Hepatobiliary Part 2 Paulson (Exam 3) Flashcards
_______ is the name for stones within the common bile duct.
Choledocholithiasis
Just like with cholelithiasis, pts with choledocholithiasis (common bile duct) have symptoms of ?
RUQ epigastic pain, nausea, vomiting
What might you see on LFT labs for choledocholithiasis?
Early: AST/ALT elevated
Late: bilirubin, ALP, GGT
What is GGT?
GGT is a liver enzyme used as a diagnostic marker for liver disease. Elevated serum GGT activity can be found in diseases of the liver, biliary system, and pancreas. In this respect, it is similar to alkaline phosphatase (ALP) in detecting disease of the biliary tract.
stones stuck in the common bile duct, as seen with choledocholithiasis, can result in?
Obstructive jaundice
Pancreatitis
Cholangitis (acute/ascending)
What is the first diagnostic tool used when choledocholithiasis is suspected?
US
If high risk for CBD stone, ERCP with stone removal
Pts with acute cholangitis aka ascending cholangitis are usually in bad shape. This is caused by?
Biliary obstruction and bacterial infection
Acute cholangitis aka ascending cholangitis causes a clinical syndrome called Charcot triad: fever, RUQ abd pain, jaundice. Reynold’s pentad is Charcot symptoms plus what two more?
Confusion and hypotension
Acute cholangitis aka ascending cholangitis is usually caused by an obstruction, such as calculi, stenosis, or malignancy. Obstruction causes and increase in intrabiliary pressure, and therefore an increase in _______ of bile ducts, which makes it_______ for bacteria to be transferred from portal circulation into biliary tract.
Permeability
Easier
Jaundice is less common at presentation for acute/ascending cholangitis. Where should you look?
Sclera of eyes and under tongue
What would you expect to find on labs for ascending/acute cholangitis?
- Leukocytosis with neutrophil predominance
- cholestatic pattern LFTs: ^^^ALP, GGT, and mostly conjugated bilirubin (obstructive pattern)
- may have positive bcx
Tokyo guidelines: Diagnosis of acute/ascending cholangitis should be suspected if at least one from each row:
- Fever and or shaking chills, lab evidence of inflammatory response (abnl WBC or ^CRP)
- ?
Jaundice, abnl LFTs
Tokyo guidelines: diagnosis considered definite if pt has either fever, abnl WBC or ^CRP, jaundice, or LFTs, plus what else?
- Biliary dilatation on imaging
- Evidence of an etiology on imaging (structure, stone, stent)
What imaging would you use for acute/ascending cholangitis for patient’s with Charcot’s Triad (fever, RUQ pain, jaundice) and abnl LFT’s?
ERCP: can confirm the diagnosis and also immediately provide biliary drainage
For imaging with suspected acute/ascending cholangitis, if Charcot’s triad of fever, jaundice, and RUQ abd pain is not present, what should you use?
Transabdominal US: looking for CBD dilatation or stones
How do you treat acute/ascending cholangitis with abx?
- Broad spectrum, modify based upon culture results
- 7-10 days
- Pip-tazo is 1st choice
- 2nd choice 3rd gen ceph plus metro (ex: ceftriaxone and metronidazole)
What is the name of the syndrome when the common hepatic duct is obstructed from an extrinsic compression, such as a gallstone?
Mirizzi syndrome
What labs are elevated in Mirizzi syndrome?
ALP and Bilirubin (90%)
How is Mirizzi syndrome diagnosed?
US 1st, followed by ERCP
Tx for Mirizzi syndrome?
Surgery, usually cholecystectomy
What is the name for a progressive hepatic fibrosis, defined histologically by fibrosis and regenerative nodules in the liver?
Cirrhosis
Etiology of liver cirrhosis?
- Alcohol abuse
- Viral hepatitis
- Hemochromatosis (iron overload)
- non-alcoholic fatty liver dz
- autoimmune hepatitis
- meds (MTX, Isoniazid)
- right sided heart failure
- celiac dz
Fibrosis disrupts the normal _____ blood flow, raising the BP and impairs the functioning of the liver.
Portal
Clinical manifestations for cirrhosis?
- JVD
- Caput medusae
- Lower limb edema
- Jaundice
- Spider telangiectasia
- palmar erythema
- Fatigue
- hair loss
- testicular atrophy
- umbilical hernia
- hepatic encephalopathy
- Weight loss
- Anemia of chronic dz
- elevated PT/INR due to loss of clotting factors
- ascites
- gynecomastia
- esophageal varices
- splenomegaly
What is hepatic encephalopathy?
- cognitive deficits, disturbances in sleep pattern, mood changes, bradykinesia, slurred speech, ataxia, coma, asterixis: flapping motion of outstretched, dorsiflexed hands, somnolence (sleepiness)
- ammonia is the best known neurotoxin that precipitates encephalopathy
- DO NOT use ammonia levels to screen asymptomatic pts for HE
What extremity changes can be seen with cirrhosis?
- Muehrcke nails: not specific to cirrhosis; paired white horizontal bands separated by normal color
- Terry nails: proximal 2/3 of nail plate appears white, distal 1/3 is red
- clubbing
- Dupuytren’s contracture: thickening and shortening of palmar fascia causes flexion deformities of the fingers
Lab findings for cirrhosis include moderately elevated AST/ALT, and serum Crea as hepatorenal syndrome develops. What labs are markedly elevated?
- ALP alkaline phosphatase (enzyme) 2-3x ULN
- GGT “gonna get tipsy” (enzyme)
- bilirubin
- PT/INR time (liver makes clotting factors)
What labs for cirrhosis are low?
- Albumin, most abundant protein in blood, created by liver, lack of it causes fluids to leave vessels causing 3rd spacing and edema
- Na/Sodium: hyponatremia common
- cytopenias: thrombocytopenia most common (platelets sequestered in spleen), leukopenia, anemia
What is the “gold standard” for diagnosing liver cirrhosis?
Liver biopsy
When is a liver biopsy for cirrhosis dx not needed?
If clinical presentation, labs, and US data strongly support the presence of cirrhosis and won’t change management
How does a cirrhotic liver appear on US?
- Small and nodular
- “increased echogenicity with irregular appearing areas”
What is another option besides US for diagnosing cirrhosis?
Fibroscan: used for staging of fibrosis; helps determine treatment
Major complications of cirrhosis?
- variceal hemorrhage
- ascites
- spontaneous bacterial peritonitis
- hepatic encephalopathy
- hepatocellular carcinoma
- hepatorenal syndrome
- hepatopulmonary syndrome
How do pts with variceal hemorrhage present?
Hematemesis, melena
What is the screening for esophageal varices, and what typically happens if found?
EGD
Band ligation
What pharmacological steps can you take when varices present?
Non-selective beta blockers (propranolol): lowers portal pressure and decreases risk of bleeding
What is the most common complication of cirrhosis?
Ascites
How is ascites treated?
- Diuretics (spironalactone and furosemide/lasix at ratio of 100:40mg/day)
- Paracentesis
- TIPS (transjugular intrahepatic portosystemic shunts) for pts w/ refractory ascites
- sodium restriction
- alcohol abstinence
Infection of the ascetic fluid causing fever, abd pain and tenderness, and AMS seen in cirrhosis is from what major complication?
Spontaneous bacterial peritonitis.
How do you diagnose spontaneous bacterial peritonitis seen in cirrhosis?
1) ascetic fluid bacterial culture
2) increase in PMN leukocytes >250cells/mm^3
What is the most common bacteria involved with cirrhosis spontaneous bacterial peritonitis?
E coli
Klebsiella
For cirrhosis spontaneous bacterial peritonitis, what broad spectrum abx should you start?
3rd gen cephalosporin (ceftriaxone, cefotaxime)
Those who have previously survived an episode of spont bacterial peritonitis from cirrhosis should have daily abx ppx of what?
Norfloxacin or Bactrim (trimeth/sulfa)
What is the development of renal failure in a patient with advanced liver dz where renal perfusion is decreased by hepatic dysfunction (reduced effective blood volume)?
Hepatorenal syndrome
What is the presence of a pleural effusion in a patient with cirrhosis and no evidence of underlying cardiopulmonary disease, usually right sided, and is treated with diuretics and sodium restriction (thoracentesis if needed)?
Hepatic hydrothorax
What is an abnormal arterial oxygenation caused by intrapulmonary vascular dilatations (IPVDs) in the setting of liver dz, suspected in patients with cirrhosis who have dyspnea, platypnea (SOB, better when supine), and impaired oxygenation?
Hepatopulmonary syndrome
What is the only definitive therapy for hepatopulmonary syndrome?
Liver transplant
Hepatic encephalopathy has many manifestations, including forgetfulness, confusion, and decline in brain function. What is a medication given to help treat HE?
- Lactulose: leads to decreased ammonia in GI tract by binding to it so you poop it out
- Titrate until pt having 2-3 loose stools/day
- can be given as enema
Lactulose is often combined with what abx to treat HE?
Lactulose + Rifamixin
What is the only effective screening/diagnosis plan for Hepatocellular carcinoma?
Serial ultrasound every 6 months
What is the preferred therapy for hepatocellular carcinoma?
Surgical resection (transplant only other curative option)
What should raise your suspicion for hepatocellular carcinoma?
Decompensation in a previously compensated pt
How do you diagnose portopulmonary HTN, where a pt has dyspnea, peripheral edema, chest pain, and syncope?
Echo (confirmed with right heart cath)
What 2 labs do you need to complete a Child-Pugh score for your pt with cirrhosis?
LFT’s and PT/INR
What 5 things are on the Child-Pugh classification that you must enter to get a score?
Ascites, biliruin, albumin, PT/INR, Encephalopathy
What score is used to prioritize patients awaiting liver transplant?
MELD score
What MELD score should you refer patients for liver transplant?
> = 10
Usually a candidate at >=15 though
What 5 things do you need for a MELD score?
Bilirubin Crea INR Na+ Dialyzed twice in last 7 days?
Indications for liver transplant include acute liver failure, cirrhosis w/ complications, some neoplasms, CF, hemochromatosis, and Wilson disease. What are the contraindications?
- Uncorrectable cardiopulmonary dz 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
How long (minimum time) must a pt available for liver transplant with alcoholic liver dz be sober before they can be eligible?
6 months
