Week 4: Infections of the liver & biliary tree Flashcards
1
Q
Case 1
A
2
Q
Clinical findings of infections of the biliary system
A
- Charcot’s triad (RUQ pain, fever and chills, jaundice) continuous pain may radiate to right infrascapular region
- Murphy’s Sign: inhibition of inspiration by pain when the area of the gallbladder fossa is palpated
3
Q
Laboratory findings of infections of the biliary system
A
- Leukocytosis
- Elevated alk phos & DB if the common bile duct is involved
4
Q
Causative organisms of infections of the biliary system
A
- GNR: E coli, Klebsiella
- GPC: Enterococcus
- Anaerobes also but not that common
5
Q
Types of infections of the biliary system
A
- Acute cholecystitis
- Cholangitis
6
Q
What is acute cholecystitis
A
- obstruction of biliary drainage
- up to 50% complicated by infection
7
Q
Complications of acute cholecystitis
A
- emphysematous cholecystitis
- pyogenic liver abscess
- bacteremia
- perforation
- peritonitis
8
Q
What is cholangitis?
A
- Infection of the common bile duct
- stasis from obstruction favors the growth of bacteria
- increased pressure predisposes bacteremia
9
Q
Complications of cholangitis
A
may be associated with hypotension and altered mental status
10
Q
Case 2
A
11
Q
Routes of hepatic invasion causing pyogenic liver abscess
A
- Cholangitis
- Hepatic artery
- Portal vein
- Direct extension from contiguous focus of infection
- cholecystitis
- subphrenic abscess
- perinephric abscess
- Penetrating trauma
12
Q
Common presentation of pyogenic liver abscess
A
- middle-aged
- 50% solitary
- Right-sided
13
Q
Diagnosis of pyogenic liver abscess
A
- Fine needle aspiration for gram-stain and culture (aerobic & anaerobic)
- Blood cultures (aerobic & anaerobic) positive 50%
14
Q
Laboratory findings of pyogenic liver abscess
A
- peripheral leukocytosis
- elevated alk phos
- Culture: polymicorbia;
- GNR: E coli, Klebsiella
- GPC: Enterococcus, Strep viridians group
- Anaerobe: Bacteroides fragilis
15
Q
Treatment of pyogenic liver abscess
A
- Long-term antibiotics (4-6 weeks) PLUS drainage
16
Q
Gram-positive cocci flowchart
A
17
Q
gram-negative bacilli flowchart
A
18
Q
Bacteroides fragilis type
A
- Anaerobic GNR
- GI flora
- Major component of polymicrobial abdominal infections
19
Q
Case 2 continued
A
20
Q
Cause of amebic liver abscess
A
- Ingestion of contaminated food/water with cysts of Entamoeba histolytica
21
Q
Stages in human amebic liver abscess
A
- Excystation in intestinal lumen
- Trophozoites migrate to colon and adhere to epithelium
- Trophozoites multiply by binary fission
- Infectious cysts released in stool
22
Q
Signs & Symptoms of Amebic Liver Abscess
A
- 10% symptomatic colitis (DDx of bloody diarrhea)
- <1% liver abscess
- Entamoeba histolytica induces apoptosis in hepatocytes & neutrophils, forming large, non-purulent, “anchovy paste” abscesses
23
Q
Diagnosis of Amebic Liver Abscess
A
- imaging & serum Ab
- Trichrome stain for cysts in stool not specific since look like nonpathogenic species
24
Q
Treatment of amebic liver abscess
A
25
Case 3
26
Hydatid cysts of liver
27
Common presentation of Hydatid cysts of liver
many are asymptomatic
28
Diagnosis of Hydatid cysts of liver
29
Treatment of Hydatid cysts of liver
* Surgical removal
* Radical surgical resection
* PAIR: puncture, aspiration, injection, re-aspiration
* Albendazole x 30d
* albendazole binds beta-tubulin of cestode
30
Albendazole MOA
* albendazole binds beta-tubulin of cestode
31
Case 4
32
What is Peritonitis?
Diffuse or localized infection in the abdominal cavity
33
Signs & Symptoms of Peritonitis
* Fever
* Abdominal pain
* Rebound
* Guarding
34
Types of peritonitis and prevalence
Primary (spontaneous) peritonitis 1%
Secondary 80-90%
35
Risks for primary (spontaneous) peritonitis
* cirrhosis with ascites (GNR)
* Peritoneal dialysis (staph aureus, CoNS)
36
Route for primary peritonitis
* Hematogenous
* lymphogenous
* transmural migration through intact intestinal lumen
37
Pathogen of primary peritonitis
* Majority are monomicrobial
* PMN \>= 250 cells/mm3
38
Secondary peritonitis cause
Intra-abdominal source
39
Risks for Secondary peritonitis
* bowel perforation
* ischemic bowel
* PID
40
Secondary peritonitis pathogen
Majority are polymicrobial (GNR, Bacteroides fragilis, Enterococci, +/- Candida)
41
What are intraperitoneal abscesses?
42
Question
43
Dx of viral hepatitis
44
Question
45
Question
46
Case 4 continued
47
Recommended testing sequence for identifying current HCV infection
48
Question
49
Question
50
HBV serologies
51
HBV antigens
52
Viral hepatitis
53
ABCs of hepatitis
54
Antiparasitic agents
55
Agents for the treatment of viral hepatitis
