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82 Cards in this Set
- Front
- Back
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xanthomas and hepatomegaly?
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- primary biliary sclerosis
- other sx: pruritis - lab: increased alk phos, cholesterol, IgM - associated with Sjogrens, Raynauds, scleroderma, autoimmune hypoTH, celiac, increased malignancy - tx: ursodeoxycholic acid, only def tx = liver transplant |
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- anti-smooth muscles
- anti-smith - pANCA |
- acute and chronic hepatitis
- SLE (sensitive but only 30-50%) - Churg-Strauss, micrscopic polyangitis |
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pt with hep C?
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- all pts should receive vaccine for hep A, B including during pregnancy
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pregnant pt with HCV?
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- OK to breast feed, vaginal delivery, sex without barrier protection if in stable relationship
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cholecdochal cyst
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- congenital abnormality of biliary ducts => dilation of intra/extra hepatic biliary ducts
- infants: juandice, acholic stools; kids - abd pain, jaundice, recurrent pancreatitis; adults: vague pain, cholangitis - US -> CT -> MRI - can become choriocarcinoma |
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baby with jaundice, acholic stools?
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- biliary atresia, choledocal cyst
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carolis syndrome
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- congenital d/o, intrahepatic dilation of bile ducts
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pancreatic pseudocyst occurs where?
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- as retroperitoneal mass
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ddx peritoneal fluid
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- portal HTN, trauma, infx, pancreatitis, malignancy
- to ddx need to know exudate vs transudate => calculate SSAG = ascites albumin - serum albumin => if >1.1 = transudative = portal HTN |
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signs of decreased liver synthetic fx?
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- decreased serum albumin, increased INR
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what PEX is not associated with hyperaldo?
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- will see decreased Na but should not see EDEMA (b/c then something else)
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pt with newly dx cirrhosis?
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- do screening endoscopy to eval esoph varices => if + give beta blocker
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octreotide
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- used for tx hepatorenal syndrome
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unconjugated hyperbili
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- unconjugated bili > 90% of T bili
- estimate Hg and periph smear to check for hemolysis |
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pt with chronic hep C but normal LFTs x 1 yr
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- no tx needed
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when to check for hep B and C in pts with hx of blood transfusion?
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- hep B: prior to 1986
- hep C: prior to July 1992 |
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when to check HCV?
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- IV drug, blood transfusion/transplant prior July 1992, HD, chronically elevated ALT, children born to HCV mom
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when to check HBV?
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- hyperendemic areas (AFrica, SE asia, ME, Amazon, Haiti, Dominican Republic), male + male, IVDA, dialysis, HIV+, pregnant, contacts of HBV pts
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liver toxins?
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- dose dependent direct liver toxins: carbon tetrachloride, acetaminophen, tetracycline, amonita phalloides
- idiosyncratic rxn: isoniazide, chlorpromazine, halothane, antiretrovirial |
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drug induced liver dz?
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- cholestasis: chlorpromazine, nitrofurantoin, erythromycine, anabolic steroids
- fatty liver: tetracycline, valproate, anti-retrovirals - hepatitis: halothane, phenytoin, isoniazide, alpha-methyldopa - toxic/fulminant liver dz: carbon tetrachloride, acetaminophen - granulomatous: allopurinol, phenylbutazone |
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labs on alcoholic hep?
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- AST:ALT >2
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biopsy of hepatitis?
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- panlobular mononuclear infiltratio nwith hepatic cell necrosis
- if negative serology then consider drug induced |
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OCP on liver?
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- abnormal LFTs but no change in biopsy
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dx of autoimmune hep?
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- consider once r/o all possible causes of drug or viral
- see +ANA, smooth muscle ab |
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wilson's dz?
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aka hepatolenticulo degeneration
- sx <30y.o., cirrhosis, neuropsych sx (parkinson, mood), kayser fleischer rings - decreased creuloplasmic => decreased Cu excretion => deposits in lier, basal ganglia, cornea - associated with Fanconi's dynrome, hemolytic anemia, neuropathy - dx: liver biopsy => hepatic Cu level > 250mcg/gram dry weight, or low ceruloplasmi + high urinary Cu excretion or K-F rings |
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hemochromatosis
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- abnormally high iron abosroption => liver disease, pigmentation, DM, impotence, arthropathy
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gallbladder Ca
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- RF: southwest native american, mex-america, chronic gb inflammation, hx gallstones, porcelain gallbladder, salmonella typhi, anatomic variation
- very rare |
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pregnant +HBV
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- if active can tranmit to baby via placenta or during delivery esp if dvlped during 3rd trimester
- + HBsAG, HBeAg, IgM, anti-HBcAb - if HBeAg negative then risk decreases from 95% to 20% - baby's risk of chronic hepB = 90%, thus give passive immunization with HBIG and active HBV vaccine |
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Pancreatic RF
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- smoking, chornic pancreatitis, fhx, DM, obesity, hgih fat diet
- ALCOHOL is not RF |
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pt with severely elevated AST, ALT, mild change in PT, albuin
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- hepatocellular pattern injury most likely 2/2 med; e.g. pt with headahces => most likely using acetaminophen though don't say in stem
- it increased PT and low albmin, think cirrhosis |
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pt with pancreatitis sx?
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- do U/S, most likely 2/2 gallstones
- don't do CT - only do CT when tx doesn't work |
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sx of chronic liver dz?
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- weight loss, gynec, test atrophy, impotence 2/2 hyperE (low SHBG)
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pt with cirrhosis now with asterixis, confusion, reversal sleep cycle?
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- hepatic encephalopathy 2/2 increase ammonia in blood b/c can't detox to urea
- increased sensitivity to GABA, false NT production - precipitating factors: increased protein diet, alkalosis, diuretic therapy, high volume paracentesis, portocaval shunts - not caused by increased urea! |
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chronic HBV infx?
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- HBsAg for > 6 months
- do livery biopsy to assess hepatic injury - if liver damage = chronic active, if no liver damage = chronic persistance |
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post cholecystectomy pain?
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- sphincter of oddi dysfx:
- sx: RUQ pain, increased LFTs during attack; do oddi manometry, see increased pressure; tx: sphincterotomy - dx of exclusion = functional pain |
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edema in cirrhosis?
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- 2/2 decreased protein => indecreased intravascular oncotic pressure
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types of gallstones
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1. cholesterol, 2. pigment (calcium bilirubate) 3. mixed
- 80% = cholesterol and mixed = radiolucent |
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pregnant and cholecystitis?
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- repeated attacks =? cholecystecty in 2nd trimester
- else give ursodeoxcholic acid to dissolve stones that will return once stop tx |
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travel, RUQ pain, dysentary, single cyst in right lobe liever
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- AMEBIC livery cyst, histolyticia, cyst aspiraition = sterile, acellular, anchovy paste
- usually invades colon => bloody diarrhea - tx: metronidazole |
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dx liver cyst
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- amebic cyst
- pyogenic liver bascess: severe presentaiton, 2nd to surgery, GI infx, acute appendicitis, tx broad spectrum abx = ceftriaxone - hydatid cyst - echinococcus granulose = dog contact - cystic ca= thick ,irregular, hpervascular wall, numerous septate |
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acalulous cholecystis
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- GB inflammation without gallsontes, 2/2 extensive burns, trauma, prlonged TPN, fasting, mechanical ventilation
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tx of gallstone pancreatitis?
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- tx pancreatitis, then do cholecystitis
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signs of met to liver?
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- suggestion of GI malignancy (+occult blood), anemia 2/2 GI leed, firm hepatomegaly, increased alk phos more than increase in ast, alt = ca infiltration rather than liver injury
- pleural effusion of L; note if on Rthen may be 2/2 hdrothorax = cirrhosis |
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post op cholestasis
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- after major surgery 2/2 hypotension, blood loss into tissues, blood transfusion
- increased pigment load from transufion, decrased liver function, decreased renal bilirubin excretion - high bili, alk phos |
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halothane
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- anesthetic causes hepatotox, not used anymore
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increased risk of alcohol liver injury?
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- women > men
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non-alcoholic fatty liver dz?
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- associated with obesity, DM II
- path: insulin resistance => increased at in liver => increased lipolysis => increased insulin levels - dx: biopsy - note: decreased glycogen synthesis in liver in DM II, but increased glucagon |
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increase in alk phos?
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- check GGT
- if high = liver - if low = other like bone |
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pt with mildly elevated LFTs on routine exam?
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repeat in 6 months, if again increased then = chronic and do viral, hemochromatosis, fatty liver testing
- if those are negative then test for muscle d/o polymyositis, thyroid dz |
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most important test of liver fx?
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- PT! b/c all clotting factors synthesized by liver
- don't interpret LFTs b/c can go down 2/2 recovery or fewer hepatocytes |
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left sided pleural effusion
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pancreatitis, maligancy
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dx of alpha 1 antitrypsin?
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measure alpha one in serum => then confirm with genetic testing
- testing is indicated in all premature chronic bronchitis, emphysema, dyspnea, non-smokers with COPD - tx: purified A1AT - test relative of homozygouses |
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mallory bodies
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alcoholic hepatitis but is not diagnositic and not used for dx
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vanishing bile duct syndrome
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primary biliary cirrhosis, not primary sclerosing cholangitis
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hbv tx
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indications: persistance increased alt, detectable serum hbsag, hbv dna
- alt is most important predictor of response to tx; BEST is 2x normal - tx: alpha interferon or lamivudine |
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hep A vs hep B vs hep C
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- hep A: flu like, jaundice, dark urine, dirty place, other people with same sx
- hep b, sx 1-6 mo s/o infx - acute hep C: asympt |
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serologic makers of hbv?
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- hbsAg = 1st serologic marker, always dectable as long as infected
- window period = period between hbsag undetected and anti-hbs undetected -anti-hbc= second serologic marker, makes IgM and IgG, IgM is present during window period - HbeAg = viral replication and infectivity, if >3mo then increased risk chronic |
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+bilirubin in dipstick?
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- hyperbili 2/2 conjugated bili and not unconjugated (not water soluble)
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rotor syndrome
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- benign defect of hepatic storage of conjugated bili => leak into plasma, normal LFTs
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hep C tx
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indications: natural hx of dz, stage, liver biopsy, lfts, + hcv rna
- if mild, tx is interferon - if medium e.g. increased alt, hcv rna+, chronic hep = tx with interferon and ribavirin (lamivudine is for hepb) |
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anaphylaxis to blood transufsions?
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IgA deficiency
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gilbert dz?
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- decreased udp glucuronl tranferase => unconjugated hyperbili
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crigler-najjar type i
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- jaundice, neuro impairment, kernicterus (bilirubin enceph), increased indirect bili, normal LFTs
- tx Liver tx, meanwhile light therapy |
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Crigler-****** type 2
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- milder, survive into adulthood, no kernicterus
- tx phenobarbital as needed |
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complications of pancreatitis?
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1. hypovolemic shock: inflammatory factors => increased vascular permeability => fluid in retroperitoneum => need several L of fluid
2. LV failure 2/2 vascular volume loss 3. cardiac tamponade 4. pseudocyst, asympt unless rupture, hemorrhage or infx 5. retroperitoneal hemorrhage => see flank or umbilical ecchymoses |
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tx PBC?
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- ursodeoxycholic acid, slows dz progression, reduces sx
- if advanced then tx is liver transplant (eg. cirrhosis, liver damage) - 7-10 yr survival after 1st sx - symptomatic tx = cholestyramine for itching relief |
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intrahepatic cholestasis of pregnancy? vs normal physiologic changes? PBL?
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- cholestatsis: 2nd, 3rd trimester => increased bile acid 2/2 genetic or hormone; see increased ALT, AST, alk phos, serum bile; must r/o viral hepatitis; dx of exclusion; tx: ursodeoxycholine, cholestyramine not as effective and SE
- normal = increased alk phos, nl bili, alt, ast, ggt - PBL - see xanthomas |
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extrahepatic copmlications of hepC?
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cryoglobulinemia => membranous GN, B-cell ly,mphoma (not T), plsmacytoses, AI dz e.g. sjogren, thyroiditis, lichen planus, porphyria cutanea tarda, ITP
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reye's syndrome
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- aka fatty liver with encephalopathy
- kid with infx, takes salicylate => mito injury => hypoglycemia, liver failure, cns damage - liver bx: fatty vacuolation without inflammation - tx glucose, ffp, mannitol - THUS ASA IS C/I IN KIDS |
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path of:
acute etoh hepatitis, acute viral hepatitis, chronic active viral hepatits, PBC |
- etoh: balloon degeneration with polymorphic (neu, mono, lymph) infiltrate
- acute viral hep: panlobular monoulear infiltrate with bridging necrosis - chroinc: piecemeal necrosis - PBC: inflammatory granulomatous destruction of biliary ducts |
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emphysematous cholecystitis
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infx GB wall by gas forming bacteria
- clostridium, escherichia, staph, strep,. pseudo, kleb - increased risk from vascular problems, immunosuppression (DM), gallstones - sx: RUQ, N/V, crepitus - KUB shows air fluid in gallbladder; U/S: curvilinear gas shadowing - tx: cholecystectomy, abx against clost (zosyn or amp-sublactam) |
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acute cholangitis
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- charcot's tirad: RUQ pain, jaundice fever
- biliar tract obstruction => bact infx |
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pancreatic pseudocyst
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- fake cyst b/c no epithelial lingin, fibrous capsuel
- contains inflammatory fluid: amylase, lipase, enterokinase - tx if persists > 6wks = drain |
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primary sclerosis cholangitis
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- onion skin pattern stricturing of ducts
- complications = biliary stricture, cholangitis, cholelithiasis, cholangiocarcinoma, CRC - associated with UC, see high HLA-B8, IgM, pANCA - dx via cholangiography => beading pattern, U/S and biopsy aren't useful - tx: ursodeoxycholate, dilation, stenting - Liver transplant else life span 12 yrs |
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hydatid cyst tx
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- 2/2 echinococccus
- surgical resection under albendazole - don't aspiration else anaphylaxis |
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cysticercosis
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- infx by tenia solium => brain, muscle
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dubin-johnson syndrome
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- black liver
- conjugated bilirubin, sephardic jews - trigger: pregnancy, ocp - urine: Nl urine coproporphyrin but 80% is type I vs type III - normal LFT is requirement for dx - no tx |
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black liver
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dubin johnson
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pt with chronic hepatitis and cirrhosis now with weight loss?
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- first step in eval is check for tumor marker AFP
- some imaging must be done b/c neg AFP doesn't rule out - checking ascite fluid is useless |
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pt with hydrothorax?
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- first do therapeutic thoracentesis, salt restriction, diuretics
- if those don't work then do TIPS - don't do portosytemic shunt b/c increased morbidity |
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pt on INH
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- will have small increase in ALT, AST which is OK
- if sx of hepatitis 2/2 iNH stop INH immediately |
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primary liver Ca
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- HCC: increased AFP, ill defined single lesion
- hepatic adneoma- benign, women on OCP, one mass - hepatic angiocarcinome: hx of exposure to vinyl chloride gas, arsenic, thorium, malignant cells line vascular sx |
