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Liver Disease


Viral hep that can cause cirrhosis Hep B & C
Conjugated bili: direct; bound to gluc acid; water soluble; caused by obstruction of outflow tract or in the liver
Unconjugated bili: indirect; water insoluble; caused by hemolysis
Fulminant acute liver dz: progress to liver fail in 14 days; no h/o liver dz; develop coagulopathy (INR >2), encephalopathy
ALT/AST hepatocell injury: correlates w/degree of cell death; >1000: hepatitis, shock, toxins (Tylenol)
Abnormal AST/ALT AST:ALT >2:1 = alcoholic hep; <500: EtOH; poss normal in cirrhosis
Alk phos liver, bone, intestinal tract, placenta, kidney; elevated in liver damage/obstruction; if elevated more than AST/ALT, more likely biliary disorder
Child-Pugh score assesses: prognosis of chronic liver dz
Alfa fetoprotein (AFP) is used to detect: hepatocellular ca; inflammation
Liver dz lab w/u Hep A, B, C; ANA; ASMA; IgG; Anti-mito Ab (primary biliary cirrhosis)
Labs for hemochromatosis ferritin, iron sat, HFE gene
Hep A clinical features Incubation 4-6 wks (average 30d); 80% jaundice pts >14 yo; fulminant course uncommon; no chronic/carrier state
Hep B clinical features Incubation 6 wks- 6 mos (average 60-90d); 60% fulminant dz; 15-25% premature mortality; cirrhosis (3-5%); HCC; Asians
Hep C clinical features Incubation 6-7 weeks; 40% jaundice; 50-70% chronic; persistent; AA men in 40s; No. 1 indication for liver transplant
Hep C dx labs ELISA (pos in 8-10 wks; good screen for chronic); HCV RNA; HCV genotype
Alcoholic hepatitis 40-60 g EtOH/day (less for women); jaundice, fever, anorexia, nausea; TBil, alb, INR; histo makes the dx; hepatomegaly, steatohepatitis; Tx supportive (severe: prednisone/pentoxifylline)
Cirrhosis: dx pathologic; Fibrosis, Regenerated nodules, Vascular distortion
Cirrhosis: complications Hepatorenal syndrome; Hepatoma (hepatocell ca); Portal HTN (Varices, Ascites, Encephalopathy, GI bleeding)
Varices Tx Active bleed (Hematemesis, melena, hematochezia; Hypotension, tachy): Emergent endoscopy; Octreotide (splanchnic VC to reduce portal pressure; dec collateral flow & variceal pressure); Minnesota tube: Last chance (bridge to TIPS)
Varices prevention screening endoscopy; endo banding (if large varices & prior bleed); beta blockers to HR<60; nitrates
Ascites 60% develop within 10 yrs of cirrhosis dx; US (check for fluid & portal v. thrombosis)
Serum ascites albumin gradient paracentesis; if gradient >1.1: portal HTN
Spont bac peritonitis peritoneal cell count: >500 PMN confirms dx
Ascites mgmt Na & fluid restriction; diuretic tx (Aldactone/Lasix); LVP & albumin replacement; TIPS for refractory ascites
Encephalopathy tx r/o infxn, correct lytes; lactulose; neomycin; rifaximin
Cirrhosis & Hepatoma (HCC) screen (US & AFP 6-12 mos); common/increasing worldwide ca; tx Partial hepatectomy, Chemoembolization, RF ablation; poss TP
Liver TP indications Hep C (No. 1 in US); EtOH (abstinent >6 mos); Cryptogenic/NASH; PBC, PSC; Autoimmune hep; Hep B; risk of relapse in new liver
NASH chronic hep or metab syn; usu Asx; liver bx; hepatocytes replaced; tx: stop offending meds; wt/glycemic ctrl
Benign masses: dx imaging > bx; 20% of popn
Most common benign liver tumor hemangioma; W>M, 20-40 (2nd most common: FNH)
Hepatic adenoma W>M, young, LT estrogen use; anabolic steroids
HCC/malignant mass usu in setting of chronic liver injury or cirrhosis; need multi-phasic imaging to dx (arterial phase hypervascularity; delayed phase wash-out)
Hep A mgmt IVIG within 14d post exposure
Hepatitis virus types (RNA / DNA): HAV: RNA virus; HAV: double-stranded DNA; HCV: single-stranded RNA; HDV: defective RNA virus (requiring assistance by HBV)
Hepatitis: modes of transmission HAV: fecal-oral route; HBV: blood or body fluids (sex, transfusion, IVDU / needles); HCV: blood or body fluids (50% IVDU); HEV: fecal-oral route
Defn Chronic HBV: Positive HBSAg >6 months
Hep E clinical features Incubation 35-40 days; 0.5% mortality (20% in PG); no carrier state
Viral hepatitis causing spiking fevers: HAV
Acute Hep C mgmt Acute HCV may benefit from interferon alpha or peginterferon (reduces risk of chronic hep)
How many patients with acute HCV clear the virus spontaneously? 20%
Chronic Hep C mgmt slow-release peginterferon; daily ribavirin in divided doses; protease inhibitors (boceprivir or teleprivir)
Chronic Hep B mgmt interferon alpha or peginterferon; possibly entecavir or tenofovir (short-term: lamivudine & telbivudine)
Use of immune globulin: Give to all household persons / close contacts of patient with HAV. Give HBIG within 7 days of exposure to HBV
Cirrhosis etiology EtOH (leading cause in US); viral hep; chronic biliary obstruction, metabolic disorders; CHF
Cirrhosis workup Labs: CBC (low WBC, anemia, low Plt), elevated PT/PTT & LFTs; US (HSM, liver nodules/atrophy); endoscopy (varices); CT & bx (dx HCC)
Created by: Adam Barnard Adam Barnard