liver and biliary tract d/o

Question 1

Definition of Acute Liver Failure

Answer 1

Acute severe liver injury (ALT often 15 ULN
coagulopathy (INR GT 1.5)
encephalopathy
no pre-existing liver dz
<26 wks duration

Question 2

Provide a DDx of ALF:

Answer 2

• Vascular (Ischemic, Budd-Chiari)
  
  • Viral (HAB, HBV, HDV * not C, HSV, EBV, CMV)
  • Autoimmune
  • Drugs/toxins (Lots, don’t forget Amanita)
  • Metabolic (Wilsons)
  • Pregnancy (HELLP, Fatty Liver)
  • Iniltrative (Lymphoma, melanoma, TB)
  • Sepsis
  • Heat Stroke

Question 3

What is the King’s College Criteria for predicting need for a transplant in APAP and non-APAP patients

Answer 3

APAP
pH LT 7.3 or lactate GT 3.5 or grade iii/iv encephalopathy
AND
INR GT 6.5
Cr GT 300

NON APAP
INR GT 6.5
OR
any 3 of:
age LT 10 or GT 40
Bili GT 300
INR GT 3.5
duration of jaundice to HE GT 7d
Etiology: non A-E Hep, idiopathic drug rxn, wilson's

Question 4

What do the following indicate
HBsAg
HBcAg
HBsAB
HBcAb
HBcAb-IgM
HBeAb

Answer 4

o HBsAg: Surface antigen. Acute or chronic infection
o HBcAg: Active infection, acute or chronic
o HBsAb: Surface antibody. Acute, past, or immunization. Best indicator of previous infx
o HBcAb: Combo IgG and IgM defining infx, acute or past. Best indicator of immunity
o HBcAb-IgM: Indicates acute infection
HBeAb: Possible represents resolving HBC infx and decreased infectivity

Question 5

List 5 complications of cirrhosis:

Answer 5

1. GI bleeding à THESE ONES GO INTO DIC
   2. Ascites
   3. Encephalopathy
   4. SBP
   Hepatorenal syndrome

Question 6

What are the causes of ascites in cirrhosis?

Answer 6

· Hypoalbuminemia
· Portal hypertension
· Impaired hepatic lymph flow
Renal salt retention

Question 7

What are the grades of hepatic encephalopathy?

Answer 7

Grade I: sleep prob, irritability, depression, mild cognitive dcts

Grade II: lethargy, disorientation, confused, personality changes, asterixis
GrIII: somnolence, marked d/o, confused seech, can’t follow commands, asterixis

Gr IV: coma

Question 8

List 5 precipitants of hepatic encephalopathy:

Answer 8

· Bleeding
		· Renal Failure
		· Infections (think SBP)
		· Drugs (sedatives)
		· Alcohol or withdraw
		· Large protein meals
		· Constipation
		· Metabolic abnormalities à hypoK, Alkalosis, BUN, Hyponatremia
		· Hypoglycemia
		· Hypoxia
		· Hypovolemia

Question 9

How does lactulose work? What is the dose?

Answer 9

· Lactulose, an osmotic cathartic, is a poorly absorbed sugar metabolized to lactic acid by colonic bacteria. This causes acidification of the fecal stream, resulting in the trapping of ammonia (NH3) as ammonium (NH4+) in the stool.
· The usual dosage of lactulose is between 30 and 60g daily or in a quantity sufficient to result in several loose bowel movements daily

Question 10

What are the criteria for initiating treatment in ER for SBP?

Answer 10

· WBC’s > 0.25 [250 cells/mm3]
· +ve leukocyte esterase on urine dip à correlation with clinically significant neutrophil elevation
· pH < 7.34 or pH gradient arterial:ascites > 0.10
· Check INR/PTT prior to tap ® treat with FFP as needed

Question 11

What are Runyon’s criteria for SBP?

At least 2 of in ascitic fluid

Answer 11

· Total Protein >10gm/L
· Glucose <2.8mmol/L
LDH>ULN of serum

Question 12

List 10 meds/toxins that can cause hepatitis.

Answer 12

OTC:
- APAP
- Salicylate

Steroids:
- Anabolic steroids
- OCP

Cardiovascular drugs:
- Amiodarone
- Verapamil
- Statins

Psyciatric:
- Haldol
- Chlorpromazine
- Mehtyldopa

Antiepileptics:
- VPA
- Carbamazepine
- Dilantin

Antibiotics:
- Tetracycline
- Amphotericin
- Erythromycin
- INH
- Ketoconazole
- Quinidine
- HART

Antineoplastics:
- MTX
- Cisplatum

Amanita!!

Question 13

List 2 primary hepatic disorders associated with pregnancy.

Answer 13

1. cholestasis of pregnancy

2. fatty liver

Question 14

What are the 4 ultrasound findings of cholecystitis?

Answer 14

o Thickened Gb wall [>3mm]
o Pericholecystic fluid
o Gallstones (present in 95%)
Sonographic murphy’s

Question 15

What are two nasty complications of cholecystitis?

Answer 15

• Gangrenous gallbladder

Emphesematous cholecystitis à seen in DM