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97 Cards in this Set

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What two vessels form the portal vein?
splenic and superior mesenteric veins
What are acinus?
• make up the functional unit of the portal tract • hepatocytes are in the ascini
What makes up the portal triad?
branches of the hepatic artery, bile duct, and portal vein
What is function of the gallbladder?
• storage and concentration of bile • bile solubilizes dietary fat & promotes its absorption & digestion
What are some of the functions of the liver?
• breakdown of major nutrients in food • filtering of toxic chemicals • glucose homeostasis • helps with disposal of bilirubin • helps in building muscles & protein • killing germs • makes bile to help digest food • synthesis of clotting factors • storage of energy and vitamins
What is the function of albumin?
Albumin, which is synthesized exclusively in the liver, is responsible for carrying molecules and keeping fluid in blood vessels
What are the fat-soluble vitamins and what are their functions?
• Vit A - visual pigments & normal development of bones • Vit D - absorption of Ca++ • Vit E - antioxidant & membrane stability • Vit K - prothrombin synthesis & clotting
What are some physical findings of liver failure?
• General - fever & weight loss • Cutaneous - spider angiomas, telangiectasias, palmar erythema, jaundice, xanthomas & xanthelasma • Endocrine - gynecomastia, testicular atrophy, hypoglycemia • GI - RUQ pain, abdominal swelling/ascites, heptosplenomegaly, G.I. Bleed • Hematological - pale skin/mucous membranes, ecchymoses • Neuro - Ataxia, encephalopathy, somnolence, confusion, asterixis & obtundation
What is the cause of fetor hepaticus?
sulfa compounds, produced by intestinal flora, are not cleared by the liver
Why would patients with liver dysfunction have GI bleeds?
due to esophageal varices from portal hypertension
What is caput medusa?
varicose type veins orginating in the umbilicus due to severe portal hypertension
What is the normal serum albumin level and how would it be affected by liver dysfunction?
• normal range 3.4 - 5.4 g/dL • serum albumin can be decreased with liver dysfunction
What is the one of the most sensitive indicators of severe liver disease?
• prolongation of the PT • PT measures clotting factors I (fibrinogen), II (prothrombin), V, VII, X
What is the normal range of the PT?
11 - 15 seconds
Which of the liver function tests (LFTs) or transaminases are more specific for the liver, AST or ALT?
ALT (SGPT) is more specific to the liver than AST (SGOT)
What does an AST to ALT ratio greater than 2:1 suggest?
alcoholic liver disease
What does an AST to ALT ratio less than 1:1 suggest (in other words, if the AST is lower than the ALT)?
viral hepatitis
What do high AST & ALT levels indicate and what are some possible causes?
• the highest levels of AST & ALT are due to extensive death of liver cells • can be caused by acute viral hepatitis, toxins (Tylenol overdose), and septic shock
What are the relative ranges of the serum transaminases in conditions such as acute hepatic necrosis, acute hepatitis, chronic active hepatitis, and cholestasis?
• Acute hepatic necrosis ~ 1000 • Acute hepatitis ~ 400 • Chronic active hepatitis ~ 300 • Cholestasis ~ 150-200
What are causes of an elevated alk phos?
• Liver damage, particularly necrosis • Cholestasis/ bile duct obstruction • Neoplastic • Infiltrative & granulomatous liver disease
What is the difference between direct & indirect bilirubin?
• Direct Bilirubin is already conjugated by the liver (can be elevated by intra or extra-hepatic obstruction) • Indirect bilirubin is unconjugated (can be elevated by hemolysis or deficiencies in conjugating enzymes)
What bilirubin level is considered clinically jaundiced?
• levels > 3.0 mg/dL • normal levels are 0.5 - 1.0 mg/dL
What cell in the liver converts unconjugated (indirect) bilirubin to conjugated (direct) bilirubin?
Kupffer cells
What happens to bilirubin when it enters the terminal ileum/intestine?
• the bilirubin is converted to stercobilinogen & urobilinogen by natural bacteria. • excreted into the bile and further metabolised by the intestine: urobilinogen » urobilin » stercobilin, which colors the feces brown.
What is the effect of a biliary obstruction on the feces and urine?
• obstruction of the biliary system prevents production of urobilogen & stercobilogen • stool is light and urine is dark showing bilirubin
What are the 4 causes of elevated blood levels of bilirubin?
• Increased bilirubin production • Decreased bilirubin uptake by the liver • Impaired conjugation in the liver • Decreased excretion of bilirubin into the bile (cholestasis) *first three are elevated unconjugated, last one is elevated conjugated bilirubin
What are causes of increased bilirubin production?
• 2º hemolysis (autoimmune) • ineffective erythropoiesis (megablastic anemia) • increased RBC fragility/turnover (2,3 DPG deficiency)
What can cause decreased hepatic uptake of bilirubin?
• Gilbert’s syndrome • certain drugs (rifampin, anesthetics & radiographic dyes)
What can cause impaired conjugation of bilirubin?
• Hepatocellular disease • Drug inhibition (chloramphenicol, anabolic steroids) • Genetic disorders such as Gilbert’s syndrome or Crigler- Najjar syndrome (decreased UDP-glucuronyl transferases).
What is the most common cause of jaundice?
neonatal jaundice
What are causes of decreased excretion of bilirubin
• altered biliary drainage • impaired hepatic excretion of bile • extra hepatic obstructions
What would be the relative alk phos level in a patient with cholestatic jaundice?
increased alk phos to 3-4 times normal
A patient with a history of pale stools and pruitis would make you suspicious for what?
cholestasis
A patient with a history of nausea & gallstones would make you suspicious for what?
bile obstruction
What would be significant lab results of a patient with a biliary obstruction?
alk phos is increased (2-3 times normal)
What would be significant lab results in a patient with hepatocellular disease?
AST & ALT increased (10-15 times normal)
What is the pneumonic for causes of hyperbilirubinemia?
HOT Liver • Hemolysis • Obstruction • Tumor • Liver Disease
What is a good diagnostic procedure if you suspect extra-hepatic obstruction?
CT or ultrasound
What would be a good diagnostic study for management & treatment of a dilated bile duct?
ERCP
What diagnostic study would be performed to determine the cause of intrahepatic jaundice?
Liver Biopsy
What are causes of Hepatitis?
• Viral (Hep A - E, CMV, EBV) • Toxins • Alcohol • Other diseases (Wilson's disease, Leukemia, Lymphoma)
Which viral hepatitis are fecal-oral?
Hepatitis A & E
Which viral hepatitis are blood borne?
Hep B, C, D
Name some drugs that can cause hepatitis
• Acetominophen • Chlorpromazine • Erythromycin • Halothane • Isoniazid
What is the most common cause of hepatitis?
Viral causes
What are symptoms of hepatitis?
• Anorexia • Arthralgias • Fatigue • Nausea, Vomiting, Diarrhea • Low grade fever • Malaise • Rash
What are clinical findings of hepatitis?
• Dark urine • Hepatomegally (on occasion) • Jaundice • Tenderness of the Liver
What does a prolonged PT indicate, regarding the liver?
severe liver destruction (~ 55%)
What are complications of Hepatitis?
• Massive hepatic necrosis (usually from B, C, D, E) • Chronic Hepatitis • Cholestatic Hepatitis Syndrome (pruritis, dark urine, light stools, hyperbilirubinemia, alk phos elevation)
What are key signs and symptoms of Mononucleosis (EBV)?
• fever • Exudative Pharyngitis • Headaches • Lymphadenopathy • Malaise • Splenomegaly
Why should you never give ampicillin or amoxicillin to treat a sore throat with a mono patient?
can cause a rash
What is the most common cause of a ruptured spleen in patients with mono?
excessive palpation
CMV is similiar to EBV in many ways. What are some ways that CMV differs from EBV?
• no pharyngitis or respiratory symptoms in CMV • more common in transplant and AIDS patients
What is the incubation and duration of Hepatitis A?
• incubation period: 2-6 weeks • duration: 4 weeks
What is used for Hepatitis A prophylaxis?
Gamaglobulin
What is the incubation period of Hepatits B?
1 - 6 months
What is HBcAG & describe its characteristics?
• Hepatitis B Core Antigen • disappears soon after the peak of ALT
What is HBeAg & describe it
• Hepatitis B envelope antigen • Positive in acute HBV
What is HBsAg and when does it show up?
• Hepatitis B surface antigen • positive in acute & chronic HBV
What is Anti-HBs and when does it show up?
• Anti- Hepatitis B surface • positive in late acute HBV and in immunized patients • shows up have after hepatitis antigen disappears
What is HBeAb and when does it appear?
• Hepatitis B envelope antibody • apears when the antigen decreases
What is HBcAb?
• Hepatitis B core antibody • IgM marker for acute infection • IgG for chronic HBV & carrier
What is the first detectable virologic marker in acute HBV infection?
HBsAg
What are characteristics of HBsAg?
• usually detectable 4 weeks after infection and typically disappears at 6 months after active infection • persisence of HBsAg after 6 months implies chronic HBV infection
What are characteristics of Anti-HBs?
• appears shortly after HBsAg disappears • persists indefinitely in patients who have recovered from acute infection • is the protective antibody against HBV infection
What are characteristics of Anti-HBc?
• IgM is acute (appears 1-2 weeks after appearance of HBsAg) • IgG is chronic (predominates after 6 months & generally persists indefinitely)
Which marker is considered to be a marker of active virus replication and highest infectivity?
HBeAg (hepatitis B envelope antigen)
What are characteristics of Anti-HBe?
• present in chronic HBV infection and signals the onset of the nonreplicative phase • generally exists in serum indefinitely unless seroconversion back to HBeAg occurs
Which serological maker is the most reliable indicator of active viral replication?
HBV DNA
What are characteristics of HBV DNA?
• present in acute HBV infection; recovery from acute HBV is accompanied by the disappearnace of HBV DNA • persistence of HBV DNA implies chronic infection • useful in predicting response to interferon therapy
What tests would be done to screen for acute viral hepatitis?
• anti-HAV IgM (acute infection) • HBsAg (1st one to appear) • anti-HBc IgM (acute phase) • anti-HCV
What tests are done to screen for chronic viral hepatitis?
• HBsAg • anti-HCV • if +HBsAg then check HBeAg (actively replicating) • +/- HBV DNA
What is the treatment for Hepatitis B after exposure?
• hepatitis B immunoglobin • active immunization with HBV vaccine (Combivax)
What lab tests confirm Hepatitis C?
• positive Anti-HCV and elevated ALT (SGPT)
What is the treatment for Hepatitis C?
alpha interferon plus ribavirin
What is required for Hepatitis D replication?
Hepatitis B
What are characteristics of Hepatitis E?
• found mostly in India, Asia, Mexico, & Africa • incubation 2-9 weeks • all U.S. cases have been imported by immigrants
What is hemosiderosis?
iron accumulation in the lungs
What are defining characteristics of Wernicke Encephalopathy?
• Nystagmus » Ophthalmoplegia • Ataxia • Confusion
What are the defining characteristics of Korsakoff Syndrome?
• Loss of new memory • Disorientation to time & place • Confabulation
What is the treatment for Wernicke-Korsakoff syndrome?
• large doses of thiamine HCl *Wernicke-Korsakoff is caused by thiamine deficiency
A patient with a positive ANA and hypergamaglobulinemia has what type of hepatitis?
Chronic autoimmune hepatitis
What is Wilson's Disease?
• a genetic disorder of copper metabolism • diagnosis made by seeing neurological, psychiatric, hepatitis, & cirrhosis in a young person • Kayser-Fleischer ring in the eye
What is haemochromatosis?
• excessive absorption of iron • iron is layed down in liver, heart, pancreas, kidney & skin
What are characteristics of Alpha 1-Antitrypsin Deficiency?
• seen in children with associated liver disease • can progress to liver disease with pulmonary manifestations
What are the 3 main cause of hepatic failure?
• Functional liver failure without overt necrosis (Reye's syndrome, tetracycline toxicity) • Chronic liver disease (chronic active hepatitis, cirrhosis) • Fulminate failure
What are clinical signs you would see on the arms that would suggest liver failure?
Pneumonic CLAPS: • Clubbing • Leukonychia • Asterixis • Palmar erythema • Scratch marks
What are characteristics of Hepatic encephalopathy?
• a metabolic disorder of the CNS & neuromuscular system with slight changes in the brain (edema) caused by elevated ammonia levels • patients can have confusion, asterixis, drowsiness, coma » death
What are precipitating factors of Hepatic Encephalopathy?
Pneumonic HEPATICS: • Hemorrhage in GI tract / Hyperkalemia • Excess protein in diet • Paracentesis • Acidosis / Anemia • Trauma • Infection • Colon Surgery • Sedatives
What is the treatment for Hepatic Encephalopathy?
• Lactulose 50 ml PO Q 2hrs until diarrhea begins
What is causes of heptic cirrhosis?
• necrosis • regenerating nodules • fibrosis
What is the #1 cause of cirrhosis in the western world?
alcohol
What is Budd-Chiari syndrome?
chronic hepatic congestion caused by thrombotic or nonthrombotic obsdtruction to hepatic venous outflow
What is the mone of the more common causes of nonalcoholic liver cirrhosis?
Biliary Cirrhosis
What are characteristics of Biliary Cirrhosis?
• caused by destruction of the intrahepatic bile ducts • 90% are found in middle aged females • common symptoms are fatigue & pruritis • 90% with have antimitochondrial antibodies
What are complications of cirrhosis?
• Spontaneous bacterial peritonitis (SBP) • Ascities
What are physical manifestations of elevated estrogen levels from liver dysfunction?
• spider angiomas • palmar ehythema • gynecomastia