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Year 2 > McGowan Test II > Flashcards

McGowan Test II Flashcards

1
Q

CNS defects
hemolysis (low LDH, Anemia, Haptoglobin)
<40yo

is what disease?

A

Wilson’s

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2
Q

tea colored urine and white clay colored stools

A

obstruction in the biliary system

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3
Q 
grandparents w new onset of DM
painless jaundice
>65yo
direct hyperbilirubinemia
epigastric pain when laying down, relief when bending forward
ca 19-9
courvoisier sign
trousseas sign of malignancy
A

pancreatic cancer

adenocarcinoma

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4
Q

Crohns, DM, native american race, rapid weight loss are RF for what?

A

gallstones

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5
Q

mc in pt w cirrhosis

gram neg bacillis - e coli
gram postive - strep, enterococci, pneumococci
only single org is isolated

dx if peritoneal fluid contains 250 pmn

blood cultures bc bacteremia is common

tx: 3rd gen cephalosporin like ceftriaxone or pipercillin tazobactam

A

spont (primary) bacterial peritonitis

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6
Q

bact contaminate the peritoneum - spillage from intraabd viscus

mixed flora - gram neg bacilli and anaerobes predom
spread to peritoneal cavit - increase pain

pt lies motionless, often w knees drawn up to avoid stretching nerve fibers of peritoneal cavity
invol guarding

dx: radiographic studies to find source or immediate surg intervention, abd tap done only to exclude hemoperitoneum in trauma

tx: antibiotics aimed at inciting flora
surgery needed often

A

secondary bacterial peritonitis

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7
Q 
Epigastric abd p
RUQ pain, 
dyspepsia/ GB disease etiology?
Cullen or Grey turner sign
crackles, diff breathing - ARDS?

Chvostek (twitch of facial n m) and Trousseau (hand posture w bp inflatition) signs = hypocalcemia

A

Acute Pancreatitis

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8
Q

Acute Pancreatitis

pathology?

mc cause?

why is there hypocalcemia?

2-3 to dx?

MC imaging follow up? avoid this why?

tx?

A

Cellular injury from activation of trypsinogen to trypsin in autodigestion of pancreas and peri-pancreatic tissues

Gallstones <5mm, heavy alcohol use, but also hypertriglyceridemia, trauma, meds, ERCP, autoimmune, infections, CFTR, Idiopathic

saponification

epigastric pain
lipase (and amylase) 3 x ULN
CT changes consistent w pancreatitits

Rapid bolus IV contrast-enhanced CT, avoided if serum Cr > 1.5

fluid resuscitation - first thing IV
then tx main cause

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9
Q

two signs you see on xray of acute panc?

A

sentinel loop - seg of air filled SI (mc LUQ)

colon cutoff sign - gas filled seg of transverse colon abruptly end at area of panc inflamm
- focal linear atelectasis of lower lobe of lung w/ w/o pleural effusion

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10
Q

how to predict severe acute pancretitis?

A

Ranson criteria
GA - LAW
C & Hobbs

Bedside index for severity in acute panc (BISAP)

  • bisap score = BUN >25,
  • impaired mental status,
  • SIRS 2 of4, age > 60,
  • pleural effusion

apache II > 8 = higher mortality
- severely ill pt, predict hospital mortality

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11
Q

complications of acute panc

A
  • intravascular vol dep
  • –leaks fluids in panc bed = 3rd spacing
  • –ileus w fluid filled loops, Pre-renal azotemia
  • fluid collections (pleural effusion)
  • necrosis w/ wo infection (including emphysematous pancreatitis)
  • –infection needs debridement (high mortality)
  • pseudocysts - high amylase
  • ARDS -> cardic dysfxn
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12
Q

emphysematous pancreatitis caused by?

A

could be from c. perfringens, enterobacter aerogenes, enterococcus faecalis

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13
Q 
epi pain, 
steatorrhea (chronic fatty diarrhea), 
unintentional wt loss
fatique
pain is cardinal symptom
attacks may last a few hours-2 wks
steatorrhea - bulky foul fatty stool occurs later in course, exocrine insuff!
A

Chronic Pancreatitis

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14
Q

Chronic Pancreatitis

mc cause?

dx?

causes?

complications?

A

alc, Chronic Pancreatitis

decreased fecal elastase <100
glucose/HbA1c - main -> dm after 25 yr chronic
autoimmune panc - elevated IgG4
calcifications on xray/ct

T oxic metabolic: alcoholic  (mc)
Idiopathic (early onset 23)
Genetic: CFTR 
Autoimmune: celiac, hypergammaglobuminemia - IGG4
Recurrent 
Obstructive - stricture, stone, tumor

brittle DM, panc insufficiency, panc ca

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15
Q

tumefactive chronic pancreatitis is code for?

A

panc ca

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16
Q

shows significant steatorrhea = malabsp of triglycerides

wt loss, gas distention and farts, large greasy foul smelling stool diarrhea

fecal elastase <100
others - trypsinogen <20, malabsorption, stim test (cholecystokinin/secretin)

exocrine detection of decreased fecal chymotrypsin
- decreased panc fecal elastase <100
Endocine -DM after 25yrs of chronic P

A

pancreatic insufficiency

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17
Q

AD, rare, Type 1
endocrine glands benign or malignant

parathyroid
- hyperca, increased PTH

pancreas

  • gastrinoma - ZE (mc in duodenum, then panc), PUD
  • insulinoma - hypoglycemia = blood sugar drop symp

pituitary

  • acromegaly: lots growth of hands, feet, haw, internal organs
  • cushing disease
A

MEN 1

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18
Q

increased bili production, impair bilirubin uptake/storage

A

unconjugated (indirect)

ie. hemolytic syndrome
gilbert syndrome

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19
Q

impaired excretion, hepatocellular dysfxn, biliary obstruction

A

conjugated (direct)

ie dubin johnson syndrome
rotor syndrome
drug rxn
pregnancy
viral hep
crigler najjar
intrahepatic cholestasis of pregnancy
hepatitis, cirrhosis obstruction
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20
Q

prehepatic, hepatic, post hepatic

A

transfusions
sickle cell
thalassemia
autoimmune

hepatitis
ca
cirrhosis 
congenital disorders
drugs
gallstones
inflammation
scar tissue
tumors
block flow of bile into intestines
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21
Q

with prehapatic or unconjugated bili, you should order what test?

A

order CBC (hemolysis!)

  • anemia and thrombocytopenia
  • haptoglobin, reticulocyte count, LDH to look for hemolysis
  • leukocytosis

Peripheral smear - schistocytes, sickle cells

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22
Q 
benign, 
asymp, 
hereditary, 
fasting -> increases indirect hyperbilirubinemia, 
abn lab results, no tx, 
reduced mortality from cv disease
reduced UDGT
A

gilbert syndrome

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23
Q 
reduced excretory fx of hepatocytes
benign, 
asyp hereditary, 
gb does NOT visualize on oral cholecystography
liver dark pigment on examination
bx show centrilobular brown pigment
A

dubin johnson

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24
Q

reduced hepatic reuptake of bilirubin conjugates

sim to DJ but liver isnt pigmented and gb is visualized on oral cholecystography

A

rotor syndromes

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25
Q 
cholestasis
benign, 
3rd trimester of preg, 
itching, 
gi symp, 
abn liver excretory fxn test
cholestatsis noted on liver bx
recurrence w subsequent preg or use of oral contraceptives
A

intrahepatic cholestasis of pregnancy

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26
Q

rapid liver shrinking size

rapid rising bilirubin level

marked prolongation of PT
signs of confusion, disorientation, somnolence,
ascites, edema

leads hepatic failure w encephalopathy

life threatening coagulation abnormalities INR > 1.5

hepatic encephalopathy -> deep coma (cerebral edema)

asterixis

A

Acute (fulminant) Liver Failure (ALF)

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27
Q

Acute (fulminant) Liver Failure (ALF)

mc causes?

Labs?

complications of ALF

A

acetaminophen
idiosyncratic drug rxn = sporatic (prescription drugs, antiTB, antiepileptics, antibiotics, herb, dietary supplements)

  • rapidly rising bilirubin level + marked prolongation of PT even as AST/ALT levels fall
  • in acetaminophen toxicity AST/ALT > 5000uL
  • ammonia level elevated -> encephalopathy and intracranial HTN >200
  • acetaminophen level ~ use Rumack-Matthew Nomogram

cerebral edema (brainstem compression) and sepsis are the lead causes of death

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28
Q

if acetomnophen OD what should you give?

what factor improves ALF survival?

A

N acetylcysteine (NAC) in acetomnophen OD

meticulous intensive care + prophylactic antibiotic coverage = one factor improves survival

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29
Q

viral, drugs, ischemia can cause this

RUQ pain = tenderness over liver, jaundice, hepatomegaly, skin changes, abd p
aversion to smoking?
acholic stools

what dx test should you run?

tx?

A

Acute Hepatitis

CBC
CMP
- liver enzymes, total bili, albumin, renal fxn
PT/INR
acetaminophen level - use rumack-matthew nomogram

N-acetylcysteine aka NAC or Mucomyst

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30
Q

ssRNA

acholic stools
aversion to smoking
n/v/anoexia, malaise, ruq p or epigastric, fever, hepatomegaly, jaundice, arthralgia, tires easy, UR symp, diarrhea/const

acute only

international travel, inadequately cooked shellfish

fecal-oral
international travel, inaqequately cooked shellfish

A

HAV

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31
Q

what do you see on HAV Labs?

A 
elevated aminotransferases (AST/ALT) - hepatocellular
elevated bilirubin and ALP = cholestasis

IgG & IgM Anti-HAV both are detectable in serum soon after onset

dx w IgM anti-HAV

IgG anti-HAV indicates previous exposure to HAV, non infectivity and immunity

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32
Q

partially dsDNA

n/v/anoexia, malaise, fever, hepaatomegaly, jaundice

Acute - 2/3 wk
Chronic - 5-10%

MSM, inject drugs, ppl at hemodialysis, healthcare workers, jailers, tx sexually transmitted diseases

  • parenteral, sexual, perinatal
  • infected blood or b. products - -percutaneous from needle
  • perinatal - endemic in sub-saharan africa and SE asia
  • HBsAg + mom may transmit to bb in delivery, risk of chronic infection in bb is high

cirrhosis (esp w HDV), hepatocellular carcinoma

A

HBV

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33
Q

what is the window period of acute hbv?

why is this usefully clinically?

A

bw HBsAg disappearing and HBsAb appearing, pt still considers acute HBV, only detectable w HBcAb IgM

important to screen blood donations

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34
Q

IgM Anti-HBc

A

window period

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35
Q

IgM Anti-HBc
HBsAg
HBeAg
HBV DNA

A

acute infection

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36
Q

Anti-HBs

IgG Anti-HBc

A

prior infection

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37
Q

HBsAg
IgG Anti-HBc
HBV DNA?

A

chronic infx, inactive

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38
Q 
HBsAg	
IgM Anti-HBc	
IgG Anti-HBc	
HBeAg	
HBV DNA
A

chronic infx, active

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39
Q

Anti-HBs

A

immunization

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40
Q

what do all these mean?

IgG Anti-HBc

HBeAg + HBV DNA

IgM Anti-HBc

Anti-HBs

HBsAg

A

not infectious

active viral relication

acute HBV

exposed to virus

have the virus

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41
Q

defective RNA virus that requires HBV

co infects w HBV or superinfects a chronic HBV carrier
non percutaneous or percutaneously in HBsAg (active) IV drug users or hemophiliac transfusion

HDV RNA - pcr

vacc against HBV

A

HDV

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42
Q

ssRNA

marked fluctuating elevations of serum aminotransferase levels

mc chronic - 8wk

HCV Ab in serum,

  • most sensitive indicator is HCV RNA
  • anti-HCV in serum w/o RNA -> recovery from prior infection

non to HCV, chronic liver dz should be vass against HAV and HBV

birth cohort screening of person born bw 45-65 (bb boomer) for HCV infection, all over 18 should have 1 lifetime screening

curable w proper tx

A

HCV

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43
Q

HCV RF?

complications

A

-coinfection w HIV, developing world unsafe med practices
-pt has tranfusion related hepatitis, HCV >90% cases
I
-IV drug use, intranasal
-bloody fights, incarceration in prison

cirrhosis, HCC, HIV coinfection
mixed cryoglobulinemia, decrease serum cholesterol

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44
Q

ssRNA herpevirus

immunocompromised host
endemic/epidemic form in Asia, ME, N africa, central america, india

HEV Ab, PCR for HEV RNA

clinical trials

high rate in pregnant women

acute = no carrier state
transplant pt, tx w tacrolimus instances of chronic w progression to cirrhoisis

A

HEV

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45
Q

dose-dep (direct hepatotoxins) - w/in 48hrs
- e.g. acetaminophen, tetracyclines, mushrooms

variable dose and time of onset
fever rash arthralgias eosinophilia
e.g. isoniazid, sulfonamides, methyldopa

supportive tx
- include gastric lavage and oral admin of charcoal or cholestyramine
w/in 1 hour post ingestion esp w acetaminophen

liver transplantation
acetaminophen overdose
- NAC after the 1hr as above

A

Toxic and Drug Induced Hepatitis (DILI drug induced liver injury)

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46
Q

tylenol/acetaminophen overdose - tx

A

*use rumack-matthew nomogram

tx w N acetylcysteine aka NAC if in toxic area

important to get 4hr acetaminop

therapy win 8 hr of ingestion
- critical ingestion tx interval for max protection against severe hepatic injury is bw 0-8hrs

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47
Q

SAAG > 1.1

occlusion of flow to hepatic v or IVC
caval webs, R side herat fail -> nutmeg liver
fx that predispose pt to hepatic v obstruction
- such as hereditary or acquired hypercoag states (polycythemia vera)

occlusion of flow in hepatic v or ivc

A

Hepatic vein obstruction - Budd Chiari Syndrome

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48
Q

Budd Chiari Syndrome tx and imaging?

A

imaging
- prominent caudate liver lobe
- screen test of choice is contrast enhanced US
- color or pulsed doppler ultrasonography
- direct venography
—delinate caval webs and occluded v = spider web pattern
- liver bx
—centrilobular congestion - nutmeg liver
hepatocellular carcinoma

symptomatic tx, anticoag, thromboylytic, liver transplant

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49
Q

mc cause jaundice in preg

A

viral hepatitis

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50
Q

maternal HTN, proteinuria, peripheral edema, coag abn

HELLP syndrome

severe elvation of serum aminotransferases, mild elevation of bili

A

pre-eclampsia

hemolysis, elevated liver enzymes, low platelets

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51
Q

eclampsia is?

A

HELLP + hyperreflexia + convulsions = eclampsia = life threatening

tx: termination of preg

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52
Q

pruritus 3rd trimester (dobby boy says 2-3 trimesters), darkening urine, light stools, jaundice

resolves after delivery by itself
bilirubin <5, might have ele ALP
bx: canalicular cholestatis
recurrent w preg

A

cholestatsis of preg

53
Q

spectrum of dz from subclin or modest hepatic dysfxn (increased aminotransferase levels) -> hep failure, coma, death

3rd trimester
bleeding, n.v, jaundice, coma

tx: termination of preg

A

acute fatty liver of preg

54
Q

inflam rxn in liver for >6mo
jaundice,

fatique/malaise/anoerxia/low grade fever

complications of cirrhosis
chronic HBV/HCV
HBV - polyarteritis nodosa
HCV - mixed cryoglobulinemia (abn proteins in blood, thicken in cold temp)

CBC, Chem panel, Coag studies
Bx - histo classification
grade - necrosis and inflam activity
stage - level of dz

progression based on degree of fibrosis

A

Chronic Hepatitis

55
Q

Fibrosis check?

A

serum fibrosure or US elastography

56
Q 
endemic in asia and sub-saharan africa
males
risk of HCC, cirrhosis
asymp healthy carrier state
younger the dz, high prob of chronicity
A

chronic HBV

57
Q 
cirrhosis progression increased in: males, drink 50g ETOH qd, infect after 40yo, immunocomp, tobacco/cannibis smoking/fatty liver
coffee slows 
normal ast/alt
risk of cirrhosis and HCC, genotype 1
Ab + RNA = chronic 
most is curable
A

chronic HCV

58
Q

female, 30-50

progressive jaundice, epistaxis, amenorrhea

exam shows healthy young woman w stigmata of cirrhosis

  • mult spider telangiectasis,
  • cut striae,
  • acne,
  • hirsutism,
  • hepatomegaly

DX:

  • aminotransferases may be>1000
  • total bilirubin is increased
  • T1: adults, hypergammaglobulinemia (IgG), SMA, ANA (anti smooth m(SMA) or antinuclear antibodies)
  • T2: kids, anti LKM antibody (anti liver/kidney microsomal antibodies )

“focus of lobular hepatitis w/ prominent plasma cells”, CD4 and CD8

tx glucocorticoids -prednisone (w-w/o azathroprine)

cirrhosis -> HCC if untreated
liver transplant

A

Autoimmune Hepatitis

59
Q

asymp -> severe liver failure w jaundice, ascites, gi bleed, encephalopathy

typically anorexia, n, v, fever, jaundice, tender heptomegaly, RUQ P

DF > 32 MELD > 21 GAD > 9

tx: steroids, pentoxifylline

A

alc hep

60
Q

excessive alc, exceeds 80g/day males, 30-40g/day females for 10+ yrs

steatosis (Fatty liver) -> alc hepatitis -> cirrhosis

fatty liver = asymp hepatomegaly and mild elevations in biochem liver test - bili and alp

SAAG > 1.1

tx: abstinence from alc
daily multivitamin, thiamine 100mg, folic acid 1mg, zinc
-glucose admin increase the thiamine requirment bc w/o -> wernicke-korsakoff syndorme

A

Alc Liver Dx

61
Q

> 32 poor prognosis
benefit from steroids
involve PT and serum bilirubin

A

maddreys discriminate function (df)

62
Q

predicts mortality based on multivariable mdoel
age, bili, bun, ptt, wbc
> 9 then give glucocorticoids for higher survival

A

glasgow alcoholic hepatitis score

63
Q

> 21 inc significant mortality in alc hepatitis

>14 for liver transplant

A

model for end stage liver diesase MELD

64
Q

alc liver dx labs?

A

high

  • AST 2x > ALT
  • WBC - leukocytosis w left shift if severe
  • bilirubin >10mg/dL
  • ALP and GGT 3x

low
-albumin, wbc (leukopenia), Hgb (anemia, macrocytic), folate, platelets (thrombocytopenia)

marked prolongatin of PTT
US, CT w intravenous contrast or MRI, US elastography
Liver bx: mallory bodies - alc hyaline

65
Q

alc liver complications?

A

mc precursor to cirrhosis in US. -> HCC

-wernicke encephalopathy - thiamine tx
confusino, ataxia, abn eye movements

  • korsakoff syndrome -severe mem issues/ confab stories
  • adverse prog fx:
    predict poor prog - ascites, variceal hemorrhage, encephalopathy, heptorenal syndrome
    —critically ill pt w alc hepatitis have 30 day mortality rates
    —severe alc hepatitis characterized by:
    —–total bili > 8-10mg, PTT >6sec
    —–susceptible to infections including invasive aspergillosis
    —–hypoalbuminemia, azotemia
66
Q

alch related or NAFLD

mc chronic liver disease

causes: metabolic syndrome - obese, dm, hypertriglyceridemia

risk for cv dz, ckd, colorectal ca

protective: activity, coffee
uncommon in AA (NASH - nonalc steatohepatitis)

asymp w RUQ discomfort, hepatomegaly
labs mild elevation ast/alt, alp, maybe normal

image: US elastography - liver sitffness est hepatic fibrosis

liver bx: diagnostic , focal infiltration by polymorhponuclear neutrophils and mallory hyaline, a pic indistinguishable from alc hepatitis

lifestyle mod,
statin not contraindicated
advanced cirrhosis. -> liver transplant

A

fatty liver - hepatic steaotsis

67
Q

AR, low levels of a1-antitrypsin

pulmonary emphysema (protease activity crazy)

panacinar emphysema at young age - lower lobes

hep accumulation of misfolded protein -> liver dz

MC diagnosed inherited hepatic dz in infants and children

mc genetic cause requiring liver transplant in children

micronodular cirrhosis -> hcc

A

alpha 1 antitrypsin def

dx by low alpha 1 antitrypsin level
- check phenotype of this
smoking abstinence/cessation
liver transplant

68
Q

progressive non-suppurative destructive intrahepatic cholangitis

infections w novosphingobium aromaticivorans or chlamydophila pna triggers

autoimmune T lymphocyte destruction of small intrahep bile ducts and cholestatis, florid duct lesions (lymph or granulomatous bile duct desctruction)

female, 50, US and N Europe

rf: UTI, smoke, hormone replacement, hair dye
associated autoimmune dz

acute: asymp isolated elevation in ALP

advanced dz: pruitius, progressive jaundice, xanthelasma, skin hyperpigmentation, steatorrhea/vit d malabsorption, osteomalacia/porosis, hypercholesterolemia

antimito antibodies against E2. of PDC-E2 (ANA, ANCA)
increased IgM, GGT/ALP (increased for 6mo to dx), bili cholesterol

tx: ursodeoxycholic acid

liver failure prognosis - age, bili in serum, alb, ptt, edema
–>HCC

A

primary biliary cholangitis - 1 biliary cirrhosis

associated w sjogrens syndrome, scleroderma, thyroid dz

69
Q

HFE gene mut on ch 6

increase in:
- iron abs from duodenum
male
- iron sat and increase serum ferritin or a fam hx
- accum of iron as hemosiderin in livr, panc, heart, adrenals, testes, pituitary, kidneys

50 >
classic triad: cirrhosis w hepatomegaly, abn skin pigmentation, dm, cardiac dysfxn (HF)

early - nonspecific, later - skin pigmentation to bronze color, dm, erectile dysfxn

HFE gene mut, mild abn liver enzymes, elevated plasma iron w greater than 45% transferrin saturation
elevated serum ferritin

imaging:

  • MRI - show liver iron stores and fibrosis
  • CT
  • liver bx
  • – homozygous for C282Y, determines if cirrhosis is present

screening for HFE in all first degree fam
phlebotomy therapy, deplete iron stores
avoid food rich in iron and monitor
admin ppi

liver transplantation

rf for fibrosis - male, excess alc, dm
if hep or panc insuff , hf,
hypogonadism -> increases mortality

A

hemochromatosis

70
Q

ch 13, ATP7B

person under 40

impaired cu excretion into bile and failure to incorporate copper into ceruloplasmin
accum in liver, brain, eye (also kidney, bones, joints, parathyroid glands)

copper is also toxic to RBC -> hemolytic anemia

liver dz in adults, neuropsychiatric dz in ya

child or ya w: hepatitis, hemolytic anemia, neurologic, psychiatric abnorm, splenomegaly w hypersplenism, coombs-neg, portal hypertension

neurologic manifestations - parkinsonism, tremor, ataxia, dysarthria, dysphagia, incoordination, spasticity

psychiatric - behavioral and personality changes and emotional lability

pathognomonic sign of condition is is brownish or gray -green Kayser-Fleischer ring

assoc: renal calculi, hemolytic anemia, subcut lipomas
kayser fleischer rings
elevated liver enzymes
increased urinary copper excetion, hep copper conc
low serum ceruloplasmin

MRI of brain should cooper there in the basal gang, brainstem
mol analysis of ATP7B mut

tx: oral penicillamin
liver transplant
cirrhosis

A

wilson’s dz

71
Q

SAAG > 1.1

passive congestion of liver - nutmeg in RHF
ischemic hep -> acute fall in cardiac output
statin thx prior to admin - protect against ischemic hepatitis

hypotension may be absent

hepatojugular reflux present, tricuspid regurg the liver may be pulsatile

jaundice associated w worse outcomes

ast/alt mild ele in abs of superimposed ischemia

markedly elevated serum N-terminal-proBNP or BNP

shock liver: rapid and striking elevation of serum aminotrans levers
greater than 5000
early rapid rise in LDH

elevations of serum alkaline phosp and bili are mild

mortality rate due to underlying dz is high

A

liver in HF

72
Q

liver cell injur -> inflammation/necrosis/stellate cell activation -> fibrosis -> destroys vascu and lobar architecture -> diminishing blood low, forming regenerative nodules

hx:

  • viral - tattoos, iv/intralnasal drug use, maternal hx, blood transfusion
  • alc consumption
  • hx of viral hep or jaundice

rf:
- alc
- iv drug abuse (intranasal) -> viral
- obesity
- viral

reduces risk: coffee, tea

mc = hep c, alc liver dz, nafld

A

Cirrhosis

73
Q

path accum of fluid in peritoneal cavity

mc cause is portal htn, second to chronic liver disease

increased abd girth and or pain

asterixis - secondary to encephalopathy

shifting dullness - percussion that changes w position, >1500ml for reliability

abd US see fluid +doppler (detect vascular in Budd Chiari)

abd paracentesis

A

ascites

74
Q

ascites labs?

A

studies on ascitic fluid 1. cell count wbc = abd is inflam, SBP? = pmn 250
2. albumin and total protein
serum ascites albumin gradient
3. culture and gram stain for aerobic and anaerobic cultures

75
Q

acute gastro hemorrhage w melena, hematochezia, hematemesis - hypovolemia manifested by vital signs and shock

dilated submucosal v in esophagus, secondary portal htn from cirrhosis

risk of bleeds eso varices?

A

esophageal varices

size larger than 5mm, red wale markings (long dilated venules on varix), severity of liver disease, active alc abuse

76
Q

AMS in presence of liver fail
ammonia levels increased in enceph

proceeds: gi bleed, constipation, sepsis

clincial dx

ammonia levels high

lactulose = acidifys colon, diarrhea,
maintstay of tx
goal 2-3 soft stools a day
poor abs antibiotics in pt don’t tol

tx: lactulose - ie rifaximin
hx: asterixis - flapping tremor, neuro symp

grades:

  1. mild confusion
  2. drowsiness
  3. stupor
  4. coma
A

hepatic encephalopathy

77
Q

male, 50-60,
cirrhosis leads to this,
asia, africa

cachexia, abd p, fever, jaundice, itch, tremors, disorientation, hepatomegaly, ascites, peri edema

AFP and US every 6 mo

pt w liver disase see abn on US or AFP
abd liver function test and liver enzymes

tx:
surgical resection or liver transplantation
radiofreq ablation
transcathter arterial embolization

A

HCC

78
Q

hemochromatosis + anemia or thalassemia cant tolerate phlebotomy so use what?

affected pt are at increased risk of infection w/ what?

A

deferoxamine

vibrio vulnificus, listeria monocytogenese, yersinia enterocolitica

79
Q 
normal until end stg dz
jaundice, 
scleral icterus, 
spider angiomata (telangiectasias - upper body), 
gynecomastia, 
ascites, 
esophageal varices, 
palmar erythema, 
asterixis, 
caput medusae
duputrans contracture, 
umbilical hernia, 
hypoalbuminemia - muehrckes lines and terrys nails
A

cirrhosis

80
Q

best imaging for cirrhosis?

A

ultrasongoraphy

  • RUQ liver
  • w/ doppler of veins

paracentesis - dx/tx
-SAAG =Serum albumin – ascites albumin
>1.1 portal HTN related
>250 PMN, think SBP

esophagoduodenoscopy -dx/tx

noninvasive predictive indices for hep fibrosis
US elastography
serum dx specific for fibrosis - fibrosure (estatography score)

81
Q

cirrhosis complications?

tx?

A

Spon bacterial peritonitis
blood culture, paracentesis ( albumin, wbc w diff, culture and gram stain)
hepatocellular carcinoma, decompensated cirrhosis
hiv co infection

tx:
- underlying cuase - viral help, pbc, wilsons, autoimmune, hemochromatosis

-portal htn supportative		
	varices	
	ascites	
	encephalopathy	
	pruritus	
	prophylactic antibiotics	
		sbp/gi bleed/invasive 
                procedures -cipro
       -TIPS (trangsjugular intrahepatic portosystemic shunt)

SBP ceftrizxone or cefotaxime - iv albumin for renal perf pressure

HCC: ablation, resection

Liver transplant

82
Q

management for cirrhosis?

A

abstain from alc, drugs, smoking, liver toxic meds, nsaids
mod acetaminophen - 2g/24hrs
egd for varices
moniter labs - liver enzymes, platelets, pt, inr
alpha fetoprotein and US every 6 mo to look for HCC
immunizations - pneumococcal, hep a and b, flu
NAFLD wt reduction, exercise, control dm

83
Q

liver transplant

A

refer = 1st onset of major complications - ascites, variceal bleed, enceph, jaundice, liver lesion, hep dysfxn
worsening meld or child pugh scores
abstinent for 6mo, no alc

84
Q

severity rating for cirrhosis

A 
MELD/ + Na	
- bili, creatinine, na (CMP)
	MELD >10 worse, >14 transplant 
child turcotte pugh scoring	
	bili, albumin -cmp
	pt, inr, PE for enceph and ascites
	A-C (c is worst)
85
Q

markers for liver damage

A

ASL/ALT: increased necrosis and liver cell injury
ALP: sensitive to cholestatic biliary obstruction
Bilirubin
LDH/GGT

86
Q

liver fxn test

A

PT/INR - w INR tst w VIt K -> corrects, then absorption isuenot disease
albumin
cholesterol
ammonia

87
Q

primary injury to hepatocytes

increased AST/ALT

A

hepatocellular

88
Q

primary injury to bile ducts

increase ALP/bilirubin

A

cholestatic

jaundice and pruitius

89
Q

what is most specific test for the liver?

A

ALT

90
Q

how are bilirubin, liver enzymes, blood counts, etc affected with:

liver dz
hemolysis
gilbert’s

A

liver dz: increased bili (Both) and liver enzymes

hemolysis: normal direct, increased indirect, anemia, increased reticulocyte count. normal liver enzymes

gilbert’s: normal direct and liver enzymes, no anemia, increased indirect (esp in fasting)

91
Q

+ when pt takes deep breath - then stop bc of pain or cough during palp of RUQ

A

murphy’s sign

92
Q

types: cholesterol, pigment
asmp until they obstruct or trigger inflamm
- then get biliary colic (this is?)
- n.v

dx: ultrasonography (RUQ US/hepatobiliary UD) which you see stones and acoustic shadow
tx: decreased fat diet

A

cholelithiasis

93
Q

RF for cholelithiasis

A 
american indians
weight loss
dm, obese
crohns
preg
oc
94
Q

protective for cholelithiasis

A

decreased carbs, increased PA, fitness of CV, coffee, Mg and healthy fats, fiver, statins, and nsaids

95
Q

mc acute cholecystitis?

A

calculous - gallstones in cystic duct, smaller = more dangerous
other little is acalculous w no stones - from infection, illness, ca, could be from ischemia, more dangerous bc can have no symptoms referable to gb, increased incidence of gangrene and perf
- s. typhi and staph can cause
- along w poly nodosa, atherosclerotic ischemic dz, aids - crypotsporidium, ascending infection

96
Q 
tea color urine, acholic stools
muscle guarding and tender
get pain when you eat a fatty meal
jaundice
- fever, anorexia, tachy, sweat, n/v

obstruction of the neck of the gb, or cystic duct

leukocytosis, increased ALP/GGT, AST

tx: antibiotics and surgery (cholecystectomy)

Image: RUQ abd ultrasonography
- thicken gb, pericholecystic fluid, sonographyc murphy sign

complications: gangrene -> perf -> abscess -> peritionitis
emphysematous cholecystitis (from gas form org)
assciated w increased risk of gb carcinoma

A

acute cholecystitis

97
Q 
stones in common bile duct
recurrent attacks of RUQ pain for hours
chills + fever
hx jaundice w pain
Increased AST/ALT (LOTS), bilirubin, leukocytosis, w slow rise of alp, ggt

this can lead to what?
gold std for dx and theraputic?

A

choledocholithiasis

acute ascending cholangitis

ERCP - check inr first, + sphincterotomy for stone extraction and stent placement

could do lap cholecystectomy

98
Q

charcot’s triad

reynolds pentad

A

RUQ p + fever/chills + jaundice

if reynolds, then add AMS + hypotension

99
Q

charcot triad/reynolds pentad

recurrent attacks of RUQ pain for hours
chills + fever
hx jaundice w pain

labs: + blood cultures (for what?)
image: ERCP + sphinceterotomy
tx: ERCP or lap cholecystectomy

A

ascending cholangitis

e.coli, klebsiella, entercoccus

100
Q

what labs will be elevated if the stone was at:

cystic duct?

common bile duct

sphincter of vadar

A

increased wbc (inflamm and infection)

increased AST/ALT/ALK, direct bili

increased of all - AST/ALT/ALK, both bili, wbc, lipases amylase

101
Q

RUQ p that limits activites of daily living, nausea
pain sim to biliary colic

normal US
normal enzymes across the board

dx: Rome III dx criteria
HIDA scan + CCK (tc 99)
abn: gb not see (with just hida?)
abn ejection fraction -> choleycystectomy < 35-38

A

biliary dyskinesia

102
Q

biliary colic

A

severe steady ache RUQ or epigastric area

radiates to R scapula

103
Q

chronic inflamed bladder + gallstones

repeat acute/subacute cholecystitis
can have rochan. sinuses - dilated epi space, invag into fibrotic tissue

inflammation cells in LP (lymphocytes, macrophages, plasma cells)

granulomatous and multi nuc giant cells from cholesterol crystals

complications: porcelain gb on xray -> incidental calcified lesion

risk of gb ca
need surgery

A

chronic cholecystitis

104
Q

liver bx shows periductal fibrosis (aka what?)

gold standard dx: on ercp, mrcp it look like beads on a string from strictures/inflammatory destruction and beading of large bile ducts

progressive, associated w IBD, panc, fibrosing dz

pANCA +, sometimes see increased ALP in esp UC pt

male 20-50
assoc w UC
coffee and smoking decreases risk
pruritus, jaundice, fatigue

increased risk of cholangiocarcinoma and colon ca

not satisfiying tx, tx like cholangitis

A

primary sclerosing cholangitis

onion skinning

can be associated w ascending cholangitis (charcot triad), along w chronic pancreatitis, chronic cholescystitis
–> hepatic fibrosis and cirrhosis -> cholangiocarcinoma

105
Q

ischemic changes in liver parenchyma causes destruction of bile ducts resulting in this

from inflammation and endothelial damage from antibodies binding to vascular endothelium, activating complement in acute rejection

can also occur in chronic rejetion - TGFB stim fibroblast from stellate cells and vascular sm cell stimulation (proliferation) -> interstitial fibrosis, inflammation and endothelial damage

A

vanishing bile duct syndrome

106
Q

what is the mc gallbladder congenital anomaly?

A

folded funus = phrygian cap

107
Q

mc biliary tract disease is attributable to?

mc type?

A

cholelithiasis

cholesterol in US, western europe, native americans (radiolucent)

pigment is the other type, mc in non western pop

  • in setting of bacterial infections, parasitic infestations, chronic red cell hemolysis dz
  • –liver flukes ( clinorchis sinensis, ascaris lumbricoides, e coli)
  • black stones (radiopaque) - in gb, brown - large bile ducts (radiolucent)
  • asians, rural
108
Q

large gallstone erode directly into adjacent loop of small bowel generating intestinal obstruction

A

gallstone ileus or bouveret syndrome

109
Q

green pus, increased wall thickening, serosis that is hemorrhagic bc there is only one blood vessel -> necrosis is what?

A

acute cholesthisis

cystic artery is the only blood supply -> emphysematous cholestitis - air around gb

110
Q

mc malignancy of extrahepatic biliary tract

A

carcinoma of gb, women bc of gallstones

  • adenocarcinomas mc in fundus
  • travel into liver, cystic duct, bile ducts, portal hepatic lymph nodes,
  • peritoneum, git, lungs common seeding sites
111
Q

SINGLE well demarcated lesion w central scare

incidental finding, normal liver

ya to middle adults

maplike pattern of strong cytoplasmic gs staining

confused with malignancy

A

focal nodular hyperplasia

112
Q

MULTIPLE nodules but no fibrous septa

looks like cirrhosis

portal htn where nodules impede blood flow

associated w hiv, rheumatoglogic dz

A

nodular regenerative hyperplasia

113
Q

mc benign neoplasm of the liver?

A

cavernous hemanigioma

females, asymp, incidental discovery

unless intraabd emergency from hemorrhage due to subcap location (rupture easy) - life threatening

often mistaken for malignancy

114
Q

benign neoplasm in young women

associated w oral contraceptives and anabolic steroids

increased risk w obesity and metabolic syndrome

incidental finding on imaging

pain from rapid growth or hemorrhage or rupture

A

hepatocellular adenoma

115
Q

one of mc adenomas

females
min risk of -> HCC

fatty w no atypia

A

HNF1-a inactivated adenoma

116
Q

one of mc adenomas

females

assoc w obese, metabolic syndrome
B catenin mutations - high risk of malig
overexpress of crp and amyloid A - mimcs FNH

A

inflammatory adenomas

117
Q

high risk for malignant transformation to HCC

oral contraceptive and anabolic steroid use association

men

A

B catenin activated adenomas

see w b catenin staining and dysplasia

118
Q

mc peds hepatocellular tumor?
<3yo
abd swelling in asymp child
could have jaundice or pruritis

associated with what?

metastasized to?

A

hepatoblastoma

FAP, beckwith-wiedemann syndome

lung metastasis

119
Q

mc epithelial tumors:

mc primary malig of hepatocytes?

A

hcc

  • mc in asia and subsaharan africa w HBV, male, 20-40yo
  • hcv in western countries, metabolic syndrome (NAFLD)

can also be from a1-at, hemochromatosis, wilsons,
-mc caused from CLD, cirrhosis
or adenomas aflatoxins (noncirrhotic livers)

cholangiocarcinoma

120
Q

rare, nonepithelial tumors

caused by vinyl cl, arsenic, thorotrast

A

angiosarcoma

121
Q

rare
mc primary hepatic lymphoma
middle aged men
assoc w HBV, HCV, HIV, PBC

second mc lymphoma?

  • mc in ya males
  • predilection for growth w/in sinusoids of liver, spleen and bone marrow
A

diffuse large b cell lymphoma is mc, followed by malt

hepatosplenic t cell lymphoma

122
Q

what are the types of hepatoblastoma?

A

epithelial type - polygonal fetal cells and smaller embryonal cells forming acini, tubules and papillary structures

mixed epi and mesenchymal type: foci of mesenchymal differentiation consist of primitive mesenchyme, osteoid, cartilage, striated m

123
Q

distinctive HCC variant
under 35yo
single large, hard scirrhous tumor w fibrous bands

under microscope - large polygonal cells w granular cytoplasm w abundant mitochondria
vesicular nuclei w prominent nucleolus, parallel lamellae w dense collagen bundles

A

fibrolamella carcinoma

124
Q

hepatic ca tx

A

surgical resection
liver transplantation
image guided tumor ablation

125
Q

adenocarcinomas from intrahepatic biliary tree?

  • mc malig tumor after HCC
  • common in SE asain contries - thailand, laos, cambodia (liver flukes)
  • found indicentally or have a cholestatic picture

adenocarcinomas from extrahepatic bile ducts?
- biliary obstruction symp

A

intrahepatic cholangiocarcinoma

biliary adenocarcinoma

  • rf: chronic inflammation, psc, liver flukes, hepatolithiasis, HBV, HCV, NAFLD, fibropolycystic liver dz
  • glandular structures lined by mali epi cells in abundant fibrous stroma
  • lymphovascular and perinueral invasion common
126
Q

what is more common: primary hepatic neoplasia or metastatic malignancy involving the liver?

A

metastatic malignancy involving the liver

mc colon, breast. lung, panc spread
anorexia, fever, jaundice, n/ RUQ pain, sweat, wt loss

127
Q

what has the highest inherited pedisposition of panc carcinioma?

A

peutz jegher syndrome, STK11

128
Q

what is the mc herediatry panc genes?

A

PRSS1, SPINK1

deal with trypsinogen

Year 2 (10 decks)

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