quid of amebic liver disease
tender liver mass on abdominal ct scan
rx of amebic abcess
metronidazole
patient with hepatic mass after traveling in endemic areas
amebic abcess
drug causing idiosyncratic reaction hepatitis(4)
halothane
phenytoin
isoniazid
@-methyl dopa
drugs causing cholestasis(4)
chlorpromazine
erythropoietine
anabolic steroids
nitrofurantoin
drugs causing fatty liver disease(3)
tetracycline
acid valproic
ARV
drugs causing granulomatous reaction(2)
allopurinol
phenylbutazone
2 ways for drugs to cause injury
toxic effect
idiosyncratic reaction
quid of toxic effect
reaction is dose dependent
example of toxic efffect(2)
tetracycline
acetaminophen
quid of idiosyncratic effect
reaction is dose independent
example of idiosyncratic effect(2)
isoniazid
ARV
clue for non alcoholic steato hepatitis NASH(4)
non drinker
serologic hepatitis negative
obese with high ALP
slightly increase SGOT,SGPT
link to have NASH
obesity
why obesity causes NASH
fat cells are not responsive to insulin and lipid is deposited in the liver
how ‘s ALT/AST in NASH
AST/ALT
dx of NASH
Liver biopsy
risk factor for NASH(5)
obesity diabete hyperlipidemia parenteral nutrition medications
medication risk factor for NASH(5)
corticosteroids tamoxifen amiodarone diltiazem HAART
quid of Murphy sign
RUQ pain worst during inspiration
clue for acute cholecystitis
pain in RUQ worsen with fatty liver meal
ALP in chlocystitis
normal
where ‘s stone in acute cholecystitis
in the cystic duct
RUQ pain with high ALP(2)
cholangitis
or
choledocolithiasis
why you have fever in cholecystitis
secondary infection
why infection can happen in acute cholecystitis(2)
because of inflammatio you can have stasis and bacterial overgrowth
risk of gangrene and perforation
what’s the first step to address in case of variceal bleeding
2 large bore IV needles or central line
patien with acute pancreatitis develops palpable epigastric mass
pseudocyst formation
why amylase is elevated in pseudocyst
leak of amylase from the pseudocyst into the circulation
best image to Dx pseudocyst
US
rx of pseudocyst(2)
observation
resolve spontaneously
indication of drainage of pseudocyst(3)
more than weeks persistance
infection
> 5 cm
patient with high bilirubin direct and hgh ALP next step(3)
CT
or
US
+ antimitochondrial antibody
panacinar emphysema plus cirrhosis
@-1 antitrypsine deficiency
rx of @ antitrypsine deficiency
Alpha 1 anti trypsine factor
asymptomatic elevation of transaminase next step?
good history on risk factor
risk factor for hepatitis(5)
drug alcohol endemic area travel blod transfusion high risk sexual practices
Med causing high transaminase(5)
NSAIDS HMGco A reductase inhibitor antiepileptic drugs izoniazid herbal preparation
clue for acute pancreatitis(3)
epigastric pain
rlieve by leaning forward
occuring after binge eating
rx of acute pancreatitis(4)
conservatively
analgesics
fluid
NPO
analgesics used in acute pancreatitis(2)
fentanyl
meperidine
most common type of gallstone in US
cholesterol stone
2 types of gallstone(2)
cholesterol
calcium bilirubinate
dx of choice of cholecystitis
US abdomen
rx for symptomatic cholecystitis
laparoscopic cholecystectomy
patient with microcytic anemia and firm hepatomegaly
metastatic cancer from colon
first site for matastasis pf colon cancer
hepatic
goal standard for metastatic hepatic colon cancer
abdomen CT scan
tinding in CT during metastatic hepatic colon cancer
cholestatic syndrome
PBC clue
antimitochondrial antibody type IGM
Biopsy of PBC(2)
destruction of intrahepatic bile ducts and cholestasis
medium size bile duct
first symptom of PBC and why?(2)
pruritis
because of cholestasis
conditions associated with PBC(5)
sjogren scleroderma celiac disease autoimmiune thyroid problem hypothyroidism
drug of choice fro PBC treatment
ursodeoxycholic acid
definitive rx of PBC and severe disease
liver transplant
jews with ictere
dubin jhonson
work up for dubin jhonson(2)
Normal AST/ALT
high bilirubin conjuguee
differentiate dubin jhonson from rotor
dark granular pigment seen in hepatocytes=Dubin jhonson
mechanism of gynecomastia in cirrhosis
excess of estrogen in the body
mechanism in testicular atrophy in cirrhosis
lot
why T3T4 are low in cirrhosis
no protein to bind T3T4
why TSH is normal in cirrhosis
because you lack thyroid binding globulin not T3T4
2 causes in cirrhosis causing hypogonadism(2)
hemochromatosis
alcohol
what causes hypogonadism(2)
primary hypogonadism
secondary due to hypothalamo hypophysaire dysfuction
why lung can have problem in cirrhosis
hapatic hydrothorax
why edema in cirrhosis
low albumin level
why hepatic hydrothorax in cirrhosis
defect of diaphragm allows ascites fluid to go in pleural space
patient with cirrhosis on diuretics develops pleural fluid effusion ,next step
TIPS
transjugular porto systemic shunt
cirrhosis and shortness of breath
pleural effusion
forst rx for hepatic hydrothorax(2)
diuretic
fluid restriction
Triad of charcot(3)
ictere
fever
RUQ pain
pentad of renold(3)
triad de charcot
plus
hypotension
confusion
pentad of renold or charcot disease?
cholangitis
clue for acute cholangitis
high ALP
first step in rx of cholangitis
antibiotics
patient with cholangitis ,getting worse with antibiotics next step
surgical decompression
what’ts the best indicator of progression of HEP C infection in liver
biopsy
role of biopsy in HEP C infection(4)
stage of the disease
rule out concommitant disease
guide rx decision
surveillance
electrolyte abnormality in cirrhosis
low K+
step of management of hepatic encephalopathy(4)
supportive care
rx the precipitating cause
correct volume and electrolyte problem
lower ammonia
way to lower ammonia
lactulose
when you can add rifamixin in the rx of high ammonia in cirrhosis
when failure with lactulose after 48 h de rx
Burn Patient develops RUQ pain
acalculous cholecystitis
lactulose side effect
rifamixin
quid of acalculous cholecystitis
inflammation of gallbladder without calcul
conditions predisposing to acalculous cholecystitis(5)
severe burns severe trauma prolonged TPN prolonged fasting mechanical ventilation
complication of acalculous cholecystitis(3)
gangrene
perforation
emphysematous changes
initial work up for acalculous cholecystitis(3)
US abdomen
more specific
HIDA scan
CT scan
IV drugs user with ascites
chronic liver disease
most common cause of chronic liver disease
alcohol
hep c
why splenomegaly in cirrhosis
because of portal HTA
rx of hepatitis B preferred drug(2)
tenofovir
entecavir
drug used in rx of hep B(4)
tenofovir
entecavir
interferon
3TC
Indication of rx(6)
acute liver disease
clinical complications of cirrhosis
advanced cirrhosis with with high HBV DNA
Patient without cirrhosis but with positive HBe AG,
HBV DNA>20000
why TDF and entecavir are prefered (2)
low risk of resistance
can be used in decompensated cirrhosis
cirrhosis and encephalopathy Rx
lactulose
cause of precipitation of cirrhosis(9)
infection hypoxia hypoglycemia hypovolemia porto systemic shunt excessive nitrogen load medication hypokaliemia metabolic alkalosis
medication percipitating cirrhosis
sedatives
cause of excessive nitrogen load
bleeding
4 phases in chronic infection caused by hepatitis B
immune tolerance
imune clearance
inactive carrier state
reactivatio
clue for immune tolerance(4)
high antigene HBS
High HBE antigene
high HBV replication
minimal destruction of hepatocytes
duree of immune phase
10 a 30 years
what happened in imune clearance phase
destruction of hepatocytes containing HBV
clue for this phase(2)
ALT high or normal
HBE antigene positive
meaning of HBe
active replication is occuring
what to do in the phase of ICP
serial ALT(q3-q 6 months) serial HBe Ag
why serial ALT and HBe in ICP
to fully document clearance
clue for inactive carrier(3)
Hbe ag -
Hbe aB +
Low HBV DNA
indication to conclude inactive carrier state(2)
> / a 3 Normal ALT
2 a 3 Normal HBV DNA
cue for reactivation of HepB(3)
high ALT
high HBV
fibrosis on biopsy
how to follow patient with chronic Hep B
serial ALT
what should be done to any patient with chronic hepatis
vaccination for Hep A and B
what should be done to any patient with hepatitis C infection
vaccination for Hep A and B
indication of rx in chronic Hep C(4)
age > 18 ans
detectable serum RNA
compensated liver disease
liver biopsy with fibrosis
quid of compenated corrhosis(2)
INR normal
rx of chronic Hepatitis C(2)
Peginterferon
plus
ribarivirin
indication of protese inhibitor in rx of hepatitis C infection
HCV 1
contrindication of rx with protease inhibitor(3)
uncontrolled depression
alcohol
drug abuse
protease inhibitor used in HCV infection(2)
telaprevir
boceprevir
patient with cirrhosis high ALT and AST and brownish deposit around cornea
wilson disease
quid of keyser fleisher ring
brownish deposit around cornea
biopsy finding in wilson
hepato lenticular degeneration
why psychiatric problem in wilson
copper leak fromhepatocytes and deposit in basa ganglia
eye problem in wilson
keyser fleisher ring
dx test for wilson(3)
liver biopsy
low ceruloplasmin
low copper in urine
finding in liver biopsy
copper >250 Mcg
meaning of low ceruloplasmine
confirmatory dx test
keyser flesher ring
Rx of wilson(2)
Penicillamine or trientine
plus
ZN
when liver transplantation is indicated in wilson(2)
decompensated liver disease
fulminant hepatic failure
best rx of choledocholithiasis
laparoscopic cholecystectomy
in case of a patient refusing the surgical rx of choledocholithiasis(2)
ursodesoxycholic acid
avoid fatty foods
pancreatitis in non alcoholic patient
gallstone
Rx of pancreatitis in non alcoholic patient
cholecystectomy
mid epigastric pain with high lipase and amylase
acute pancreatitis
quid of hapatic adenoma
hepatic tumor in young female taking OCP
complication of hepatic adenoma(2)
intratumor hemorrage
malignant tranformation
biopsy in hepatic adenoma
enlarged heaptocytes containing glycogen and lipid deposits
rx of hepatic encephalopathy
serum ammonia level
why hyperandrogenism in aptient with cirrhosis
inabiloity of the liver to metabolise estrogen
effect of high estrogen in cirrhosis(5)
spider angioma gynecomastia little testicle palmar erythema decreased body haior
liver function(3)
metabolic
synthetic
excretoire
liver synthesis(3)
protein
cholesterol
clot factor
excretory role of liver
bile
metabolic role of liver(2)
detoxification of drug
and steroids
clue for amebic liver disease(4)
trip to mexico
history of bloody diarrhea
RUQ pain
uniform cyst in right lobe
risk factor for gallbladder carcinoma(3)
chronic gallblader inflammation
porcelain gallbaldder
salmonella typhi carriage
chronic gallblader inflammation cause
stones
indication of cholecystectomy in gallbladder carcinoma
when ca is confined to gallbladder wall(lamina propria)
risk factor for porcelain gallblader
chronic inflammation by gallstones
complication of porcelain gallbladder
cancer
glomerulonephritis with low complement(4)
GNA
MPGN
Lupus
Mixed cryoglobulinemia
link between Cryoglobulinemia and RA(2)
IGM will be targeted towards IGG
rhumatoid factor can be positive
quid or cryo
it’s a vasculitis
target in cryo (4)
articulation
skin
rein
foie
skin finding in mixed Cryo
purpura
first step in aptient with suspected mixed cryo
test for hepatitis C
confirmatory Dx for mixed Cryo(2)
kidney biopsy
or
skin biopsy
clue for porphyria cutanea tarda(3)
photosensitivity
fragile skin
erosion and vesicles on dorsum of the hands
disease causing porphyria cutanea tarda
mixed cryo
clue for Mixed Cryo
periodic increase of Tranaminases
complication of Mixed cryo(2)
cirrhosis
hepatocellular carcinoma
cause of Non alcoholic fatty liver disease in obese patient
insulin resistance
physiopatho af NAF liver disease(3)
high lipllysis in periphery
high triglyceride synthesis
high hepatic uptake of fatty acids
criteria for NAF liver disease(3)
steatohepattitis
viral serology -
patient with virl hepatitis develops high PT and decresed transaminases Dx
Fulminant hepatitis
decrease transaminase in the setting of viral hepatitis meaning?(2)
recovery
fulminant hepatitis
patient with positive HBS antibody (2)
vaccination
prior infection
first marker to be positive in Hep B
Hbs Ag
second marker to be positive in Hep B
anti hbc IGM
most specific marker to Dx acute Hep B
IGM HBC antibody
why Hbc ag can not be seen
it’s sequestered within HBS ag coat
Meaning of HBe Ag
infectivity
Meaning of HBe Antibody
low infectivity
Meaning of HBc antibody
recovery
what are the 3 types of gallstones
cholesterol
pigment stone
mixed stone
quid of pigmented stones
calcium bilirubinate stones
why pregnant women are prone for cholesterol stones
hypomotility of gallbaldder
cause of gallbaldder hypomotility(4)
advanced age
TPN
prolonged fasting
hypertriglyceridemia
5 causes of cholesterol gallstones formation
hypomotile gallbladder
malabsorption of acid biliaire
OCP
Meds
Med causing cholesterol stones(3)
clofibrate
octreoctide
ceftriaxone
risk factor for pigmented stones(3)
hemolysis
chronic biliairy tract infection
parasitic infection
protective factor against stones(5)
NSAIDS Aspirin caffeine physical activity low carbohydrate diet
quid pof Hepatic shock
patient with low TA develops high AST/ALT with mild elevation of bilirubin
what happen in hepatic shock
ischemic hepatic injury
pregnant women develop Hep C infection next step(2)
Hep A vaccine
Hep B vaccine if not immune
clue for hepatic cyst (hydatic)(2)
thick wall cyst
egg shell calcification
cause of hepatic cyst
ecchinococus granulosis
what you should not do in hydatid cyst
aspiration of the cyst
why you should not aspirate in hydatid cyst
risk of hypersensitivity
rx in hydatid cyst
surgery under albendazole coverage
quid of fulminant hepatic failure
acute viral hepatitis complicated with encephalopathy
rx of FHF
orthotopic liver transplant
other way of considering FHF
hepatic encephalopathy within 8 weeks of acute liver disease
young person with high transaminase and neurologic finding resting tremor and muscular rigidity
wilson
FHF in pregnant women in 3 e trimestre
Hep E
all patients receiving blood before 1986
screen Hep B and C
all patients receiving blood before 1992
screen Hep C
after marrow transplantation pateint develops decreased bile ducts quantity in liver biopsy what disease has the same pattern
PBC
cause of ductopenia(8)
PBC hogkin sarcoidosis cmv infection HIV Med induced failing liver transplantation graft versus host disease
after marrow transplantation pateint develops decreased bile ducts quantity in liver biopsy dx
graft versus host disaese
most common cause of ductopenia
PBC
other name for ductopenia
vanishing bile duct syndrome
asian american with ictere bilirubin in urine
rotor
quid of bilirubin in urine
conjugated hyperbilurubinemia
bilirubin in gilbert
high conjugated hyper bilirubinemia
patient taking INH develops high transaminase
continue with RX
will resolve spntaneously
patient with multiple trou noir on CT scan
metastatic disease from colon cancer
primary cancer to metastase in liver(3)
colon cancer
lung
breast
clue for Ca in the United states
weight loss
test of choice for pancreatic cancer
CT abdomen
3 causes of decompensated liver with high transaminase
ALT>AST(3)
medication
viral hepatitis
shock liver
medication causing decompensated liver with high transaminase
acetaminophen
antidote of paracetamol intox
acetylcysteine
Transminase in severe hepatic injury
> 1000
3 causes of ALT>AST(3
medication
viral hepatitis
shock liver
complication of elective cholecystectomy
sphincter d’oddy dysfunction
3 causes of ALT>AST(3
medication
viral hepatitis
shock liver
complication of elective cholecystectomy
sphincter d’oddy dysfunction
rx of sphincter d’oddy dysfunction
ERCP with sphicterotomy
patient after elective cholecystectomy has persistent RUQ pain DX?
sphincter d’oddy dysfunction
ratio AsT/ALT in alcoholic patient(2)
AST/ALT >2
or
AST >ALT 2f
why in alcoholic patient AST >ALT
deficiency in pyridoxal 6 phosphate
quid of in pyridoxal 6 phosphate
cofactor of ALT
U/s in emphysematous cholecystitis (2)
circular linear shadows gaseaous in gallbladder
no gall stones
patient with RUQ pain ,abdominal xray showing air fluid level in the gallbladder
emphysematous cholecystitis
U/s in emphysematous cholecystitis
circular linear shadows gaseaous in gallbladder
cholecystitis with no gall stones
acalculous
emphysematous
cause of emphysematous cholecystitis
gas forming bacteria
clue for Hep A infection (2)
trip in Mexico
or
endemic area
risk factor for Emphysematous cholecystitis
diabetes
clue for Hep A infection
trip in Mexico
the most common malignant in liver
metastasis
patient alternance of dairrhea and constipation presenting with high ALP and multiple hepatic nodules on CT Dx?
Metastasis from colon cancer
Multiple nodules in Liver Next step
check GI for primary Cancer
transaminase in hepatic shock
ALT
AST > 1000
transaminase in post op cholestasis(2)
Normal AST ALT
High ALP
hepatic shock
ALT
AST > 1000
quid of asymptomatic gallstones
gallstones seen in US but no Symptom
rx for asymptomatic gallstone
nothing
rx for symptomatic gallstone
laparoscopic cholecystectomy
normal liver span
6-12 cm in the midclavicular line
3 types of hepatic liver disease linked with alcohol(3)
fatty liver
alcoholic hepatitis
alcoholic fibrosis /cirrhosis
clue for fatty liver in biopsy
steatosis
clue for alcoholic hepatitis in biopsy(4)
mallory body
liver cell necrosis
perivenular distribution of inflammation
liver cell necrosis
what the 2 phases reversible with cessation alcohol
steatosis
hepatitis
clue for hypertriglyceridemia in a patient with suspected acute pancreatitis
xanthomas
quid of XAnthoma
yellow red papules on arms and shoulders
mechanism of xanthoma(2)
fat deposit on tendon
or in subcutaneous tissue
in acute pancreatitis what to always do
order profile lipidic
bleeding in liver failure(2)
varices
coagulopathy
manif of varices
hematemesis
manif of caogulopathy
epistaxis
bleeding from IV sites
management of coagulopathy
fresh frozen plasma
what cause coagulopathy in liver failure
all clot fator are formed in the liver except factor 8
why FFP is the best treatment in coagulopathy caused by liver failure
because it has all the clotting factor
screening test for acute Hep B(2)
IGm HBc antibody
HBs Ag
drug of choice for PBC
ursodeoxycholic acid
Dx differentiel in patient with indirect high bilirubinemia(4)
hemolysis
gilbert
criggler najar
=/ gilbert from criggler Najar type 1(2)
high bilirubin in Criggler Najar 20-25
in gilbert 3 a 5
quid of SAAG
serum albumin ascire gradient
SAAG calculation
albumin serique-albumin ascites
SAAG> 1,1
hypertension portale
AES in patient with acute phase of hepatite B,patient pique non immune a hep B(2)
vaccine +
immunoglobulin
quid for acute phase of Hep B(4)
IgM anti HBc
Hbs Ag
HBe Ag
DNA +
quid of window phase
IgM anti Hbc +
DNA positive
quid of recovery phase(4)
anti HBe
antihbc iGG
anti HB s
DNA -
chronic carrier(2)
HBS ag
IGG anti HBC
acute flare of chronic
Hbs ag +
HBe Ag
IGG anti HBc
DNA +
vaccinated patient
anti hbs ag
immune by contact with the virus
IgG anti HbC
anti HBS ag
PAS positive in hepatology
@-1 anti trypsine deficiency
Symptom of hypogonadism(3)
decraese libido
eerctile dysfunvtion
loss of axillary and pubic hair
indication of TIPS
refractory hydrothorax in cirrhosis
step in hepatic encephalopathy
search for precipitating cause
approach to chronic hepatitis C
Serial ALT to follow up
what’s the next step after rx acute pancreatitis caused by gallstones
schedule cholecystectomy
clue helping in the Dx of cirrhosis encephalopathy
serum ammonia
when to make dx of gallbladder carcinoma(2)
per-op
or
post op
immunlogy in mixed cryo
IGM is directed towards IGG anti hepatite C virus
when to suspect Hep C infection
waxing and waning increase of transaminases
extrahepatic manif of chronic hep C(3)
mixed cryo
porphyria cutanea tarda
membranoproliferative glomerulonephritis
hepatitis induced by INH transaminase less than 100
continue with the rx
