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Clin Med II - Exam 3 > Hepatobiliary - Paulson > Flashcards

Hepatobiliary - Paulson Flashcards

1
Q

what is unconjugated bilirubin

A

bilirubin before it gets to the liver

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2
Q

what is conjugated (direct) bilirubin

A

bilirubin combined w. glucoronic acid → becomes soluble → can secrete into bile

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3
Q

how does jaundice manifest (3)

A

clay colored stools

dark-tea colored urine

pruritis

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4
Q

what causes jaundice

A

unconjugated vs conjugated bilirubin not making its way to stool and urine

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5
Q

how does increased unconjugated (indirect) bilirubin occur (3)

A
  1. increased production → hemolytic anemia
  2. decreased uptake of bilirubin by liver → CHF, Gilbert syndrome
  3. decreased conjugation of bilirubin by liver → Crigler-Naijar syndrome, Gilbert syndrome
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6
Q

how does increased conjugated (direct) bilirubin occur (2)

A
  1. any dz that damages liver → hepatitis, toxic induced liver failure, Dubin Johnson syndrome, Rotor syndrome
  2. biliary tree is obstructed → intraphepatic vs extrahepatic
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7
Q

what are the 2 kinds of stones in cholelithiasis

A
  1. cholesterol
  2. pigment stones
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8
Q

90% of gallstones in Western countries are

A

cholesterol

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9
Q

what are the 2 types of pigment stones

A

brown

black

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10
Q

__ stones are associated w. infxn

A

brown

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11
Q

__ stones are associated w. sterile bile (less infxn)

A

black

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12
Q

pe for cholelithiasis will show

A

nothing → normal

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13
Q

what are the 5 f’s for cholesterol stones

A

fat

forty

female

fertile (pregnancy)

fair → white

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14
Q

what % of cholelithiasis is asymptomatic unless obstruction/inflammation

A

80

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15
Q

if cholelithiasis is symptomatic, what are the symptoms (3)

A
  1. intense discomfort in RUQ +/- radiation to shoulder blade
  2. n/v
  3. diaphoresis
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16
Q

sx for gallstones last __

and are often triggered by __

A

30 mins or more

fatty meal

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17
Q

dx for cholelithiasis is usually

A

incidental

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18
Q

what is the gold standard dx for cholelithiasis

A

echo

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19
Q

what will echo for cholelithiasis show

A

echogenic foci that cast acoustic shadow

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20
Q

microlithiasis will have __ appearance on echo

A

sludge

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21
Q

gallstones are __ dependent

A

gravitationally → move w. pt position

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22
Q

are there be lab abnormalities associated w. cholelithiasis

A

no

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23
Q

how do you tx asymptomatic cholelithiasis

A

you don’t

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24
Q

how do you tx cholelithiasis positive for typical biliary symptoms (2)

A

NSAIDs or opioids for acute attack

cholecystectomy

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25
how do you tx cholelithiasis positive for atypical sx (2)
no cholecystectomy further work up
26
cholelithiasis with typical biliary sx but no stones is concerning for
gallbladder d.o
27
what are the symptoms of acute cholecystitis (6)
RUQ pain leukocytosis fever ill appearing +/- n/v +/- hx fatty meal
28
what are the 2 types of acute cholecystitis
calculous acalculous
29
calculous acute cholecystitis is caused by __ obstruction by stone
cystic duct
30
what are the 4 pathogens associated with acute calculous cholecystitis
e.coli klebsiella strep c.diff
31
which type of acute cholecystitis is mc
calculous
32
acalculous acute cholecystitis is associated w.
severe underlying illness
33
what are 4 pt populations associated w. acalculous acute cholecystitis
critically ill bedridden elderly TPN
34
pe for acute cholecystitis might show (6)
tachycardia voluntary/involuntary guarding of abd rebound tenderness RUQ RUQ ttp (+) murphy sign +/- palpable liver
35
what is murphy's sign
36
labs for acute cholecystitis will show (2)
leukocytosis w. left shift +/- elevated LFTs
37
diagnostic test for acute cholecystitis
US
38
what will US for acute cholecystitis show
gallbladder wall thickening/edema +/- pericholecystic fluid and dilation of bile duct
39
is cholelithiasis diagnostic of acute cholecystitis
no *but it supports diagnosis*
40
what test is more reliable than a positive murphy sign during pe
sonographic murphy sign
41
what test should you order if US for acute cholecystitis is unclear
HIDA (hepatibiliary iminodiacetic acid)
42
HIDA for acute cholecystitis is (+) if
gallbladder is not visualized
43
tx for acute cholecystitis (3)
pain control → NSAIDs vs opioids abx until resolution OR cholecystectomy cholecystectomy vs cholecystotomy
44
abx for acute cholecystitis
cephalosporins vs carbapenems
45
indications for emergency cholecystectomy rt acute cholecystitis (2)
progressive sx → fever, hemodynamically unstable, intractable pain suspicion for gallbladder gangrene or perf
46
cholecystecomy for a low risk pt w. acute cholecystitis should be
lap chole during admit
47
for non-emergent pt's w. acute cholecystitis where risk \> benefit for cholecystectomy, how should you proceed
1. gallbladder drainage w. percutaneous cholecystotomy → resolves acute episode in 90% 2. once acute episode is resolved → reassess risk for surgery → schedule elective cholecystectomy if possible
48
mc complication of untreated acute cholecystitis
gangrenous cholecystitis
49
3 other complications of acute cholecystitis (besides gangrenous cholecystitis)
perforation → abscess or peritonitis cholecystoenteric fistula emphasematous cholecystitis
50
mc complaint in chronic cholecystitis
biliary colic
51
what hepatobiliary condition has questionable clinical significance
chronic cholecystitis
52
chronic cholecystitis is almost always associated w.
stones
53
what will US for chronic cholesystitis show
cholelithiasis w. wall thickening from scarring
54
tx for chronic cholecystitis
cholecystecomy
55
95% of porcelain gallbladder cases are associated w.
cholelithiasis
56
why do we care about porcelain gallbladder
increased risk for gallbladder carcinoma
57
symptoms for porcelain gallbladder
asymptomatic!
58
porcelain gallbladder is usually diagnosed
incidentally
59
what tests can confirm dx of porcelain gallbladder
US CT
60
tx for porcelain gallbladder
referral for resection dt increased risk for gallbladder carcinoma
61
what is porcelain gallbladder
calcification of gallbladder wall
62
what is choledocholithiasis
stones w.in common bile duct
63
can choledocholithiasis occur in a pt w.o a gallbladder
yes! → stones get stuck in common bile duct
64
choledocholithiasis may be asymptomatic; if not, symptoms include (3)
RUQ pain epigastric pain n/v
65
what will early and late labs show for choledocholithiasis
**early:** AST/ALT elevations **later:** bilirubin, ALT, GGT more pronounced
66
dx and tx for choledocholithiasis
dx: US tx: cholecystectomy
67
what is acute cholangitis - ascending cholangitis
stasis/infxn in biliary tract biliary obstruction PLUS bacterial infxn
68
why is it called ascending cholangitis
bacteria migrate from duodenum into common bile duct
69
what are 3 common pathogens associated w. acute cholangitis/ascending cholangitis
e.coli klebsiella enterobacter
70
what is charcot triad and what is it associated w.
fever abd pain jaundice **acute cholangitis/ascending cholangitis**
71
what is reynold's pentad and what is it associated w.
confusion hypotn fever abd pain jaundice **acute cholangitis/ascending cholangitis**
72
\_\_ will be much more elevated than \_\_ and \_\_ in acute cholangitis/ascending cholangitis
ALP much more elevated than ALT and AST
73
besides LFTs, what other labs will be elevated in acute cholangitis/ascending cholangitis
GGT bilirubin
74
mc 2 symptoms for acute/ascending cholangitis
fever abd pain → RUQ or diffuse
75
\_\_ is less common in acute/ascending cholangitis, so you should look \_\_ (2)
jaundice eyes, under tongue
76
older/immune compromised pt's may have an atypical presentation for acute/ascending cholangitis; __ may be the only symptom
hypotn
77
labs for acute/ascending cholangitis will show
leukocytosis w. neutrophil predominance increased ALP, GGP, and bilirubin (mostly unconjugated)
78
what is the cholestatic pattern of LFTs
increased ALP, GGT, and bilirubin (mostly conjugated)
79
all who are suspected of having cholangitis should have
blood cultures
80
if a pt w. cholangitis has ercp, you should also culture (2)
bile a stent that is removed
81
in the tokyo diagnostic guidelines for cholangitis, dx should be suspected if a pt has at least one from each row
1. fever and/or shaking chills, lab evidence of inflammatory response → abnormal WBC or increased CRP 2. jaundice, abnormal LFTs
82
in tokyo guidelines for cholangitis, dx is considered definite if a pt meets suspected criteria AND also has
biliary dilation on imaging e.o etiology on imaging → stricture, stone, stent
83
in tokyo guidelines for cholangitis, a pt must meet one __ criteria, PLUS one __ criteria
suspected definitive
84
who should get an ercp test for cholangitis
pt's w. charcot's triad PLUS abnormal LFTs
85
ercp can confirm dx of cholangitis and also
immediately provide biliary drainage
86
what is ercp
endoscopic retrograde cholangiopancreatography
87
if charcot's triad is not present in a pt w. cholangitis, what test should you order
transabdominal US
88
what will transabdominal US for cholangitis show
CBD dilation or stones
89
if transabdominal US for cholangitis is positive what should you order
ercp w.in 24 hr for drainage/stone removal
90
if transabdominal us for cholangitis is normal, what should you order
mrcp (magnetic resonance cholangiopancreatography) → *might have missed small stones*
91
steps in dx for pt w. cholangitis w.o charcot's triad
1. **transabdominal US** 2. if (+) for CBD dilation or stones → **ercp** w.in 24 hr 3. if (-) for CBD dilation or stones → **mrcp**
92
tx for cholangitis (4)
1. admit 2. watch for/manage sepsis 3. abx 4. biliary drainage **ASAP**
93
abx for cholangitis
1. broad spectrum or parenteral abx targeted at colonic bacteria → **unasyn/zosyn, ceftriaxone + metronidazole** 2. modify based on culture 3. duration: 7-10 days
94
tx of choice for biliary drainage
ercp
95
besides ercp, other options for biliary drainage for cholangitis
percutaneous transhepatic cholangiography open surgical decompression
96
\_\_ is recommended for pt's who develop cholangitis dt stones
risk for recurrence → cholecystectomy
97
if cholangitis from benign obstruction, pt's may need
surgical repair OR endoscopic therapy
98
if cholangitis from malignant stenosis pt's often need
stent placement
99
what is mirizzi syndrome
common hepatic bile duct obstruction from impacted stone in cystic duct
100
mirizzi syndrome has an association w.
bladder ca
101
symptoms of mirizzi syndrome (3)
jaundice fever RUQ
102
90% of pt's w. mirizzi syndrome have what 2 lab abnormalities
elevated ALP and bilirubin
103
dx for mirizzi syndrome (2)
US then ESRP
104
tx for mirizzi syndrome
cholecystecomy
105
what is cirrhosis
progressive hepatic fibrosis → leading to portal htn
106
4 rf for cirrhosis
etoh hepatitis NAFLD celiac *lots more*
107
⅔ of male pt's w. cirrhosis will have
gynecomastia
108
pe for cirrhosis often shows (7)
palpable liver flank dull to percussion **fluid wave** splenomegaly caput medusa cruveihier-baumgarten murmur umbilical hernia
109
nonspecific symptoms rt cirrhosis (4)
fatigue anorexia weakness wt loss/wasting
110
liver dysfxn rt cirrhosis causes (4)
**pruritis** jaundice hematemesis melena
111
skin symptoms rt cirrhosis (3)
jaundice spider angioma/tenalngiectasia palmar erythema
112
jaundice is seen in cirrhosis when bilirubin is \>
2-3 mg/dL
113
abdominal sx of cirrhosis
ascites
114
symptoms of hepatic encephalopathy (6)
cognitive deficits or neuromuscular function disturbances in sleep pattern mood changes/inappropriate behavior somnalence, confusion, unconsciousness bradykinesia asterixis
115
what is asterixis
flopping motion of outstretched, dorsiflexed hands
116
what is a common initial presentation of hepatic encephalopathy
disturbance in sleep pattern
117
besides gynecomastia, men w. cirrhosis might also have (3)
loss of chest/axillary hair inversion of normal male pubic hair pattern testicular atrophy
118
in terms of pe, cirrhotic liver may be
enlarged normal sized small
119
best known neurotixin that precipitates encephalopathy
ammonia
120
is ammonia needed to dx cirrhosis
no!
121
should ammonia be used to screen for cirrhosis
no!
122
what nail changes are associated w. cirrhosis
muehrcke nails terry nails
123
what are muehrcke nails
paired white horizontal bands separated by normal color
124
what are terry nails
proximal ⅔ of nail plate appears white distal ⅓ is red clubbing dupuytren's contracture
125
what is dupuytren's contracture
thickening and shortening of palmar fascia → causes flexion deformities of fingers
126
lab findings for cirrhosis
**elevated:** AST/ALT/ALP/GGT, bilirubin, PT, Cr **decreased:** Na, albumin, cytopenias
127
in cirrhosis, __ is usually more elevated than \_\_
AST more elevated than ALT
128
what lab value is much higher in cirrhosis r.t etoh
GGT
129
in cirrhosis, ALP is usually elevated \<
less than 2-3x ULN
130
mc cytopenia in cirrhosis
thrombocytopenia
131
which 2 cytopenias develop later in cirrhosis
leukopenia anemia
132
gold standard for dx of cirrhosis
liver bx
133
bx for cirrhosis is not needed if __ strongly support dx (3), and bx won't change management
clinical lab radiologic
134
US for cirrhosis may show
small, nodular liver increased echogenicity w. irregular appearing areas
135
ex of noninvasive test of hepatic fibrosis
FibroScan
136
FibroScan is used for (2)
staging of fibrosis → helps determine tx
137
major complications of cirrhosis (7)
variceal hemorrhage ascites spontaneous bacterial peritonitis (SBP) hepatic encephalopathy hepatocellular carcinoma hepatorenal syndrome hepatopulmonary syndrome
138
variceal hemorrhages result from
portal htn
139
variceal hemorrhages are associated w. \_\_ and are asymptomatic until present w __ (2)
high mortality rates → bleeding episodes hematemesis, melena
140
all pt's w. cirrhosis should be screened for variceal hemorrhage using
EGD
141
if variceal hemorrhages are found on EGD, what procedure is performed
variceal band ligation
142
pharm prevention for variceal hemorrhage
nonselective beta blockers → **propranolol, nadolol**
143
mc complication of cirrhosis
ascites
144
tx for ascites (4)
diuretics Na restriction etoh abstinence!!! +/- repeated paracentesis
145
diuretic therapy for ascites
spironolactone PLUS furosemide in a ratio of 100:40 mg/day
146
fluid removal goal for paracentesis for ascites
4-5 L
147
if more than 4-5 L of fluid is removed during during paracentesis, __ should be given
albumin
148
what is SAAG
serum ascites albumin gradient → determines if pt has portal htn
149
tx for pt w. refractory ascites
TIPS → transjugular intrahepatic portosystemic shunt
150
SBP is caused by
infxn of ascetic fluid
151
symptoms of sbp (4)
fever abd pain abd tenderness ams
152
dx for sbp
ascetic fluid bacterial culture AND/OR elevated PMN leukocyte count
153
value for polymorphonuclear leukocyte count for sbp dx
250 cells/mm3 or higher
154
2 mc pathogens related to sbp
e.coli kelbsiella
155
tx for sbp
empiric abx **asap!**
156
empiric abx choices for sbp
cefotaxamine 2 g iv q8h
157
pt's who have previously survived sbp need
prophylactic abx tx indefinitely → norfloxacin or bactrim
158
what is hepatorenal syndrome
renal failure in pt w. advanced liver dz → renal perfusion decreased by hepatic dysfxn
159
hepatorenal syndrome causes
reduced blood volume
160
hepatorenal syndrome is a dx of
exclusion → when other causes of renal dysfxn have been r.o
161
presence of pleural effusion in pt w. cirrhosis and n.e of underlying cardiopulmonary dz
hepatic hydrothorax
162
hepatic hydrothorax is usually __ sided
right
163
hepatic hydrothorax is caused by
movement of ascites into pleural space thru deficits in diaphragm
164
tx for hepatic hydrothorax (3)
diuretics Na restriction +/- thoracentesis
165
abnormal arterial oxygenation 2/2 to intrapulmonary vascular dilations (IPVDs) in setting of liver dz
hepatopulmonary syndrome
166
you should suspect hepatopulmonary syndrome in pt who have (3)
dyspnea platypnea impaired oxygenation
167
what is platypnea
SOB worse w. sitting up
168
chest imaging and PFTs in pt w. hepatopulmonary syndrome are often
normal
169
only definitive tx for hepatopulmonary syndrome
liver transplant
170
only effective supportive tx for hepatopulmonary syndrome
long term O2
171
pharm for hepatic encephalopathy (2)
lactulose nonabsorbable abx → **rifamixin**
172
lactulose should be titrated until pt is having
2-3 loose stools/day
173
methods of administration for lactulose
PO enema
174
when is rifamixin used for hepatic encephalopathy (2)
added to lactulose OR used in pt who can't tolerate lactulose
175
what pharm tx might have mortality benefit in hepatic encephalopathy
lactulose PLUS rifamixin
176
pt's w. recurrent hepatic encephalopathy should be given what prophylactic pharm
lactulose PLUS rifamixin
177
sx of hepatocellular carcinoma
decompensation of cirrhosis in previously compensated pt
178
hcc is usually asymptomatic outside of cirrhosis symptoms; but some pt may have
upper abd pain wt loss early satiety palpable abd mass
179
labs for hcc are usually \_\_ but may include elevated \_\_
nonspecific AFP
180
only effective screening/dx for hcc
serial us q 6 mo
181
preferred tx for hcc
surgical resection
182
only possible curative tx for hcc
liver transplant
183
what is portopulmonary htn
pulmonary htn in pt. w. portal htn
184
possible sx of portopulmonary htn
fatigue dyspnea peripheral edema cp syncope
185
dx for portopulmonary htn is suggested on \_\_ and confirmed with \_\_
echo right heart cath
186
pt w. portopulmonary htn have high mortality rates w.
liver transplant
187
general management for cirrhosis (4)
**abstain from etoh!!** tx of chronic viral hepatitis vaccinate against hepatitis if not already immune med adjustments if needed for hepatic impairment
188
median survival is 6 months or less in pt with decompensated cirrhosis and a child-pugh score __ or higher OR meld score __ or higher
child-pugh: 12 or higher meld: 21 or higher
189
besides child-pugh and meld scores, what is another prognostic factor of 6 months or less for decompensated cirrhosis
hospitalization w. acute liver-related illness
190
poor prognosis for decompensated cirrhosis is related to decreased __ pressure
mean arterial
191
child-pugh score evaluates (5)
ascites bilirubin albumin PT encephalopathy
192
which cirrhosis score is used to prioritize pt awaiting liver transplant
meld
193
pt's with a meld score __ or higher are referred for transplant, and are usually a candidate at __ or higher
**referred:** 10 **candidate:** 15
194
what factors does the meld score evaluate (4)
bilirubin creatinine INR Na
195
which score predicts outcomes
meld
196
highest priority for liver transplant consideration
acute liver failure
197
4 indications for liver transplant (4)
acute liver failure cirrhosis w. complication some neoplasms liver based metabolic conditions w. systemic manifestations
198
what are examples of liver-based metabolic conditions w. systemic manifestations (3)
wilson dz CF hemochromatosis
199
contraindications for liver transplant (7)
uncorrectable cardiopulmonary dz → too risky for surgery AIDS malignancy outside liver not meeting oncologic criteria for cure uncontrolled sepsis persistent nonadherence w. medical care lack of adequate social support

Clin Med II - Exam 3 (14 decks)

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