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43 Cards in this Set

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How is liver disease categorized?
Liver disease is categorized by whether it affects the biliary tree or the parenchymal cells.
Biliary tree disorders generally elevate ______ and _______.
Biliary tree disorders generally elevate ALKALINE PHOSPHATASE and BILIRUBIN.
Hepatocellular injury elevates ___________ more dramatically than ___________ or ____________.
Hepatocellular injury elevates LIVER TRANSAMINASES (ALT, AST) more dramatically than BILIRUBIN or ALKALINE PHOSPHATASE.
What are the causes of elevated transaminases greater than 2000 mg/dL?
Transaminases greater than 2000 mg/dL are caused by :
1. viral hepatitis
2. drug-induced hepatitis
3. ischemic hepatitis such as with with shock.
What are causes of hepatocellular injury that raise transminases more modestly (not as high as 2000 mg/dL)?
1. Alcohol
2. Passive liver congestion from right-sided heart failure
3. Autoimmune disorders
4. Inherited storage disorders
5. Tumors
6. Non-alcoholic steatohepatitis
Hepatitis A and E are passed by the ________ route, while hepatitis B, C, and D are acquired parentally, usually through ________, ________ or ________.
Hepatitis A and E are passed by the FECAL-ORAL route, while hepatitis B, C, and D are acquired parentally, usually through SEXUAL CONTACT, TRANSFUSION or IVDU.
Hepatitis A virus (HAV) is endemic in developing countries where it causes approximately 35% of cases of ____________.
Hepatitis A virus (HAV) is endemic in developing countries where it causes approximately 35% of cases of ACUTE VIRAL HEPATITIS.
Infection with hep B virus (HBV) is often __________. Less than 5% of individuals who are infected as adults develop chronic infection; by contrast 90% of ______________ hep B infections become chronic.
Infection with hep B virus (HBV) is often ASYMPTOMATIC. Less than 5% of individuals who are infected as adults develop chronic infection; by contrast 90% of PERINATALLY ACQUIRED hep B infections become chronic.
Hep C virus is the most common chronic blood-borne infection in the US, with 60% of transmission due to __________.
Hep C virus is the most common chronic blood-borne infection in the US, with 60% of transmission due to IVDU.
Unlike hep B, most individuals develop _________ infection with hep C.
Unlike hep B, most individuals develop CHRONIC infection with hep C.
The course of hep C infection is insidious, and most patients do not notice any symptoms during the first ______ decades of infection.
The course of hep C infection is insidious, and most patients do not notice any symptoms during the first TWO decades of infection.
Hep D virus (HDV) requires _________ with _____ in order to replicate. Seroprevalence is low in the US except in IVDU and recipients of multiple transfusions.
Hep D virus (HDV) requires COINFECTION with HBV in order to replicate.
Hep E virus (HEV) infection is usually inconsequential and self-limited, although mortality rates greater than 30% have been seen in ________________.
Hep E virus (HEV) infection is usually inconsequential and self-limited, although mortality rates greater than 30% have been seen in WOMEN INFECTED DURING THE THIRD TRIMESTER OF PREGNANCY.
Chronic liver disease is any condition that causes hepatic inflammation for longer than _____ months.
Chronic liver disease is any condition that causes hepatic inflammation for longer than SIX months.
The most common causes of chronic liver disease include chronic viral hepatitis from:
1.
2.
The most common causes of chronic liver disease include chronic viral hepatitis from:
1. HBV
2. HCV
Other etiologies for chronic liver disease include:
1. alcohol
2. autoimmune diseases
3. drugs
4. hemochromatosis
5. Wilson's disease
6. alpha1-antitrypsin deficiency.

Each of these disorders can lead to cirrhosis, with alcohol abuse as the leading cause.
Alcohol is a common co-contributor to cirrhosis in other conditions, particularly hepatitis ____
Alcohol is a common co-contributor to cirrhosis in other conditions, particularly hepatitis C.
Cirrhosis occurs more frequently in individuals who have a history of _________ and continue to drink.
Cirrhosis occurs more frequently in individuals who have a history of ALCOHOL HEPATITIS and continue to drink.
What drugs cause hepatocellular injury?
1. methyldopa
2. acetaminophen
3. trazodone
4. phenytoin
5. nitrofurantoin
6. isoniazid
7. antilipid agents (statins and fibrates)
8. sulfonamides

All are associated with drug-induced hepatitis.
Autoimmune hepatitis causes liver inflammation. Although autoantibodies are often found, they do not directly cause the hepatitis. Type 1 is responsible for 80% of adult cases in the US. Most of type 1 occurs in _________ , whereas type 2 is more common in _________.
Most of type 1 occurs in YOUNG WOMEN, whereas type 2 is more common in CHILDREN.
What are some of the inherited causes of liver disease?
Autosomal recessive causes of liver disease include:
1. hemochromatosis
2. Wilson's disease
3. alpha-1 antitrypsin deficiency
Hemochromatosis results from abnormally increase intestinal ________ absorption and ______ deposition in a variety of organs including the ______, ______, ______, and _______.
Hemochromatosis results from abnormally increase intestinal IRON absorption and IRON deposition in a variety of organs including the LIVER, HEART, PANCREAS, and PITUITARY.
In Wilson's disease, impaired _______ excretion into the bile results in accumulation of ______ in the liver and other tissues resulting in ________ and/or _________ abnormalities.
In Wilson's disease, impaired COPPER excretion into the bile results in accumulation of COPPER in the liver and other tissues resulting in CIRRHOSIS and/or NEUROPSYCHIATRIC abnormalities.
Acute hepatitis is often obvious, occuring with _____________ pain and jaundice. Nausea, anorexia, and malaise are often present.

If hepatic failure has occurred, encephalopathy and coagulopathy are likely as well.
Acute hepatitis is often obvious, occuring with RUQ pain and jaundice.
Chronic hepatitis (in contrast with acute hepatitis), is often insidious and nonspecific with fatigue, anorexia, and/or pruritis.

You must use your H&P to detect ________ and subtle signs.
You must use your H&P to detect RISK FACTORS and subtle signs.
What are risk factors for viral hepatitis?
1. IVDU
2. Prior transfusion
3. Tattoos
4. Cocaine use
5. Occupational exposure
6. Sexual behavior
7. Travel history
8. Birthplace in an endemic area
Besides assessing risk factors for liver disease, what other components of the clinical history are pertinent?
1. Ask about toxin exposure (alochol and medications)
2. Family history of liver or autoimmune disease is also pertinent.
Scleral icterus is visible when bilirubin level is about _________ .
Scleral icterus is visible when bilirubin level is about 3 mg/dL.

Most patients with chronic liver disease remain anicteric until acute exacerbation or end-stage disease occurs.
Other signs of chronic liver disease result from __________ and include spider angiomata, palmar erythema, Terry's nails (dark red distal nail, pale proximate nail), and jaundice.
Other signs of chronic liver disease result from CIRRHOSIS and include spider angiomata, palmar erythema, Terry's nails (dark red distal nail, pale proximate nail), and jaundice.
Advanced disease occurs with postnecrotic cirrhosis and advanced hepatic fibrosis.

Portal hypertension develops and, beyond a critical threshold, results in _________.
Portal hypertension develops and, beyond a critical threshold, results in ASCITES, seen as bulging flanks, or detected as shifting dullness.
Other manifestations of portal hypertension (besides ascites) include __________ (engorged vessels around the umbilicus), bleeding ___________ , severe hemorrhoids, muscle wasting, encephalopathy, and peripheral edema.
Other manifestations of portal hypertension (besides ascites) include CAPUT MEDUSA (engorged vessels around the umbilicus), bleeding VARICES, severe hemorrhoids, muscle wasting, encephalopathy, and peripheral edema.
Patients with _____________ may have bronze skin color.
Patients with HEMOCHROMATOSIS may have bronze skin color.
Patients with either alcohol-induced liver disease or hemochromatosis may have _______ atrophy, although this is not seen in patients with other causes of liver disease.
Patients with either alcohol-induced liver disease or hemochromatosis may have TESTICULAR atrophy, although this is not seen in patients with other causes of liver disease.
Patients with __________ deficiency may present with early ____________ in the lung bases.
Patients with ALPHA1-ANTITRYPSIN deficiency may present with early EMPHYSEMA in the lung bases.

Note: alpha1-antitrypsin deficiency causes emphysema, chronic hepatitis and eventually cirrhosis.
What laboratory tests should I order when I suspect liver disease?
Liver enzymes (transaminases or aminotransferases) are sensitive indicators of liver injury.

These include ALT and AST.
____ is more specific for liver injury, whereas ____ may be elevated owing to skeletal, cardiac, and liver muscle injury or injury to the brain and kidney.
ALT is more specific for liver injury, whereas AST may be elevated owing to skeletal, cardiac, and liver muscle injury or injury to the brain and kidney.
Transaminases are elevated with all causes of hepatitis.

If the levels are super high, what does this indicate?
The degree of elevation is usually higher in acute than in chronic injury and correlates with the severity of liver injury only in ACUTE, but not chronic, hepatitis.
Acute viral hepatitis can cause transaminase elevations up to _____ times normal. In contrast, alcohol-induced hepatitis usually elevates transaminases to about _____ times normal, which a characteristic AST/ALT ratio of 2:1.
Acute viral hepatitis can cause transaminase elevations up to 100 times normal. In contrast, alcohol-induced hepatitis usually elevates transaminases to about 2 to 3 times normal, which a characteristic AST/ALT ratio of 2:1.
In advanced cirrhosis, enzymes may be _______ despite ongoing damage because nearly all the normal hepatocytes have been destroyed.
In advanced cirrhosis, enzymes may be NORMAL despite ongoing damage because nearly all the normal hepatocytes have been destroyed.
Once you detect liver disease, what should you do?
Continue work-up with viral hepatitis antibody screening.
What if viral serology results are negative?
Look further for storage or autoimmune disorders.
What labs can I use to assess the severity of liver disease?

_________ and ___________ are more sensitive markers of hepatic biosynthetic function in patients with CHRONIC liver disease.
Unlike acute hepatitis, aminotransferase levels do not correlate well with the degree of accumulated injury in patients with chronic hepatitis.

ALBUMIN and PROTHROMBIN TIME are more sensitive markers of hepatic biosynthetic function in patients with CHRONIC liver disease.
Albumin less than _______ or an increase prothrombin time above ___________ indicated significantly reduced hepatic synthetic function.
Albumin less than 3 g/dL or an increase prothrombin time above 11-16 seconds indicated significantly reduced hepatic synthetic funcion.