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3 GI 2/5 Liver

Step Up to Medicine, Chap 3, Liver

Which classification is used to estimate hepatic reserve in liver failure: measures disease severity, and is predictor of morbidity and mortality? Child's classification
Which Child's class indicates milder liver disease? Most severe liver disease? Class A=mild (bili <2). Class C= most C-vere (severe) (bili >3).
2 MCC of cirrhosis? Alcoholic liver disease (MCC) and chronic viral infection (esp Hep C)
Gold std for diagnosing cirrhosis? Liver biopsy
Name 2 drugs commonly assoc'd with cirrhosis. Acetaminophen toxicity and methotrexate
Which complication of bone marrow transplant can lead to cirrhosis? Hepatic veno-occlusive disease
Treatment for portal HTN? Use transjugular intrahepatic portal-systemic shunt (TIPS) to lower pressure
Most dangerous complication of portal HTN? Bleeding (hematemesis, melena, hematochezia) 2/2 esophogastric varices is MC
Tx for bleeding varices? Give fluids for stabilization of hemodynamics, octreotide drip (fewer SE than vasopressin), beta blocker (prevents recurrence as long-term therapy). Can also do variceal ligation or banding.
Test of choice to diagnose pt with hematemesis? Emergent upper GI endoscopy
If IV vasopressin is given to treat bleeding varices, what drug is also given to prevent complications and side effects? Nitro (prevents coronary vasoconstriction/MI, decreased CO, HTN)
Indications for paracentesis of ascitic fluid? New-onset ascites, worsening ascites, or suspected SBP.
What measurement of ascitic fluid helps determine the cause of the ascites? Which numbers point toward portal HTN as the likely cause? Serum ascites albumin gradient. >1.1=portal HTN. <1.1= consider other causes
Tx for ascites? Bed rest, low-sodium diet, and diuretics (furosemide and spironolactone). Theraptueic paracentesis if dyspnea or early satiety. Peritonovenous shunt or TIPS to reduce portal HTN.
What is the mechanism of lactulose in treating hepatic encephalopathy? Metabolism of lactulose by bacteria in the colon favors formation of NH4+ which is poorly absorbed by the GI tract thus promoting excretion of ammonia
What is the mechanims of neomycin in treating hepatic encephalopathy? Decreases ammonia production by bacteria in intestines
How often should labs be ordered on cirrhotic pts? Which labs should be ordered? Every 3-4 mos. Order CBC, renal f'n tests, electroyltes, LFTs, and coag tests. Also do endoscopy to look for esophageal varices.
Name two things that often precipitate hepatorenal syndrome? Infection or diuretics.
Azotemia, oliguria, hyponatremia, hypotension, low urine sodium (<10mEq/L) in a pt with cirrhosis. Hepatorenal syndrome. Indicates end-stage liver disease.
Tx for hepatorenal syndrome? Liver transplant. Very poor prognosis, and usually fatal w/out transplant.
Top 3 bacteria causing SBP? E coli (MCC), Klebsiella, Strep pneumo
Diagnostic parameters in paracentesis fluid for SBP? WBC >500, PMN >250 with positive culture.
How long must a pt abstain for alcohol before being considered for liver transplantation? 6mos
AR disease of copper metabolism Wilson's disease
Cause of Wilson's disease? Deficiency of ceruloplasmin (copper-binding protein necessary for excretion) in liver--> hepatocyte death--> leakage of copper into various organs (corneas, kidneys, brain)
3 findings used to diagnose Wilson's disease? 1. Hepatic disease (elevated aminotransferases, impaired coag factors and albumin synthesis). 2. Serum ceruloplasmin levels (normal levels don't exclude dx though). 3. Liver biopsy (elevated [copper])
Treatment for Wilson's disease? Chelating agents (D-penicillamine), Zinc (prevents dietary uptake; give alone if no sx or with chelators if symptomatic), liver transplant (unresponsive to therapy or fulminant liver failure).
AR disease of iron absorption Hemochromatosis
Cause of hemochromatosis Excess absorption of iron in intestines--> increased accumulation of iron as ferritin and hemosiderin in organs--> organ fibrosis
Primary organ affected in hemochromatosis? Liver (also affects pancreas, heart, skin,joints, thyroid, gonads, and hyopthalamus)
Name 2 endocrine disorders caused by hemochromatosis. Bronze diabetes: iron deposition in pancreas and hyperpigmentation of skin. Also hypothyroidism.
Iron studies in hemochromatosis show? Elevated seru iron and serum ferritin. Elevated iron saturation (transferrin near 100%).
Diagnostic test required for hemochromatosis? Liver biopsy (determines hepatic iron concentration)
Tx for hemochromatosis? Repeated phlebotomies. Liver transplant in advanced cases.
Benign liver tumor MC seen in young women (15-40yo). Hepatocellular adenoma
Risk factors for hepatocellular adenoma? OCP use, female sex, and anabolic steroid use.
Tx for hepatocellular adenoma? D'C OCPs, surgical resection for tumors >5cm that don't regress after D'C'ing OCPs. Otherwise there's a risk of rupture.
MC type of benign liver tumor Cavernous hemangioma
Diagnostic test of choice in cavernous hemangioma? Which diagnostic test is contraindicated? Why? Diagnose with imaging tests (CT w/IV contrast, US). Do NOT use biopsy b/c of risk of rupture and hemorrhage.
Which conditions can increase the size of cavernous hemangiomas? Pregnancy and OCP use.
Tx for cavernous hemangioma? Most cases req' no tx. Consider resection if pt is symptomatic or if high risk of rupture (large tumors).
Benign liver tumor in women of reproductive age with NO assoc'n with OCP use? Focal nodular hyperplasia
Tx for focal nodular hyperplasia? None
2 MC malignant liver tumors? HCC and cholangocarcinomas
Which subtype of HCC is assoc'd with Hep B/C and cirrhosis? Non-fibrolamellar (MC type of HCC). Usually unresectable with short survival time (months).
Which subtype of HCC is NOT assoc'd with Hep B/C or cirrhosis, and is more commonly seen in young people? Fibrolamellar (more often resectable; longer survival time)
Name 3 chemical carcinogens assoc'd with HCC. Aflatoxin, vinyl chloride, and thorotrast.
What is prognosis of HCC if unresectable? If resectable? <1 yr if unresectable. 25% survival at 5 years if resectable.
Tumor marker used as screening tool in HCC? AFP (also helpful in monitoring response to therapy)
Liver disease assoc'd with obesity, hyperlipidemia, and DM NASH
AD condition with decreased activity of hepatic uridine diphosphate glucoronyl transferase causing isolated elevation of unconjugated bilirubin Gilbert's syndrome
Pt on crash diet coming in with jaundice and elevation of unconjugated bilirubin Gilbert's disease (also illness, fever, alcohol, infection)
Blood draining into duodenum via CBD Hemobilia
MCC hemobilia Trauma
Dx test for hemobilia? Arteriogram
Which infections are associated with hyatid liver cysts? Infection from tapeworm Echinococcus granulosus, or less commonly Echinococcus multilocularis
MC location for hyatid liver cysts? right lobe of liver
Tx for hyatid liver cysts? Surgical resection with mebendazole post-op.
MCC pyogenic liver abscess? Biliary tract obstruction (obstruction of bile outflow allows bacterial proliferation). ALso GI infection (diverticulitis, appendicitis), penetrating liver trauma (GSW, trauma)
Which 4 organsisms are implicated in pyogenic liver abscesses? E coli, Klebsiella, Proteus, Enterococcus
MC location for liver abscess (both pyogenic and amebic)? Right lobe
Clinical features of pyogenic liver abscess? Fever, malaise, anorexia, weight loss, nausea/vomiting, RUQ pain, and jaundice
Dx of pyogenic liver abscess? US or CT with elevated LFTs
Treatment of pyogenic liver abscess. IV antibiotics and percutaneous drainage of abscess (may need surgical drainage). Fatal if untreated.
Liver abscess most commonly seen in men, especially MSM Amebic liver abscess
Causative organism in amebic liver abscess? Entamoeba histolytica (fecal-oral transmission. amebae reach liver via hepatic portal vein)
Clinical features of amebic liver abscess? Fever, RUQ pain, n/v, hepatomegaly, diarrhea
Dx of amebic liver abscess? Serologic testing (IgG immunoassay) establishes diagnosis. Stool antigen test not sensitive. LFTs elevated. Difficult to distinguish from pyogenic abscess on imaging.
Tx for amebic liver abscess? IV metronidazole. Therapeutic aspiration if risk of rupture due to large size or if no response to medical therapy.
Liver disease caused by occlusion of hepatic venous outflow-> hepatic congestion and microvascular ischemia Budd Chiari syndrome
Which myeloproliferative disorder can cause Budd Chiari? Polycythemia vera (also hypercoagulability, pregnancy, chronic inflammation, infection, cancer, trauma)
Tx for Budd Chiari? Surgery (balloon angioplasty with stent placement in IVC, portocaval shunts) and liver transplantation w/cirrhosis
When does jaundice become clinically evident? Bilirubin >2
Dark urine is only seen with which type of bilirubin? Why? Toxicity? Conjugated (direct) bilirubin b/c it's water soluble (loosely bound to albumin) so it can be excreted in urine. Non-toxic.
Name 3 major causes of jaundice. 1. Hemolysis, 2. Liver disease, 3. Biliary obstruction
Why is unconjugated bilirubin toxic? B/c the unbound form can cross BBB and cause neuro deficits
Dark urine and pale stools signify which type of hyperbilirubinemia? Dark urine and pale stools
Where is the defect- prehepatic or posthepatic?: Unconjugated hyperbilirubinemia Prehepatic
Where is the defect- prehepatic or posthepatic?: conjugated hyperbilirubinemia Posthepatic
Jaundice, gray stools, dark urine, pruritus, elevated alk phos, increased serum cholesterol, skin xanthomas, malabsorption of fats and ADEKs Cholestasis
Dubin-Johnson: unconj or conj hyperbilirubinemia? Conj
Rotor's syndrome: unconj or conj hyperbilirubinemia? Conj
Gilbert's syndrome: unconj or conj hyperbilirubinemia? Unconj
Crigler Najar, types I and II: unconj or conj hyperbilirubinemia? Unconj
Physiologic disease of newborn: unconj or conj hyperbilirubinemia? Unconj
Urine positive for bilirubin: unconj or conj hyperbilirubinemia? Conj
Urine negative for bilirubin: unconj or conj hyperbilirubinemia? Unconj
Isolated unconjugated hyperbilirubinemia in an asymptomatic pt with no hemolysis? Likely Gilbert's
Which aminotransferase is more sensitive for liver damage: AST or ALT? ALT (L for Liver)
What is the expected AST:ALT ratio in alcoholic hepatitis? >2:1 (AST never >500, ALT never >300) (the higher the ratio, the more likely alcohol is the cause)
Name 4 places alk phos is found. Liver, bone, gut, placenta.
How is a GGT level useful in conjunction with an elevated alk phos? If GGT is also elevated, suggests hepatic origin of obstruction. If GGT is normal, think pregnancy or bone disease as cause.
If LFTs show cholestasis, what test should be ordered? Abd or RUQ ultrasound
Created by: sarah3148
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