PANCE Blueprint GI and Nutrition (8%)

ReelDx Virtual Rounds (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
• 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 (e.g., travelers to endemic areas, laboratory workers), and provide postexposure prophylaxis with standard immune globulin or, for some, vaccination

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

• 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

• Pregnant women, third 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
• 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 C Serology

Hepatitis A Serology

Acute liver failure is characterized by rapid deterioration of liver function, particularly the synthesis of clotting factors and toxin clearance, in someone without pre-existing liver disease

• The most common cause in the US is acetaminophen overdose
• Common laboratory findings include elevated aminotransferases (AST, ALT), elevated bilirubin, prolonged prothrombin time (PT), and increased INR, low glucose, and elevated ammonia
• Common complications include cerebral edema and intracranial hypertension, coagulopathy and bleeding, renal failure, sepsis, and metabolic derangements

DX:  Diagnostic criteria include the presence of coagulopathy (INR ≥ 1.5), the presence of hepatic encephalopathy, the absence of preexisting liver disease, and the duration of illness < 26 weeks

• Acetaminophen level, viral hepatitis serologies, autoimmune markers (ANA, ASMA, IgG), toxicology screen, pregnancy test in women of childbearing age, and abdominal ultrasound or CT scan to rule out chronic liver disease or obstruction

TX: N-acetylcysteine (NAC) is used to treat acetaminophen toxicity but can also benefit other causes by improving hepatic blood flow and oxygen delivery

• Liver transplantation is the definitive treatment for patients with fulminant liver failure who are unlikely to recover with supportive care alone

ReelDx Virtual Rounds (Cirrhosis)

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
• The second most common cause is 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 - treat 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

DX: Diagnosis is based on clinical findings, imaging (e.g., ultrasound with elastography, CT, or MRI), and liver function tests showing elevated AST/ALT, bilirubin, INR, and low albumin; liver biopsy may confirm the diagnosis

TX: Focuses on treating the underlying cause (e.g., antiviral therapy for hepatitis, alcohol cessation), preventing complications, and monitoring for HCC

• Portal hypertension: Managed with beta-blockers (e.g., propranolol) and endoscopic variceal ligation (EVL) for varices
• Ascites: Treated with salt restriction, diuretics (e.g., spironolactone, furosemide), and paracentesis for symptomatic relief
• Hepatic encephalopathy: Managed with lactulose and rifaximin
• Liver transplantation, the definitive treatment for decompensated cirrhosis or associated HCC

• 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
• Prognosis depends on the degree of liver dysfunction, often assessed using the Child-Pugh score or MELD score

AKA

Metabolic dysfunction-associated steatotic liver disease (MASLD)

Metabolic dysfunction-associated steatotic liver disease (MASLD), previously termed Nonalcoholic Fatty Liver Disease (NAFLD), is a spectrum of liver conditions NOT related to alcohol consumption

• The spectrum ranges from simple steatosis to nonalcoholic steatohepatitis (NASH)/metabolic dysfunction-associated steatohepatitis (MASH), which can progress to cirrhosis and hepatocellular carcinoma

DX: Diagnosis is often made incidentally when imaging studies (ultrasound, CT, MRI) show fatty liver in the absence of significant alcohol consumption

• Liver function tests may show mild to moderate elevation in ALT and AST, typically with an AST/ALT ratio <1, unlike alcoholic liver disease
• Absence of hepatitis B and C
• The definitive diagnosis can be made with a liver biopsy, showing steatosis, lobular inflammation, and ballooning, but this is NOT routinely performed due to its invasive nature
• Non-invasive markers and scoring systems (e.g., Fibrosis-4 index, NAFLD fibrosis score) can help assess liver fibrosis risk

TX: The mainstay of treatment is lifestyle modification to reduce weight and control metabolic risk factors

MASLD vs. MASH

While MASH is a subset of MASLD, not everyone with fatty liver will develop MASH!

Portal Hypertension is an increase in portal venous pressure (above 5-10 mmHg), commonly caused by obstruction to blood flow through the liver, leading to complications from venous congestion.

• Most common cause is cirrhosis, though other causes include portal vein thrombosis, Budd-Chiari syndrome, and schistosomiasis
• Symptoms include abdominal distension (ascites), splenomegaly, and signs of collateral venous circulation such as esophageal varices and caput medusae
• Complications include variceal bleeding, ascites, hepatic encephalopathy, and renal dysfunction (hepatorenal syndrome)

DX: Confirmed by imaging, such as ultrasound with Doppler, which shows increased portal vein pressure and collateral vessels; endoscopy is used to identify esophageal varices

• Measurement of hepatic venous pressure gradient (HVPG) is the GOLD STANDARD that can confirm the diagnosis and quantify the severity of portal hypertension
• Labs: Elevated liver enzymes (AST, ALT), bilirubin, INR, and low albumin

TX:  Involves treating complications:

• Non-selective beta-blockers (e.g., propranolol) to reduce variceal bleeding risk
• Endoscopic band ligation or sclerotherapy for active variceal bleeding
• Diuretics (spironolactone, furosemide) and paracentesis for ascites
• TIPS (transjugular intrahepatic portosystemic shunt) for refractory varices or ascites

Surgical options (e.g., shunt procedures) are rarely used but may be indicated for refractory cases

Prevention includes managing underlying liver disease, avoiding alcohol, and screening for varices in at-risk patients