Liver

Liver-

-Acute/Chronic Hepatitis-

-Hepatitis is inflammation of the liver

-Types/Causes of Hepatitis:  viral infections, bacterial infections, fungal infections, parasitic infections, toxic exposure, side effect of medication, immunologic

-4 phases of infection:  viral replication, prodromal phase, icteric phase, and convalescent phase

-physical exam is dependent on the type of hepatitis and time of presentation

-possible physical exam findings include:  low grade fever, vomiting, dehydration, icterus, urticarial or petechial rashes, enlarged liver and RUQ tenderness

-Hepatitis A- Picromavirus which is an RNA virus

-Hepatitis A is spread by oral fecal route

-Diagnosis elevated IgM acutely and IgG chronically

-Treatment of Hepatitis A is symptomatic 

-Hepatitis A has a vaccine 

-Hepatitis B is a DNA virus

-transmission is by serum, saliva and semen

-high risk groups are IV drug users, homosexual males, hemodialysis patients, heterosexuals with multiple partners,  and health care workers

-chronic carrier state of hepatitis B is at increased risk for hepatocellular carcinoma

-HbsAg s the first sign of Hepatitis B before clinical disease 

-Anti-HBs appears after HbsAg is cleared

-Anti-HBc core antibody is the earliest detectable antibody to infection in most patients

-HbeAg e antigen is indicative of high infectivity

-typically have RUQ pain, fatigue, elevated LFT's, atypical lymphocytes, and 15% serum sickness

-treatment is supportive care.  Patients with coagulopathy, dehydration, and encephalopathy need to be hospitalized

-HBIG (Hepatitis B Immunoglobulin) should be given post exposure plus the Hepatitis B vaccine

-Hepatitis B vaccine is given 3 stages

-Hepatitis C virus is a single stranded RNA virus

-90% of Hepatitis C patients are post transfusion patients

-can be transmitted parenterally, perinatally, and sexually

-more patients have Hepatitis C then HIV

-incubation period 50 days

-chronic carriers 50-70% of the time

-treatment is supportive, can give interferon or PEG interferon 15-60% response rate

-there is no vaccine or immunoglobulin that is effective

-Hepatitis D (also called Delta Hepatitis)

-it is a defective RNA virus that requires hepatitis B for replication

-transmission is similar to hepatitis B

-no effective vaccine or immunoglobulin is effective

-One third with concurrent infections will develop fulminant hepatitis

-Hepatitis E is Enteric RNA Virus

-a major cause of hepatitis endemic to Asia

-Transmitted oral fecal route

-No vaccine or immunoglobulin is helpful

-Hepatitis F is enteric ally transmitted

-No vaccine or immunoglobulin is helpful

-Hepatitis G is a severe sporadic hepatitis 

-it has been recently isolated

-CMV (Cytomegalovirus) Hepatitis is a latent infection that reactivated during immunosuppression

-most common opportunistic viral infection in patients with liver transplant

-Treatment of CMV hepatitis is Grancyclovir 

-Epstein Barr (EBV) Hepatitis caused by mononucleosis

-Only 5 percent of patients with mononucleosis will develop jaundice

-Other viral causes of hepatitis include herpes simplex and varicella zoster

-Toxic Induced Hepatitis examples include:  Halothane, INH, Thorazine, Dilantin, Tylenol, Mushrooms, oral contraceptives, erythromycin, esolate, chlorpromazine

-Alcoholic Hepatitis may develop in 10 percent of alcoholics and lead to hepatic failure

-Seen in chronic alcoholics not just new exposures to alcohol

-Symptoms of alcoholic hepatitis include:  RUQ pain, leukocytosis, hypoglycemia, anemia, AST twice ALT, elevated INR, gynecomastia, spider angiomas, muscle waisting, ascites, and palmer erythema

-treatment is supportive

-want to supplement thiamine and glucose and Mg when necessary

-want a high calorie, vitamin supplemental diet with low protein content

-Autoimmune Hepatitis is a progressive inflammatory disorder of the liver

-More common in young women and girls

-serum gamma globulin levels are twice normal, positive ANA and or anti smooth muscle antibodies

-Treatment of autoimmune hepatitis is with steroids and immuran

-liver transplant is a possible therapy

-Chronic Hepatitis B and C patients need a liver transplant for end stage liver disease

-MELD score will help evaluate their mortality rate

-the majority of patients with acute hepatitis C do not spontaneous clear and thus develop chronic hepatitis

-Cirrhosis-

-cirrhosis is a late stage of progressive hepatic fibrosis characterized by distortion of the hepatic tissue and formation of regenerative nodules

-it is irreversible in the late stages, and only treatment is liver transplant

-most common causes of cirrhosis in the US are alcoholic liver disease and hepatitis C

-the most common causes of cirrhosis are chronic viral hepatitis (B and C), alcoholic liver disease, hemochromatosis, and non alcoholic fatty liver disease

-other causes of cirrhosis include autoimmune hepatitis, primary and secondary biliary cirrhosis, primary sclerosing cholangitis, medications (methotrexate, INH), Wilson disease, alpha 1 anti-trypsin deficiency, idiopathic adulthood ductopenia, granulomatous liver disease, idiopathic portal fibrosis, infections, right heart failure, and venous occlusive disease

-symptoms or cirrhosis include anorexia, weight loss, weakness, and fatigue

-maybe asymptomatic

-patients with decompensated cirrhosis may have jaundice, pruritus, and signs of upper GI bleeding

-as cirrhosis progresses, patients can have a decrease in the mean arterial pressure

-patients with cirrhosis may have parotid gland enlargement, gynecomastia, ascites, hepatomegaly, splenomegaly, testicular atrophy, clubbing, and asterixis 

-AST and ALT are usually moderately elevated in cirrhosis

-alkaline phosphatase is usually elevated in cirrhosis

-GGT levels usually correlate with alkaline phosphatase levels with cirrhosis

-bilirubin levels may be normal in compensated cirrhosis

-albumin levels usually fall

-INR levels generally increase because these proteins are synthesized in the liver and advance cirrhosis there are less of them

-usually have hyponatremia because of ascites and the inability to excrete free water

-pancytopenia is common with cirrhosis 

-Liver biopsy is required to definitively confirm cirrhosis

-major complications of cirrhosis include:  variceal hemorrhage, ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, hepatocellular carcinoma, hepatorenal syndrome, and hepatopulmonary syndrome

-major goals of managing patients with cirrhosis include showing or reversing progression of liver disease, preventing superimposed insults to liver, discontinuing hepatotoxic meds, managing symptoms and lab abnormalities, preventing identifying and treating complications of cirrhosis, and determining the appropriateness and timing of liver transplant

-Neoplasms-

-Common benign liver lesions include:  hepatic hemangiomas, focal nodular hyperplasia, hepatic adenoma, idiopathic portal hypertension, and regenerative nodules

-Common malignant liver lesions include hepatocellular carcinoma, cholangiocarcinoma, and metastatic disease

-Hepatic hemangiomas are called this because of the cavernous vascular space occupied and they are the most common mesenchymal hepatic tumors.  Cause symptoms when larger than 4 cm

-Focal Nodular Hyperplasia is benign liver tumor that is hyperplastic response to an anomalous artery

-Hepatic adenomas is a benign epithelial liver lesion that occurs in a non cirrhosis liver.  The majority of patients have used oral contraceptives for 2 years before diagnosis. These have a small risk of neoplastic transformation

-Idiopathic Non Cirrhosis Portal Hypertension is a condition where there is multiple foci of proliferating hepatocytes forming nodules throughout the liver.  

-Regenerative nodules are nodules that form in response to hepatic injury.  Usually seen with cirrhosis

-Hepatocellular Carcinoma is a primary liver malignancy that occurs in the setting of chronic liver disease such as chronic hepatitis B or cirrhosis

-Cholangiocarcinoma is a malignancy of the bile ducts.  Risk factors include primary sclerosing cholangitis and choledochal cysts

-Metastatic liver tumors are the most common form of malignant hepatic neoplasms

-CT scan or MRI is usually the imaging studies of choice

-Surgical resection is recommended for lesions that are symptomatic or if hepatocellular carcinoma cannot be excluded on lab results, imaging or by fine needle aspirate