1
Q
S4 = ?
A
stiff ventricle
2
Q
normal JVP
A
<=8 (5 + 3)
3
Q
grading of pulses
A
0-4:
- 0+ = no pulse
- 1+ = faint pulse
- 2+ = less than normal
- 3+ = normal
- 4+ = bounding
4
Q
heparin mechanism of action
A
binds to antithrombin III, which inactivates thrombin and cofactors (esp. factor Xa)
5
Q
clopidogrel: TN? MOA?
A
TN: Plavix MOA: thienopyridine-class antiplatelet agent, irreversible (binds to P2Y12, an adenosine diphosphate (ADP) chemoreceptor on platelet cell membranes)
6
Q
HCTZ: site of action?
A
distal convoluted tubule
7
Q
spironolactone: site of action?
A
collecting duct
8
Q
the 2 most common causes of cirrhosis
A
1) alcoholic liver disease
2) chronic viral infection (hep C, hep B)
9
Q
Child’s classification of liver dz: parameters
A
most to least severe: C > B > A
parameters: albumin, ascites, bilirubin, encephalopathy, nutritional status
10
Q
gold standard for dx cirrhosis
A
liver biopsy
11
Q
classic SIGNS of chronic liver dz
A
- 2/2 portal HTN: ascites, varices, hemorrhoids, caput medusae
- 2/2 hyperestrinism: gynecomastia, testicular atrophy, palmar erythema, spider angiomas
12
Q
what is the most life-threatening complication of cirrhosis?
A
variceal hemorrhage
13
Q
clinical features of variceal hemorrhage?
A
hematemesis, melena, hematochezia, exacerbation of hepatic encephalopathy
14
Q
tx of esophago/gastric varices in cirrhosis – acute and long-term management?
A
acute management: - IV abx (to prevent SBP) - IV ocreotide for 3-5d (reduces portal HTN) - endoscopic tx (ligation/banding or sclerotherapy) long-term management: - beta blockers to prevent rebleeding - TIPS - liver transplant
15
Q
tx of ascites?
A
Most cases: - low-sodium diet (--> diuresis) - diuretics (furosemide, spironolactone) Severe cases: - therapeutic paracentesis if tense ascites, SOB, early satiety - TIPS or peritoneovenous shunt
16
Q
tx of hepatic encephalopathy?
A
- lactulose: promotes ammonia excretion
- neomycin (abx): reduces ammonia production
- diet: limit protein (30-40 g/d)
17
Q
complications of liver failure?
A
AC, 9H’s
AC
- Ascites
- Coagulopathy
HYPO (2)
- Hypoalbuminemia
- Hypoglycemia (2/2 decreased glycogen storage)
HYPER (4)
- portal Hypertension
- Hyperammonemia [–> hepatic enceph]
- Hyperbilirubinemia [–> jaundice]
- Hyperestrinism [–> gynecomast, testes atrophy, palmar erythema, spider angiomas]
HEPAT (3)
- Hepatic encephalopathy
- Hepatocellular carcinoma
- Hepatorenal syndrome (2/2 renal hypoperfusion)
18
Q
clinical features of hepatorenal syndrome?
A
azotemia (elevated nitrogen), oliguria, hyponatremia, hypotension, low urine sodium (<10mEq/L)
19
Q
3 most common etiologies of spontaneous bacterial peritonitis (SBP)?
A
- E Coli (most common)
- Klebsiella
- Strep pneumo
20
Q
clinical features of spontaneous bacterial peritonitis (SBP)?
A
abdominal pain, fever, vomiting, rebound tenderness, sepsis (severe SBP)
21
Q
dx of spontaneous bacterial peritonitis (SBP)?
A
paracentesis –> WBC > 500 & PMN > 250; positive gram stain | culture
22
Q
Wilson’s dz: mode of inheritance, defect?
A
- autosomal recessive dz of copper metabolism
- deficiency of ceruloplasmin, a copper-binding protein that is necessary for copper excretion –> copper accumulation and deposition
23
Q
Wilson’s dz: clinical features?
A
- liver dz
- kayser-fleischer rings (do NOT interfere w/ vision)
- CNS findings: EPS, psych disturbances
- renal involvement: aminoaciduria, nephrocalcinosis
24
Q
Wilson’s dz: tx?
A
- chelating agents: D-penicillamine –> detoxifies + promotes excretion
- zinc: prevents uptake
- liver transplant (if refractory to tx)
25
primary hemochromatosis: mode of inheritance, defect?
- autosomal recessive dz of increased iron abosrption
26
hemochromatosis: affected organs and associated complications?
- liver (primary)
- pancreas --> bronze diabetes
- heart --> CHF, arrhythmias
- joints --> arthritis (2nd and 3rd MCP)
- skin --> bronze "tan"
- thyroid, gonads, hypothalamus
27
hemochromatosis: tx?
repeated phlebotomies
28
hepatocellular adenoma: risk factors and tx?
- RFs: OCP, female sex (esp 15-40y), anabolic steroid use
| - tx: low malignant potential; d/c OCPs, consider surgical resection if >5cm, since risk of rupture
29
cavernous hemangioma of liver: about + tx?
most common type of benign liver tumor; most cases do not require tx --> consider resection if symptomatic or high risk of rupture (large); bx contraindicated due to risk of rupture/hemorrhage
30
focal nodular hyperplasia: malig potential? assoc'n w/ OCPs? tx?
NO malig potential
NO association with OCPs
NO tx necessary
31
most common causes of malignant liver tumors?
```
hepatocellular carcinomas (80%) - high risk in Africa and Asia
cholangiocarcinomas
```
32
most common causes of benign liver tumor?
hemangioma
33
HCC: risk factors?
- cirrhosis, esp in association with EtOH or Hep B/C (develops in 10% of cirrhotic pts)
- chemical carcinogens (aflatoxin, vinyl chloride, Thorotrast)
- alpha 1 antitrypsin defic
- hemochromatosis, Wilson's dz
- schistosomiasis (snails --> parasite)
- hepatic adenoma (low risk)
- cig smoking
- glycogen storage dz (type 1)
34
HCC: tumor marker?
alpha fetoprotein (AFP): elevated in 40-70% of HCC pts, can be used to track response to tx
35
nonalcholic steatohepatitis (NASH): risk factors?
obesity, hyperlipidemia, DM
36
Gilbert's syndrome: mode of inheritance, defect?
- autosomal dominant (prev 7%)
| - decreased UDGT activity --> isolated elevation of indirect/unconjugated bilirubin
37
hemobilia: defn?
blood draining into duodenum via CBD and ampulla of vater
38
hemobilia: tx?
- fluid resuscitation
| - if severe, surgery: ligation of hepatic arteries or arteriogram with emoblization of vessels
39
hydatid liver cysts: etiologies?
- echinococcus granulosus (most common) --> can contract infection from close contact with dogs (definitive host)
- echniococcus multilocularis (less common)
40
hydatid liver cysts: most common location?
right lobe
41
hydatid liver cysts: tx?
surgical resection (caution not to spill contents; cover with albendazole) + post-surg mebendazole
42
pyogenic liver abscess: etiologies?
```
E coli
Klebsiella
Proteus
Enterococcus
Anaerobes
```
43
amebic liver abscess: RF?
male sex (9:1), homosexual men (fecal-oral)
44
amebic liver abscess: etiology?
entamoeba histolytica
45
amebic liver abscess: tx?
IV metronidazole; may require image-guided percutaneous aspiration if high risk of rupture
46
budd-chiari: causes?
- hypercoagulability
- myeloproliferative d/o's (PCV)
- pregnancy
- chronic inflammatory dz
- infection
- various cancers
- trauma
unifying theme: obstruction of hepatic venous outflow
idiopathic: 40% of cases
47
3 major causes of jaundice? bilirubin level at which jaundice becomes apparent?
- causes: hemolysis, liver dz, biliary obstruction
| - bili > 2 mg/dL
48
features of conjugated/direct hyperbilirubinemia?
dark urine, pale stools
| NB: conjugated bili = free, water soluble --> excreted in urine
49
features of unconjugated/indirect hyperbilirubinemia?
- bound to albumin --> not water soluble
| - crosses BBB --> neurologic dysfunction
50
bilirubin metabolism
- spleen: hgb --> bilirubin (unconj)
- unconj bili-albumin from spleen to liver
- liver: dissociation of bili-alb complex + conjugatoin
- excretion into GI tract
- gut: bacterial conversion of conj bili --> urobilinogen + urobilin
- poop it out
51
causes of conjugated hyperbili (positive urine bili, b/c conj = water-soluble)?
- decreased intrahepatic excretion of bilirubin (2/2 hepatitis, cirrhosis, inherited d/o's like Dubin-Johnson | Rotor's, drug-induced, PBC, PSC)
- extrahepatic biliary obstruction (gallstones, pancreatic ca, cholangiocarinoma, etc.)
52
causes of unconjugated hyperbili (negative urine bili, b/c unconj != water-soluble)?
- excess production of bili (hemolytic anemia)
- reduced hepatic uptake (gilbert's, drugs, crigler-najjar, physiologic jaundice of newborn, diffuse liver dz such as hepatitis | cirrhosis)
53
cholestasis: defn?
blockage of bile flow (either intra or extrahepatic) --> jaundice, pruritis, elevated AlkPh, fat malabsorption)
54
is ALT or AST more specific to the liver?
ALT (L is for Liver!)
55
if AST:ALT > 2:1, think ... ?
alcoholic hepatitis
56
etiology: ALT and AST = mildly elevated (low hundreds)?
chronic viral hepatitis or acute alcoholic hepatitis
57
etiology: ALT and AST = moderately elevated (high 100s - low 1000s)?
acute viral hepatitis
58
etiology: ALT and AST = severely elevated (>10K)?
extensive hepatic necrosis (2/2 ischemia, shock liver, acetaminophen tox, severe viral)
59
ddx for elevated ALT, AST?
```
A - autoimmune
B - hep B
C - hep C
D - drugs/toxins
E - EtOH
F - fatty liver (triglyc)
G - growths (tumors, ca)
H - hemodynamic d/o's (eg CHF)
I - iron deposn (hemochromatosis), copper deposn (Wilson's), alpha 1 antitrypsin defic
```
60
cholestatic LFTs?
markedly elevated alk phos, GGT
| mildly elevated AST, ALT
61
alk phos: sources?
liver, bone, gut, placenta
62
ursodeoxycholic acid: indication?
medical tx for dissolving gallstones in pts who are symptomatic but poor surgical candidates
63
well-defined liver cyst w/ eggshell calcifications on abd CT?
hydatid 2/2 echinococcus (dogs = definitive host!)
64
Schilling test?
historically used to determine whether a patient had vit B12 defic due to pernicious anemia or malabsorption
65
hypersegmented neutrophils
folic acid or B12 defic
66
all pts with presumed ITP must be tested for X and Y?
HIV and hep C
67
sideroblastic anemia: pathophys?
defective heme synthesis, most commonly due to pyridoxine (B6)=dependent impairment in early steps of protoporphyrin synthesis
tx w/ pyridoxine (B6)
68
extrahepatic manifestations of hep C
heme: essential mixed cryoglobulinemia
renal: membranoproliferative glomerulonephritis
skin: porphyria cutanea tarda, lichen planus
endocrine: increased risk of DM
69
hep B is associated with which vasculitic dz?
polyarteritis nododa: affects small and medium vessels
70
normal liver span
6-12 cm in the midclavicular line
71
hyposthenuria: defn?
impairment in kidney's ability to concentrate urine; associated with sickle cell dz and trait
72
lupus "anticoagulant" (aka antiphospholipid antibody) --> what change in PTT?
spuriously elevated (laboratory artifact)
73
Wilson's dz is also know as ???
hepatolenticular degeneration
Medicine
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