Bernadino: Liver Dysfunction and Gallbladder Disease Flashcards
What is the most common etiology of jaundice in an infant?
physiologic (goes away in a few weeks)
What are the most common causes of jaundice in an adolescent?
Gilbert’s syndrome
HAV
What are the MC causes of jaundice in young adults?
mostly viral hepatitis
followed by EtOH, autoimmune
biliary tract
What are the MC causes of jaundice in the elderly?
malignancy
toxins/drugs
stones
What can cause jaundice in the first and second trimester?
viral hepatitis
What causes jaundice in the 3rd trimester?
preeclampsia
cholestasis of pregnancy
What is Gilbert syndrome?
AD-benign
An increase in unconjugated bilirubinemia brought on by illness, fasting stress, fatigue, EtOH, nicotinic acid intake, premenstrual periods in some women
*my dad has this!
What indicates hepatocellular jaundice?
AST/ALT elevation > bilirubin or alk phos
Suggests parenchymal inflam.
What causes unconjugated hyperbilirubinemia?
Hemolysis
Gilbert’s syndrome
Medication (typically abx)
What causes conjugated hyperbilirubinemia?
Intrinsic liver disease
Medication
Biliary tract obstruction
What are the 3 ways that jaundice can present?
- Jaundice= >2-3 mg/dl
- first noticeable in sclera (icterus)
- Intense itching–seen w/ cholestasis but does NOT correlate w/ degree of hyperbilirubinemia
What causes the intense itching associated w/ jaundice? How do you tx itching caused by jaundice?
retained bile acids
correct obstruction or use bile acid binding agents
Spider hemangiomas, dupuytren’s contractures, caput medusa, palmer erythema and xanthelasma are all…..
physical evidence of chronic liver disease
What are spider hemangiomas? Are they specific to cirrhosis? How does number and size correlate to severity of liver disease?
altered estrogen metabolism in chronic liver ds.>
small pulsating arteriole>
usually on face or chest
-Not specific to cirrhosis, seen in prego and normal ppl
What increases the risk of variceal hemorrhage?
Increased number of spider hemangiomas
What are dupuytrens contractures? In what populations are they seen in?
progressive fibrosis of palmar fascia → abnormal flexion of fingers
MC in EtOH related liver ds and WHITE males
-Also seen in diabetes, repetitive use injuries, and malignancies
What is caput medusa?
Portal HTN →
blood from portal venous system shunted through periumbilical veins →
umbilical vein →
abdominal wall vessels
*Presence of caput medusa → increased risk of mortality in 1 yr
What is a palmer erythema? Is it specific for liver disease?
vasodilation and increased blood flow>
occurs on thenar and hypothenar eminences and finger tipes
*Not specific for liver disease Seen in: prego hyperthyroidism RA hematologic malignancies
What is an xanthelasma?
chronic cholestasis marked by hypercholesterolemia>
Lipid deposition in the dermis and subcutaneous tissue>
extensor surfaces of extremities and around eyes
What is the first choice for diagnosing gallstones or cholecystitis
Transabdominal US
How does cholecystitis appear on US?
pericholecystic fluid
GB wall thickening (4 mm)
What complications are associated w/ cholelithiasis and cholelocholithiasis?
- Biliary pain
- Acute cholecystitis
- Chronic cholecystitis – scarring wall → no contraction
- Choledocholithiasis - stones in bile duct
- Cholangitis - infxn of bile duct
- Gallstone pancreatitis - reflux into pancreas
***What characterizes biliary pain?
colic- crescendo/decrescendo minutes to hurs spasm of GB if cystic duct obstruction often POST PRANDIAL RUQ Radiates to interscapular region of right shoulder N and V Pain > 6 hrs; fever suggests cholecystitis/cholangitis
What causes biliary type pain w/ NO stones?
missed stones
Microlithiasis (stones too small to see on US)
HIDA scan → can show bile leak
How does Acute cholecystitis present?
Murphy sign- RUQ tenderness on inspiration
Palpable gallbladder
Labs come back and show elevated WBC, mild increase in amylase and lipase and normal liver functions. The US shows gallbaldder w/ wall thickening > 4 mm.
Dx?
acute cholecystitis
How do you tx acute cholecystitis?
Broad spectrum abx
Pain management
Cholecystectomy w/in 96 hrs of Sx onset - 70% of pts w/ biliary colic will develop complications w/in 2 yrs of onset of Sx
What is Acalculous cholecystitis?
Occurs in 5-10% of acute cholecystitis cases.
Usually in hospitalized, critically ill pts after major surgery or trauma.
Leads to gallbaldder stasis and ischemia.
How do ou tx acalculous cholecystitis?
broad spectrum abx
cholecystectomy
cholecyst tube
What are serious complications of laprascopic cholecystectomys?
bleeding, abcess formation, leaks
What is cholangitis? MC cause?
Infection of the bile duct
85% are caused by gall stones
What pathogens can cause cholangitis?
E. coli, Klebsiella, Pseudomonas, enterococci, and Proteus
How do you tx cholangitis?
broad spectrum abx
ERCP for bile duct decompression
What causes 40% of acute pancreatitis cases?
gallstones and EtOH>
stone passage, stone obstruction>
biliopancreatic reflux
How do you manage pancreatitis?
hydration
bowel rest
pain control
possibly abx
What are complications associated w/ necrotizing pancreatitis?
organ failure, pseudocyst, diabetes, disconnected duct, etc.
What cancer is an uncommon adenocarcinoma that often causes proximal obstruction and has a poor prognosis w/ 5 yr survival?
Gallbladder cancer
What is cholangiocarcinoma? What is the diference between intrahepatic and extrahepatic tumors?
adenocarcinoma of biliary epithelium
intrahepatic> early sx
extrahepati> late sx (worse prognosis)
How to you tx cholangiocarcinoma?
surgical resection
What is the most sensitive method to detect ascites?
transabdominal US
What is good at detecting pancreatic cancer and liver metasteses?
CT
What is used to dx liver lesions seen on US or CT?
MRI or MRCP
What is used to dx sclerosing cholangitis?
MCRP
What imaging method is best for looking at stones?
EUS
What is a HIDA scan?
IV technetium labeled> taken up and excreted by hepatocytes>
visualization of bile duct, gall bladder, small bowel
*non-visualization of GB is considered a + test
