1 / 80

Liver and Pancreas

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

zahur
Download Presentation

Liver and Pancreas

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Liver and Pancreas

  2. AST/ALT ABNORMAL LIVER TESTS • > 300 • Viral, toxin-induced, ischemia, meds • < 300 • EtOH Hepatitis, cholestasis • AST/ALT ratio • > 2 = EtOH • < 1 = Viral or obstructive

  3. 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

  4. DILI • Acetaminophen • Antibiotics: Bactrim, Augmentin, E-cin • Phenytoin • Valproic acid • Immunomodulators • INH

  5. 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

  6. Viral Hepatitis: Clinical • Symptoms include fatigue, anorexia nausea and vomiting • Lab shows elevated AST/ALT and bili • May resolve, turn fulminant, or become chronic

  7. 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.

  8. 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)

  9. Extra intestinal Manifestations of Hep B • Polyarteritis Nodosa • Arthritis • Glomerulonephritis • Urticaria • Mixed Cryoglobulinemia • Polyneuropathy

  10. Hepatitis B Serology

  11. HBV Scenarios Acute infection Carrier Vaccinated Exposed Immune Acute Window Exposed Ab lost

  12. 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

  13. 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

  14. Treatment of CHB • HbeAG – • HBV DNA > 20000 , ALT > 2 x ULN • RX • Continue till HBsAG loss

  15. 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.

  16. 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

  17. Extrahepatic Manifestations • Glomerulonephritis/MPGN • Cryoglobulins • Porphyria cutanea tarda (PCT) • Thrombocytopenia • Autoantibody • ITP • Neuropathy • Thyroiditis • Sjogren’s Syndrome • Inflammatory arthritis

  18. 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.

  19. 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.

  20. 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

  21. Hepatitis E • Monsoon flooding • Fecal-oral route • No chronic forms • Fulminant hepatitis in 3rd trimester of pregnancy

  22. 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.

  23. 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.

  24. 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

  25. 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

  26. NAFLD • NAFLD: Steatosis • NASH: Steatohepatitis • Characteristics: • Metabolic Syndrome • Elevated AST/ALT • Liver Biopsy • Dx of exclusion: • RX: • RF Modification • Antioxidants • Oral hypoglycemics

  27. 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

  28. 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

  29. 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

  30. Liver Diseases in Pregnancy

  31. 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

More Related