Case 4- the alcoholic

Question 1

high mcv=

Answer 1

macrocytic anemia

Question 2

coffee ground vomit?

Answer 2

acid+ blood= coffee grounds.

Question 3

tarry stool?

Answer 3

old blood

Question 4

Esophageal varices- outcomes?

Answer 4

> 50% die in year 1, >50% recur (and 50% of those people die).

Question 5

vitamin def from chronic drinking?

Answer 5

B12 (macrocytic anemia, degeneration of lateral and posterior columns= sensory/vibration loss)
B1 (wernicke enceph= reversible, Korsakov-non reversible)
Folic acid- not really a problem in the US.

Question 6

Signs of blood loss?

Answer 6

orthostatic hypertension, tachycardia, diluted blood

Question 7

Liver cirrhosis causes?

Answer 7

small fibrotic liver, portal hypertension, ascites, liver proteins not synthesized

Question 8

Difference in livers of early, mid, late alcoholics?

Answer 8

Early- fatty yellow greasy (can’t deal with fats). normal enzymes.
Mid- large and tender liver. less fat–more dying cells/inflammation. Enzymes super high
Late- small and fibrotic . Normal-high- low enzymes (depends on how dead the liver is)

Question 9

What causes the generalized edema?

Answer 9

hypoalbuminemia

Question 10

Causes of liver cirrhosis

Answer 10

Toxins: alcohol
Infectious: hep b, c
Hereditary: hemochromatosis (Fe buildup), Wilsons (Cu-forget the name for the ring in the eye…) a1-antitrypsin deficiency

Question 11

Signs of ascites?

Answer 11

protruding abdomen, increase “belt size” with weight loss, fluid wave.

Question 12

6F’s of abdominal swelling

Answer 12

Flatus, fat, fluid, fetus, feces, fatal growth

Question 13

Differential for abdominal paracentesis

Answer 13

look for PMN to see if it’s infectious. >250 neutrophils is bad. Theres a big chart but its too small to read.

Question 14

SAAG

Answer 14

serum-ascites-albumin gradient.
If SAAG2.5: CHF, Early Budd chiari, IVC obstruction
<1.1= Biliary leak, nephrotic syndrome, pancreatitis, peritoneal carcinomatosis, Tb.

Question 15

Why did he have boobs, small testicles and not lots of pubic hair? this is also why he had red palms and spider telangiectasia (spider veins)

Answer 15

high estrogen

Question 16

conjugated bilirubin

Answer 16

soluble, in urine, =direct

Question 17

unconjugated

Answer 17

=indirect, in blood

Question 18

Hepatic encephalopathy

Answer 18

high ammonia, causes asterixis (hand flapping), fatigue (obtundation), spatial perception issues (tested with 5pt star) , day/night reversal

Question 19

What told us he was past the hepatitis stage and into cirrhosis?

Answer 19

AST mildly high. In hep its >400 (vs 117)

Question 20

When I went to Abu Dhabi my dad sneakily tested my liver enzymes (must have thought I drank too much?) when I did blood tests. Whats a good indicator of alcohol use?

Answer 20

Gamma glutamyl transferase (GGT)

Question 21

This gets high in extrahepatic obstructions (like gall stones and cancer)

Answer 21

alkaline phossphatase

Question 22

LDH is?

Answer 22

lactate dehydrogenase tells us if there’s tissue damage. Non specific.

Question 23

Treatments for

1. Bleeding
2. Hepatic encephalopathy
3. Ascites

Answer 23

1. IV fluid IMMEDIATELY.
2. Lactulose–increases colon acidity to ammonia turns to ammonium and can’t be absorbed by colon. Also, low protein diet
3. Restrict water, low sodium (seems like this would make the volume issue worse?)

Question 24

Withdrawal Sx and treatment

Answer 24

Benzos for seizures. For more inhibition of GABA receptors seems pretty silly.

Question 25

How do we evaluate him for treatment?

Answer 25

CHild-Pugh scores to see if he can handle surgeries. Otherwise he’s pretty much a goner.

Question 26

Alcohol EDU bs- standard drink, unhealthy drinking, etc

Answer 26

5oz wine, 12 oz beer, 1.5 hard liquor
Men >4/day or >14/week
Women >3/day >7/week

Question 27

What should you screen all adult primary care patients for?

Answer 27

Unhealthy alcohol use. Single item question= Do you sometimes drink, if so how many times have you had more than 3/4 (F/M) drinks in one day.