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GI II Exam 2 > DSA: Approach to the Hepatobiliary Patient (McGowan) > Flashcards

DSA: Approach to the Hepatobiliary Patient (McGowan) Flashcards

1
Q

What are 4 molecules that are used to assess TRUE LIVER FUNCTION? (P/A/C/A)

A

PT/INR, albumin, cholesterol, and ammonia

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2
Q

What two findings are typically elevated with hepatocellular injury and cholestatic injury?

A

H: injury to hepatocytes

  • alkaline and aspartate aminotransferase (ALT, AST)
  • ALT is MORE specific than AST

C: injury to the bile ducts

  • alkaline phosphatase and bilirubin elevation
  • jaundice and pruritus
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3
Q

What do the Liver Function Tests for Coagulation Factors, Albumin, and Ammonia tell us about liver status?

A

CF: SINGLE BEST measure of hepatic synth function

  • all clotting factors except factor 8 synthed here
  • replace Vit. K w/no change = hepatic disease

Albumin: hypoalbuminemia correlates w/severity of liver dysfunction

Ammonia: elevation does NOT correlate w/hepatic function or degree of acute encephalopathy

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4
Q

What does a positive Murphy Sign indicate?

A

Acute Cholecystitis

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5
Q

Cholelithiasis

What are the two types, when does pain present and where does it radiate, and what labs/imaging is associated with it?

A

Two types of GALLSTONES:

  • Cholesterol (80%): >50% cholesterol monohydrate
  • Pigment (20%): primarily made of Ca bilirubinate

C: most silent; can have steady RUQ/epigastric pain 30-90 min after eating and can radiate to RIGHT SCAPULA (also nausea/vomiting)

L/I: normal labs, some bilirubin elevation; ULTRASOUND is best diagnostic (see stones and “acoustic shadowing”)

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6
Q

What are the 6 ‘F’s’ of Gallstones?

What are specific protective measures for women and men?

A

Female, Fair (Caucasian), Fat, Fertile, Forty, and Family History

W: consumption of caffeinated coffee
M: high intake of Mg/mono and polyunsaturated fats

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7
Q

Acute Cholecystitis

What are the two types, what are common symptoms, what are 3 common lab findings, and what are two complications it can cause? (GG/EC)

A

Two types of Gallbladder INFLAMMATION:

  • Calculous: gallstones (90%); cystic duct impaction
  • Acalculous: no stones; many causes

S: (+) Murphy Sign, sometimes Jaundice, acholic stool or tea-colored urine

L: leukocytosis, bilirubinemia, inc. ALP/GGT lvls
- RUQ ultrasound (thick wall, pericholecystic fluid)

C: gallbladder gangrene, emphysematous cholecystitis

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8
Q

Choledocholithiasis

What is it, what can it lead to, how does it present, and how can it be treated (2)?

A
  • stones in the COMMON BILE DUCT
    • can lead to Ascending Cholangitis (infection)

S: biliary pain, +/- jaundice, nausea, vomiting

  • inc. AST/ALT, DIRECT hyperbilirubinemia
  • ALP/GGT rise slowly

T: ERCP with sphincterotomy/stone extraction and cholecystectomy

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9
Q

Ascending Cholangitis

What is it, what are its two classical presentations (CT/RP), what 3 organisms are seen on blood cultures (E/K/E), and how is it treated (2)?

A
  • infection of choledocholithiasis (LEUKOCYTOSIS)

P: Charcot Triad (RUQ pain, fever, jaundice) and Reynold Pentad (Triad, altered mental status, hypotension)

BC: E. coli, Klebsiella, Enterococcus (GRAM -)

T: ECRP with sphincterotomy/stone extraction and cholecystectomy

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10
Q

What is Endoscopic Retrograde Cholangiopancreatography (ERCP)?

A
  • invasive but diagnostic/therapeutic
  • measure INR prior to procedure and get pregnancy test

Complications: ACUTE PANCREATITIS

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11
Q

How are the following treated:

  1. Cholelithiasis
  2. Acute Cholecystitis
  3. Choledocholithiasis
  4. Cholangitis
  5. Primary Sclerosing Cholangitis
A
  1. monitor, elective cholecystectomy
  2. NPO, IV fluids, Abx, Surgery (urgent cholecystectomy)
  3. ERCP, laparoscopic cholecystectomy
  4. Urgent ERCP (stones removed)
  5. no satisfactory therapy, treat cholangitis as outlined above; possible liver transplant w/END-STAGE CIRRHOSIS
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12
Q

Biliary Dyskinesia

What is it, how does it present, and how can HIDA scans be used?

A
  • symptomatic functional disorder of the gallbladder (unknown etiology)

C: RUQ pain (like biliary colic) with normal ultrasound (use ROME III criteria), normal liver enzymes/conjugated bilirubin/amylase/lipase

HIDA: radionucleotide ion - nuclear medicine Technetium Tc 99m

  • Abnormal: no gallbladder seen (stone)
    • cholecystokinin ejection fraction < 35-38%
  • get cholecystectomy
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13
Q

What is an imaging finding of Chronic Cholecystitis, what is at an increased risk of developing, and when should surgery be used?

A

Porcelain Gallbladder: seen on plain X-Ray
- calcified lesions of gallbadder

  • inc. risk of developing gallbladder cancer (POOR PROGNOSIS)
  • use surgery if: symptomatic or if porcelain gallbladder is seen on imaging
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14
Q

Primary Sclerosing Cholangitis (PSC)

Who is it commonly seen in, how does it present clinically (P/J/O), what are diagnostic findings, and how is it treated?

A
  • fibrosis of BILE DUCTS = “beads on a string”, usually Males with IBD (ulcerative colitis); dec. risk with smoking and coffee consumption

C: pruritis, jaundice, osteoporosis

D: ALP/bilirubin elevated, use ERCP/MRCP

T: no proven therapy; use symptomatic treatment or potential liver transplant

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15
Q

What are two findings upon ERCP and Liver biopsy of a patient with Primary Sclerosing Cholangitis?

What is a patient with PSC at an increased risk of developing?

A

ERCP: “beads on a string” due to fibrosis

Liver Bx: “onion skinning”

  • pts are at inc. risk for CHOLANGIOCARCINOMA and inc. risk of colon cancer in patients with Ulcerative Colitis
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16
Q

What bilirubin levels are clinical jaundice seen at?

What are the normal lvls for conjugated and unconjugated?

A
  • seen at bilirubin > 3 mg/dL (norm: 0.2-1.2 mg/dL)

Direct (cong): 0.1-0.3 mg/dL
Indirect (uncong): 0.2-0.9 mg/dL

17
Q

What are common diseases associated with elevated Unconjugated (2) and Conjugated (4) bilirubin? (JAUNDICE)

A

Unconjugated

  • Hemolytic Syndrome, Gilbert Syndrome
  • also Crigler-Najjar Syndrome/Viral Hepatitis

Conjugated

  • Dubin-Johnson Syndrome, Rotor Syndrome
  • Drug Rxn and Pregnancy
18
Q

Hemolytic Syndrome

What bilirubin is increased and what should you check if you believe your pt. has a hemolytic syndrome (H/R/L)

A
  • inc. unconjugated hyperbilirubinemia (PREHEPATIC)
  • order CBC to look for AMENIA/THROMBOCYTOPENIA
    • also: haptoglobin, reticulocyte count, LDH
  • check peripheral smear: shistocytes/sickle cell
19
Q

Gilbert Syndrome

What bilirubin is increased, what activity is reduced, and how does fasting affect lab values?

A
  • inc. unconjugated hyperbilirubinemia (PREHEPATIC)
    • hereditary, benign, asymptomatic
  • dec. activity of uridine diphosphate glucuronyl transferase
  • 24-36 hour fast inc. hyperbilirubinemia
20
Q

Dubin-Johnson Syndrome vs Rotor Syndrome

What bilirubin is increased?

A

DJS: dec. excretory function of hepatocytes

  • benign hereditary jaundice, dark black liver
  • gallbladder NOT seen on oral cholecystography

RS: dec. hepatic reuptake of bilirubin conjugates

  • benign, hereditary jaundice, no liver pigmentation
  • gallbladder SEEN on oral cholecystography

-inc. conjugated bilirubin

21
Q

Intrahepatic Cholestasis of Pregnancy

What is it, what does it look like clinically, and what bilirubin is increased?

A
  • caused by cholestasis
  • benign jaundice occurring during THIRD trimester of pregnancy, with itching and GI symptoms
  • inc. conjugated bilirubin
22
Q

Acute (Fulminant) Liver Failure

What is it most commonly caused by, what are two major causes of death (CE/S), how does it present (4), and how can it be treated?

A
  • massive hepatic necrosis with impaired consciousness (8 weeks of the onset of illness) usually due to ACETAMINOPHEN poisoning (2nd: idiosyncratic drugs)

CoD: cerebral edema and sepsis (80% w/deep comas)

P: encephalopathy –> deep coma; rapidly inc. bilirubin, markedly prolonged PT time (AST/ALT can be > 5000 in acetaminophen poisoning)

T: support pt (fluid, circulation, breathing), early transplant transfer, N-Acetylcysteine (NAC) for OD

23
Q

Hepatitis A (HAV)

What is it, how is it transmitted, what labs does it have, and how is it treated?

A
  • ssRNA that can cause aversion to smoking; usually ACUTE lasting up to 6 weeks (self-limited)

T: fecal-orally, usually during international travel

L: Markedly elevated AST/ALT, elevated bilirubin and ALP (cholestasis), detection of IgM anti-HAV is EXCELLENT TEST (IgG indicates previous exposure)

Treatment: HAV vaccine

24
Q

Hepatitis B (HBV)

What is it, what is is commonly associated with (PN), how is it transmitted, and what labs does it have?

A
  • partially dsDNA that can be associated with POLYARTERITIS NODOSA, glomerulonephritis

T: parenteral, sexual, perinatal, percutaneous (needle)
- Endemic in Africa/Southeast Asia

L: Markedly elevated AST/ALT (higher than HAV)

Treatment: HBV Vaccine

25
Q

Hepatitis B (HBV)

What is the difference between Acute/Chronic and what are two complications of infection?

A

Acute: subsides in 2-3 weeks w/90% recovery
Chronic: 10% of acute progress

Risk: inc. risk of cirrhosis (especially with HDV superinfection) and hepatocellular carcinoma

26
Q

What is the Window Period of HBV infection?

A
  • time between HBsAg disappearance and HBsAb appearance (can be several weeks)
  • patient still considered to have ACUTE HBV and infection is ONLY detectable with HBcAb IgM

important when screening blood donations

27
Q

Hepatitis D (HDV)

What is it, when does it infect, what labs are associated with it, and how is it treated?

A
  • defective RNA virus requiring HBV for replication (either coinfects or superinfects chronic HBV carrier)

L: HDV Ag and HDV RNA (PCR)

T: vaccinate against HBV (hepatitis B vaccine)

28
Q

Hepatitis C (HCV)

What is it, how is it transmitted, what labs are associated with it, and how can it be treated?

A
  • ssRNA virus that is most commonly CHRONIC that is transmitted by transfusion, IV drug use, and bloody fisticuffs

L: fluctuating AST/ALT levels, most sensitive indicator of infection is HCV RNA (also HCV Ab in serum)
- dec. in serum cholesterol

T: no vaccine; chronic disease should be vaccinated against HAV/HBV

29
Q

Hepatitis C (HCV)

What are 4 complications of infection (C/HCC/HIV/MC) and how can it be screened (2)?

A

C: cirrhosis, hepatocellular carcinoma, HIV co-infection, mixed cryoglobulinemia

P: birth cohort screening for persons born between 1945-1965 (Baby Boomers) and new recs over 18 should have once in a lifetime HCV screening

30
Q

Hepatitis E (HEV)

What is it, who is it commonly seen in (2), how is it transmitted, and what is its mortality?

A
  • ssRNA herpevirus that is self-limited and is ACUTE with NO carrier state
  • commonly seen in IMMUNOCOMPROMISED pts and in endemic Asia, Middle East, Africa, India, Central America (transmitted fecal-oral OR by swine)
  • HIGH mortality rate in pregnant women specifically
31
Q

What is a major dose-dependent hepatotoxin and what are two common idiosyncratic drugs indicated in Drug-induced Liver Injury?

A

HT: ACETAMINOPHEN, mushroom poisoning (48 hr onset)

I: isoniazid and sulfonamides (variable dose/time of onset)

Treatment: supportive, liver transplant if necessary, NAC for acetaminophen

32
Q

What is Rumack-Matthew Nomogram?

A
  • used for Tylenol/Acetaminophen overdose (treat with N-acetylcysteine or NAC)
  • therapy should begin within 8 hours of ingestion; important to get a 4 hour acetaminophen level
  • can help you determine how much toxicity the liver may experience based on the timing and amount of acetaminophen ingested
33
Q

Budd-Chiari Syndrome

What is it, what are two common presentations of it, what is seen on imaging, and what complication can it lead to?

A
  • occlusion of flow to hepatic vein or IVC causing caval webs, right-sided heart failure (NUTMEG LIVER) due to hypercoagulable states

I: occlusion/absence of flow in hepatic veins/inferior vena cava with PROMINENT CAUDATE LIVER LOBE

  • use Contrast Enhanced color/pulsed Ultrasonography (CEUS)
  • liver biopsy = centrilobular congestion (NUTMEG)

Comp: bleeding varices, hepatocellular carcinoma

34
Q

What is the most common cause of jaundice in pregnancy?

A

VIRAL HEPATITIS

35
Q

Hepatic Disease of Pregnancy

Pre-eclampsia (MH/P/PE/C)/eclampsia, Cholestasis of pregnancy, and Acute Fatty Liver of pregnancy

A

P/E: maternal hypertension, proteinuria, peripheral edema, coagulation abnormalities

  • Eclampsia = w/hyperreflexia and convulsions
  • life-threatening!
  • also HELLP syndrome

CP: pruritus in the 3rd trimester, darkening of urine, light stools, jaundice

AFL: spectrum of disorders, can cause hepatic failure, coma, death in severe cases

GI II Exam 2 (8 decks)

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