Gastroenterology
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| Viral hep that can cause cirrhosis | Hep B & C
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| Conjugated bili: | direct; bound to gluc acid; water soluble; caused by obstruction of outflow tract or in the liver
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| Unconjugated bili: | indirect; water insoluble; caused by hemolysis
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| Fulminant acute liver dz: | progress to liver fail in 14 days; no h/o liver dz; develop coagulopathy (INR >2), encephalopathy
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| ALT/AST | hepatocell injury: correlates w/degree of cell death; >1000: hepatitis, shock, toxins (Tylenol)
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| Abnormal AST/ALT | AST:ALT >2:1 = alcoholic hep; <500: EtOH; poss normal in cirrhosis
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| Alk phos | liver, bone, intestinal tract, placenta, kidney; elevated in liver damage/obstruction; if elevated more than AST/ALT, more likely biliary disorder
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| Child-Pugh score assesses: | prognosis of chronic liver dz
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| Alfa fetoprotein (AFP) is used to detect: | hepatocellular ca; inflammation
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| Liver dz lab w/u | Hep A, B, C; ANA; ASMA; IgG; Anti-mito Ab (primary biliary cirrhosis)
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| Labs for hemochromatosis | ferritin, iron sat, HFE gene
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| Hep A clinical features | Incubation 4-6 wks (average 30d); 80% jaundice pts >14 yo; fulminant course uncommon; no chronic/carrier state
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| Hep B clinical features | Incubation 6 wks- 6 mos (average 60-90d); 60% fulminant dz; 15-25% premature mortality; cirrhosis (3-5%); HCC; Asians
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| Hep C clinical features | Incubation 6-7 weeks; 40% jaundice; 50-70% chronic; persistent; AA men in 40s; No. 1 indication for liver transplant
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| Hep C dx labs | ELISA (pos in 8-10 wks; good screen for chronic); HCV RNA; HCV genotype
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| Alcoholic hepatitis | 40-60 g EtOH/day (less for women); jaundice, fever, anorexia, nausea; TBil, alb, INR; histo makes the dx; hepatomegaly, steatohepatitis; Tx supportive (severe: prednisone/pentoxifylline)
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| Cirrhosis: dx | pathologic; Fibrosis, Regenerated nodules, Vascular distortion
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| Cirrhosis: complications | Hepatorenal syndrome; hepatoma (hepatocellular ca); Portal HTN (pressure > 12mmHg; varices, ascites, encephalopathy, GI bleeding)
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| Varices Tx | Active bleed (Hematemesis, melena, hematochezia; Hypotension, tachy): Emergent endoscopy; Octreotide (splanchnic VC to reduce portal pressure; dec collateral flow & variceal pressure); Minnesota tube: Last chance (bridge to TIPS)
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| Varices prevention | screening endoscopy; endo banding (if large varices & prior bleed); beta blockers to HR<60; nitrates
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| Ascites | 60% develop within 10 yrs of cirrhosis dx; US (check for fluid & portal v. thrombosis)
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| Serum ascites albumin gradient | paracentesis; if gradient >1.1: portal HTN
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| Spont bac peritonitis | peritoneal cell count: >500 PMN confirms dx
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| Ascites mgmt | Na & fluid restriction; diuretic tx (Aldactone/Lasix); LVP & albumin replacement; TIPS for refractory ascites
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| Encephalopathy tx | r/o infxn, correct lytes; lactulose; neomycin; rifaximin
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| Cirrhosis & Hepatoma (HCC) | screen (US & AFP 6-12 mos); common/increasing worldwide ca; tx Partial hepatectomy, Chemoembolization, RF ablation; poss TP
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| Liver TP indications | Hep C (No. 1 in US); EtOH (abstinent >6 mos); Cryptogenic/NASH; PBC, PSC; Autoimmune hep; Hep B; risk of relapse in new liver
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| NASH | chronic hep or metab syn; usu Asx; liver bx; hepatocytes replaced; tx: stop offending meds; wt/glycemic ctrl
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| Benign masses: dx | imaging > bx; 20% of popn
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| Most common benign liver tumor | hemangioma; W>M, 20-40 (2nd most common: FNH)
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| Hepatic adenoma | W>M, young, LT estrogen use; anabolic steroids
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| HCC/malignant mass | usu in setting of chronic liver injury or cirrhosis; need multi-phasic imaging to dx (arterial phase hypervascularity; delayed phase wash-out)
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| Hep A mgmt | IVIG within 14d post exposure
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| Hepatitis virus types (RNA / DNA): | HAV: RNA virus; HAV: double-stranded DNA; HCV: single-stranded RNA; HDV: defective RNA virus (requiring assistance by HBV)
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| Hepatitis: modes of transmission | HAV: fecal-oral route; HBV: blood or body fluids (sex, transfusion, IVDU / needles); HCV: blood or body fluids (50% IVDU); HEV: fecal-oral route
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| Defn Chronic HBV: | Positive HBSAg >6 months
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| Hep E clinical features | Incubation 35-40 days; 0.5% mortality (20% in PG); no carrier state
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| Viral hepatitis causing spiking fevers: | HAV
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| Acute Hep C mgmt | Acute HCV may benefit from interferon alpha or peginterferon (reduces risk of chronic hep)
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| How many patients with acute HCV clear the virus spontaneously? | 20%
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| Chronic Hep C mgmt | slow-release peginterferon; daily ribavirin in divided doses; protease inhibitors (boceprivir or teleprivir)
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| Chronic Hep B mgmt | interferon alpha or peginterferon; possibly entecavir or tenofovir (short-term: lamivudine & telbivudine)
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| Use of immune globulin: | Give to all household persons / close contacts of patient with HAV. Give HBIG within 7 days of exposure to HBV
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| Cirrhosis etiology | EtOH (leading cause in US); viral hep; chronic biliary obstruction, metabolic disorders; CHF
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| Cirrhosis workup | Labs: CBC (low WBC, anemia, low Plt), elevated PT/PTT & LFTs; US (HSM, liver nodules/atrophy); endoscopy (varices); CT & bx (dx HCC)
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| Most common primary for liver mets | Colon (no. 1), GI tract (adenocarcinoma), breast, lung. Primary liver cancer is uncommon.
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| Risk factors for liver cancer | Aflatoxins (in food with Aspergillus flavus). Cirrhosis. Parasitosis (liver fluke: Clonorchis sinensis). Alpha-antitrypsin deficiency
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| Types of liver cancer (4) | HCC (nodules with prominent vascularity). Cholangiocarcinoma (adenocarcinoma from bile ducts). Hepatoblastoma (HCC fetal variant w/familial adenomatous polyposis). Metastatic
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| Portal HTN etiologies | Cirrhosis (EtOH, hepatitis, hemochromatosis). Budd-Chiari (phlebitis). Extrinsic compression (trauma, inflammation, tumor). Schistosomiasis
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| In varices, collateral circulation develops thru: | coronary vein (stomach/esophagus), superior hemorrhoidal veins, anterior abd wall veins , plexus of Retzius
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| Portal HTN tx | Vasopressin with nitrates, octreotide, propranolol
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| Portal HTN surgical mgmt | Paracentesis and peritoneovenous conduits (for ascites). Portal decompression: TIPS, portosystemic shunt, splenectomy, GE devascularization (Sugiura). Liver transplant
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| Elevated AST, ALT, indirect bilirubin = | Hepatitis
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| Isolated elevated indirect bilirubin = | Gilbert syndrome
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| Elevated indirect bilirubin w/defective glucuronyl transferase | Crigler-Najjar
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| Photosensitivity, abd pain w/ neurologic dysfunction, erythema or skin fragility | Porphyria
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| Spontaneous bacterial peritonitis (SBP) = | infected ascites
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| Hep B transmission | Sex; bloodborne (1 in 63K risk); perinatal (c-section does not lower risk): vax+HBIG
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| histological pattern of advanced fibrosis in liver = | cirrhosis
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| Most common cause of abnormal liver tests | fatty liver dz
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| Hep A incubation | average 30d
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| Hep B incubation | average 60-90d
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| Hep C incubation | average 6-7 wk
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| Hep A clinical sxs | 80% jaundice pts >14 yo; fulminant or cholestatic hep
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| Hep B clinical stuff | 15-25% premature mortality; cirrhosis/hepatocell ca; Asians
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| Hep C clinical stuff | 40% jaundice; 70% chronic; persistent; AA men in 40s; No. 1 indication for liver transplant
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| Most common benign liver tumor | hemangioma; W>M, 20-40 (2nd most common: FNH: focal nodular hyperplasia)
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| No. 1 indication for liver transplant | Hep C
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| Hep B: more likely to become chronic if: | young at age of infxn (or immunocompromised); 95% of pts clear the virus & develop Abs; chronic Hep B increases risk of cirrhosis & HCC
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