Liver

What is the only hepatitis that is a DNA virus?

hepatitis B!! all others are RNA viruses

What types of symptoms occur in the prodrome stage of hepatitis?

very non-specific; anorexia, N/V, malaise, flu like, fever, arthralgia, aversion to smoking, RUQ pain

why do we see peripheral edema in patients w/ cirrhosis?

dec albumin --> inc portal pressure (from fibrotic, enlarged liver)

what symptoms are more chronic hepatitis?

hepatomegaly, spider nevi, ascites, variceal bleeding, peripheral edema, gynecomastia, testicular atrophy, caput medusa

when does the icteric phase occur?

1-2 weeks after prodrome

what symptoms do we see in the icteric phase?

+/- jaundice (1st presents under the tongue, then sclera), pruritis, dark urine (inc direct & indirect bilirubin), HSM (both enlarged bc they share portal system)

what symptoms do we see in the convalescent phase?

feelings of recovery which last 2-4 weeks; labs may normalize

labs of hepatitis

inc bilirubin (last to rise)

dec serum albumin (cannot maintain vasc pressure --> pitting edema & ascites)

LOW TO NORM WBC w/ ATYPICAL LYMPHOCYTES

prolonged PT (most sensitive LFT)--> give Vit K

hypoglycemia

ALT>AST (can be norm if pt burnt through all their enzymes)

what 3 conditions do we normally see atypical lymphocytes?

MONO, CMV, Hepatitis

what is the incubation period of Hep A?

2-6 weeks

what route does Hep A spread through?

fecal oral (shell fish & day care)

does Hep A have a carrier or chronic state?

NO CARRIER OR CHRONIC STATE; typically self limiting

how is Hep A tx?

high carb, low protein diet, avoid hepatotoxic substances, rest; stop statins, stay away from alc & acetaminophen

what indicates an acute infection of Hep A?

presence of IgM ANTI-HAV

what indicates immunity to Hep A?

presence of IgG ANTI-HAV

What hepatitis lives in the environment for a long time?

Hep B

what route is Hep B transmitted?

saliva, semen, vaginal secretions, blood

aka "sex, drugs, rock n roll"

what populations of high incidence of Hep B?

IVDA, male homosexuals, chronic dialysis pt's

what is the incubation period of Hep B?

6 weeks - 6 months

how does Hep B usually present?

subclinical/anicteric

can Hep B cause chronic liver disease?

YES!

how do we tx Hep B?

alpha interferon (can lead to agranulocytosis, thrombocytopenia, suicidal ideation), lamuvidine, adefovir dipivoxil, Entecavir

Newer Tx: Vemlidy (for chronic hep B)- high cure rate & high tolerance

What is the M/C/C of post transfusion hepatitis?

Hep C

What does Hep C have a high association with?

HIV! (always check an HIV pt for Hep C & Hep B)

what are the major genotypes of HCV?

1a, 2a, 2b, 3a are M/C in U.S.

Can Hep C become chronic?

YES

Is there a vaccine for Hep C?

No!

what is the incubation period of Hep C?

6-7 weeks

what populations have a high risk of developing Hep C?

IVDA, intranasal drug use, acupuncture, tattooing, sharing razors, needlestick injuries

how do we dx Hep C?

positive ELISA test

how do we confirm Hep C infection?

positive RIBA; CONFIRM w/ RNA LEVEL (if HIGH, pt has ACTIVE DISEASE)

how do we tx Hep C?

alpha interferon ( IFN therapy w/w/o ribavirin, Peg-INF monotherapy, Peg-INF w/ ribavirin)

NEW MED: Harvoni (ledipasir/sofosbuvir)- inc effectivity, dec AE

LIVER TRANSPLANT if chronic

What is Hep D a coinfection with?

HEP B (required to replicate)

what is the best way to prevent Hep D?

vaccinate against Hep B

what does chronic Hep D cause in most patients?

cirrhosis (in 70%)

what is the incubation period of Hep E?

2 weeks - 2 months (15-60 days)

what route does Hep E spread through?

fecal oral, water born, **mother child transmission, blood tranfusions

does Hep E become chronic?

yes usu in immunosuppressed but typically doesn't cause chronic

how is Hep E diagnosed?

HEV IgM/IgG & confirmed w/ Hep EV RNA

how is Hep E tx?

supportive care

what is the 1st EVIDENCE of HBC INFX?

HBsAG; surface antigen, seen before clinical s/sx, indicates active or carrier state

what follows the disappearance of the HBsAg?

appearance of anti-HBs

what indicates the 1ST SIGN OF IMMUNITY?

ANTI-HBs; appears 2-6 mo after HbsAg disappears

when does Anti-HBs appear?

if vaccinated previously or if the pt was previously infected

what does it mean if you have negative HBsAg & Anti-HBs but positive Anti-HBe?

you have active infection in window period

what does Anti-HBc IgM indicate?

acute infection (sole marker of HBV infxn during window period)

what does Anti HBc IgG indicate?

chronic hepatitis

what does HBeAg indicate?

implies ongoing viral replication & high infectivity (presence >3mo --> inc chance of chronic Hep B)

what does HBe-ANTI indicate?

may be positive w/ recovery from Hep B

what is HBe-anti seen with?

HBsAg negative & HBs-AB positive

what is seroconversion of HBeAg to anti-HBe associated with?

dec in serum HBV DNA & remission of liver disease

will being vaccinated make HBe-Anti?

NO! only positive in patients that have beat the disease. indicates immunity.

what is the tx of Hep B?

hep B immunoglobulin protective if given within 7 days of exposure, rest, gradual return to activities, avoid ETOH, physical exertion, hepatotoxic drugs

how can hep A be prevented?

give immune globulin if close contact of HAV

how can hep B be prevented?

HBIG: given if + exposure to HBV followed by vax series

HBV vax

when should HBV vax be given?

@ 0, 1, 6 months & give booster +/- 9 years

what is one of the m/c/c of inc LFTs?

fatty liver

what is fatty liver?

change in the liver resulting from excessive accumulation of lipid w/in hepatocytes

what is a cause of fatty liver disease?

ETOH- causes derangement in lipid metabolites causing a buildup of TGs in liver

is Fatty Liver always alcohol induced?

No, there is NASH (non-alcoholic steatohepatitis- one of the m/c/c of inc liver enzymes in children)

is fatty liver disease reversible or irreversible?

REVERSIBLE!

how does a fatty liver appear on US?

hyperechoic

what are the s/sx of fatty liver disease?

enlarged smooth, non-tender liver; recent or prolonged ETOH use; jaundice in 25% of cases

what labs are associated w/ fatty liver disease?

normal blood count, elevated AST/ALT (AST<300), norm/inc ALK PHOS

what is better imaging for fatty liver disease: CT or MRI?

MRI (useful for excluding fatty infiltration)

what is the tx of fatty liver disease?

stop drinking, supportive care, dieting (gradual weight loss- abrupt can lead to progression)

is alcoholic hepatitis reversible or irreversible?

reversible!

what is alcoholic hepatitis?

liver damage characterized by degeneration & necrosis of hepatocytes, seen w/ infiltration of PMNs

what do we see with alcoholic hepatitis?

fibrosis --> progresses to cirrhosis

what are the acute s/sx of alcoholic hepatitis?

fatigue, anorexia, N/V, large tender liver, jaundice

what are the chronic s/sx of alcoholic hepatitis?

spider nevi, gynecomastia, testicular atrophy, asterixis

what AST/ ALT ratio is seen w/ alcoholic hepatitis?

AST>ALT 2:1 ratio

what other labs do we see w/ alcoholic hepatitis?

ALK PHOS inc (obstructive states), inc bilirubin, inc PT, dec albumin, inc MCV (think B12 def, folate def, thiamine def)

what is the tx of alcoholic hepatitis?

abstinence, multivitamins/folic acid, Vit K

is cirrhosis reversible or irreversibleI

IRREVERSIBLE! End stage of ETOH liver disease

what do we see with cirrhosis of the liver?

micronodular liver (nodular --> portal HTN), fibrotic & sclerotic

what does hematemesis indicate in cirrhosis?

esophageal varices (portal HTN --> hypvolemia, tachycardia, dec CO)

what is the tx of cirrhosis?

supportive only, TIPS (connects portal vein to hepatic vein & bypasses blood through liver --> dec portal pressure --> dec varices & ascites- not detoxifying ammonia), only cure is transplant

what are the m/c/c of hepatocellular carcinoma?

HBV, HCV, ETOH, hemochromatosis, biliary cirrhosis, autoimmune hepatitis

how does hepatocellular carcioma present?

sudden deterioration of stable cirrhosis (decompensate quickly)

what are the s/sx of hepatocellular carcinoma?

cachexia, weakness, wt loss, ascites

"looks like balloons from waist down & lose muscle mass"

what do we see in the labs of hepatocellular carcinoma?

ELEVATED ALPHA-FETO PROTEIN, elevated alk phos, leukocytosis

what is a better test for hepatocellular carcinoma: CT or MRI?

MRI- shows vascularity of tumor

what test is diagnostic for hepatocellular carcinoma?

Liver Bx (usu not done b/c afraid of tumor spillage)

what is the tx of hepatocellular carcinoma?

attempts at surgical resection--> thermally ablate to try & prevent spillage; liver transplant (rare)

what is hepatic encephalopathy?

state of CNS dysfxn due to livers inability to break down toxins due to preexisting liver disease (grade from 0-4)

what is the m/c elevated toxin in hepatic encephalopathy?

ammonia (NH3)

what is the tx of hepatic encephalopathy?

Lactulose 30cc po Tid-Qid is #1 Tx (does cause diarrhea)

Neomycin 1gm po Bid also useful to dec colonic [ ] of ammoniagenic bacteria

what is Wilson's Disease?

rare autosomal recessive disorder (defect Ch 13), seen w/ excessive copper deposition in liver & brain

what are the s/sx of Wilson's Disease?

Kayser-Fleischer Rings, splenomegaly, hemolytic anemia, portal HTN, cirrhosis, neurologic (rigidity & parkinsonian tremors)

what is dx of Wilson's Disease?

INC URINARY OUTPUT OF COPPER, low ceruloplasmin level, elevated hepatic copper, liver bx

what is the tx of Wilson's Disease?

restriction of dietary copper (shellfish, organ foods, legumes)

DOC: PENICILLAMINE, B6, oral zinc acetate

only cure: liver transplant

family should be tested

what is hemochromatosis?

autosomal recessive disease (mut Ch 6) causing inc accumulation of iron as hemosiderin in the liver, heart, pancreas, adrenal glands, kidneys

what should you test for if you see elevated liver enzymes?

hemochromatosis

what is the m/c autosomal recessive liver disease in the world?

hemochromatosis

what are the s/sx of hemochromatosis?

hepatomegaly, "bronze diabetics", impotence, bleeding from varices

what labs do we see in hemochromatosis?

inc Fe, inc ferritin, dec TIBC, polycythemic, positive DNA test, liver bx

what is the most specific/most reliable iron marker?

ferritin

what is the tx for hemochromatosis?

phlebotomy, deferoxamine, liver transplant if cirrhosis, family members screened