t alcohol consumption - >30% of hepatocytes w/ TG accumulation
**reversible quickly w/ abstinence! no fibrosis / necrosis!

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2
Q

fatty liver pres

A
  • most asx

- may have vague malaise, fatigue, RUQ pain

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3
Q

fatty liver labs

A
  • w/ alcohol, expect AST:ALT 2:1 or more
  • *mild elevation - AST rarely >300-500 and ALT rarely >300!
  • can have normal labs!!
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4
Q

NAFL patho

A

fatty liver due to metabolic complications - a/w insulin resistance w/ increased lipolysis, TG accum in liver and FA uptake!
***does NOT progress and NOT a/w sig inflammation!

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5
Q

NASH patho

A

progressive NAFLD w/ >50% of hepatocytes w/ TG accumulation with inflammation and fibrosis!
*progresses to cirrhosis (1-5%) and hepatocellular carcinoma!

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6
Q

RF NAFL & NASH

A
  • insulin resistance, metabolic syndrome, diabetes, obesity, dys/hyperlipidemia, hypothyroidism
  • can see NAFLD acutely w/ pregnancy - confusion, RUQ pain, jaundice - must deliver to correct!
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7
Q

when to suspect NAFLD and NASH…

A

Asx patient with elevated AST and ALT, espeically w/ diabetes / obesity / hyperlipidemia!

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8
Q

workup for NAFLD

A
  1. CMP to see elevated LFT
    • AST < ALT = NONALCOHOLIC!
    • AST: ALT = 2:1 or more…ALCOHOLIC!
  2. check RF - lipids, glucose, AIC and check meds (methotrexate, glucocorticoids, tetracyclines, tamoxifen)
    - acute changes: LDH, AST, ALT, lactate
    - chronic changes: PT, bilirubin, albumin
  3. R/o hepatitis!! w/ serology!
  4. r/o autoimmune w/ ANA, gammaglobulin, antismooth muscle antibody
  5. r/o hemochromatosis w/ iron studies!
  6. often have elevated alk phos and ferritin
  7. u/s is best imaging
  8. biopsy only for severe - only way to differeentiate NAFLD AND NASH
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9
Q

NAFLD diagnostic criteria

A
  1. evidence (imaging / histology) of steatosis
  2. r/o alcohol consumption
  3. r/o other causes of steatosis
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10
Q

labs c/w alcoholic liver dz

A
  1. ast: ast >2 and moderately increased (hundreds)
  2. increased ggt
  3. macrocytic anemia
  4. increased carbohydrate-deficient transferrin
    * always check bili, alk phos and GGT, albumin and coag tests
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11
Q

diagnosis of alcoholic liver dz…

A
  • consistent hx, PE findings
    1. labs -elevated ast: alt 2:1 or more, elevated ggt, macro anemia
    2. r/o hepatitis, hemochromatosis, autoimmune
    3. steatosis on imaging: u/s (cannot distinguish from nonalcoholic steatosis!)
  • may need biopsy if unclear after imaging
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12
Q

distinguishing NAFL and NASH…

A

LIVER BIOPSY then calculate NAFLD score -
<3 = NAFL
3-4 = borderline NASH
5+ = NASH

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13
Q

NAFLD management

A
  1. WEIGHT LOSS!!! most beneficial!
  2. control other CVD risk factors - statin for lipids, diabetes
  3. vitamin E in non-diabetics
  4. avoid alcohol!
    - monitor labs q 1 year and u/s q 1 year
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14
Q

metabolic syndrome - criteria

A

3 or more of:

  1. blood glucose 100+ or on tx
  2. bp 130/85 or more or on antihypertensives
  3. triglycerids of 150 or more or on tx
  4. hdl < 50 women
  5. waist circum 102cm or more in men or 88 cm or more in women
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15
Q

cirrhosis! patho and causes

A

chronic liver dz/ w/ fibrosis and nodules, most due to alcohol and hep c/b

  • irreversible!
  • 2 major effects:
    1. portal HTN: ascites, edema, caput medusa, hemorroids, splenomegaly, varicosities
    2. biochem changes w/ hepatocyte death: low albumin, increased conjugated bili, abnl coags
  • always look at meds, family hx (think about alpha 1 antitrypsin def, hemochromatosis, wilsons..)
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16
Q

cirrhosis - whats used to classify severity?

A

child classification - a (best) and c (worst)

- assesses ascites, albumin, bili, encephalopathy and nutrition status

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17
Q

cirrhosis pres

A
  • lots asx
  • nonspecific malaise, fatigue, RUQ discomfort, anorexia, bleeding
  • stimata: caput medusa, ascites, palmar erythema, spider angiomatas, peripheral edema, fluid wave, gynecomastia, testicular atrophy
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18
Q

whats considered “decompensated cirrhosis?”

A

once a patient has complications of cirrhosis = decompensated

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19
Q

complications of liver dz

A

AC, 9H:

  1. ascites
  2. coagulopathy
  3. high ammonia
  4. hepatic encephalopathy
  5. hypoalbumin
  6. hepatorenal syndrome
  7. high bilirubin
  8. hypoglycemia
  9. portal hypertension
  10. hepatocellular carcinoma
  11. hyperestrinism (vascular changes)
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20
Q

portal htn - liver dz

A
  • pres: bleeding, ascites
  • dx: paracentesis can help if ascites present
  • tx: TIPS, nonselective BB for varices if present
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21
Q

ascites - liver dz

A

MOST COMMON COMPLICATION! MUST HAVE PORTAL HTN TO HAVE ASCITES! then also have low albumin!

  • pres: shifting dullness, fluid wave, distension
  • dx: paracentesis indicated w/ new-onset / changing, suspect SBP, SOB/tense abdomen
    • *serum ascites albumin gradient >1.1 suggests portal htn! (transudate, while <1.1 suggests exudate d/t inflam / pancreatitis/ biliary / CA)
  • confirm w/ ultrasound
  • tx: bed rest, salt restriction and diuretics: lasix + aldactone! may need abx if suspect SBP
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22
Q

hepatorenal syndrome - liver dz

A
  • seen w/ advanced liver disease - renal failure d/t poor perfusion and arterial vasoconstriction that does NOT respond to fluids!
  • often precipitated by infection or diuretics!
    sx: azotemia, oliguria, hypotension, hyponatremia and low urine sodium
  • tx: liver transplant - poor prognosis!
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23
Q

SBP - liver dz

A
  • infection of ascitic fluid most d/t E coli
  • pres: abdominal pain, rebound, fever
    • suspect in anyone w/ ascites w/ new onset fever or change in mental status
  • dx: paracentesis w/ wbc >500 and PMN <250, culture
  • tx: for prophylaxis: rocephin, tailor to culture and repeat paracentesis 2-3 days later to doc decreased PMN
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24
Q

cirrhosis tx

A
  1. avoid alcohol and toxic meds!

2. monior labs q 3-4 mo, endoscopy for varices (nonselective BB for prophylaxis), CT biopsy if suspect HCC

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25
ascites - medications
1. spironolactone (aldactone): 100-400 mg PO qd alt: amiloride, tiramterene - monitor K 2. lasix -2nd line / adjunct w/ aldactone - if intractable: paracentesis, replace albumin and 1/2 dose of diuretic - TIPS and shunt * *stop diuretics if sodium 2
26
#1 cause of intractable ascites...
EXCESS SODIUM!!
27
hepatic encephalopathy - patho
reversible mental status changes, ASTERIXIS, neuromuscular twitching in liver dz d/t ammonia accumulation -often in pt w/ liver dz w/ insult (hemorrhage, infection, fluid or electrolyte disturbance)
28
hepatic encephalopathy stages
1. mild confusion, changes in speech / sleep 2. marked confusion, lethargy, asterixis 3. stuporous, incoheret, asterixis, arousable 4. coma - fetor hepaticus: musty breath
29
hepatic encephalopathy - dx
1. r/o tox, hypoglycemia | 2. EEG - symmetric slowing of basic rhythm
30
hepatic encephalopathy tx
1. lactulose - titrate to 2-3 bm/d 2. if worsening or no change after 2 days add rifaximin (very expensive, not long-term tx) 3. neomycin / FQ / flagyl - will help decrease ammonia production by decreasing bowel flora 4. reduce protein to 30-40 g/day
31
LFT abnormalities...
ALT is more specific!! - with mild increase (hundreds) think about chronic viral hepatitis (BCD), alcoholic - moderate increase: acute viral - severe (thousands): shock liver, ischemic, severe acute viral hepatitis
32
cause of increased LFT + asx
1. autoimmune 2. hep B 3. hep C 4. drugs 5. ethanol 6. fatty liver 7. growths (ca) 8. hemodynamic dz (CHF) 9. iron, copper
33
acute and chronic hepatitis
acute: 6 mo | * can be caused by EBV, CMV and HSV in immunosuppressed
34
hepatitis transmission
A and E: fecal-oral, most in developing countries NO CHRONIC FORMS!!! B: parenteral and sexual; perinatal in asia and africa C: parenteral - IV DRUG USERS D: only as coinfection w/ B or superinfection in chronic B **chronic forms of b,c,d!!
35
acute hepatitis pres
wide range from asx to fulminant! - often have jaundice, N/V, anorexia, aversion to smoke, RUQ pain, dark urine (d/t increased conjugated bili), malaise * *polyarteritis nedosa w/ B and cryoglobulinemia w/ C
36
acute liver failure
- fulminant: develop hepatic encephalopathy within 8 weeks of acute liver disease onset. all have coagulopathy (INR 1.5 and up) - subfulminant: develop hepatic enceph 8 weeks-6 mo w/in onset of acute liver disease * *most d/t tylenol tox, idiosyncratic drug rxns (abx, AED, anti-TB meds) - death most commonly d/t cerebral edema and sepsis
37
acute liver failure tx
aimed at correcting metabolic disturbances - lactulose for encephalopathy, acetylcysteine for tylenol tox, GI prophylaxis, mannitol for cerebral edema
38
hep a testing
-elevated AST and ALT, then increased alk phos (not seen w/ hep b) -serum IgM anti-HAV with clinical symptoms= gold std for diagnosis of acute infection -peaks in 1st week, gone in 3-6 mo IgG indicates exposure - positive after 1 mo, persists for years-decades
39
hep a prognosis
expect recovery! supportive tx and bed rest. most recover in 3-6 months! only see symptoms in adults! kids = asx!
40
hep b testing
- higher ast and alt than in hep a, no signs of cholestasis 1. HBsAg: 1st sign of acute infection before biochemical changes - if positive >6 mo = chronic infection - if negative = virus cleared! 2. anti-hbs: appears once surface antigen is gone! 1-3 mo after infection * pos = sign of RECOVERY, NONINFECTIOUS, IMMNUNE 3. Anti-HBc = IgM and IgG - after surface antigen, before antibody - pos = acute or chronic - IgM pos in acute and flares of chronic - IgG pos in acute and persists 4. hbeag: indicates replication and infectivity 5. hbv dna - mimics hbeag - if positive >6 weeks - risk of chronic!
41
hep b tx / prognosis
- chronic form more in KIDS and immunocompromised! most clear in 3-6 mo - tx: interferon alpha (alt = lamivudine) for CHRONIC - potential exposure / neonate: immune globulin w/in 7 days then vaccinate!
42
hep c testing
1. hep c antibody: positive in 2-6 mo - more indicative of exposure 2. hep c RNA - positive 1st w/in 2 weeks! 3. always check genotype - changes treatment! - w/ positive antibody, check RNA or if suspect acute / known exposure automatically get RNA at same time as antibody! - w/ positive RNA, marked increase in enzymes and neg antibody = likely ACUTE infection! - RNA often lower in acute - w/ positive RNA, positive antibody and moderate elevated enzymes = more likely chronic - higher more stable RNA levels, fibrosis - pos antibody + neg RNA = CLEARED previous infection
43
hep c tx - chronic
peginterferon and ribaviron - longer for genotype 1
44
hep d testing
-to infect, must have positive Hbsag and Igm Anti HBc and then check for HDV antibodies!
45
hep e testing
``` test for Igm HEV #1 cause of acute hep worldwide! ```
46
hepatocellular adenoma - RF , a/w...
benign liver tumor most in young women (15-40) a/w steroid use and OCPs!!
47
hepatocellular adenoma pres
- asx or RUQ pain / fullness | - dx: often single mass seen on imaging - ct or u/s
48
hepatocellular adenoma tx
-stop OCP -resect if >5 cm d/t risk of RUPTURE! 10% risk of malignant transformation!
49
cavernous hemangioma
MOST COMMON BENIGN LIVER TUMOR! vascular tumor d/t dilation of vessels
50
cavernous hemangioma pres
most asx, may have RUQ pain (r/o other causes if present) - dx w/ imaging: u/s or ct w/ iv contrast! * *BIOPSIES ARE CONTRAINDICATED!!!
51
cavernous hemangioma tx
-most dont need treatment unless symptomatic or high risk of rupture!
52
focal nodular hyperplasia
second most common benign tumor of liver - NO MALIGNANT POTENTIAL!!! -NOT a/w OCP and has a CENTRAL SPOKE WHELL SCAR!
53
focal nodular hyperplasia pres
most asymptomatic! | -usually nodular mass in both R and L lobes w/ fibrous scar w/ radiating septa!
54
focal nodular hyperplasia workup
- can dx w/ imaging (ct / mri) w/ characteristic scar and asx - if painful, r/o other causes of pain - if uncertain / no scar, must dx histiologically
55
focal nodular hyperplasia tx
- w/ central scar and asx - no treatment | - if growing / persistent sx - resection
56
liver cancers...
mostly metastatic! | most common primary = hepatocellular carcinoma!!! (>80% primary)
57
hepatocellular carcinoma
#1 primary tumor (most liver tumors= mets!) - rare in u.s. but #1 cause of cancer deaths worldwide!!
58
hepatocellular carcinoma types
1. nonfibrolammelar - more common - a/w hep B, C, cirrhosis! - typically NOT resectable and SHORT survival (less than 1 year) 2. fibrolamellar - less common - NOT a/w hep b, c or cirrhosis - more in teens / young adults - more likely resectable w/ longer survival
59
HCC risk factors
1. cirrhosis (develops in 10%) 2. liver carcinogens 3. hepatocellar adenoma 4. inheritied liver dz - wilsons, AAT, hemocrhomatosis 5. smoking
60
HCC pres
-male, 50s-60s w/ PAINFUL HEPATOMEGALY w/ constitutional fever, weight loss fatigue and signs of cirrhosis
61
HCC workup
1. check hep b, c, lft, coags 2. check AFP - elevated in 40-70% - for diagnosis and treatment monitoring 3. imaging - u/s or CT * *positive for hypervascular mass >2cm w/ elevated AFP in pt w/ cirrhosis is DIAGNOSTIC for HCC!!!! 4. biopsy - only done for non-operative patients!!
62
HCC tx
tx of choice: resection - done for child class A - if non op- ablation, percutaneous ethanol injection, embolization * systemic chemo not effective! - mets: bone, lung, peritoneum
pulmonary
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