Gi/rheumatoid Test2 Set2

Front 1

Histological patterns of drug-induced hepatic injury (7)

Back 1

1)zonal necrosis
2)hepatitis
3)fatty liver
4)alcoholic-like liver disease
5)cholestasis
6)vasulcar lesions
7)hepatic tumors

Front 2

Zonal necrosis
a)causes (5)

Back 2

a1)APAP
a2)halothane
a3)allyl alcohol
a4)Reye's in kids due to ASA use
a5)reverse transcriptase and protease inhibitors used in HIV

Front 3

Zonal Necrosis signs and prognosis (5)

Back 3

1)may be asymptomatic or result in liver failure
2)elevated liver enzymes (ALT more than alkaline phos)
3)elevated bilirubint
4)loss of clotting factors
5)may cause sudden death or progress to cirrhosis

Front 4

NONSPECIFIC hepatitis
a)causes (2)
b)what is it (3)

Back 4

a1)ASA
a2)oxacillin

b1)inflammation w/ scattered necrosis
b2)no bile stasis or lobular disarray
b3)resolves w/ dc of drug

Front 5

Acute viral hepatitis
a)causes (5)
b)what is it (3)

Back 5

a1)isioniazid
a2)phenytoin
a3)ketoconazole
a4)methyldopa
a5)halothane

b1)see tissue eosinophilia
b2)acute = up to 3months
b3)high fatality rate and chronic hepatitis may result

Front 6

Chronic Hepatitis
a)causes (5)

Back 6

a1)isoniazid
a2)methyldopa
a3)nitrofurantoin
a4)sulfonamides
a5)amiodarone

Front 7

MACROvesicular Fatty liver
a)causes (4)
b)what is it (2)

Back 7

a1)ethanol
a2)corticosteroids
a3)amiodarone
a4)DM/obesity

b1)large globs of TG fill up hepatocytes (up to 5%)
b2)decr TG transport from cell b/c of apoproteins synthesis

Front 8

MICROvesicular Fatty liver
a)causes (3)
b)what is it (2)

Back 8

a1)Reye's
a2)VPA
a3)high dose tetracycline

b1)elevated plasma transaminase activity and bilirubin
b2)more severe liver damage than macro

Front 9

Alcoholic-like liver disease
b)what is it/causes (2)

Back 9

a)hepatitis w/ fibrosis or cirrhosis caused by amiodarone/perhexiline

b)quiescent fibrosis or cirrhosis (MTX/vitamin A)

Front 10

Cholestasis
a)what is it
b)bland cholestasis? (2 and 2 causes)

Back 10

a)decr bile formation or bile flow resulting in jaundice

b1)accumulation of bile in cells and canaliculi
b2)few systemic manifestations
b3)estrogens and anabolic steroids

Front 11

Inflammatory cholestasis (4 and 4 causes)

Back 11

1)necrosis w/ inflammation
2)happens in portal triads and may have bile plus of insoluble drug complexes
3)infiltrate of PMN/eosinophils
4)liver enzyme elevation (alkaline phosphatase more than ALT)

1)chlorpromazine
2)erythromycin
3)estolate
4)amoxicillin/clav

Front 12

Vascular lesions (3 types and causes of each)

Back 12

Hepatic Vein Thrombosis- estrogens

Venoocclusive Disease- anticancer drugs

Peliosis Hepatitis- anabolic steroids

Front 13

Hepatic Tumors (3 types and causes)

Back 13

Ademona- estrogens/androgens

Carcinoma- estrogens/androgens

Angiosarcoma- anabolic steroids, vinyl chloride, some contrast dyes

Front 14

Treating symptoms of Hepatic injury (4)

Back 14

1)cholestyramine to incr bile salt excretion to decr itching

2)glucocorticoids if an allergic component is involved

3)N-acetyl cysteine in hepatic damage caused by APAP

4)carnitine in hepatic damage caused by VPA

Front 15

Zonal necrosis can also be caused by.....

Back 15

mt-DNA retroviral therapy (10%)

Front 16

ENZYMATIC markers of acute hepatic INJURY and normal values for them (these are NOT good indicators of....) (3)

Back 16

1)Aminotransferases (ALT/SGPT and AST/SGOT) 11-47 and 7-53 respectively
2)Alkaline phosphatase (50-136)
3)GGTP (10-50)

NOT good indicators of liver function

Front 17

Markers of Hepatic FUNCTION and normal values of them (4)

Back 17

1)bilirubin (0.2-1) (metabolic liver fxn)
2)ammonia (10-33) (metabolic liver fxn)
3)albumin (3.4-5.4) (synthetic liver fxn)
4)PT (10-13sec) (synthetic liver fxn)

Front 18

Mayo End-Stage Liver disease Score (MELD) is used for....

Back 18

seeing who needs a liver transplant

Front 19

Causes of liver disease in USA (4)

Back 19

1)ALCOHOL is most common cause of liver diease (also w/ poor nutrition and being F)
2)Drugs
3)Viral
4)CV/immune/metabolic

Front 20

Manifestations of Alcoholic Liver disease (4)

Back 20

1)steatosis (fatty liver)
2)steatonecrosis (fatty liver too)
3)cirrhosis (scars)
4)liver failure

Front 21

Common Clinical Findings in Cirrhosis (stigmata of cirrhosis) (6 of many)

Back 21

1)ascites
2)spleno/hepatomegaly
3)clay color stools/cola colored urine
4)rebound tenderness
5)janudice
6)icterus

Front 22

Ascites what is it?

Back 22

pathologic collection of fluid in peritoneal cavity

Front 23

Nonpharma tx of Ascites (3)

Back 23

1)alochol abstinence
2)Na restriction to less than 2g per day
3)fluid restriction ONLY IN SEVERE HYPONATREMIA (Na less than 120)

Front 24

Drugs to use to tx Ascites (2)

Back 24

1)spironolactone (first line)
2)furosemide (add to spironolactone)

Front 25

Use of Spironolactone in Ascites
a)dose
b)MOA (2)
c)onset
d)ADR (2)

Back 25

a1)start at 100mg po qd

b1)inhibits the axn of aldosterone
b2)pts w/ ascites have high levels of aldosterone due to incr RAAS and decr metabolism of aldosterone in liver

c)SLOW (1wk)

d1)hyperkalemia (common w/ monotherapy)
d2)gynecomastia w/ high doses

Front 26

Furosemide and Ascites
a)rationale for combo w/ spironolactone (2)
b)ratio of sprinolactone to furosemide

Back 26

a1)faster onset of diuresis
a2)potassium balance

b)100mg spironolactone to 40mg furosemide to maintain K balance

Front 27

Goal of diuresis in Ascites (3)

Back 27

1)net fluid loss of 0.5kg/d
2)pts w/ massive edema may need 1kg/d
3)TOO aggressive diuresis may cause hepatic encephalopathy and hepatorenal syndrome

Front 28

Monitor what in Ascites to see if Diuretics are working (5)

Back 28

1)I/O and daily weight
2)renal fxn (Cr, BUN)
3)Electrolytes (Na/K/Mg)
4)BP
5)s/sx of dehydration

Front 29

For Refractory Ascites use what? (4)

Back 29

1)SERIAL PARACENTESIS
2)reserved for pts w/ tense ascites refractory to other drugs
3)albumin infusion should be considered when over 5L of volume removed
4)disadv is risk of infexn (peritonitis), hypotension

Front 30

Candidates for empiric therapy for Spontaneous Bacterial Peritonitis have any ONE of the following.... (3)

Back 30

1)fluid neutrophil cell count over 250 (take WBC count and multiply by % neutrophil)
2)positive ascitic fluid culture
3)pt w/ cirrhosis presenting w/ convincing s/sx

Front 31

Drugs used to tx Spontaneous Bacterial Peritonitis (2)

Back 31

1)FIRST LINE EMPIRIC cefotaxime 2g IV q8h for 5d (can substitute w/ ceftriaxone)
2)alternative in allergic pts if fluoroquinolone therapy (levofloxacin)

Front 32

Prophylaxis Abx for recurrent Spontaneous Bacterial Peritonitis (when to...and what to do) (3)

Back 32

1)long term prophylaxis if hx of SBP or serum bilirubin is less than 2.5
2)or if low protein ascites (less than 1)
3)give short course prophylaxis (7d) if pt gets variceal hemorrhage

Front 33

Hepatic Encephalopathy possible pathyphysiology (2)

Back 33

1)nitrogenous by-products of proteins result in hyperammonemia
2)aromatic AAs may act as false NTs to GABA receptors in CNS

Front 34

Precipitating Factors for Hepatic Encephalopathy (6)

Back 34

1)diuretic induced azotemia
2)high protein diet (protein goes to ammonia and other nitrogen toxins via GI bacteria)
3)CNS depressant cause altered metabolism and incr CNS sensitivity
4)GI hemorrhage provides a source of protein for ammonia production
5)Constipation = greater absorption of GI contents
6)Infexn increases catabolic state and dehydration due to fever (H. pylori)

Front 35

Drugs used to tx Hepatic Encephalopathy (3) and 1 nondrug

Back 35

1)Lactulose (FIRST LINE)
2)Neomycin
3)Flumazenil (for refractory)
4)Diet changes

Front 36

Lactulose and Hepatic Encephalopathy
a)MOA (2)
b)confirm working by...
c)dosing
d)monitor what? (3)
e)other dose form

Back 36

a1)converted by bowel flora into lactic, acetic, formic acids to decr colon pH from 7 to 5
a2)acidification of colonic pH results in ion trapping of NH3 by converting it into NH4

b)acidification of stool by checking stool pH

c1)form is 20g per 30mL (TITRATE TO 2-3 SOFT STOOLS PER DAY)

d1)do NOT monitor ammonia
d2)monitor # of stools per day
d3)monitor clinical improvement

e)Retention enema is lactulose and tap water

Front 37

Neomycin and Hepatic Encephalopathy
a)dosing
b)MOA
c)it and lactulose (2)

Back 37

a)500-1000mg PO q6h; never IV because you are targeting the GI

b)decr [] of urease-containing bacteria in gut which decr the production of ammonia from proteins and AAs

c1)NO combo; give as monotherapy b/c neomycin may decr gut bacteria needed to metabolize lactulose
c2)COMBO IS reserved for pts not responding to either med alone

Front 38

Flumazenil MOA/use

Back 38

BZD antagonist used short term in refractory pts

Front 39

Diet changes good in Hepatic Encephalopathy (3)

Back 39

1)zinc supplementation in zince deficient pts
2)Branched chain AAs (not to tx HE; but good in pts waiting for transplant)
3)PROTEIN RESTRICTION (less than 0.8-1.0g/kg/d) in refractory pts

Front 40

Treatment options in Esophageal Varices for emergent tx of acute bleeding (5)

Back 40

1)hemodynamic stabilization
2)endoscopy
3)somatostatin
4)octreotide
5)vasopressin (ADH)

Front 41

Hemodynamic stabilization of esophageal varices w/ acute bleeding (4)

Back 41

1)fluid resuscitation
2)blood transfusion w/ PRBC
3)fresh frozen plasma
4)platelet transfusion (if needed)

Front 42

Endoscopy w/ esophageal varices w/ acute bleeding (3)

Back 42

1)ESSENTIAL TO DETERMINE SOURCE OF BLEED
2)endoscopic banding ligation (EBL)
3)injexn sclerotherapy

Front 43

Somatostatin and esophageal varices w/ acute bleeding
a)MOA
b)line of therapy

Back 43

1)SELECTIVE vasoconstriction of mesenteric circulation results in decr variceal pressure and decr mucosal blood flow

2)at least as effective as vasopressin w/ much better ADR profile

Front 44

Octreotide and esophageal varices w/ acute bleeding
a)MOA
b)dosing
c)ADR (3)

Back 44

1)synthetic analogue of somatostatin w/ longer half-life (1hr vs. 3min); SELECTIVE VASOCONSTRICTION

2)IV bolus followed by continuous infusion for 2-3days

3a)n/v/d
3b)ab cramps
3c)blood glc derangements

Front 45

Vasopressin (ADH) and esophageal varices w/ acute bleeding
a)MOA
b)other

Back 45

1)potent NONSELECTIVE vasoconstrictor

2)IV NTG must be given w/ it to prevent complications of systemic vasoconstriction

Front 46

Other management issues of Esophageal Varices (2)

Back 46

1)abx prophylaxis to prevent occurence of SBP
2)acid suppressive therapy (PPI's)

Front 47

Primary Prevention of Esophageal Varices (2 and 1 not to use)

Back 47

1)NONselective BB (FIRST LINE)
2)EBL is 2nd line
3)NO long acting nitrates as primary prevention

Front 48

BB and primary prevention of Esophageal Varices
a)dosing of 2 agents to use
b)monitoring effect (2)
c)MOA (2)
d)relative CI's (3)

Back 48

a1)propanolol 10mg TID
a2)nadolol 20mg QD

b1)titrate dose base on HR (decr resting HR by 25%)
b2)HR not less than 55bpm and SBP not less than 90mmHg

c1)decr CO via B1 effect
c2)block vasodilatory receptors via B2 effect

d1)CHF exacerbation
d2)severe COPD/asthma
d3)DM

Front 49

Secondary Prevention of Esophageal Varices (3)

Back 49

1)nonselective BB in addition to EBL is first line

2)combo drug therapy of propanolol or nadolol PLUS LA nitrate (isosorbide mononitrate)
3)counsel pt on nitrate (HA and orthostasis)

Front 50

Alcoholics need what vitamin and why?

Back 50

Thiamine (B1); cofactor in brain to utilitze glucose

Front 51

Altered PK that occur w/ liver disease (3 things that occur w/ 2,1,2 accompanying PK changes)

Back 51

1)decr blood supply to liver and reduced metabolic activity leads to:
a)decr drug CL
b)incr drug half-life

2)decr protein binding leads to:
a)incr fraction of unbound drug in serum

3)accumulation of interstitial fluid leads to:
a)incr Vd
b)incr drug half-life

Front 52

Hepatic Biotransformation changes w/ liver disease (2 w/ 2,2 and ex of each)

Back 52

1)Phase I rxns
a)involves P450 system
b)drug metabolism by these rxns is SIGNIFICANTLY impaired in pts w/ cirrhosis
c)valium (SO DONT USE IT)

2)Phase II rxns
a)involve conjugation of drugs
b)drugs metabolized by these rxns are usually unaffected by liver impairment
c)lorazepam

Front 53

Tx for alcohol withdrawal

Back 53

BZDs!!!

Front 54

Dosing changes recommended in pts w/ liver disease (4)

Back 54

1)monitor response to drug therapy
2)anticipate drug accumulation and enhanced effects
3)reduce dose and titrate to response
4)avoid drugs metabolized by Phase I

Front 55

If a pt is prescribed 45g po TID of lactulose; how many mL do they get for each dose

Back 55

20g/30mL; so 45/20 is 2.25; 30mL x 2.25 is 67.5mL

Front 56

How to monitor progress in Hepatic Encephalopathy (3)

Back 56

1)monitor stools
2)avoid constipating stuff
3)no high protein diet