Gi_Pm_Clinmed_Jaundice I&ii

Front 1

What forms the Ampulla of Vater?

Back 1

Where biliary tree system dumps into Duodenum. Common Bile Duct and Main Pacreatic Duct

What is Sphincter of Oddi

Hint 1

Sheath of Smooth mm fibers surrounding the intra-duodenal segment of CBD and Ampulla, constricts to control bile and pancreatic secretions ino the duodenum

Front 2

What serum Bilirubin Level indicates Jaudice? What are 3 types of Jaundice?

Back 2

Bilirubin > 2.5-3.0 mg/dL

-Prehepatic: hemolysis, large hematomas
-Hepatic: Many Dzz
-Posthepatic: Gallstones with Obst. Cx of Biliary Tract, Cholangitises

Front 3

What is increased if PRe-hepatic jaundice?

What if Hepatic Jaundice

Back 3

Unconjugated Bilirubin on Albumin

Hepatic: since liver conjugates the Unconjugated--with liver problem, both Serum Conjugated and Unconjugated will be elevated.

What if post hepatic

Hint 3

Conjugated Bilirubin will be higher.
and if it can't get into feces it will go to Urine OR Skin

Front 4

When conjugated bilirubin can't get into feces or urine, but rather to skin, why does it itch

Back 4

Bile Salts and Acids itch

Front 5

How are liver enzymes in Prehepatic J?

Back 5

normal

In Hepatic J?

Hint 5

AST and ALT will be elevated
maybe Alk Phos

-with increased levels of Conjugated and Unconjugated

Front 6

How are liver enzymes in Post-hepatic J?

Back 6

Elevation of Liver Enzymes
-Increased Alk Phos--Greatly

Hint 6

so if inc Alk phos think stone or post hepatic J.

Front 7

What is Cholelithiasis?

Back 7

Gallstones
-20million Ami s have it, most are ASx

What is main role of GB

Hint 7

Absorb excess water/electors, concentrae bile
-Secretes H+ and Mucin

--If Gallbladder stasis occurs, risk for lithogenesis

Front 8

The following are risk factors for what?
Prolonged TPNut
Pregger
Oral Contra
Obesity
DM

Back 8

Cholelithiasis
-Stones

Think of 6 Fs

Hint 8

Female, Fat, Fertile, Forty, Flatulent, Fair Skinned
= cholelithiasis

Front 9

What is Clnical Presentation of Cholelithiasis?

Back 9

Biliary Colic (wave like build and decrease in pain)
-in RUQ in 1/3 Pts
--due to slow contraction, but stopped, so it contracts harder

What precipitates colic

Hint 9

Meal
-may last up to 3 hours
-Vomiting and Diaphoresis are common

Front 10

What if Biliary "coli" pain rises steeply and lasts MORE than 6 hours indicates what?

Back 10

Cholecystitis

What is this?

Hint 10

Obstruciton of cystic duct by gallstones with resultant acute inflammation of the GB
--90% assc w/ stone
-may have bacteria, but its usually secondary cause

Front 11

What positive sign will you have with Cholecystitis?

Back 11

Murphey's Sign
--Take Deep Breath in, you push in and they ARREST their breathing

--Why can cholecystitis have jaundice even w/o stone?

Hint 11

Also will have Jaundice, with or with out stone. B/c with cystitis, WALL is thickened, so even without a stone you can have blockage

Front 12

Tx for Cholecystitis?

Back 12

ASx is elective Cholecystectomy

What if calcified or "porcelain" GB?

Hint 12

Increased risk for Malignancy
--should undergo cholecystectomy

Front 13

What is diff btw Choledocholethiasis and Cholelithiasis

Back 13

Choledochel is stone obst Common Bile Duct. Lithiasis is just presence of stones.

What is Tx for Choledochalithiais>

Hint 13

Cholecystectomy

Front 14

What are other Tx options of Cholecystitis?

Back 14

Ectomy--laparascopic/lapartomy
-
-Chemical Dissolution
ERCP with SPhincterotomy
-Lithotripsy

Front 15

What is Cholangitis

Back 15

Infection of Common Bile Duct?

Common Agents?

Hint 15

E. Coli (gram-)
Enterococcus (gram+)

Front 16

What is Triad of Sx for Cholangitis

Back 16

Charcot's Triad
-RUQ Pain
-Fever
-Jaundice

Front 17

With continued thickening of bile duct, what results

Back 17

Fibrosis
so
Sclerosing Cholangitis
--can get in UC too (50-75% have it)

Who is mostly effected?

Hint 17

Mostly Young Men
may have elevated Alk Phos
Jaundice or Enlarged liver

--note: SC is rare--has primary cause assc/ IBD (UC), and Secondary Cause assc/ Surgery/Trauma/Chronic Panc.

Front 18

How is it Diagnosed?
What is Sclerosing Cholangitis linked to?

Back 18

SC diagn by ERCP/
inc risk of Cholangiocarcinoma

Tx for Sclerosing Cholangitis?

Hint 18

If Pruritus --bile acid binding agents
or
Tx viatmin deficiencys

Front 19

This has non-specific presentation of Jaundice, Hepatomegaly and Pain. Is a cancer?

Back 19

Gall Bladder Carcinoma
--Risks are what?

Hint 19

Galls tone disease, longe term
-Porcelain GB
Parasites in asia

Front 20

What are some causes of LIVER Jaundice?

Back 20

Toxins/Drugs
Infections
Chronic Liver Dzz secondary to ETOH

Front 21

With Hep A, transmission Fecal/Oral
-replication limited to liver, describe seromarkers IgM and IgG

Back 21

IgM during 1st 6-12 months

IgG develops after acute illness and remains detectable indefinitely

Front 22

With Hep B, transmission percutaneous/body fluids.
Describe Sero markers

Back 22

HBsAg: present early on in process-precedes elevation of LFTs/Bilirubin. Becomes undetecable in 2 months FOllowing onset of jaundice in uncomplicated dz.

What about HBeAg?

Hint 22

HBeAG appears shortly after HBsAg
--appearance coincides with high degree of viral replication and reflects infectivity
--Anit-Hbe signals reduced infectivity

Front 23

When is HBcAg detectable?

Back 23

--HBcAg (core) is NOT detectable in Serum?
However, IgM to HBcAg (a-HBcAg-AB) appears early
IgG to HBcAg appears later and persists

What is the "protective antibody

Hint 23

--Anti-HBsAg- is Protective antibody--appears late in dz.

Front 24

What persists indef in Pts recovered from Hep B

Back 24

IgG Anti-HBsurface
IgG Anti-HBcore
will stay

Front 25

What is formerly known as NANB Hep?

Back 25

Hep C--blood borne--incubation 7 weeks

=Can progress to chronic hepatitis--liver failure/transplant

What are the Sero markers? WHen do they appear?

Hint 25

Anti-HCV --- 30-90 days post
HCV RNA : PCR eval

Use Hep C RIBA to comfirm

Front 26

What Hep is the delta ? What is required?

Back 26

Hep D -- requires coinfection with Hep B (blood/blood products) or Can SuperInfect someone who already has Hep B

What are Sero Markers

Hint 26

HDV detectable in serum and liver cells

Anti-HDV: IgM and IgG

Front 27

What Hep is Waterborne, and identified in Asia, India, Africa and Central America?
Transmission?

Back 27

Hep E
-Enteric Transmision -- incubation is 5-6weeks

Which other Hep does it Resemble?

Hint 27

Hep E resembles Hep A

Front 28

Presentation of Viral hep

Back 28

Anorexia, N&V
Fatigue, Malaise
Arthralgias, Myalgias, headach
Photophobia, pharyngitis, cough
low fever

What happens when jaundice develops?

Hint 28

Prodromal Sx usually abate
-Liver becomes enlarged and tender

Front 29

What liver functions change in Viral Hepatitis:
AST/ALT
Enias?
PT?

Back 29

Serum AST/ALT range from 400-4000
-Neutropenia/Lymphopenia are t
-PT level elevation

Front 30

What distinguishes a Patient that HAS had the Virus vs someone with Vaccine?

Back 30

Past infection will have Anti-HBc AB

vac will not
Vac will have Anti-HBs AB

Front 31

With Acute HBV, highly infectious, what will the status be fore the following (ie, + or -, or G or M Ig etc)
HBsAg?
HBeAg?
Anti-HBe?
Anti-HBc?

Back 31

With Acute HBV, highly infectious, what will the status be fore the following (ie, + or -, or G or M Ig etc)
HBsAg: + (presents early, gone 2mo post jaundice)
HBeAg: + (appears shortly after surface Ag)
Anti-HBe: NEG (when Pos= REDUCED Infectivity)
Anti-HBc: IgM (appx 6wks after infection)

Front 32

CHRONIC HBV, HIGHLY Infectious
HBsAg?
HBeAg?
Anti-HBe?
Anti-HBc?

Back 32

HBsAg: +
HBeAg: +
Anti-HBe: Pos (should be Neg I believe?)
Anti-HBc: IgG

For Late Acute or Chronic with LOW Infectivity?
HBsAg?
HBeAg?
Anti-HBe?
Anti-HBc?

Hint 32

HBsAg: +
HBeAg: NEG
Anti-HBe: + (makes sense, positive when LOW infectivity)
Anti-HBc: IgG

Front 33

Recovery of Hepatitis B
HBsAg?
HBeAg?
Anti-HBcore?
Anti-HBsurface?

Back 33

Recovery of Hepatitis B
HBsAg: Neg
HBeAg: Neg
Anti-HBcore: Pos IgG
Anti-HBsurface: Pos

Remote past Infection?

Hint 33

HBsAg: -
HBeAg: -
Anti-HBcore: + IgG
Anti-HBsurface: +

Front 34

If Hep B Vaccine:
HBsAg?
HBeAg?
Anti-HBcore?
Anti-HBsurface?

Back 34

HBsAg: -
HBeAg: -
Anti-HBcore: -
Anti-HBsurface: + (protective Ab)

Front 35

Prognosis for Hep A and Hep B

Back 35

HAV: majority will recover w/o sequelae

HBV: 95% of adults recover,
95% of Neonates develop CHRONIC Infection

What about Hep C

Hint 35

Chronic Active for HCV
-

Front 36

Tx for Acute Viral Hep?

Back 36

Supportive care for 1st 6 months. Then recheck all blood work
--If still HBV, they will prolly have chronic active hepatitis.

What are some elements of supportive care

Hint 36

Restricted physical activity
High C diet
Anti emetics, anti-pruritics if bil salt itch

Front 37

Moving on to What?

Back 37

Jaundice II Lecture

ETOH Hepatitis
Pts have

Hint 37

Spider angiomas, ascites, edema, bleeding and encephalopathy

Front 38

What are keys labs to distinguish ETOH from Viral hepatitis

Back 38

Elevated AST/ALT ration > 2 in ETOH
--AST will be 2x ALT

others: leukocytosis, thrombocytopenia (direct toxic effect on BM)
-elevated bilirubin
Elevated prothrombin time
reduced serum albumin

Mnemonic for ETOH Liver Enzymes?

Hint 38

AlkoholikerSipsTrinken /ALT ration >2

Front 39

Tx for ETOH Hep?

Back 39

Vitamen Supplement
thiamine and Vit K

What is most common cause of Cirrhosis of Liver

Hint 39

Alcohol
-10-15% of Alkys develop cirrhosis
--Women develop it earlier and with less abuse

Front 40

What is important precursor fro Cirrhosis

Back 40

Alcoholic Fatty Liver Dz
--CAN be reveresed

Front 41

What is Prognosis of Cirrhotics if Pt continues to drink

Back 41

5 year mortality for 50% with cont ETOH

What is typical COD?

Hint 41

Hepatic Coma due to buildup of ammonia and go into encephalopathy

Front 42

Tx for Cirrhosis

Back 42

Supportive care:
Low Protein Diet, Multivits, Abstinence
Avoid hepatotoxins

Front 43

What Auto recessive dz affects liver with abnormally liver excretion of Copper?

Back 43

Wilsons

What is deficiency in

Hint 43

Ceruloplasmin
-Clinical manifestations of copper ecess are REARE before 6 years

Front 44

Clinical Presentation of Wilsons?

Back 44

50% present with Liver Dz
--Acute Hepatitis
Fulminant Hepatitis
Chronic Hepatitis
cirrhosis

Whats wrong if hemolysis occurs?

Hint 44

Necrosis of hepatocytes likely

Front 45

What are the Extrahepatic Sx f Wilson's Dz

Back 45

Neurologic or Psychiatric Sx
--w/ Kayser Fleischer Rings
-Resting or mvmt dzo
-spastcity, rigidity, dysphagia or dysarthria

In women?

Hint 45

Amenorrhea with Wilsons
+ Spontaneous Abortions

Front 46

Pathogensis of Wilson's

Back 46

Reduced Ceruloplasmin (long arm of Chrom 13) causes Free Copper in Unbound Form = Toxic
-leads to necrosis, inflammation, fibrosis, cirrhosis in liver

If death, what is COD?

Hint 46

Death from CNS effects or Hepatic Failure

Front 47

When is Diagnosis of Wilson's Considered?

Back 47

Consider in any Pt < 40 (not younger than 6yrs likely) with:
Unexplained Neuro Synd.
Sx of hepatitis, chronic active hep, unexplained LFT abnormals
-Hemolytic Anemia with Hep
-Unexplained Cirrhosis
-Relative with Wilsons

Hint 47

Note:
With Tx, all manifestations can be prevented
Penacillamine

Front 48

How is Wilsons diagnosis confirmed?

Back 48

Low Serum Ceruloplasmin in Patient with Kayser Fleischer Rings

OR?

Hint 48

Low Serum Ceruloplasmin in a patient with elevated hepatic liver [Cu]

Front 49

Tx of Wilsons?

Back 49

Remove Detoxifying Deposits of Cu
-Penicillamine
--Lifelong Therapy recd
May need Transplant

Front 50

What dz has chronic comlications of cirrhosis, DM, Arthritis, Cardiomyopathy, Hypogonadotropic hypogonadism

Back 50

Hemochromatosis
--Inherited or Acquired (thalassemia or siderblastic anemia)

Front 51

What is Diagnosis for Hemochromatosis?

Back 51

Hepatomegally
Skin Pigment
DM + heart Dz
--Liver Biopsy + Elevated [Iron]

Front 52

Tx for hemochrom?

Back 52

Removal of excess body iron
-1-2x weekly Phlebotomy
---usually required for 2-3 years

What is Chelation Tx?

Hint 52

Deferoxamine

Front 53

Moving on to Cases:
Case1:
Fevers, chills, N&V, Myalgias, Belly Pain
Indicates?

Back 53

Something Viral
--+ Low Grade Fever,
Scleral Icterus (jaundiced)
-Mild tenderness in Epigastric--Tender Hepatomegally (15cm, norma is 6-12 cm)

Bilirubin 10.8, Direct/conjugated is 4.2
--indicates Hepatic or Posthepatic
--AST/ALT Elevated
Alk Phos-mildly elevated

Hint 53

Hepatic jaundice--(Post Hepatic Jaundice would have Much Higher Alk Phos)
--Since its Hepatic, check Hep Panels

Front 54

NOTE: end of lecture notes
BUT
CASEs with ANswers at end of Jaundice II LEcter

Back 54

Start with PAM THomas