Dr. Stillwell Flashcards
GGT (gamma glutamyl transferase)
- SPECIFIC to the liver -> high GGT -> liver probs
- when ONLY it is elevated -> EtOH issues
Alcoholic Hepatitis
- AST>ALT 2:1
- hepatocyte BALLOONING degeneration
- MALLORY HYALINE BODIES
Drug and Toxin induced hepatitis
- acetominophen (Tylenol) most common
- Reyes syndrome -> give kid w/ viral infection aspirin -> hepatic encephalopathy
Nonalcoholic Steatohepatitis (NASH)
- metabolic syndrome
- can lead to HCC
autoimmune hepatitis
-elevated ANA and anti-smooth muscle Abs (ASMA)
Primary Biliary Cirrhosis (PBC)
- INTRAlobular bile ducts
- refractory pruritus
- anti-mitochondrial Abs + (AMA)
Primary Sclerosing Cholangitis (PSC)
- INTRA and EXTRAhepatic bile ducts
- p-ANCA +
- ulcerative colitis associated
- high risk for cholangiocarcinoma
- beads on a string
- ONION SKIN FIBROSIS
Wilson’s disease
- liver disease + neurologic + psychiatric issues
- Kayser-Fleischer rings
- AST > ALT
- LOW cerulloplasmin
- Tx: PENICILLAMINE
Hemochromatosis
- bronzing/hyperpigmentation
- risk for YERSINIA
alpha-1 antitrypsin deficiency
- affect lungs and liver
- young person with COPD
- lungs -> emphysematous bullae
- PAS + inclusions
what do you do if you find granulomas on biopsy?
do thorough work up bc it may NOT be sarcoidosis
Bartonella (cat scratch)
- can cause hepatic granulomas
- HIV+ -> Peliosis Hepatis -> blood filled cavities/islands
Hepatitis A virus
- RNA virus (no enveloppe)
- fecal oral
- incubation 4 weeks (1 month)
- dark urine 1st -> jaundice and icterus
- does not become chronic -> CANNOT reactivate once you get it
- there is a vaccine (Havrix, Vaqta)
Hepatitis E virus
- RNA virus
- fecal oral or blood transfusions; perinatal mortality
- incubation 4 weeks
- urticarial rash if symptomatic
- PREGNANT woman 3rd trimester -> hepatic failure if not immune/vaccinated
- immunocompromised -> can get chronic HEV
Hepatitis B virus
- DNA virus
- mother-child transmission predominant mode -> mothers HBAgs+ are 90% likely to transmit
- ground glass hepatocytes
- has a vaccine
acute HBV
- incubation 2 months
- ptxs who recover from HBV (95% who clear HBAgs) -> NOT truly cured bc still have HBV DNA on PCR
- SERUM SICKNESS
chronic HBV
- neonates more likely to get chronic HBV
- HbAgs+ is MORE infectious if they are HBe ag+ than if they have started making HBe ag+ Abs w/ a negative HBAgs test
- can get MEMBRANOUS GN or POLYARTERITIS NODOSA or CRYOGLOBULINEMIA + bullous pemphigoid
window period with HBV
-phase b/w clearance of HBAgs and the making of HBs Abs -> only anti-HBc IgM/Ab is detectable
Hepatitis D virus
- RNA virus
- ALWAYS have to be dual infected w/ HBV and HDV
- has the same HBAgs
- DIRECT damage to hepatocytes
- diagnose by anti-HDV Ab
Hepatitis C virus
- IVDA
- perinatal transmission at time of birth and in 5% of infants born to mothers with HCV
- NOT passed easily through sexual contact
- incubation period 2 months
- genotype 1 -> most widely dispersed
acute HCV
- develop fibrosis -> cirrhosis -> HCC
- most undetected but still cause acute hepatitis
- # 1 risk for liver transplant
- Cholestati pruritus
- most have a +HCV RNA PCR but may not have a anti-HCV Ab early on
- worried about acute HCV -> must check HCV RNA PCR
chronic HCV
- poor correlation with transaminase levels and liver histo
- HCV ptxs with cirrhosis -> high risk of HCC
- EtOH and marijuana increase risk for progression
-amount of inflammation and fibrosis is best clinical predictor of chronic HBC (use Fibroscan)
HCV extra hepatic manifestations
- CRYOGLOBULINEMIA
- MEMBRANOPROLIFERATIVE GN
- PORPHYRIA CUTANEOUS TARDA
what do you do for any ptx with acute or chronic renal failure?
should have HCV and HBV testing
Candida esophagitis
- most common fungal infection in immunocompromised hosts
- high risk if on PPIs
- with oral/esophageal Candida -> look for immunocompromised state (HIV, malignancy, DM)
- cobblestone
- pseudohyphae
oral Candida + dysphagia
likely esophageal Candida
Germ tube test
-differentitated C. albicans and C. dubliensis from other species
C. krusei
NEVER sensitive to fluconazole
C. auris
- hospital outbreaks
- treat with echinocandins
HSV esophagitis
- HSV-1
- transplants»_space; HIV+
- volcano ulcers - punched out ulcers
- multinucleated giant cells
- cowdry type A inclusions
CMV esophagitis
- HIV+»_space; transplant ptxs
- LINEAR ulcers
- OWLS eye inclusion
acute cholecystitis
- cystic duct obstruction, enlarged GB wall (normal size is = 3mm thick)
- bacteria: E. coli, Klebsiella, Enterococcus
- Dx - US -> GB wall thickening (>/4mm), pericholecystic fluid, edema/double wall sign
chronic cholecystitis
- Rokitansky-Aschoff sinuses
- Porcelain GB -> increased risk for GB cancer
Acalculous cholecystitis
-ICU ptxs -> hypoperfusion of GB -> ischemia
cholangitis
- Charcot’s triad -> fever, RUQ pain, jaundice
- Dx: ERCP
- Mirizzi’s syndrome -> gallstone lodges in cystic duct compressing on common bile duct
bacteria causing liver abscess
-E. coli, Klebsiella, Enterococcus, Strep Viridans
fungi causing liver abscess
Candida
parasites causing liver abscess
Entomoeba histolytica and Echinococcus
- E. histolytica -> anchovy paste and treat w/ metronidazole
- Echinococcal (hytadid cyst) -> anaphylactic shock if you biopsy
what ptxs can you see hepatosplenic candidiasis?
AML***
-CT full of Candida liver abscesses (also pancreatic)
a pos stool toxin, culture or parasite
-does NOT mean there is an invasive infection -> may just be a colonizer
most acute gastroenteritis infections
- VIRAL origin -> antibiotics DON’T help
- SUPPORTIVE treatment
Norovirus
- EPIDEMIC gastroenteritis
- Cruise ships and Dorm rooms
- short incubation time (1-2 days)
- NOT killed by EtOH and standard hand gels -> use soap and water
rotavirus
- children (6 months - 2 years old) -> goes through NURSERIES
- dehydration cause of death
- vaccine: RotaTeq, Rotarix -> can lead to intususpeption
Non-typhoidal Salmonella
- cause gastroenteritis
- contaminated chicken/eggs/milk
- see in TURTLES
- summer months
- non-infectious reactive arthritis syndrome (like Chlamydia, Shigella, Campylobacter, Yersinia) -> HLA-B27 +
- chronic carrier (>1 year) -> Gallstones
- Tx: Supportive…quinolone or TMP/SMX if needed
salmonella vs. shigella
- salmonella -> BLACK
- shigella -> CLEAR
Typhoidal Salmonella
- cause enteric fever (typhoid fever)
- traveling from ENDEMIC countries
- chronic carriage -> gallstones and GB carcinoma
- 1st week -> PULSE TEMP DISSOCIATION
- 2nd week -> ROSE SPOTS
- 3rd week -> ILEOCECAL LYMPHATIC HYPERPLASIA
- Dx: Widal test -> detect serum Abs against O and H antigens
- Tx: ceftriaxone or azithromycin
Shigella
- produces SHIGA TOXIN -> cause HUS and dysentery
- Tx: SUPPORTIVE with rehydration
- avoid intestinal anti-motility drugs
Campylobacter
- contaminated chicken or waterborne
- PPIs allow it to thrive -> decrease acidity
- crampy abdominal pain in PERIUMBILICAL region
- CAMPY blood agar
- Tx: azithromycin or quinolones
Yersina
- PIGS/HOGS -> undercooked raw pork
- Fe loving
- Thalassemias or Hemochromatosis -> bacteremia and septic shock
- CIN agar -> red w/ white-rimmed colonies
Vibrios Parahhaemolyticus
- Seafood -> New Orleans or TX coast lines
- TCBS media -> black
- Tx: supportive; tetracyclines (doxy) if needed
Vibrios Cholera
- CHOLERA TOXIN
- “rice water” stools with mucous and FISHY ODOR
- TCBS media -> blue-green
- SHOOTING STAR on dark field microscopy
- Tx: supportive; tetracyclines if needed
Tropheryma Whipplei (Whipples disease)
- sewage workers
- PAS+ foamy Macs in small bowel lamina propria
Clostridium Difficile
- get after Clindamycin therapy
- use with Quinolones -> nosocomial outbreaks
- thrives with PPIs and H2 blockers
- cause pseudomembranous colitis
- LEUKOCYTOSIS
- asymptomatic carrier with + stool test -> NO therapy
- C. diff toxin -> send 3x
- PCR/NAAT for toxin B gene -> send 1x
- Tx: ORAL vancomycin or metronidazole
causes of eosinophilia
- GI parasites -> most common worldwide
2. Allergic rxn -> most common in developing world
how many samples do you want for O and P studies?
3 separate stool samples for Dx
Ascaris Lumbricoides
- Nematode
- travel to LUNGS and reswallowed -> Loeffler Syndrome -> Charcot Leyden Crystals
- oval and mammillated eggs
- Tx: Albendazole or Mebendazole
Enterobius Vermicularis (PINWORM)
- Nematode
- KIDS
- 40 million infected in US
- PERIANAL ITCHING
- Dx: perianal SCOTCH TAPE test
- eggs FLAT on one side (bean-shaped)
- Tx: Albendazole or Mebendazole
Trichuris Trichiuria (WHIPWORM)…“trick trick”
- Nematode
- Tropical
- rectal prolapse with worm burden
- BARREL or lemon shaped eggs with HYALINE plugs
- Tx: Albendazole or Mebendazole
Necator Americanus and Ancylostoma Duodenale (HOOKWORMS)
- Nematode
- DIRECTLY enter skin -> go to LUNGS (eosinophilia)
- “ground itch” - similar to cutaneous larva migrans
- GI bleed -> Fe deficiency microcytic anemia + Eosinophilia
- Tx: Albendazole or Mebendazole
Stronglyoides Stercoralis (Strongyloidiasis)
- Nematode
- Tropical
- Directly enter skin -> go to LUNGS (eosinophilia)
- AUTOINFECTION
- immunodeficient -> fatal HYPERINFECTION SYNROME
- Larva currens (running larva) on butt -> move 1 cm in 5 min…(cutaneous larva migrans moves 1-2 cm per day)
- periumbilical URTiCARIA AND PURPURIC RASH
- Tx: Ivermectin > Albendazole
Trichinella Spiralis
- Nematode
- BEAR/WALRUS undercooked meat w/ encysted larva
- MYALGIA + PERIORBITAL/FACIAL EDEMA (also hypothyroidism)
- Eosinophilia
- Tx: Albendazole or Mebendazole
Toxocara canis and cati (ocular/visceral larva migrans)
- Nematode
- dog/cat roundworms
- larva in EYE
- children + eosinophilia + fever
- prominent EOSINOPHILIA
- Tx: Albendazole or Prednisone
Baylisascaris Pyocyonis
- Nematode
- RACCOONS
- larva migrate to NERVOUS SYSTEM -> eosinophilia + meningoencephalitis
- Tx: Albendazole or Predisone
Angiostrongyliasis Cantonensis (rat lungworm)
- Nematode
- most common cause of eosinophilic meningitis and encephalitis
- Tx: Albendazole or Prednisone
Taenia Saginata (BEEF tapeworm)
- Cestode
- undercooked BEEF
- AFB +
- proglottids have 12-15 uterine branches
- Tx: Praziquantal
Taenia Solium (PORK tapeworm)
- Cestode
- undercooked PORK w/ cysticerci
- AFB -
- eggs are thick RADIATE shell w/ hooklets and walls
- ingest EGGS -> CYSTICERCOSIS (cysts in the brain) -> neurocysticercosis and SEIZURES or increased intracranial pressure
- Tx: Praziquantal
Diphyllobothrium Latum (fish tapeworm)
- Cestode
- undercooked fish
- LARGEST tapeworm
- vit. B12 deficiency -> MEGALOBLASTIC ANEMIA
- egg with operculum
- Tx: Praziquantal
Hymenolepis nana (Dwarf tapeworm)
- Cestode
- SMALLEST tapeworm
- most common in the world
- complete WHOLE LIFE CYCLE IN HOST
- warm countries and schoolchildren
- Tx: Praziquantal
Liver Flukes - Trematodes
- Fasciola hepatica -> common bile duct obstruction, pancreatitis, PSC, hepatitis
- Clonorchis sinensis
Tx: Praziquantal
Intestinal Flukes - Trematodes
- Fasciolopsis buski -> vit. B12 deficiency
Tx: Praziquantal
Giardia Lamblia
- Protozoa
- chronic infection -> develop lactose intolerance -> post-infectious IBS
- trophozoites looks like ghost
- Tx: Metronidazole or Tinidazole
Entamoeba histolytica
- Protozoa
- those on steroids with misdiagnosed colitis have 25% mortality rate
- can cause amoebic liver abscesses and dysentery
- trophozoites INGEST RBCs
- FLASK-SHAPED ULCERS
- Karyosome (spot in nucleus)
- Tx: Metronidazole -> Paramomycin
Blastocystis hominis
- Protozoa
- most common parasite in human stool
- commensal -> no fecal leukocytes seen
- large central vacuole
Cryptosporidium parvum
- Protozoa
- water-related outbreaks of diarrhea
- immunodeficient in HIV+ ptxs (low CD4) -> LIFE THREATENING or can have LONG TERM
- MODIFIED ACID FAST STAINS (special stains) -> not usually diagnosed on routine O and P study
- ROUND and smaller than isospora
- Tx: supportive - Paramomycin or Nitazoxanide if needed
Isospora belli
- Protozoa
- common in immunodeficient ptxs (AIDS)
- sometimes associated w/ EOSINOPHILIA
- larger than crypto and OVAL
- MODIFIED ACID FAST STAIN (special stain) -> not diagnosed on routine O and P study
- Tx: supportive - TMP-SMX if needed
Cyclospora cayatanensis
- Protozoa
- Sx more severe/chronic in ptxs w/ AIDS and biliary diseases including acaculous cholecystitis
- larger than Crypto
- MODIFIED ACID FAST STAIN
- Tx: TMP-SMX
Microsporidiosis
- acutally a FUNGI (thought to be protozoa)
- more severe and symptomatic in HIV+ ptxs w/ CD <100
- Tx: Albendazole
