Liver fibrosis:
Dx:
excessive CT acumulation in response to chronic liver cell injury
Dx by biopsy
Liver fibrosis - causes:
drugs
chemicals
alcohol
disorders affecting liver/hepatic blood flow
Liver fibrosis - ssx:
Asx
any sx secondary to primary disorder
Liver cirrhosis:
late stage of hepatic fibrosis, widespread distortion of architecture
Cirrhosis - ssx:
non-specific (anorexia, fatigue, wt loss)
late: portal HTN
Cirrhosis - PE:
Abd: Ascites, splenomegaly
Skin: Jaundice, pallor, petechiae, purpura
Extremities: clubbing
bleeding
Cirrhosis - workup:
Prognosis:
Labs: LFT often normal, PT, CBC, viral assay
Biopsy
Irreversible; transplantation
Primary biliary cirrhosis:
AI, progressive destruction of intrahepatic bile ducts, leads to cholestasis, cirrhosis, liver failure
Primary biliary cirrhosis - classic sx:
middle aged woman unexplained pruritus fatigue - insidious dry mouth RUQ pain jaundice
Primary biliary cirrhosis - work up:
GGT - elev
Alk phos - elev
AST, ALT - minimally abn
Enti-mitochondrial Ab - elev (AI)
confirm by biopsy
Primary biliary cirrhosis - PE:
enlarged, firm, non-tender liver
mb splenomegaly
Vascular disorders of the liver:
hepatic ischemia
congestive hepatopathy
hepatic artery disorders (occlusion, aneurysm)
hepatic vein disorders (budd-chiari, occlusive)
portal vein disorders
peliosis hepatitis
Ischemic hepatitis:
causes:
diffuse liver damage d/t inadequate blood or O2
most often systemic -
impaired perfusion (chf, acute hypoTN)
hypoxemia (resp failure, CO2 toxicity)
Increased metabolic demand (sepsis)
Ischemic hepatitis - ssx:
N/V
HM - TTP
Ischemic hepatitis - work up:
Clinical eval LFTs: very high aminotransferases mod inc. in bilirubin LDH inc w/in hrs Procedure: US, MRI, arteriography
Ischemic cholangiopathy:
focal damage to the biliary tree d/t disrupted flow from hepatic artery via peribiliary arterial plexus
Ischemic cholangiopathy - ssx:
pruritis
dark urine
pale stool
Ischemic cholangiopathy - work up:
Labs - cholestasis
Img - US initially, MRCP, ERCP
Ischemic cholangiopathy - causes:
vascular injury during procedure:
liver transplant, laparoscopic cholecystectomy, radiation, chemoembolization, etc
resulting bile duct injury
Congestive hepatopathy:
diffuse venous congestion in the liver resulting from RCHF (via IVC)
Congestive hepatopathy - ssx:
most asx
RUQ discomfort
severe congestion - massive jaundice
Congestive hepatopathy - PE:
Work up:
ascites
hepatomegaly
+ hepatojugular reflex
LFTs - mod elev
Hepatic artery occlusion - causes:
thrombosis emboli iatrogenic vasculitis eclampsia cocaine sickle cell crisis
Hepatic artery occlusion - ssx:
Work up:
asx w/o infarction or ischemic hepatitis
infarct -> RUQ pain, fever, N/V, jaundice
US (mb Doppler), followed by angiography
Hepatic aneurysm - causes:
Work up:
infection
arteriosclerosis
trauma
vasculitis
if they occur - tend to be saccular & multiple!
US, followed by contrast CT
Budd-Chiari syndrome:
causes:
obstruction of the hepatic venous outflow from small hepatic veins inside the liver to the IVC
hyper coagulable states
clot
Budd-Chiari - ssx:
PE:
Asx to fulminant liver dz acute: fatigue RUQ pain N/V jaundice hepatomegaly - ttp ascites
chronic: fatigue
HM
abd pain
LE edema
Budd-Chiari - work up:
prognosis:
LFTs
vascular img
most die <3 yrs if untx
Veno-occlusive dz:
causes:
caused by endothelial injury, leading to non-thrombotic occlusion of the terminal hepatic venues and hepatic sinusoids
irradiation
graft vs. host dz
hepatotoxins
Veno-occlusive dz - ssx:
PE:
work up:
sudden jaundices
ascites
tender, smooth HM
LFTs
US, liver bx
Portal vein thrombosis - causes:
surgery hyper coagulable states cancer cirrhosis trauma
leads to GI bleeding from varices (usu eso/stomach)
Portal vein thrombosis - ssx:
Work up:
Asx unless assoc w/other dz (pancreatitis)
LFTs
US - usu dx
Peliosis hepatitis:
causes:
multiple blood-filled cystic spaces develop randomly in the liver (mm - 3cm)
damage to sinusoidal lining cells from use of hormones (OCPs, anabolic steroids), tamoxifen, vit A
Peliosis hepatitis - ssx:
Dx:
Usu asx occasionally cysts rupture -> hemorrhage, mb death jaundice HM liver failure
often found incidentally on US or CT
Portal HTN:
increased resistance to blood flow, commonly arises from dz w/in the liver
uncommon - from blockage of splenic or portal vein, or impaired venous output
Portal HTN - causes:
cirrhosis
schistosomiasis
hepatic vascular abnormalities
leads to eso varices, portal-systemic encephalopathy
Portal HTN - ssx:
PE:
often asx
sx from complications (hemorrhage)
low systolic BP SM ascites, peripheral edema caput medusa, dilated abd wall veins jaundice spider angioma
Portal HTN - work up:
prognosis:
transjugular catheter (invasive) US or CT
mortality d/t hemorrhage >50%
Portal-systemic encephalopathy:
causes:
neuropsychiatric syndrome
fulminant hepatitis caused by virus, drug, toxin
commonly - cirrhosis, portal HTN
metabolic stress (inf, electrolyte imbalance, dehydration, diuretics)
gut protein d/o (GI bleed, high protein intake)
non-specific cerebral depressant (alcohol, sedative, analgesic)
Portal-systemic encephalopathy - pathophys:
absorbed products that would otherwise be detoxified through the liver end up in systemic circulation where they may be toxic to the brain
Portal-systemic - ssx:
Work up:
constructional apraxia
agitation, mania (uncommon)
“liver flap” (asterixis)
psychometric eval
CMP - electrolytes, albumin, LFT
EEG - diffuse slow wave activity
Post-op liver dysfunction:
mild liver dysfunction following major surgery, in the absence of pre-existing d/o. 3 types: post-op jaundice post-op hepatitis post-op cholestasis
Hepatic cysts:
commonly found incidentally on US or CT
usu asx, no clinical significance
polycystic liver assoc. w/polycystic kidneys (rare)
Benign liver tumors:
common, asx
ssx: HM
RUQ discomfort
intraperitoneal hemorrhage
LFTs normal to slight abn
often found incidentally on US, CT; may need Bx
Most common primary liver cancer:
hepatocellular carcinoma
more common outside US (E. Asia, sub-saharan Africa)
usu. pts with cirrhosis; common in HepB/C
Hepatocellular carcinoma - ssx:
prior dx - cirrhosis RUQ pain wt loss RUQ mass unexplained deterioration in few, 1st manifestation: bloody ascites shock peritonitis
Hepatocellular carcinoma - work up:
prognosis:
AFP (alpha-fetoprotein)
Img: US, CT, MRI
Liver Bx (if dx unclear)
prognosis poor
Metastatic liver cancer - from? prevalence?
from GI, breast, lung, pancreas
more common that primary liver CA
Metastatic liver cancer - ssx:
PE:
early asx non-specific: wt loss anorexia fever
liver enlarged, hard, or tender massive HM with nodules - adv hepatic bruits (uncommon) SM ascites jaundice (mild)
Metastatic liver cancer - work up:
CT or MRI w/contrast
suspect w/wt loss, HM, & primary tumor elsewhere
LFTs non-specific
Liver Bx - definitive
Hepatic granulomas:
causes:
localized collections of chronic inflammatory cells w/epithelioid cells & giant multinucleated cells
drugs
systemic d/o
inf (TB, schistosomiasis)
Hepatic granuloma - ssx:
work up:
typically asx or reflect underlying cause
LFTs
US, CT, MRI
Liver Bx - definitive
Cholelithiasis:
presence of one or more calculi in the GB
10% of adults in dev. countries/20% of >65
Cholelithiasis - risk factors:
F>M obesity American Indian ethnicity Western diet (SAD) FHx 5 F's (female, fat, 40, fertile, FHx)
Cholelithiasis - pathophys:
biliary sludge - during GB stasis types of stones: * cholesterol stones (>85%) * black pigment stones * brown pigment stones
Cholelithiasis - ssx:
80% asx RUQ pain - rad to back, down arm sudden onset, intense up to 12 hrs, dull ache N/V common onset after fatty meal FEVER UNCOMMON unless cholecystitis
Cholelithiasis - work up:
labs unrevealing
US - diagnostic
Acute cholecystitis:
Ssx:
inflammation of the GB, dev over hours, usu d/t stone obstruction of cystic duct (>95%)
pain similar to biliary colic, lasts longer >6hrs
subsides 2-3days, resolves 1 wk (85%)
vomiting
Acute cholecystitis - PE:
work up:
R subcostal ttp
+ Murphy’s sign
- Courvoisier sign
fever
Abd US Cholescintigraphy Abd CT (to ID complications - perforation)
Chronic cholecystitis:
Ssx:
longstanding GB inflammation, usu d/t stones
damage - from modest infiltrate of chronic inflammatory cells, to fibrotic, shrunken GB
extensive calcification - PORCELAIN GB
recurrent biliary colic
Chronic cholecystitis - PE:
work up:
upper abd tenderness
afebrile
abd US
Acalculous biliary pain - causes:
biliary colic w/o stones
abnormal GB emptying overly sensitive biliary tract sphincter of Oddi dysfx hypersensitivity of adj duodenum possibly stones that spontaneously passed microscopic stones
Acalculous biliary pain - work up:
Labs: abn
elev - alk phos, bili, AST, ALT
elev - lipase
Abd US
ERCP w/manometry - show Oddi dysfx
Postcholecystectomy syndrome:
cause:
abd sx post cholecystectomy (GB removal)
alteration of bile flow
leads to: continuously increased bile flow to upper GI
diarrhea, colicky lower GI pain
Choledocholithiasis:
Ssx:
presence of stones in the bile duct, leading to biliary colic, obstruction, gallstone pancreatitis, cholangitis
usu secondary cholesterol stones originating in GB (85%)
biliary colic
duct dilation
jaundice
cholangitis
Acute cholangitis:
EMERGENCY
bile duct infection (gm -) & inflammation
can lead to stricture, stasis, choledocholithiasis
Acute cholangitis - ssx:
PE:
Charcot’s triad:
- abd pain
- Jaundice
- fever/chills
RUQ abd tenderness
liver tender, enlarged
confusion
hypotension
Recurrent pyogenic cholangitis:
intrahepatic brown stone formation repeat cycles of obstruction, inf, inflammation * occurs in SE Asia * sludge + bacteria debris in bile duct * undernutrition * parasitic inf
What do you suspect in pt w/jaundice & biliary colic?
common duct stone
What do you suspect in pt w/ jaundice, biliary colic, fever, & leukocytosis?
acute cholangitis
Cholangitis/cholodocholithiasis work up:
Labs:
elev bilirubin, alk phos, ALT, GGT
CBC - leukocytosis
LFTs - AST, ALT
Abd US
Sclerosing cholangitis:
chronic cholestatic syndromes characterized by patchy inflammation, fibrosis, strictures of intra/extrahepatic bile ducts
leads to inflammatory & fibrosing lesion, scarring bile ducts
Primary sclerosing cholangitis:
Ssx:
MC form, cause unknown (AI?)
80% have IBD - usu UC
10-15% develop cholangiocarcinoma
progressive fatigue -> then pruritis jaundice (late) steatorrhea / fat soluble vit deficiencies 75% - stones (GB or ducts) Asx until late, then HM / SM / cirrhosis
Primary sclerosing cholangitis - work up:
elev. alk phos, GGT
elev. Gamma Globulin, IgM
neg. anti-mitochondrial Ab
US - to exclude extrahep obstruction
MRCP - multiple strictures intra/extrahep bile ducts
ERCP - 2nd choice, invasive
AIDS cholangiopathy:
Ssx:
biliary obstuction 2° strictures caused by opportunistic info
* pre-antiretroviral therapy - 25% prevalence
RUQ / epigastric pain severe pain -> papillary stenosis milder pain -> sclerosing cholangitis diarrhea fever jaundice
AIDS cholangiopathy - work up:
elev alk phos, GGT
ERCP
US
Cholangiocarcinoma:
Ssx:
PE:
rare
usu malignant
extrahepatic bile duct - MC
pruritis painless obstructive jaundice abd pain anorexia wt loss
non-tender mass (Couviorsier sign)
HM
GB carcinoma:
Ssx:
native american ethnicity
pts w/lg stones (>3cms)
porcelain GB (d/t chronic cholecystitis)
70-90% have gallstones
varies, asx -> biliary pain -> advanced dz w/wt loss, constant pain, mass, jaundice, + couvoisier’s
median survival - 3 months
cure if found early
Ddx - RUQ pain:
Hepatitis NASH cirrhosis cholecystitis/cholelithiasis cholangitis biliary colic Budd-Chiari syndrome pancreatitis pneumonia, pleurisy
Ddx - epigastric:
GERD gastritis PUD pancreatitis myocardial ischemia pericarditis AAA
Ddx - LUQ:
spleen infarct / rupture gastritis / gastric ulcer pancreatitis hiatal hernia sickle cell, mono, hemolytic d/o
Ddx - R/L flank:
kidney inflammation
pyelonephritis
polycystic kidney dz
Ddx - periumibilical:
early appendicitis
gastroenteritis
bowel obstruction
peritonitis
Ddx - RLQ:
appendicitis IBD / UC / Crohn's cecal diverticulitis inguinal hernia nephrolithiasis F: PID, ovarian cyst, ectopic, endometriosis M: testicular or epididymal inflammation
Ddx - suprapubic:
cystitis
acute urinary retention
F: uterine cramps, PID, cervicitis, endometriosis
M: acute prostatitis
Ddx - LLQ:
diverticulitis IBD / UC / Crohn's nephrolithiasis F: PID, ovarian cyst, ectopic, endometriosis M: testicular or epididymal inflammation
Ddx - diffuse abd pain:
early appendicitis gastroenteritis intestinal obstruction mesenteric ischemia peritonitis IBS celiac
Ddx - extra-abdominal causes of abd pain:
abd wall - hematoma
infection - herpes zoster
metabolic - DKA, porphyria, sickle cell dz
thoracic - MI, PE, radiculitis
toxic - spider bite, opioid withdrawal, heavy metal poison
Define diarrhea:
> 200g/day stool wt
increased stool fluidity
3 BM/day
4 mechanisms of diarrhea:
osmotic - too much water in bowels, inc. amt of poorly absorbed solute
causes - malabsorption, osmotic laxatives, lactose intolerance
secretory - inc secretion or inhibited absorption
causes - enterotoxin, hormones, gastric hypersecretion, laxatives, bile salts, fatty acids
exudative - mucus, blood, protein
causes - Crohn’s, UC, infectious, ischemic, vasculitis, radiation
motility - increased (hyperthyroid, post-gastrectomy) or decreased (DM, hypothyroid, scleroderma) contact btw contents & mucosa, increased motility (IBS)
Diarrhea - red flags:
blood pus fever chronicity signs of dehydration unintended wt loss failure to thrive
complications:
dehydration
electrolyte imbalance
Constipation - red flags:
abdominal distension vomiting blood in stool wt loss severe or worsening sx
Constipation - acute/organic:
obstruction
adynamic ileus
meds (opioid, anticholinergic)
Constipation - chronic/functional or organic:
carcinoma hypothyroid CNS disorder slow transit IBS
Gas - red flags:
wt loss
blood in stool
GI bleeding:
Sm bowel - angioma, AV malformation, tumor, Meckel’s
Colon/anus - fissure, colitis, carcinoma, polyp, IBD, diverticular dz, hemorrhoids
Dyschezia:
difficulty evacuating (urge, but can't) often from discoordination: hypotonia or prolapse
O&Px3 tests for:
protozoa, worms, eggs, parasites
worms - round, hook, tape, flat, fluke
Stool diagnostic tests
Labs (appearance, pH, WBC, blood, etc) O&Px3 culture hemoccult fecal leukocytes lactoferrin (latex agglutination assay) fecal lysozyme comp digestive stool analysis sIgA serology transit/retention time
Acute abdomen d/t infection or chemical presents as:
sharp, localized pain
somatic nerves in perietal peritoneum respond to irritation
Acute abd d/t distention or spasm presents as:
vague, dull, nauseating, diffuse
ANS fibers on viscera respond to distention & contraction
Acute abd - referred pain:
aching pain perceived distant from the source, not reproducible at distant site
MC cause of acute abd pain:
Appendicitis!!
obstruction from: lymphoid hyperplasia (mono, crohn's, GE, measles) fecaliths parasites foreign material (swallowed?) TB tumors (benign, malignant)
Appendicitis - classic presentation:
periumilical pain -> migrates to RLQ N/V - after onset anorexia <48 hr onset non-specific: indigestion, flatulence, malaise, diarrhea
Appendicitis - PE:
low grade fever McBurney's pt tenderness rebound tenderness pain to percussion - pain in RLQ rigidity & guarding Rovsing's sign Obturator sign Psoas sign cough sign Markle sign (heel drop) DRE & pelvic maybe
Acute mesenteric ischemia:
dec. mesenteric blood flow -> wall ischemia, inflammation, infarction (at splenic flexure)
d/t diminished perfusion or occlusive dz
rarely seen in <60 yrs
Acute mesenteric ischemia - ssx:
severe abd pain w/minimal findings sudden onset pain -> arterial embolism gradual onset pain -> venous thrombosis peritoneal signs as necrosis occurs: * abd tenderness * guarding * absent bowel sounds * hemoccult positive * sx of shock
mortality rate - 70-90%
Ischemic colitis:
Ssx:
episodic, transient reduction of bowel blood flow from small vessel atherosclerosis
mild, slow onset
LLQ pain
rectal bleeding
mucosal/submucosal bleeding mb seen
Abd hernia:
ssx:
acquired - surgical or congenital weakness of wall, protrusion of contents Asx unless strangulated * increasing pain * N/V * signs of peritonitis
SURGICAL REPAIR
Intestinal obstruction - classification:
complete or partial
simple or strangulated
location: high sm, low sm, lg intestine
onset: acute or gradual
Intestinal obstruction - causes:
adhesions hernia tumor diverticulitis foreign body volvulus intussusception fecal impaction
Intestinal obstruction - ssx:
Sm Int: sudden onset periumbilical or epigastric cramping vomiting obstipation (complete) diarrhea (partial) NTTP (if not strangulated) severe, constant pain (strangulated) palpable dilated bowel loops
colon: gradual onset of pain obstipation vomiting abd distension non-tender palpable mass borborygmi
Ileus:
Causes:
temporary arrest of intestinal peristalsis
post-surgical appendicitis diverticulitis perforation AAA hypokalemia drugs (opioid, anticholinergic) lower lobe pneumonia MI
Ileus - ssx:
PE:
distension vomiting abd discomfort colicky pain watery stool
absent bowel sounds
NTTP (unless inflammatory cause)
