Goljan inflammatory and infectious disorders of liver Flashcards
pathogen for ascending cholangitis
E. coli
pathogen for liver abscess
E. coli;
Bacteroides fragilis;
streptococcus faecalis
pathogen for granulomatous hepatitis
mycobacterium Tb;
histoplasma capsulatum
pathogen for spontaneous peritonitis
E. coli in adults;
strept pneumoniae in children
pathogen for leptospirosis
leptospira interrogans
pathogen for amebiasis
entamoeba histolytica
pathogen for clonorchiasis
clonorchis sinensis (chinese liver fluke)
pathogen for schistosomiasis
schistosoma mansoni
pathogen for echinococcosis
echinococcus granulosus (sheepherder’s disease)
Define ascending cholangitis
inflammation of bile ducts (cholangitis) from concurrent biliary infection and duct obstruction (stone);
life threatening disease
clinical findings of ascending cholangitis
fever, jaundice, RUQ pain
What is ascending cholangitis likely to cause?
MC cause of multiple liver abscesses
Tx for ascending cholangitis
decompression and drainage;
piperacillin-tazobactam
Epidemiology for autoimmune hepatitis
type 1 is predominant form in US and worldwide (80%);
type 2 is uncommon in US;
young women
what are the range of autoimmune presentations?
symptomatic w/ increased transaminases;
fulminant hepatitis;
cirrhosis
Genetic associations w/ autoimmune hepatitis
HLA-D3 and DR4 association
What are autoimmune associations w/ AI hepatitis?
Hashimoto’s thyroiditis;
Graves’ disease
clinical findings of AI hepatitis
fever;
jaundice;
hepatosplenomegaly
lab findings for type I AI hepatitis
positive ANA (>60%);
anti-smooth muscle Ab (>85%);
increased serum transaminases;
decreased serum albumin in severe disease;
prolonged prothrombin time in severe disease
Tx for AI hepatitis
initial Tx w/ corticosteroids + azathioprine;
liver transplantation if resistant to Tx
where do a majority of liver abscess occur?
right lobe w/ majority being solitary
What are causes of liver abscess?
ASCENDING CHOLANGITIS (MC); INTRA-ABDOMINAL INFECTION (pathogen spread via portal vein, diverticulitis, bowel perforation); DIRECT EXTENSION (empyema of gallbladder, subphrenic abscess); HEMATOGENOUS SPREAD (bacterial endocarditis)
Clinical findings of liver abscess
spiking, intermittent fever;
RUQ or right CVA tenderness;
jaundice is uncommon
How is liver abscess diagnosed?
ultrasound (least expensive);
CT scan
Tx for liver abscess
percutaneous drainage;
metronidazole + ceftriaxone
What does granulomatous hepatitis indicate?
sign of miliary spread
When will spontaneous peritonitis occur?
develops in ascities => cirrhosis, nephrotic syndrome
Tx for spontaneous peritonitis
cefotaxime
Describe the pathogen that causes leptospirosis
G-; tightly wound spirochetes;
crook at end resembles shepherd’s staff
what are the reservoirs for leptospira interrogans and how it is transmitted?
dogs (MC), rats; spirochetes excreted in urine
transmitted by swimming in contaminated water (ponds on farms);
farmers, miners, people who work w/ sewage
What type of disease is leptospirosis
biphasic disease => Weil’s disease
Describe the septicemic phase of leptospirosis
fever, jaundice, hemorrhagic diathesis;
renal failure (interstitial nephritis);
conjunctivitis and photophobia, meningitis;
phase terminated by appearance of Ab
describe immune phase of leptospirosis
presence of numerous organisms in urine => darkfield micro to confirm
Tx of leptospirosis
pen G
What is the most common cause of liver abscess worldwide?
amebiasis => entamoeba histolytica
What is the common location for amebiasis?
usually produces a right lobe abscess
Tx for amebiasis
metronidazole followed by paromomycin
What is the life cycle of the pathogen that causes Clonorchiasis?
nonschistosomal=> egg (human) =>
ciliated miracidial larva =>
infects snail (1st intermed host) =>
produces fork-tailed cercarial larvae =>
infect 2nd intermed host (fish) =>
form infective metacercariae =>
man ingests 2nd intermed host => gets disease
How is clonorchiasis contracted?
by ingesting encysted larvae in fish;
larvae enter CBD and become adults
What is a risk for clonorchiasis?
may produce cholangiocarcioma
Tx for clonorchiasis
praziquantel
Describe the life cycle of the pathogen causing schistosomiasis
egg (human) => ciliated miracidial larva=> infects snail (1st intermed host)=> produces fork-tailed cercarial larvae => penetrate skin in human => gets disease
How does Schistosoma mansoni cause schistosomiasis in the human? (not the life cycle)
larvae in SMV enter into portal vein =>
develop into adult worms that deposit eggs=>
host develops immune response w/ concentric fibrosis in a “pipestem cirrhosis) in the vessel wall
Complications of schistosomiasis
portal HTN;
ascites;
esophageal varices
Tx for schistosomiasis
praziquantel
Where is echinococcosis likely to be found?
single or multiple cysts containing larval forms => may be in liver (MC), lungs, brain
Life cycle of echinococcus granulosus
eggs develop into larval form only;
larval form only develops into adult that can lay eggs
How does echinococcosis pathogen get to the point of infection in human?
infected sheep (intermed host w/ larva in liver cyst) dog eats sheep liver (definitive host & larva develops into adult to lay eggs); human eats eggs from dog is intermed host (eggs develop into larvae that penetrate bowel and enter liver => hydatid cyst
What is a likely way a child may contract echinococcosis?
eating grass contaminated w/ dog excreta
What leads to the ultimate infection of echinococcosis?
inner germinal layer of hydatid cysts has protoscolices (larva) in brood capsules => rupture of cysts can produce anaphylaxis
Tx of echinococcosis
percutaneous drainage + albendazole
Epidemiology of neonatal hepatitis
idiopathic;
congenital infections like CMV;
inborn errors of metabolism=>a1-antitrypsin def
What does biopsy show in neonatal hepatitis?
multinucleated giant cells => “giant cell” hepatitis
Triad associated w/ Reye syndrome?
encephalopathy;
microvesicular fatty change;
transaminase elevation
What is the typical cause of Reye syndrome?
aspirin given to young child w/ infection
Pathogenesis of reye syndrome
mitochondrial damage (virus, salicylates); disruption of urea cycle (increase serum ammonia); defective Beta-oxidation of fatty acids
What may be the effect of salicylates in Reye syndrome? How is it viewed on micro?
microvesicular fatty change => small cytoplasmic globules w/o nuclear displacement;
no inflammatory infiltrate
Initial Clinical findings in Reye syndrome
afebrile, quiet, lethargic sleepy, and vomiting => hepatomegaly and liver dysfxn present
Clinical findings as Reye syndrome progresses
Signs & Sx related to cerebral edema & pressure increase;
1) sleepy but respond; vomit
2) stuporous, seizures, decorticate rigidity, intact papillary reflexes
3) deepening coma, decerebrate rigidity, fixed pupils
4) coma, loss of deep tendon reflex, fixed dilated pupils, flaccidity/decerebrate
5) death
lab findings w/ Reye syndrome
transaminasemia;
normal to slight increase in total bilirubin;
increased serum ammonia and PT (levels give severity);
hypoglycemia;
CSF usually normal
Tx for Reye syndrome
supportive;
mannitol, glycerol, hyperventilation to reduce cerebral edema
mortality rate for Reye syndrome
25-50% mortality rate
Pathogenesis of acute fatty liver of pregnancy? risks?
abnormality in Beta-oxidation of fatty acids;
FATAL TO MOTHER AND FETUS UNLESS DELIVERED
Define preeclampsia
HTN, proteinuria, dependent pitting edema in 3rd trimester
How does preeclampsia damage the liver? what lab will be elevated?
liver cell necrosis around portal triads (zone 1);
increased serum transaminases
Define HELLP syndrome
Hemolytic anemia w/ schistocytes;
Elevated Liver enzymes
Low Platelets (DIC)
Define fulminant hepatic failure
acute liver failure w/ encephalopathy w/in 8wks of hepatic dysfxn
causes of fulminant hepatic failure
Viral hepatitis (MC overall cause);
drugs (acetaminophen MC);
Reye syndrome
gross and micro findings of fulminant hepatic failure
wrinkled capsular surface due to loss of hepatic parenchyma;
dull red-yellow necrotic parenchyma w/ blotches of green (bile)
clinical findings in fulminant hepatic failure
hepatic encephalopathy;
jaundice
Lab findings w/ fulminant hepatic failure
DECREASE transaminases (liver parenchyma destroyed); INCREASE in PT and ammonia
