HEPATOBILIARY/PANCREATIC Flashcards
Child’s classification?
stratifies risk of surgery in pts w/ liver failure
measure 3 labs (albumin, bilirubin, PT) and 3 clinical findings (encephalopathy, ascites, nutrition)
Varices ppx in pts w/ cirrhosis?
Tx for bleeding varices?
beta blockers
band the varices, correct coagulopathy, IV octreotide to lower portal pressure
(if bleeding continues, repeat banding; if more, TIPS or gastric balloon tamponade)
Pathophys of ascites in cirrhosis?
portal HTN + hypoalbuminemia
Hepatic encephalopathy:
pathophys?
presentation?
tx?
↓NH4 metabolism → ↑NH4 → CNS toxicity
∆MS, asterixis, rigidity, hyperreflexia, fetor hepaticus
lactulose (prevents NH4 absorption) + neomycin (kills GI flora that make NH4) + low • protein diet
Hepatorenal syndrome:
pathophys?
tx?
end-stage liver dz → renal vx vaso-constriction → progressive renal failure (despite normal kidneys)
Tx liver txp
Spontaneous bacterial peritonitis (SBP) =
presentation?
dx?
tx?
infx of ascitic fluid → abd pain, fever, n/v, rebound tenderness
Dx paracentesis (↑WBC)
Tx IV abx + repeat paracentesis in 2-3 days
Hyperestrinism in cirrhosis is a/w:
↓estrogen metabolism → ↑estrogen → spider angiomas, palmar erythema, gynecomastia, testicular atrophy
Wilson’s disease:
dx?
tx?
Dx ↓ceruloplasmin, ↑AST/ALT, liver bx
Tx D-penicillamine (copper chelating agent) + zinc (copper uptake competition)
Hemochromatosis:
dx?
Dx ↑ferritin, ↓TIBC, liver bx
Hepatic adenoma: presentation? dx? tx? a/w...
usually asx, can present as hypovolemic shock and distended abdomen if ruptured
Dx CT scan or U/S
Tx d/c OCP, if it persists → resection due to possibility of rupture
a/w OCP and anabolic steroid use
Cavernous hemangioma:
dx?
tx?
etiology?
Dx CT scan or U/S
reassurance
VAT – vinyl chloride, aflatoxin, thorotrast
(MC benign liver tumor)
Focal nodular hyperplasia: what will imaging show?
CT scan = central stellate scar or sunburst pattern
Hepatocellular carcinoma:
presentation?
dx?
tx?
vague RUQ pain and mass + s/sx of chronic liver dz (portal HTN, ascites, jaundice)
Dx CT scan, ↑αFP
Tx resection w/ negative margins (as long as there’s no mets)
Gilbert’s disease:
pathophys?
presentation?
AD ∆UDP-glucuronyltransferase  
usually asx, but can present w/ mild jaundice after fasting
Hemobilia:
pathophys/presentation?
dx?
tx?
injury to liver or biliary tract → blood drains into duodenum via CBD → UGIB, jaundice, RUQ pain
Dx arteriogram (gold std); EGD shows bleeding from ampulla of Vater
Tx supportive care, stop bleeding if severe
Hydatid cysts: tx?
inject hypertonic saline inside cyst and • carefully excise it + post-op mebendazole
Budd-Chiari syndrome:
pathophys/presentation?
tx?
mcc?
occlusion of hepatic vein outflow → hepatic congestion + portal HTN → hepatomegaly, RUQ pain, ascites, jaundice
Transjugular Intrahepatic Portosystemic Shunt (TIPS) as a bridge to liver transplant
polycythemia vera
 ↑AST/ALT (ALT>AST) =
chronic viral hepatitis (virALT)
↑AST/ALT (AST>ALT) =
acute alcoholic hepatitis (toAST)
↑↑AST/ALT =
acute viral hepatitis
↑↑↑AST/ALT =
severe hepatic necrosis
↑AlkP + GGT nl =
pregnancy or bone dz (e.g. Paget’s)
↑AlkPhos + ↑GGT =
biliary obstruction
Etiology of…
↑bilirubin (conjugated 50%) =
↑bilirubin (conjugated 50%): obstructive jaundice (cancer, choledocholithiasis)
↓albumin = due to…
chronic liver dz, nephrotic syndrome, malnutrition, inflammatory states
Acute cholecystitis:
tx?
NPO, IVF, abx → lap chole within 24 hrs
Choledocholithiasis:
pathophys?
stones in CBD
NPO, IVF, ±abx → ERCP to remove stone
Gallstone pancreatitis:
pathophys/presentation?
tx?
impacted stone in pancreatic duct → reflux of pancreatic enzymes → midepigastric pain
if amylase returns to normal → Tx lap chole
if amylase elevated → ERCP to remove stone
Acute cholangitis:
pathophys/presentation?
tx?
impacted stone in CBD → infx → Charcot triad → Reynold pentad
NPO, IVF, abx → ERCP to decompress CBD • → finally lap chole
Boas sign =
Charcot triad =
Reynold pentad =
referred right scapular pain of biliary colic
RUQ pain, fever, jaundice
Charcot triad + ∆MS, hypotension
Gallstone ileus =
gallstone enters bowel through cholecystenteric fistula → gets stuck in terminal ileum → SBO
Acalculous cholecystitis:
MC population?
tx?
ICU pts
NPO, IVF, abx → lap chole within 24 hrs; perc drain w/ cholecystostomy if nonsurgical • candidate
GB adenocarcinoma:
presentation?
dx?
tx?
mass in GB fossa
CT
adical cholecystectomy (GB + hilar LN + • liver resection w/ negative margins)
Porcelain GB =
tx?
dystrophic calcification of GB has 50% risk of adenocarcinoma
take it out
1° sclerosing cholangitis (PSC): pathophys/presentation? dx? tx? a/w...
thickening of bile duct walls → narrowed lumens → gradual jaundice and pruritus → liver failure, cirrhosis, portal HTN
Dx ERCP (beading of bile ducts)
Tx cholestyramine (helps w/ pruritus), liver txp (definitive)
UC
1° biliary cirrhosis (PBC):
pathophys/presenatition?
tx?
causes of 2° BC?
+anti-mitochondrial antibody → destruction of intrahepatic bile ducts → gradual jaundice and pruritus → liver failure, cirrhosis, portal HTN
screen w/ AMA, confirm w/ liver bx
ursodeoxycholic acid
biliary obstruction, sclerosing cholangitis, cystic fibrosis, or biliary atresia
Cholangiocarcinoma: location? presentation? dx? tx?
bile ducts
s/sx of obstructive jaundice (dark urine, clay stools, pruritus)
Dx ERCP
Tx Whipple if resectable
(MCC US = PSC, MCC China = Chlonorchis sinensis)
Choledochal cysts:
presentation?
dx?
tx?
cystic dilation of biliary tree → RUQ mass/pain, jaundice, fever
Dx ERCP
Tx resection
Biliary stricture:
dx?
complications?
ERCP
2° biliary cirrhosis, acute cholangitis, liver abscess
Biliary dyskinesia =
dx?
tx?
motor dysfxn of sphincter of Oddi → recurrent biliary colic w/o stones
Dx HIDA scan (fill up GB w/ contrast and give CCK to determine ejection fraction)
Tx lap chole
Etiology of pancreatitis
I GET SMASHED – idiopathic, gallstones (#1), EtOH (#2), trauma, steroids, mumps, autoimmune, scorpion sting, hypertriglyceridemia (#3), hypercalcemia, ERCP, drugs
Dx chronic pancreatitis?
stool elastase test
Trousseau phenomenon:
Courvoisier sign:
Trousseau phenomenon: migratory SVT in 10% of pancreatic cancer pts
Courvoisier sign: palpable GB w/o pain in 30% of cancer pts
