Liver & Biliary Flashcards by Stephanie Escobar

Hepatotoxicity causes of Cirrhosis:
_________
Meds (acetaminophen)
Aflatoxins (Aspergillus)

Inflammatory causes of Cirrhosis:
________
Primary biliary cirrhosis
Primary sclerosing cholangitis

Congestive causes of Cirrhosis:
________

Alcohol use disorder
Hepatitis B/C/D
Budd-Chiari syndrome
----------------------------------
Metabolic causes of Cirrhosis:
Nonalcoholic steatohepatitis (NASH)
Hemochromatosis
Wilson disease
α1-antitrypsin deficiency

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____, alcoholic use d/o, and NASH are the most common causes of cirrhosis in the US.

Hepatitis C

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Pathophysiology of Cirrhosis:
Degeneration and necrosis of hepatocytes →
____ regenerative nodules replace liver parenchyma →

Loss of liver function (Synthesis of plasma proteins, albumin, and clotting factors, biliary excretion etc.)

Fibrotic

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Cirrhosis presents with following labs
\_\_\_\_ Anemia
Thrombocytopenia
↑ Transaminases (AST, ALT)
↑ Ammonia
↑ \_\_\_ due to decreased production of coagulation factors
↓ Total protein (↓ albumin)

Macrocytic
(due to vitamin B12 or folic acid deficiency)

↑ PT/INR

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Diagnosis:

+) anti-mitochondrial antibodies (AMA-M2
↑ ALP
↑ bilirubin

Primary biliary cirrhosis

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Diagnosis?

↑ pANCA
↑ GGT
↑ ALP
↑ bilirubin

Primary sclerosing cholangitis

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Best initial imaging study for cirrhosis:

Abdominal ultrasound

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HCC screening, pts with cirrhosis should have an abdominal ultrasound every ___ and periodic monitoring of ___

6 months

alpha-fetoprotein (AFP)

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Routine vaccinations in pts with cirrhosis include:
\_\_\_\_\_\_\_\_\_\_
hepatitis A vaccine
hepatitis B vaccine
influenza vaccine
tetanus vaccine

pneumococcal vaccine (PPSV23)

PHiT

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Transjugular intrahepatic portosystemic shunt (TIPS): a method used to lower portal pressure and reduce ascites indications:

Refractory ascites
Recurring _____
Bridging time until possible liver transplant

esophageal varices

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TIPS procedure can increase risk of what complication?

Hepatic Encephalopathy

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In cirrhotics, blood is often shunted to the spleen resulting in splenomegaly and _____

Thrombocytopenia

→ from splenic sequestration of plts

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Laboratory study classically elevated in Hepatic Encephalopathy

ammonia

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2 medications used to treat Hepatic Encephalopathy

Rifaximin (abx that absorbs ammonia)

Lactulose (laxative)

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When portal vein thrombosis is detected in patients with cirrhosis ____ must be ruled out as the cause.

HCC

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Virchow’s Node (L supraclavicular lymphadenopathy)

is classically associated with metastatic __ cancer but can develop in other abdomino-pelvic malignancies causing ___

gastric

(gallbladder, pancreas, kidneys, testicles, prostate, ovaries)

ASCITIES

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Initial imaging of choice for ascites

Abdominal ultrasound

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(Medication) should be avoided in patients with severe hyponatremia, hepatic encephalopathy, and/or renal function deterioration.

Diuretics

use with caution

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Portal Vein Thrombosis
↑ Blood flow via portosystemic anastomoses

Congestion via paraumbilical veins and ___ veins → caput medusae

epigastric

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Portal Vein Thrombosis
↑ Blood flow via portosystemic anastomoses
Congestion via rectal veins → hemorrhoidal or ____

anorectal varices

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Portal Vein Thrombosis
↑ Blood flow via portosystemic anastomoses

Congestion via veins of the gastric fundus and lower esophagus → _____ &/or _____

Esophageal varices (hematemesis)
Gastric varices (melena)

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Portal Vein Thrombosis
↑ Blood flow via portosystemic anastomoses →
congestive _____ (organ) & ascites

splenomegaly (thrombocytopenia)

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Portal Vein Thrombosis
u/s shows ___ transformation of the portal vein
&
portal vein dilation to > __ mm

cavernous

> 13

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Acute management of variceal hemorrhage: 
1.  IVF 
2. (procedure)
3. Transfuse blood
--------------------------------------
Medical therapy
1. \_\_\_\_ + \_\_\_\_
--------------------------------------
Endoscopic management
1. Erythromycin
--------------------------------------
Procedures
\_\_\_\_\_ (procedure of choice)
Alternative: injection sclerotherapy

Intubate
----------
Octreotide + Ceftriaxone
-----------
Endoscopic band ligation

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Primary bleeding ppx of variceal hemorrhage: 1. (Medication) 2. (procedure)

1. nonselective beta-blockers (carvedilol, sotalol, labetalol, propranolol) 2. Endoscopic band ligation

Hepatic vein thrombosis aka | _______ syndrome

Budd-Chiari syndrome

``` Presents with: Abdominal pain/ distention Tender hepatomegaly Ascites Jaundice signs of portal vein thrombosis Dx & Tx? ```

Budd-Chiari syndrome Tx: anticoagulant (+/- Balloon angioplasty/stenting; TIPS if portal HTN; Liver transplant)

Biliary Cancer Risk factors for _____ → Primary sclerosing cholangitis & Biliary Cyst Risk factors for _____ → Chronic Cholelithiasis & Porcelain gallbladder

Cholangiocarcinoma gallbladder Adenocarcinoma

2 Risk factors for gallbladder adenocarcinoma

Chronic Cholelithiasis Porcelain gallbladder (Adenocarcinoma is the most common)

2 Risk factors for cholangiocarcinoma

Primary sclerosing cholangitis | Biliary Cysts

Pt with months h/o abdominal pain painless obstructive jaundice (↑ D. Bili, ALP, GGT) painless, palpable gallbladder (Courvoisier sign) suggests what malignancy?

Cholangiocarcinoma

Commonly seen tumor markers in biliary cancer: ↑ AFP ↑ __ & ___

CA 19-9 (also pancreatic) | CEA

Pt present with classic triad of: abdominal pain palpable RUQ mass & jaundice U/S reveals extrahepatic and/or intrahepatic cystic dilation of the biliary tree Diagnosis?

Biliary cyst | Premalignant for cholangiocarcinoma

Inpatient px with RUQ pain and leukocytosis, but otherwise normal labs. No gallstones seen on u/s. Diagnosis and Treatment?

Acalculous cholecystitis (pt can have juandice and abn labs too tho) Tx: Enteric ABx coverage Percutaneous Cholecystostomy (to drain) Once stable, cholecystectomy

Acute cholangitis presents with fever jaundice RUQ abdominal pain and elevated _____

ALP Total/ Direct Bilirubin GGT

Hyperactive bowel sounds are most c/w small bowel _____. Hypoactive bowel sounds are most c/w small bowel _____.

Obstruction | Illeus/ Ischemia after long time obstructed

Pt presents with colicky abd pain, obstipation, distention and hyperactive bowel sounds. Labs show leukocytosis and mild transaminitis. KUB shows dilated small bowel and air in the intrahepatic bile ducts (pneumobilia). Diagnosis and Treatment?

Gallstone Illeus (mechanical obstruction) Treatment: Enterotomy to remove stone and simultaneous or delayed cholecystectomy.

Acetaminophen overdose and viral hepatitis cause hyperbilirubinemia and [lab value]

Transaminitis (in the thousands)

Sphincter of Oddi dysfunction is a functional biliary disorder due to dyskinesia or stenosis of the sphincter of Oddi. Patients experience recurrent, episodic pain in the right upper quadrant or epigastric region, with corresponding elevations in ____ & _____.

AST/ALT and ALP Opioids may cause sphincter contraction and precipitate/worsen sxs.

Sphincter of Oddi ___ is the gold standard for the diagnosis of SOD; _____ is the treatment of choice in most cases.

manometry | sphincterotomy

Pt with recent h/o hepatic or biliopancreatic procedure, now has: RUQ pain Obstructive Jaundice (↑ D. Bili, ALP, GGT) Melena or Hematemesis or + FOBT Diagnosis

Hemobilia (bleeding into the biliary tract) a rare cause of upper GI bleeding usually s/t hepatic or bilio-pancreatic procedures (Tx: self resolves; if not endoscopic embolization)

Treatment of Hemobilia

Usually self-limited & often managed conservatively (IVFs & transfusions) however, Angiography w/ Embolization or surgery may be required for persistent bleeding.

Biliary colic occurs when the gallbladder contracts against a gallstone that temporarily blocks the cystic duct. Classic symptoms include episodic postprandial RUQ or epigastric pain, n/v; Vital signs, WBCs & LFTs remain normal. Dx is confirmed with an

``` abdominal ultrasound (demonstrating the presence of gallstones) ```

___ is used to diagnose acute cholecystitis in patients with an equivocal abdominal ultrasound. It is not indicated as first-line imaging.

HIDA scan

Gallstone Pancreatitis cx by acute cholangitis | Imaging & Treatment:

Abdominal U/S ERCP (relieves the biliary obstruction during which a sphincterotomy, stone extraction, and/or biliary stent placement can be done)

In pt with gallstone pancreatitis who also has fevers, right upper quadrant pain, jaundice, altered mental status, and hypotension what other complication might be present?

Acute cholangitis | should be suspected

Alcohol toxicity can cause acute pancreatitis but is not usually associated with acute ___

cholecystitis/cholangitis

Treatment for acute cholecystitis includes supportive care __(4)__. Urgent Laparoscopic cholecystectomy is recommended but should be performed Emergently in cases of ____

IVFs, NPO, ABxs & analgesics perforation or gangrene

Acute cholecystitis usually presents with sudden onset of steady epigastric or RUQ pain after a large or fatty meal. The pain may radiate to the ___. Other classical findings include F/N/V and leukocytosis.

right scapula

Uncomplicated cholecystitis can cause MILD elevations in ___, ___, and ___ without obvious CBD or pancreatic disease.

AST/ALT/ALP (Transaminases) T. Bilirubin (1.0-4.0) Amylase ----------------------------

Pt presents with firm, non-tender mass in RUQ. Abdominal CT shows a bright rim in the gallbladder wall with a central bile-filled dark area. Diagnosis, Treatment, and high risk association:

Porcelain gallbladder (calcified rim of gallbladder) Cholecystectomy Gallbladder adenocarcinoma

Cholecystectomy prior to discharge and ideally within __ days is the standard of care in low-risk patients with acute (nonemphysematous) cholecystitis.

In high-risk pts (severe systemic illness) with cholecystitis cholecystectomy may be delayed up to 2 weeks after complete recovery Until then management is done with (2)

Antibiotics +/- Percutaneous gallbladder drainage

Some patients with Emphysematous cholecystitis who cannot tolerate urgent cholecystectomy undergo ____ only.

percutaneous cholecystostomy | gallbladder drainage

Emphysematous cholecystitis (air or gas INSIDE the gallbladder wall) treatment?

urgent cholecystectomy

The initial presentation of a biliary cyst may be acute cholangitis and should be suspected in a patient with a cystic bile duct mass. Initial management is urgent ____ afterwards _____ should be performed to reduce the risk of cholangiocarcinoma.

endoscopic biliary drainage surgical excision of the cyst

Pt with h/o Ulcerative Colitis presents for RUQ pain, weight loss, dark urine, & itchiness On exam: jaundice, hepatomegaly, & RUQ mass Labs significant for marked elevations in ALT/AST/ALP and Bilirubin Tumor markers: CAE and CA-19 are elevated AFP is normal. Diagnosis?

Cholangiocarcinoma

Ulcerative Colitis and Primary Sclerosing Cholangitis are associated with _____

Cholangiocarcinoma

HCC usually occurs in the setting of (2)

``` Alcohol use disorder Viral Hepatitis (chronic) ```

__ cancer often causes MULTIPLE liver masses and is frequently associated with elevations in tumor markers __ or __.

Metastatic Colon cancer CEA CA 19-9

___ cancer often causes common bile duct dilation from obstruction and an increase in tumor marker CA 19-9.

Pancreatic cancer px w/ subacute RUQ pain and weight loss.

Management of Acute Cholecystitis (5) Mid epigastric → RUQ pain +/- peritonitis; Fever & Leukocytosis

``` Pain analgesia ABxs (Pip-Tazo; 3º Ceph +/- Metro) IVFs NPO (PAIN mnemonic) ``` Cholecystectomy w/in 3 days (urgently) Cx: Gangrene or rupture → cholecystectomy (E.Coli, Enterococci, B. Fragility and/or C. Perfinges) For elective cholecystectomy w/o infection → Unasyn (Amp-Sulfa) or Cefazolin ppm

Treatment of Acalculous cholecystitis

Percutaneous Cholecystotomy tube | GB drainage