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Questions and Answers
What distinguishes between parenchymal and obstructive liver diseases?
What distinguishes between parenchymal and obstructive liver diseases?
Which of the following is NOT a cause of increased unconjugated bilirubin in pre-hepatic liver disease?
Which of the following is NOT a cause of increased unconjugated bilirubin in pre-hepatic liver disease?
Which drug is recognized as the leading cause of acute liver failure?
Which drug is recognized as the leading cause of acute liver failure?
What is a distinctive feature of Halothane Hepatitis?
What is a distinctive feature of Halothane Hepatitis?
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Which type of liver disease is characterized by an increased presence of conjugated bilirubin?
Which type of liver disease is characterized by an increased presence of conjugated bilirubin?
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What condition is commonly associated with cirrhosis and portal hypertension?
What condition is commonly associated with cirrhosis and portal hypertension?
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Which of the following is least likely to contribute to hepatic encephalopathy?
Which of the following is least likely to contribute to hepatic encephalopathy?
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Which of the following statements about HELLP syndrome is correct?
Which of the following statements about HELLP syndrome is correct?
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What is the primary mechanism by which cholestatic disease leads to hepatocyte destruction?
What is the primary mechanism by which cholestatic disease leads to hepatocyte destruction?
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Which of the following symptoms is NOT typically associated with cholestatic disease?
Which of the following symptoms is NOT typically associated with cholestatic disease?
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What diagnostic method is preferred to differentiate between extrahepatic and intrahepatic causes of biliary obstruction?
What diagnostic method is preferred to differentiate between extrahepatic and intrahepatic causes of biliary obstruction?
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Which of the following conditions is an autoimmune liver disease that does not feature test questions?
Which of the following conditions is an autoimmune liver disease that does not feature test questions?
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In cirrhosis, what is the predominant structural change observed in the liver?
In cirrhosis, what is the predominant structural change observed in the liver?
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Which factor is critical for the absorption of Vitamin K in cholestatic diseases?
Which factor is critical for the absorption of Vitamin K in cholestatic diseases?
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Which of the following laboratory findings would you expect in a patient with liver dysfunction?
Which of the following laboratory findings would you expect in a patient with liver dysfunction?
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What is the consequence of decreased synthesis of thrombopoietin due to liver dysfunction?
What is the consequence of decreased synthesis of thrombopoietin due to liver dysfunction?
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In the context of hepatic encephalopathy, which symptom would indicate a neuropsychological issue?
In the context of hepatic encephalopathy, which symptom would indicate a neuropsychological issue?
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Which condition can lead to the formation of esophageal varices due to blood flow disruption through the liver?
Which condition can lead to the formation of esophageal varices due to blood flow disruption through the liver?
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What is the primary factor leading to renal dysfunction in Hepatorenal Syndrome?
What is the primary factor leading to renal dysfunction in Hepatorenal Syndrome?
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Which autoimmune liver disease is characterized by the destruction of bile ducts leading to cholestasis?
Which autoimmune liver disease is characterized by the destruction of bile ducts leading to cholestasis?
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In cirrhotic cardiomyopathy, what circulatory state is often observed?
In cirrhotic cardiomyopathy, what circulatory state is often observed?
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What condition is characterized by sustained high blood pressure in the portal venous system?
What condition is characterized by sustained high blood pressure in the portal venous system?
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Which intervention is considered definitive treatment in severe cases of renal dysfunction associated with liver disease?
Which intervention is considered definitive treatment in severe cases of renal dysfunction associated with liver disease?
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Which condition is characterized by impaired bile acid transport and presents in the second or third trimester of pregnancy?
Which condition is characterized by impaired bile acid transport and presents in the second or third trimester of pregnancy?
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What is the most common cause of elevated liver enzymes in adults?
What is the most common cause of elevated liver enzymes in adults?
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Which of the following statements is true regarding HELLP syndrome?
Which of the following statements is true regarding HELLP syndrome?
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Which factor is commonly associated with Non-alcoholic Steatohepatitis (NASH)?
Which factor is commonly associated with Non-alcoholic Steatohepatitis (NASH)?
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Acute Hepatitis is primarily defined by which characteristic?
Acute Hepatitis is primarily defined by which characteristic?
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What is the primary treatment recommended for Acute Fatty Liver of Pregnancy (AFLP)?
What is the primary treatment recommended for Acute Fatty Liver of Pregnancy (AFLP)?
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Which type of hepatitis is most likely to progress into chronic liver failure?
Which type of hepatitis is most likely to progress into chronic liver failure?
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Which of the following is a complication usually observed in cirrhosis resulting in portal hypertension?
Which of the following is a complication usually observed in cirrhosis resulting in portal hypertension?
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Which of the following conditions is falsely stated regarding its impact on liver health?
Which of the following conditions is falsely stated regarding its impact on liver health?
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Which condition typically shows steatosis with inflammation and fibrosis upon liver biopsy?
Which condition typically shows steatosis with inflammation and fibrosis upon liver biopsy?
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What condition is characterized by a triad of liver dysfunction, unexplained hypoxemia, and intrapulmonary vascular dilation?
What condition is characterized by a triad of liver dysfunction, unexplained hypoxemia, and intrapulmonary vascular dilation?
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In the context of ascites, what is the most critical consideration when serum sodium levels fall below 120-125 mEq/L?
In the context of ascites, what is the most critical consideration when serum sodium levels fall below 120-125 mEq/L?
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What type of lesions in intrapulmonary vascular dilation are characterized by precapillary dilations and functional shunts?
What type of lesions in intrapulmonary vascular dilation are characterized by precapillary dilations and functional shunts?
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Which treatment option is NOT indicated for managing ascites?
Which treatment option is NOT indicated for managing ascites?
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Which of the following statements about varices is accurate?
Which of the following statements about varices is accurate?
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In patients with portal hypertension, what factor increases the risk for post pulmonary hypertension?
In patients with portal hypertension, what factor increases the risk for post pulmonary hypertension?
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What characterizes Hepatic Hydrothorax?
What characterizes Hepatic Hydrothorax?
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Which of the following is NOT a mechanism by which beta-blockers help lower portal pressure?
Which of the following is NOT a mechanism by which beta-blockers help lower portal pressure?
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What is the estimated percentage of liver transplant patients affected by Hepatopulmonary Syndrome?
What is the estimated percentage of liver transplant patients affected by Hepatopulmonary Syndrome?
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Cystic fibrosis and A1 Antitrypsin Disease are examples of conditions that cause which type of complications?
Cystic fibrosis and A1 Antitrypsin Disease are examples of conditions that cause which type of complications?
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Study Notes
Liver Diseases Classification
- Liver diseases are classified as either parenchymal (hepatocellular) or obstructive.
- They can also be classified as acute or chronic.
Pre-Hepatic Causes
- Pre-hepatic causes of liver disease result in increased unconjugated bilirubin.
- Examples include hemolysis and hematoma reabsorption.
Hepatocellular (Parenchymal) Injury
- Hepatocellular injury leads to increased conjugated bilirubin, ALT/AST, PT, and AP, as well as decreased albumin if chronic.
Acute Hepatocellular Injury
- Drug toxicity is a common cause of acute liver failure, with Tylenol being the leading cause.
- Other drugs that can cause liver toxicity include NSAIDs, amiodarone, anabolic steroids, long-term glucocorticoids, carbon tetrachloride, TPN, cancer chemotherapeutic agents, and some herbal remedies.
- Halothane (Fluothane) Hepatitis is an extremely rare cause of acute liver failure, occurring in approximately 1 in 35,000 cases. It is caused by a reactive trifluoroacetyl metabolite.
- Alcoholic hepatitis is another cause of acute liver injury.
- Pregnancy-related causes include hyperemesis gravidarum, intrahepatic cholestasis, preeclampsia, HELLP syndrome, and acute fatty liver of pregnancy.
Chronic Hepatocellular Injury
- Alcoholic liver disease and non-alcoholic fatty liver disease (NAFLD) are common causes of chronic liver injury.
- NAFLD is caused by excessive fatty deposits in the liver and can range in severity from steatosis to steatohepatitis/NASH.
- NASH is associated with metabolic syndrome, including insulin resistance, obesity, central adiposity, type-II diabetes, HTN, and elevated triglycerides.
- It is the most common cause of elevated liver enzymes in adults.
Acute vs Chronic Hepatitis
- Acute hepatitis is a hepatocellular injury due to viral infection, drug reaction, or exposure to hepatotoxins.
- Chronic hepatitis lasts for more than 6 months and lab values don't always correlate with disease severity.
- Liver biopsies are used for classification.
Hepatocellular Carcinoma
- Hepatocellular carcinoma is the most common primary liver malignancy and the third most common cause of death globally.
- Men are more likely to be affected than women.
- Risk factors are varied.
Cholestatic / Post-Hepatic Causes
- Cholestatic / Post-Hepatic causes result in increased conjugated bilirubin, AST/ALT (if late diagnosis), AP, GGTP, and 5'-NT, as well as decreased albumin (late diagnosis).
- This category includes biliary disease, which affects over 20 million individuals in the US.
Portal Hypertension
- Disrupted blood flow due to liver disease leads to shunt formation, resulting in portal hypertension.
- Portal hypertension can cause esophageal varices, ascites, hepatorenal syndrome (HRS), and pulmonary hypertension.
- Increased hepatic resistance and intrahepatic vasoconstriction lead to further increases in portal pressure.
- The body responds with splanchnic vasodilation, causing a decreased effective arterial circulation.
- This leads to SNS and RAAS activation, resulting in sodium and water retention, hypervolemia, and increased CO.
Signs and Symptoms
- Signs and symptoms of liver disease include jaundice, thrombocytopenia, bleeding, endocrine abnormalities, diabetes, and hepatocellular carcinoma.
Laboratory Findings
- Laboratory findings include increased ALT, AST, AP, GGT, bilirubin, PT, and decreased albumin.
Liver Disease Causes
- Common causes of liver disease include alcoholic liver disease, chronic hepatitis, nonalcoholic steatohepatitis, hemochromatosis, Wilson's disease, primary biliary cirrhosis, primary sclerosing cholangitis, alpha-1 antitrypsin deficiency, prolonged cholestasis, toxins/drugs, hepatic venous outflow obstruction, and cystic fibrosis.
Treatment
- Treatment for liver disease depends on the severity of the disease.
Multiple System Involvement
- Liver disease affects multiple systems, including coagulation, renal function, neurologic function, cardiovascular system, and pulmonary system.
Coagulation
- Liver disease disrupts hemostasis.
- Decreased synthesis of clotting and inhibiting factors occurs.
- This includes decreased synthesis of vitamin K-dependent clotting factors (II, VII, IX, X), particularly in cholestatic diseases.
- The liver also synthesizes all procoagulant and anticoagulant factors except for factors III (thromboplastin), IV (calcium), and VIII (VWB).
- Decreased synthesis of thrombopoietin leads to thrombocytopenia.
- Decreased synthesis of inhibiting factors (protein C, protein S, antithrombin III) occurs.
- Increased consumption of platelets and clotting factors occurs along with decreased clearance of activated factors.
- Hyperfibrinolysis and accelerated intravascular coagulation/DIC can also occur.
Renal Dysfunction
- Sodium and water retention contribute to renal hypoperfusion and decreased glomerular filtration rate (GFR).
- Increased prostaglandin levels help maintain renal perfusion.
- Patients with liver disease are more sensitive to nephrotoxic drugs.
- The definitive treatment for severe hepatorenal syndrome is liver transplant, sometimes combined with a kidney transplant.
Hepatic Encephalopathy
- Hepatic encephalopathy is caused by the accumulation of neurotoxins, most commonly ammonia.
- It manifests with neuropsychological and neuromotor symptoms.
Neuropsychological Symptoms
- Impaired level of consciousness and attention.
- Impaired ability to follow commands.
- Altered affect.
Neuromotor Symptoms
- Hyper-reflexiveness, including asterixis, clonus, and Babinski's sign.
- Nystagmus.
- Decerebrate posturing.
Cirrhotic Cardiomyopathy
- Patients with cirrhosis have hyperdynamic circulation with increased cardiac output.
- Low BP (systolic and diastolic dysfunction) is common, especially post-induction.
- Low systemic vascular resistance (SVR) results from the release of nitric oxide.
- Increased overall fluid volume combined with decreased circulating volume is common.
- Decreased responsiveness to beta-adrenergic stimulation occurs.
- Prolonged Q-T interval is seen.
Pulmonary Complications
- Pulmonary complications of liver disease include hepatopulmonary syndrome (HPS), post-pulmonary hypertension, and hepatic hydrothorax.
Hepatopulmonary Syndrome (HPS)
- Affects up to 20% of liver transplant patients.
- Characterized by a triad of liver dysfunction, unexplained hypoxemia, and intrapulmonary vascular dilation (IPVD).
- Two types of IPVD lesions exist:
- Type I: Precapillary dilations, resulting in functional shunts.
- Type II: Larger dilations in the central lungs, resulting in anatomic shunts.
Post Pulmonary Hypertension
- Affects 4-6% of liver transplant patients.
- Pulmonary hypertension in a patient with portal hypertension.
- Increased risk in female patients and those with autoimmune hepatitis.
Hepatic Hydrothorax (HH)
- Occurs when ascites fluid from the peritoneal cavity passes into the pleural space through defects in the diaphragm.
Ascites
- Ascites is associated with a 50% mortality within 3 years.
- Infections are common.
- Treatment involves paracentesis, slow correction of hyponatremia, sodium restriction, diuretics, and albumin replacement if >6-8L of fluid is drained by paracentesis.
Varices
- Varices are the end result of portal hypertension.
- They are treated with beta-blockers to decrease portal pressure and endoscopic ligation.
Sepsis
- Sepsis is a serious complication of liver disease.
Cirrhosis
- Cirrhosis is the end result of chronic liver diseases.
- Lobules are replaced with fibrosis and regenerative nodules.
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Description
This quiz covers the classification of liver diseases, including parenchymal and obstructive types, as well as acute and chronic distinctions. It also explores pre-hepatic causes and the factors leading to hepatocellular injury, emphasizing drug toxicity and its effects. Test your knowledge on liver health and conditions related to liver diseases.
