Hepatobiliary Disease Flashcards
Why is LFT a misnomer?
AST/ALT, ALP, and Bilirubin are more indicative of liver damage compared to function.
Function tests:
- PT/INR
- Albumin
- Cholesterol
- Ammonia
Hepatocellular vs. Cholestatic disease
Hepatocellular: Injury to hepatocytes
- Elevated AST/ALT*
- ALT more specific
Cholestatic: injury to bile ducts
- Elevated ALP and Bilirubin
Bilirubin test are indicative of what?
Hepatic uptake, metabolic, and excretory functions
AST/ALT tests are indicative of what?
liver cell injury
- Highest in hepatocellular necrosis
- Complete biliary obstruction
- Moderate response to EtOH induced damage
Alkaline Phophatase indications
Cholestasis
Biliary obstruction
Liver infiltration
NORMAL elevation in childhood and pregnancy
y-Glutamyl Transpeptidase (GGT)
Correlates with ALP
If elevated, think liver problem
What is the best measure of hepatic synthetic function?
INR test.
If corrects with Vit. K replacement= fat malabsorption, not liver disease
In Hemolysis, is there an elevation in unconjugated or conjugated bilirubin?
Unconjugated
Liver is fine and working to conjugate, but there is an abundance of bilirubin
Murphy’s Sign
Tests for acute cholecystitis.
Pain on palpation in RUQ
Cholelithiasis
Formation of gallstones
- Cholesterol
- Pigment (calcium)
Signs of Cholelithiasis
- Biliary Colic- steady RUQ pain 30-90 mins post prandial that can radiate to right shoulder
- NV
Patient shows an acoustic shadow on Ultrasound. What is this indicative of?
Cholelithiasis
F’s of Cholelithiasis
Forty Fat Fertile Female Family History
What are some protective factors from cholelithiasis?
Low carb diet
Physical activity
Caffeinated coffee (thank god)
ASA and NSAIDs
Where is the most common place for a calculous to be impacted and cause acute cholecystitis?
Cystic duct
PE presentation of acute cholecystitis
RUQ pain NV Fever and Leukocytosis Tea-colored urine or acholic stools Increased bilirubin, ALP, GGT
Choledocholithiasis
Stone in the common bile duct obstructing both biliary and liver secretions. JAUNDICE
- Can lead to ascending cholangitis
- ERCP diagnostic and therapeutic
Ascending Cholangitis
Infiltration of duodenal bacteria into the biliary tract Charcot Triad: 1. RUQ pain 2. Fever 3. Jaundice
Reynolds Pentad:
Charcot + AMS + hypotension- EMERGENCY
Common bacteria seen on gram stain in ascending cholangitis
E. Coli
Klebsiella
Enterococcus
What should be measured prior to performing an ERCP?
INR (don’t want them to bleed out)
Pregnancy test in women
Biliary Dyskinesia
Gallbladder just randomly stops working Presents like biliary colic - RUQ pain - NV Normal US HIDA scan shows abnormal ejection fraction Tx: Cholycystectomy
Chronic Cholecystitis
Repeated acute cholecystitis
Lab tests are Normal
XR: Porcelain Gallbladder= risk of gallbladder cancer
What malignancy is Courvoiseir’s sign indicative of?
cancer of the head of the pancreas
Remember: Courvoiseir’s= enlarged NONTENDER Gallbladder
Primary Sclerosing Cholangitis
"Beads on a string" due to dilations and strictures in biliary tree Males UC association PE: Pruritis and Jaundice Increased risk of Cholangiocarcinoma
What is the most common cause of fulminant liver failure (ALF)?
Acetaminophen overdose
Describe ALF
massive hepatic necrosis with impaired consciousness that can result in cerebral edema and sepsis
PE exam findings in ALF
rapidly shrinking liver, rising bilirubin, prolonged PT, AMS
What can be given to a patient suffering from ALF due to Acetaminophen overdose?
N-Acetylcysteine (NAC)
Mucomyst (brand)
3 top causes of acute hepatitis
- Viral
- Drugs
- Ischemia
What would be seen on PE in acute hepatitis?
Jaundice
Hepatomegaly
RUQ pain
Dermatological changes (Polyarteritis, cryoglobulinemia)
A patient presents with NV, RUQ pain, hepatomegaly, a and jaundice. They are a smoker, but now say they can’t even stand the smell. Ddx?
Hepatitis A - aversion to smoking - echoic stools - elevated bilirubin and ALP Detection of IgM anti-HAV is excellent prognosis
Common risk factors of HBV
Anal sex IV drug use Medical worker (needle sticks) Incarcerated previous STI
What kind of lab pattern does HBV show?
Hepatocellular (elevated AST/ALT)
What are HBV positive patients at risk of developing?
HCC
Cirrhosis
Describe the window period of HBV infection
Early in the disease course, HBsAg is cancelled out by Anti-HBs, and IgM-antiHBc is the only thing detected.
If in stem you see IgM-antiHBc positive, patient has ACTIVE infection
Acute HBV infection serology
HbsAg +
IgM-antiHBc +
HBeAg and HBV DNA +
What does a positive HBeAg and HBV DNA serology indicate?
Active replication which is active disease
What is the only positive serology finding in an immunized person with no previous infection?
Anti-HBs
only see Ab’s to core if you’ve had the infection
What is required to have an HDV infection?
HBV
What type of Hepatitis strain is associated with HIV infection?
HCV
What Hepatitis strain is associated with immunocompromised patients?
HEV
What is the minimal time period after ingestion to use the Rumack-Matthew Nomogram to evaluate acetaminophen Overdose?
4 hours
Critical ingestion-treatment interval for protection against hepatic injury is 0-8 hours
Budd-Chiari Syndrome
Occlusion of the hepatic vein or IVC
- Caused by Right-sided HF or Caval Webs that obstructs IVC
- Leads to nutmeg liver
- Screening test of choice is a CEUS (contrast-enhanced ultrasound)
What is HELLP syndrome and what is it associated with?
Hemolysis, Elevated liver enzymes, Low platelet count,
Associated with Pre-eclampsia and Eclampsia leading to hepatic disease of pregnancy
Acute Fatty liver of pregnancy
many disorders lead to hepatic dysfunction that can result in failure, coma, and death.
You will get pregnant, and DIE
Clinical jaundice is defined as:
bilirubin >3 mg/dL
2 unconjugated (indirect) bilirubinemias we need to know
Hemolytic Syndrome
Gilbert Syndrome
Criggler-Najjar because I said so
4 causes of conjugated (direct) bilirubinemias
- Dubin-Johnson: black liver
- Rotor Syndrome
- Drug reaction
- Pregnancy
If GGT is elevated, what is the suspected source of jaundice?
Liver
If normal: suspect bone or something else
If you suspect Jaundice secondary to hemolysis, what would be seen on CBC?
Anemia
Thrombocytopenia
Increased LDH, haptoglobin, reticulocyte count
Gilbert Syndrome
Reduced uridine diphosphate glucoronyl transferase
- increased indirect bili
- Benign, no harmful, actually protective against CV disease
Dubin Johnson Syndrome
reduced excretion of bilirubin from hepatocytes due to mutation in ABCC2 gene encoding for MDRP2.
Black liver
Rotor Syndrome
Reduced uptake of bilirubin in the liver causing elevated direct bilirubin.
OATP1B1 protein
Bilirubinemia due to pregnancy
Mainly Direct bilirubin
- itching in the 3rd trimester, GI symptoms, excellent prognosis
