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Liver and Pancreas. AST/ALT. ABNORMAL LIVER TESTS. > 300 Viral, toxin-induced, ischemia, meds < 300 EtOH Hepatitis, cholestasis AST/ALT ratio > 2 = EtOH < 1 = Viral or obstructive. Alcoholic Hepatitis. Jaundice, fever, ascites, HE, AST/ALT > 2 with AST/ALT < 300-400.Increased WBC

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ast alt
AST/ALT

ABNORMAL LIVER TESTS

  • > 300
    • Viral, toxin-induced, ischemia, meds
  • < 300
    • EtOH Hepatitis, cholestasis
  • AST/ALT ratio
    • > 2 = EtOH
    • < 1 = Viral or obstructive
alcoholic hepatitis
Alcoholic Hepatitis
  • Jaundice, fever, ascites, HE, AST/ALT > 2 with AST/ALT < 300-400.Increased WBC
  • PATH: Steatosis, Fibrosis,Mallory bodies
  • Treatment:
  • If MDF > 32 start prednisone 40 mg X 4 wks
  • After 7 days on steroids if no improvement and Lillie score >.45 Stop Steroids.
  • If steroids are C/I add pentoxifiline to prevent HRS
slide13
DILI
  • Acetaminophen
  • Antibiotics: Bactrim, Augmentin, E-cin
  • Phenytoin
  • Valproic acid
  • Immunomodulators
  • INH
viral hepatitis transmission
Viral Hepatitis: Transmission
  • Fecal-Oral: Hepatitis A and E
  • Sexual: Hepatitis B and D; also C (to a lesser extent)
  • Note: Hepatitis D requires coexisting Hep. B infection
viral hepatitis clinical
Viral Hepatitis: Clinical
  • Symptoms include fatigue, anorexia nausea and vomiting
  • Lab shows elevated AST/ALT and bili
  • May resolve, turn fulminant, or become chronic
hepatitis a
Hepatitis A
  • Fecal-oral transmission
  • Symptoms: Adult > children
  • Transplacental transmission occurs
  • No carrier states, rarely fulminant
  • Can have cholestasis for up to 6 mos
  • Vaccine: Patients with liver dz/risks/ travelers
  • Acute infection: + IgM anti-HAV, Vaccination: + IgG anti-HAV
  • IG prophylactic for Hep A
  • HAV Vaccination 2 doses 6-12 months apart.
hepatitis b
Hepatitis B
  • Incubation 1-6 months
  • Transmitted sexually, parenterally, mucous membrane exposure
  • Can present with serum sickness (fever, arthritis, urticaria, angioedema)
  • Associated with polyarteritis nodosa (PAN)
extra intestinal manifestations of hep b
Extra intestinal Manifestations of Hep B
  • Polyarteritis Nodosa
  • Arthritis
  • Glomerulonephritis
  • Urticaria
  • Mixed Cryoglobulinemia
  • Polyneuropathy
hbv scenarios
HBV Scenarios

Acute infection

Carrier

Vaccinated

Exposed

Immune

Acute

Window

Exposed

Ab lost

hepb vaccine prophylaxis
HepB vaccine/prophylaxis
  • 95% of immunocompetent pts develop antibody (anti-HBs)
  • Only 50% of HD pts develop antibody
  • May be given to pregnant pts
  • 3 doses at 1, 2 and 6 months
  • HBIG Alone:
    • sexual contacts of carriers and household members of acute Hep B
  • HBIG + vaccine (exposed is HBsAg negative)
    • blood exposure to pt w/acute Hep B
    • newborns of Hep B mothers
treatment of chb
Treatment of CHB
  • HBeAg + HBV DNA > 20000, ALT > 2 x ULN
  • Observe for 6 months and treat if no spontaneous conversion.
  • Consider Liver Bx
  • Rx: Peg IFN o
  • Entecavir, tenofovir, telbivudine
  • Continue Rx for 6 months after seroconversion
treatment of chb1
Treatment of CHB
  • HbeAG –
  • HBV DNA > 20000 , ALT > 2 x ULN
  • RX
  • Continue till HBsAG loss
hepatitis c
Hepatitis C
  • Most common liver disease in the US
  • IVDU, cocaine use, prisons, blood products prior to 1990, tattoo
  • Genotype 1 most common in the US
  • 85 % of Hep C infected become chronic
    • 25% cirrhosis post 20-25 years of infection
    • 5 %/yr risk to develop HCC in those with cirrhosis
  • 5% sexual transmission over 10-20 yrs
  • <5% trans placental transmission. HIV co-infection increases transmission rate.
serological tests
Serological Tests
  • Third generation anti-HCV+ >95% sensitive
  • If high pre-test probability and anti-HCV negative can do PCR testing (more often in renal failure or transplant)
  • Genotype testing required for treatment candidates only
extrahepatic manifestations
Extrahepatic Manifestations
  • Glomerulonephritis/MPGN
  • Cryoglobulins
  • Porphyria cutanea tarda (PCT)
  • Thrombocytopenia
    • Autoantibody
    • ITP
  • Neuropathy
  • Thyroiditis
  • Sjogren’s Syndrome
  • Inflammatory arthritis
slide33

Recommended regimen for treatment-naive patients with HCV genotype 1 who are eligible to receive IFN.

Daily sofosbuvir

RBV

plus weekly PEG for 12 weeks is recommended for IFN-eligible persons with HCV genotype 1 infection, regardless of subtype.

Recommended regimen for treatment-naive patients with HCV genotype 1 who are not eligible to receive IFN.

Daily sofosbuvir

RBV for 12 weeks is recommended for IFN-ineligible patients with HCV genotype 1 infection, regardless of subtype.

slide34

Recommended regimen for treatment-naive patients with HCV genotype 2, regardless of eligibility for IFN therapy:

Daily sofosbuvir

RBV for 12 weeks is recommended for treatment-naive patients with HCV genotype 2 infection.

Recommended regimen for treatment-naive patients with HCV genotype 3, regardless of eligibility for IFN therapy:

Daily sofosbuvir

RBV for 24 weeks is recommended for treatment-naive patients with HCV genotype 3 infection.

hepatitis d
Hepatitis D
  • Requires coexistent B
  • Usually found in IVDA
  • Coinfection: does not worsen acute Hep B or  risk for chronic state
  • Superinfection: frequently severe/fulminant
  • Dx: Anti-HDV IgM
hepatitis e
Hepatitis E
  • Monsoon flooding
  • Fecal-oral route
  • No chronic forms
  • Fulminant hepatitis in 3rd trimester of pregnancy
slide37

A 30 y/o female presents with c/o fatigue,arthralgias,weight loss, amenorrhea. PE reveals Icterus and HSM. No h/o alcohol or drug abuse. No FH of Liver disease.Labs: T.Bili 6mg/dl, AST 300 U/L,ALT350 U/L, ALP 100 U/ml, Albumin 2.9 g/dl. Iron studies are normal. Hepatitis profile and HIV is negative.

Which of the following are correct:

  • 1. ANA and ASMA are likely to be positive
  • 2. Liver Biopsy should be done to confirm Dx
  • 3. She will likely respond to steroid therapy
  • 4. All of the above are correct.
autoimmune hepatitis
Autoimmune Hepatitis
  • AIH: Asymptomatic mild disease to Fulminant
  • Liver failure.
  • Fatigue, Jaundice, Maliase
  • Type I:ANA +, ASMA +, Increased IG,SLA/LP Ab
  • Common in USA
  • Type II: LKM1
  • Common in Europe, poor prognosis, Rx failures
  • RX:
  • Steroids
  • Immunomodulators.
primary biliary cirrhosis
Primary Biliary Cirrhosis
  • Usually middle aged women
  • Pruritis, fatigue
  • Increased alk phos
  • The clue:
  • elevated Antimitochondrial Antibodies (AMA)
    • Anticentromere antibodies
    • Associated with sicca syndrome and scleroderma
  • Treat with ursodiol
primary sclerosing cholangitis
Primary Sclerosing Cholangitis
  • An autoimmune fibrosis of large bile ducts
  • Clinical: RUQ pain, fatigue, weight loss
  • 70% of cases associated with ulcerative colitis
  • Increased risk of cholangiocarcinoma
  • Diagnose with ERCP
    • Beading of the bile ducts on ERCP/MRCP
    • 10-15% get bile duct carcinoma
nafld
NAFLD
  • NAFLD: Steatosis
  • NASH: Steatohepatitis
  • Characteristics:
  • Metabolic Syndrome
  • Elevated AST/ALT
  • Liver Biopsy
  • Dx of exclusion:
  • RX:
  • RF Modification
  • Antioxidants
  • Oral hypoglycemics
other liver tests
Other liver tests

ABNORMAL LIVER TESTS

  • Autoimmune hepatitis (ANA, ASMA, Anti-liver/kidney microsomal, anti-SLA)
  • PBC (AMA)
  • PSC (p-ANCA 70%)
  • Hemochromatosis Iron Saturation >45%
  • Wilsons Disease (low ceruloplasmin, incresed serum and urine Cu)
  • Alfa 1 antitrypsin def
hemochromatosis
Hemochromatosis
  • Most common genetic disease in Caucasians
  • Iron deposits in liver, heart, pancreas, pituitary, Joints
  • Bronze pigmentation, new onset DM,arthritis,hypogonadism.
  • Can lead to cirrhosis and HCC
  • Iron Sat > 45%
  • Increased Ferritin
  • Abnormal Lft’s
  • HFE gene mutation C282Y and H63D
  • RX: Phlebotomy
  • Goal ferritin < 50
wilson s disease
Wilson’s Disease
  • Rare Autosomal Recessive d/o 1:30000
  • Increased cooper uptake and decreased biliary excretion.
  • May present as fulminant liver failure
  • Neuropsychiatry symptoms
  • Increased AST/ALT
  • Low ALP
  • Low Cerruloplasmin
  • Increased urinary copper excretion
  • KF rings on slit lamp
portal htn
Portal HTN
  • Increased portal blood flow:

Increased cardiac index

Splanchnic vasodilation

Hypervolemia

  • Increased resistance to portal blood flow:

Fixed resistance from fibrosis

Dynamic resistance

  • RX:
  • NSBB
  • Octreotide
  • Diuretics
  • TIPS
portal htn1
Portal HTN
  • Most common cause is cirrhosis
  • Manifestations:
  • Hepatic Encephalopathy
  • Gastro-esophageal Varices
  • Ascites
workup
Workup

ASCITES

  • Need to know if ascites is CHF, cirrhosis or malignancy (exudate)
  • Serum-ascites albumin gradient > 1.1 = transudate (Portal HTN)
  • If ascites protein > 2.5, then CHF
  • If ascites protein < 2.5, then cirrhosis
  • <1.1 = ascites is NOT from portal hypertension
        • “Higher SAAG = higher pressure”
workup1
Workup

ASCITES

Tap all new ascites

  • Tap all ascites in cirrhotics with clinical change
  • Labs
    • < 250 cells/μl
    • 1 neutrophil/250 RBC
    • 2 lymphocyte/750 RBC
    • Innoculate cultures at the bedside
    • Gram stain
  • If TB is suspected, you need a peritonal bx
treatment
Treatment

ASCITES

  • 2g Na restriction/day
  • No benefit in restricting fluids
  • Spironolactone 100mg/day + Lasix 40mg/day
  • Large volume paracentesis
  • TIPS for paracentesis-resistant ascites
slide56
SBP
  • Translocation of bacteria across they bowel wall into susceptible ascites.
  • Subclinical
  • Fever, Abd pain,encepahlopathy
  • DX:
  • PMN > 250
  • GN organisms E.coli most common
  • Treat SBP with 3rd generation cephalosporin IV for 5 day and then PO Abx
  • Pplx with oral quinolones after SBP
  • IV Albumin to prevent HRS.
hepatic encephalopathy
Hepatic Encephalopathy
  • Ppting Factors:
  • GI bleed, SBP, Sepsis, sedatives, constipation, electrolyte abnormalities, acute liver injury, HCC, surgery.
  • RX:
  • Recognize and Correcting ppting factors
  • Correct electrolytes.
  • Lactulose
  • Rifaximin.
hepatorenal syndrome hrs
Hepatorenal syndrome (HRS)
  • HRS Type I: Rapid decline in renal function
  • HRS Type II: Chronic usually due to refractory ascites.
  • DDX: ATN, Pre-renal
  • DX:
  • Sr Creatinine > 1.5
  • No improvement after holding diuretics and volume expansion with IV Albumin
  • Absence of shock, hypotension,proteinuria,nephrotoxics
  • Low urine sodium.
slide60
HRS
  • Rx:
  • Avoiding and holding all nephrotoxics.
  • Hold diuretics
  • IV Albumin
  • Midodrine and octreotide
  • OLT is the definitive treatment
fulminant hepatic failure
Fulminant Hepatic Failure
  • Jaundice and hepatic encephalopathy in the absence of chronic liver disease.
  • Acetaminophen is the most common cause in US ( worsened by alcohol, malnutrition and fasting state)
  • Acute viral hepatitis is the most common cause world wide.
  • Other meds: INH, NSAIDS, herbal meds
  • Other causes: AIH, BCS, AFLP, HELLP, Amanita Phalloids
fulminant hepatic failure1
Fulminant Hepatic Failure
  • Complications: Hypoglycemia, Cerebral edema,coagulopathy,infection
  • RX;
  • Supportive care in ICU
  • Early recognition and transfer to the transplant center.
  • NAC for acetaminophen toxicity
  • Acyclovir for HSV hepatitis.
  • Pen G for mushroom toxicity
  • Antiviral for acute hepatitis B
history pearls
History Pearls

ABNORMAL LIVER TESTS

  • Pruritus/Cholestasis
      • PBC, PSC
  • Undercooked food, oysters, daycare
    • Hep A
  • ICU, hypotension, Rt. Sided heart failure
    • Hepatic congestion
  • Chronic pancreatitis
    • Stenosis of CBD
history pearls1
History Pearls

ABNORMAL LIVER TESTS

  • Neurological/Psych findings
    • Wilson’s disease
  • Metabolic syndrome
    • Fatty liver
  • Hyperpigmentation
    • Hemochromatosis or PBC
  • Kayser-Fleischer rings and sunflower cataracts
    • Wilson’s disease
history pearls2
History Pearls

ABNORMAL LIVER TESTS

  • Splenomegaly
    • Portal HTN or infiltrative process
  • Pulsatile liver
    • Tricuspid insufficieny
  • Hepatic bruits
    • HCC
acute pancreatitis
Acute Pancreatitis
  • Alcohol
  • Biliary Tract Disease
  • Trauma
  • Post ERCP
  • Hyperlipidemia
  • Pancreatic Malignancy
poor prognostic indicators in pancreatitis
Poor Prognostic Indicators In Pancreatitis
  • SBP < 90 , HR > 130
  • PO2 < 60 mmHg
  • Urine out put < 50ml/hr or BUN/Cr Elevation
  • GI Bleeding
  • Pancreatic necrosis
  • HCT > 44
  • CRP > 150
  • Apache score > 8
  • Ranson score > 3
complications of pancreatitis
Complications of Pancreatitis
  • Sepsis;

Necrosis, infected pseudocyst,Abscess

  • Early:

Shock, ARDS, GIB, DIC, Uremia,hypocalcemia

Splenic infarction & rupture, Pl Effusion.

Late:

Phlegmon, Pseudocyst, abscess

Ascites, Pleural Effusion

Splenic Vein thrombosis– GV--GIB

ranson criteria
Ranson Criteria

Admission

During 48 hrs

PO2 < 60 mmHg

Drop in HCT > 10 %

BUN increases > 5mg/dl

Calcium < 8 mg/dl

Fluid sequestration

  • Age > 55
  • WBC > 15K
  • Glucose > 200
  • AST > 250
  • LDH > 350
pearls
Pearls
  • Acute Pancreatitis is a clinical and lab Dx and not imaging
  • Alcohol and Gall Stones most important causes
  • Prophylactic Abx (Imipenum) in necrotising pancreatitis
  • Early enteral Feeding is preferred.
pancreatic adenocarcinoma
Pancreatic Adenocarcinoma
  • Risk Factors:

Age, Smoking, Chronic pancreatitis,Hereditary pancreatitis, Obesity, Fatty diet

  • Manifestation:

Pain radiating to back, Wt Loss, jaundice,

Painless jaundice due obstruction of CBD by pancreatic head mass

Diagnosis:

CT-Scan pancreas protocol, EUS, MRI, ERCP