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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 (hepatocellular ca); Portal HTN (pressure > 12mmHg; 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)
Most common primary for liver mets Colon (no. 1), GI tract (adenocarcinoma), breast, lung. Primary liver cancer is uncommon.
Risk factors for liver cancer Aflatoxins (in food with Aspergillus flavus). Cirrhosis. Parasitosis (liver fluke: Clonorchis sinensis). Alpha-antitrypsin deficiency
Types of liver cancer (4) HCC (nodules with prominent vascularity). Cholangiocarcinoma (adenocarcinoma from bile ducts). Hepatoblastoma (HCC fetal variant w/familial adenomatous polyposis). Metastatic
Portal HTN etiologies Cirrhosis (EtOH, hepatitis, hemochromatosis). Budd-Chiari (phlebitis). Extrinsic compression (trauma, inflammation, tumor). Schistosomiasis
In varices, collateral circulation develops thru: coronary vein (stomach/esophagus), superior hemorrhoidal veins, anterior abd wall veins , plexus of Retzius
Portal HTN tx Vasopressin with nitrates, octreotide, propranolol
Portal HTN surgical mgmt Paracentesis and peritoneovenous conduits (for ascites). Portal decompression: TIPS, portosystemic shunt, splenectomy, GE devascularization (Sugiura). Liver transplant
Elevated AST, ALT, indirect bilirubin = Hepatitis
Isolated elevated indirect bilirubin = Gilbert syndrome
Elevated indirect bilirubin w/defective glucuronyl transferase Crigler-Najjar
Photosensitivity, abd pain w/ neurologic dysfunction, erythema or skin fragility Porphyria
Spontaneous bacterial peritonitis (SBP) = infected ascites
Hep B transmission Sex; bloodborne (1 in 63K risk); perinatal (c-section does not lower risk): vax+HBIG
histological pattern of advanced fibrosis in liver = cirrhosis
Most common cause of abnormal liver tests fatty liver dz
Hep A incubation average 30d
Hep B incubation average 60-90d
Hep C incubation average 6-7 wk
Hep A clinical sxs 80% jaundice pts >14 yo; fulminant or cholestatic hep
Hep B clinical stuff 15-25% premature mortality; cirrhosis/hepatocell ca; Asians
Hep C clinical stuff 40% jaundice; 70% chronic; persistent; AA men in 40s; No. 1 indication for liver transplant
Most common benign liver tumor hemangioma; W>M, 20-40 (2nd most common: FNH: focal nodular hyperplasia)
No. 1 indication for liver transplant Hep C
Hep B: more likely to become chronic if: young at age of infxn (or immunocompromised); 95% of pts clear the virus & develop Abs; chronic Hep B increases risk of cirrhosis & HCC
Created by: Abarnard
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