tiki taka ck hepatology

8/10/2019 Tiki Taka Ck Hepatology

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HEPATOLOGY TiKi TaKa ______________________

. LIVER DISEASES:__________________________________

. ACUTE HEPATITIS:____________________________________

. Jaundice - fatigue - weight loss - drak urine (bilirubin in urine).. Hepatitis B & C present with serum sickness phenomena (arthralgia - urticaria- fever).

. HBV is associated with polyarteritis nodosa (PAN) !. HCV is associated with Cryoglobulinema.. HEV is most severe in PREGNANT WOMEN .. It can be fatal.

. Dx -> ++ CONJUGATED (DIRECT) BILIRUBIN.. Dx -> ++ ALLLLLLLLT -> VIRALLLLLLLLL hepatitis.. Dx -> ++ ASSSSSSSST -> DRUGSSSSSSSSS hepatitis.

. Dx -> AST:ALT = 2:1 -> ALCOHOLIC hepatitis.

. Dx -> Most accurate test -> Serology (IgG & IgM).

. N.B. EVALUATION OF LIVER DAMAGE:___________________________________-> ACUTE HEPATITIS -> Liver function tests & Viral serology.-> CHRONIC HEPATITIS -> Liver biopsy.# HEPATITIS B:

_______________

. HEPATITIS B DIAGNOSIS -> SEROLOGY:____________________________________

. The 1st test to become ABNORMAL in ACUTE HB infection is SURFACE ANTIGEN (HBsAg).. ++ ALT, e-antigen & symptoms all occur after the appearance of HBsAg.

...................... Surface Ag ........ e-Ag ......... Core Ab .......... Surface Ab

. ACUTE disease -----> ++ ........ ++ ......... ++ ..........(--)

. WINDOW PHASE ------> -- ........ -- ......... (++) ..........--(RECOVERING)

. VACCINATED --------> -- ........ -- .......... -- ...........(++). HEALED RECOVERED --> -- ........ -- .......... (++) ...........(++)


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. CHRONIC disease ---> Same as acute disease but based on persistance of HbsAg> 6 months

. Anti HBc Ig "G" Ab -> Denotes CHRONICITY !

. Best means of screening for HBV infection -> HBsAg & IgM Hbc Ab.

. N.B. ACUTE VIRAL REPLICATION indicators:__________________________________________. Hepatitis B DNA plymerase = e-Antigen = Hepatitis B PCR for DNA.

. CHRONIC HEPATITIS B TREATMENT:________________________________. Chronicity = More than 6 months with +ve serology.. Tx -> Anti-viral therapy -> LAMIVUDINE + INTERFERON.

# HEPATITIS C:______________

. HEPATITIS C DIAGNOSIS:________________________. Best initial test -> Hepatitis C antibody.. Most accurate test ->

1 - Hepatitis C PCR for RNA:determine the degree of viral activity & response to therapy.2 - Liver biopsy: determine the seriousness of the disease i.e. extent of liverdamage.

. Chronic HCV classically presents with waxing & waning transaminases levels &few syms.. Pts may complain of arthralgias or myalgias.. Extra-hepatic sequlae: Cryoglobulinemia - porphyria cutanea tarda & glomerulonephritis.

. CHRONIC HEPATITIS C TREATMENT:________________________________

. All chronic hepatitis C pts with ++ ALT, detectable HCV RNA & histologic evidence.. Tx -> Anti-viral therapy -> RIBAVIRIN + INTERFERON.. Chronic HCV pts with persistently NORMAL liver enzymes & MINIMAL histologicalfindings,. NO NEED TO BE TTT WITH INTERFERON OR ANTI-VIRAL DRUGS.. JUST follow up with yearly liver function tests.

. All chronic HCV pts sh'd receive vaccinations to Hepatitis A & B if not already immune.. Both vaccinations are safe during pregnancy.. Incidence of vertical transmission is very low 2-5 % (No need for C.S. for pr

egnants).. HCV infected mothers should NORMALLY BREAST-FEED their babies.. SE of Ribavirin -> Anemia.

____________________________. SE of Interferon -> Arthralgia - myalgia - flu-like $ - thrombocytopenia - depression.

________________________________________________________________________________________


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. VACCINATION:______________. Vaccination for both hepatitis A & B are done universally in childhood.. No vaccine & No post-exposure prophylaxis for hepatitis C.. INDICATIONS for HEPATITIS A & B:

___________________________________1 - CHRONIC LIVER DISEASE -> Cirrhosis.2 - HOUSE HOLD CONTACTS -> of pts with hepatitis A & B.3 - HOMOSEXUAL MEN !4 - Chronic recepients of blood products.5 - Injection drug users.

. SPECIFIC INDICATIONs FOR HEPATITIS A & B VACCINE:___________________________________________________. A -> TRAVELERS.. B -> Health care workers & patients on dialysis.

. POST-EXPOSURE PROPHYLAXIS FOR HEPATITIS B:____________________________________________. Health care worker got stucked with a needle contaminated with blood from HBVpt.. A child born to a mother with chronic hepatitis B.

. GIVE -> HEPATITIS B IMMUNOGLOBULIN + HEPATITIS B VACCINE.. If the person had already been vaccinated,. Check the levels of protective HBsAb (surface antibodies).. If protective antibodies are ALREADY present -> No further ttt.

. FULMINANT HEPATIC FAILURE:____________________________. Hepatic encephalopathy developing within 8 weeks of the onset of acute liverfailure.. More common in pts using heavily using acet5aminophens & alcohols.. Mostly their is co-infection of hepatitis B & D.. Markedly ++ ALT, ++ PT & coagulopathy.

. HIGH PRIORITY CANDIDATES FOR LIVER TRANSPLANTATION. (The only effective ttt!).

. N.B. PROTHROMBIN TIME IS THE SINGLE MOST IMPORTANT TEST TO ASSESS LIVER FUNCTION !

_____________________________________________________________________________________

. ASYMPTOMATIC ++ OF LIVER FUCTION TESTS (AST & ALT) APPROACH:______________________________________________________________.1. Ask for H/O of drug or alcohol intake, travel outside USA, blood transfusion or sex..2. Drugs (NSAIDs - Antibiotics - Anti-epileptic - Anti-tuberculous).

.3. Repeat the tests again to confirm the elevations !.4. If elevation persists > 6 months -> Chronic..5. So .. test for HBV & HCV, Hemochromatosis & fatty liver.

. INH (ISONIAZID) INDUCED HEPATITIS:____________________________________. INH may induce sub-clinical hepatitis.. Mild elevation of ALT & AST (< 100 IU/L).. The hepatic injury is typicall self-limited.. No ttt is needed .. The condition will resolve spontaneously.


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. CHRONIC HEPATITIS -> CIRRHOSIS:__________________________________________________________________. CHRONIC ALCOHOL ABUSE & VIRAL HEPATITIS ARE THE MOST COMMON CAUSES.. GENERAL FEATURES OF CIRRHOSIS:

_________________________________1 - Edema -> from low oncotic pressure -> Tx: Spironolactone & diuretics.2 - Gynecomastia.3 - Palamar erythema.4 - Splenomegaly.5 - Thrombocytopenia (Caused by splenic sequestration).6 - Encephalopathy (Tx: lactulose).7 - Ascites (Tx: spironolactone).8 - Esophageal varices (Tx: propranolol will prevent bleeding - Banding if rebleed).. HYPER-ESTROGENISM in Cirrhosis:

_________________________________. Due to -- clearance of Estrogen due to ++ portosystemic shunt.. -- sex hormone binding globulin synthesis.. Gynecomastia - testicular atrophy - spider angiomata - palmar eryhtema & -- body hair.

. ASCITES:___________. Paracentesis if (New ascites - pain, fever & tenderness).

. SERUM TO ASCITES ALBUMIN GRADIENT (SAAG):___________________________________________-> < 1.1 -> EXUDATE -> NO portal hypertension.-> > 1.1 -> TRANSUDATE -> PORTAL HYPERTENSION (++ Capillary hydrostatic pressure).

. SPONTANEOUS BACTERIAL PERITONITIS:____________________________________

-> Pt with cirrhosis & ascites presenting with low grade fever, abd. pain & orconfusion.-> Dx -> Best initial test -> Cell count > 250 neutrophils.-> Dx -> Most accurate -> Fluid culture.-> Tx -> CEFOTAXIME.-> Prevent recurrence -> TMP-SMX.

. HEPATIC HYDRO-THORAX:_______________________. Transudative pleural effusions in pts with cirrhosis,. who have no underlying cardiac or pulmonary disease.. Results in a RT-sided pleural effusion.. Tx -> Salt restrictions & diuretics.

. TIPS "Trans-jugular Intra-hepatic Porto-systemic Shunt" placement in refractory cases.

. CHRONIC LIVER DISEASES (CAUSES OF CIRRHOSIS):_______________________________________________{1} ALCOHOLIC CIRRHOSIS:

_________________________. Diagnosis of exclusion !!. H/O of long-standing alcohol abuse.


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{2} PRIMARY BILIARY CIRRHOSIS (PBC):_____________________________________. Not related to IBD !!. Middle-aged woman.. ITCHING !. XANTHELASMA (Cholesterol deposits).. H/O of other autoimmune diseases.. Best initial test -> ++ ALP Alkaline phosphatase with NORMAL BILIRUBIN level.. ++ IgM.. Most accurate test -> Anti-mitochondrial antibody (AMA) & Liver biopsy.. Tx -> Ursodeoxycholic acid.

{3} PRIMARY SCLEROSING CHOLANGITIS (PSC):__________________________________________. Inflammatory bowel disease (IBD) accounts for 80% of causes (UC > CD).. ITCHING !. Best initial test -> ++ ALP Alkaline phosphatase with ++ BILIRUBIN level.. Most accurate test -> ERCP -> BEADING of the biliary system.. +ve ASMA (Anti-smooth muscle antibody).. +ve ANCA.. Tx -> Ursodeoxycholic acid.

{4} WILSON's DISEASE = HEPATO-LENTICULAR DEGENERATION:

_______________________________________________________. -- Ceruloplasmin -> ++ Copper.. Abnormal Copper deposition in liver, basal ganglia & cornea.. Young pt < 30 ys.. Cirrhosis + Choreiform movement disorder + Neuropsychiatric abnormalities.. May present with hemolysis.. Best initial test -> Slit lamp (Keiser Fleischer rings) & -- Ceruloplasmin level < 20mg. Most accurate test -> Liver biopsy -> Copper level > 250 mcg/gram.. Tx -> Penicillamine.

{5} HEMOCHROMATOSIS:_____________________

. Genetic disorder -> over-absorption of copper.. Iron deposits in various body tissues.. Heart -> Restrictive cardiomyopathy.. Skin -> Darkening & pigmentation.. Joint -> Psedogout & CPPD.. Pancreas -> Bronze Diabetes.. Pituitary -> Panhypopituitarism.. Genitalia -> Infertility.. Infections -> LISTERIA, VIBRIO VULNIFICUS & YERSINIA ENTEROCOLITICA.. Liver -> HEPATOMA & cirrhosis -> HEPATOCELLULAR CARCINOMA (Most common causeof death).. Dx -> Best initial test -> ++ serum iron & ferritin levels & -- TIBC.. Dx -> Most accurate test -> Liver biopsy - MRI liver - HFe gene mutation dete

ction.. Tx -> Phlebotomy.

{6} AUTO-IMMUNE HEPATITIS:___________________________. Young woman with other auto-immune diseases (Coomb's +ve AIHA, thyroiditis &ITP).. Best initial test -> ANA & ASMA & Liver/kidney microsomal antibody.. Serum protein electrophoresis (SPEP) -> Hyper-gamma globulinemia.. Most accurate test -> Liver biopsy.


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. Tx -> prednisone.{7} NON-ALCOHOLIC STEATOHEPATITIS (NASH):

__________________________________________. Associated with obesity - DM - Hyperlipidemia.. Hepatomegaly.. Patho-physiology -> INSULIN RESISTANCE.. Dx -> Best initial test -> ALT > AST.. Dx-> Most accurate test -> Liver biopsy (Fatty infiltration).. The liver biopsy looks alike Alcoholic liver disease !!. Tx -> No specific therapy.. Control the underlying cause e.g. weight loss - DM control.

{8} ALPHA - 1 ANTI-TRYPSIN DEFECIENCY:_______________________________________. PAN-ACINAR EMPHYSEMA + CIRRHOSIS.. Co-existing lung involvement.. Family H/O of cirrhosis.

{9} CARDIAC CIRRHOSIS:_______________________. Co-existing right-sided heart failure.

. MANAGEMENT OF CIRRHOSIS:____________________________________________________

{A} . PERIODIC SURVEILLANCE OF Liver Function Tests (INR - Albumin - Bilirubin):

_________________________________________________________________________________

{B} . COMPENSATED:___________________. U/$ surveillance for Hepatocellular carcinoma & Alpha feto-protein every 6 months.

. Esophageal endoscopy for varices surveillance.

{C} . DECOMPENSATED -> ASSESS COMPLICATIONS:_____________________________________________. VARICEAL HEMORRHAGE -> Start non selective BB - Repeat esophageal endoscopy every year.. Ascites -> Dietary sodium restriction, diuretics, paracentesis & Alcohol abstinence.. Hepatic encephalopathy -> identify the cause (infection - GIT bleeding) & Lactulose.

. VARICEAL BLEEDING MANAGEMENT:_______________________________

. The 1st step in ttt of ACUTE VARICEAL BLEADING is to establish vascular access,. with TWO LARGE BORE INTRAVENOUS NEEDLES OR CENTRAL LINE.. Then .. Control the bleeding itself !. In 50 % of cases, bleeding ceases on its own.. Other 50 % -> Vasoconstrictors (Terlipressin) = Synthetic analogue of vasopressin.

. HEPATIC ENCEPHALOPATHY MANAGEMENT:____________________________________


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. Decline in neurologic function due to hepatic damage.. Due to ++ AMMONIA level in circulation & production of false neurotransmitters.. TTT principles -> Correction of ppt factor & lowering of blood ammonia concentration.. PPT factors -> hypovolemia - GIT bleeding - infection - hypoxia - hypoglycemia & -- K.. Lower blood ammonia using DISACCHARIDE (LACTULOSE) -> Ammonia trap.. Add NEOMYCIN -> Destroy ammonia producing colonic bacteria (OTO & NEPHRO-TOXIC).. Lower protein in diet (BUT .. NOT PTN FREE DIET xxxx) !

. COAGULOPATHY MANAGEMENT:__________________________. Bleeding disorders occur as the liver synthesizes all clotting factors exceptfactor 8.. Chief among these are Vit. K dependent factors 1972.. Acute bleeding is best ttt with FFP FRESH FROZEN PLASMA.. FFP contains all clotting factors.

* AMEBIC LIVER ABSCESS:_______________________. Amebiasis is aprotozoal disease caused by ENTAMOEBA HISTOLYTICA.

. H/O of travel to endemic area e.g. MEXICO.. Followed by dysentery, RUQ. pain & diarrhea.. The primary infection is the colon leading to bloody diarrhea,. Ameba may be transported to the liver by portal circulation -> Amebic liver abscess.. Fever up to 39.5 c.. ++ WBCs & ++ ALP.. Generally SINGLE & located in the RT lobe.. Dx -> Stool exam. -> trophozites.. CT -> Liver mass (cystic not solid lesion).. Needle aspiration is not performed due to risk of bleeding & peritonitis.. The fluid inside is called "anchovy paste" - STERILE & odourless unless 2ry infected.

. Tx -> ORAL METRONIDAZOLE. (NOT SURGICAL RESECTION!).

* HYDATID DISEASE:___________________. Hydatid cyst in liver.. Caused by ECHINOCOCCUS GRANULOSUS.. Defnitive host is DOG.. Unilocular cystic lesions in liver, lungs, muscles & bones.. Most pts are asymptomatic.. Symptoms are due to compression of the surrounding tissues.. CT -> EGG SHELL CALCIFICATION of hepatic cyst.. Aspiration isn't indicated -> anaphylactic shock 2ry to spelling of cyst contents.

. Tx -> Surgical resection under the cover of ALBENDAZOLE.

* ISCHEMIC HEPATIC INJURY = SHOCK LIVER:_________________________________________. Accompanies severe hypotension or shock.. Rapid massive +++ in transaminases.. Minimal ++ in bilirubin & ALP.. Once the predisposing factor disappears, the transaminases return to normal.

. LIVER MALIGNANCIES:


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__________________________________________

* LIVER METASTASIS:____________________. 20 times more common than HCC.. Tumors of GIT, lung & breast are the most common culprits.. May be asymptomatic & discovered accidentally.. If symptomatic: Hepatomegaly, jaundice, cholestasis & ++ alkaline phosphatase(ALP).. NORMAL ALPHA FETO-PROTEIN (AFP).. Dx -> CT -> Multiple hepatic nodules of varying sizes.. Confirmed by liver biopsy.. Multiple liver masses are much more likely to be the result of a metastatic disease.. Mostly -> CANCER COLON -> DO COLONOSCOPY.

* HEPATOCELLULAR CARCINOMA (HCC):__________________________________. Less common than metastasis.. ++++ ALPHA FETOPROTEIN.. CT -> SOLITARY large lesion.

* HEPATIC ADENOMA:

___________________. Benign rare liver tumor.. Young & middle aged women with H/O of OCP intake.. Palpable liver mass.. Liver biopsy -> Mildly atypical hepatocytes containing glycogen & lipid deposits.. Normal liver finction tests.. Normal AFP.. ++ ALP & GGT.. Complications -> Severe intra-tumor hemorrhage & malignant transformation.

. ALCOHOLIC LIVER DISEASES:

___________________________. Females are more susceptible than males to alcoholic liver diseases !!. Alcoholic fatty liver is reversible condition.. AST:ALT -> 2:1.

. 80 % of alcoholics will develop fatty liver.. 20 % of alcoholics will develop hepatitis.. 50 % of alcoholics will develop cirrhosis.

. H/O of heavy alcohol use.. Hepatomegaly (Liver span > 12 cm in MCL).. ++ MCV.. ++ AST : ALT = 2:1.

. Stages -> 1. Fatty liver "steatosis" - 2. Hepatitis - 3. Fibrosis "Cirrhosis".. Fatty liver is due to short alcohol use.. Hepatitis & cirrhosis require long term use.. Alcohol Hepatitis is characterized by: -> MALLORY BODIES. -> Neutrophils infiltration.-> Liver cell necrosis.


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-> Peri-venular inflammation.

. On CESSATION of alcohol intake:-> Steatosis & hepatitis & early fibrosis are REVERSIBLE.-> True cirrhosis (with generation nodules) are IRREVERSIBLE, regardless of abstinence.

. HYPER-BILIRUBINEMIA APPROACH:______________________________________________________________

{A} MAINLY UN-CONJUGATED:__________________________. Over-production (hemolysis).. Reduced up-take (drugs & porto-systemic shunt).. Conjugation defect (Gilbert's $).{B} MAINLY CONJUGATED -> EVALUATE LIVER ENZYME PATTERN:

________________________________________________________. {1} Predominantly ++ AST & ALT:

__________________________________. Viral Hepatitis.. Autoimmune hepatitis.

. Drug induced hepatitis.. Hemochromatosis.. Ischemic hepatitis.. Alcoholic hepatitis.. {2} NORMAL AST & ALT & ALP:

______________________________. DUBIN JOHNSON's $YNDROME.. ROTOR's $YNDROME.. {3} Predominantly ++ ALP -> Do abdominal imaging U$ or CT & AntimitochondialAbs:

________________________________________________________________________________

____. Cholestasis of pregnancy.. Malignancy (pancreas - ampullary).. Cholangiocarcinoma.. Primary biliary cirrhosis.. Primary sclerosing cholangitis.. Choledocholithiasis.

. N.B. U/$ -> Biliary dilatation = Extra-hepatic cholestasis.. N.B. U/$ -> No biliary dilatation = Intra-hepatic cholestasis.

. UN-CONJUGATED HYPER-BILIRUBINEMIA FAMILIAL DISORDERS:

_______________________________________________________

{1} GILBERT's $YNDROME:________________________. Disorder in conjugation.. -- Glucuronyl transferase (enzyme that mediates glucuronidation).. Mild jaundice.. In-direct bilirubin < 3 mg/dl.. Tx -> Un-necessary.


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{2} CRIGLER NAJJAR TYPE - 1 $YNDROME:______________________________________. Disorder in metabolism.. Severe jaundice.. Bilirubin encephalopathy (Kernicterus).. In-direct bilirubin 20 - 25 mg/dl. may reach 50 mg/dl.. Normal liver enzymes & liver histology.. IV PHENOBARBITAL -> NO CHANGE in serum bilirubin.. Tx -> Phototherapy or plasmapharesis the LIVER TRANSPLANT.

{3} CRIGLER NAJJAR TYPE - 2 $YNDROME:______________________________________. Disorder in metabolism.. Severe jaundice (less severe than type 1).. NOOOO Bilirubin encephalopathy (Kernicterus).. In-direct bilirubin dark granular pigment in hepatocytes (Not seen in Rotor's $).

. PANCREATIC DISEASES:____________________________________________

. ACUTE PANCREATITIS:_____________________. Severe mid-epigastric abdominal pain radiating to the back.. Vomiting without blood - Anorexia - Tendrness in the epigastric area.. Main causes are ALCOHOLISM & GALL STONES.. Other causes -> Hypertiglyceridemia - trauma - infection - iatrogenic ERCP.. Dx -> Best initial test -> * ++ Amylase & lipase (most sensitive & specific) -> ++ Amylase/lipase3 times.

* ABDOMINAL ULTRA$OUND -> Diffusely enlarged hypoechoic pancreas.. Dx -> Most accurate test -> Abdominal CT scan: * Detect dilated common bile ducts. * Comment on intra-hepatic ducts.. Dx -> N.B. -> ++ ALT > 150 & ++ ALP -> Biliary pancreatitis.. MRCP -> Detects causes of biliary & pancreatic duct obstruction not found onCT scan.. ERCP -> If there is dilatation of the common bile duct without a pancreatic head mass.. ERCP -> Detect stones or strictures in the pancreatic duct system & remove th


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em.. Tx -> NPO - Bowel rest - Hydration - pain medications.

. N.B. (1):____________. If the cause of acute pancreatitis was gall stones not alcoholism,. Once the pt. recovers with normalization of the pancreatic enzymes & medically stable,. CLOLECYSTECTOMY IS A MUST !. N.B. (2):

____________. Acute pancreatitis in pts without gall stones or a H/O of alcohol use.. HYPER-TRIGLYCERIDEMIA > 1000 mg/dl -> Acute pancreatitis.. Eruptive xanthoma on exam.. Dx -> FASTING LIPID PROFILE.

. COMPLICATIONS OF SEVERE PANCREATITIS:________________________________________. 1 . Pseudocyst.. 2 . Peri-pancreatic fluid collection.. 3 . Necrotizing pancreatitis.. 4 . ARD$.. 5 . ARF.

. 6 . GIT bleeding.

. SEVERE PANCREATITIS:______________________. Pancreatitis with failure of at least 1 organ !. Predisposing factors: Age > 75 ys, Alcoholism & obesity.. CULLEN SIGN -> Peri-umbilical bluish coloration indicating hemoperitoneum.. GREY-TURNER SIGN -> Reddish brown coloration around flanks = retroperitonealbleeding.. ++ CRP > 150 mg/dl in the 1st 48 hs.. ++ Urea & creatinine in the 1st 48 hs.. Severe cases -> (-- BP, -- Ca, -- O2, -- pH) & (++ WBCs, ++ glucose).. Hypotension, Hypoxia, Metabolic Acidosis, Hypocalcemia, Leukocytosis & Hyperg

lycemia.. Hypocalcemia due to fat malabsorption.. severe pancreatitis may lead to release of activated pancreatic enzymes,. that enter the vascular system & ++ the vascular permeability,. so, large volumes of fluid migrate from the vascular system to surrounding peritoneum,. resulting in widespread vasodilatation, capillary leak, shock & end organ damage.. Dx -> CT or MRCP to detect pancreatic necrosis & extra-pancreatic inflammation.. Tx -> Supportive with several liters of IV fluids.

. NECROTIZING PANCREATITIS:

___________________________. Dx -> CT.. Tx -> If > 30 % necrosis -> IV Antibiotics (Imipenem) & CT guided biopsy.. If the biopsy showed infected necrotic pancreatitis -> SURGICAL DEBRIDEMENT.. Surgical debridement is done to prevent ARD$ & death.

. PANCREATIC PSEUDOCYST:________________________. Palpable mass in the epigastrium 4 weeks after the onset of acute pancreatitis.


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. Not true cysts as they lack an epithelial lining just walled by a thick fibrous capsule. The pseudocyst is compromized of inflammatory fluid, tissues & debris.. The fluid contains high levels of amylase, lipase & enterokinase.. Dx -> U/$.. Tx -> Usually resolves spontaneously.. Tx -> Drainage if persisting > 6 weeks or > 5 cm in diameter or becomes 2rlyinfected.. May be complicated by severe hemorrhage if eroded into a blood vessel.

. DRUG INDUCED PANCREATITIS:____________________________. Mild & usually resolves with supportive care !. CT scan is diagnostic.. Pt on diuretics -> Furosemide & thiazides.. Pt on antibiotics -> Metronidazole & tetracyclines.. Pt with IBD -> Sulfasalazine.. Pt on immunosuppressives -> Azathioporine.. Pt with seizures or bipolar disorder -> Valproic acid.. Pt with AIDS -> Didanosine & pentamidine.

. CHRONIC PANCREATITIS:_______________________. Due to alcohol abuse - cystic fibrosis (Children) - Autoimmune causes.

. Epigastric chronic abdominal pain.. Intermittent pain free intervals.. Malabsorption -> chronic diarrhea & steatorrhea.. Weight loss & DM may occur lately.. AMYLASE & LIPASE may be normal .. Non diagnostic.. Plain film or CT scan -> Pancreatic calcifications. (DIAGNOSTIC).. If x-ray & CT are -ve for calcifications -> ERCP or MRCP.. Tx -> Pain management with frequent small meals & pancreatic enzymes supplement.. Alcohol & smoking cessation.

. PANCREATIC CARCINOMA:_______________________

. More in males & black race & age > 50 ys.. Risk factors -> Chronic pancreatitis, smoking & DM.. CIGARETTE SMOKING is the MOST CONSISTENT RISK FACTOR.. Dull upper abdominal pain radiating to the back, weight loss & jaundice.. Tumors located in pancreatic body or tail -> pain & weight loss.. Tumors located in pancreatic head -> Steatorrhea, weight loss & jaundice.. COURVOISIER's sign -> Palpable, non tender gall bladder at the Rt. costal margin.. VIRCHOW's NODE -> Left supra-clavicular adenopathy.. ++ serum bilirubin & ++ ALP.. ++ CA 19-9 levels (Serum cancer associated antigen).. Dx -> ABDOMINAL U/$ & CT (if U$ is not diagnostic).. Tx -> Resection of the involved tissue.

. GUESS WHAT -> ALCOHOLISM & GALL STONES ARE NOT RISK FACTORS OF PANCREATIC CANCER !!

. PANCREATIC CANCER VS CHRONIC PANCREATITIS:____________________________________________. Both may present with epigastric pain.. (Old age, jaundice & weight loss) favors malignancy.. Mild elevation of amylase & lipase are consistent with chronic pancreatitis.. ++ serum Bilirubin & ALP = compression of the intra-pancreatic bile duct = Malignancy.


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. Best initial test -> ABDOMINAL U/$ -> DILATED BILE DUCTS & MASS IN HEAD OF PANCREAS.. CT abdomen is more specific than U/$.. If CT failed -> i.e. No mass lesion -> Do ERCP.. If ERCP failed -> due to pancreatic duct obstruction -> Do MRI.

. GALL BLADDER DISEASES:________________________________________________

. GALL STONE DISEASE = CHOLELITHIASIS:______________________________________. Types of gall stones (Cholesterol - Pigment "Ca bilirubinate" - Mixed).. Msot common is Cholesterol stone & least common is pigment "Ca bilirubinate".. 80 % of stones are RADIO-OPAQUE.. FAT - FERTILE - FEMALE - FORTY - FILTHY !. Native American - DM - Obesity - OCP & pregnancy are common predisposing factors.. Bloating & dyspepsia after eating fatty foods.. RUQ abdominal pain.. Dx -> Abdominal U/$.. Tx -> LAPAROSCOPIC CHOLECYSTECTOMY.

. If refused the operation -> Give ursodeoxycholic acid & advise to avoid fattyfoods.. Asymptomatic gall stones should NOT be treated.. Symptomatic gall stones -> LAPAROSCOPIC CHOLECYSTECTOMY.

. ACUTE CHOLECYSTITIS = ACUTE GALL BLADDER INFLAMMATION:________________________________________________________. CHARCOT's TRIAD -> Fever + severe jaundice + RUQ abd pain radiating to the Rtshoulder.. REYNOLD's PENTAD -> + Confusion + Hypotension -> (Suppurative cholangitis).. Most commonly due to obstruction of the common bile duct by stone.. The original incinting event is a gall stone obstructing the CYSTIC DUCT (NotCBD) !!!

. MURPHY's SIGN -> pain on palpation of area of gall bladder fossa on deep inspiration.. ++ WBCs & ++ ALP (cholestasis & obstruction).. Dx -> U/$.. Tx -> Supportive care & broad spectrum antibiotics.. Most pts recover completely, but despite adequate fluids & antibiotics,. Some pts continue to have persistent abd. pain, hypotension, high fever & confusion.. This is an indication of URGENT BILIARY DECOMPRESSION by ERCP.. ERCP -> Sphincterotomy & stone removal or stent insertion.. Lap. cholecystectomy won't accomplish drainage of the biliary tree "main concern" !. Pt will undergo cholecystectomy later on but drainage of the biliary tree is

more imp.

. EMPHYSEMATOUS CHOLECYSTITIS:______________________________. Due to 2ry infection of the gall bladder with gas forming bacteria e.g. Clostridium.. Mostly diabetic male pts aged 50 - 70 ys.. Vascular predisposing factor e.g. obstruction or stenosis of the cystic artery.. Right upper quadrant pain - nausea - vomiting - low grade fever.


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. Crepitus in the abdominal wall adjacent to the gall bladder.. Complications -> Gangrene & perforation.. Dx -> Abdominal radiograph -> Air fluid level in the gall bladder.. Dx -> Abdominal ultrasound -> Curvilinear gas shadowing in the gall bladder.. Tx -> Immediate fluid & electrolyte resuscitation, cholycystectomy & antibiotics.

. A-CALCULOUS CHOLECYSTITIS:____________________________. Acute inflammation of the gall bladder in absence of gall stones.. Most commonly seen in hospitalized pts wit the following conditions:. Extensive burns - severe trauma - Prolonged TPN or fasting & mechanical ventillation.. pathophysiology -> ischemia - biliary stasis - infection or external compression.. Complications -> Gangrene - perforation - emphysematous cholecystitis.. Dx -> U/$ -> Signs of cholecystitis but No gall stones.. CT & HIDA scan are more sensitive & specific.. PORCELAIN GALL BLADDER:

_________________________. Due to chronic cholecystitis.. Calcium laden gall bladder.. Calcium salts are deposited intra-murally 2ry to chronic irritation from gall

stones.. RUQ. pain with firm non tender mass in the RUQ.. X-ray -> Rim like calcification in the area of gall bladder.. CT -> Calcified rim with central bile-filled dark area.. Mostly develop to GALL BLADDER CARCINOMA.. Tx -> CHOLECYSTECTOMY.

. GALL BLADDER CARCINOMA = CHOLANGIOCARCINOMA:______________________________________________. Rare malignancy.. More in hispanic or Native american females who have H/O of gall stones.. Typicallu diagnosed during or after chlecystectomy !. Can NOT be easily diagnosed pre-operatively.

. CA 19-9 is NOT a specific marker.

. POST-OPERATIVE CHOLESTASIS:_____________________________. Benign condition developing after a major surgery.. Major = Hypotension - extensive blood loss into tissues - massive blood replacement.. Jaundice by the 2nd or 3rd post-operative day.. Bilirubin peaks at 10 - 40 mg/dl by the 10th day.. ALP may be elevated.. AST & ALT NORMAL.

. POST-CHOLECYSTECTOMY $YNDROME:

________________________________. Persistent abdominal pain, nause & dyspepsia after cholecystectomy.. Biliary causes -> Retained common bile duct - cystic duct stone.. Extra-biliary causes -> Pancreatitis - PUD.. Dx -> U/$ followed by ERCP.

. POST-CHOLECYSTECTOMY PAIN:____________________________. Due to functional etiology e.g. SPHINCTER OF ODDI DYSFUNCTION or CBD stone.. Normal ERCP & U/$ can rule out CBD stones.


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. It is a diagnosis of exclusion.. Tx of sphincter of Oddi dysfunction -> ERCP with sphincterotomy.

. VANISHING BILE DUCT $YNDROME:_______________________________. progressive destruction of the intra-hepatic bile ducts.. Histological hallmark -> Ductopenia.. Primary bilary cirrhosis is the most common cause of ductopenia in adults.. Primary scerosing cholangitis is not related to ductopenia.

. DIFFERENT DIAGNOSTIC TOOLS USED FOR GALL BLADDER DISEASES:____________________________________________________________

{1} * ABDOMINAL ULTRA$OUND:____________________________. Best initial investigation of gall bladder diseases.{2} * ERCP = ENDOSCOPIC RETRO-GRADE CHOLANGIO-PANCREATOGRAPHY:

_______________________________________________________________. Best diagnostic & therapeutic tool in evaluation of chronic pancreatitis & CBD disease.. Most accurate test of detecting causes, location & extent of bile duct obstruction.. Therapeutic: Stone extraction, sphincterotomy, balloon dilatation & stent pla

cement.. TTT of choice in case of sphincter of Oddi dysfunction.

{3} * ABDOMINAL RADIOGRAPHS:_____________________________. Neither sensitive nor specific.. > 80 % of gall stones are radio-lucent so can't be visualized.

{4} * HIDA SCAN:_________________. Use technitium labelled compounds to demonstarate bile duct obstruction & GBdiseases.. It is superior to U/$ in confirming suspected acute cholecystitis (Acalculus

type).

{5} * PTC = PER-CUTANEOUS TRANS-HEPATIC CHOLANGIOGRAPHY:_________________________________________________________. study the intra & extra hepatic biliary tree.

. IMMUNOLOGIC BLOOD TRANSFUSION REACTIONS:____________________________________________________________________________________

. 1 . FEBRILE NON-HEMOLYTIC:

_____________________________. Most common reaction.. Fever & chills.. Within 1 - 6 hours of transfusion.. Caused by cytokine accumulation during blood storage.

. 2 . ACUTE HEMOLYTIC:_______________________. Fever, flank pain, hemoglobinuria, renal failure & DIC.. Within 1st hour of transfusion.


16/16

. +ve direct Coomb's test & pink plasma.. Caused by ABO INCOMPATIBILITY.

. 3 . DELAYED HEMOLYTIC:_________________________. Mild fever & hemolytic anemia.. Within 2 - 10 days of transfuion.. +ve direct Coomb's test & +ve new antibody screen.. caused by ANAMNESTIC ANTIBODY RESPONSE.

. 4 . ANAPHYLACTIC:____________________. Rapid onset of shock, angioedema, urticaria & respiratory distress.. Within a few seconds to minutes of the transfusion.. Caused by RECEPIENT anti-Ig"A" Abs.

. 5 . URTICARIAL = ALLERGIC:_____________________________. Urticaria - flushing - angioedema & pruritis.. Within 2 - 3 hours of transfusion.. Caused by RECEPIENT Ig"E" Abs & mast cell activation.

. 6 . TRANSFUSION RELATED ACUTE LUNG INJURY:_____________________________________________

. Respiratory distress & signs of non-cardiogenic pulmonary edema.. Within 6 hours of transfusion.. Caused by DONOR ANTI-LEUKOCYTE ANTIBODIES.

. N.B. Individuals who received blood transfusions before 1992 sh'd be screenedfor HCV.

. N.B. Individuals who received blood transfusions before 1986 sh'd be screenedfor HBV.

Dr. Wael Tawfic Mohamed

_________________________

tiki taka ck hepatology

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