Hepatobilliary Dz Flashcards
fibrosis → disruption of liver
architecture → portal HTN +
impaired biosynthetic function
→ multiple complications
How to make Dx?
chirrosis
liver biopsy
WHat causes varices
portal HTN → dilated
veins in butt (hemorrhoids), gut
(esophageal varices), and caput
(caput medusae)
Ppx against varicies
Beta blockers
treatment for bleeding esophageal varicies
- band the varices
- correct coagulopathy
- IV octreotide to lower portal pressure
→ if bleeding continues, repeat banding → if bleeding continues, TIPS or gastric balloon tamponade
MC etiologies of chirrosis
alcohol > HBC and HCV
What is Childs classifications?
stratifies risk of surgery in pts w/ liver failure: measure 3 labs (albumin, bilirubin, PT) and 3 clinical findings (encephalopathy, ascites, nutrition)
pathophys of ascities
portal HTN + hypoalbuminemia –> fluid collection in abd cavity
how to Dx and treat acites
Dx PE (shifting dullness, fluid wave) + paracentesis (to determine cause)
Tx salt restriction + loop diuretic
pathophys of hepatic encephalopathy + s/s
Tx?
↓NH4 metabolism → ↑NH4 → CNS toxicity → ∆MS, asterixis,
rigidity, hyperreflexia, fetor
hepaticus
Tx lactulose (prevents NH4 absorption) + neomycin (kills GI flora that make NH4) + low protein diet
pathyphys of hepatorenal syndrome + tx?
end stage liver dz → renal vein vasoconstriction → progressive renal failure (despite normal kidneys)
liver txp
acites + abd pain, fever, n/v,
rebound tenderness
how to dx and tx?
apontaneous bacterial peritonitis
- Dx paracentesis (↑WBC)
- Tx IV abx + repeat paracentesis in 2-3 days
Estrogen inc or dec in chirrosis? What are the consequences of this?
elevated E 2/2 to dec E metabolism –> spider angiomas, palmar erythema, gynecomastia,
testicular atrophy
treatment for coagulopathy in cirrhotics?
FFP transution (vit K wont work bc they cannot make clotting factors)
consequence of AR ∆ceruloplasmin
wilsons disease = copper accumulation in liver (cirrhosis), corneas (Kayser-Fleischer rings), brain (movement d/o), RBCs (schistocytes)
how to dx and treat wilsons dz
Dx ↓ceruloplasmin, ↑AST/ALT, liver bx
Tx D-penicillamine (copper chelating agent) + zinc (copper uptake competition)
(cirrhosis), heart (restrictive
CM), joints (arthritis), skin
(bronze suntan), pancreas (DM
hemachromatosis
how to dx and treat hemachromatosis
- Dx ↑ferritin, ↓TIBC, liver bx
* Tx repeated phlebotomies
etiology of 1/1 vs 2/2 hemachromatosis
1° hemochromatosis: AR dz that ↑GI iron absorption
2° hemochromatosis: ↑iron 2/2
multiple transfusions or chronic
hemolytic anemia
anabolic steroids or OCP use + usually asx, can present as hypovolemic shock and distended abdomen if ruptured
hepatic adenoma
how is hepatic adenoma dx and treated
- Dx CT scan or U/S
* Tx d/c OCP, if it persists → Tx resection due to possibility of rupture
MC benign liver tumor
cavernous hemangioma
what are etiologies od a cavernous hemangioma
VAT –
vinyl chloride
aflatoxin
thorotrast
CT scan with central stellate scar or sunburst pattern in liver
tx?
focal nodular hyperplasia
reassurance
ague RUQ pain and mass +
s/sx of chronic liver dz (portal
HTN, ascites, jaundice)
Dx? Tx?
HCC
Dx with CT scan and inc aFP
Tx is resection as long as it has not spread
etiologies a/w HCC
cirrhosis (MCC), A1AT deficiency, hemochromatosis, Wilson dz, smoking, chemical carcinogens
fatty liver in a nonalcoholic pt,
usually asx with mild elevated ALT and AST
NASH
usually asx, but can present
w/ mild jaundice after fasting
+ pathophys and treatment
Gilberts = AD ∆UDP-glucuronyltransferase
–> elevated unconjugated/indirect bili bc there is dec enzyme that conjegates bili
reassurance
What is hemobilia
how is it dz and 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
What can cause hemobilia?
trauma (MCC), surgery (CBD exploration), tumors, infx
cyst in liver, what is on differential
- ADPKD
- hydatid cysts (Echinococcus
granulosus (dog tapeworm) →
multilocular cyst w/ calcified
walls)
treatment for hydatid cyst
Tx inject hypertonic saline inside cyst and
• carefully excise it + post-op mebendazole
how do liver abcess prsent?
tx?
fever, RUQ pain, jaundice
multiple/small bacterial abscesses → Tx IV abx
single/large bacterial abscess → Tx perc drain
amebic abscess (in Mexicans) → Tx Flagyl
What is budd chiari syndrome?
tx? etiology?
occlusion of hepatic vein
outflow → hepatic congestion +
portal HTN → hepatomegaly,
RUQ pain, ascites, jaundice
Tx TIPS as a “bridge to liver txp”
Etiology: polycythemia vera
(MCC), OCPs (#2)
↑AST/ALT (ALT>AST): ?
↑AST/ALT (AST>ALT): ?
↑↑AST/ALT: ?
↑↑↑AST/ALT: ?
↑AΦ + GGT nl: ?
↑AΦ + ↑GGT: ?
↑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
↑AΦ + GGT nl: pregnancy or bone dz (e.g. Paget’s)
↑AΦ + ↑GGT: biliary obstruction
↑bilirubin (conjugated 50%): ?
↑bilirubin (conjugated 50%): obstructive jaundice (cancer, choledocholithiasis)
↓albumin: ?
chronic liver dz, nephrotic syndrome, malnutrition, inflammatory states
How are gallstones worked up?
US then get HIDA if inconclusive
ERCP if choledocholithiasis/acute cholangitis
What is Boas sign?
referred right scapular pain of biliary colic
What is charcot triad?
RUQ pain
Fever
Jaundice
What is reynold’s pentad
RUQ pain
Fever
Jaundice
change in MS
hypotension
what is acute cholangitis
stone in CBD + infection
what is gallstone pancreatitis
tx
impacted stone in pancreatic duct –> reflux of pancreatic enzymes –> mid epigastric pain
if amylase returns to normal → Tx lap chole
if amylase elevated → ERCP to remove stone
what is billiary colic?
tx?
cholelithiasis →
RUQ pain after fatty meals ± n/v
elective lap chole
tx for choledocholithiasis
Tx NPO, IVF, ±abx → ERCP to remove stone
where is stone in acute cholecystitis?
tx?
cystic duct
Tx NPO, IVF, abx → lap chole within 24 hrs
who usually gets acalculous cholecystitis
tx?
ICU pts
Tx NPO, IVF, abx → lap chole within 24 hrs; perc drain w/ cholecystostomy if nonsurgical candidate
what is porcelin GB? Why is it significant?
dystrophic calcification of GB has 50% risk of adenocarcinoma, take it out
What is gallstone ileus
gallstone enters bowel through cholecystenteric fistula → gets stuck in terminal ileum → SBO
thickening of bile duct walls →
narrowed lumens → gradual
jaundice and pruritus → liver
failure, cirrhosis, portal HTN
How is it Dx? Tx? Etiology?
1° sclerosing cholangitis (PSC)
• Dx ERCP (beading of bile ducts)
• Tx cholestyramine (helps w/ pruritus), liver txp (definitive)
• Etiology: idiopathic, but highly
associated w/ UC
destruction of intra-hepatic bile ducts → gradual jaundice and pruritus → liver failure, cirrhosis, portal HTN
Dx? Tx?
1° biliary cirrhosis (PBC)
Dx screen w/ AMA (anti-mitochondrial ab), confirm w/ liver bx
Tx ursodeoxycholic acid
what can cause 2° biliary cirrhosis?
(progressive cirrhosis 2/2 to biliary obst)
sclerosing cholangitis, cystic fibrosis, biliary atresia
tumor of bile ducts → s/sx of
obstructive jaundice (dark
urine, clay stools, pruritus)
how to make dx? tx? etiologies?
cholangiocarcinoma
dx with ERCP
Tx whipple if resectable
etiologies: PSC (MCC US), Chlonorchis sinensis (MCC China)
What is Klatskin tumor?
tumor of proximal 1/3 of CBD, poor px since it’s not resectable
What are choledocal cysts and how do they present? How are they Dx and tx?
cystic dilation of biliary tree →
RUQ mass/pain, jaundice, fever
dx with ERCP
Tx with resection
iatrogenic injury → s/sx of
obstructive jaundice (dark
urine, clay stools, pruritus)
Dx? Tx? complications?
billiary stricture
Dx with ERCP
Tx endoscopic stent > surgical bypass
complications = 2° biliary cirrhosis, acute cholangitis, liver abscess
pathophys and presentaion of billiary dyskinesia
dx? tx?
motor dysfxn of sphincter of
Oddi → recurrent biliary colic
w/o stones
HIDA scan (fill up GB w/ contrast and give CCK to determine ejection fraction)
lap chole
