PANCE Blueprint GI and Nutrition (9%)

Hepatic Disorders (PEARLS)

The NCCPA™ Gastroenterology and Nutrition PANCE Content Blueprint covers two topics under the category hepatic disorders

Acute and chronic hepatitis Symptoms: Tea-colored urine, vague abdominal discomfort, nausea, pruritus, pale stool

Hepatitis A

  • Acute - fatigue malaise, nausea, vomiting, anorexia, fever and right upper quadrant pain.
  • Transmission: Fecal-oral
  • Serum IgM anti-HAV
  • Vaccine: killed (inactivated) - given in two doses, recommended for travelers.

Hepatitis B

  • Acute and Chronic
  • Transmission: Sexual or sanguineous
  • Serology:
  • HBeAg – highly infectious
  • HBsAg – ongoing infection
  • Anti-HBc – had/have infection
    • IgM – acute
    • IgG – not acute
  • Anti-HBs – immune
  • Risk of hepatocellular carcinoma
  • Vaccine is given to all infants (birth, 1-2 mo, 6-18 mo)

Hepatitis C

  • Chronic
  • Asymptomatic
  • Transmission: IV drug use is most common. Also sexual or sanguineous
  • Screen with testing for anti-HCV antibodies
  • Diagnosis with HCV RNA quantitation
  • Risk of cirrhosis and hepatocellular carcinoma
  • Treatment: antiretrovirals target complex of enzymes needed for HCV RNA synthesis

Hepatitis D

  • Only occurs when coinfected with Hepatitis B
  • Risk of hepatocellular carcinoma

Hepatitis E

  • Pregnant woman, 3rd world countries
  • Hepatitis E + mother = high infant mortality

Treatment: Supportive. Vaccinate against other viral hepatitis. HIV treatment PRN.

  • Hepatitis C: Direct acting antiretrovirals target complex of enzymes needed for HCV RNA synthesis

Alcoholic Hepatitis

  • Liver enzymes: AST:ALT ratio > 2:1

Toxic Hepatitis

  • Acetaminophen toxicity: Treatment with N-Acetylcysteine within 8-10 hrs

Fatty Liver Disease:

  • Risk factors: Obesity, hyperlipidemia, insulin resistance
  • Liver enzymes: ALT > AST
  • Liver biopsy: Large fat droplets (macrovesicular fatty infiltrates)

Hepatitis B Serology

Hepatitis Serology      
Anti-HBc IgM Anti-HBc IgG HBsAg Anti-HBs Interpretation
+ - + - Acute HBV
- - + - Early acute HBV
- + - + Resolved acute HBV
- - - + HBV vaccine/Immunity
- - - - No infection or immunity
- + + - Chronic HBV

Hepatitis C Serology

HCV RNA Anti-HCV
Acute Hepatitis C + ±
Resolved Hepatitis C - ±
Chronic Hepatitis C + +

Hepatitis A Serology

IgM HAV Ab IgG HAV Ab
Acute Hepatitis A +
Past exposure - +
Cirrhosis (ReelDx) A chronic liver disease characterized by fibrosis, disruption of the liver architecture, and widespread nodules in the liver

  • The most common cause is alcoholic liver disease
  • Second most common cause: chronic hepatitis B and C infections
  • Labs: typically AST > ALT
  • ↑ risk for hepatocellular carcinoma - 10-25% of patients with cirrhosis - monitor AFP
  • Hepatic vein thrombosis (Budd Chiari Syndrome): a triad of abdominal pain, ascites, and hepatomegaly

Distortion of liver anatomy causes

  • Portal HTN: decreased blood flow through the liver → hypertension in portal circulation; causes ascites, peripheral edema, splenomegaly, varicosity of veins
  • Ascites - accumulation of fluid in the peritoneal cavity due to portal HTN and hypoalbuminemia
    • The most common complication of cirrhosis
    • Abdominal distension, shifting fluid dullness, fluid wave
    • Abdominal ultrasound, diagnostic paracentesis  - measure serum albumin gradient 
    • Salt restriction and diuretics (furosemide and spironolactone)
    • Paracentesis if tense ascites, SOB, or early satiety
  • Esophageal variceal rupture - dilated submucosal veins, retching or dyspepsia, hypovolemia, hypotension, and tachycardia
  • Hepatorenal syndrome: progressive renal failure in ESLD, secondary to renal hypoperfusion from vasoconstriction - azotemia (elevated BUN), oliguria (low urine output, and hypotension
  • Hepatic encephalopathy: ammonia accumulates and reaches the brain causing ↓ mental function, confusion, poor concentration
    • Asterixis (flapping tremor) - have patient flex hands
    • Dysarthria, delirium, and coma
  • Hepatocellular failure → decreases albumin synthesis and clotting factor synthesis
    • Prolonged PT - PTT in severe disease - tx with fresh frozen plasma

Presentation:

  • Ascites, pulmonary edema/effusion, esophageal varices, Terry’s nails (white nail beds)
  • Skin changes: spider angiomata, palmar erythema, jaundice, scleral icterus, ecchymoses, caput medusae, hyperpigmentation

Treatment: Avoid alcohol, restrict salt, transplant

  • Monitoring: periodic lab values q 3 to 4 months (CBC, renal function, electrolytes, LFT, coagulation panel), perform endoscopy for varices, CT-guided biopsy for hepatocellular carcinoma
Pyloric stenosis (ReelDx) (Prev Lesson)
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