Liver & Biliary Flashcards
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
____, alcoholic use d/o, and NASH are the most common causes of cirrhosis in the US.
Hepatitis C
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
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
Diagnosis:
+) anti-mitochondrial antibodies (AMA-M2
↑ ALP
↑ bilirubin
Primary biliary cirrhosis
Diagnosis?
↑ pANCA
↑ GGT
↑ ALP
↑ bilirubin
Primary sclerosing cholangitis
Best initial imaging study for cirrhosis:
Abdominal ultrasound
HCC screening, pts with cirrhosis should have an abdominal ultrasound every ___ and periodic monitoring of ___
6 months
alpha-fetoprotein (AFP)
Routine vaccinations in pts with cirrhosis include: \_\_\_\_\_\_\_\_\_\_ hepatitis A vaccine hepatitis B vaccine influenza vaccine tetanus vaccine
pneumococcal vaccine (PPSV23)
PHiT
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
TIPS procedure can increase risk of what complication?
Hepatic Encephalopathy
In cirrhotics, blood is often shunted to the spleen resulting in splenomegaly and _____
Thrombocytopenia
→ from splenic sequestration of plts
Laboratory study classically elevated in Hepatic Encephalopathy
ammonia
2 medications used to treat Hepatic Encephalopathy
Rifaximin (abx that absorbs ammonia)
Lactulose (laxative)
When portal vein thrombosis is detected in patients with cirrhosis ____ must be ruled out as the cause.
HCC
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
Initial imaging of choice for ascites
Abdominal ultrasound
(Medication) should be avoided in patients with severe hyponatremia, hepatic encephalopathy, and/or renal function deterioration.
Diuretics
use with caution
Portal Vein Thrombosis
↑ Blood flow via portosystemic anastomoses
Congestion via paraumbilical veins and ___ veins → caput medusae
epigastric
Portal Vein Thrombosis
↑ Blood flow via portosystemic anastomoses
Congestion via rectal veins → hemorrhoidal or ____
anorectal varices
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)
Portal Vein Thrombosis
↑ Blood flow via portosystemic anastomoses →
congestive _____ (organ) & ascites
splenomegaly (thrombocytopenia)
Portal Vein Thrombosis
u/s shows ___ transformation of the portal vein
&
portal vein dilation to > __ mm
cavernous
> 13
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
Primary bleeding ppx of variceal hemorrhage:
- (Medication)
- (procedure)
- nonselective beta-blockers
(carvedilol, sotalol, labetalol, propranolol) - 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.
3
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
