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GIGU2 Exam 2 > Approach To The Pancreatic Patient - Dr. McGowen > Flashcards

Approach To The Pancreatic Patient - Dr. McGowen Flashcards

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1
Q

Acute Pancreatitis EM : what is it, risks, SX

A
  1. autodigestion by self enzymes getting activated
  2. Biliary tract problems like gallstones, heavy alcohol, hyperglyceridermia, trauma, ERCP, medications
  3. epigastric pain, radiate to back, cullen or turner sign, ARDS, Chvostek and Trousseau sign = hypocalcemia
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2
Q

Acute Pancreatitis EM : Labs and DX

A
  1. Lipase elevated X3*, elevated Hct = pancreatic necrosis, high ALK/ BUN/ Cr/ billirubin, LOW Ca = tetany
  2. at least 2 of these** (epigastric pain, elevated Lipase 3X upper limit, CT changes consistent with pancreatitis)
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3
Q

Acute Pancreatitis : imaging

  1. CT no contrast
  2. CT IV contrast
  3. ABD XRAY
  4. Chest XRAY
  5. US
A
  1. CT without contrast : enlarged pancreas
  2. CT + IV contrast : necrosis, AVOID if cr is over 1.5, can make pancreatitis worse
  3. ABD X-ray : Sentinel loop (air in LUQ intestines), Colon cutoff sign (gas in colon stoping abruptly at sight on pancreatitis)**
  4. Chest X-ray : pleural effusion (supinated then prone fluid)
  5. US not helpful (only gallstones if present)
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4
Q

Acute Pancreatitis : complications

A
  1. intravascular volume depletion = fluid leaking out causing pre-renal azotemia (acute tubular necrosis)*
  2. fluid (plueral effusion), emphysematous pancreatitis)
  3. ARDS*
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5
Q

Acute Pancreatitis : TX

A
  1. fluid resuscitation (LOTS) ** (dont increase fluids it can lead to pain and ARDS)
  2. Ca gluconate IV : tetany
  3. give albumin and plasma :
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6
Q

APACHE 2

A

acute physiology and chronic health evaluation (predicts mortailty) =over 8 is higher mortality

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7
Q

C & HOBBS

A 
score if this happens in the first 48hrs = worsening prognosis
1. Ca < 8
2. Hct >10% DROP
3. O2 <60mmHg
4. Base deficit > 4
5. BUN increase > 5
Sequestering fluid > 6L
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8
Q

BISAP**

A

Bedside Index for severity in Acute Pancreatitis

  1. BUN > 25
  2. Impaired mental status
  3. SIRS > or = 2 of 4 present
  4. over 60yo
  5. pleural effusion
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9
Q

3 organisms causing emphysematous pancreatitis

A
  1. Clostridium Perfringens
  2. Enterobacter aerogenes
  3. Enterococcus faecalis
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10
Q

Chronic Pancreatitis : what is it, risks

A
  1. irreversible damage to pancreas cells (self activating digestion), from a SAPE (sentinel acute pancr. event) —-> inflammatroy process that results in injury and fibrosis (Necrosis/fibrosis)
  2. TIGAR-O
    - Toxic Metabolic (alcohol)
    - Idiopathic : smoking
    - genetics : CF
    - autoimmune : Celiac, hypergammaglobunimia (IgG)
    - Recurrent : recurrent AP
    - Obstructive : stricture, stone, tumor
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11
Q

Chronic Pancreatitis : SX

A

constant or intermittent epi pain, CARDINAL SX
= pain hours to weeks, then becomes more constant
= pancreatic exocrine or endocrine insufficiency (steatorrhea –> malabsorption) (DM )

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12
Q

Chronic Pancreatitis : Labs and DX

A
  1. high lipase, amylase,
  2. high Fecal Fat
  3. LOW fecal chymotrypsin
  4. LOW fecal elastase
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13
Q

Chronic Pancreatitis : Imaging

  1. Plain ABD Xray
  2. CT ABD
  3. ERCP
  4. MRCP
  5. EUS
A
  1. Plain ABD X-ray : Calcifications
  2. CT ABD : (if not seen in xray)calcifications —-> tumefactive chronic pan. = concern for pan cancer
  3. ERCP : dilated pancr duct, stones, need more
  4. MRCP : enhance imaging
  5. EUS : biopsy of pancreas
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14
Q

Chronic Pancreatitis : TX

A

pain control, pan enzyme supp, low fat diet, X alcohol, Tx DM,

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15
Q

Chronic Pancreatitis : complications + prognosis

A
  1. DM**, Pancreatic insufficiency = steatorrhea, Pancreatic cancer
  2. Eventually pancreatic cancer causes death
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16
Q

Pancreatic Cancer : what type, where, risks

A
  1. Adenocarcinoma*,
  2. pancreatic head (biliary obstr. and jaundice)
  3. smoking, obese, AA, over 65yo, DM, chronic pancr., cirrhosis, FH
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17
Q

Pancreatic Cancer : SX

A

= painless jaundice ** (if pain usuaully epi and at night when laying back, relived by bending forward)
= New onset DM in elderly **
= Trousseau sign of Malignancy (many venous thrombosis = migratory thrombophlebitis)
= Courvoisers sign : nontender enlarged palpable gallbladder (mass)

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18
Q

Pancreatic Cancer :DX and TX

A
  1. CT ABD and CA 19-9 (mutation in KRAS)

2. whipple procedure surgery (10% curabe)

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19
Q

which lab thing is most important when assessing pancreas function

A

Lipase more then amylase (elevated in other conditions also)

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20
Q

AST/ALT, Alk Phasphate, bilirubun levels show what

A

if there is damage to the liver (nothing to do with the function of the liver)

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21
Q

true liver function enzymes to be measured

A
  1. PT/INR
  2. Albumin
  3. Cholesterol
  4. Ammonia
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22
Q

Hepatocellular disease

A

= primary injury to hepatocytes

= elevated AST/ ALT (most specific is ALT unless alcohol injury)

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23
Q

Cholestatic Disease

A

= primary injury to bile ducts
= primarly Alk phosphatase and bilirumbin elevated
= bile does not get to SI, pruritus ** + jaundice, no hepatocellular necrosis)

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24
Q

elevated alk phosphatase is also seen when

A

childhood, preg, bone disease

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25
Coagulation factors measurement
best mesure for hepatic synthetic function (all clotting factors except F8 is made in liver) = common to use INR
26
clinical signs of jaundice happens at what level
>2mg/dL
27
Jaundice figure out what first and DX
1. unconjugated or conjugated = fractionated bilirubin = indirect vs direct = Fractionate ALP : ordering GGT (gamma-glutamyl transferase) 1. elevated GGT = liver source 2. normal GGT= bone or other source (placenta)
28
high ALP in children
growing bones
29
conjugated jaundice
below liver problem DIRECT , hepatitis, FE problem, lipase, biliary obstruction = image with US
30
unconjugated jaundice
prehepatic problem INDIRECT = CBC anemia or thrombocytopenia, hemolysis**, sickle cells, mishaped RBCs , fasting ** = image peripheral smear = LOW haptoglobin, HIGH retic count, HIGH LDH
31
Gilbert syndrome
fasting (sick / post exercise / on purpose) ----> indirect high bilirubin
32
Cholelithiasis is what 2 types , and what and SX
1. cholesterol (80%) + Pigment stones calcium bilirubinate (20%) 2. gallstones 3. asymp, RUQ pain, can radiate upper right scapula -> biliary colic
33
Cholelithiasis DX
US **** = stones show acoustic shadow
34
Cholelithiasis Risks
1. fair, fat, FH, F, Fertile, Forty (males only more if they have cirrhosis and hep C) 2. prolonged fasting = biliary sludge
35
acute cholecystitis : what 2 types and how
1. Calculous : gallstones impacting cystic duct , inflammation in gallbladder 2. Acalculous : true cholecystitis = no stones , from burns trauma, infections of gallbladder
36
acute cholecytitis SX
large fatty meal gives acute attack, N,V, RUQ and epi pain, MURPHY, (jaundice, pale color stools, dark urine)
37
acute cholecytitis labs and imaging
1. elevated bilirubin, ALP, GGT | 2. RUQ abd US show stones, wall thickening, pericholecystic fluid, acoustic shadows)
38
acute cholecytitis tx | complications
1. surgery, ABs | 2. Gangrene of gallbladder ----> perforation, Emphysematous cholecystitis (gas forming infection)
39
Emphysematous cholecystitis risk and what to do
DM = urgent cholecystectomy | air in lumen and wall of gallbladder
40
Chronic Cholecystitis : what, how, SX
1. chronic inflammation of GB, usually from gallstones = repeated acute subacute cholecystitis 2. asymp for years, chronic or post-prandial RUQ or epi pain
41
Chronic Cholecystitis : tx and complications
1. surgery, | 2. Porcelain gallbladder : XRAY ----> incidental calcified lesions
42
calcified gallbladder means
high risk of gallbladder cancer (poor prognosis)
43
courvoisier gallbladder
enlarged palpable nontender gallbladder with jaundice | = associated with cancer of the head of the pancreas
44
porcelain gallbladder
chronic cholithiasis causes calcified scarring | = associated with GB carcinoma
45
choledocholithiasis : is what, sx
1. stones in common bile duct | 2. severe RUQ pain , fever, jaundice
46
choledocholithiasis : DX and labs
1. high AST, ALT, direct hyperbilirubin, hihg lipase and amylase (secondary pancreatitis****)
47
choledocholithiasis : imaging
INR then ERCP
48
choledocholithiasis : TX
= ERCP with sphincteromy and stone extraction /stent placement **** = do preg test, INR, kidney function before ERCP = cholecystectomy is another option
49
choledocholithiasis complications
acute pancreatitis = from ERCP | = acute ascending cholangitis
50
Ascending cholangitis : is what and risk
1. infection in biliary tract from an obstruction | 2. choledocholithiasis
51
Ascending cholangitis SX
``` = Charcot TRIAD : 1. RUQ pain 2. fever 3. jaundice = Reynold PENTAT : 1. altered mental status 2. hypotension 3. RUQ pain 4. fever 5. jaundice ```
52
acute suppurative cholangitits
pus in biliary duct from infection | = reynolds pentat
53
Ascending cholangitis : DX and imaging
1. high WBC 2. + blood culture 3. high AST/ALT, lipase, direct biilirubin = ERCP, INR
54
Ascending cholangitis complications | and tx
1. acute pancreatitis from ERCP (monitor lipase) | 2. ERCP + sphincterotomy and stone extraction + stent placement *****, or cholecystectomy
55
Biliary Dyskinesia is what and sx
1. functional disorder of GB, unknown reason | 2. frustrated pt, RUQ pain episodes, severe limiting daily activities, N when pain
56
Biliary Dyskinesia DX
= normal US, labs = RUQ pain like biliary colic = normal in HIDA scan, you can see GB ejection fraction
57
Biliary Dyskinesia tx
low fat | surgery (cholecystectomy
58
Primary Sclerosing Cholangitis (PSC) : risk, and sx
1. male, IBD (esp UC), lowered risk with smoking onset, still don't advice it 2. pruritis* , fatigue, jaundice*, RUQ pain*
59
Primary Sclerosing Cholangitis (PSC) : DX and labs
1. high Alk phosphatase, high direct bilirubin = cholestasis 2. IMAGING : = MRCP / ERCP ----> "beads on string" in duct wall , segmental fibrosis of bile duct with saccular dilations b/w strictures = Liver bx ----> "onion - skinning" in the biopsy
60
Primary Sclerosing Cholangitis (PSC) : tx and complications
1. none, liver transplant or support sxs | 2. high risk of getting cholangiocarcinoma, colon cancer (from UC), ascending cholangitits
61
Primary Biliary cholangitis (PBC) : is what and how, risks
PB Cirrhosis 1. chronic disease of liver and biliary tree, destructive intrahepatic cholagitis 2. autoimmune destruction of small intrahepatic bile duct and cholestasis 3. F, over 50yo, UTI, smoking, hormone therapy, hair dye
62
Primary Biliary cholangitis (PBC) : SX
1. asympt isilated elevation in alk phosphatase | 2. pruritus*, fatigue, jaundice*, xanthelasma*, steatorrhea, hyperpigmentation, portal HTN
63
Primary Biliary cholangitis (PBC) : DX ,
high serum alk Ph. (GGT elevated)**** = antimitochondrial Abs (AMA) **** = high IgM, = do liver bx if AMA-
64
Primary Biliary cholangitis (PBC) : TX and complications
1. ursodeoxycholic acid, liver transplant at end stage disease 2. cirrhosis --> liver failure
65
Acute Hepatitis : what and risks
1. 3-6mo, acute liver inflammation 2. viral, bacterial, parasitic 3. drugs 4. Budd-chiari syndrome 5. ischemia
66
Acute Hepatitis : SX
1. fever, stools are acholic, abd pain, dark urine, N/V, | 2. RUQ pain tenderness over liver
67
Acute Hepatitis : dx and tx
1. viral hep has higher ALT, alcohol induced is higher AST, Acetaminophen level **, PT/INR 2. N-acetylcyteine aka NAC (Mucomyst) (if acetominophen overdose), anti-viral, gastric lavage
68
Acute Hepatitis : complications `
Fulminant liver failure, cirrhosis,
69
Acute (Fulminant) Liver Failure (ALF) : | how does it happen, risks
= massive hepatic necrosis + impaired consciousness 1. Acetaminophen overdose 2. drug reactions (herbals, anti-TB, ABs) 3. Budd Chiari syndrome 4. Fatty liver in preg, viral hep, poisonous mushrooms
70
Acute (Fulminant) Liver Failure (ALF) : TX and complications `
1. Meticulous intensive care, prophylatic AB coverage = improves**** 2. liver transplant early 3. N-Acetylcysteine (NAC) = cerebral edema (brainstem compression), sepsis, death (80% death)
71
Acute (Fulminant) Liver Failure (ALF) : DX
1. severe hepatocellular damage = elevated AST/ALT + RAPID rising bilirubin + prolongation of PT/INR even when AST/ ALT falls 2. acetpminophen level (AST/ALT over 5000 3. elevated ammonia = encephalopathy, intracranial HTN
72
Acute (Fulminant) Liver Failure (ALF) : SX
1. N, V, jaundice, itching, high liver enzymes, , coma, 2. SHRINKING Liver size FAST, confusion = hepatic failure and encephalopathy, 3. coag abnormal = bleeding life threatening 4. Asterixis
73
Hepatitis A (HAV) : what type, how TR, SX
1. RNA virus 2. Fecal-oral (contaminated poor hygiene places, travel) 3. ACUTE, more severe in adults, RUQ pain, acholic stools, jaundice, N/V, dark urine
74
Hepatitis A (HAV) : DX and TX
1. high bilirubin + alk phosphatase = cholestasis * 2. high AST/ ALT = hepatocellular* 3. HAV AB = IgM anti-HAV **** 4. IgG anti-HAV = previous exposure, non-infective =support, vaccine available
75
Hepatitis B (HBV) : type of, and risk and how
1. DNA virus | 2. blood TR, infected blood, sexual contact, saliva, semen, vagina, mother to baby (90%)
76
Hepatitis B (HBV) : SX
1. ACUTE (90% recover) ----> chronic (10%) 2. asymptomatic ----> fulminate + death 3. N/V, fever, RUQ pain, jaundice 4. glomerulonephritis, serum sickness, polyarteritis nodosa****
77
Hepatitis B (HBV) : window period and TX
1. when HBsAg disappears and liver enzymes decrease and HBsAb appear (weeks to months) = Still ACUTE HBV = detectable with HBcAb IgM**** 2. vaccine
78
Hepatitis B (HBV) : DX
1. elevated AST/ALT, prolonged PT/INR, | 2. SEROLOGY : HBsAg, HBsAb, HBcAb IgM
79
Hepatitis B (HBV) : complications
can lead to chronic HBV | ESPECIALLY risk of cirrhosis (portal HTN)rd522* and hepatiocellular carcinoma if superinfected with HEP D
80
what do you see in : 1. Window period 2. Acute HBV 3. previous HBV 4. Chronic inactive HBV 5. Chronic active HBV 6. Immunization
1. HBcAb IgM 2. HBsAg + HBcAb IgM + HBeAg + HBV DNA 3. HBsAb + HBcAb IgG 4. HBsAg + HBcAb IgG + (can have HBV DNA) 5. HBsAg + HBcAb IgM + HBcAb IgG + DNA HBV 6. HBsAb
81
Hepatitis D (HDV) : how it infects, type of virus,
1. Blood TR, WITH HBV** | 2. RNA virus
82
Hepatitis D (HDV) : SX and DX and TX
1. with HBV, RUQ pain, N/V, jaundice, fever 2. HDV Ag + ADV DNA (PCR)**** 3. vaccine against HBV
83
Hepatitis D (HDV) : Complications
makes HBV worse, faster to cirrhosis and fulminant acute hepatitis
84
Hepatitis C (HCV) : type and risk
1. RNA mostly chronic viral 2. BLOOD , IV drug use, intranasal (cocaine) , tattoos and piercings, bloody knuckles in fisticuffs in boxing 3. can be TR with HCV
85
Hepatitis C (HCV) : SX and complications
1. mild or asymp (until cirrhosis) 2. cirrhosis, hepatocellular carcinoma , HIV coinfection = mixed cryoglobulinemia ----> purpura ****
86
Hepatitis C (HCV) : Dx
1. HCV Ab (HCV RNA or anti-HCV PCR) | 2. can elevate AST/ALT fluctuating
87
Hepatitis C (HCV) : TX and prevention
1. anti-viral curable (no vaccine) 2. test donated blood for HCV AB 3. test persons born 1945 to 1965, and at least 1 time after 18yo = if + then don't share razor, toothbrush, sex
88
Hepatitis E (HEV) : type, TR, where
1. RNA | 2. fecal oral, waterborne, from swine*, undercooked meats, can cause endemics
89
Hepatitis E (HEV) : SX
acute or chronic (immunocompromized) = transplant pt with tacrolimus can cause cirrhosis = fulminant if preg RUQ pain,
90
Hepatitis E (HEV) : DX
1. IgM or IgG HEV Ab | 2. PCR for HEV RNA
91
Hepatitis E (HEV) : tx and complications
1. no vaccine, support | 2. 10%-20% mortality in pregnant, acute liver failure
92
Toxic and Drug- Induced hepatitis = drug induced liver injury (DILI) : 2 ways and how
1. Dose dependent : DIRECT hepatotoxins = acetominophen, valproic acid 2. Idiosyncratic : variable dose and time onset
93
Toxic and Drug- Induced hepatitis = drug induced liver injury (DILI) : SX DX TX
1. looks like acute cholecystitis , rash, fever 2. anti-mitochondria, exclude others, 3. support, stop medication causing it, NAC****
94
Toxic and Drug- Induced hepatitis = drug induced liver injury (DILI) : complications
fulminant liver failure
95
Acetaminophen overdose : SX DX TX Complications
1. RUQ pain, N/V, encephalopathy = asterixis*** 2. aceptominophen levels (at least 4hrs post injestion) 3. Rumack Matthew Nomogram* (0-8hrs tx) nomogram b/w 4-24hrs, ICU*, Transplant*, NAC* 4. fulminant liver failure , death
96
Rumack Matthew Nomogram*
graph that you plot to estimate damage to liver 1. measure Acetoinophen at least 4hrs after injestion then plot line level on nomogram to 24hrs to see how much % damage to liver
97
Hepatic Vein Obstruction (Budd Chiari Syndrome) : what is it , risks, and SX
1. occlusion of hepatic vein or IVC** 2. hypercoagulable state, IBD 3. RUQ pain from hepatic enlargement (back up of blood, dilated vessels) ascites, jaundice
98
Hepatic Vein Obstruction (Budd Chiari Syndrome) : DX and biopsy
((((DX))))) 1. CEUS**** = contrast -enhanced US or 2. Pulsed- Doppler US**** (hepatic vein BF or IVC BF 3. Prominent caudate liver lobe can be seen**(thats where veins drain to) 4. Direct venography = spider-web pattern** 5. liver biopsy = centrilobular congestion = NUTMEG LIVER + fibrosis , with many large regenerative nodules
99
Hepatic Vein Obstruction (Budd Chiari Syndrome) : TX and complications
1. anti-coags, liver transplant | 2. bleeding varices, hepatocellular carcinoma
100
Chronic hepatits is what, Sx, DX
1. over 6mo infection or inflammation to liver 2. jaundice, HBV = polyarteritis, HCV = cryoglobulinemia 3. biopsy to see fibrosis (cirrhosis), serum labs, US
101
Chronic hepatitis : complications
cirrhosis, portal HTN
102
Chronic HCV DX
HCV Ab, HCV RNA (at times) , normal AST/ALT, decrease in serum cholesterol
103
Autoimmune Hepatits (AIH) : 2 types and SX
TYPE 1 CLASSIC : anti-SM and ANTI-nuclear Abs (ANA)**** TYPE 2 : anti-liver or kidney (anti - LKM)ABs 1. 80 % F 30yo-50yo, progressive jaundice, healthy only with stigmata of cirrhosis 2. rash, arthralgia, UC, thyroiditis
104
Autoimmune Hepatits (AIH) : DX
1. hypergammaglobulinemia (IgG), SMA ANA, anti-LKM Ab | 2. high AST/ALT, bilirubin total
105
Autoimmune Hepatits (AIH) : TX and complications
1. glucocorticoids | 2. cirrhosis, ----> hepatocellular carcinoma
106
Alcohol - Induced Liver Disease : how it happens and what
1. fatty liver steatosis--> alcoholic hep steatohepatits----> cirrhosis happens
107
Alcohol - Induced Liver Disease : SX
1. fatty liver : asymp, mild elevated liver tests, alcohol consumption stopped can be reversed 2. alcoholic hepatits : asympt, severe liver failure + jaundice, ascities, GI bleeding, encephalopathy
108
Alcohol - Induced Liver Disease : DX labs
1. 2X high AST** | 2. high WBCs, low Hgb, low Folic acid , low plts
109
Alcohol - Induced Liver Disease : DX imaging + biopsy
1. US exclude obstruction, CT with IV contrast / MRI : lesions and vessels, US elastography : sees fibrosis 2. Mallory Bodies (Alcoholic hyaline)
110
Alcohol - Induced Liver Disease : TX
1. no alcohol 2. multivitamines (thiamine, folic acid, zinc) 3. if glucose if given from hypoglycemia then up the thiamine ** (avoid wernicke korsakoff syndrome) 4. steroids if severe 5. liver transplant (if no alcohol for 6mos)
111
Alcohol - Induced Liver Disease : Prognosis ****
1. 30days 50% mortality if alcoholic hepatitis 2. Maddrey's discriminant function : PT and bilirubin, over 32 is poort prog., give steroids 3. Glasgow alcoholic hepatitis score : factros like age, bilirubin, BUN, PT, WBCs, over 9 give glucocorticoids 4. MELD/MELD-Na (model end stage liver D) : over 21 significant mortality in alcoholic hepatitis
112
Alcohol - Induced Liver Disease : complications
1. wernicke encephalopathy : give thiamine , ataxia, nystagmus, confusion, Reversible 2. Korsakoff syndrome : severe memory issue, confabulate make up stories 3. Cirrhosis = hepatocllular carcinoma in future
113
non-alchoholic induced Fatty liver disease (NAFLD) : is what and risk and protection against it
1. most common cause of chronic liver D in US** 2. Metabolic syndrome, 3. physical activity and coffee
114
non-alchoholic induced Fatty liver disease (NAFLD) : SX
asymp, mild RUQ discomfort, hepatomegaly (75%)
115
non-alchoholic induced Fatty liver disease (NAFLD) : DX labs and imaging
1. high AST/ALT 2. US elastography = DX with BIOPSY : looks like alcoholic Fatty Liver , steatosis, malloey hyaline, polymorphonuclear N, fibrosis at times = NASH (
116
non-alchoholic induced Fatty liver disease (NAFLD) : TX and complications
1. weight loss, restrict fat, vit E, exercise, | 2. cirrhosis
117
Alpha 1 Anti-trypsin deficiency : is what and risks
Defected a1-AT (antitrypsin) is produced and accumulated in hepatocytes, liver damage = protease inhibitors LOW CAUSES : 1. pulmonary emphysema + Panacinar 2. emphysema (young age) lower lobe**** (COPD in smokers is the upper lobe) 3. liver disease : misfolded proteins accumulate, inherited as infnacts and children
118
Alpha 1 Anti-trypsin deficiency : DX
1. a1-antitrypsin level and phenotype**** : | (PiZ and PiZZ homozygous = severe reduction in enzyme levels)*
119
Alpha 1 Anti-trypsin deficiency : TX and complications
1. smoking stop and never, liver transplant * | 2. Emphysema at young age, micronodular cirrhosis risk of Hepatocellular carcinoma
120
Hemochromatosis : caused how and what happens
1. HFE gene mutation AR, increased duodenal absorption of Fe+3 (High hemosiderin in liver, pancreas, heart, adrenals, testes, kidney, pituitary)
121
Hemochromatosis : SX
``` TETRAD : 1. cirrhosis + hepatomegally 2. abnormal skin pigment bronze color) 3. DM (bronze DM) 4. Cardiac dysfunciton also arthritis* ```
122
Hemochromatosis : DX , imaging, biopsy
1. high FE saturation, high ferritin, FH, high Fe 2. HFE gene mutation* 3. 45% or higher transferrin sat**** 4. MRI and CT* 5. biposy : cirrhosis
123
Hemochromatosis : screen who
first degree Family members (HFE testing)
124
Hemochromatosis : TX
1. Phlembotomy **** 2. if pt cant tolorate (from anemia, or thalassemia) : DEFEROXAMINE chelating agent 3. liver transplant
125
Wilson Disease : is what and how does it happen + mutation
1. excessive absorption of Cu from SI and decrease excretion of Cu in bile and ceruloplasmin by liver**** 2. accumulated in liver, brain, eye 3. causes hemolytic anemia = ATP7B mutation
126
Wilson Disease : sx
1. Neurologic : basal ganglia problems, tremor , ataxia, like parkinsons, dysphagia, 2. Behavioral and Personality changes 3. Kayser - Fleischer Ring **** (brownish gray-green ring around eye color part)
127
Wilson Disease : DX
1. Low serum ceruplasmin **** 2. Keyser - Fleischer rings 3. - Coombs test (no Ags against RBCs causing hemolysis) 4. MRI shows increased basal ganglia , brainstem and crebellar Cu****
128
Wilson Disease : TX and complications
1. Oral Penicillamine (increase Urinary excretion or chelated Cu), liver transplant 2. Cirrhosis**, hemolytic anemia, renal tubular, acidosis, hypoparathyroidism
129
Liver in heart failure : what happens and protection against worse outcomes
1. right heart failure : passive congestion of liver (nutmeg liver) 2. Ischemic hepatitis : liver shock from acute MI, arrhythmia, or some shock = give statin therapy
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Liver in heart failure : SX
hypotension | hepatojugular reflux
131
Liver in heart failure : DX
1. heart failure : = AST/ALT elevated, N-terminal-proBNP , BNP EVELAVTED** 2. ischemic hepatitis "shock liver" : FAST elevation of AST/ALT (over 5000)**, FAST elevation of LDH (lactate)**
132
Liver in heart failure : TX and complications
1. tx shock or reason | 2. high mortality due to underlying disease
133
Cirrhosis : is what and risks
SAAG > 1.1 G/DL* 1. complication of several liver problems = Ethanol = HCV = NAFLD 2. alch, obese, genes, autoimmune, viral, IV drugs , meds
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Cirrhosis : SX
= jaundice = ascites = encephalopathy = pruritis
135
Cirrhosis : what is seen in PE
``` = ascities = muscle wasting = jaundice = umbilical hernia = asterixis = muekrcke lines + Terry nails (from hypoalbiminemia) = caput medusae = palmar erythma ```
136
Cirrhosis : DX + imaging*
= high EST/ALT, bilirubin, alk ph, glucose = low Na, albumin , cholesterol, plt, WBCs, Hgb, ceruplasmin = US + Doppler RUQ** = Paracentesis = EGD = US elastography
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Cirrhosis : dx complications present
= SBP (Spontaneous bacterial peritonitis) : y/n | = paracentesis (HIGH PMNs means yes)
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Cirrhosis : complications
1. hepatocellular carcinoma | 2. Portal HTN
139
Cirrhosis : prognosis
Survival prognostic score (for transplant list done) 1. CTP score (C is worse and over 7) 2. MELD score (10 is bad, over 14 need transplant)
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MELD score
bilirubin, Cr, Na | INR
141
CTP score
CHILD TURCOTTE PUGH bilirubin, albumin, PT/INR check ascites and encephalopathy
142
Cirrhosis : management
= immunizations (including flu annually) = monitor labs = Alpha fetoprotein (AFP) and US every 6mos to screen for HCC especially if over 55yo****
143
Ascites : most common cause of this and SX
1. fluid in peritoneal cavity = most common from portal HTN (chronic liver disease) 2. elevated jugular P, SHIFTING DULLNESS : percussion that changes from supinated to lateral recumbant (if at least 1500mL)
144
Ascites : DX + imaging
1. ABD US + doppler(vascular to see Budd-Chiari) ABD Paracentesis : find cause and exclude SBP 2. -WBC count (high can show SBO) -Albumin gradient (SAAG) = albumin serum (-) albumin ascitic fluid -gram stain
145
Ascites : TX
paracentesis (DX and TX) + tx cause
146
Peritonitis : Primary = Spontaneous Bacterial Peritonitis (SBP) : what is it and how
1. most common in cirrhosis | 2. spread of organism to ascitic fluid (Gram - like E.Coli, Gram + like strep, enterococci, pneumonococci)
147
Peritonitis : Primary = Spontaneous Bacterial Peritonitis (SBP) : DX
sample fluid and more then 250 PMNs/uL and do blood culture
148
Peritonitis : Primary = Spontaneous Bacterial Peritonitis (SBP) : TX
Fluoroquinolones , ABs appropriate
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secondary peritonitis : is what
bacteria from intraabdominal viscus and flora contaminate peritoneum (gram - and anaerobes), pt usually motionless knees drawn up, DO CT, surgery + fluoroquinolone
150
Esophageal varices : SX pt comes with
= acute GI bleed (hemoatochezia, melena, hematemsis), \ | = hypovolemia, shock
151
Esophageal varices : DX and Risks
``` = EGD = Risks : 1. larger then 5mm 2. red wale markings 3. ctp scoring of liver disease severity 4. alcohol use present ```
152
Esophageal varices : TX
1. acute resuscitation in ICU 2. EGD + Banding emergency ** 3. IV fluids/ blood
153
Esophageal varices : prevention
nonselective Beta-adrenergic bockers + band ligation (decrease bleeding again in future)
154
Hepatic encephalopathy : what is it and sx
1. altered mental status in liver failure, HIGH ammonia levels and neurotoxins build up and not removed by liver 2. GI bleed, constipation, sepsis, high proteins meals
155
Hepatic encephalopathy : DX
elevated ammonia
156
Hepatic encephalopathy : TX
= Lactulose (nonabsorbable disaccharide) causing colonic acidification + D = 2-3 soft stools per day = remove precipitants
157
Hepatic encephalopathy :SX
confusion, slurred speech, asterixis, sleepy, can lead to coma
158
Hepatocellular carcinoma : risks
1. Cirrhosis * 2. M 3. 50yo-60yo 4. asia and africa 5. Aflatoxin exposure
159
Hepatocellular carcinoma : sx
liver disease Hx, cachexia, abd pain, fever, jaundice, asterixis, itching
160
Hepatocellular carcinoma : dx and imaging
1. Known liver disease : = US = rising a-fetoprotein (AFP) 2. abnormal liver function test
161
Hepatocellular carcinoma : tx
liver trasplant, surgical resection , radiofrequency ablation
162
Hepatocellular carcinoma : screening and prevention
AFP and US every 6 months | HBV vaccine

GIGU2 Exam 2 (4 decks)

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