Flashcards in 9.2 Hepatobiliary Deck (32):
1
Sickle cell pt with RUQ pain, jaundice, and increased TBili
Think what
DO NOT assume choledocholithiasis.
Think: Cholecystitis (from bilirubin stones), causing an acute sickle crisis, causing hemolysis.
This would have normal LFTs
2
Liver abscess
-which 2 infections to know, and their tx
1. echinococcus cyst--do surgery
2. amoeba--MTX
3
only indication for emergeny cholecystectomy
During cholecystitis not responding to NPO, IVF, Abx.
To prevent perf
4
GIlbert's, crigler najjar, dubin-johnson, rotor's
difference
Gilbert's, Crig-Naj: unconj Bili
Dubin-johnson, rotors: conj bili (therefore dark urine, clay stools)
5
AST/ALT in 1000s: ddx
(6)
-amanita mushroom
-shock liver (ischemia)
-tylenol OD
-acute viral hepatitis (hep A,B)--2 weeks after exposure
-autoimmune
-Budd-Chiari
6
Ab dx:
PBC
PSC
autoimmune hepatitis
anti-smooth muscle
ANCA
AMA
7
painless jaundice, think what causes (4)
-what test
CA: panc, cholangiocarcinoma, ampulla of vater
PSC, PBC
biliary strictures
Do MRCP
8
Pt with painless jaundice and GI bleed, think what
Ampulla of Vater cancer
9
Sepsis + D.Bili elevated + ALP elevated
Think what
cholestasis or gallstones.
RUQ U/S to r/o
10
Pancreatitis causes:
-Big 2
-next 3 to think of
stones, ETOH
trauma, hyperCa, hyperTG
order Ca+, lipid panel
also med-induced, etc
11
When to do CT in pancreatitis, according to onlinemeded (3 times)
CT at day1 often shows nothing.
1. initial presentation and lipase low, but story is likely pancreatitis
2. initial presentation of pancreatitis and sick enough to go to unit and need meropenem
3. Day2-week2 to assess complications
CT can also dx chronic panc
12
pancreatitis pseudocyst
-tx
6/6 rule
-If <6cm and <6 weeks, allow to spontaneously resolve. rCT in 2 weeks
-If not, then surgical drainage (percutaneous, open surgery, or stomach)
13
Pancreatitis complications (4 to know).
How to tell apart?
Time and fever/leuks.
1. Abscess: 1-2 wks, fever+leuks
2. Pseudocyst: 1-2 wks, NO fever/leuks
3. Necrotizing panc. 1-2 days, fever/leuks. hemoconcentration
4. Hemorrhagic panc. 1-2 days, NO fever/leuks. declining Hct
14
Necrotizing pancreatitis: tx
IVF, NPO, analgesia.
NO ABX UNTIL proven infection (may need bx)
15
Necrotizing pancreatitis:
-vignette, sxs
-what to do
Pt admitted for acute pancreatitis. Day 2 gets:
-renal failure
-ARDS, low sats
-hypoCa despite Ca (saponification)
-hypotensive, poor fluid response (fluid sequestration)
-early intubation
-central line for pressor support
-CXR for ARDS
-CT scan to show extent of necrosis.
-FNA bx to confirm infection, then start IV meropenem
16
Cirrhosis ddx
"VW HAPPENS"
Viral (hep b,c)
Wilson's
Hemachromatosis
A1-antitrypsin
PBC
PSC
ETOH
NASH/NAFLD
Something rare--eg autoimmune
17
PBC cirrhosis vignette
female, 40s, jaundice, cirrhosis, normal biliary imaging
18
SAAG score
-what is this, how to use
Serum albumin - ascites albumin
get in pts with ascites
>1.1: Portal HTN related
-Cirrhosis
-R side HF
-Budd chiari
<1.1: not portal HTN related
-CA
-peritoneal TB
-nephrotic syndrome
-protein malabsorption
19
Ascites tx:
-Na
-H2O
-other
Na <2g/day
H2O <2L/day
Diuresis with spirono and Lasix.
Tap 4-6L paracentesis, albumin infusion.
Severe: TIPS
20
Spont bact peritonitis
-how to dx
-what bugs
-what if polymicrobial
-tx
-250 polys after tap, with cx+
-Strep pneumo, G- rods
-if polymicrobial, not SBP. Actually secondary bacterial peritonitis from viscreal organs. Add MTZ to ceftriaxone, do ex lap.
-Ceftriaxone, with FQ ppx
21
hepatic encephalopathy
-tx (2)
lactulose--alters pH to trap ammonia in gut to poop out. titrate to 3-4 BMs/day
rifaximin--abx to kill gut flora, make less nitrogen
22
hepatorenal syndrome
-tx (3 things)
Pt has renal fail and cirrhosis, fatal.
-hold diuretics
-give albumin
-octreotide
23
Wilson's disease
-how to dx and confirm
-low serum ceruloplasmin (bound to copper)
-high urine Copper
-Kayser-fleischer rings
confirm with Liver bx
24
Wilson's dz
-tx
-what if refractory
-penicillamine (Copper chelator, to excrete in urine)
-transplant
25
Hemochromatosis
-classic sxs
-dx (first test, confirm)
-tx
triad: cirrhosis, diabetes, hyperpigmentation (bronze diabetes)
-dx with high ferritin, then liver bx
-tx with deferoxamine or serial phlebotomy. transplant too
26
PSC vs PBC
-sxs
-dx
-tx
PSC: obstruction of extrahepatic ducts (macroductal)
-beads on string on MRCP. ANCA+
-cholestyramine, urso acid
PBC: intrahepatic ducts (microductal)
-nothing on imaging. AMA+, liver bx
-urso acid
27
Hep B tx
Hep C tx
-peg interferon
-antivirals (eg lamivudine)
-ribavirin+interfron
-also Boceprevir
28
Hep B and C
-sex transmitted?
Hep B yes
Hep C no
29
Liver dz: hepatic encephalopathy. What happens if untx?
high ammonia is like 3% normal saline. ammonium is going to brain, causing fluid shifts.
Risk for herniation
30
On test: Cirrhosis and:
1. COPD
2. diabetes, tan skin
3. chorea, eye
4. IBD
5. ETOH
6. positive serology
7. long list of negative tests
1. A1AT def
2. hemochromatosis
3. wilsons
4. PSC
5. alcohol
6. Hep
7. NASH (dx of exclusion)
31
why give variceal bleeder ceftriaxone?
give in first 12h to ppx SBP
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