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STEP 2CK Review > 9.2 Hepatobiliary > Flashcards

9.2 Hepatobiliary Flashcards

1
Q

Sickle cell pt with RUQ pain, jaundice, and increased TBili

Think what

A

DO NOT assume choledocholithiasis.

Think: Cholecystitis (from bilirubin stones), causing an acute sickle crisis, causing hemolysis.
This would have normal LFTs

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2
Q

Liver abscess

-which 2 infections to know, and their tx

A
  1. echinococcus cyst–do surgery

2. amoeba–MTX

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3
Q

only indication for emergeny cholecystectomy

A

During cholecystitis not responding to NPO, IVF, Abx.

To prevent perf

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4
Q

GIlbert’s, crigler najjar, dubin-johnson, rotor’s

difference

A

Gilbert’s, Crig-Naj: unconj Bili

Dubin-johnson, rotors: conj bili (therefore dark urine, clay stools)

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5
Q

AST/ALT in 1000s: ddx

6

A
  • amanita mushroom
  • shock liver (ischemia)
  • tylenol OD
  • acute viral hepatitis (hep A,B)–2 weeks after exposure
  • autoimmune
  • Budd-Chiari
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6
Q

Ab dx:
PBC
PSC
autoimmune hepatitis

A

anti-smooth muscle
ANCA
AMA

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7
Q

painless jaundice, think what causes (4)

-what test

A

CA: panc, cholangiocarcinoma, ampulla of vater
PSC, PBC
biliary strictures

Do MRCP

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8
Q

Pt with painless jaundice and GI bleed, think what

A

Ampulla of Vater cancer

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9
Q

Sepsis + D.Bili elevated + ALP elevated

Think what

A

cholestasis or gallstones.

RUQ U/S to r/o

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10
Q

Pancreatitis causes:

  • Big 2
  • next 3 to think of
A

stones, ETOH

trauma, hyperCa, hyperTG
order Ca+, lipid panel

also med-induced, etc

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11
Q

When to do CT in pancreatitis, according to onlinemeded (3 times)

A

CT at day1 often shows nothing.

  1. initial presentation and lipase low, but story is likely pancreatitis
  2. initial presentation of pancreatitis and sick enough to go to unit and need meropenem
  3. Day2-week2 to assess complications

CT can also dx chronic panc

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12
Q

pancreatitis pseudocyst

-tx

A

6/6 rule
-If <6cm and <6 weeks, allow to spontaneously resolve. rCT in 2 weeks

-If not, then surgical drainage (percutaneous, open surgery, or stomach)

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13
Q 
Pancreatitis complications (4 to know).
How to tell apart?
A

Time and fever/leuks.

  1. Abscess: 1-2 wks, fever+leuks
  2. Pseudocyst: 1-2 wks, NO fever/leuks
  3. Necrotizing panc. 1-2 days, fever/leuks. hemoconcentration
  4. Hemorrhagic panc. 1-2 days, NO fever/leuks. declining Hct
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14
Q

Necrotizing pancreatitis: tx

A

IVF, NPO, analgesia.

NO ABX UNTIL proven infection (may need bx)

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15
Q

Necrotizing pancreatitis:

  • vignette, sxs
  • what to do
A

Pt admitted for acute pancreatitis. Day 2 gets:

  • renal failure
  • ARDS, low sats
  • hypoCa despite Ca (saponification)
  • hypotensive, poor fluid response (fluid sequestration)
  • early intubation
  • central line for pressor support
  • CXR for ARDS
  • CT scan to show extent of necrosis.
  • FNA bx to confirm infection, then start IV meropenem
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16
Q

Cirrhosis ddx

A

“VW HAPPENS”

Viral (hep b,c)
Wilson's
Hemachromatosis
A1-antitrypsin
PBC
PSC
ETOH
NASH/NAFLD
Something rare--eg autoimmune
17
Q

PBC cirrhosis vignette

A

female, 40s, jaundice, cirrhosis, normal biliary imaging

18
Q

SAAG score

-what is this, how to use

A

Serum albumin - ascites albumin

get in pts with ascites

> 1.1: Portal HTN related

  • Cirrhosis
  • R side HF
  • Budd chiari

<1.1: not portal HTN related

  • CA
  • peritoneal TB
  • nephrotic syndrome
  • protein malabsorption
19
Q

Ascites tx:

  • Na
  • H2O
  • other
A

Na <2g/day
H2O <2L/day
Diuresis with spirono and Lasix.
Tap 4-6L paracentesis, albumin infusion.

Severe: TIPS

20
Q

Spont bact peritonitis

  • how to dx
  • what bugs
  • what if polymicrobial
  • tx
A
  • 250 polys after tap, with cx+
  • Strep pneumo, G- rods
  • if polymicrobial, not SBP. Actually secondary bacterial peritonitis from viscreal organs. Add MTZ to ceftriaxone, do ex lap.
  • Ceftriaxone, with FQ ppx
21
Q

hepatic encephalopathy

-tx (2)

A

lactulose–alters pH to trap ammonia in gut to poop out. titrate to 3-4 BMs/day

rifaximin–abx to kill gut flora, make less nitrogen

22
Q

hepatorenal syndrome

-tx (3 things)

A

Pt has renal fail and cirrhosis, fatal.

  • hold diuretics
  • give albumin
  • octreotide
23
Q

Wilson’s disease

-how to dx and confirm

A
  • low serum ceruloplasmin (bound to copper)
  • high urine Copper
  • Kayser-fleischer rings

confirm with Liver bx

24
Q

Wilson’s dz

  • tx
  • what if refractory
A
  • penicillamine (Copper chelator, to excrete in urine)

- transplant

25
Q

Hemochromatosis

  • classic sxs
  • dx (first test, confirm)
  • tx
A

triad: cirrhosis, diabetes, hyperpigmentation (bronze diabetes)
- dx with high ferritin, then liver bx
- tx with deferoxamine or serial phlebotomy. transplant too

26
Q

PSC vs PBC

  • sxs
  • dx
  • tx
A

PSC: obstruction of extrahepatic ducts (macroductal)

  • beads on string on MRCP. ANCA+
  • cholestyramine, urso acid

PBC: intrahepatic ducts (microductal)

  • nothing on imaging. AMA+, liver bx
  • urso acid
27
Q

Hep B tx

Hep C tx

A
  • peg interferon
  • antivirals (eg lamivudine)
  • ribavirin+interfron
  • also Boceprevir
28
Q

Hep B and C

-sex transmitted?

A

Hep B yes

Hep C no

29
Q

Liver dz: hepatic encephalopathy. What happens if untx?

A

high ammonia is like 3% normal saline. ammonium is going to brain, causing fluid shifts.

Risk for herniation

30
Q

On test: Cirrhosis and:

  1. COPD
  2. diabetes, tan skin
  3. chorea, eye
  4. IBD
  5. ETOH
  6. positive serology
  7. long list of negative tests
A
  1. A1AT def
  2. hemochromatosis
  3. wilsons
  4. PSC
  5. alcohol
  6. Hep
  7. NASH (dx of exclusion)
31
Q

why give variceal bleeder ceftriaxone?

A

give in first 12h to ppx SBP

32
Q

Hep C HCC vs Hep B HCC

  • what difference
  • what screening
A

you can get HCC without cirrhosis with Hep B (so aggressive screening!)

U/S and AFP q6mo for Hep C with cirrhosis, or Hep B asian males>40, asian females>50

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