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
ReelDx Virtual Rounds (Hepatitis)

Symptoms: Tea-colored urine, vague abdominal discomfort, nausea, pruritus, pale stool

Hepatitis A

Patient will present as → a 38-year-old female who has just returned from a 2-week trip to Mexico. She complains of nausea, vomiting, loss of appetite, and right upper quadrant abdominal pain. She has been sick for the past 3 days. She complains of passing dark-colored urine for the past 2 days. She has had no exposure to blood products, has no history of intravenous drug use, and has no significant risk factors for sexually transmitted disease. On examination, she looks acutely ill. Her pulse is 100 beats/minute, blood pressure 110/70 mm Hg, respirations 18, and temperature 101°F. Her sclerae are icteric, and her liver edge is tender.
  • Acute - fatigue malaise, nausea, vomiting, anorexia, fever, and right upper quadrant pain.
  • Transmission: Fecal-oral
  • DX: Serum IgM anti-HAV
    • The IgG antibody to HAV (IgG anti-HAV) test is done to help distinguish acute from prior infection. A positive IgG anti-HAV suggests prior HAV infection or acquired immunity
  • TX: Supportive care
  • Vaccine: killed (inactivated) - given in two doses
    • Routine vaccination beginning at age 1 is recommended for all.
    • Vaccinate people at risk (eg, travelers to endemic areas, laboratory workers), and provide postexposure prophylaxis with standard immune globulin or, for some, vaccination

Hepatitis B

Patient will present as → a 37-year-old male presents to the occupational health clinic after a needlestick exposure in a patient with cirrhosis. In addition to a standard bloodborne pathogen laboratory panel sent for all needlestick exposures at his hospital, additional hepatitis panels are ordered. The patient’s results are shown below:

HIV 4th generation Ag/Ab: Negative/Negative
Hepatitis B surface antigen (HBsAg): Negative
Hepatitis C antibody: Negative
Anti-hepatitis B surface antibody (HBsAb): Positive
Anti-hepatitis B core IgM antibody (HBc IgM): Negative
Anti-hepatitis B core IgG antibody (HBc IgG): Positive

  • 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

Patient will present as → a  55-year-old rock musician who comes to the office because he has been feeling increasingly tired for 6 months. He has a history of intravenous drug use and alcohol abuse. He states that he feels quite tired, but otherwise has no complaints. The examination is noncontributory. His laboratory investigations are normal aside from elevated liver enzymes.
  • 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

  • Hepatitis D occurs only when coinfected with Hepatitis B
  • Risk of hepatocellular carcinoma
  • Suspect hepatitis D particularly when cases of hepatitis B are severe or when symptoms of chronic hepatitis B are worsening
  • DX: If serologic tests for hepatitis B confirm infection and clinical manifestations are severe, antibody to HDV (anti-HDV) levels should be measured
    • Anti-HDV implies active infection. It may not be detectable until weeks after the acute illness.
  • Treat and prevent infection as for hepatitis B.

Hepatitis E

Patient will present as → a 33-year-old Caucasian woman who comes to the emergency department because of vomiting and fever. The patient works as a global health nurse and her medical history is relevant for recent travel to India. Upon further questioning, the patient mentions that she is concerned because it has been 9 weeks since her last menstruation. Physical examination shows yellowing of the skin and sclera, right upper quadrant tenderness, and hepatomegaly. Her temperature is 101.3°F, pulse is 98/min, respirations are 14/min, and her blood pressure is 120/70 mmHg. Laboratory studies reveal increased aminotransferase levels and a positive pregnancy test.
  • 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:

Patient will present as → a 43-year-old obese woman with a history of diabetes presents for a routine visit. She denies having any complaints. On physical exam, her physician notices mild hepatomegaly without tenderness to palpation. A liver enzyme panel is sent and reveals elevated transaminases. She is sent for a hepatic ultrasound to evaluate for nonalcoholic fatty liver disease or steatohepatitis.
  • Risk factors: Obesity, hyperlipidemia, insulin resistance
  • DX: Liver function panel: ALT > AST, elevated alkaline phosphatase, viral hepatitis panel to exclude viral cause of chronic hepatitis
    • Ultrasound of liver for all patients - findings steatohepatitis (increased echogenicity and coarsened echotexture of the liver)
    • Liver biopsy: Large fat droplets (macrovesicular fatty infiltrates)
  • TX: lifestyle modification - weight loss, alcohol cessation, diabetes control, low-fat diet

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)
ReelDx Virtual Rounds (Cirrhosis)
Patient will present as → a 63-year-old white male with a chief complaint of blood in his stool. He is accompanied by his wife who also reports weight gain, abdominal distension, and swelling of his legs. Physical exam reveals a healthy-appearing male with 3+ bilateral lower extremity edema and distended abdomen with evidence of shifting dullness. You also note several skin lesions seen here. The patient is hemoccult positive and has blood on his urine dipstick. He denies tobacco and illicit drug use but admits to drinking 1-2 x per week and has about 6 beers on each occasion.

A chronic liver disease characterized by fibrosis, disruption of the liver architecture, and widespread nodules in the liver

  • The most common cause is an 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
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