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clin med > hepatic part 3 > Flashcards

hepatic part 3 Flashcards

1
Q

Cholelithiasis?

A

gallstones

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2
Q

Cholelithiasis cause

A

Most are cholesterol stones

Some are Pigment stones

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3
Q

what are black and brown pigment stones made of in Cholelithiasis

A

Black- made of Ca bilirubinate

Brown- made of Ca salts and unconjugated bilirubin

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4
Q

Cholelithiasis sx

A

Most Asx
Biliary colic
Most are sx recurrent but trmt is not an emergency

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5
Q

biliary colic?

A

Intense, steady discomfort in RUQ, epigastric, or substernal that goes to the back, R scapula, or shoulder
Referred pain
Diaphoresis, NV, bloating
Lasts 30 min and plateaus in 1hr but goes away within 5-6 hrs
Occurs after eating

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6
Q

Cholelithiasis pe

A

No fever, uncomfortable, NV, sweating, RUQ ttp
- murphy sign: stop in breathing with inspiration
No peritoneal signs

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7
Q

dx Cholelithiasis

A

RUQ US is modality of choice

CT is less sensitive but can pick up other things

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8
Q

trmt Cholelithiasis

A

Ultimate trmt for symptomatic choleithiasis is lap cholecystectomy
Don’t treat if Asx but tell pt to come back if sx worsen, nv, jaundice
Ursodeoxycholic acids- meds that dissolve stones if refuses surgery

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9
Q

Mirizzi syndrome-?

A

stone putting pressure on CBD

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10
Q

Cholecystitis?

A

Inflammation of the GB usually dt a stone in the cystic duct→ obstruction and inflammation in the GB
GB is trying to contract but it inflames cause nothing can get out of it

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11
Q

Cholecystitis cause

A

Cholelithiasis

Acute cholecystitis- d/t impacted stone in cystic duct leads to obstruction and inflammation

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12
Q

Cholecystitis sx

A 
Similar to stone
RUQ or epigastric pain, constant severe pain that radiates to the shoulder/scapula/back
NV,* fever, anorexia
Postprandial- over 1 hr after eating
Pain for over 6 hrs*
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13
Q

Cholecystitis pe

A

Ill, febrile, may be lying still bc moving hurts
RUQ ttp with + murphy sign
Guarding

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14
Q

Cholecystitis dx

A

CBC→ leukocytosis with left shift (inc immature wbc)
RUQ US is 1st line→ will see GB wall thickening, pericholecystic fluid, and + sonographic murphy sign
HIDA if US is normal and you have high suspicion

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15
Q

trmt Cholecystitis

A

IV atb
Mild to moderate- 2nd or 3rd gen cephalosporin, cefazolin, cefuroxime, ceftriaxone
2nd or 3rd gen cephalosporin, ciprofloxacin, levofloxacin AND metronidazole
Lap chole is definitive

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16
Q

Acalculous cholecystitis?

A

In pts who are ill with no oral intake for long periods of time

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17
Q

Acalculous cholecystitis

trmt?

A

Immediate referral and admission
IV atb and cholecystectomy
Percutaneous cholecystostomy if too critical for surgery

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18
Q

Choledocolithiasis?

A

Stone in common bile duct

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19
Q

Choledocolithiasis sx

A 
Biliary type pain
RUQ pain
NV
May be Intermittent 
Jaundice*
20
Q

Choledocolithiasis dx

A

US shows dilated CBD over 6 mm
CT shows dilated CBD
MR cholangiopancreatography- diagnostic, not as expensive
ERCP- diagnostic and therapeutic
Can cause iatrogenic pancreatitis
High AST, ALT, ALP, GGT and bili
Lipase is high if obstruction is in the pancreatic duct too

21
Q

Choledocolithiasis trmt

A

ERCP with sphincterotomy to remove stone
Lap chole to remove GB
ATB if cholangitis present too

22
Q

Cholangitis?

A

Bacterial infection in biliary tree in pts with obstruction (usually choledocholitiasis)

23
Q

Cholangitis cause

A

Ascending infection from duodenum

MC E coli→ get UA

24
Q

Cholangitis sx

A

Charcot’s triad= fever/chills + RUQ pain + jaundice
Reynold’s pentad= charcot’s triad + confusion + hypotension→ indicates shock
Mild to life threatening

25
Q

Cholangitis dx

A 
Leukocytosis
Aminotransferases in 1000
High bilirubin
High ALP
High GGT
26
Q

Cholangitis trmt

A

Remove stone
IV atb
ERCP for dx and therapeutics

27
Q

Most pts survive 9-17 yrs

A

Primary sclerosing cholangitis

28
Q

Primary sclerosing cholangitiscause

A

Inc immune response from intestinal endotoxins
Inflammation of biliary tract → fibrosis and strictures of biliary system
Assoc. With IBD and UC

29
Q

Primary sclerosing cholangitis sx

A

Progressive obstructive jaundice
Fatigue, pruritus (bilirubin in skin), anorexia, indigestion
May be seen during asx period after elevated ALP on lab

30
Q

Primary sclerosing cholangitis dx

A

MRCP- magnetic resonance cholangiopancreatography
Segmental fibrosis of bile ducts with saccular dilation between strictures
High ALP (liver enzyme)

31
Q

Primary sclerosing cholangitis trmt

A

Ursodeoxycholic acid orally to improve liver tests

Balloon dilation or stent for strictures

32
Q

3rd MC inpatient GI dx in US

A

Acute pancreatitis

33
Q

Acute pancreatitis

cause

A

MCC gallstones and alcohol abuse- more common if smaller stones
Iatrogenic, scorpion sting, meds
Mechanism unknown
Autodigestion of the pancreas bc pancreatic zymogens (trypsinogen) are activated and injure acinar cells (lipase release)

34
Q

Acute pancreatitis

sx

A

Acute onset, epigastric pain may be worse with walking, lying flat, better sitting up and leaning forward
Radiation to the back
NV, sweating
h/o ETOH, heavy meal, or GB disease

35
Q

Acute pancreatitis

pe

A

Vomiting, fever, tachycardic, pallor, sweating
+ tenderness in upper abdomen without peritoneal signs
Dec BS from ileus
Abdominal ecchymosis suggest hemorrhagic pancreatitis
Grey turner sign- ecchymosis around kidneys
Cullen sign- around belly button

36
Q

Acute pancreatitis

dx criteria: 2/3 must be met

A

Hx consistent with dx
Lipase 3 times normal limit
CT findings of pancreatitis- fat stranding→ suggest inflammation

37
Q

Acute pancreatitis

dx

A 
High lipase
Leukocytosis
Hyperglycemia if chronic
US if GB cause but wont help you see pancreas
Imaging not routinely indicated
CT if you don't know what it is
38
Q

Revised Atlanta Classification

for Acute pancreatitis

A

Mild- no organ failure or systemic complications
Moderate- organ failure or systemic complications under 48 hrs
Severe- organ failure over 48 hrs

39
Q

Ranson criteria for assessing severity

for Acute pancreatitis

A 
No rebound abd tenderness/guarding, normal hematocrit, normal serum Cr? Nonsevere 
Looks at age, WBC count, glucose, LDH, AST, hematocrit, BUN, serum Ca, pO2, base deficit, fluid sequestration
1 to 3→ Mild pancreatitis
Over 3→ severe pancreatitis
Predicted mortality
0-2→ 0-3%
3-5→ 11-15%
6→ 40%
40
Q

Acute pancreatitis

trmt

A 
NPO if severe
IVF with normal saline
Analgesics- morphine, hydromorphone
Antiemetics- zofran 
If severe give LOTS of IV fluids
IV ATB if necrosis
Admit to hospital
41
Q

Grey turner sign-

A

ecchymosis around kidneys

42
Q

Cullen sign-

A

around belly button

43
Q

Chronic pancreatitis cause

A

MC in chronic alcoholics
Tumor, obstruction, autoimmune, idiopathic
Acute pancreatitis→ necrosis→ chronic pancreatitis

44
Q

Chronic pancreatitis

sx

A

Recurrent epigastric or LUQ pain
Anorexia, NV, weight loss, constipation, steatorrhea*
Episodes last few hrs to wks

45
Q

Chronic pancreatitis

pe

A 
Varying presentations
Epigastric abd ttp
Guarding
Ileus 
Similar to acute but gradual onset
46
Q

Chronic pancreatitis

dx

A

Lipase normal*
Typical labs for pancreatitis
Fatty stools
No imaging routinely indicated

47
Q

Chronic pancreatitis

trmt

A 
Stop drinking
IV fluids and pain control (no opioids bc they're addictive)
Low fat diet
Pancreatic enzyme supplements with meals
Antacids
Steroids if autoimmune
Surgery if underlying GB disease
ERCP for an obstruction
Admit if severe pain, new jaundice, new fever

clin med (35 decks)

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