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Clin Med semester 2 > Hepatobiliary: Part 2 (Paulson) > Flashcards

Hepatobiliary: Part 2 (Paulson) Flashcards

1
Q

Choledocholithiasis= stones within the ______

A

common bile duct

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2
Q

Choledocholithiasis: -many Pts are symptomatic or asymptomatic?

A

**symptomatic: RUQ or epigastric pain, nausea, vomiting. –Pain often more prolonged that that of typical biliary colic –RUQ or epigastric pain on exam, may be jaundiced

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3
Q

Choledocholithiasis: -Labs that are elevated early on? -Later on?

A

-AST/ALT elevated early -Later, more typical cholestatic pattern of elevation (bilirubin, ALP, and GGT more pronounced than ALT/AST)

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4
Q

What is a cholestatic pattern of elevation?

A

-bilirubin, ALP (alk. phosphatase), and GGT more pronounced than ALT/AST)

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5
Q

Choledocholithiasis can result in cholangitis, obstructive jaundice, and ________

A

pancreatitis

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6
Q

Choledocholithiasis: -1st imaging study? -if high risk for CBD(common bile duct) stone, ____ should follow

A

-Ultrasound 1st, if high risk for CBD stone–> ERCP with stone removal, followed by cholecystectomy (or cholecystectomy with intraoperative cholangiography, followed by ERCP=endoscopic retrograde cholangiopancreatography)

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7
Q

Acute Cholangitis aka ________

A

Ascending Cholangitis

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8
Q

Acute Cholangitis= stasis and infection in the biliary tract causes a clinical syndrome with ____ (which Sx?)

A

fever, jaundice, and abdominal pain

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9
Q

Acute Cholangitis=Biliary obstruction + _________

A

bacterial infection

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10
Q

Acute Cholangitis: -what are the MC causes for biliary obstruction?

A

calculi (kidney stone), stenosis, malignancy

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11
Q

Acute Cholangitis: -obstruction causes increased _____

A

Obstruction causes ↑ intrabiliary pressure –> ↑ permeability of bile ductules –> easier for bacteria to be transferred from portal circulation into biliary tract

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12
Q

Acute Cholangitis: increased pressure also makes it easier for bacteria to go from bile to _____

A

systemic circulation–> septicemia

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13
Q

Acute Cholangitis: -common organisms?

A

E. coli, Klebsiella, Enterobacter. (EEK)

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14
Q

Acute Cholangitis clinical manifestations classic presentations: -Charcot Triad?

A

**Fever, abdominal pain, jaundice

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15
Q

Acute Cholangitis clinical manifestations classic presentations: -Reynold’s Pentad?

A

-Confusion, hypotension, fever, abdominal pain, jaundice –Associated with suppurative cholangitis

CH + FAJ

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16
Q

Acute Cholangitis: -MC presenting symptoms are fever & ______ -____ is a less common at presentation

A

abdominal pain –Pain usually RUQ or diffuse -jaundice less common–> Look in eyes and under tongue 1st

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17
Q

Acute Cholangitis: -older Pts and immunosuppressed may have _____

A

atypical presentation —>Perhaps hypotension only

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18
Q

Acute Cholangitis: Labs?

A

-Leukocytosis with neutrophil predominance -Cholestatic pattern of LFTs ↑ALP, GGT, and bilirubin (mostly conjugated)

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19
Q

Acute Cholangitis: Blood culture?

A
  • May have positive blood cultures –All who are suspected of having cholangitis should have blood cultures –If a patient has ERCP, should also culture bile or a stent that is removed
    (notes: make sure you get blood cultures on all Pts with whom you suspect Acute Cholangitis aka Ascending Cholangitis)
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20
Q

2013 Tokyo Guidelines- Diagnostic Criteria: -diagnosis of acute cholangitis should be suspected if a Pt has:

A

At least 1 from each row:

  • Fever and/or shaking chills, lab evidence of inflammatory response (abnormal WBC or ↑ CRP)
  • Jaundice, abnormal LFTs
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21
Q

2013 Tokyo Guidelines- Diagnostic Criteria: - Diagnosis considered **definite if Pt meets above criteria and also has:

A
  • biliary dilatation on imaging
  • evidence of an etiology on imaging (**stricture, stone, stent)
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22
Q

Acute cholangitis: -Imaging required for Pt’s with Charcot’s triad + abnormal LFTs?

A

ERCP (endoscopic retrograde cholangiopancreatography) –Can confirm the diagnosis and also immediately provide biliary drainage

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23
Q

Acute Cholangitis: -imaging required if Charcot’s triad is NOT present?

A

**Transabdominal ultrasound: –Looking for CBD dilatation or stones: -If seen –> need ERCP within 24 hours for drainage/stone removal -If normal –> MRCP=Magnetic resonance cholangiopancreatography (**might have missed small stones)

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24
Q

Acute Cholangitis: tx

A
  • Admit to hospital:
  • Watch for/manage sepsis
  • Abx: Broad spectrum parenteral abx targeted at colonic bacteria –>Modify based upon culture results
  • Abx for 7-10 days

Biliary drainage: Should happen ASAP** –ERCP is treatment of choice

–Other options: percutaneous transhepatic cholangiography or open surgical decompression

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25
Q

Empiric Abx therapy for gram-negative and anaerobic pathogens for Acute Cholangitis

A
  • Ampicillin-sulbactam
  • Pip-taz
  • Ticarcillin-clavulanate
  • Broad spectrum: Ceftriazone plus metronidazole
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26
Q

Acute Cholangitis: -mortality rate %? -who is at risk for recurrence?

A

-Mortality rates used to be 50—65%, Now 11-20% -Those who develop acute cholangitis from gallstones are at risk for recurrence –Cholecystectomy recommended

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27
Q

Acute cholangitis: -if obstruction is from a benign stenosis, may need _____

A

surgical repair or endoscopic therapy

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28
Q

Acute cholangitis: -malignant stenosis: recurrent _______ is common

A

obstruction -Often need stent placement

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29
Q

Mirizzi Syndrome is common hepatic duct obstruction from ______ compression -Mirizzi syndrome can result from?

A

extrinsic -From an impacted stone in the cystic duct

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30
Q

Mirizzi Syndrome: -MC Sx?

A

most Pts present with jaundice, fever, and RUQ pain

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31
Q

Mirizzi Syndrome: -Labs?

A

↑ALP and bilirubin (90% of patients)

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32
Q

Mirizzi Syndrome: -Diagnosis? (what is first line)

A

Ultrasound 1st, usually followed by ERCP

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33
Q

Mirizzi Syndrome: -Treatment?

A

-Surgery, usually cholecystectomy –If poor candidate, lithotripsy option –Associated with high frequency of bladder cancer

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34
Q

Cirrhosis is progressive ______ fibrosis

A

hepatic

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35
Q

Cirrhosis: histologically defined by _____

A

-fibrosis & regenerative nodules in the liver

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36
Q

Cirrhosis: -How many possible clinical manifestations? -Nonspecific Sx?

A

-Many possible clinical manifestations -Nonspecific Sx: Fatigue, anorexia, weakness, weight loss/wasting

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37
Q

Cirrhosis etiology: -MC causes?

A
  • Alcohol abuse=MC**
  • Chronic viral hepatitis (Hep B and Hep C)
  • Hemochromatosis
  • Nonalcoholic fatty liver disease
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38
Q

Cirrhosis etiology -less common causes?

A
  • Autoimmune hepatitis
  • Primary and secondary biliary cirrhosis
  • Primary sclerosing cholangitis
  • Medications (ie: MTX, isoniazid)
  • Polycystic liver disease -Right-sided heart failure
  • Wilson disease
  • Celiac disease
  • Alpha-1 antitrypsin deficiency
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39
Q

Cirrhosis: -describe the pathophysiology behind this disease process

A

Regardless of cause, fibrosis develops to the point of architectural distortion–> Fibrosis disrupts normal portal blood flow –> raises the blood pressure and impairs the functioning of the liver

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40
Q

Cirrhosis Clinical manifestations: Sx of hepatic dysfunction?

A

-May include: pruritis, jaundice, hematemesis, melena, hematochezia, abdominal distension, confusion, muscle cramps

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41
Q

Hematochezia=

A

passage of fresh blood per anus, usually in or with stools.

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42
Q

Melena=

A

passage of black, tarry stools

43
Q

Cirrhosis: skin findings

  • when is Jaundice seen?
  • Other skin findings: Where are spider angiomas MC found?
A

Jaundice= Yellow coloring of skin, eyes, membranes–> **Usually not seen until bilirubin >2-3 mg/dL

  • Spider angiomata (aka spider telangiectasias)=Vascular lesions –>Most frequently on trunk, face, & upper limbs
  • Palmar erythema–> Usually peripheral over the palm with central pallor
44
Q

Cirrhosis:

  • Chest findings?
  • In Men: loss of ____
A

Gynecomastia: In up to 2/3 of Pts

In men:

  • Loss of chest or axillary hair, inversion of normal male pubic hair pattern
  • & Testicular atrophy
45
Q

Cirrhosis: Ascites

  • How do you test for ascites?
  • flank is ____ to percussion
A

=Abdomen often extremely distended

test for ascites using the **Fluid wave test

-*Flank is dull to percussion

46
Q

Cirrhosis: abdominal findings

-liver palpation–Cirrhotic Liver may be _____ ?

A
  • Cirrhotic liver may be enlarged, normal sized, or small
  • If palpable, generally feels firm and nodular
47
Q

Cirrhosis: abdominal findings

  • ______ is common
  • Caput medusa= ?
  • Describe the murmur associated with Cirrhosis
  • Hernia associated with cirrhosis?
A
  • *Splenomegaly common
  • Caput medusa= dilated veins 2/2 portal HTN
  • **Cruveilhier-Baumgarten murmur= Venous hum that may be auscultated in Pts with portal HTN, best heard over epigastrium
  • *Umbilical hernia (2/2 portal HTN)
48
Q

Cirrhosis: Neurologic findings

-Hepatic encephalopathy is associated with the following Sx:

A

Hepatic encephalopathy:

  • Cognitive deficits & impaired neuromuscular function
  • Disturbances in sleep pattern often initial changes
  • Mood changes, inappropriate behavior, disorientation
  • Somnolence, confusion, unconsciousness
  • Bradykinesia
  • Asterixis= Flapping motion of outstretched, dorsiflexed hands
  • Hyperactive or hypoactive reflexes
  • Slurred speech
  • Nystagmus
  • Ataxia
  • Focal neurologic deficit (**hemiplegia most common)
  • Coma (notes: Liver fx— gets toxins out of body— so with cirrhosis the toxins start building up–> leading to Hepatic encephalopathy

Asterixis= ask Pt to hold their arms out in front of them and their hands start “flapping” (dorsiflexed hands)

49
Q

Hepatic Encephalopathy: ______ is the best known neurotoxin that precipitates encephalopathy

A

-**Ammonia

50
Q

Hepatic encephalopathy:

-are elevated ammonia levels needed to make the Dx of HE?

A

NO! Elevated levels are NOT needed to make diagnosis

  • Not specific for HE
  • Do NOT use to screen asymptomatic patients
51
Q

Cirrhosis: Extremity changes

-change associated w/ nails:

Describe Muehrche nails

Describe Terry nails

A

Muehrcke nails= Paired white horizontal bands separated by normal color

Terry nails= Proximal 2/3 of the nail plate appears white, distal 1/3 is red

52
Q

Cirrhosis: extremity changes

  • Dupuytren’s contracture=
  • other extremity changes?
A

=Thickening & shortening of palmar fascia causes flexion deformities of the fingers

-clubbing

53
Q

Cirrhosis: lab findings

  • AST/ALT are ____
  • ALP is ____
  • GGT levels are _____
  • Bilirubin levels are _____ as cirrhosis progresses
A
  • AST/ALT usually moderately elevated
  • Usually AST more so than ALT
  • ALP usually elevated. <2-3x ULN (upper limits of normal)
  • GGT: Levels usually much higher in cirrhosis caused by alcohol than other causes
  • Bilirubin levels: ↑ as cirrhosis progresses
    (notes: -GGT= much higher in Pts with alcohol abuse problems (GGT= think “gonna get tipsy” (alc causes GGT to leak from liver cells)
54
Q

Cirrhosis: Lab findings

  • albumin levels?
  • PT?
  • Sodium levels?
  • Serum Cr?
A
  • Albumin: ↓ as cirrhosis worsens
  • PT: ↑ as the ability of a cirrhotic liver to make clotting factors ↓
  • Hyponatremia common
  • Serum Cr may ↑ as hepatorenal syndrome develops

(liver is the only organ that makes albumin–> albumin and proteins fx to keep fluid in their cells — decreased albumin leads to 3rd spacing (ascites and pancreatitis)

55
Q

Cirrhosis: lab findings

-what happens with platelet levels?

A

Cytopenias: –>**Thrombocytopenia is MC

-**Leukopenia & anemia develop later

56
Q

Cirrhosis:

-Which diagnostic test is gold standard?

A

**Liver biopsy is gold standard

-Bx not needed if clinical, lab, and radiologic data strongly support the presence of cirrhosis & won’t change management

57
Q

Cirrhosis: other diagnostic tests

  • ultrasound findings?
  • noninvasive tests?
A

Ultrasound:

  • Liver may appear small & nodular
  • Increased echogenicity with irregular appearing areas
  • Noninvasive tests of hepatic fibrosis (ie: FibroScan): Used for staging of fibrosis helps determine treatment
58
Q

Major Complications of Cirrhosis (list 7 ex’s)

A

Variceal hemorrhage

Ascites

Spontaneous bacterial peritonitis

Hepatic Encephalopathy

Hepatocellular carcinoma

Hepatorenal Syndrome

Hepatopulmonary Syndrome

59
Q

Variceal hemorrhage: -varices result from ______

A

portal HTN

60
Q

Variceal Hemorrhage:

-Associated with ____ mortality rates

Pts are asymptomatic until they present with:

A
  • Associated with high mortality rates from bleeding episodes
  • Asymptomatic until present with: Hematemesis, melena
61
Q

All Pts with cirrhosis should undergo screening for varices with _____

A

EGD

62
Q

If variceal Hemorrhages are found, they typically have _____

A

band ligation

63
Q

Variceal Hemorrhage:

-Pharmacologic prevention?

A

-Nonselective beta blockers: lower portal pressure and ↓ risk of bleeding I.e.: propranolol, nadolol

64
Q

What is the MC complication of cirrhosis?

A

**Ascites

65
Q

Ascites is accumulation of fluid in the _____

A

peritoneal cavity

66
Q

Ascites: tx?

  • describe diuretic therapy (specific ratio) ?
  • describe paracentesis (remove how much fluid?)

For larger fluid overload volumes what can be given?

A

**diuretics & sodium restriction, alcohol abstinence= 1st line

-Some may need repeated paracentesis

**Diuretic therapy: Spironolactone + furosemide in a ratio of 100:40 mg/day

Paracentesis: For tense ascites, need to rapidly decompress abdomen–> Remove 4-5L –>For larger volumes, albumin can be given

67
Q

If SAAG is high, what does this indicate?

A

SAAG= serum ascites to albumin gradient

if SAAG is high–> it’s prbly due to portal HTN–> leading to **Ascites

68
Q

Ascites: -describe TIPS?

A

TIPS= Transjugular intrahepatic portosystemic shunts

**TIPS is used for Pts with refractory ascites

(notes: TIPS procedure decreases portal HTN and helps mediate a lot of these issues (ie ascites– it’s a shunt b/w the portal vein and hepatic vein)

69
Q

Spontaneous Bacterial Peritonitis (SBP) is an infection of the _____

A

ascetic fluid

70
Q

Spontaneous Bacterial Peritonitis: Sx?

A

Fever, abdominal pain, abdominal tenderness, and AMS (**confusion)

71
Q

Spontaneous Bacterial Peritonitis: diagnosed with positive _____ &/or increased ______ count

-MC cases are due to which 2 organisms?

A

+ ascetic fluid bacterial culture and/or ↑ polymorphonuclear leukocyte count (≥250 cells/mm3) on eval of ascetic fluid –>**Most cases due to E. coli & Klebsiella

72
Q

Spontaneous Bacterial Peritonitis:

-mortality rate?

A

High mortality without early antibiotic treatment

73
Q

Spontaneous Bacterial Peritonitis: -tx?

A

Start empiric treatment ASAP! Ie: cefotaxime 2 g IV Q8H

-Those who have previously survived an episode should get **daily abx ppx: Norfloxacin or Bactrim

74
Q

Hepatorenal Syndrome= the development of renal failure in a Pt with advanced ______

-describe what happens to renal perfusion

A

liver disease

–>Renal perfusion decreased by hepatic dysfunction (reduced effective blood volume)

75
Q

Hepatorenal Syndrome: -diagnosis?

A

Diagnosis of exclusion when other causes of renal dysfunction have been excluded

76
Q

Hepatic Hydrothorax= presence of ______ ______ in a Pt with cirrhosis and no evidence of underlying cardiopulmonary disease

A

pleural effusion

77
Q

Hepatic Hydrothorax:

  • which side is MC and why
  • Tx?
A
  • **Usually right sided–>From movement of ascites into the pleural space through defects in the diaphragm
  • Tx: diuretics, & sodium restriction –Thoracentesis if needed
78
Q

Hepatopulmonary Syndrome= abnormal arterial oxygenation caused by ______

A

intrapulmonary vascular dilatations (IPVDs) in the setting of liver disease

79
Q

Hepatopulmonary Syndrome: -suspect in Pts with cirrhosis who have _______

A

dyspnea, Platypnea, impaired oxygenation

80
Q

platypnea=

A

SOB that is relieved while lying DOWN

81
Q

Hepatopulmonary Syndrome:

  • imaging studies?
  • what is the ONLY definitive therapy?
A
  • Chest imaging often nonspecific and PFTs often normal
  • Progressive
  • Only definitive therapy is liver transplantation
  • NO effective medical therapies apart from long-term oxygen therapy
82
Q

Hepatic Encephalopathy: address any _________ factors

A

precipitating (hepatic encephalopathy= a decline in brain function that occurs as a result of severe liver disease. In this condition, your liver can’t adequately remove toxins from your blood. This causes a buildup of toxins in your bloodstream, which can lead to brain damage)

83
Q

Hepatic Encephalopathy: Why should Pts be prescribed lactulose?

A

Lactulose–>Leads to decreased ammonia from the GI tract–>Titrate until patient is having 2-3 loose stools/day -Can be given as an enema if patient can’t take PO (notes: you’re trying to get rid of the ammonia in their system, in order to relieve their confusion -lactulose– causes increased pooping (2-3 loose stool per day, in order to get rid of that ammonia) this is why Pts aren’t a fan of this med, may be non compliant)

84
Q

Hepatic Encephalopathy:

-other tx options 2nd to lactulose?

A
  • Nonabsorbable antibiotics (ie **rifaximin)
  • Generally added to lactulose therapy or used in those who can’t tolerate lactulose
  • *Lactulose & rifaximin often combined
  • May have mortality benefit (for Pts taking both meds)
85
Q

Hepatic Encephalopathy:

-those with recurrent HE are given lactulose and Rifaximin as ______

A

prophylaxis

86
Q

Pts with cirrhosis have an INCREASED risk of developing ________ carcinoma

A

hepatocellular carcinoma (HCC)

87
Q

Decompensation in a previously compensated Pt should raise suspicion that ____ may have developed

A

hepatocellular carcinoma (HCC)

88
Q

Hepatocellular Carcinoma:

sx?

labs?

A
  • Usually asymptomatic except for those related to chronic liver disease
  • Some may have upper abdominal pain, weight loss, early satiety, palpable abdominal mass

Labs: usually nonspecific. –May have elevated AFP levels

89
Q

Hepatocellular Carcinoma:

-what is the only effective screening/dx plan?

A

*serial ultrasound every 6 months

90
Q

Hepatocellular Carcinoma: tx?

A
  • *Surgical resection= preferred therapy
  • Liver transplant only other possible curative option
91
Q

Portopulmonary Hypertension=

A

Pulmonary hypertension in patients with portal hypertension

92
Q

Portopulmonary Hypertension: -Sx?

A

May have fatigue, dyspnea, peripheral edema, chest pain, and syncope

93
Q

Portopulmonary Hypertension:

Dx?

tx?

-mortality?

A
  • Dx suggested on echo–> Confirmed with Right heart cath
  • Very difficult to treat with medical therapy

–High perioperative mortality with liver transplantation

94
Q

Cirrhosis: General Management

A
  • **Abstain from alcohol -Substantially improves survival
  • Tx of chronic viral hepatitis
  • Vaccinate against Hepatitis for those not already immune
  • Medication adjustments if needed for hepatic impairment
95
Q

Prognosis for compensated Cirrhosis

A

Median survival >12 years

96
Q

Prognosis for Decompensated Cirrhosis

  • Median survival?
  • MELD score?
A
  • Median survival ≤ 6 months in patients with decompensated cirrhosis and a Child-Pugh score ≥ 12 or -MELD (Model for End-stage Liver Disease) score ≥ 21
  • Those who had been hospitalized with an acute liver-related illness also had a median survival of ≤6 months -

The lower the mean arterial pressure, the worse the survival

97
Q

Child-Pugh Score classification -

A

Classes: A- score of 5-6, and 7-9= class B, score 10-15= class C

-refer Pt to transplant center if score hits 10

Must order: -LFTs (albumin and bilirubin) & PT & INR

98
Q

MELD Score=

-what labs does it require?

A

Model for end stage liver disease Labs: Bilirubin, Creatinine, INR, Sodium, (think CISB)

99
Q

MELD:

-Refer Pts with a score of ____

A

Refer at ≥10

-Usually a candidate for liver transplant at ≥15

100
Q

MELD score also predicts _____

A

outcomes

101
Q

Indications for liver transplantation:

A
  • Acute liver failure (highest priority)
  • Cirrhosis with complication
  • Some neoplasms
  • Liver-based metabolic conditions with systemic manifestations (ie: Wilson disease (systemic dz that effects the liver), CF, hemochromatosis)
102
Q

Contraindications for liver transplantation:

A
  • Uncorrectable cardiopulmonary disease too risky for surgery
  • AIDS
  • Malignancy outside liver not meeting oncologic criteria for cure
  • Uncontrolled sepsis
  • Persistent nonadherence with medical care
  • Lack of adequate social support
103
Q

Alcoholic liver disease requires a minimum abstinence of at least _______

A

6 months

104
Q

šDecompensated cirrhosis:

  • Median survival is _____
  • Child Pugh score _____
  • MELD score ______
  • the lower the _____, the WORSE the survival
A

š-Median survival ≤ 6 months in patients with decompensated cirrhosis

  • Child-Pugh score ≥ 12
  • or MELD (Model for End-stage Liver Disease) score ≥ 21
  • Those who had been hospitalized with an acute liver-related illness also had a median survival of ≤6 months
  • **The lower the mean arterial pressure (MAP), the worse the survival

Clin Med semester 2 (24 decks)

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