Gi Lecture 6

Front 1

What are the functions of the liver?

Back 1

Regulate amino acid levels, glucose into glycogen, iron storage, bile production, protein production, cholesterol production, detox of drugs and toxins, clotting factor production, removal of microorgainisms, immunity

Front 2

What are 2 main markers of cholestasis?

Back 2

Alk phos, GGT

Front 3

What is the main test for liver excretion?

Back 3

Bilirubin (direct and indirect)

Front 4

What are the two main tests of liver synthetic function?

Back 4

Albumin, INR, glucose

Front 5

What are prehepatic causes of increased bilirubin (would be indirect b/c hasn't been conjugated by liver yet)?

Back 5

Hemolytic disease, transfusions, GI bleed, etc.

Front 6

What are Heptaic causes of increased bili?

Back 6

Mass, infection, etc.
Able to conjugate, but unable to excrete into duodenum.

Front 7

What are post-hepatic causes of increased bili (Conjugated)?

Back 7

Obstruction

Front 8

What is urobilinogen?

Back 8

Broken down conjugated bili

Front 9

What is conjugated bili?

Back 9

Water soluble bili - if in blood stream, can go to kidney, skin, eyes, etc.

Front 10

What is the first manifestation of conjugated hyperbilirubinemia?

Back 10

Tea-colored urine

Front 11

What are the hepatocellular enzymes that are useful as indicators of liver injury?

Back 11

Aminotransferases (ALT, AST), Alk phos

Lactate dehydrogenase: great marker for hemolysis

Front 12

Is AST or ALT more specific to the liver?

Back 12

ALT

Front 13

Of AST and ALT, which tends to be higher? What is the exception?

Back 13

ALT usually > AST.
Exception: alcoholic hepatitis

Front 14

What are 5 common causes of a mild elevation of liver enzymes?

Back 14

Fatty liver, Chronic hep C, chronic Hep B, alcoholic liver disease, hemochromatosis.

Front 15

What are 4 uncommon causes of mild elevation of liver enzymes?

Back 15

Drug induced liver disease, autoimmune hep, alpha1 anti trypsin deficiency, wilsons disease.

Front 16

What are 3 causes of ALT/AST > 1000?

Back 16

Acute viral hep (A, B, rarely C), acute drug toxicity (acet od*, alcohol), hepatitis ischemia secondary to shock

Front 17

What is the most common cause of acute drug toxicity?** What would you expect to occur to the liver enzymes?

Back 17

Acetaminphen OD.
ALT/AST > 1000

Front 18

What measures would you take if AST/ALT are markedly elevated?

Back 18

Confirm abnormality by repeating, running CK. Consider hx and PE findings. Obtain disease specific markers (hep panel, iron/TIBC, ANA, Ceruloplasmin, alpha1 antitrypsin, CT, US, liver bx)
Look at AST/ALT ratio**

Front 19

What are 4 broad causes of elevated alk phos?**

Back 19

Hepatic, Bony, Biliary, Physiologic

Front 20

What are 7 causes of hepatic causes of elevated alk phos?

Back 20

Fatty liver, alcoholic liver dz, liver tumors, primary biliary cirrhosis, drug induced liver disease, hepatic granulomas, hepatic cysts

Front 21

What are two causes of bony causes of elevated alk phos?

Back 21

Paget's and metastatic cancer

Front 22

What are 2 causes of biliary causes of elevated alk phos?

Back 22

Bile duct obstruction, primary sclerosing cholangitis

Front 23

What are two examples of physiologic causes of elevated alk phos?

Back 23

Puberty, pregnancy

Front 24

What should you do if you have elevated alk phos?

Back 24

Repeat to confirm test, get full liver panel to see if other LFTs are elevated, anti-mitochondrial ab, AFP, hx and PE, abd US, CT, ERCP, bx

Front 25

What is the most common cause of direct toxicity (hepatocellular damage) of the liver?

Back 25

Acetaminophen

Front 26

What can cause cholestasis?

Back 26

Most common: abx.
Estrogen, androgens

Front 27

What are two causes of chronic hepatitis?

Back 27

Continued use of hepatotoxic drugs: Anti-TB meds** Rifampin

Front 28

What is steatosis?

Back 28

Abnormal retension of lipids w/in cells

Front 29

What are 3 causes of steatosis?***

Back 29

Methotrexate**, glucocorticoids, TPN**

Front 30

What is autoimmune hepatitis?

Back 30

Disease of young people - auto-abs to hepatocytes.

Front 31

What are clinical manfiestations of autoimmune hepatitis?

Back 31

Spider nevi, striae, acne, hirsutism, hepatomegaly

Front 32

What is the 4th most common cause of death in 35--55 yo?**

Back 32

Alcoholic liver disease (fatty liver, etoh hep, end stage liver disease)
Acute and chronic ETOH

Front 33

What lab do you really need to look at for Alcoholic liver disease?

Back 33

AST/ALT ratio****

Front 34

What labs should you be looking at for alcoholic hepatitis***?

Back 34

****AST, bili, alk phos (elevations),
**AST:ALT ratio > 2
Decreased albumin
Macrocytic anemia,
Thiamine deficiency (Wernicke's encephalopathy)

Front 35

How is diagnosis made of alcoholic hep?

Back 35

H&P and labs

Front 36

What is the treatment for alcoholic hepatitis?

Back 36

Support withdrawal symptoms, nutrition support

Front 37

What occurs in a Thiamine deficiency?

Back 37

Thiamine is necessary for KREB. w/out it, cell metabolism doesn't happen --> encephalopathy.
If you were going to give someone dextrose w/out thiamine and they are thiamine def, metabolisms uses all thiamine available and causes encephalopathy. Give banana bag.

Front 38

What nutritional support should you have for alcoholic hepatitis?**

Back 38

Fluids, calories, proteins, vitamins (thiamine, folate pyridoxine, vit k), minerals (phos, mg)

Front 39

What are two drugs given for hepatitis C?

Back 39

Telaprevir (Incivek) and Boceprevir (Victrelis)

Front 40

What are adverse effects of treatment for hep C?

Back 40

Dysgeusia (distortion of taste), anemia, neutropenia, pruritis, nausea, diarrhea

Front 41

What is the incidence of chronic liver cirrhosis?

Back 41

9th leading cause of death in US

Front 42

What is the end result of chronic liver cirrhosis?

Back 42

Hepatocellular injury most commonly caused by hepatitis or alcoholism. Serious and irreversible. - takes over architecture of liver and impedes normal fx.

Front 43

What is the pathophysiology of cirrhosis?

Back 43

Areas fibrose while areas around it grow and form nodules. end up with fibrosis and nodular regeneration. This causes hepatic cell dysfunction, portosystemic shunting and portal hypertension.

Front 44

What are 6 main etiologies of cirrhosis?

Back 44

Drugs/ toxins, infections, autoimmune, metabolic disorders, vascular disorders, a few miscellaneous

Front 45

What are two major causes of drug/ toxin induced cirrhosis? What is one other?

Back 45

Alcohol***, methotrexate***.
Also, carbon tetrachloride.

Front 46

What is the main cause of infection induced cirrhosis? What is another cause?

Back 46

Hep B or C****, Schistosomiasis parasite.

Front 47

What are 3 autoimmune disorders that can cause cirrhosis?***

Back 47

Autoimmune hep, primary biliary cirrhosis, primary sclerosing cholangitis

Front 48

What are 3 metabolic disorders that can cause cirrhosis?***

Back 48

alhpa 1 antitrypsin deficiency, hemochromatosis, Wilson's disease***

Front 49

What are Kayser-Fleischer rings?*

Back 49

Copper accumulation around the iris in Wilson's disease. Causes brown circle ring.

Front 50

What are 3 vascular disorders hat can cause cirrhosis?

Back 50

Budd-Chiari syndrome, chronic heart failure, veno-occlusive disease

Front 51

What are 7 risk factors of cirrhosis?

Back 51

ETOH, IV drugs --> hep, cocaine, sexual promiscuity, hx of transfusion before 1992, hx of clinical hep, fam hx of liver disease

Front 52

What are 7 lab findings in cirrhosis?

Back 52

Thrombocytopenia/ leukopenia/ anemia, hyponatremia, hypoalbuminemia (loss of sodium, albumin into peritoneal space in ascites), elevated globulin, prolonged PT, elevated bili, elevated AST and ALT

Front 53

What are 3 imaging studies used in dx of cirrhosis?

Back 53

CT abd - ID hepatic lesions.
US portal/hepatic vessels, liver bx

Front 54

What are 6 signs of decompensation - complications of cirrhosis?

Back 54

Ascites, upper GI bleed, hepatic encephalopathy, liver failure, carcinoma of liver, spontaneous bacterial peritonitis.

Front 55

What is the most common complication of cirrhosis?

Back 55

Ascites.
Poor quality of life and prognosis.
Increased risk of infections and renal failure.

Front 56

What is hepatic encephalopathy?

Back 56

Worsening of brain function when liver is unable to filter toxins.

Front 57

What are 3 classifications of portal hypertension?

Back 57

Prehepatic, intrahepatic, post-hepatic

Front 58

What are three causes of prehepatic portal hypertension

Back 58

Portal vein thrombosis, splenic arteriovenous fistula, idiopathic tropical splenomegaly

Front 59

What causes intrahepatic portal hypertension?

Back 59

Cirrhosis

Front 60

What are two causes of post hepatic portal hypertension?

Back 60

Severe heart failure, restrictive pericarditis

Front 61

What are the 4 most common causes of ascites?

Back 61

Cirrhosis, neoplasm, CHF, TB peritonits

Front 62

What is the most common cause of ascites in the US?

Back 62

Cirrhosis

Front 63

What are 2 causes of transudative ascites?

Back 63

Portal htn, CHF

Front 64

What are 2 causes of exudative ascites?

Back 64

Inflammation, malignancy

Front 65

What is SAAG (serum to ascites albumin gradient)?

Back 65

High serum to ascites albumin gradient (>1.1) in portal htn, chf, cirrhosis.
Low (<1.1) in nephrotic syndrome, malnutriton, malignancy

Front 66

What is the chief factor of the pathophysiology of ascites?

Back 66

Splanchnic vasodilation.

Increased hepatic resistance to portal flow in cirrhosis --> portal hypertension, collateral vein formation, shunting of blood to systemic circulation.

Front 67

What is a transudate mostly made of?*

Back 67

Sodium and water

Front 68

What are 4 main lab tests you should do on ascites? What are several others?

Back 68

Main: cell ct, culture, total protein, albumin.

Other: glucose, LDH, TG, Bili, Cytology, Amy, TB culture

Front 69

What is Child-Turcotte-Pugh (CTP)?

Back 69

Severity assessment of cirrhosis.

Also: model for end stage liver disease.

Front 70

What are 5 tests included in Child-Turcotte-Pugh in evaluation of severity of cirrhosis?

Back 70

Bili, Albumin, INR, ascites, hepatic encephalopathy

Front 71

What 3 tests are included in MELD (model for end stage liver disease)?

Back 71

Bili, INR, Creat

Front 72

What are 3 nutritional management strategies should be considered in cirrhosis?

Back 72

Calories (may be malnourished due to ascites compressing stomach).
Protein (may be malnourished, but may need to restrict in encephalopathy).
Zinc (needed to break down urea).

Front 73

What is a first line treatment of ascites?****

Back 73

Na restriction (500-2000 mg/day).

Front 74

What are 4 management strategies of ascites?

Back 74

Diuretics, shunts, paracentesis, liver transplant.

Front 75

What is the problem with using diuretics for ascites?

Back 75

Risk of dehydrating (pulling fluid from vascular system and not 3rd space).
Would want to use aldosterone antagonist + lasix because ald ant spares potassium.

Front 76

How would shunting be helpful in managing ascites?

Back 76

Can be used to bypass portal liver circulation to decrease hypertension or can be placed from peritoneal space into vascular system, but with that, there is a risk of infection and clotting.

Front 77

What is the treatment of varices (as a result of portal hypertension -- usually esophageal)?

Back 77

IV vasopressin, balloon tamponade, endoscopy**, shunts, beta blockade (decreases portal flow), octreotide (decreases gastric secretion, increases vasoconstriction)

Front 78

What is portosystemic encephalopathy?

Back 78

Same thing as hepatic enceph. Reversible neuro syndrome. Mood changes, confusion, drowsiness, disorientation, coma. Buildup of toxins, mostly ammonia probably.

Front 79

What hx would you consider as precipitating factors do developing portosystemic encephalopathy?**

Back 79

ETOH binge, GI bleed, massive protein intake.**

Front 80

What might you see on PE in portosystemic encephalopathy?

Back 80

Gynecomastia, teticular atrophy, pamal erythema, spider nevi, splenomegaly, caput medusae, ascites, peripheral edema, shrunken liver

Front 81

What is the therapy for portosystemic encephalopathy?**

Back 81

Non-absorbably disaccharides (lactulose), antibiotics, nutrition

Front 82

What is hepatorenal syndrome?

Back 82

Severe liver disease that progresses to renal failure due to severe vasoconstriction of renal circulation.

Poor prognosis.

Front 83

What are 3 clinical presentations you might see with hepatorenal syndrome?

Back 83

Oligouria, azotemia, hyponatremia

Front 84

What are two complications of hepatorenal syndrome?

Back 84

Hemorrhage, infection

Front 85

What 3 treatments for hepatorenal syndrome?

Back 85

Vasoconstrictor drugs, shunting and transplant

Front 86

What is a major nutrition management strategy for hepatorenal syndrome?

Back 86

Sodium restriction

Front 87

What percentage of people with ascites develop spontaneous bacterial peritonitis?

Back 87

10-30%

Front 88

What is diagnostic for spontaneous bacterial peritonitis in ascitic fluid?

Back 88

250 pmns/cu mm

Front 89

What is the most common organism to cause spontaneous bacterial peritonitis?

Back 89

E. coli*** and other gram negs

Front 90

What is the treatment of choice for spontaneous bacterial peritonitis?

Back 90

3rd gen cephalosporins

Front 91

What are contraindications for giving a liver transplant?

Back 91

Cardiopulmonary disease, malignancy, etoh/drug use

Front 92

What are 4 complications to liver transplant?

Back 92

Infection, graft rejection, renal failure, neurologic problems

Front 93

Is hepatic adenoma benign or malignant? And what is it most commonly associated with?***

Back 93

Benign.
Assoc w/ OCPS*****

Front 94

What is the clinical presentation of hepatic adenoma?

Back 94

Acute abd pain from necrosis and hemorrhage, normal liver function

Front 95

What are 2 complications assoc w/ hepatic adenoma?

Back 95

Necrosis and rupture

Front 96

What is treatment for hepatic adenoma?

Back 96

Resection if > 5cm. Otherwise watch it.
Stop ocps

Front 97

What is the most common benign neoplasm of the liver?

Back 97

Cavernous hemangioma. Incidental finding on CT.
Tumor made up of blood vessels. Usually asymptomatic.

Front 98

How would you treat a cavernous hemangioma on the liver?

Back 98

You wouldnt usually.

Front 99

What is the most common malignant tumor of the liver*****?

Back 99

Metastatic liver cancer.

Front 100

Where does metastatic liver cancer usually come from?

Back 100

Eyes, pancreas, breast, gallbladder, bile ducts, colon, rectum, stomach.

Front 101

What are 3 symptoms of metastatic liver cancer?

Back 101

Abd pain, weight loss, hepatomegally

Front 102

How would you treat metastatic liver cancer?

Back 102

Treat underlying cancer. Liver resection if isolated mets.

Front 103

What are two things associated with hepatocellular carcinoma?

Back 103

Cirrhosis, history of hepatitis (usually C)

Front 104

What is the clinical presentation of hepatocellular carcinoma?

Back 104

RUQ pain, hepatomegaly, hapatic bruit/ rub, ascites, malaise, anorexia, weight loss.

Front 105

What is used to make a dx of hepatocellular carcinoma?

Back 105

LFTs, gallium scan, AFP, abd US, angiography, liver bx

Front 106

What are treatments for hepatocellular carcinoma?

Back 106

No good tx. Surgery if disease is limited. Chemo/ RT.

Front 107

What are 2 forms of iron overload syndromes?

Back 107

Hereditary hemochromatosis, transfusion induced iron overload.

Front 108

What is hereditary hemochromatosis?

Back 108

Rare, but most common genetic disease in caucasians. Most common cause of primary iron overload.

Front 109

What is transfusion induced iron overload?

Back 109

Assoc w/ diseases that req transfusions freq (B-thal, Sickle Cell, myelodysplastic syndromes).***
Also, stem cell transplantation.

Front 110

What is transferrin?

Back 110

Iron transport protein.

Front 111

What is ferritin?

Back 111

Cellular storage protein for iron. Precursor of hemosiderin. Located in reticuloendothelial macrophages and hepatocytes.

Front 112

What levels of ferritin indicate iron overload?

Back 112

>1000

Front 113

What are the 3 most common clinical manifestations of iron overload?

Back 113

Fatigue, arthralgia, libido loss

Front 114

What are several clinical findings in iron overload?

Back 114

Elevated ferritin, elevated AST/ALT, skin bronzing, hepatomegaly, etc.

Front 115

What can occur in hemochromatosis if not identified early?

Back 115

Iron deposition in the body leading to multiple organ system damage

Front 116

What are 4 GI system complications of excess iron deposit stores (ferritin and hemosiderin)?

Back 116

Hepatomegaly, fibrosis / cirrhosis, portal htn, hepatocellular carcinoma (most serious)

Front 117

What is the most common musculoskeletal system complication of iron overload?

Back 117

Arthralgia due to calcium pyrophosphate deposition in joints: mostly wrists, DIP, MIP. Causes chondrocalcinosis or pseudogout.

Front 118

What are 5 cardiovascular complications of iron overload?

Back 118

Bradyarrhythmias, diastolic dysfunction w/ restriction, CHF, AV block, cardiomyopathy

Front 119

What are 4 endocrine complications of iron overload?

Back 119

Decreased libido/ ED, testicular atrophy, amenorrhea, sterility, osteoporosis, DM*** in 50% of symptomatic pts

Front 120

How common is bronzing of skin in iron overload?

Back 120

90% of pts

Front 121

How does the skin become bronzed due to iron overload?

Back 121

Deposition of iron in skin causes inflammation and enhances melanin production by melanocytes

Front 122

What are 3 diagnostic tests for iron overload?

Back 122

Transferrin saturation, genetic testing, liver biopsy

Front 123

How is transferrin saturation determined?

Back 123

Divide serum iron by TIBC. If it is greater than 45% = hemochromatosis. Or serum ferritin levels > 300

Front 124

What is the treatment for iron overload?

Back 124

**Phlebotomy, **Chelation.
Nutrition, screen fam members

Front 125

What is chelation of iron?

Back 125

Binds to iron to get it out of the body. Good for transfusion caused iron overload. Oral or IV.

Front 126

What are 6 nutrition modifications for tx of iron overload?

Back 126

Limit intake of red meat, avoid iron supps, avoid vit c, avoid ETOH, avoid raw shellfish, vaccinate against Hep A and B.

Front 127

Where is the spleen located?

Back 127

LUQ. Between 9th and 11th ribs.

Front 128

What are 5 functions of the spleen?

Back 128

Removes old rbcs, blood reserve, iron recycling, ab synthesis, bacterial removal

Front 129

What is Traube's space?

Back 129

Area between left 6th and 9th rib near the anterior axillary line. Usually hyperresonant due to gastric bubble. If dull, could indicate splenomegaly.