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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
Q

how do you tx cholelithiasis positive for atypical sx (2)

A

no cholecystectomy

further work up

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26
Q

cholelithiasis with typical biliary sx but no stones is concerning for

A

gallbladder d.o

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27
Q

what are the symptoms of acute cholecystitis (6)

A

RUQ pain

leukocytosis

fever

ill appearing

+/- n/v

+/- hx fatty meal

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28
Q

what are the 2 types of acute cholecystitis

A

calculous

acalculous

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29
Q

calculous acute cholecystitis is caused by __ obstruction by stone

A

cystic duct

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30
Q

what are the 4 pathogens associated with acute calculous cholecystitis

A

e.coli

klebsiella

strep

c.diff

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31
Q

which type of acute cholecystitis is mc

A

calculous

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32
Q

acalculous acute cholecystitis is associated w.

A

severe underlying illness

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33
Q

what are 4 pt populations associated w. acalculous acute cholecystitis

A

critically ill

bedridden

elderly

TPN

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34
Q

pe for acute cholecystitis might show (6)

A

tachycardia

voluntary/involuntary guarding of abd

rebound tenderness RUQ

RUQ ttp

(+) murphy sign

+/- palpable liver

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35
Q

what is murphy’s sign

A
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36
Q

labs for acute cholecystitis will show (2)

A

leukocytosis w. left shift

+/- elevated LFTs

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37
Q

diagnostic test for acute cholecystitis

A

US

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38
Q

what will US for acute cholecystitis show

A

gallbladder wall thickening/edema

+/- pericholecystic fluid and dilation of bile duct

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39
Q

is cholelithiasis diagnostic of acute cholecystitis

A

no

but it supports diagnosis

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40
Q

what test is more reliable than a positive murphy sign during pe

A

sonographic murphy sign

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41
Q

what test should you order if US for acute cholecystitis is unclear

A

HIDA (hepatibiliary iminodiacetic acid)

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42
Q

HIDA for acute cholecystitis is (+) if

A

gallbladder is not visualized

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43
Q

tx for acute cholecystitis (3)

A

pain control → NSAIDs vs opioids

abx until resolution OR cholecystectomy

cholecystectomy vs cholecystotomy

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44
Q

abx for acute cholecystitis

A

cephalosporins vs carbapenems

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45
Q

indications for emergency cholecystectomy rt acute cholecystitis (2)

A

progressive sx → fever, hemodynamically unstable, intractable pain

suspicion for gallbladder gangrene or perf

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46
Q

cholecystecomy for a low risk pt w. acute cholecystitis should be

A

lap chole during admit

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47
Q

for non-emergent pt’s w. acute cholecystitis where risk > benefit for cholecystectomy, how should you proceed

A
  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
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48
Q

mc complication of untreated acute cholecystitis

A

gangrenous cholecystitis

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49
Q

3 other complications of acute cholecystitis (besides gangrenous cholecystitis)

A

perforation → abscess or peritonitis

cholecystoenteric fistula

emphasematous cholecystitis

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50
Q

mc complaint in chronic cholecystitis

A

biliary colic

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51
Q

what hepatobiliary condition has questionable clinical significance

A

chronic cholecystitis

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52
Q

chronic cholecystitis is almost always associated w.

A

stones

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53
Q

what will US for chronic cholesystitis show

A

cholelithiasis w. wall thickening from scarring

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54
Q

tx for chronic cholecystitis

A

cholecystecomy

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55
Q

95% of porcelain gallbladder cases are associated w.

A

cholelithiasis

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56
Q

why do we care about porcelain gallbladder

A

increased risk for gallbladder carcinoma

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57
Q

symptoms for porcelain gallbladder

A

asymptomatic!

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58
Q

porcelain gallbladder is usually diagnosed

A

incidentally

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59
Q

what tests can confirm dx of porcelain gallbladder

A

US

CT

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60
Q

tx for porcelain gallbladder

A

referral for resection dt increased risk for gallbladder carcinoma

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61
Q

what is porcelain gallbladder

A

calcification of gallbladder wall

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62
Q

what is choledocholithiasis

A

stones w.in common bile duct

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63
Q

can choledocholithiasis occur in a pt w.o a gallbladder

A

yes! → stones get stuck in common bile duct

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64
Q

choledocholithiasis may be asymptomatic; if not, symptoms include (3)

A

RUQ pain

epigastric pain

n/v

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65
Q

what will early and late labs show for choledocholithiasis

A

early: AST/ALT elevations

later: bilirubin, ALT, GGT more pronounced

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66
Q

dx and tx for choledocholithiasis

A

dx: US
tx: cholecystectomy

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67
Q

what is acute cholangitis - ascending cholangitis

A

stasis/infxn in biliary tract

biliary obstruction PLUS bacterial infxn

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68
Q

why is it called ascending cholangitis

A

bacteria migrate from duodenum into common bile duct

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69
Q

what are 3 common pathogens associated w. acute cholangitis/ascending cholangitis

A

e.coli

klebsiella

enterobacter

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70
Q

what is charcot triad and what is it associated w.

A

fever

abd pain

jaundice

acute cholangitis/ascending cholangitis

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71
Q

what is reynold’s pentad and what is it associated w.

A

confusion

hypotn

fever

abd pain

jaundice

acute cholangitis/ascending cholangitis

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72
Q

__ will be much more elevated than

__ and

__ in acute cholangitis/ascending cholangitis

A

ALP much more elevated than ALT and AST

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73
Q

besides LFTs, what other labs will be elevated in acute cholangitis/ascending cholangitis

A

GGT

bilirubin

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74
Q

mc 2 symptoms for acute/ascending cholangitis

A

fever

abd pain → RUQ or diffuse

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75
Q

__ is less common in acute/ascending cholangitis, so you should look

__ (2)

A

jaundice

eyes, under tongue

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76
Q

older/immune compromised pt’s may have an atypical presentation for acute/ascending cholangitis; __ may be the only symptom

A

hypotn

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77
Q

labs for acute/ascending cholangitis will show

A

leukocytosis w. neutrophil predominance

increased ALP, GGP, and bilirubin (mostly unconjugated)

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78
Q

what is the cholestatic pattern of LFTs

A

increased ALP, GGT, and bilirubin (mostly conjugated)

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79
Q

all who are suspected of having cholangitis should have

A

blood cultures

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80
Q

if a pt w. cholangitis has ercp, you should also culture (2)

A

bile

a stent that is removed

81
Q

in the tokyo diagnostic guidelines for cholangitis, dx should be suspected if a pt has at least one from each row

A
  1. fever and/or shaking chills, lab evidence of inflammatory response → abnormal WBC or increased CRP
  2. jaundice, abnormal LFTs
82
Q

in tokyo guidelines for cholangitis, dx is considered definite if a pt meets suspected criteria AND also has

A

biliary dilation on imaging

e.o etiology on imaging → stricture, stone, stent

83
Q

in tokyo guidelines for cholangitis, a pt must meet one __ criteria,

PLUS

one __ criteria

A

suspected

definitive

84
Q

who should get an ercp test for cholangitis

A

pt’s w. charcot’s triad PLUS abnormal LFTs

85
Q

ercp can confirm dx of cholangitis and also

A

immediately provide biliary drainage

86
Q

what is ercp

A

endoscopic retrograde cholangiopancreatography

87
Q

if charcot’s triad is not present in a pt w. cholangitis, what test should you order

A

transabdominal US

88
Q

what will transabdominal US for cholangitis show

A

CBD dilation or stones

89
Q

if transabdominal US for cholangitis is positive what should you order

A

ercp w.in 24 hr for drainage/stone removal

90
Q

if transabdominal us for cholangitis is normal, what should you order

A

mrcp (magnetic resonance cholangiopancreatography) → might have missed small stones

91
Q

steps in dx for pt w. cholangitis w.o charcot’s triad

A
  1. transabdominal US
  2. if (+) for CBD dilation or stones → ercp w.in 24 hr
  3. if (-) for CBD dilation or stones → mrcp
92
Q

tx for cholangitis (4)

A
  1. admit
  2. watch for/manage sepsis
  3. abx
  4. biliary drainage ASAP
93
Q

abx for cholangitis

A
  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
Q

tx of choice for biliary drainage

A

ercp

95
Q

besides ercp, other options for biliary drainage for cholangitis

A

percutaneous transhepatic cholangiography

open surgical decompression

96
Q

__ is recommended for pt’s who develop cholangitis dt stones

A

risk for recurrence → cholecystectomy

97
Q

if cholangitis from benign obstruction, pt’s may need

A

surgical repair OR endoscopic therapy

98
Q

if cholangitis from malignant stenosis pt’s often need

A

stent placement

99
Q

what is mirizzi syndrome

A

common hepatic bile duct obstruction from impacted stone in cystic duct

100
Q

mirizzi syndrome has an association w.

A

bladder ca

101
Q

symptoms of mirizzi syndrome (3)

A

jaundice

fever

RUQ

102
Q

90% of pt’s w. mirizzi syndrome have what 2 lab abnormalities

A

elevated ALP and bilirubin

103
Q

dx for mirizzi syndrome (2)

A

US then ESRP

104
Q

tx for mirizzi syndrome

A

cholecystecomy

105
Q

what is cirrhosis

A

progressive hepatic fibrosis → leading to portal htn

106
Q

4 rf for cirrhosis

A

etoh

hepatitis

NAFLD

celiac

lots more

107
Q

⅔ of male pt’s w. cirrhosis will have

A

gynecomastia

108
Q

pe for cirrhosis often shows (7)

A

palpable liver

flank dull to percussion

fluid wave

splenomegaly

caput medusa

cruveihier-baumgarten murmur

umbilical hernia

109
Q

nonspecific symptoms rt cirrhosis (4)

A

fatigue

anorexia

weakness

wt loss/wasting

110
Q

liver dysfxn rt cirrhosis causes (4)

A

pruritis

jaundice

hematemesis

melena

111
Q

skin symptoms rt cirrhosis (3)

A

jaundice

spider angioma/tenalngiectasia

palmar erythema

112
Q

jaundice is seen in cirrhosis when bilirubin is >

A

2-3 mg/dL

113
Q

abdominal sx of cirrhosis

A

ascites

114
Q

symptoms of hepatic encephalopathy (6)

A

cognitive deficits or neuromuscular function

disturbances in sleep pattern

mood changes/inappropriate behavior

somnalence, confusion, unconsciousness

bradykinesia

asterixis

115
Q

what is asterixis

A

flopping motion of outstretched, dorsiflexed hands

116
Q

what is a common initial presentation of hepatic encephalopathy

A

disturbance in sleep pattern

117
Q

besides gynecomastia, men w. cirrhosis might also have (3)

A

loss of chest/axillary hair

inversion of normal male pubic hair pattern

testicular atrophy

118
Q

in terms of pe, cirrhotic liver may be

A

enlarged

normal sized

small

119
Q

best known neurotixin that precipitates encephalopathy

A

ammonia

120
Q

is ammonia needed to dx cirrhosis

A

no!

121
Q

should ammonia be used to screen for cirrhosis

A

no!

122
Q

what nail changes are associated w. cirrhosis

A

muehrcke nails

terry nails

123
Q

what are muehrcke nails

A

paired white horizontal bands separated by normal color

124
Q

what are terry nails

A

proximal ⅔ of nail plate appears white

distal ⅓ is red

clubbing

dupuytren’s contracture

125
Q

what is dupuytren’s contracture

A

thickening and shortening of palmar fascia → causes flexion deformities of fingers

126
Q

lab findings for cirrhosis

A

elevated: AST/ALT/ALP/GGT, bilirubin, PT, Cr

decreased: Na, albumin, cytopenias

127
Q

in cirrhosis, __ is usually more elevated than

__

A

AST more elevated than ALT

128
Q

what lab value is much higher in cirrhosis r.t etoh

A

GGT

129
Q

in cirrhosis, ALP is usually elevated <

A

less than 2-3x ULN

130
Q

mc cytopenia in cirrhosis

A

thrombocytopenia

131
Q

which 2 cytopenias develop later in cirrhosis

A

leukopenia

anemia

132
Q

gold standard for dx of cirrhosis

A

liver bx

133
Q

bx for cirrhosis is not needed if __ strongly support dx (3),

and bx won’t change management

A

clinical

lab

radiologic

134
Q

US for cirrhosis may show

A

small, nodular liver

increased echogenicity w. irregular appearing areas

135
Q

ex of noninvasive test of hepatic fibrosis

A

FibroScan

136
Q

FibroScan is used for (2)

A

staging of fibrosis →

helps determine tx

137
Q

major complications of cirrhosis (7)

A

variceal hemorrhage

ascites

spontaneous bacterial peritonitis (SBP)

hepatic encephalopathy

hepatocellular carcinoma

hepatorenal syndrome

hepatopulmonary syndrome

138
Q

variceal hemorrhages result from

A

portal htn

139
Q

variceal hemorrhages are associated w. __

and are asymptomatic until present w __ (2)

A

high mortality rates → bleeding episodes

hematemesis, melena

140
Q

all pt’s w. cirrhosis should be screened for variceal hemorrhage using

A

EGD

141
Q

if variceal hemorrhages are found on EGD, what procedure is performed

A

variceal band ligation

142
Q

pharm prevention for variceal hemorrhage

A

nonselective beta blockers → propranolol, nadolol

143
Q

mc complication of cirrhosis

A

ascites

144
Q

tx for ascites (4)

A

diuretics

Na restriction

etoh abstinence!!!

+/- repeated paracentesis

145
Q

diuretic therapy for ascites

A

spironolactone PLUS furosemide in a ratio of 100:40 mg/day

146
Q

fluid removal goal for paracentesis for ascites

A

4-5 L

147
Q

if more than 4-5 L of fluid is removed during during paracentesis, __ should be given

A

albumin

148
Q

what is SAAG

A

serum ascites albumin gradient → determines if pt has portal htn

149
Q

tx for pt w. refractory ascites

A

TIPS → transjugular intrahepatic portosystemic shunt

150
Q

SBP is caused by

A

infxn of ascetic fluid

151
Q

symptoms of sbp (4)

A

fever

abd pain

abd tenderness

ams

152
Q

dx for sbp

A

ascetic fluid bacterial culture

AND/OR

elevated PMN leukocyte count

153
Q

value for polymorphonuclear leukocyte count for sbp dx

A

250 cells/mm3 or higher

154
Q

2 mc pathogens related to sbp

A

e.coli

kelbsiella

155
Q

tx for sbp

A

empiric abx asap!

156
Q

empiric abx choices for sbp

A

cefotaxamine 2 g iv q8h

157
Q

pt’s who have previously survived sbp need

A

prophylactic abx tx indefinitely → norfloxacin or bactrim

158
Q

what is hepatorenal syndrome

A

renal failure in pt w. advanced liver dz → renal perfusion decreased by hepatic dysfxn

159
Q

hepatorenal syndrome causes

A

reduced blood volume

160
Q

hepatorenal syndrome is a dx of

A

exclusion → when other causes of renal dysfxn have been r.o

161
Q

presence of pleural effusion in pt w. cirrhosis and n.e of underlying cardiopulmonary dz

A

hepatic hydrothorax

162
Q

hepatic hydrothorax is usually __ sided

A

right

163
Q

hepatic hydrothorax is caused by

A

movement of ascites into pleural space thru deficits in diaphragm

164
Q

tx for hepatic hydrothorax (3)

A

diuretics

Na restriction

+/- thoracentesis

165
Q

abnormal arterial oxygenation 2/2 to intrapulmonary vascular dilations (IPVDs) in setting of liver dz

A

hepatopulmonary syndrome

166
Q

you should suspect hepatopulmonary syndrome in pt who have (3)

A

dyspnea

platypnea

impaired oxygenation

167
Q

what is platypnea

A

SOB worse w. sitting up

168
Q

chest imaging and PFTs in pt w. hepatopulmonary syndrome are often

A

normal

169
Q

only definitive tx for hepatopulmonary syndrome

A

liver transplant

170
Q

only effective supportive tx for hepatopulmonary syndrome

A

long term O2

171
Q

pharm for hepatic encephalopathy (2)

A

lactulose

nonabsorbable abx → rifamixin

172
Q

lactulose should be titrated until pt is having

A

2-3 loose stools/day

173
Q

methods of administration for lactulose

A

PO

enema

174
Q

when is rifamixin used for hepatic encephalopathy (2)

A

added to lactulose OR used in pt who can’t tolerate lactulose

175
Q

what pharm tx might have mortality benefit in hepatic encephalopathy

A

lactulose PLUS rifamixin

176
Q

pt’s w. recurrent hepatic encephalopathy should be given what prophylactic pharm

A

lactulose PLUS rifamixin

177
Q

sx of hepatocellular carcinoma

A

decompensation of cirrhosis in previously compensated pt

178
Q

hcc is usually asymptomatic outside of cirrhosis symptoms; but some pt may have

A

upper abd pain

wt loss

early satiety

palpable abd mass

179
Q

labs for hcc are usually __

but may include elevated __

A

nonspecific

AFP

180
Q

only effective screening/dx for hcc

A

serial us q 6 mo

181
Q

preferred tx for hcc

A

surgical resection

182
Q

only possible curative tx for hcc

A

liver transplant

183
Q

what is portopulmonary htn

A

pulmonary htn in pt. w. portal htn

184
Q

possible sx of portopulmonary htn

A

fatigue

dyspnea

peripheral edema

cp

syncope

185
Q

dx for portopulmonary htn is suggested on __

and confirmed with __

A

echo

right heart cath

186
Q

pt w. portopulmonary htn have high mortality rates w.

A

liver transplant

187
Q

general management for cirrhosis (4)

A

abstain from etoh!!

tx of chronic viral hepatitis

vaccinate against hepatitis if not already immune

med adjustments if needed for hepatic impairment

188
Q

median survival is 6 months or less in pt with decompensated cirrhosis and a child-pugh score __ or higher

OR

meld score __ or higher

A

child-pugh: 12 or higher

meld: 21 or higher

189
Q

besides child-pugh and meld scores, what is another prognostic factor of 6 months or less for decompensated cirrhosis

A

hospitalization w. acute liver-related illness

190
Q

poor prognosis for decompensated cirrhosis is related to decreased __ pressure

A

mean arterial

191
Q

child-pugh score evaluates (5)

A

ascites

bilirubin

albumin

PT

encephalopathy

192
Q

which cirrhosis score is used to prioritize pt awaiting liver transplant

A

meld

193
Q

pt’s with a meld score __ or higher are referred for transplant,

and are usually a candidate at __ or higher

A

referred: 10

candidate: 15

194
Q

what factors does the meld score evaluate (4)

A

bilirubin

creatinine

INR

Na

195
Q

which score predicts outcomes

A

meld

196
Q

highest priority for liver transplant consideration

A

acute liver failure

197
Q

4 indications for liver transplant (4)

A

acute liver failure

cirrhosis w. complication

some neoplasms

liver based metabolic conditions w. systemic manifestations

198
Q

what are examples of liver-based metabolic conditions w. systemic manifestations (3)

A

wilson dz

CF

hemochromatosis

199
Q

contraindications for liver transplant (7)

A

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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