9.2 Hepatobiliary Flashcards Preview

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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

32

Hep C HCC vs Hep B HCC
-what difference
-what screening

you can get HCC without cirrhosis with Hep B (so aggressive screening!)

U/S and AFP q6mo for Hep C with cirrhosis, or Hep B asian males>40, asian females>50