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97 Cards in this Set
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think liver biopsy for diagnosis of (at least) the following:
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cirrhosis
hc [wilson's dz -- can be helpful, I'm not sure if it's necessary] hemochromatosis |
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don't biopsy this liver prob...
why? |
cavernous hemangiomas
rupture / hemorrhage |
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liver transplant is helpful for (at least) the following
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hepatorenal syndrome
if med rx isn't enough: -- wilson's -- hemochromatosis HCC unless you're one of the 10% of resectable pts |
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the gold standard for diagnosis of cirrhosis
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liver biopsy
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_ estimates severity of liver dz
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child's classification
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child's classification: class A (the best) features
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no ascites
bili < 2.0 no encephalopathy excellent nutritional status albumin > 3.5 |
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bilirubin in mild vs. severe liver dz
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< 2.0
> 3.0 |
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albumin in mild vs. severe liver dz
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> 3.5
< 3.0 |
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bilirubin in severe liver dz
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> 3.0
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albumin in severe liver dz
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< 3.0
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11 causes of cirrhosis
grouped to help me remember them |
nonalcoholic steatohepatitis
------ alcohol acetaminophen, methotrexate hepatitis b & c ------ autoimmune hepatitis primary biliary cirrhosis, secondary biliary cirrhosis hemochromatosis Wilson's AAT deficiency hepatic congestion 2^ -- right-sided heart failure -- constrictive pericarditis hepatic veno-occlusive dz -- e.g. after marrow transplant |
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what % of heavy drinkers develop cirrhosis
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15-20%
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drugs that cause cirrhosis
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acetaminophen
methotrexate |
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treatment for bleeding varices includes
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IV octreotide
variceal ligation [endoscopic sclerotherapy] |
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two meds for acutely bleeding esophageal varices, and which one is better and has replaced the other one
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octreotide -- less s/e
vasopressin |
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ascites can be managed by _____ in most cases
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salt restriction and diuretics
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prophylactic medication for esophageal varices
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nonselective beta blocker
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______ (a complication of cirrhosis) can exacerbate hepatic encephalopathy
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varices -- ? bleeding or not ?
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initial treatment for bleeding varices
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fluids
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treatment for varices acutely
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IV fluids
IV antibiotics prophylactically IV octreotide emergent upper GI endoscopy for either -- *ligation* -- [sclerotherapy] |
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the most common complication of cirrhosis
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ascites
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ascites in cirrhosis is due to
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portal HTN
hypoalbuminemia |
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ascites sxs
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abdominal distention
shifting dullness fluid wave |
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if you suspect pt. has ascites, what do you do diagnostically?
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paracentesis to determine if it's due to portal htn vs. something else
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indications for diagnostic paracentesis
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new-onset ascites
worsening ascites spontaneous bacterial peritonitis |
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differential diagnosis of causes of ascites
(10) |
cirrhosis
portal htn chf massive fluid overload chronic renal dz hypoalbuminemia tuberculous peritonitis malignancy endotoxin --> NO release --> peripheral vasodilation --> ^ renin --> ^ aldosterone impaired liver inactivation of aldosterone |
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a key lab value in discerning the cause of ascites
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serum ascites albumin gradient
if > 1.1 g/dL, portal HTN is likely the cause |
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when doing diagnostic paracentesis, you want to rule out ______ by
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spontaneous bacterial peritonitis
Gram stain and culture |
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treatment for ascites
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bed rest
low-sodium diet furosemide spironolactone paracentesis if -- tense -- shortness of breath -- early satiety TIPS/peritoneovenous shunt |
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precipitants of hepatic encephalopathy (7)
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alkalosis
hypokalemia -- e.g. 2^ diuretics GI bleeding hypovolemia narcotics sleeping pills systemic infection |
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monitor cirrhosis pts by.,..
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labs every 3-4 months:
CBC renal function tests / electrolytes LFTs, coags - - - - - - - - - - - - - - - - - endoscopy to determine presence of varices |
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cirrhosis pts:
if carcinoma is suspected, perform a.... |
CT-guided biopsy
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treatment for hepatic encephalopathy and why
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lactulose
-- its metabolism by bacteria favors NH4+ formation, which is poorly absorbed vs. NH3 neomycin -- kills bowel flora --> v ammonia production limit protein to 30 to 40 g/day -- reduces production of NH3 in the first place |
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mechanism of hepatorenal syndrome
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splanchnic vasodilation -->
kidney hypoperfusion --> RAAS --> vasoconstriction of renal vessels --> renal hypoperfusion |
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this gi problem does not respond to volume expansion
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hepatorenal syndrome
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hepatorenal syndrome rx
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liver transplantation is the only cure
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hepatorenal syndrome 5 lab findings
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azotemia
oliguria hyponatremia hypotension U Na+ < 10 (low) |
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if you see
fever change in mental status in an ascites pt think |
spontaneous bacterial peritonitis
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most common causes of spontaneous bacterial peritonitis
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E coli
Klebsiella Streptococcus pneumoniae |
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diagnosis of spontaneous bacterial peritonitis
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paracentesis
-- WBC > 500 -- PMN > 250 + culture, or culture-negative |
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spontaneous bacterial peritonitis initial rx
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broad spectrum abx
-- give specific antibiotic once organism is identified |
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cirrhosis hyperestrinism signs
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spider angiomas
palmar erythema gynecomastia testicular atrophy |
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cirrhosis
coagulopathy lab values |
^ PT
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treat coagulopathy in cirrhosis with
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fresh flozen plasma
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genetics of wilson's dz
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recessive
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genetics of hemochromatosis
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recessive
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wilson's disease molecularly:
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deficiency of ceruloplasmin
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wilson's dz most common initial manifestation
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liver dz
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how does wilson's dz affect the eye
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kayser-fleischer rings
-- yellowish rings in cornea they do not interfere with vision |
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organ systems affected by wilson's dz
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liver
eye brain renal |
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how does wilson's dz affect kidneys
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aminoaciduria
nephrocalcinosis |
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how does wilson's dz affect the brain
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parkinsonian sxs
-- resting tremor -- rigidity -- bradykinesia chorea drooling incoordination depression personality changes psychosis |
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where does copper deposit in the brain in wilson's dz
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basal ganglia
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wilson's dz diagnosis -- (a few to many of the following may be present)
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^ aminotransferases
v coags v albumin v serum ceruloplasmin ^ copper on liver biopsy |
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treatment for wilson's dz
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D-penicillamine
zinc liver transplantation if unresponsive to the above |
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hemochromatosis pathophys
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excessive iron absorption in the intestine -->
accumulation of iron (as ferritin and hemosiderin) in various organs --> hydroxyl free radicals --> fibrosis |
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secondary hemochromatosis can occur with
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multiple transfusions
chronic hemolytic anemias |
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early in dz course of hemochromatosis
you may find _____ next diagnostic steps? |
elevated ALT, AST
iron studies. if elevated --> liver biopsy |
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complications of hemochromatosis
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cirrhosis
-- carcinoma risk x 200 CHF arrhythmias 2nd and 3rd metacarpophalangeal joints hips knees hyperpigmentation of skin -- like sun tan, "bronzelike" diabetes hypogonadism hypothyroidism |
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diagnosis of hemochromatosis
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^ ALT, AST
^ serum iron ^ serum ferritin ^ transferrin saturation v TIBC liver biopsy |
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_____ is required for the diagnosis of hemochromatosis
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liver biopsy
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treatment for hemochromatosis
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repeated phlebotomies
treat complications liver transplantation in advanced cases |
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hepatocellular adenoma
seen in which pts / why |
women
15-40 yrs oral contraceptives anabolic steroids |
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a couple complications / sequelae of hepatocellular adenoma
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malignancy (<1%)
rupture --> hemoperitoneum, hemorrhage |
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diagnosis of hepatocellular adenoma
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CT scan
ultrasound hepatic arteriography |
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hepatocellular adenoma rx
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discontinue oral contraceptives
surgically resect tumors > 5cm |
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the most common type of benign liver tumor
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cavernous hemangiomas
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cavernous hemangiomas size may increase due to
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pregnancy
oral contraceptives |
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cavernous hemangiomas diagnosis
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ultrasound
CT scan with IV contrast |
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cavernous hemangiomas: do not do ____ for diagnosis
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biopsy
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biopsy is contraindicated in this benign tumor
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liver cavernous hemangiomas
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there is no association of ______ with oral contraceptives
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focal nodular hyperplasia
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risk factors for hepatocellular carcinoma
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cirrhosis
-- alcohol -- hepatitis B & C aflatoxin, vinyl chloride, Thorotrast AAT deficiency Hemochromatosis Wilson's dz schistosomiasis hepatic adenoma smoking glycogen storage dz type 1 |
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distinctive clinical features of HCC
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painful hepatomegaly
erythrocytosis thrombocytosis hypercalcemia hypoglycemia high cholesterol carcinoid syndrome hypertrophic pulmonary osteodystrophy |
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HCC can --> ^ / v this electrolyte
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hypercalcemia
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how does HCC affect cholesterol?
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high cholesterol
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how does HCC affect glucose?
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hypoglycemia
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think HCC if you see (3)
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cirrhosis
palpable liver mass ^ AFP |
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_____ is required for definitive diagnosis of HCC
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liver biopsy
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HCC:
if surgery is an option, do this as part of the diagnostic regimen b/c |
MRI
MRA they provide more detail about the tumor's anatomy |
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gilbert's syndrome genetics
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autosomal dominant
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gilbert's syndrome is due to
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v activity of uridine diphosphate glucuronyl transferase
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a couple common causes of unconjugated bilirubin
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hemolysis
Gilbert's syndrome |
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causes of hemobilia
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trauma (most common)
papillary thyroid carcinoma surgery tumors infection |
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diagnosis of hemobilia
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arteriogram
upper GI endoscopy shows blood coming out of ampulla of Vater |
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hydatid liver cysts are caused by
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Echinococcus granulosus
Echinococcus multilocularis |
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hydatid liver cysts rx
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surgery
(avoid spilling contents of the cyst into the peritoneal cavity) mebendazole |
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what's dangerous about hydatid liver cysts?
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larger cysts may cause
rupture --> fatal anaphylactic shock |
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treatment for hydatid liver cysts is ____
treatment for amebid liver abscess is ____ |
mebendazole
IV metronidazole |
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most common causes of pyogenic liver abscess
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biliary tract obstruction (most common cause)
GI infection -- diverticulitis -- appendicitis penetrating liver trauma |
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diagnosis of pyogenic liver abscess
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US
CT scan ^ LFTs |
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prognosis of liver abscess
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fatal if untreated
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liver abscess rx
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IV antibiotics
percutaneous drainage |
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amebic liver abscess
which pts? why? |
homosexual men
fecal-oral contact |
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amebic liver abscess is caused by
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Entamoeba histolytica
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amebic liver abscess dx
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immunoglobulin G enzyme immunoassay
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amebic liver abscess rx
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IV metronidazole
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