Flashcards in 9.2 Hepatobiliary Deck (32)
Sickle cell pt with RUQ pain, jaundice, and increased TBili
DO NOT assume choledocholithiasis.
Think: Cholecystitis (from bilirubin stones), causing an acute sickle crisis, causing hemolysis.
This would have normal LFTs
-which 2 infections to know, and their tx
1. echinococcus cyst--do surgery
only indication for emergeny cholecystectomy
During cholecystitis not responding to NPO, IVF, Abx.
To prevent perf
GIlbert's, crigler najjar, dubin-johnson, rotor's
Gilbert's, Crig-Naj: unconj Bili
Dubin-johnson, rotors: conj bili (therefore dark urine, clay stools)
AST/ALT in 1000s: ddx
-shock liver (ischemia)
-acute viral hepatitis (hep A,B)--2 weeks after exposure
painless jaundice, think what causes (4)
CA: panc, cholangiocarcinoma, ampulla of vater
Pt with painless jaundice and GI bleed, think what
Ampulla of Vater cancer
Sepsis + D.Bili elevated + ALP elevated
cholestasis or gallstones.
RUQ U/S to r/o
-next 3 to think of
trauma, hyperCa, hyperTG
order Ca+, lipid panel
also med-induced, etc
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
-If <6cm and <6 weeks, allow to spontaneously resolve. rCT in 2 weeks
-If not, then surgical drainage (percutaneous, open surgery, or stomach)
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
Necrotizing pancreatitis: tx
IVF, NPO, analgesia.
NO ABX UNTIL proven infection (may need bx)
-what to do
Pt admitted for acute pancreatitis. Day 2 gets:
-ARDS, low sats
-hypoCa despite Ca (saponification)
-hypotensive, poor fluid response (fluid sequestration)
-central line for pressor support
-CXR for ARDS
-CT scan to show extent of necrosis.
-FNA bx to confirm infection, then start IV meropenem
Viral (hep b,c)
Something rare--eg autoimmune
PBC cirrhosis vignette
female, 40s, jaundice, cirrhosis, normal biliary imaging
-what is this, how to use
Serum albumin - ascites albumin
get in pts with ascites
>1.1: Portal HTN related
-R side HF
<1.1: not portal HTN related
Diuresis with spirono and Lasix.
Tap 4-6L paracentesis, albumin infusion.
Spont bact peritonitis
-how to dx
-what if polymicrobial
-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
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
-tx (3 things)
Pt has renal fail and cirrhosis, fatal.
-how to dx and confirm
-low serum ceruloplasmin (bound to copper)
-high urine Copper
confirm with Liver bx
-what if refractory
-penicillamine (Copper chelator, to excrete in urine)
-dx (first test, confirm)
triad: cirrhosis, diabetes, hyperpigmentation (bronze diabetes)
-dx with high ferritin, then liver bx
-tx with deferoxamine or serial phlebotomy. transplant too
PSC vs PBC
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
Hep B tx
Hep C tx
-antivirals (eg lamivudine)
Hep B and C
Hep B yes
Hep C no
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