CLM liver/GI-cardiac powerpoints

CLM exam 2

what is the largest solid organ in the body

liver

where is the liver located

right upper quadrant of the abdomen

what are the functions of the liver

process and synthesize amino acids into circulating proteins

breaks down excess amino acids and make byproducts

store carbohydrates from the gut in the form of glycogen and helps prevent hypoglycemia

cholesterol synthesis

primary location of detoxification

what are lab tests to check protein synthesis in the liver

albumin

prealbumin

prothrombin time/INR

what lab tests check excretion into bile ducts and drainage into duodenum

bilirubin

alkaline phosphatase (ALP)

4’-nucleotidase

gamme-glutamyl transpeptidase (GGT)

what disease state is the impairment of excretion into bile ducts and drainage into the duodenum

cholestasis

what lab tests check for hepatocellular injury

aspartate aminotransferase (AST)

alanine aminotransferase (ALT)

what lab tests check for detoxification in the liver

ammonia

what lab tests check for lipid metabolism/synthesis

cholesterol

what lab tests are used to check for liver damage

albumin

INR/PT

ALP

AST/ALT

bilirubin

ammonia

what lab tests are used to check for alcohol intake

GGT

AST — usually 2x ALT

ALT

what is a normal range for albumin

3.5-4.8 g/dL

what happens when there are low concentrations of albumin in the body

drop oncotic pressure → fluid leaks into interstitial space → edema

does prealbumin or albumin have a shorter half life

prealbumin

what protein is less affected by liver disease and hydration status

prealbumin

what is a normal INR/PT

0.9-1.2/12.7-15.4 seconds

where are most clotting factors made

in the liver

what, besides liver dysfunction, can elevate INR/PT

vitamin K deficiency

where is alkaline phosphatase found

in liver, bone, small intestine, kidneys, placenta, and leukocytes

what level of alkaline phosphatase indicates cholestasis

concentration 4x greater than normal

what is the normal range of total bilirubin

0.2-1.3 mg/dL

what type of bilirubin is not water soluble

total bilirubin

what type of bilirubin is bound to albumin in the blood

total bilirubin

what is the normal range of direct bilirubin

0-0.3 mg/dL

what type of bilirubin is water soluble

direct bilirubin

what type of bilirubin is excreted by the kidneys

direct bilirubin

what causes yellowing of the skin and sclera of the eyes (jaundice)

elevated bilirubin

what is the total bilirubin range that presents with visible jaundice

2-4 mg/dL

how is indirect (unconjugated) bilirubin produced

breaking down erythrocytes from circulation

how is indirect bilirubin removed from circulation

by converting direct bilirubin via the liver

what can cause elevated indirect bilirubin

increased breakdown of red blood cells

reduced hepatic conversion to direct bilirubin

how is direct (conjugated) bilirubin synthesized

by conjugating indirect bilirubin in hepatocytes

what does elevated direct bilirubin suggest

hepatic or biliary tract disease — interferes with secretion of bilirubin from hepatocytes or clearance of bile from liver

what is direct hyperbilirubinemia classified as

positive cholestatic liver test

how much ammonia does the liver remove during first pass metabolism

>90%

what does elevation in ammonia correlate with

severity of encephalopathy and likelihood of death

what is the current treatment of encephalopathy targeted towards

reducing ammonia levels

what is the normal AST range

14-36 units/L

what is the normal ALT range

9-52 units/L

what is a child-pugh score

score to assess prognosis of chronic liver disease (usually cirrhosis)

provides prediction of increasing severity of liver disease and survival rate

what child-pugh score is indicative of a better survival rate

A

what child-pugh score is indicative of the worst survival rate

C

what is included in a child-pugh score

total bilirubin, albumin, INR, ascites, encephalopathy

what is a MELD score

prognostic system used to predict 3 month mortality due to liver disease

what does a higher MELD score mean

higher 3-month mortality related to liver disease

what is included in a MELD score

dialysis, creatinine, bilirubin, INR, sodium levels

what lab tests are related to hepatitis A

anti-HAV IgM

total anti-HAV

what lab tests are related to hepatitis B

HBeAg

HBsAg

Anti-HBc IGM

Anti-HBc

Anti-HBe

Anti-HBs

what lab tests are related to hepatitis C

HCV PCR

Anti-HCV

what lab tests are related to hepatitis D

Anti-HDV

HDV PCR

what lab tests are related to primary biliary cirrhosis

antimitochondrial antibody

what are the three diagnostic criteria for pancreatitis

characteristic symptoms

elevation of amylase or lipase to at least 3x ULN

characteristic findings on imaging (CT or MRI)

must have at least 2 of the 3

what is lipase

enzymes secreted by the pancreas that aids in fat digestion

what is the serum half-life of lipase

7-14 hours

what is amylase

enzyme that breaks down starch into individual sugar molecules

what is the serum half-life of amylase

1-2 hours

how do we detect noninvasive H. pylori

serology (most common)

urea breath test

fecal antigen test

how do we detect invasive H pylori

histology

culture

rapid urea test

what does serology detect for H pylori testing

circulating IgG against bacteria proteins

what does urea breath test detect

ability of bacteria to produce urease

what are clinical symptoms of clostridioides difficile

asymptomatic OR chronic diarrhea + acute colitis

what are tests for C. diff

enzyme immunoassays for toxin A + B

enzyme immunoassays for glutamate dehydrogenase (GDH)

nucleic acid amplification test (NAAT)

cell culture

C. diff antigen

cell cytotoxicity assay

stool culture

what are the characteristics of immunoassays for toxins A + B

rapid

low sensitivity

what are the characteristics for immunoassay for glutamate dehydrogenase

low specificity

detects nontoxigenic strains

what are characteristics of nucleic acid amplification tests (NAAT)

rapid and accurate diagnosis

becoming a standard test for initial eval

being used if initial test result is negative

detects asymptomatic carriers

what is the first test used when C diff is suspected

immunoassay for GDH and toxin A + B

what happens when the stool sample is positive for GDH and toxin A/B

testing is consistent with C diff infection

what happens if the stool sample is positive for GDH but negative for toxin A/B

indeterminant result → use PCR to detect C diff toxin

what happens if the stool sample is negative for GDH but positive for toxin A/B

indeterminant result → use PCR to detect C diff toxin

what happens if the stool sample is negative for GDH and toxin A/B

testing is not consistent with C diff infection

what are the primary causes of dyslipidemia

genetic mutations

overproduction or defective clearance of TG and LDL

under production or excessive clearance of HDL

what are the secondary causes of dyslipidemia

disease states

medications

lifestyle choices

what conditions can cause secondary dislypidemia

diabetes mellitus

obesity

sedentary lifestyle

hypothyroidism

cigarette use

pregnancy

cholestasis

liver failure

what drugs or diets can cause secondary dyslipidemia

alcohol

beta blockers

thiazides

contraceptives

high carb diet

high saturated fats diet

corticosteroids

atypical antipsychotics

what conditions usually have high LDL, low HDL, high TG

diabetes

hypothyroidism

obesity/sedentary lifestyle

nephrotic syndrome

what conditions usually have high TG

acute hepatitis

pregnancy

systemic lupus erythrematosis

uremia

alcohol

amiodarone

oral contraceptives

what conditions usually have high LDL and high TG

corticosteroids

diet

thiazides

what are the major plasma lipids

cholesterol

triglycerides

phospholipids

what is cholesterol

component of cell wall membranes

precursor to steroid hormones and bile acids

either dietary or synthesized in the liver

what are triglycerides

fat found in blood that the body uses for energy

exogenous and endogenous

what are phospholipids

lipid molecules that contain a phosphate group

not absorbed through the diet

intracellular metabolism and blood coagulation

what are apolipoproteins

proteins embedded in the surface of lipoproteins

what is the role of apolipoproteins

assembly and secretion of lipoproteins

major structural of lipoproteins

act as ligands for LDL receptors on cell surfaces

cofactors for activation of enzymes

what are the largest but least dense lipoproteins

chylomicrons

what are the smallest but most dense lipoproteins

HDLs

what is included in a fasting lipid panel

total cholesterol (TC)

high-density lipoprotein (HDL)

low-density lipoprotein (LDL) — calculated value

triglycerides (TG)

what is included in a non-fasting lipid profile

total cholesterol (TC)

high density lipoprotein (HDL)

what is the equation for total cholesterol

TC = LDL + HDL + TG/5 (used if TG <400)

when must a measured LDL be obtained

when TG >400

what is non-HDL

TC - HDL

secondary target when TG >200

what is an optimal LDL

<70 mg/dL

what is a high LDL

>160 mg/dL

what is calculated LDL

TC - HDL - TG/5

do not use if TG >400

what are the instructions for the lipid panel profile

no food for 9-12 hours

water and meds ok

black coffee ok

soda not ok

what are interfering factors for a lipid panel

pregnancy

recent weight loss

vigorous exercise

acute myocardial infarction

low in severe liver disease or malnutirition

optimal lipid panel levels

LDL — <70 mg/dL

HDL — 40-60 mg/dL

triglycerides — <150 mg/dL

what is atherosclerosis

deposits of fatty plaques on the inner walls of the arteries

what are the criteria for classification of ASCVD

MI or acute coronary syndrome

coronary or other revascularization procedure

transient ischemic attack

ischemic stroke

atherosclerotic peripheral artery disease

what are CVD risk factors

age — >45 for men, >55 for women

family Hx of premature CHD — male <55, female <65

cigarette smoking

HTN or HTN meds

HDL <40 mg/dL

adult treatment therapy III summary

patient treatment therapies based on CHD, CV risk factors, 10-year risk assessment, targeted LDL levels

therapeutic lifestyle changes

drug therapy