Case 4- the alcoholic Flashcards
high mcv=
macrocytic anemia
coffee ground vomit?
acid+ blood= coffee grounds.
tarry stool?
old blood
Esophageal varices- outcomes?
> 50% die in year 1, >50% recur (and 50% of those people die).
vitamin def from chronic drinking?
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.
Signs of blood loss?
orthostatic hypertension, tachycardia, diluted blood
Liver cirrhosis causes?
small fibrotic liver, portal hypertension, ascites, liver proteins not synthesized
Difference in livers of early, mid, late alcoholics?
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)
What causes the generalized edema?
hypoalbuminemia
Causes of liver cirrhosis
Toxins: alcohol
Infectious: hep b, c
Hereditary: hemochromatosis (Fe buildup), Wilsons (Cu-forget the name for the ring in the eye…) a1-antitrypsin deficiency
Signs of ascites?
protruding abdomen, increase “belt size” with weight loss, fluid wave.
6F’s of abdominal swelling
Flatus, fat, fluid, fetus, feces, fatal growth
Differential for abdominal paracentesis
look for PMN to see if it’s infectious. >250 neutrophils is bad. Theres a big chart but its too small to read.
SAAG
serum-ascites-albumin gradient.
If SAAG2.5: CHF, Early Budd chiari, IVC obstruction
<1.1= Biliary leak, nephrotic syndrome, pancreatitis, peritoneal carcinomatosis, Tb.
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)
high estrogen
conjugated bilirubin
soluble, in urine, =direct
unconjugated
=indirect, in blood
Hepatic encephalopathy
high ammonia, causes asterixis (hand flapping), fatigue (obtundation), spatial perception issues (tested with 5pt star) , day/night reversal
What told us he was past the hepatitis stage and into cirrhosis?
AST mildly high. In hep its >400 (vs 117)
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?
Gamma glutamyl transferase (GGT)
This gets high in extrahepatic obstructions (like gall stones and cancer)
alkaline phossphatase
LDH is?
lactate dehydrogenase tells us if there’s tissue damage. Non specific.
Treatments for
- Bleeding
- Hepatic encephalopathy
- Ascites
- IV fluid IMMEDIATELY.
- Lactulose–increases colon acidity to ammonia turns to ammonium and can’t be absorbed by colon. Also, low protein diet
- Restrict water, low sodium (seems like this would make the volume issue worse?)
Withdrawal Sx and treatment
Benzos for seizures. For more inhibition of GABA receptors seems pretty silly.
